bluuebunny/crossref_metadata_2025 huggingface dataset:
Present Bias Amplifies the Household Balance-Sheet Channels of Macroeconomic Policy
Authors: Maxted Peter , Laibson David , Moll Benjamin
Published: September 2024

We study the effect of monetary and fiscal policy in a heterogeneous-agent model where households have present-biased time preferences and naive beliefs. The model features a liquid asset and illiquid home equity, which households can use as collateral for borrowing. Because present bias substantially increases households’ marginal propensity to consume (MPC), present bias increases the effect of fiscal policy. Present bias also amplifies the effect of monetary policy, but at the same time, slows down the speed of monetary transmission. Interest rate cuts incentivize households to conduct cash-out refinances, which become targeted liquidity injections to high-MPC households. Present bias also introduces a motive for households to procrastinate refinancing their mortgages, which slows down the speed with which this monetary channel operates.
Earthquake preparedness based on reliability and relief of the emergency supply network: Pre-storage and pre-matching
Authors: Cui Hongjun , Su Yue , Zhu Minqing , Gu Jianling , Li Weimin , Dong Xiushi , Liu Lijun
Published: September 2024

The efficiency of post-disaster relief operations is impacted by the design of the emergency supply networks in the earthquake preparedness phase. This paper proposes a bi-objective mixed integer programming model to improve the preparedness of the emergency supply network. The maximization of connectivity reliability and relief is taken as the objective function as the design perspectives were inclined towards prioritizing human survival over cost. The number and location of storage points, the preset level and the pre-matching of demand nodes with their supply storage points are determined based on this. Then, applicability is evaluated through numerical examples, and critical parameters are demonstrated by sensitivity analysis. Finally, practicality is evaluated through practical examples. The results demonstrate that the method in this paper designs an emergency supply network with high reliability and relief level. The reliability of the supply network is improved by 42.3% and the rescue level reaches 96.6% compared with the pre-optimization period. Results may provide theoretical support for urban pre-earthquake preparedness and can help traffic planners and local governments formulate better earthquake prevention strategies.
SCUBE3 promotes osteogenic differentiation and mitophagy in human bone marrow mesenchymal stem cells through the BMP2/TGF‐β signaling pathway
Authors: Chen Hongyu , Wu Xiaoyong , Lan Yinan , Zhou Xijie , Zhang Ye , Long Long , Zhong Yuliang , Hao Zhengan , Zhang Weijun , Xue DeTing
Published: September 2024

In clinical settings, addressing large bone defects remains a significant challenge for orthopedic surgeons. The use of genetically modified bone marrow mesenchymal stem cells (BMSCs) has emerged as a highly promising approach for these treatments. Signal peptide‐CUB‐EGF domain‐containing protein 3 (SCUBE3) is a multifunctional secreted glycoprotein, the role of which remains unclear in human hBMSCs. This study used various experimental methods to elucidate the potential mechanism by which SCUBE3 influences osteogenic differentiation of hBMSCs in vitro. Additionally, the therapeutic efficacy of SCUBE3, in conjunction with porous GeLMA microspheres, was evaluated in vivo using a mouse bone defect model. Our findings indicate that SCUBE3 levels increase significantly during early osteogenic differentiation of hBMSCs, and that reducing SCUBE3 levels can hinder this differentiation. Overexpressing SCUBE3 elevated osteogenesis gene and protein levels and enhanced calcium deposition. Furthermore, treatment with recombinant human SCUBE3 (rhSCUBE3) protein boosted BMP2 and TGF‐β expression, activated mitophagy in hBMSCs, ameliorated oxidative stress, and restored osteogenic function through SMAD phosphorylation. In vivo, GELMA/OE treatment effectively accelerated bone healing in mice. In conclusion, SCUBE3 fosters osteogenic differentiation and mitophagy in hBMSCs by activating the BMP2/TGF‐β signaling pathway. When combined with engineered hydrogel cell therapy, it could offer valuable guidance for the clinical management of extensive bone defects.
Beyond adverse events in anesthesiology: ‘unanticipated events’ and strategies for improved reporting
Authors: Brook Karolina , Wilde Molly , Vannucci Andrea , Agarwala Aalok V.
Published: September 2024

Purpose of review

Patient safety in anesthesiology has advanced significantly over the past several decades. The current process of improving care is often based on studying adverse events (AEs) and near misses. However, there is a wealth of information not captured by focusing solely on these events, potentially resulting in missed opportunities for care improvements.

Recent findings

We review terms such as AEs and nonroutine events (NREs), and introduce the concept of unanticipated events (UEs), defined as events that deviate from intended care that may/may not have been caused by error, may/may not be preventable, and may/may not have caused injury to a patient. UEs incorporate AEs in addition to many other anesthetic events not routinely tracked, allowing for trend analysis over time and the identification of additional opportunities for quality improvement. We review both automated and self-reporting tools that currently exist to capture this often-neglected wealth of data. Finally, we discuss the responsibility of quality/safety leaders for data monitoring.

Consistent reporting and monitoring for trends related to UEs could allow departments to identify risks and mitigate harm before it occurs. We review various proposed methods to expand data collection, and recommend anesthesia practices pursue UE tracking through department-specific reporting interfaces.
Shall We Not Pressurize It? Effects of Bone Cement Pressurization on Mortality and Revision After Hip Hemiarthroplasty for Neck of Femur Fracture Patients: A Comparative Cohort Study
Authors: Farhan-Alanie Muhamed M. , Stephens Alastair , Umar Hamza , Ridha Ali , Arastu Mateen , Blankstein Michael
Published: September 2024

OBJECTIVES:

This study aimed to compare 30-day postoperative mortality, and revision for aseptic femoral component loosening and all-causes after hip hemiarthroplasty, performed with or without pressurization of the bone cement, in patients with neck of femur fracture.

METHODS:

Design:

Retrospective cohort study.

Setting:

Level I trauma center

Patient Selection Criteria:

Patients ≥60 years with OTA/AO 31B who underwent a cemented hip hemiarthroplasty from December 10, 2007 (database inception) to November 15, 2023 (search date) were reviewed.

Outcome Measures and Comparisons:

Comparisons were made between patients who underwent hip hemiarthroplasty with versus without pressurization of the bone cement for outcomes 30-day postoperative mortality, revision for aseptic femoral component loosening, and revision for all-causes.

RESULTS:

There were 406 procedures among 402 patients, and 722 procedures among 713 patients that were performed with and without pressurization of the bone cement, respectively. Mean ages were 83.1 and 84.3 years (P = 0.018), with 72.2% and 68.6% (P = 0.205) women in the pressurized and non-pressurized cement patient groups, respectively. There were no differences in 30-day postoperative mortality (7.2% vs. 8.2%; HR 0.89, 95% CI 0.46–1.73, P = 0.727). There were no differences in all-cause revision (HR 1.04, 95% CI 0.27–4.04, P = 0.953). No revisions were performed for aseptic loosening. Survival at 10 years postoperatively was 15.3% (95% CI 11.46–19.64) and 12.6% (95% CI 7.67–18.82) among patients who underwent hemiarthroplasty with and without bone cement pressurization, respectively.

CONCLUSIONS:

There were no differences in 30-day postoperative mortality among patients who underwent hemiarthroplasty with, compared to, without bone cement pressurization. Bone cement pressurization did not confer any advantages for revision outcomes that may be attributed, in part, to patients' high mortality rate and low survival beyond 10 years postoperatively.

LEVEL OF EVIDENCE:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Research Progress of Camptocormia in Parkinson Disease
Authors: Lu Yilin , Zhang Xiang , Li Junyu , Li Weishi , Yu Miao
Published: September 2024

Camptocormia, also known as bent spine syndrome, primarily affects individuals with Parkinson disease (PD). This review provides an overview of camptocormia in PD, covering its definition, epidemiology, causes, diagnosis, and treatment. In the epidemiology section, we delve into its prevalence, gender disparities, and ongoing genetic research. Regarding diagnosis and assessment, we discuss evolving diagnostic criteria and measurement techniques, as well as new diagnostic tools. For management and treatment, a wide array of options is available, from conservative methods such as physical therapy and botulinum toxin injections to surgical interventions such as spinal orthopedic surgery and deep brain stimulation. We stress the significance of personalized care and multidisciplinary collaboration. This comprehensive review aims to provide clinicians, researchers, and healthcare professionals with a comprehensive understanding of camptocormia in PD, highlighting its clinical features, diagnostic strategies, management approaches, and future perspectives.
Cervical Disc Arthroplasty Device Failure Causing Progressive Cervical Myelopathy and Requiring Revision Cervical Corpectomy
Authors: Parish Jonathan , Monk Steve H. , O’Brien Matthew , Hani Ummey , Coric Domagoj , Holland Christopher M.
Published: September 2024

Background:

Cervical disc arthroplasty is a well-established alternative to anterior cervical fusion but requires precise placement for optimal outcomes. We present the case of a 2-level cervical disc arthroplasty with suboptimal implantation of the interbody devices, requiring revision corpectomy. Supplemental video, Supplemental Digital Content 1 (http://links.lww.com/CLINSPINE/A358) content of the revision surgery is also provided. This report highlights the importance of proper implant sizing and position and reviews the nuances of surgical revision.

Methods:

A retrospective review of the clinical and radiographic data was performed from prior to the index operation through the 3-month postoperative period after the surgical revision.

Results:

The patient presented approximately 2 years post-cervical arthroplasty with increasing neck pain and early cervical myelopathy. An imaging workup revealed severe cervical stenosis at the caudal level with cord compression and concern for device failure. Intraoperatively, the core of the caudal device was found to have ejected into the spinal canal. A cervical corpectomy of the intervening vertebra with the removal of both devices was performed. The patient had a complete neurologic recovery.

Conclusion:

Although failure of a cervical disc arthroplasty device is rare, the likelihood can be significantly increased with poor sizing (over or under sizing), asymmetric placement, endplate violation, or poor patient selection. In the case presented herein, early device failure was unrecognized, and the patient went on to develop progressive cervical myelopathy requiring revision corpectomy.
Healthcare Provider Experiences With Unvaccinated COVID-19 Patients: A Qualitative Study
Authors: Griffin Candice , Lee Christie , Shin Phil , Helmers Andrew , Kalocsai Csilla , Karim Allia , Piquette Dominique
Published: September 2024

IMPORTANCE:

In the setting of an active pandemic the impact of public vaccine hesitancy on healthcare workers has not yet been explored. There is currently a paucity of literature that examines how patient resistance to disease prevention in general impacts practitioners.

OBJECTIVES:

The COVID-19 pandemic created unprecedented healthcare challenges with impacts on healthcare workers’ wellbeing. Vaccine hesitancy added complexity to providing care for unvaccinated patients. Our study qualitatively explored experiences of healthcare providers caring for unvaccinated patients with severe COVID-19 infection in the intensive care setting.

DESIGN:

We used interview-based constructivist grounded theory methodology to explore experiences of healthcare providers with critically ill unvaccinated COVID-19 patients.

SETTING AND PARTICIPANTS:

Healthcare providers who cared for unvaccinated patients with severe COVID-19 respiratory failure following availability of severe acute respiratory syndrome coronavirus 2 vaccines were recruited from seven ICUs located within two large academic centers and one community-based hospital. We interviewed 24 participants, consisting of eight attending physicians, seven registered nurses, six critical care fellows, one respiratory therapist, one physiotherapist, and one social worker between March 2022 and September 2022 (approximately 1.5 yr after the availability of COVID-19 vaccines in Canada).

ANALYSIS:

Interviews were recorded, transcribed, de-identified, and coded to identify emerging themes. The final data was analyzed to generate the thematic framework. Reflexivity was employed to reflect upon and discuss individual pre-conceptions and opinions that may impact collection and interpretation of the data.

RESULTS:

Healthcare providers maintained dedication toward professionalism during provision of care, at the cost of suffering emotional turmoil from the pandemic and COVID-19 vaccine hesitancy. Evolving sources of stress associated with vaccine hesitancy included ongoing high volumes of critically ill patients, resource shortages, and visitation restrictions, which contributed to perceived emotional distress, empathy loss, and professional dissatisfaction. As a result, there were profound personal and professional consequences for healthcare professionals, with perceived impacts on patient care.

CONCLUSIONS:

Our study highlights struggles of healthcare providers in fulfilling professional duties while navigating emotional stressors unique to vaccine hesitancy. System-based interventions should be explored to help providers navigate biases and moral distress, and to foster resilience for the next major healthcare system strain.
Biomarker-directed therapy in multiple myeloma
Authors: Bryant Adam , Quach Hang
Published: September 2024

Purpose of review

Multiple myeloma is currently treated with a one-size-fits-all approach despite significant heterogeneity in patient outcomes and disease molecular constitution. A personalised approach would tailor therapy to unique patient or disease characteristics.

Recent findings

Well established prognostic biomarkers such as cytogenetic risk and patient frailty status are being evaluated as potential predictive biomarkers. Specifically, treatment intensity can be augmented in high-risk patients or conversely attenuated in those at lower risk or lower ability to withstand treatment toxicities. Alternatively, targeted therapy can be rationally designed to exploit vulnerable pathways in myeloma cells as identified using predictive biomarkers. The t(11;14) translocation, found in approximately 15–20% of myeloma cases, is a leading biomarker for response to BCL-2 inhibitors such as venetoclax.

Active research efforts exploring venetoclax combination therapies, as well as new generation BCL-2 inhibitors are underway. Following the development of venetoclax, numerous other cellular pathways are under investigation as candidate predictive biomarkers to rationally inform newer targeted therapies in myeloma.
Patient-Centered Nursing for the Christ-Centered Nurse
Authors: Meilner Shauna L.
Published: September 2024

Patient-centered care (PCC), a term coined decades ago, is a key but challenging focus of nursing practice. The history, development, and current dialogue about PCC along with biblical perspectives on caregiving, wisdom, and discernment help nurses who follow Christ to offer compassionate PCC. Strategies are proposed for meaningfully engaging patients and families as active participants in healthcare. The Christian nurse can best provide consistent, effective PCC by remaining Christ-centered.
A novel mouse model recapitulates the effects of rs2254524 variant in the lanosterol synthase gene on salt sensitivity and organ damage
Authors: Faienza Sipontina , Citterio Lorena , Messaggio Elisabetta , Zagato Laura , Lanzani Chiara , Simonini Marco , Canciani Barbara , Sanvito Francesca , Rampoldi Luca , Pavlovic Davor , Manunta Paolo
Published: September 2024

Objective:

The blood pressure (BP) response to salt intake (salt sensitivity) shows great variability among individuals and is more frequent in hypertensive patients. Elevated levels of the steroid hormone Endogenous Ouabain (EO) are associated with hypertension (HT) and salt sensitivity. The lanosterol synthase gene (LSS) plays a key role in the biosynthesis of steroids and its rs2254524 variant (Val642Leu) is linked to salt sensitivity in humans. This study aims to investigate the pathophysiological significance of the Lss missense variation in a new knock-in mouse model of salt-sensitive HT onset.

Methods:

We generated a mouse model carrying the murine homolog (Val643Leu) of the human LSS variant. C57BL/6N Lss
V643L/V643L mice were fed different NaCl diets (low-salt, LSD; normal-salt, NSD; high-salt, HSD) and were characterized at functional, histological, and molecular levels.

Results:

At baseline, mutant mice showed an enlarged kidney compared to the wild-type (WT) counterpart, but the Lss V643L variant did not affect EO biosynthesis nor systolic BP at 3 and 12 months. In HSD, we observed an increased systolic BP only in 12-month-old Lss
V643L/V643L mice, compared to NSD. Moreover, only the HSD Lss
V643L/V643L mice showed cardiac hypertrophy and a higher incidence of cardiac fibrosis compared to WT at 12 months. Finally, the Lss mRNA level was differentially regulated by HSD in the adrenal gland, liver, and heart of Lss
V643L/V643L mice compared to WT.

Conclusions:

The novel Lss mouse model resembles the salt-sensitive HT phenotype observed in hypertensive patients and provides a good model of salt-sensitive HT and HT-mediated organ damage.
Estimated versus measured aortic stiffness: implications of diabetes, chronic kidney disease, sex and height
Authors: Côté Nadège , Fortier Catherine , Jafari Kaveh , Paré Mathilde , Addour Saliha , Goupil Rémi , Agharazii Mohsen
Published: September 2024

Background:

Aortic stiffness is measured by carotid–femoral pulse wave velocity (PWV), but it can also be estimated (ePWV) based on age and brachial mean arterial pressure (MAP). However, diabetes mellitus and/or chronic kidney disease (DM/CKD) may cause more pronounced damage to the arterial wall, changing the pressure and PWV relationship. Furthermore, sex and height could affect PWV through their relationship to the arterial diameter and path length. The aim of the present study was to quantify the extent to which DM/CKD, sex and height affect the validity of ePWV in predicting PWV.

Methods:

This cross-sectional study evaluated PWV in adult participants at high risk of aortic stiffness, using Complior and the second derivative transit time algorithm (PWV2nd). PWV2nd was converted into intersecting tangent PWV (PWVITc), and ePWV was calculated using the Reference Values for Arterial Stiffness Collaboration formulas.

Results:

Among 825 patients (62% males), the mean age was 60 ± 17 years, 34% had diabetes mellitus, 69% had CKD, and 24% did not have DM/CKD. MAP, ePWV, PWV2nd, and PWVITc were, respectively, 96 ± 14 mmHg, 9.8 (8.1–11.8) m/s, 9.5 (7.8–11.9) m/s and 11.3 (8.8–15.9) m/s. There was a significant interaction between DM/CKD, sex, and the predictive value of ePWV. Increasing height lowered the intercept but did not affect the slope of the relationship between estimated and measured PWVs.

Conclusion:

These findings suggest that the current ePWV equations do not accurately predict PWV in patients with DM/CKD, and that sex and height should also be considered in the future ePWV equations.
Prevalence, awareness, treatment, and control rates of hypertension in the general population of Australia: a systematic review and meta-analysis
Authors: Wang X. , Shaw J.E. , Yu J. , Jennings G. , Stavreski B. , Magliano D. , Gill T.K. , Adams R. , Rodgers A. , Woodward M. , Schlaich M.P. , Singleton R. , Zhou B. , Schutte A.E.
Published: September 2024

A recent call-to-action highlighted that Australia is lagging behind high-income countries regarding hypertension control rates.

We performed a systematic literature search of reports on prevalence, awareness, treatment and control rates since 2010. We also undertook an individual participant data meta-analysis of six population-based studies in the general population from 1980 to 2018 to understand the size of the problem and trajectories over time.

The aggregated data showed that after 2010, hypertension prevalence was 31% [95% confidence interval (CI) 27–34%], and awareness, treatment, and control rates among people with hypertension were 56% (41–71%), 54% (46–62%) and 34% (22–47%), respectively. Since 1980, these figures have shown slight improvement. However, we noted a low availability of quality nationwide databases for Australia.

We require critical action to improve the prevention, detection and treatment of hypertension, and highlight the need for large-scale investment in tracking population health in order to produce vital health statistics for the nation.
Metroticket approach in a retrospective cohort study to predict overall survival after surgical resection for hepatocellular carcinoma
Authors: Hoang Marjorie T. Q. , Koh Ye Xin , Sultana Rehena , Allen John C. , Moris Dimitrios , Cheow Peng Chung , Chung Alexander Y.F. , Jeyaraj Prema Raj , Mack Peter O. P. , Ooi London Lucien P. J. , Tan Ek Khoon , Teo Jin Yao , Kam Juinn Huar , Moe Fiona N.N. , Chua Jacelyn S.S. , Ng Ashley W.Y. , Goh Jade S.Q. , Goh Brian K. P. , Zani Sabino , Chow Pierce K. H.
Published: September 2024

Background:

Surgical resection is a curative therapy for early-stage hepatocellular carcinoma (HCC) patients meeting the Milan criteria as well as a widely used therapy in intermediate-stage HCC. However, intermediate-stage HCC encompasses a wide spectrum of disease and there is a lack of good predictive models for the long-term clinical outcome of HCC patients currently. Here, the authors adopt Mazzaferro’s Metroticket 2.0 to create a robust survival prediction model for intermediate-stage HCC patients undergoing surgical resection. Our algorithm considers age, AFP levels, ALBI score, and nodule size/number to generate survival estimates in an accessible graph format. Importantly, their model surpasses the American Joint Committee on Cancer staging model and was validated with independent US patient data.

Methods:

The authors conducted a retrospective analysis of OS and RFS in early- and intermediate-stage HCC patients treated with liver resection, including a training cohort in Singapore and a validation cohort in North Carolina, USA.

Results:

The authors recorded 278 deaths (35.0%) and 428 patients (53.9%) in the first 5 years after surgical resection; higher ALBI score, higher lnAFP, more advanced age and higher tumour burden index were identified as significant parameters. The overall predictive capability of our model, with the inclusion of AFP, is reflected with a UNO’s C-statistic of 0.655, which is 1.11 times better than the 0.5895 C-statistic of the 8th AJCC TNM Staging model.

Conclusions:

The authors’ modified Metroticket model allows for more granular and better-informed prognostication. This will help surgeons and patients make accurate comparisons between the clinical outcomes of surgical resection and other non-surgical treatments.
The role of point-of-care ultrasound to assess fluid responsiveness and fluid tolerance in the intensive care unit
Authors: Huard Karel , Joyal Rose , Beaubien-Souligny William
Published: September 2024

Fluid accumulation is epidemiologically associated with adverse outcomes in various clinical contexts. Assessing fluid responsiveness identifies conditions where intravenous fluids can increase cardiac output, improve organ blood supply during hypoperfusion and prevent the administration of ineffective fluids with deleterious effects. Point-of-care ultrasound (POCUS) enables fluid administration guided by fluid responsiveness, serving as one of the few non-invasive technological aids widely accessible both within and outside the intensive care unit. In this review, we focus on how POCUS can complement the evaluation of fluid responsiveness and fluid tolerance. The topics include a review of POCUS techniques to estimate the change in cardiac output following preload modifying manoeuvers, evaluation of thoracic fluid tolerance through lung ultrasound, and evaluation of systemic fluid tolerance through venous Doppler and the venous excess ultrasound (VExUS) assessment.
Differences in Injury Patterns and Delays in Care-Seeking Behaviors in the Anabaptist Population
Authors: Salzwedel Marsha , Rhodes-Lyons Heather Xenia , Kracht Elizabeth
Published: September 2024

BACKGROUND:

The lifestyle differences of Anabaptists and their views on health care may yield different injury patterns than standard populations and require a customized approach to injury prevention and health care delivery.

OBJECTIVE:

To identify differences in injury patterns and delays in care-seeking behaviors among the Anabaptists in Wisconsin.

METHODS:

This single-center retrospective cohort study was conducted from (23 years) January 1, 2000, to December 31, 2023. Local Trauma Registry data collected patient demographics, injury details, morbidity outcomes, in-hospital mortality, and preexisting comorbidity. Anabaptist trauma patients were isolated by confirmed identification in the Trauma Registry. The analysis utilized both descriptive statistics and a logistic regression model with the outcome of Anabaptist.

RESULTS:

A total of 14,431 patients were included in the analysis; 81 (0.4%) were confirmed as Anabaptist. The Anabaptist population showed a higher likelihood of helicopter transportation (odds ratio [OR] 4.64, p < .01) and an activation of Pediatric Level I (OR 4.07, p < .01). As the emergency department shock index increased by one unit, the odds of being Anabaptist increased by 9.87 (p < .01). The injury mechanisms that were associated with the Anabaptist population included buggy collisions (OR 312.58, p < .01), caught or crushed (OR 5.21, p = .01), machinery (OR 5.38, p < .01), near drowning (OR 14.09, p < .01), scooter (OR 13.93, p = .04), and woodworking (OR 12.81, p = .01).

CONCLUSIONS:

This study identified differences in injury patterns and delays in care-seeking behaviors in the Anabaptist population.
Stressing the System: Pediatric Trauma Centers May Be Unready to Implement Comprehensive Acute Stress Screening Programs for Pediatric Trauma Patients
Authors: Renaud Elizabeth Jay , Bromberg Julie R. , McRoberts Christina , Almonte Geraldine , Lin Timmy R. , Hensler Emily , Mello Michael J.
Published: September 2024

BACKGROUND:

Children experiencing trauma are at risk of developing acute and chronic stress disorders. In 2022, the American College of Surgeons Committee on Trauma required verified pediatric trauma centers to screen at-risk patients and provide mental health provider referrals as needed.

OBJECTIVE:

The study objective is to assess the current readiness of pediatric trauma centers to meet the new American College of Surgeons requirements.

METHODS:

This study used an exploratory, electronic, cross-sectional survey design. The Pediatric Trauma Society distributed a survey on mental health screening practices to its members in February 2023. Results were summarized with descriptive statistics. Chi-square test was used to compare responses of Levels I and II pediatric trauma centers.

RESULTS:

There were 91 survey responses from the PTS membership of 1247 (response rate of 7.3%). Fifty-nine participants were from Level I and 27 from Level II pediatric trauma centers. 63.8% of Level I and 51.9% of Level II center respondents currently screened for acute stress (χ2(1) = 1.09, p = .30). Of these, 75.7% of Level I and 57.1% of Level II center respondents routinely screened all admitted trauma patients (χ2(1) = 1.68, p = .19). However, only 32.4% of Level I and 21.4% of Level II respondents reported having outpatient acute stress referral protocols. For pediatric trauma centers currently without screening, 65% of Level I and 46.2% of Level II pediatric trauma center respondents felt they needed more than six months to establish a program (χ2(1) = 1.15, p = .28). Most respondents (68.9%) reported staff shortages as a barrier to the delivery of acute stress services.

CONCLUSIONS:

Pediatric trauma center compliance with acute stress screening requirements for verification is variable. Pediatric trauma centers may benefit from technical assistance with acute stress screening.
Long-term maternal outcomes of pregnancy after orthotopic liver transplantation in the Netherlands: A retrospective multicenter cohort study
Authors: Meinderts Jildau R. , Metselaar Herold J. , van Hoek Bart , den Hoed Caroline M. , Rijntjes Douwe , Groenewout Mariette , van Vilsteren Frederike G.I. , Groen Henk , Berger Stefan P. , Prins Jelmer R. , de Jong Margriet F.C.
Published: September 2024

Pregnancy after orthotopic liver transplantation (OLT) puts the mother, child, and transplanted organ at risk. Little is known about long-term outcomes. We performed a nationwide retrospective cohort study to evaluate short-term and long-term outcomes of post-OLT pregnancies. The secondary aim was to assess predictors for adverse pregnancy outcomes. A composite outcome of preeclampsia, preterm birth, low birth weight, and neonatal intensive care unit admission was made. Survival of women who received a transplant at <50 years of age with and without pregnancy after OLT were compared (Dutch Organ Transplantation Registry data). Descriptive statistics, regression analysis, Kaplan-Meier and log-rank analysis, and generalized estimating equation analysis were used. Among the included 70 women with 113 pregnancies >20 weeks of gestation, hypertension occurred in 20% and preeclampsia in 12%. The live birth rate was 87%; 33% were preterm, and 23% had low birth weight. Long-term follow-up (median 10 y [IQR: = 4–14]) showed small changes in serum creatinine and bilirubin (p < 0.001). Sixteen mothers (23%) died during follow-up (median 8 y [IQR: = 4–12]), with all their children aged <18 years. No difference in survival was found when comparing women with and without pregnancy after OLT. The composite outcome occurred in 43/98 of pregnancies. Higher body mass index (BMI) and maternal age at conception increased the composite outcome risk (OR: 1.24, p < 0.01, and OR: 1.25, p = 0.01, respectively). To conclude, pregnancy after OLT does not seem to influence long-term outcomes of graft, kidney function, or patient survival in most cases. However, although pregnancy does not seem to impact survival after OLT, we do show that a substantial number of children will lose their mothers early in life. We believe this is important for pregnancy couseling of patients with an OLT and their partners.
Protein S contributes to the paradoxical increase in thrombin generation by low-dose dabigatran in the presence of thrombomodulin
Authors: Zhang Chi , Chen Weixiang , Zhang Yue , Jiang Tingbo
Published: September 2024

Low dose of dabigatran paradoxically increased thrombin generation through inhibition of protein C activation. Protein S is a co-factor in the activation of protein C. However, the role of protein S in the enhancement of thrombin generation has not been addressed. Firstly, we measured thrombin generation by calibrated automated thrombinography (CAT) and prothrombin fragments 1+2 (F1+2) assays. Secondly, we assessed activated protein C (APC) formation in normal or protein S-deficient plasma spiking with dabigatran. Then, protein C activation was measured. Finally, heavy chain of factor Va (FVa) and its degradation products were detected by western blot. CAT assay showed that 70–141 ng/ml dabigatran paradoxically increased thrombin generation in normal plasma. However, higher concentrations of dabigatran (283 ng/ml) suppressed the level of ETP. F1+2 assay showed the similar results. In protein S-deficient or protein C-deficient plasma, the paradoxical increase in thrombin generation was absent. Level of generated APC was to a similar extent inhibited by dabigatran in normal and protein S-deficient plasma. Low-dose dabigatran inhibited the protein S-dependent inactivation of factor Va. Protein S participated in the paradoxical enhancement of thrombin generation in normal plasma spiking with low concentrations of dabigatran. Increased thrombin generation at low dabigatran can be explained by reduced thrombin–thrombomodulin mediated APC formation and subsequent reduced FVa inactivation that is protein S-dependent.
Improved prevention of bleeding episodes with emicizumab in 3 patients with concomitant hemophilia A and von Willebrand disease
Authors: Ansteatt Kristin T. , Roberts Jonathan C. , Helms Jackie M. , Tarantino Michael D.
Published: September 2024

The typical phenotype of hemophilia A (HA) is that of frequent bleeding episodes, up to several per month, unless prophylactic factor VIII (FVIII) replacement or alternatives are given. Related bleeding may be heightened in severity or frequency by co-morbid bleeding disorders. Based on the reported prevalence of von Willebrand disease (VWD) of up to 1% of the general population, the co-existence of HA and VWD occurs, but is likely less recognized. Prophylactic FVIII replacement may or may not adequately prevent bleeding in persons with HA and mild VWD, and plasma-derived concentrates containing FVIII and von Willebrand factor (VWF) may be used for more successful bleeding prophylaxis. However, therapy adherence remains problematic for many reasons, one being treatment via intravenous access. Emicizumab is a nonfactor subcutaneous prophylactic therapy for HA that may overcome this concern. We describe three patients, with severe HA and VWD, for whom regular FVIII/VWF prophylaxis was deemed inadequate. FVIII/VWF prophylaxis was replaced with weekly prophylactic injections of the bispecific monoclonal antibody, emicizumab. When the patients were transitioned to emicizumab, all experienced a significant reduction in their annualized bleed rate (ABR). Although the mechanism of action does not directly affect or replace VWF function, emicizumab may be an effective prophylaxis alternative to FVIII/VWF concentrate in patients with concomitant severe HA and VWD.
Is tranexamic acid appropriate for all patients undergoing high-risk surgery?
Authors: Abad-Motos Ane , García-Erce Jose A. , Gresele Paolo , Páramo Jose A.
Published: September 2024

Purpose of review

Tranexamic acid (TXA), an antifibrinolytic agent, reduces surgical bleeding in a variety of procedures, such as cardiac, orthopedic, abdominal, and urologic surgery, cesarean section, and neurosurgery. However, there are surgical interventions for which its use is not yet widespread, and some caution persists because of concerns regarding thrombotic risk. The purpose of this review is to analyze the most recent evidence in various subgroups of surgical specialties and the association of TXA with thrombotic events and other side effects (e.g. seizures).

Recent findings

Recent clinical trials and meta-analyses have shown that the efficacy and safety vary according to the clinical context, timing of administration, and dose. Some reports found that TXA reduces major bleeding by 25% without a significant increase in thrombotic events.

Wider use of TXA has the potential to improve surgical safety, avoid unnecessary blood use, and save healthcare funds.
Implementing Patient-Centered Outcomes Research Institute Stakeholder Engagement Principles in Models of Palliative Care Delivery and Advance Care Planning Research
Authors: Walling Anne M. , Verma Manisha , Grudzen Corita R. , Enguidanos Susan , Barrett Nadine J. , Johnson Kimberly S. , Combe Angela K. , Johnston Fabian M. , Greer Joseph A.
Published: September 2024

Background:

Given the many challenges of conducting research that addresses the palliative and end-of-life care needs of patients with serious illnesses, stakeholder engagement starting from the moment of study conceptualization and design is critical to ensure successful participant recruitment, data collection, intervention delivery, data analysis, and dissemination.

Methods:

Guided by a conceptual model published by the Patient-Centered Outcomes Research Institute (PCORI) entitled, “Measuring What Matters for Advancing the Science and Practice of Engagement”14 and with the support of a PCORI Engagement Officer, representatives from 9 PCORI-funded study teams formed a working group to survey team members and review, outline, and describe key lessons learned and best practices for promoting stakeholder engagement in palliative care research.

Results:

Almost all study teams engaged with patients/caregivers, clinicians, researchers, and health care system experts as stakeholder partners. About half the teams also included payers and training institutions as part of their stakeholder advisors as well as a range of content experts. Study teams relied on a variety of support structures and resources, and they employed 10 distinct methods for maintaining engagement. All engagement methods were generally considered to be effective by teams who used the method, though there was some variability in team-rated engagement quality of each method. Nine barriers to stakeholder engagement were identified across the 9 studies as well as 9 strategies (or facilitators) to overcome these barriers. We share examples of how stakeholder engagement impacted studies in all phases, including the preparatory phase, study initiation phase, execution phase, and data analysis/dissemination phase.

Conclusions:

Teams utilized a variety of resources and support structures as well as capitalized on multiple engagement methods for fostering stakeholder engagement, resulting in a high level of collaboration and integration.
The impact of oral melatonin on pain and anxiety reduction during venipuncture in pediatric patients: a double-blind randomized clinical trial
Authors: Rahafard Sara , Akbari Jokar Zohre , Hosseini Seyed Ahmad , Alaee Ehsan
Published: September 2024

Background:

Pain resulting from therapeutic procedures and injections is a prevalent source of stress for children. Immediate side effects of pain in infants include syncope, irritability, sleep disturbances, and nutritional issues. This study aimed to investigate the effects of oral melatonin on alleviating pain and anxiety in pediatric patients undergoing venipuncture.

Methods:

This double-blind, randomized controlled trial was conducted in the pediatric emergency ward. Patients were randomly assigned to one of two groups; the intervention group received 0.5 mg/kg of oral melatonin (maximum 5 mg) 30 min before venipuncture, while the placebo group received an equivalent amount of a placebo 30 min before the procedure. Using the Face, Legs, Activity, Cry, Consolability (FLACC) scale, postcanulation fear, pain severity, compliance, and potential side effects were evaluated.

Results:

In total, 202 patients (113 male and 89 female) in the intervention and control groups were included in the analysis. The mean pain score during venipuncture was 1.52±3.04 in the intervention group and 2.04±6.57 in the control group (P<0.001). In the intervention group, only 19 (18.8%) patients reported pain during venipuncture, whereas 79 (78.2%) patients in the control group reported pain (P<0.001). Less than half (44.6%) of the patients in the intervention group experienced anxiety during venipuncture, while the majority (94.1%) of the patients in the control group exhibited anxiety (P<0.001). The venipuncture success rate was 60.4% in the intervention group and 51.5% in the control group (P=0.257).

Conclusion:

Administering 0.5 mg/kg of oral Melatonin 30 min before venipuncture reduces procedure-related pain and anxiety in pediatric patients and may be associated with higher venipuncture success rates.
Malignant metastatic melanoma in brain with unknown primary origin: a case report
Authors: Khanal Kunjan , Rajbhandari Binod , Pandey Asim , Sherpa Pasang Lamu , Parajuli Samriddhi , Pandey Norina , Sedain Gopal , Bhattachan Maya
Published: September 2024

Introduction:

Melanoma, a malignant tumor derived from neural crest melanocytes, predominantly affects the skin but can involve any organ with neural crest migration. Metastatic melanoma of unknown origin, particularly when it involves the brain, is associated with significant morbidity, mortality, and a typically poor prognosis.

Case presentation:

The authors present a 71-year-old man with a history of hypertension and seizure disorder who experienced a headache, transient loss of consciousness, and vomiting. Imaging revealed a mass with perilesional edema in the right temporal, right occipital, left frontal, and left periventricular regions. A craniotomy and excision of the right temporal lesion confirmed malignant metastatic melanoma through histological examination. Despite normal findings in skin, mucosal, anogenital, and ophthalmological examinations, and a comprehensive CT scan of the chest, abdomen, and pelvis that revealed no primary tumor, the diagnosis of metastatic melanoma of unknown origin was made. The patient did not receive treatment due to financial constraints.

Clinical discussion:

About 2–6% of melanoma patients present with tumors of unknown primary origin. Brain metastases occur in ~60% of advanced melanoma cases and carry a high risk of spontaneous bleeding. While traditional survival rates are low, surgical resection, stereotactic radiosurgery, immunotherapy, and BRAF/MEK inhibitors can improve outcomes.

Conclusion:

Headaches, lethargy, vomiting, and altered sensorium should prompt investigation for brain metastases from melanoma, even without a detectable primary tumor. Treatment strategies including immunotherapy and stereotactic surgery aim for a median survival of 8–10 months. Socio-economic factors, as highlighted in this case, significantly affect treatment access and patient outcomes.
Updated Risk Score Algorithms for Acute HIV Infection Detection at a Sexually Transmitted Infections Clinic in Lilongwe, Malawi
Authors: Bell Griffin J. , Chen Jane S. , Maierhofer Courtney N. , Matoga Mitch , Rutstein Sarah E. , Lancaster Kathryn E. , Chagomerana Maganizo B. , Jere Edward , Mmodzi Pearson , Bonongwe Naomi , Mathiya Esther , Ndalama Beatrice , Hosseinipour Mina C. , Emch Michael , Dennis Ann M. , Cohen Myron S. , Hoffman Irving F. , Miller William C. , Powers Kimberly A.
Published: September 2024

Background:

Detection of acute (preseroconversion) HIV infection (AHI), the phase of highest transmission risk, requires resource-intensive RNA- or antigen-based detection methods that can be infeasible for routine use. Risk score algorithms can improve the efficiency of AHI detection by identifying persons at highest risk of AHI for prioritized RNA/antigen testing, but prior algorithms have not considered geospatial information, potential differences by sex, or current antibody testing paradigms.

Methods:

We used elastic net models to develop sex-stratified risk score algorithms in a case–control study of persons (136 with AHI, 250 without HIV) attending a sexually transmitted infections (STI) clinic in Lilongwe, Malawi, from 2015 to 2019. We designed algorithms for varying clinical contexts according to 3 levels of data availability: (1) routine demographic and clinical information, (2) behavioral and occupational data obtainable through patient interview, and (3) geospatial variables requiring external datasets or field data collection. We calculated sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) to assess model performance and developed a web application to support implementation.

Results:

The highest performing AHI risk score algorithm for men (AUC = 0.74) contained 5 variables (condom use, body aches, fever, rash, genital sores/ulcers) from the first 2 levels of data availability. The highest performing algorithm for women (AUC = 0.81) contained 15 variables from all 3 levels of data availability. A risk score cut point of 0.26 had an AHI detection sensitivity of 93% and specificity of 27% for men, and a cut point of 0.15 had 97% sensitivity and 44% specificity for women. Additional models are available in the web application.

Conclusions:

Risk score algorithms can facilitate efficient AHI detection in STI clinic settings, creating opportunities for HIV transmission prevention interventions during this critical period of elevated transmission risk.
Disentangling the Effects of Comorbidity and Polypharmacy on Cognitive Function and Physical Frailty in Individuals With HIV
Authors: Michael Henry Ukachukwu , Brouillette Marie-Josée , Tamblyn Robyn , Fellows Lesley K. , Mayo Nancy E.
Published: September 2024

Objective:

To estimate the extent to which comorbidity, polypharmacy, and anticholinergic/sedative burden interrelate to influence cognitive ability, perceived cognitive deficits (PCD), and physical frailty in people living with HIV.

Design:

Cross-sectional Structural Equation Modeling of data from 824 older people living with HIV in Canada, participating in the Positive Brain Health Now study.

Method:

Structural Equation Modeling was used to link observed variables, including comorbidity, polypharmacy, anticholinergic, and sedative burden, to cognitive ability and 2 latent constructs—physical frailty and PCD. The model was adjusted for age, sex, education, nadir CD4, duration of HIV, and symptoms of anxiety/depression. Maximum Likelihood with Robust standard errors and bootstrapping were used to test the robustness and significance of the model's indirect effects.

Results:

Anticholinergic burden had a direct significant negative relationship with cognitive ability (βstd = −0.21, P < 0.05) and indirect effect on PCD (βstd = 0.16, P < 0.01) and frailty (βstd = 0.06, P < 0.01) through sedative burden. Sedative burden was directly associated with PCD (βstd = 0.18, P < 0.01) and indirectly with frailty through PCD (βstd = 0.07, P < 0.01). Comorbidity and polypharmacy exerted indirect effects on PCD and physical frailty through anticholinergic and sedative burden. The model fits the data well (CFI: 0.97, TLI: 0.94, RMSEA: 0.05, SRMR: 0.04).

Conclusions:

Anticholinergic and sedative burden function as a pathway through which polypharmacy and comorbidities influence physical frailty and PCD. Reducing the use of anticholinergic and sedative medications could help prevent and manage cognitive impairment and frailty in older people living with HIV.