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Background: In October 2022 a multisite social determinants of health screening initiative was expanded across seven emergency departments of a large, urban hospital system. The aim of the initiative was to identify and address those underlying social needs that frequently interfere with a patient's health and well-being, often resulting in increased preventable system utilization., Methods: Building on an established Patient Navigator Program, an existing screening process, and long-standing community-based partnerships, an interdisciplinary workgroup was formed to develop and implement the initiative. Technical and operational workflows were developed and implemented, and new staff members were hired and trained to screen and support patients with identified social needs. In addition, a community-based organization network was formed to explore and test social service referral strategies., Results: Within the first five months of implementation, more than 8,000 patients were screened across seven emergency departments (EDs), of which 17.3% demonstrated a social need. Patient Navigators see between 5% and 10% of total nonadmitted ED patients. Among the three social needs of focus, housing presented as the greatest need (10.2%), followed by food (9.6%) and transportation (8.0%). Among patients identified as rising/high risk (728), 50.0% accepted support and are actively working with a Patient Navigator., Conclusion: There is growing evidence to support the link between unmet social needs and poor health outcomes. Health care systems are uniquely positioned to provide whole person care by identifying unresolved social needs and by building capacity within local community-based organizations to support those needs., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

The coronavirus disease (COVID-19) pandemic has stressed the US health care system in unprecedented ways. In March and April 2020, emergency departments (EDs) throughout New York City experienced high volumes and acuity related to the pandemic. Here, we present a structured after-action report of a coalition of 9 EDs within a hospital system in the New York City metropolitan area, with an emphasis on best practices developed during the prolonged surge as well as specific opportunities for growth. We report our experience in 6 key areas using a framework built around lessons learned. This report represents the most salient concepts related to our institutional after-action report, and those seemingly most relevant to our peer institutions dealing with similar circumstances.

The coronavirus pandemic catalyzed a digital health transformation, placing renewed focus on using remote monitoring technologies to care for patients outside of hospitals. At NewYork-Presbyterian, the authors expanded remote monitoring infrastructure and developed a COVID-19 Hypoxia Monitoring program-a critical means through which discharged COVID-19 patients were followed and assessed, enabling the organization to maximize inpatient capacity at a time of acute bed shortage. The pandemic tested existing remote monitoring efforts, revealing numerous operating challenges including device management, centralized escalation protocols, and health equity concerns. The continuation of these programs required addressing these concerns while expanding monitoring efforts in ambulatory and transitions of care settings. Building on these experiences, this article offers insights and strategies for implementing remote monitoring programs at scale and improving the sustainability of these efforts. As virtual care becomes a patient expectation, the authors hope hospitals recognize the promise that remote monitoring holds in reenvisioning health care delivery., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Intraocular pressure lowering surgery in congenital aniridia glaucoma (CAG) can be complicated by dysgenesis of the limbal region, anterior chamber angle, iris, and lens. The anterior segments of 23 eyes (17 patients) with congenital aniridia were investigated under general anesthesia using ultrasound biomicroscopy (UBM). The structures of the anterior segment were examined: distance of ciliary body processes from the anterior chamber angle and positioning of Schlemm's canal. A surgical plan was created on the basis of these data. Schlemm's canal was detected in 21 of the 23 examined eyes. The mean distance from the anterior chamber angle was 1.3 ± 0.4 mm (range: 0.5-to 2.1 mm). The mean distance between the anterior chamber angle and the ciliary body was 561 ± 301 µm (range: 270-1,300 µm). The mean prominence of the ciliary body towards the lens was 799 ± 352 µm (range: 210-1,660 µm). This resulted in a precise UBM-based trabeculotomy. In addition, the ciliary body was detected and coagulated ab externo with a diode laser probe (810 nm) using diaphanoscopy and UBM. An initial UBM examination of the anterior segment is essential in eyes with CAG scheduled for trabeculotomy or cyclophotocoagulation. Clin. Anat. 31:64-67, 2018. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

The social amoeba Dictyostelium discoideum is a well-established model organism to study the interaction between bacteria and phagocytes. In contrast, research using D. discoideum as a host model for fungi is rare. We describe a comprehensive study, which uses D. discoideum as a host model system to investigate the interaction with apathogenic ( Saccharomyces cerevisiae ) and pathogenic ( Candida sp.) yeast. We show that Dictyostelium can be co-cultivated with yeasts on solid media, offering a convenient test to study the interaction between fungi and phagocytes. We demonstrate that a number of D. discoideum mutants increase ( atg1 - , kil1 - , kil2 - ) or decrease ( atg6 - ) the ability of the amoebae to predate yeast cells. On the yeast side, growth characteristics, reduced phagocytosis rate, as well as known virulence factors of C. albicans ( EFG1, CPH1, HGC1, ICL1 ) contribute to the resistance of yeast cells against predation by the amoebae. Investigating haploid C. albicans strains, we suggest using the amoebae plate test for screening purposes after random mutagenesis. Finally, we discuss the potential of our adapted amoebae plate test to use D. discoideum for risk assessment of yeast strains.

An accumulating body of epidemiologic data, clinical trials, and mechanistic studies suggests that yogurt consumption as part of a healthy diet may be beneficial to cardiometabolic health. This brief review focuses on children and adolescents, introducing new concepts underlying the effect of yogurt consumption on body weight maintenance and the prevention of cardiovascular diseases. Specific properties of yogurt are discussed, which highlight that yogurt is an easy-to-digest, nutrient-dense, and satiating food that contains high-quality protein and specific amino acids. Moreover, the role of yogurt as a modulator of the gut microbiota in infancy is explored. We also propose the idea that the specific matrix of yogurt has bioavailability and metabolic properties that can be exploited to increase the functionality of this dairy product.

Introduction: Heparin is safe and prevents venous thromboembolism in critical illness. We aimed to determine the guideline concordance for thromboprophylaxis in critically ill patients and its predictors, and to analyze factors associated with the use of low molecular weight heparin (LMWH), as it may be associated with a lower risk of pulmonary embolism and heparin-induced thrombocytopenia without increasing the bleeding risk., Methods: We performed a retrospective audit in 28 North American intensive care units (ICUs), including all consecutive medical-surgical patients admitted in November 2011. We documented ICU thromboprophylaxis and reasons for omission. Guideline concordance was determined by adding days in which patients without contraindications received thromboprophylaxis to days in which patients with contraindications did not receive it, divided by the total number of patient-days. We used multilevel logistic regression including time-varying, center and patient-level covariates to determine the predictors of guideline concordance and use of LMWH., Results: We enrolled 1,935 patients (62.3 ± 16.7 years, Acute Physiology and Chronic Health Evaluation [APACHE] II score 19.1 ± 8.3). Patients received thromboprophylaxis with unfractionated heparin (UFH) (54.0%) or LMWH (27.6%). Guideline concordance occurred for 95.5% patient-days and was more likely in patients who were sicker (odds ratio (OR) 1.49, 95% confidence interval (CI) 1.17, 1.75 per 10-point increase in APACHE II), heavier (OR 1.32, 95% CI 1.05, 1.65 per 10-m/kg2 increase in body mass index), had cancer (OR 3.22, 95% CI 1.81, 5.72), previous venous thromboembolism (OR 3.94, 95% CI 1.46,10.66), and received mechanical ventilation (OR 1.83, 95% CI 1.32,2.52). Reasons for not receiving thromboprophylaxis were high risk of bleeding (44.5%), current bleeding (16.3%), no reason (12.9%), recent or upcoming invasive procedure (10.2%), nighttime admission or discharge (9.7%), and life-support limitation (6.9%). LMWH was less often administered to sicker patients (OR 0.65, 95% CI 0.48, 0.89 per 10-point increase in APACHE II), surgical patients (OR 0.41, 95% CI 0.24, 0.72), those receiving vasoactive drugs (OR 0.47, 95% CI 0.35, 0.64) or renal replacement therapy (OR 0.10, 95% CI 0.05, 0.23)., Conclusions: Guideline concordance for thromboprophylaxis was high, but LMWH was less commonly used, especially in patients who were sicker, had surgery, or received vasopressors or renal replacement therapy, representing a potential quality improvement target.

Objective. To examine the association between fish and marine long-chain omega-3 polyunsaturated fatty acid (LC n-3 PUFA) consumption and incidence of type 2 diabetes (T2D) in prospective cohort studies. Methods. Meta-analytic procedures were used to estimate the relative risk (RR) using random effects or fixed effects generic inverse variance model. Publication bias and study heterogeneity were assessed using Egger's test and I(2) statistic. Results. We found no significant association between the intake of fish/seafood (pooled RR: 1.04; P = 0.63, 95% CI: 0.9 to 1.2, 549, 955 participants) or marine LC n-3 PUFA (pooled RR: 1.08, P = 0.39, 95% CI: 0.90 to 1.30, 346, 710 participants) and T2D risk. Significant study heterogeneity was observed in fish/seafood and marine LC n-3 PUFA studies (P < 0.00001). Subgroup analysis revealed no obvious sources for high heterogeneity. We also found a significant protective effect of oily fish intake on T2D risk (pooled RR = 0.89, P = 0.005, 95% CI: 0.82 to 0.96). Dose-response analysis suggested that every 80 g per day intake of oily fish may reduce 20% risk of T2D. Conclusion. We found no significant effect of fish/seafood or marine LC n-3 PUFA intake on risk of T2D but a significant effect of oily fish intake on risk of T2D.

Previous studies have shown that fish protein, as well as marine n-3 PUFA, may have beneficial effects on cardiovascular risk profile. The objectives of this study were to investigate the combined effects of fish gelatine (FG) and n-3 PUFA supplementation on (1) energy intake and body weight, (2) lipid profile and (3) inflammatory and CVD markers in free-living insulin-resistant males and females. Subjects were asked to consume, in a crossover study design with two experimental periods of 8 weeks each, an n-3 PUFA supplement and n-3 PUFA supplement plus FG (n-3 PUFA + FG). n-3 PUFA + FG led to an increase in protein intake and a decrease in carbohydrate intake compared with n-3 PUFA (P < 0·02) in males and females. Sex-treatment interactions were observed for TAG (P = 0·03) and highly sensitive C-reactive protein (hsCRP) (P = 0·001) levels. In females, n-3 PUFA reduced plasma TAG by 8 % and n-3 PUFA + FG by 23 %, whereas in males, n-3 PUFA reduced plasma TAG by 25 % and n-3 PUFA + FG by 11 %. n-3 PUFA increased serum hsCRP by 13 % and n-3 PUFA + FG strongly reduced hsCRP by 40 % in males, whereas in females, n-3 PUFA reduced serum hsCRP by 6 % and n-3 PUFA + FG increased hsCRP by 20 %. In conclusion, supplementation with FG may enhance the lipid-lowering effect of marine n-3 PUFA in females and beneficially counteract the effect of n-3 PUFA on serum hsCRP in males. Further studies are needed to identify the sex-dependent mechanisms responsible for the divergent effects of FG on TAG and hsCRP levels in females and males, respectively.

We describe a young woman who developed Clostridium sordellii toxic shock syndrome after having had an abortion medically induced by mifepristone (RU-486; Mifeprex [Danco Laboratories]) 7 days before admission to our hospital. Although the patient was aggressively treated, death occurred <3 days after admission. It is hoped that very early recognition of this disease will decrease the mortality associated with this rarely reported ailment that occurs among young, otherwise healthy women.

Acute respiratory distress syndrome (ARDS) was first described about 30 years ago. Modern definitions and statements have recently been proposed to describe ARDS accurately, but none is perfect. Diffuse alveolar damage is the basic pathological pattern most commonly observed in ARDS, and the term includes permeability edema. The alveolar epithelium of the alveolar-capillary barrier is clearly a key component requiring repair, given its multipotent functional activity. Lung inflammation and neutrophil accumulation are essential markers of disease in ARDS, and a wide variety of pro- and anti-inflammatory cytokines have been described in the alveolar fluid and blood of patients. These molecules still have to prove their value as diagnostic or prognostic biomarkers of ARDS. Supportive therapy in ARDS improved in the past decade; mechanical ventilation with lung protective strategies and patient positioning are gaining interest, but the indications for corticosteroids for ARDS are still debated. Nitric oxide may have a place in the treatment of one-third of patients. Novel approaches, such as surfactant replacement and liquid ventilation, may further improve supportive therapy. Innovative interventions may be on the horizon in treatments that help to resolve or modulate common pathways of ARDS, such as inflammation (eg, granulocyte-colony stimulating factor) or epithelial repair (eg, keratinocyte growth factor).

The Autocontrol Project is concerned with the accessing, processing and communication of high quality information so that a clinical team can make and implement decisions for practice change, and then evaluate if improvement has been achieved. High quality information is used as evidence for change. In this study, we have evaluated how evidence is used by a clinical team to explain an identified problem of inappropriate use of blood gas tests. In an experimental study of the Surgical Intensive Care Unit, video recordings of team meetings of nurses and doctors were undertaken, structured according to a problem-based format. Evidence of current practice patterns derived from the hospital information system, as well as the results of a questionnaire to the unit's staff about knowledge and use of blood gas measurements, were supplied to the participants beforehand. At the second meeting, the output of the first meetings and a summarised analysis of pertinent literature were made available. This second meeting was required to finalise the list of causes of inappropriate blood gas use and propose pragmatic strategies for practice change. The video data of the meetings were coded to analyse the use of evidence, the categories of causes, issues and solutions proposed, and the quality of team interaction. The results indicate that in order to achieve consensus, the team used different types of evidence, including objective evidence of practice patterns, personal experience about direct and indirect organisational influences, and literature-based research evidence of best practice. Furthermore, group dynamics were favoured by the problem-based meeting structure, and a high level of cognitive critiquing between team members was observed. This research suggests that a combination of approaches involving identification of both operational factors (e.g. appropriate access to different types of evidence and meeting structure) and cognitive and behavioural approaches (e.g. ensuring expression of different viewpoints) is needed to support strategic decision-making for practice change in a clinical unit. This combined approach should favourably influence the provision of an effective and efficient evidence support environment for the clinical team.

The Autocontrol methodology has been developed in order to support the optimisation of decision-making and the use of resources in the context of a clinical unit. The theoretical basis relates to quality assurance and information systems and is influenced by management and cognitive research in the health domain. The methodology uses population rather than individual decision making and because of its dynamic feedback design promises to have rapid and profound effect on practice. Most importantly the health care professional is the principle user of the Autocontrol system. In this methodology we distinguish three types of evidence necessary for practice change: practice based or internal evidence, best evidence derived from the literature or external evidence concerning the practice in question, and process based evidence on how to optimise the process of practice change. The software used by the system is of the executive decision support type which facilitates interrogation of large databases. The Autocontrol system is designed to interrogate the data of the patient medical record however the latter often lacks data on concomitant resource use and this must be supplemented. This paper reviews the Autocontrol methodology and gives examples from current studies.

We report a case of adenine phosphoribosyltransferase deficiency in which the initial presentation was chronic renal failure. Diagnosis was made after infrared microscopy analysis of microcrystalline deposits on a kidney allograft biopsy specimen. This type of presentation is rarely seen, the most frequent manifestation of this disease being urolithiasis. This is the first report of recurrence of the microcrystalline nephritis in a kidney transplant with subsequent loss of allograft function.

A personal computer-based arrhythmia generator has been developed based upon mathematical models of modulated parasystole and the related equations. A system of nonlinear difference equations is used to generate the time series of RR intervals of ECG that contain normal as well as ectopic QRS waves. The ECG waveform is synthesized according to the computed RR interval and the type of QRS wave and output via DA converter in a real-time base. Various types of ECGs with ventricular ectopic beats and those with very long periods were generated by selecting values for a small number of model parameters. This method requires neither large RAM nor external memory for storing a library of arrhythmic ECGs. The theory, hardware design, software implementation on a personal computer, and experimental reconstruction of clinical ECGs based on the model are discussed.

Repeated blood sampling (0.2 ml) in the conscious rat during the course of 10 cardiac index measurements using the Fick procedure did not alter the cardiac index as measured initially (285 ml x min-1 x kg-1). However, oxygen consumption and hematocrit were reduced 7-19% and 4-14%, respectively. Replacement of blood removed during sampling with donor blood prevented these responses, but also led to reduced cardiac index and arterial oxygen content, 22-28% and 10-21%, respectively. In additional studies in anesthetized rats, hemorrhage (25 ml/kg) increased plasma K+ by 29% and reduced plasma Na+ by 3%, suggesting that compensatory fluid replacement originated in cells as well as interstitium. This fluid replacement after blood loss helps sustain normal systemic hemodynamics, but blood loss can produce metabolic alterations that should be taken into account in any biochemical study. Although metabolic alterations can be prevented by replacing lost blood with donor blood, cardiopulmonary function may be adversely affected.

Twenty dogs underwent 1 hour of topical hypothermic arrest; five were untreated, five received methyl prednisolone (30 mg/kg), five received 0.2% procaine, and five received both drugs. Arrest was almost immediate (less than 2 min) with procaine, but was delayed 14 +/- 3 minutes in the other groups. Steroid-treated dogs had the highest post-ischemic left ventricular (LV) blood flows (110 +/- 22 cc/100 g/min) (P less than 0.05). Membrane-stabilizing drugs did not prevent myocardial edema; LV water rose 2% (P less than 0.01) in all groups. Post-ischemic LV compliance was depressed most (55%) in the untreated group, and less after procaine (30%) (P less than 0.05). Postischemic LV performance was depressed 44% (P less than 0.01) in the untreated dogs, and returned to near normal levels with steroid (89% recovery), procaine (97% recovery), and both drugs (95% recovery). We conclude that steroids and/or procaine protect against postischemic myocardial depression but do not prevent myocardial edema. Combining steroids and procaine provide no apparent added benefit, but procaine has the technical advantage of almost immediate cardioplegia.

In 14 dogs the determinants of myocardial blood supply and metabolic demands were assessed during cardiopulmonary resuscitation (CPR) and under steady-state conditions in fibrillating hearts on cardiopulmonary bypass. During open chest cardiac massage (nine dogs), coronary diastolic blood pressure and blood flow were low. Vasopressor infusion (methoxamine or epinephrine) raised diastolic pressure from 33 +/- 3 to 55 +/- 3 mm. Hg and increased coronary blood flow (CBF) 124 percent (from 38 +/- 3 to 85 +/- 11 c.c. per 100 Gm. per minute. Comparison of these drugs in fibrillating hearts on cardiopulmonary bypass showed that epinephrine increased the "vigor of fibrillation" (intraventricular balloon pressure rose 24 percent and oxygen uptake increased 42%) but impeded subendocardial flow 53% (endocardial/epicardial flow ratio fell from 0.79 to 0.48). In contrast, methoxamine did not significantly change intraventricular balloon pressure, oxygen uptake, coronary flow, or its distribution. We conclude that augmentation of diastolic pressure with alpha adrenergic drugs during CPR improves coronary perfusion and that inotropic drugs may worsen myocardial ischemia during CPR by raising oxygen demands while simultaneously impeding subendocardial blood supply.

Postischemic myocardial edema depresses left ventricular function and coronary perfusion. Pharmacologic cardioplegia is being used increasingly to enhance myocardial protection during cardiac operations. In the present study we varied the colloid osmotic and osmotic pressures and the infusion pressures of four cardioplegic solutions to determine their respective roles in producing or preventing myocardial edema in a nonischemic setting. We found that myocardial edema during potassium cardioplegia (1) is independent of infusion pressures, (2) is caused by isosmotic crystalloid solutions, (3) is worsened by hyposmolar crystalloid solutions, (4) is avoided by the addition of colloid, and (5) is avoided if the solution is made hyperosmotic with the addition of mannitol.

The differential effects of KCl vs. KHCO3 for intravenous K+ repletion were evaluated in a series of nephrectomized dogs previously depleted of 20% of total-body K by a 2-wk regimen consisting of K-free diet plus DOCA plus chlorothiazide. Twenty-four percent of K losses (5% of original TBK) were replaced by a 2-h infusion of either CKl or KHCO3. Blood pH was maintained at normal levels by controlling the rate of respiration. Skeletal muscle biopsies were taken before and 2 h after repletion, and blood samples were taken at intervals throughout. The following differences resulting from KHCO3 compared to KCl repletion were found: a) a greater cellular K uptake, a lower rate of increase, and a lower steady-state extracellular K+ concentration; b) a less increase in intracellular K+ concentration and a less decrease in intracellular Na+ concentration. These differences, which were independent of extracellular pH or kidney function, are thought to be secondary to unequal distribution of Cl- and HCO3-ions.

A method previously established in the experimental animal for predicting the acute response to either metabolic stress (bicarbonate administration) or respiratory stress(manipulation of oxygenator gas during cardiopulmonary bypass) has been extended to man. The method is based on a single nomogram. The accuracy of the nomogram is demonstrated using data from 13 patients on cardiopulmonary bypass. Similar agreement obtains between the nomogram and data reported by others. The nomogram can be used to estimate the therapeutically required dose of bicarbonate.

We analyzed the performance of two cohorts of surgical residents: one from "pass/fail" and the other from "graded" medical schools. A performance index indicates that the group from graded schools performed significantly better (P less than 0.001). No resident from a pass/fail institution ranked above the 87th percentile, and this group accounted for 82 per cent of those ranking below the 15th percentile. A residency training program that seeks excellence among its trainees would do well to select preferentially students who apply from medical schools providing a specific class standing as part of the total evaluation of the student. It is suggested that the pass/fail controversy is symbolic of the erosion of standards that inevitably occurs when the university becomes involved in transient sociopolitical turmoil.