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Background: Offspring born to mothers with pre-eclampsia (Pre-E) suffer higher risks of adult cardiovascular diseases, suggesting that exposure to an antiangiogenic environment in-utero has a lasting impact on the development of endothelial function. The goal of this study is to test the hypothesis that in-utero exposure to Pre-E results in alterations of angiogenic factors/cytokines that negatively impact vascular development during infancy. Methods: Infants born from mothers with and without Pre-E were recruited and followed up at 6 months. Plasma cytokines, blood pressure, microvessel density, and vascular reactivity were assessed. Results: 6-month-old infants born to mothers with Pre-E had unchanged blood pressure (p= 0.86) and microvessel density (p= 0.57). Vascular reactivity was decreased in infants born to mothers with Pre-E compared to infants born to healthy mothers (p= 0.0345). Interleukin 8 (IL-8) (p= 0.03) and Angiopoeitin-2 (Ang-2) (p= 0.04) were increased in infants born to mothers with Pre-E. We observed that higher IL-8 was associated with lower vascular reactivity (rho = −0.14, p< 0.0001). Conclusion: At 6 months of age, infants born to mothers with Pre-E had impaired vascular reactivity and higher IL-8 and Ang-2, but similar blood pressure and microvessel density compared to infants born to non-Pre-E mothers. Impact Statement:

Changes in cord blood antiangiogenic factors are documented in infants of mothers with pre-eclampsia and may contribute to offspring risks of adult cardiovascular disease. How these factors evolve during early infancy and their correlation with offspring vascular development have not been studied.

This study found that 6-month-old infants born to mothers with pre-eclampsia had decreased vascular reactivity, which was correlated with higher IL-8.

These findings underscore the lasting impact of maternal pre-eclampsia on offspring vascular development and highlight the need for long-term follow-up in children born to mothers with pre-eclampsia.

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The relationship between body mass index (BMI) and eosinophilic esophagitis (EoE) among children is not well characterized.

Pilot study of a peer-led, navigation program for minoritized Veterans in VHA mental health clinics shows feasibility of further testing and acceptability of the intervention. Results also show promising improvements in mental health outcomes. However, modifications are needed to increase program session attendance and retention.This study tested whether a peer-led navigation program, PARTNER-MH, can be delivered effectively by peer specialists in the Veterans Health Administration (VHA) healthcare system to racially minoritized Veterans who are receiving mental healthcare. The study evaluated our ability to recruit and retain participants, deliver the intervention, and examined satisfaction with the program. We also explored preliminary effects of the program. Participants were successfully recruited for the study and peers were able to deliver the program effectively. Participants reported high satisfaction with the program and significant improvements in mental health outcomes, although completion rate of the program was low. Results provide support for future testing of PARTNER-MH in a larger trial, with modifications to increase program session attendance and retention.Graphical Abstract

It is crucial to provide an adequate level of sedation and analgesia during burn dressing changes in the pediatric population due to the amount of pain and anxiety patients experience during the procedure. To evaluate the safety and efficacy of an intensivist-based deep sedation regimen using a combination of propofol and ketamine to provide procedural sedation to pediatric burn patients. This is a retrospective chart review of pediatric patients who underwent inpatient burn wound dressing changes from 2011 through 2021. Demographic and clinical data, including age, length of the procedure, recovery time, medication doses, and adverse events, were collected. A total of 104 patients aged between 45 and 135 months with a median total burn body surface area (TBSA) of 11.5 percent (interquartile range [IQR] 4.0, 25.0) underwent 378 procedural sedation encounters with propofol- and ketamine-based sedation. The median total dose of propofol was 7 mg/kg (IRQ 5.3, 9.2). Of these sedations, 64 (17 percent) had minor adverse events, of which 50 (13 percent) were transient hypoxemia, 12 (3 percent) were upper airway obstruction, and 2 (0.5 percent) were hypotension. There were no serious adverse events. Hypoxemia was not related to age, weight, gender, burn TBSA, or total dose of propofol. There were 35 (33.6 percent) patients who had repetitive sedation encounters with no statistically significant changes in propofol dose or adverse events with the repeated encounters. Children can be effectively sedated for repetitive inpatient burn dressing changes. Given the high-risk patient populations, this procedure should be performed under the vigilance of highly trained providers.

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Many Clinical Pastoral Education programs pivoted to remote delivery during the COVID-19 pandemic. Our survey explored educators’ preparedness, self-efficacy, and views regarding remote Clinical Pastoral Education. Few respondents were either very (14.2%) or not at all (16.5%) prepared. Most were confident facilitating remote learning (69.8%–88.5%), believing remote Clinical Pastoral Education can achieve outcomes equivalent to in-person (59.1%). Six qualitative themes emerged: educator development, educator challenges, remote Clinical Pastoral Education efficacy, remote group dynamics, clinical practice/supervision implications, and benefits and opportunities.

Clinical Pastoral Education (CPE) programs faced extraordinary challenges during the COVID-19 pandemic. We examined how ACPE-certified educators responded to maintain program delivery. Survey results (n= 210) suggested a substantial and abrupt increase in remote delivery for CPE instruction and supervised clinical practice, primarily driven by those previously fully in-person. Respondents reported abrupt changes impacted 1152 students. Participants rated their utilization and helpfulness of professional, organizational, and technology resources during the pivot and beyond.

Background: We aimed to use the Extracorporeal Life Support Organization registry to describe the current practice of rest mechanical ventilation setting in children receiving veno-venous extracorporeal membrane oxygenation (V-V ECMO) and to determine if relationships exist between ventilator settings and mortality.Methods: Data for patients 14 days to 18 years old who received V-V ECMO from 2012-2016 were reviewed. Mechanical ventilation data available includes mode and settings at 24 h after ECMO cannulation. Multivariable logistic regression analysis was performed to determine if rest settings were associated with mortality.Results: We reviewed 1161 subjects, of which 1022 (88%) received conventional mechanical ventilation on ECMO. Rest settings, expressed as medians (25th%, 75th%), are as follows: rate 12 breaths/minute (10, 17); peak inspiratory pressure (PIP) 22 cmH2O (20,27); positive end expiratory pressure (PEEP) 10 cmH2O (8, 10); and fraction of inspired oxygen (FiO2) 0.4 (0.37, 0.60). Survival to discharge was 68%. Higher ventilator FiO2(odds ratio:1.13 per 0.1 increase, 95% confidence interval:1.04, 1.23), independent of arterial oxygen saturation, was associated with mortality.Conclusions: Current rest ventilator management for children receiving V-V ECMO primarily relies on conventional mechanical ventilation with moderate amounts of PIP, PEEP, and FiO2. Further study on the relationship between FiO2and mortality should be pursued.

AbstractBackground:We aimed to conduct a multi-centre study characterising emergency department utilisation and critical readmissions experienced by children with Fontan circulation.Methods:We conducted a retrospective review of children who underwent the Fontan operation at three institutions (i.e., centres A, B, and C) between 2009 and 2014, with follow-up through December 2015. Multi-variable analyses were performed to determine factors associated for emergency department utilisation within 1 year of surgery, emergency department utilisation at any time following surgery, or critical readmission (defined as admission to ICU, operating room, or cardiac catheterisation).Results:We reviewed 297 patients, of which 147 patients (49%) had 607 emergency department encounters. Forty-six patients (15%) required 71 critical readmissions. Multi-variable analyses revealed centre C (p = 0.02) and post-operative hospitalisation ≥ 14 days (p = 0.03) to be significantly associated with emergency department utilisation within 1 year, whereas centre B (p < 0.001), post-operative hospitalisation ≥ 14 days (p = 0.002), and African-American/Black race (p = 0.04) were significantly associated with critical readmission.Conclusions:In this multi-centre study, nearly half of patients with Fontan circulation received emergency department care, often presenting with high disease acuity requiring readmission. Emergency department utilisation and need for critical readmission were independently influenced by the centre at which surgery was performed, prolonged post-operative hospitalisation, and racial background. These data could help guide quality improvement efforts aimed at reducing morbidity in this unique patient population.

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Supplemental Digital Content is available in the text.Extracorporeal membrane oxygenation (ECMO) is a low-volume, high-risk modality of care. Clinical specialists (CS) who manage ECMO circuit emergencies vary in background and approach to circuit emergencies based on institutional training standards, leading to variation that may impact the quality of care. Validated checklists to assess CS performance are crucial to eliminate disparities and improve efficiency. This study focused on the development and validation of checklists to evaluate the clinical performance of ECMO CS in three ECMO circuit emergencies. A research team with diverse clinical background from our institution developed the first iteration of three ECMO emergency checklists: (1) venous air, (2) arterial air, and (3) oxygenator failure. A modified Delphi technique with a panel of 11 national content experts in ECMO was used to develop content validity evidence. Rating scales from 1 to 7 were used to evaluate each checklist item. The response rate for three rounds of Delphi was 100%. Items with mean score >4 were kept, and new item recommendations were added based on comments from the panel. The venous air, arterial air, and oxygenator failure checklists were revised from 10, 13, and 9 items to 12, 12, and 10 items, respectively. A Cronbach’s α of 0.74 during the second round of responses indicated an acceptable degree of agreement. This study demonstrated content validation of three ECMO emergency checklists to assess performance of ECMO CS using a consensus-based Delphi technique. Future validity evidence should be acquired by implementing these checklists in the simulation environments.

Late preterm infants (born 34–36 weeks gestation) without cystic fibrosis (CF) are at risk for growth failure during the first 2 years of life. Infants with CF are at risk of being born premature, and thus at risk for growth failure. The aim for this study was to assess weight-for-length (WFL) at 2 years of age for late preterm infants compared with term infants with CF. Data were collected from the US CF Foundation Patient Registry. We compared growth parameters between late preterm and term infants with CF born from 2010 to 2013. Our primary outcome was WFL <10 and <50 percentile at 2 years of age. A multivariate logistical regression analysis evaluated late preterm gestation and WFL<10 or <50 percentile. A total of 2955 infants were born from 2010 to 2013 with CF. Eight percentage late preterm. Forty-five percentage late preterm versus 43% term were below the 50th percentile for WFL at age 2 years (P= 0.75). Twelve percentage late preterm versus 6% term for WFL <10 percentile at age 2 years (P= 0.010). The multivariate regression model identified 2-fold increased odds of being <10th percentile for WFL at age 2 years (P= 0.025) for preterm over term. Late preterm infants used higher calorie dense feeds and more feeding tubes (P= 0.035 and P= 0.006). Late preterm infants with CF are at higher risk of being below the 10th percentile for WFL at 2 years of age compared with their term peers. This indicates a population that is at risk for growth failure.

Background Given improved contemporary survival of adults with congenital heart disease (ACHD), we aimed to evaluate trends in ACHD surgery and outcomes at a single center over a 27-year period.Methods Surgical databases were retrospectively queried for patients >18 years old who underwent ACHD surgery between January 1, 1994, and December 31, 2020. A total of 2,195 included patients underwent 2,425 cardiac surgical procedures within the specified time frame. Patients were grouped by era: I, 1994-2000; 2, 2001-2010; and 3, 2011-2020. Trends in primary cardiac diagnosis and surgical management were evaluated.Results The median age increased across the eras. The most common primary cardiac diagnoses (n = 2,425) overall were left ventricular outflow tract anomalies (n = 2,019, 83%), atrial septal defect (n = 407, 17%), right ventricular outflow tract anomalies (n = 360, 15%), and ventricular septal defect (n = 110, 4.5%). The most commonly observed procedures overall were operations on the left ventricular outflow tract (n = 1,633, 67%), aorta (n = 675, 28%), coronary arteries (n = 449, 19%), right ventricular outflow tract (n = 323, 13%), and atrial septal defect (n = 264, 11%). Major complications occurred in 10% of cases, and 58 patients died within 30 days of their operation yielding an operative mortality of 2.4%.Conclusion To our knowledge, this is the largest single center report on surgery for adults with congenital heart disease. Surgery for ACHD has been performed at our center with relatively low morbidity and mortality over the last few decades.

The COVID-19 pandemic led to severe disruptions in health care and a relaxation of rules surrounding opioid prescribing—changes which led to concerns about increased reliance on opioids for chronic pain and a resurgence of opioid-related harms. Although some studies found that opioid prescriptions increased in the first 6 months of the pandemic, we know little about the longer-term effects of the pandemic on opioid prescriptions. Further, despite the prevalence of pain in veterans, we know little about patterns of opioid prescriptions in the Veterans Health Administration (VA) associated with the pandemic. Using a retrospective cohort of VA patients with chronic low-back pain, we examined the proportion of patients with an opioid prescription and mean morphine milligram equivalents over a 3-year period—1 year prior to and 2 years after the pandemic’s onset. Analyses revealed that both measures fell during the entire observation period. The largest decrease in the odds of filling an opioid prescription occurred in the first quarter of the pandemic, but this downward trend continued throughout the observation period, albeit at a slower pace. Clinically meaningful differences in opioid prescriptions and dose over time did not emerge based on patient race or rurality; however, differences emerged between female and male veterans, with decreases in opioid prescriptions slowing more markedly for women after the pandemic onset. These findings suggest that the pandemic was not associated with short- or long-term increases in opioid prescriptions or doses in the VA.

Recent studies have suggested that removing foods from the diet to manage atopic dermatitis (AD), based on positive allergy test results, may lead to immediate allergic reactions on reintroduction of that food.

Objective.Given the known side effects of opioids and their potential effects on cognition, we sought to evaluate the benefits of motivational interviewing (MI) to promote physical activity on 2 subsets of participants with fibromyalgia (FM): nonusers and users of opioids.Methods.This was a secondary data analysis of a 36-week randomized controlled trial to assess the efficacy of MI to promote physical activity among participants with FM. Participants were randomized to 1 of 2 treatment arms: 6 phone-based MI sessions (n = 107) or 6 sessions of FM self-management instructions [attention control (AC), n = 109]. The primary outcomes were changes in physical function (Medical Outcomes Study Short Form-36), pain severity (Brief Pain Inventory), global FM symptom severity (Fibromyalgia Impact Questionnaire), and the amount of light to moderate physical activity (LMPA) from baseline to each followup visit. At study entry, subjects were categorized as opioid nonusers versus users. Repeated measures ANOVA was used to assess treatment effects adjusting for potential confounders.Results.Of the 216 participants, 145 (67%) were nonusers and 71 (33%) were opioid users. Among nonusers, MI was associated with improved physical function, reduced pain severity, and global FM severity, and increased LMPA at 6-month followup. Among opioid users, there were no significant differences in any outcome measures between the MI and AC groups.Conclusion.Exercise-based MI was associated with sustained clinical benefits 6 months after completion of therapy, but only for those who were not taking opioids.

AbstractThe general techniques of guitar soloing have changed very little since the beginnings of the rock era in the 1950s, even though the style of playing has seen dramatic changes. Using the methods of analysis from the fields of statistics and musicology, we have looked into how soloing techniques have changed from 1950s’ rock to modern heavy metal. This not only helps in discerning the differences in playing between eras but is an addition to the toolbox of musicology. Pitch distributions were calculated and then analysed using cluster and tree methods. Speed and technique were analysed using the Generalized Estimating Equations. We found no distinct delineation between the decades for pitch distributions. There was an increasing, though non-significant, trend in the use of special techniques, which became significant when comparing the later decades grouped against the earlier decades. Most notably, there was a significant difference in speed between the decades, with an increase in the later decades.

IMPORTANCE Hospitalized older adults often lack decisional capacity, but outside of the intensive care unit and end-of-life care settings, little is known about the frequency of decision making by family members or other surrogates or its implications for hospital care. OBJECTIVE To describe the scope of surrogate decision making, the hospital course, and outcomes for older adults. DESIGN, SETTING, AND PARTICIPANTS Prospective, observational study conducted in medicine and medical intensive care unit services of 2 hospitals in 1 Midwestern city in 1083 hospitalized older adults identified by their physicians as requiring major medical decisions. MAIN OUTCOMES AND MEASURES Clinical characteristics, hospital outcomes, nature of major medical decisions, and surrogate involvement. RESULTS According to physician reports, at 48 hours of hospitalization, 47.4% (95% CI, 44.4%-50.4%) of older adults required at least some surrogate involvement, including 23.0% (20.6%-25.6%) with all decisions made by a surrogate. Among patients who required a surrogate for at least 1 decision within 48 hours, 57.2% required decisions about life-sustaining care (mostly addressing code status), 48.6% about procedures and operations, and 46.9% about discharge planning. Patients who needed a surrogate experienced a more complex hospital course with greater use of ventilators (2.5% of patients who made decisions and 13.2% of patients who required any surrogate decisions; P &lt; .001), artificial nutrition (1.7% of patients and 14.4% of surrogates; P &lt; .001), and length of stay (median, 6 days for patients and 7 days for surrogates; P &lt; .001). They were more likely to be discharged to an extended-care facility (21.2% with patient decisions and 40.9% with surrogate decisions; P &lt; .001) and had higher hospital mortality (0.0% patients and 5.9% surrogates; P &lt; .001). Most surrogates were daughters (58.9%), sons (25.0%), or spouses (20.6%). Overall, only 7.4% had a living will and 25.0% had a health care representative document in the medical record. CONCLUSIONS AND RELEVANCE Surrogate decision making occurs for nearly half of hospitalized older adults and includes both complete decision making by the surrogate and joint decision making by the patient and surrogate. Surrogates commonly face a broad range of decisions in the intensive care unit and the hospital ward setting. Hospital functions should be redesigned to account for the large and growing role of surrogates, supporting them as they make health care decisions.

ABSTRACTUrogenital Chlamydiaserovars replicating in reproductive epithelium pose a unique challenge to host immunity and vaccine development. Previous studies have shown that CD4 T cells are necessary and sufficient to clear primary Chlamydia muridarumgenital tract infections in the mouse model, making a protective CD4 T cell response a logical endpoint for vaccine development. Our previous proteomics studies identified 13 candidate Chlamydiaproteins for subunit vaccines. Of those, PmpG-1 is the most promising vaccine candidate. To further that work, we derived a PmpG303-311-specific multifunctional Th1 T cell clone, designated PmpG1.1, from an immune C57BL/6 mouse and used it to investigate the presentation of the PmpG303-311epitope by infected epithelial cells. Epithelial presentation of the PmpG303-311epitope required bacterial replication, occurred 15 to 18 h postinfection, and was unaffected by gamma interferon (IFN-?) pretreatment. Unlike epitopes recognized by other Chlamydia-specific CD4 T cell clones, the PmpG303-311epitope persisted on splenic antigen-presenting cells (APC) of mice that cleared primary genital tract infections. PmpG1.1 was activated by unmanipulated irradiated splenocytes from immune mice without addition of exogenous Chlamydiaantigen, and remarkably, activation of PmpG1.1 by unmanipulated immune splenocytes was stronger 6 months postinfection than it was 3 weeks postinfection. Enhanced presentation of PmpG303-311epitope on splenic APC 6 months postinfection reflects some type of “consolidation” of a protective immune response. Understanding the antigen-presenting cell populations responsible for presenting PmpG303-311early (3 weeks) and late (6 months) postinfection will likely provide important insights into stable protective immunity against Chlamydiainfections of the genital tract.

The article discusses the statistical modeling used in evaluating sleep deprivation status in the U.S. According to the author, between 50 million to 70 million of Americans suffer from sleep deprivation problem which increases their risks and susceptibility to disease, accidents and poor quality of life. The statistical data used in assessing sleep disorders includes actigraph, K-statistic as well as nonlinear dynamics and dimensionality along with its advantage and disadvantages.

Hydrocolloid dressings (HCD) are helpful in chronic wound care, but research is limited in acute postoperative wounds. HCD can potentially be incorporated into a simplified wound care regimen after excisional surgeries.