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Objective: To evaluate whether patient-controlled epidural analgesia (PCEA) improves postoperative pain during ambulation following elective open hepatectomy. Background: Strategies to alleviate postoperative pain are a critical element of recovery after surgery. However, the optimal postoperative pain management strategy following open hepatectomy remains unclear. Methods: We conducted a prospective, nonblinded, randomized comparison of PCEA (intervention) versus intravenous patient-controlled analgesia (IV PCA; control) for postoperative pain following elective open hepatectomy. The primary end point was pain during ambulation on postoperative day (POD) 2. The study was powered to detect a clinically significant 2-point difference on the pain numeric rating scale (NRS). Secondary end points included pain at rest, morbidity, time to return of bowel function, and length of stay. Results: From 2015 to 2020, 231 patients were randomized (116 patients in the PCEA arm and 115 in the IV PCA arm). The incidence of epidural failure was 3% (n=4/116), with no epidural-related complications. Patients in the PCEA arm had a <2-point difference in NRS pain scores during ambulation on POD 2 vs. IV PCA (median 4.0 vs. 5.0, P <0.001). There was no difference in overall complications between the PCEA and IV PCA arms (33% vs. 40%, P =0.276). Secondary outcomes, including pain scores at rest, were similar between the study arms. Conclusions: PCEA was safe following open hepatectomy and was associated with a small difference in pain with activity on POD 2 that did not reach our pre-specified definition of clinical significance. [ABSTRACT FROM AUTHOR]

Severe acute respiratory syndrome coronavirus (SARS-CoV-2) or COVID-19 has grown to become a global pandemic. Although much has been learned about the virus, the complete impact is still not fully understood. This highly infectious pathogen can cause multiple complications in infected individuals, leading to impairments and functional limitations. To date, there has been limited literature available to describe the rehabilitation needs of patients with COVID-19. New York City (NYC) was initially identified as the United States epicenter, where various health system faced unique considerations when managing patients with COVID-19. The purpose of this article was to share the clinical perspectives of the acute physical therapy (PT) team working in one of the large health system in NYC. The report will describe the role PT played in the evaluation, assessment, and treatment of patients with COVID-19 as they navigated the acute hospital setting. [ABSTRACT FROM AUTHOR]

Background: In patients with heart failure (HF), good health-related quality of life (HRQOL) is as valuable as, or more valuable than, longer survival. However, HRQOL is remarkably poor, and HF symptoms are strongly associated with poor HRQOL. Yet, the multidimensional, modifiable predictors have been rarely examined. Objective: The aim of this study was to examine the baseline psychosocial, behavioral, and physical predictors of HF symptoms and HRQOL at 12 months and the mediator effect of HF symptoms in the relationship between depressive symptoms and HRQOL. Methods: We collected data from 94 patients with HF (mean ± SD age, 58 ± 14 years). Data included sample characteristics, depressive symptoms, perceived control, social support, New York Heart Association (NYHA) functional class, medication adherence, sodium intake, self-care management, and HF symptoms at baseline, as well as HF symptoms and HRQOL at 12 months. Multiple regression analyses were performed to address the purpose. Results: Baseline depressive symptoms (P < .001), medication adherence (P = .010), sodium intake (P = .032), and NYHA functional class (P = .040) significantly predicted 12-month HF symptoms, controlling for covariates (F = 7.363, R² = 47%, P < .001). Baseline medication adherence (P = .001), NYHA functional class (P < .001), and HF symptoms (P = .013) significantly predicted 12-month HRQOL (F = 10.701, R² = 59%, P < .001). Baseline HF symptoms fully mediated the relationship between baseline depressive symptoms and 12-monthHRQOL. Conclusion: Symptoms of HF and HRQOL could be improved by targeting multidimensional, modifiable predictors, such as self-care, depressive symptoms, and NYHA functional class. [ABSTRACT FROM AUTHOR]

Background: Relationships between brain-derived neurotrophic factor (BDNF), insulin-like growth factor (IGF-1), aldosterone, and cognition in aging were evaluated in the population-based Epidemiology of Hearing Loss Study (1993 to present).Methods: Beginning in 1998 to 2000, cognitive impairment was assessed by report of physician diagnoses and the Mini-Mental State Examination. In 2009 to 2010 and 2013 to 2016, information was collected on diagnosis of mild cognitive impairment/dementia. Decline in cognitive function was assessed by principal component analysis from additional tests administered during 2009 to 2010 and 2013 to 2016. BDNF, IGF-1, and aldosterone were measured in serum collected in 1998 to 2000.Results: There were 1970 participants (mean age=66.9 y; 59.1% female) without cognitive impairment at baseline. Among women, low BDNF was associated with 16-year incident cognitive impairment [hazard ratio=1.76; 95% confidence interval (CI)=1.04, 2.98]. Among men, increasing IGF-1 was associated with decreased risk [per SD: relative risk (RR)=0.57; 95% CI=0.35, 0.92], whereas increasing aldosterone levels were associated with increased risk (per SD: RR=1.28; 95% CI=1.01, 1.62) for 5-year incident mild cognitive impairment/dementia. Overall, low BDNF was associated with increased risk (RR=1.52; 95% CI=1.02, 2.26) for 5-year cognitive decline.Conclusion: Low levels of serum BDNF and IGF-1 were associated with poorer cognition during aging. There may be differential biomarker effects by sex. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study is to examine, by a prospective randomized controlled trial, the influence of liberal (LIB) vs restricted (RES) perioperative fluid administration on morbidity following pancreatectomy. Summary of Background Data: Randomized controlled trials in patients undergoing major intra-abdominal surgery have challenged the historical use of LIB fluid administration, suggesting that a more restricted regimen may be associated with fewer postoperative complications. Methods: Patients scheduled to undergo pancreatic resection were consented for randomization to a LIB (n = 164) or RES (n = 166) perioperative fluid regimen. Sample size was designed with 80% power to decrease Grade 3 complications from 35% to 21%. Results: Between July 2009 and July 2015, we randomized 330 patients undergoing pancreaticoduodenectomy (PD, n = 218), central (n = 16), or distal pancreatectomy (DP, n = 96). Patients were equally distributed for all demographic and intraoperative characteristics. Intraoperatively, LIB patients received crystalloid 12mL/kg/h and RES patients 6mL/kg/h. Cumulative crystalloid given (median, range, mL) days 0 to 3 was LIB: 12,252 (6600 to 21,365), RES 7808 (2700 to 16,274) P < 0.0001. Sixty-day mortality was 2 of 330 (0.6%). Median operative time for PD was 227minutes (105 to 462) and DP 150 (44 to 323). Grade 3 complications occurred in 20% of LIB and 27% of RES patients (P = 0.6). Median length of stay was 7 and 5 days for PD and DP, respectively, in both arms. Conclusions: In a high volume institution, major perioperative complications from pancreatic resection were not significantly influenced by fluid regimens that differed approximately 1.6-fold. [ABSTRACT FROM AUTHOR]

Nonsteroidal anti-inflammatory drugs (NSAIDs) may prevent dementia, but previous studies have yielded conflicting results. This study estimated the association of prior NSAID use with incident cognitive impairment in the population-based Epidemiology of Hearing Loss Study (EHLS, n=2422 without cognitive impairment in 1998-2000). Prospectively collected medication data from 1988-1990, 1993-1995, and 1998-2000 were used to categorize NSAID use history at the cognitive baseline (1998-2000). Aspirin use and nonaspirin NSAID use were separately examined. Cox regression models were used to estimate the associations between NSAID use history at baseline and incident cognitive impairment in 2003-2005 or 2009-2010. Logistic regression analyses were used to estimate associations with a second outcome, mild cognitive impairment/dementia, available in 2009-2010. Participants using aspirin at baseline but not 5 years prior were more likely to develop cognitive impairment (adjusted hazard ratio=1.77; 95% confidence interval=1.11, 2.82; model 2), with nonsignificant associations for longer term use. Nonaspirin NSAID use was not associated with incident cognitive impairment or mild cognitive impairment/dementia odds. These results provided no evidence to support a potential protective effect of NSAIDs against dementia. [ABSTRACT FROM AUTHOR]

To develop 2 instruments that predict the probability of perioperative red blood cell transfusion in patients undergoing elective liver resection for primary and secondary tumors.Hepatic resection is the most effective treatment for several benign and malign conditions, but may be accompanied by substantial blood loss and the need for perioperative transfusions. While blood conservation strategies such as autologous blood donation, acute normovolemic hemodilution, or cell saver systems are available, they are economically efficient only if directed toward patients with a high risk of transfusion.Using preoperative data from 1204 consecutive patients who underwent liver resection between 1995 and 2000 at Memorial Sloan-Kettering Cancer Center, we modeled the probability of perioperative red blood cell transfusion. We used the resulting model, validated on an independent dataset (n = 555 patients), to develop 2 prediction instruments, a nomogram and a transfusion score, which can be easily implemented into clinical practice.The planned number of liver segments resected, concomitant extrahepatic organ resection, a diagnosis of primary liver malignancy, as well as preoperative hemoglobin and platelets levels predicted the probability of perioperative red blood cell transfusion. The predictions of the model appeared accurate and with good discriminatory abilities, generating an area under the receiver operating characteristic curve of 0.71.Preoperative factors can be combined into risk profiles to predict the likelihood of transfusion during or after elective liver resection. These predictions, easy to calculate in the frame of a nomogram or of a transfusion score, can be used to identify patients who are at high risk for red cell transfusions and therefore most likely to benefit from blood conservation techniques. [ABSTRACT FROM AUTHOR]

Abstract: We present a case of primary cutaneous actinomycosis of unclear pathogenesis. A 30-year-old-man with no significant medical or surgical history presented to the emergency department with a 2-week history of a tender perineal mass. The patient denied trauma or perforating injury to the area. Examination of the area revealed an indurated, nonfluctuant, erythematous papulonodule located 2 cm from the anus. The lesion was unresponsive to oral and topical antibiotics and was therefore excised. The excision specimen revealed a dense mixed infiltrate partially filling the reticular dermis and extending into the subcutaneous fat. The infiltrate surrounded grains of basophilic material with an outer rim of eosinophilic radiating Splendore-Hoeppli material. Within the grains, filamentous bacteria were highlighted with Periodic acid-Schiff and Grocott's methenamine silver. The organisms were gram-positive and acid-fast negative. Given the clinical and histopathologic findings, actinomycosis was diagnosed. Two weeks later, the patient reported resolution of symptoms. The patient was lost to follow-up. This case highlights an unusual presentation of actinomycosis and the crucial role histopathology plays in diagnosis., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: In patients with heart failure (HF), good health-related quality of life (HRQOL) is as valuable as, or more valuable than, longer survival. However, HRQOL is remarkably poor, and HF symptoms are strongly associated with poor HRQOL. Yet, the multidimensional, modifiable predictors have been rarely examined., Objective: The aim of this study was to examine the baseline psychosocial, behavioral, and physical predictors of HF symptoms and HRQOL at 12 months and the mediator effect of HF symptoms in the relationship between depressive symptoms and HRQOL., Methods: We collected data from 94 patients with HF (mean ± SD age, 58 ± 14 years). Data included sample characteristics, depressive symptoms, perceived control, social support, New York Heart Association (NYHA) functional class, medication adherence, sodium intake, self-care management, and HF symptoms at baseline, as well as HF symptoms and HRQOL at 12 months. Multiple regression analyses were performed to address the purpose., Results: Baseline depressive symptoms (P < .001), medication adherence (P = .010), sodium intake (P = .032), and NYHA functional class (P = .040) significantly predicted 12-month HF symptoms, controlling for covariates (F = 7.363, R = 47%, P < .001). Baseline medication adherence (P = .001), NYHA functional class (P < .001), and HF symptoms (P = .013) significantly predicted 12-month HRQOL (F = 10.701, R = 59%, P < .001). Baseline HF symptoms fully mediated the relationship between baseline depressive symptoms and 12-month HRQOL., Conclusion: Symptoms of HF and HRQOL could be improved by targeting multidimensional, modifiable predictors, such as self-care, depressive symptoms, and NYHA functional class.

Purpose: Patients with heart failure (HF) have notably poor health-related quality of life (HRQOL). A 5-point improvement in HRQOL is associated with reduction in hospitalization and mortality rates. Heart failure symptoms are associated with poor HRQOL, but little is known about whether changes in HF symptoms lead to changes in HRQOL over time. Therefore, we examined the association of changes in HF symptoms with changes in overall, physical, and emotional aspects of HRQOL over a 12-month period, controlling for typical covariates., Methods: Data on HF symptoms and HRQOL (Minnesota Living Heart Failure questionnaire) were collected from 94 patients with HF (mean age, 58 years; 58.5% female) at baseline and 12-month follow-up. Psychosocial factors (depressive symptoms, perceived control, and social support), behavioral factors (medication adherence and sodium intake), sociodemographic and clinical factors (age, comorbidities, and body mass index), and a physical factor (functional status) were collected at baseline. Multiple and logistic regression analyses were used to analyze the data., Results: In complete models, changes in HF symptoms were associated with changes in the total HRQOL (P < .001) and the physical (P < .001) and emotional (P < .001) aspects of HRQOL over 12 months, controlling for all the factors. Changes in HF symptoms were significantly associated with the likelihood of at least a 5-point improvement in HRQOL (P = .001), controlling for covariates., Conclusions: Improvement in HF symptoms was associated with improvement in HRQOL over 12 months. Thus, development and delivery of interventions that target improvement in HF symptoms may improve HRQOL.

Background: Pancreaticoduodenectomy (PD) can be associated with significant blood loss and transfusion requirements, with potential adverse short- and long-term consequences. The aim of this study was to determine whether acute normovolemic hemodilution (ANH), an established blood conservation technique, reduces perioperative allogeneic transfusions in patients undergoing PD., Methods: One hundred thirty patients undergoing PD were randomized to ANH or standard management (STDM). In the ANH group, intraoperative blood collection was performed to a target hemoglobin of 8.0 g/dL; crystalloid and colloid were used for volume replacement. Strict transfusion triggers were applied during and after operation. Perioperative complications were prospectively assessed and graded for severity., Results: From July 2005 to May 2009, 209 patients were registered, 79 excluded, 65 were randomized to ANH, and 65 to STD. The groups were well matched for demographic, operative, and histopathologic variables. Patients undergoing ANH received over 2 L more fluid intraoperatively (6250 mL, range 2000-11850) compared with patients undergoing STD (3900 mL, range 2000-9000) (P < 0.001). Transfusion rates were similar (ANH = 16.9%, 30 units vs STD = 18.5%, 33 units; P = 0.82), as was overall perioperative morbidity (ANH = 49.2% vs STD = 47%, P = 0.86). There was, however, a trend toward more grade-3 complications in patients undergoing ANH (32% vs 23.1% STD, P = 0.17), and complications related to the pancreatic anastomosis (leak/fistula/abscess) were significantly higher in the ANH group (21.5% vs 7.7%, P = 0.045). The intraoperative fluid volume was higher for all patients with pancreatic anastomotic complications (n = 19), regardless of randomization arm (ANH 6000 mL, range 2800-11350 mL vs STD 5000 mL, range 2000-11850 mL, P < 0.042)., Conclusion: In this randomized trial of patients undergoing PD, ANH did not reduce allogeneic transfusions and resulted in more pancreatic anastomotic complications, likely related to greater intraoperative fluid administration. The benefits of ANH do not necessarily extend to all procedures, and restrictive intravenous fluid management during PD may help improve postoperative outcome.

Background: Hepatic resection is the most effective treatment for many malignant and benign conditions affecting the liver and biliary tree. Despite improvements, major partial hepatectomy can be associated with considerable blood loss and transfusion requirements. Transfusion of allogeneic blood products, although potentially life-saving, is associated with many potential complications. The primary aim of this study was to determine if acute normovolemic hemodilution (ANH), an established blood conservation technique, reduces the requirement for allogeneic red cell transfusions in patients undergoing major hepatic resection., Methods: One hundred thirty patients undergoing major hepatic resection (> or =3 segments) were prospectively randomized to undergo either ANH or standard anesthetic management (STD). In the ANH group, intraoperative blood collection was performed to a target hemoglobin of 8.0 g/dL. Low central venous pressure anesthetic technique was used intraoperatively for both groups. A standardized transfusion protocol was applied to all patients intraoperatively and throughout the hospital stay., Results: From April 2004 to March 2007, 63 patients were randomized to ANH and 67 to STD. Demographics, diagnoses, liver function, extent of resection, intraoperative blood loss, operative time, incidence and grade of complications, and length of hospital stay were similar between the 2 groups. ANH reduced the overall allogeneic red cell transfusion rate by 50% compared with STD [12.7% (n = 8) vs. 25.4% (n = 17), respectively; P = 0.067. ANH patients were less often transfused intraoperatively (n = 1, 1.6%) compared with the STD group (n = 7, 10.4%) (P = 0.036), had higher postoperative hemoglobin levels (P = 0.01), and tended to require fewer red cell units overall (28 vs. 47 units). In patients with intraoperative blood loss > or =800 mL, ANH reduced not only the allogeneic red cell transfusion rate (18.2% vs. 42.4%, P = 0.045) but also the proportion of patients requiring fresh frozen plasma (21.1% vs. 48.3%, P = 0.025)., Conclusion: For patients undergoing major liver resection, ANH is safe, effectively reduces the need for allogeneic transfusions, and should be considered for routine use. Given the modest transfusion rate in the STD arm, future efforts should attempt to target ANH use to patients most likely to benefit.

Unlabelled: Hospital nursing care has traditionally been billed using a fixed daily room and board rate. This approach hides the variability of nursing care within and across nursing units and does not align nursing costs with daily charges for actual patient care. Anew nursing intensity billing (NIB) model for assigning hospital daily room charges is proposed, and initial results are reported., Methods: Two charge methods, one using traditional room and board daily billing and another using an NIB approach, were developed for 12 adult medical or surgical units at the Medical University of South Carolina (MUSC) Medical Center using retrospective data from January 1 to May 31, 2005. The room and board charge was assigned as private room or intermediate care based primarily on patient location. The NIB model added an additional focused care charge between private and intermediate care, and the charge for the 3 levels was based on daily nursing intensity entered as actual hours of nursing care delivered. The mean and sum of charges were compared between the 2 methods. Charge rates were simulated at $700, $950, and $1,200 for the 3 levels, which correlated with the existing proprietary room rates. Nursing cost-to-charge ratios were calculated for room and board and NIB methods., Results: The NIB model resulted in a 32.2% increase in charges or a total sum of $4,870,250 for the 12 nursing units over the 5-month period. The variability of nursing cost-to-charge ratio was reduced from 0.34 to 0.80 for room and board to 0.33 to 0.45 for the NIB method., Conclusion: The NIB method of assigning charges based on nursing intensity rather than on patient location increased overall charges and more evenly distributed direct nursing costs to daily charges. Assigning charges based on nursing intensity is appealing as it reflects actual care given in the acute care environment. The NIB provides evidence to support higher charge rates and has the ability to redistribute hospital charges based on nursing care. The relationship between increased daily hospital charges and actual reimbursement is unknown.