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Fires, explosions, and spills at petrochemical industry facilities create air pollution exposure risks for surrounding residences, which are disproportionately communities of color and low-income c...

Purpose This report from VitalSign6 project describes treatment selection, follow-up rates and remission outcomes by initial depression severity using the PCP-FIRST model. Methods This retrospective analysis included 32,106 patients aged ≥12 years screened with the Patient Health Questionnaire 2-item (PHQ-2) from November 2016 to July 2019 across 37 primary care clinics. PHQ-2 positive-screen patients (PHQ-2 ≥ 3) received 9-item PHQ (PHQ-9) and 7-item Generalized Anxiety Disorder scales, clinician assessments, and evaluation for pharmacotherapy management with measurement-based care (MBC). Results Of PHQ-2 screened patients, 18.7% (5994/32,106) were positive and received a PHQ-9. Of 5994 patients with PHQ-9, 2571 received a clinical diagnosis of depression of whom, 333 had none-mild depression (PHQ-9 Conclusions Despite this being a real-world, usual care sample, remission outcomes exceed real world remission rate expectations of 6% in primary care.

Background Prophylactic antiseizure medications (ASMs) for pediatric traumatic brain injury (TBI) are understudied. We evaluated clinical and radiographic features that inform prescription of ASMs for pediatric TBI. We hypothesized that despite a lack of evidence, levetiracetam is the preferred prophylactic ASM but that prophylaxis is inconsistently prescribed. Methods This retrospective study assessed children admitted with TBI from January 1, 2017, to December 31, 2019. TBI severity was defined using Glasgow Coma Scale (GCS) scores. Two independent neuroradiologists reviewed initial head computed tomography and brain magnetic resonance imaging. Fisher exact tests and descriptive and regression analyses were conducted. Results Among 167 children with TBI, 44 (26%) received ASM prophylaxis. All 44 (100%) received levetiracetam. Prophylaxis was more commonly prescribed for younger children, those with neurosurgical intervention, and abnormal neuroimaging (particularly intraparenchymal hematoma) (odds ratio = 10.3, confidence interval 1.8 to 58.9), or GCS ≤12. Six children (13.6%), all on ASM, developed early posttraumatic seizures (EPTSs). Of children with GCS ≤12, four of 17 (23.5%) on levetiracetam prophylaxis developed EPTSs, higher than the reported rate for phenytoin. Conclusions Although some studies suggest it may be inferior to phenytoin, levetiracetam was exclusively used for EPTS prophylaxis. Intraparenchymal hematoma >1 cm was the single neuroimaging feature associated with ASM prophylaxis regardless of the GCS score. Yet these trends are not equivalent to optimal evidence-based management. We still observed important variability in neuroimaging characteristics and TBI severity for children on prophylaxis. Thus, further study of ASM prophylaxis and prevention of pediatric EPTSs is warranted.

Background: Despite advances in surgery and pharmacotherapy, there remains significant residual ischemic risk after coronary artery bypass grafting surgery. Methods: In REDUCE-IT (Reduction of Cardiovascular Events With Icosapent Ethyl–Intervention Trial), a multicenter, placebo-controlled, double-blind trial, statin-treated patients with controlled low-density lipoprotein cholesterol and mild to moderate hypertriglyceridemia were randomized to 4 g daily of icosapent ethyl or placebo. They experienced a 25% reduction in risk of a primary efficacy end point (composite of cardiovascular death, myocardial infarction, stroke, coronary revascularization, or hospitalization for unstable angina) and a 26% reduction in risk of a key secondary efficacy end point (composite of cardiovascular death, myocardial infarction, or stroke) when compared with placebo. The current analysis reports on the subgroup of patients from the trial with a history of coronary artery bypass grafting. Results: Of the 8179 patients randomized in REDUCE-IT, a total of 1837 (22.5%) had a history of coronary artery bypass grafting, with 897 patients randomized to icosapent ethyl and 940 to placebo. Baseline characteristics were similar between treatment groups. Randomization to icosapent ethyl was associated with a significant reduction in the primary end point (hazard ratio [HR], 0.76 [95% CI, 0.63–0.92]; P =0.004), in the key secondary end point (HR, 0.69 [95% CI, 0.56–0.87]; P =0.001), and in total (first plus subsequent or recurrent) ischemic events (rate ratio, 0.64 [95% CI, 0.50–0.81]; P =0.0002) compared with placebo. This yielded an absolute risk reduction of 6.2% (95% CI, 2.3%–10.2%) in first events, with a number needed to treat of 16 (95% CI, 10–44) during a median follow-up time of 4.8 years. Safety findings were similar to the overall study: beyond an increased rate of atrial fibrillation/flutter requiring hospitalization for at least 24 hours (5.0% vs 3.1%; P =0.03) and a nonsignificant increase in bleeding, occurrences of adverse events were comparable between groups. Conclusions: In REDUCE-IT patients with a history of coronary artery bypass grafting, treatment with icosapent ethyl was associated with significant reductions in first and recurrent ischemic events. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01492361.

Objectives To evaluate the pubocervical fascia (PF) in patients with pelvic organ prolapse (POP) using 3-dimensonal endovaginal ultrasonography (EVUS) and to correlate the PF appearance with both pelvic examination and intraoperative findings during ultrasonographic robotic-assisted laparoscopic sacrocervicopexy and pubocervical fascia reconstruction (u-RALS-PFR). Methods A retrospective analysis was performed in 120 women with symptomatic POP. Preoperative evaluation was done using EVUS. We identified areas of PF weakness based on pelvic examination as hypoechoic and hyperechoic defects (HHD) between the bladder and vagina. Study measurements included distance from the HHD to the pubic symphysis, HHD to the bladder neck, HHD to the posterior bladder wall, and hypoechoic-hyperechoic area. We correlated these metrics with the respective POP-Q stages and findings during u-RALS-PFR. Results Using the quantitative measures during EVUS, we found a significant association between mean HHD (2.7 cm) and POP-Q stage III, and between HHD and number of plications performed during surgery. The larger the HHD, the more severe the POP-Q stage of the anterior compartment of the vaginal wall; thus, more plications were performed on the PF (7-12 plications) during robotic sacrocervicopexy, and consequently the anterior arm of the Y-mesh was significantly trimmed (6-8 cm). Conclusion HHD obtained by EVUS was associated with severe POP-Q stage III and seemed to correlate with the number of plications during robotic sacrocervicopexy. Performing these plications on the PF significantly decreased the length of the anterior vaginal mesh needed for the procedure. These findings may open new applications for preoperative ultrasonography in evaluation and treatment of patients with apical and anterior POP.

Xanthogranulomatosis is an inflammatory lesion characterized by lipid-containing macrophages, extracellular lipid, hemorrhage, and necrosis. We describe disseminated intracoelomic xanthogranulomatosis in 5 eclectus parrots ( Eclectus roratus) and 2 budgerigars ( Melopsittacus undulatus). Postmortem, clinicopathologic, and historical case material was reviewed. Ages ranged from 3 to 24 years; there were 5 males and 2 females. Table food was included in the diet of 3/5 cases, and animal products were included in 2/3 cases. Common clinicopathologic abnormalities included leukocytosis (4/5 cases) and elevated concentrations of bile acids (3/4 cases) and cholesterol within 6 months prior to death (2/4 cases). At postmortem examination, all 7 birds had grossly visible, irregular, soft, tan to yellow, amorphous plaques distributed on the surfaces of the viscera and body wall. Histologic evaluation and oil red O stain revealed xanthogranulomatous inflammation with phagocytized and extracellular lipid, necrosis, cholesterol clefts, fibrosis, and mineralization. Infectious agents were not identified with special stains in all cases. Concurrent hepatobiliary disease was present in 6/7 cases, and 6/7 had lipid accumulation within the parenchyma of various visceral organs. Five cases had atherosclerosis of great vessels. We describe a unique form of disseminated coelomic xanthogranulomatosis in 2 psittacine species. This condition should be recognized as a differential diagnosis in cases of disseminated coelomic mass formation and coelomic distension in psittacine birds, particularly in eclectus parrots and budgerigars.

Purpose of the review By reviewing the most recent common mental health disorders (CMHD) studies in people living with HIV (PLWH) (2018-2020), this review discusses the prevalence of CMHD, factors associated with CMHD in PLWH, mental health in PLWH from vulnerable groups, the impact of CMHD on HIV disease progression and adherence to antiretroviral therapy and the efficacy of different treatment approaches. Recent findings After screening for eligibility 142 studies were included in the final systematic review. Only 27% of studies were conducted in Sub-Saharan Africa, which carries the highest burn of HIV disease globally. Despite the well-established increased risk of CMHD in PLWH, the current prevalence remains high, with studies reporting 28%-62% of PLWH having mental health symptoms. Conclusion Despite the significant challenges that CMHDs present to successful HIV treatment, there are many mental health treatments and interventions which can improve outcomes in PLWH and opportunities to task-shift and integrate mental health care with HIV care. Supplementary Information The online version contains supplementary material available at 10.1007/s11904-021-00583-w.

Background Negative pressure wound therapy (NPWT) is an option for securing meshed split thickness skin grafts (mSTSGs) after burn excision to optimize skin graft adherence. Recently, the use of autologous skin cell suspension (ASCS) has been approved for use in the treatment of burn injuries in conjunction with mSTSGs.To date, limited data exists regarding the impact of NPWT on healing outcomes when the cellular suspension is utilized. It was hypothesized that NPWT would not negatively impact wound healing of ASCS+mSTSG. Materials and Methods A burn, excision, mSTSG, ASCS ± NPWT model was used. Two Duroc pigs were utilized in this experiment, each with 2 sets of paired burns. Four wounds received mSTSG+ASCS+NPWT through post-operative day 3, and 4 wounds received mSTSG+ACSC+ traditional ASCS dressings. Cellular viability was characterized prior to spraying. Percent re-epithelialization, graft-adherence, pigmentation, elasticity, and blood perfusion and blood vessel density were assessed at multiple time points through 2 weeks. Results All wounds healed within 14 days with minimal scar pathology and no significant differences in percent re-epithelialization between NPWT, and non-NPWT wounds were observed. Additionally, no differences were detected for pigmentation, perfusion, or blood vessel density. NPWT treated wounds had less graft loss and improved elasticity, with elasticity being statistically different. Conclusions These data suggest the positive attributes of the cellular suspension delivered are retained following the application of negative pressure. Re-epithelialization, revascularization, and repigmentation are not adversely impacted. The use of NPWT may be considered as an option when using ASCS with mSTSGs for the treatment of full-thickness burns.

Survivorship treatment summaries and care plans are increasingly incorporated into cancer care but there are limited data on their accuracy and acceptability. We have evaluated written care plans developed as part of a once‐off, nurse‐led survivorship consultations across four medical oncology clinics in South Australia as part of a state‐wide pilot. While the accuracy of treatment summaries was high, level of detail in care plans was moderate to low, as was survivors' perception of plans' utility. Refereed/Peer-reviewed

Chronic kidney disease (CKD) is a common cause of morbidity and mortality in domestic cats, but the cause is still largely elusive. While some viruses have been associated with this disease, none have been definitively implicated as causative. Recently, Rodent chaphamaparvovirus 1 was recognized as the cause of murine inclusion body nephropathy, a disease reported for over 40 years in laboratory mice. A novel virus belonging to the same genus, Carnivore chaphamaparvovirus 2, was recently identified in the feces of cats with diarrhea. The goal of this study was to investigate the possible role of chaphamaparvoviruses including members of Rodent chaphamaparvovirus 1 and Carnivore chaphamaparvovirus 2 in the development of feline CKD. The presence of these viruses was retrospectively investigated in formalin-fixed paraffin-embedded feline kidney samples using polymerase chain reaction, in situ hybridization, and immunohistochemistry. Cats were divided into 3 groups: normal ( N = 24), CKD ( N = 26), and immunocompromised ( N = 25). None of the kidney tissues from any of the 75 cats revealed the presence of chaphamaparvovirus DNA, RNA, or antigen. We conclude that viruses belonging to the chaphamaparvovirus genus are unlikely to contribute to the occurrence of feline CKD.

Several care models have been developed to improve treatment for depression, all of which provide “enhanced” evidence-based care (EEC). The essential component of these approaches is Measurement-Based Care (MBC). Specifically, Collaborative Care (CC), and Algorithm-guided Treatment (AGT), and Integrated Care (IC) all use varying forms of rigorous MBC assessment, care management, and/or treatment algorithms as key instruments to optimize treatment delivery and outcomes for depression. This meta-analysis systematically examined the effectiveness of EEC versus usual care for depressive disorders based on cluster-randomized studies or randomized controlled trials (RCTs). PubMed, the Cochrane Library, and PsycInfo, EMBASE, up to January 6th, 2020 were searched for this meta-analysis. The electronic search was supplemented by a manual search. Standardized mean difference (SMD), risk ratio (RR), and their 95% confidence intervals (CIs) were calculated and analyzed. A total of 29 studies with 15,255 participants were analyzed. EEC showed better effectiveness with the pooled RR for response of 1.30 (95%CI: 1.13–1.50, I2 = 81.9%, P I2 = 85.5%, P I2 = 94.3%, P I2 = 68.0%, P = 0.303, 27 studies). This meta-analysis supported EEC as an evidence-based framework to improve the treatment outcome of depressive disorders.Review registration: PROSPERO: CRD42020163668

Neurofibromatosis type 1 (NF1) is a genetic syndrome associated with multiple complications that cause chronic pain, including plexiform neurofibroma (PN) tumors. However, no randomized studies have examined non-pharmacological interventions for pain specifically targeting individuals with NF1 and PNs. In the current randomized controlled trial, an Acceptance and Commitment Therapy intervention was conducted with older adolescents and adults ages 16–59 years with NF1, PNs, and chronic pain. We hypothesized that pain interference would decrease from pre-to post-intervention compared to a wait-list control group. We also examined potential mediators, including pain acceptance and inflexibility. The intervention consisted of two 2-h in-person sessions followed by 8 weeks of online training including weekly email assignments and biweekly video chats. Outcome measures evaluating pain interference, pain intensity, pain anxiety, and depression and process measures evaluating pain acceptance and pain inflexibility were administered at baseline and after the 8-week intervention. Sixty-two participants (M age = 30.7 ± 11.5 years, 61.3% female) completed the intervention. Results indicated that the ACT intervention significantly reduced how much pain interfered with daily functioning. Improvements in pain acceptance and, separately, pain inflexibility, mediated the treatment benefit for individuals in the ACT group. No improvements in pain intensity, pain anxiety, or depression were noted following the intervention. Durable treatment benefits were seen at 6 months albeit only among those who improved more during the 8-week intervention. While the immediate post-intervention effects were seen after 4 h of in-person training and limited online sessions, more support is likely needed to maintain these effects long-term. Results indicate that remote ACT interventions have promise and could make this treatment accessible to more patients with NF1, PNs and chronic pain.

Vaccine-induced thrombotic thrombocytopenia is a newly described disease process in the setting of expanding access to COVID-19 vaccination. The United States Centers for Disease Control and Prevention recommends treatment with an alternative to heparin in patients suspected of having vaccine-induced thrombotic thrombocytopenia. At this time there have been no reported outcomes from the treatment of vaccine-induced thrombotic thrombocytopenia with bivalirudin as a heparin alternative. We describe the early outcomes from the treatment of vaccine-induced thrombotic thrombocytopenia with bivalirudin as a heparin alternative. A 40-year-old Caucasian woman was found to have thrombocytopenia, cerebral venous sinus thrombosis, and pulmonary embolism following vaccination for COVID-19 with Ad26.COV2.S. She exhibited a steady rise in platelet count: 20×109/L at hospital day 0, 115×109/L at discharge on hospital day 6, and 182×109/L on outpatient follow-up on day 9. While the patient exhibited a transient drop in hemoglobin, there was no clinical evidence of bleeding. This patient did not demonstrate any clinical sequelae of thrombosis, and she reported resolution of her headache. Vaccination with Ad26.COV2.S appears to be associated with a small but significant risk for thrombotic thrombocytopenia within 13 days of receipt. The Centers for Disease Control and Prevention guidance to consider an alternative to heparin was not accompanied by specifically recommended alternatives. A single patient treated with bivalirudin for suspected vaccine-induced thrombotic thrombocytopenia subsequently experienced symptom improvement and a rise in platelet count and did not demonstrate any immediate negative outcomes. A provider may consider bivalirudin as an alternative to heparin in patients with suspected vaccine-induced thrombotic thrombocytopenia following Ad26.COV2.S vaccination, pending more definitive research.

Study Objectives: Congenital central hypoventilation syndrome (CCHS) is a rare disorder affecting the autonomic nervous system that is caused by variants in the paired-like homeobox 2B (PHOX2B) gen...

Haemophagocytic lymphohistiocytosis is a life-threatening systemic inflammatory syndrome defined by persistent fever, cytopenia and multi-organ dysfunction. Primary haemophagocytic lymphohistiocytosis classically presents in childhood as a result of genetically abnormal perforin or inflammasome function, leading to the aberrant release of pro-inflammatory cytokines causing a hyperinflammatory state. Secondary haemophagocytic lymphohistiocytosis is an acquired phenomenon occurring at any age as a result of immune dysregulation to a specific trigger such as infection, haematological malignancy or autoimmune disease. Secondary haemophagocytic lymphohistiocytosis occurring in the pregnant woman represents a diagnostic challenge and carries a significant mortality. This has led to its first inclusion in the fourth Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the United Kingdom annual maternal report in 2017. This article presents an overview of haemophagocytic lymphohistiocytosis, reviews the literature on haemophagocytic lymphohistiocytosis in pregnancy, suggests diagnostic pathways and explores the safety and efficacy of existing and potential treatment strategies for haemophagocytic lymphohistiocytosis occurring during pregnancy.

Wound infections and sepsis are significant causes of morbidity after burn injury and can be alleviated by early excision and grafting. In situations that preclude early surgery, topical agents allow for a safer delay. Cerium nitrate compounded with silver sulfadiazine (Ce-SSD) is a burn cream that provides broad antibacterial activity, forms a temporary barrier, and promotes re-epithelialization. Methemoglobinemia is a rare, but oft-cited, systemic complication of Ce-SSD. In this retrospective review, 157 patients treated with Ce-SSD between July 2014 and July 2018 were identified, and the monitoring protocol for methemoglobinemia during Ce-SSD treatment was evaluated. The median age was 59 years (interquartile range [IQR], 47–70.5 years), with TBSA of 8.5% (IQR, 3–27), adjusted Baux score of 76 (IQR, 59–94), and inhalation injury present in 9.9% of patients. Primary endpoints included incidence of symptomatic and asymptomatic methemoglobinemia. Of the 9.6% (n = 15) of patients with methemoglobinemia, 73.3% (n = 11) had maximum methemoglobin levels ≥72 hours from the time of the first application. One patient developed clinically significant methemoglobinemia. Patients with TBSA ≥20% were more likely to develop methemoglobinemia (odds ratio 9.318, 95% confidence interval 2.078–65.73, P = .0078); however, neither Ce-SSD doses nor days of exposure were significant predictors. Ce-SSD application to temporize burn wounds until excision and grafting is safe, effective, and, in asymptomatic patients with TBSA

Fecal management systems have become ubiquitous in hospitalized patients with fecal incontinence or severe diarrhea, especially in the setting of perianal wounds. Although fecal management system use has been shown to be safe and effective in initial series, case reports of rectal ulceration and severe bleeding have been reported, with a relative paucity of clinical safety data in the literature.The purpose of this study was to determine the rate of rectal complications attributable to fecal management systems, as well as to characterize possible risk factors and appropriate management strategies for such complications.This was a retrospective cohort study.The study was conducted at a large academic medical center.All medical and surgical patients who underwent fecal management system placement from December 2014 to March 2017 were included.We measured any rectal complication associated with fecal management system use, defined as any rectal injury identified after fecal management system use confirmed by lower endoscopy.A total of 629 patients were captured, with a median duration of fecal management system use of 4 days. Overall, 8 patients (1.3%) experienced a rectal injury associated with fecal management system use. All of the patients who experienced a rectal complication had severe underlying comorbidities, including 2 patients on dialysis, 1 patient with cirrhosis, and 3 patients with a recent history of emergent cardiac surgery. In 3 patients the bleeding resolved spontaneously, whereas the remaining 5 patients required intervention: transanal suture ligation (n = 2), endoscopic clip placement (n = 1), rectal packing (n = 1), and proctectomy in 1 patient with a history of pelvic radiotherapy.The study was limited by its retrospective design and single institution.This is the largest study to date evaluating rectal complications from fecal management system use. Although rectal injury rates are low, they can lead to serious morbidity. Advanced age, severe comorbidities, pelvic radiotherapy, and anticoagulation status or coagulopathy are important factors to consider before fecal management system placement. See Video Abstract at http://links.lww.com/DCR/B698.ANTECEDENTES:Los sistemas de manejo fecal se han vuelto omnipresentes en pacientes hospitalizados con incontinencia fecal o diarrea severa, especialmente en el contexto de heridas perianales. Aunque se ha demostrado que el uso del sistema de tratamiento fecal es seguro y eficaz en la serie inicial, se han notificado casos de ulceración rectal y hemorragia grave, con una relativa escasez de datos de seguridad clínica en la literatura.OBJETIVO:Determinar la tasa de complicaciones rectales atribuibles a los sistemas de manejo fecal. Caracterizar los posibles factores de riesgo y las estrategias de manejo adecuadas para tales complicaciones.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Centro médico académico de mayor volumen.PACIENTES:Todos los pacientes médicos y quirúrgicos que se sometieron a la colocación del sistema de manejo fecal desde diciembre de 2014 hasta marzo de 2017.PRINCIPALES MEDIDAS DE VALORACION:Cualquier complicación rectal asociada con el uso del sistema de manejo fecal, definida como cualquier lesión rectal identificada después del uso del sistema de manejo fecal confirmada por endoscopia baja.RESULTADOS:Se identificaron un total de 629 pacientes, con una duración media del uso del sistema de manejo fecal de 4,0 días. En general, 8 (1,3%) pacientes desarrollaron una lesión rectal asociada con el uso del sistema de manejo fecal. Todos los pacientes que mostraron una complicación rectal tenían comorbilidades subyacentes graves, incluidos dos pacientes en diálisis, un paciente con cirrosis y tres pacientes con antecedentes recientes de cirugía cardíaca emergente. En tres pacientes el sangrado se resolvió espontáneamente, mientras que los cinco pacientes restantes requirieron intervención: ligadura de sutura transanal (2), colocación de clip endoscópico (1), taponamiento rectal (1) y proctectomía en un paciente con antecedentes de radioterapia pélvica.LIMITACIONES:Diseño retrospectivo, institución única.CONCLUSIONES:Este es el estudio más grande hasta la fecha que evalúa las complicaciones rectales del uso del sistema de manejo fecal. Si bien las tasas de lesión rectal son bajas, pueden provocar una morbilidad grave. La edad avanzada, las comorbilidades graves, la radioterapia pélvica y el estado de anticoagulación o coagulopatía son factores importantes a considerar antes de la colocación del sistema de manejo fecal. Consulte Video Resumen en http://links.lww.com/DCR/B698.

OBJECTIVE: To estimate differences in average annual health care expenditures of adult women with chronic overlapping pain conditions (COPCs) by pain treatment modality as follows: (1) no long‐term opioid or complementary and integrative health (CIH) use; (2) CIH only use; (3) long‐term opioid only use; and (4) long‐term opioid and CIH use. DATA SOURCE: Cross‐sectional Medical Expenditure Panel Survey data (2012–2016). STUDY DESIGN: We estimated differences between average annual expenditures of adult women with COPCs by their use of long‐term opioids and CIH modalities. Generalized linear regression with a log link function was used to estimate adjusted marginal effects in annual expenditures. The distribution family was chosen based on Modified Park Tests. We controlled for pain severity, patient demographic characteristics, physical limitations, comorbidities, mental health, insurance status, physical therapy use, and census region. We also employed propensity‐score based marginal mean weighting through stratification to balance our treatment groups on observed covariates. DATA COLLECTION/EXTRACTION METHODS: We identified adult women (>17 years) with one or more self‐reported COPC using 3‐digit International Classification of Diseases (ICD)‐9/10‐Clinical Modification (CM) codes (N = 9169) and categorized their use of CIH and long‐term opioids. PRINCIPAL FINDINGS: Compared to women without long‐term opioid or CIH use, CIH only use was significantly associated with lower inpatient expenditures (−$947 [−$1699, −$196]; p‐value

Background It is important to document the domains surrounding end-of-life (EOL) care in the electronic health record (EHR). No pediatric navigator exists for these purposes. Measures Medical charts were reviewed for documentation surrounding code status and care at the time of death from January 2017 to June 2019. Intervention Creation of a navigator in the EHR to consolidate advance care planning documents, code status orders and notes and EOL flowsheets. Outcomes After implementing the navigator, 96% code status changes had supporting documentation, an increase of 35%. The percentage of deaths supported by a psychosocial team (social worker, chaplain and certified child life specialist) increased by 25%. Post-mortem documentation became electronic. Patient level metrics began to be electronically collected. Conclusions/Lessons Learned Little has been published regarding use of the EHR to consolidate EOL documentation in pediatrics. Development of a systematic approach to documentation is critical to providing EOL care and standardizing care delivered.

We document abortion method decision-making through analyzing posts on Reddit, a popular social media platform.

Objective Although many studies report that women with HIV (WWH) are more vulnerable to cognitive impairment than men with HIV (MWH), this trend is not described consistently in the literature. In this systematic review and meta-analysis, we investigated whether the weight of evidence supports the existence of a significant sex difference in cognitive functioning among people with HIV and, if so, whether specific domains are affected. Method A systematic literature search retrieved 4,062 unique articles published between January 2000 and June 2019. Eligibility criteria were that studies directly compared adult WWH and MWH using a neuropsychological test battery. After extensive screening, we included 11 studies in the systematic review (N = 3,333) and 6 in the meta-analysis (N = 2,852). Results Six studies included in the systematic review found WWH performed significantly more poorly on measures of cognitive performance than MWH; the other five found no sex differences. Meta-analytic results indicated that WWH performed significantly more poorly than MWH in three cognitive domains (psychomotor coordination, visuospatial learning, and memory), but magnitudes of effect sizes were small (d = −.16, −.43, and − .30, respectively). Analyses detected no sex differences in global cognitive functioning and in the other cognitive domains. Conclusions Sex differences in cognitive performance are small, and sociodemographic and psychiatric characteristics of WWH and MWH differ between studies. Cognitive differences between WWH and MWH may be explained by sex-based variation in these characteristics, the impact of which seems to outweigh that of HIV-related clinical variables (e.g., CD4 count and viral load).

Digital microscopy (DM) is increasingly replacing traditional light microscopy (LM) for performing routine diagnostic and research work in human and veterinary pathology. The DM workflow encompasses specimen preparation, whole-slide image acquisition, slide retrieval, and the workstation, each of which has the potential (depending on the technical parameters) to introduce limitations and artifacts into microscopic examination by pathologists. Performing validation studies according to guidelines established in human pathology ensures that the best-practice approaches for patient care are not deteriorated by implementing DM. Whereas current publications on validation studies suggest an overall high reliability of DM, each laboratory is encouraged to perform an individual validation study to ensure that the DM workflow performs as expected in the respective clinical or research environment. With the exception of validation guidelines developed by the College of American Pathologists in 2013 and its update in 2021, there is no current review of the application of methods fundamental to validation. We highlight that there is high methodological variation between published validation studies, each having advantages and limitations. The diagnostic concordance rate between DM and LM is the most relevant outcome measure, which is influenced (regardless of the viewing modality used) by different sources of bias including complexity of the cases examined, diagnostic experience of the study pathologists, and case recall. Here, we review 3 general study designs used for previous publications on DM validation as well as different approaches for avoiding bias.

Postnatal neurogenesis provides an opportunity to understand how newborn neurons functionally integrate into circuits to restore lost function. Newborn olfactory sensory neurons (OSNs) wire into highly organized olfactory bulb (OB) circuits throughout life, enabling lifelong plasticity and regeneration. Immature OSNs can form functional synapses capable of evoking firing in OB projection neurons. However, what contribution, if any, immature OSNs make to odor processing is unknown. Indeed, because immature OSNs can express multiple odorant receptors, any input that they do provide could degrade the odorant selectivity of input to OB glomeruli. Here, we used a combination of in vivo 2-photon calcium imaging, optogenetics, electrophysiology and behavioral assays to show that immature OSNs provide odor input to the OB, where they form monosynaptic connections with excitatory neurons. Importantly, immature OSNs responded as selectively to odorants as mature OSNs. Furthermore, mice successfully performed odor detection tasks using sensory input from immature OSNs alone. Immature OSNs responded more strongly to low odorant concentrations but their responses were less concentration dependent than those of mature OSNs, suggesting that immature and mature OSNs provide distinct odor input streams to each glomerulus. Together, our findings suggest that sensory input mediated by immature OSNs plays a previously unappreciated role in olfactory-guided behavior.

The early postnatal period is a time of increased risk for psychiatric admission. However, there is scope to further examine if this increase in risk extends to the entire perinatal period (pregnancy and first postnatal year), and how it compares to admission outside of the perinatal period. Data were linked across birth and hospital admission registers from July 2000 to December 2009. The study cohort, consisting of all pregnant and childbearing women with a psychiatric history, was divided into two groups: case women (at least one perinatal principal psychiatric admission in the study period) (38%) and comparison women (no perinatal principal psychiatric admissions) (62%). Outcomes were admission rate and length of stay adjusted for diagnosis, socio-demographic factors and timing of admission. Antenatal and postnatal admissions rates were both higher than non-perinatal admission rates for case women for all diagnoses. There was little evidence that women with perinatal admissions were at an increased risk of admissions at other times. Socially disadvantaged women had significantly fewer and shorter admissions than their respective counterparts. The entire perinatal period is a time of increased risk for admission across the range of psychiatric disorders, compared to other times in a woman’s childbearing years. Reduced admission rate and length of stay for socially disadvantaged women suggest lack of equity of access highlighting the importance of national perinatal mental health policy initiatives inclusive of disadvantaged groups.

ObjectiveTo review and recommend patient-reported outcome (PRO) measures assessing multidimensional domains of quality of life (QoL) to use as clinical endpoints in medical and psychosocial trials for children and adults with neurofibromatosis (NF) type 1, NF2, and schwannomatosis.MethodsThe PRO working group of the Response Evaluation in Neurofibromatosis and Schwannomatosis (REiNS) International Collaboration used systematic methods to review, rate, and recommend existing self-report and parent-report PRO measures of generic and disease-specific QoL for NF clinical trials. Recommendations were based on 4 main criteria: patient characteristics, item content, psychometric properties, and feasibility.ResultsThe highest-rated generic measures were (1) the Pediatric Quality of Life Inventory (PedsQL) Generic Core Scales for NF clinical trials for children or for children through adults, (2) the Functional Assessment of Cancer Therapy–General for adult medical trials, and (3) the World Health Organization Quality of Life–BREF for adult psychosocial trials. The highest-rated disease-specific measures were (1) the PedsQL NF1 Module for NF1 trials, (2) the NF2 Impact on Quality of Life Scale for NF2 trials, and (3) the Penn Acoustic Neuroma Quality of Life Scale for NF2 trials targeting vestibular schwannomas. To date, there are no disease-specific tools assessing multidimensional domains of QoL for schwannomatosis.ConclusionsThe REiNS Collaboration currently recommends these generic and disease-specific PRO measures to assess multidimensional domains of QoL for NF clinical trials. Additional research is needed to further evaluate the use of these measures in both medical and psychosocial trials.

Background Evidence-informed clinical practice guidelines (CPGs) are useful tools to inform transparent healthcare decision-making. Consideration of health economic evidence (HEE) during CPG development in a structured manner remains a challenge globally and locally. This study explored the views, current practice, training needs and challenges faced by CPG developers in the production and use of HEE for CPGs in South Africa. Methods This mixed-methods study comprised an online survey and a focus group discussion. The survey was piloted and subsequently sent to CPG role players - evidence reviewers, CPG panellists, academics involved with training in relevant disciplines like health economics and public health, implementers and funders. The focus group participants hold strategic roles in CPG development and health economic activities nationally. The survey evaluated mean values, measures of variability, and percentages for Likert scales, while narrative components were thematically analysed. Focus group data were manually coded, thematically analysed and verified. Results The survey (n = 55 respondents to 245 surveys distributed) and one focus group (n = 5 participants from 10 people invited) occurred between October 2018 and February 2019. We found the most consistent reason why HEE should inform CPG decisions was ‘making more efficient use of limited financial resources’. This was explained by numerous context and methodological barriers. Focus groups participants noted that consideration of complex HEE are not achievable without bolstering skills in applying evidence-based medicine principles. Further concerns include lack of clarity of standard methods; inequitable and opaque topic selection across private and public sectors; inadequate skills of CPG panel members to use HEE; and the ability of health economists to communicate results in accessible ways. Overall, in the absence of clarity about process and methods, politics and interests may drive CPG decisions about which interventions to implement. Conclusions HEE should ideally be considered in CPG decisions in South Africa. However, this will remain hampered until the CPG community agree on methods and processes for using HEE in CPGs. Focused investment by national government to address the challenges identified by the study is imperative for a better return on investment as National Health Insurance moves forward.

COVID-19 continues to be a major societal disruptor that threatens the wellness and health of millions of people worldwide. We rightfully celebrate the over 20 million survivors in the United States, yet, what constitutes actual recovery, as many face continuing repercussions of their illness? This paper reviews COVID-19, focusing on its sequela of acute respiratory distress syndrome (ARDS) and the accompanying intensive care unit stay, treatment options and its increased morbidity. Outlined is the importance of long-term, comprehensive care for post-infection patients, as well as the numerous barriers to adequate care. We suggest looking to doctors of osteopathic medicine to bridge the gaps in multifactorial care, including psychological and physical dysfunction. Osteopathic medicine is discussed as a potential benefit during this pandemic by reviewing its effectiveness in a previous pandemic. However, additional work must be conducted to improve awareness of needed care and delivery of that care.

Author(s): Yum, Jung; Hoffman, Taryn; Naraghi, Leily | Abstract: Introduction: Pneumoperitoneum is a life-threatening diagnosis that requires timely diagnosis and action. We present a case series of patients with perforated hollow viscus who were accurately diagnosed by emergency physicians using point-of-care ultrasound (POCUS) while in the emergency department (ED).Case Series: Three elderly patients presented to the ED with the complaints of syncope, abdominal pain with constipation, and unresponsiveness. The emergency physicians used POCUS to diagnose and then expedite the necessary treatment.Conclusion: Point-of-care ultrasound can be used by emergency physicians to diagnose pneumoperitoneum in the ED.

Lower-limb exoskeletons have the potential to improve mobility in individuals with movement disabilities, such as cerebral palsy (CP). The goal of this study was to assess the impact of plantar-flexor assistance from an untethered ankle exoskeleton on dynamic stability during unperturbed and perturbed walking in individuals with CP. Seven participants with CP (Gross Motor Function Classification System levels I-III, ages 6–31 years) completed a treadmill walking protocol under their normal walking condition and while wearing an ankle exoskeleton that provided adaptive plantar-flexor assistance. Pseudo-randomized treadmill perturbations were delivered during stance phase by accelerating one side of a split-belt treadmill. Treadmill perturbations resulted in a significant decrease in anteroposterior minimum margin-of-stability (− 32.1%, p

BACKGROUND: While total sleep duration and rapid eye movement (REM) sleep duration have been associated with long-term mortality in non-surgical cohorts, the impact of preoperative sleep on postoperative outcomes has not been well-studied. METHODS: In this secondary analysis of a prospective observational cohort study, patients who recorded at least 1 sleep episode using a consumer wearable device in the 7 days before elective colorectal surgery were included. 30-day postoperative outcomes among those who did and did not receive at least 6 hours of total sleep, as well as those who did and did not receive at least 1 hour of rapid eye movement (REM) sleep were compared. RESULTS: 34 out of 95 (35.8%) patients averaged at least 6 hours of sleep per night, while 44 out of 82 (53.7%) averaged 1 hour or more of REM sleep. Patients who slept less than 6 hours had similar postoperative outcomes compared to those who slept 6 hours or more. Patients who averaged less than 1 hour of REM sleep, compared to those who achieved 1 hour or more of REM sleep, had significantly higher rates of complication development (29.0% vs. 9.1%, P=0.02), and return to the OR (10.5% vs. 0%, P=0.04). After adjustment for confounding factors, increased REM sleep duration remained significantly associated with decreased complication development (increase in REM sleep from 50 to 60 min: OR 0.72, P=0.009; REM sleep ≥ 1 hour: OR 0.22, P=0.03). CONCLUSION: In this cohort of patients undergoing elective colorectal surgery, those who developed a complication within 30 days were less likely to average at least 1 hour of REM sleep in the week before surgery than those who did not develop a complication. Preoperative REM sleep duration may represent a risk factor for surgical complications, however additional research is necessary to confirm this relationship.

This is a 12-part series on the most commonly billed diagnoses in primary care. The article discusses the pathophysiologic processes of acute pharyngitis as well as the clinical manifestations and treatments and how they are linked to disease pathogenesis.

Introduction Lubiprostone capsules are approved for managing three different chronic constipation conditions. A “sprinkle” formulation may facilitate use in individuals with difficulty swallowing capsules. Our objective was to evaluate the bioequivalence, pharmacokinetics (PK), and bioavailability of lubiprostone sprinkles vs lubiprostone capsules, compared with placebo. Methods A 1-week randomized, placebo-controlled, double-blinded, bioequivalence study (study 302) and a single-dose PK and bioavailability crossover study (study 304) were conducted. In study 302, 522 subjects with chronic constipation were randomized to lubiprostone sprinkle 24 μg twice daily (BID), lubiprostone capsule 24 μg BID, or placebo. The primary efficacy endpoint was observed spontaneous bowel movement (SBM) counts (equivalence defined as showing the 90% confidence interval [CI] of the “between-group SBM ratio” to be contained within 0.8–1.25). Study 304 included two cohorts of healthy volunteers randomized to a single 48-μg lubiprostone dose, sprinkle, or capsule (n = 35) or to a single 48-μg sprinkle dose, in fed or fasted state (n = 14). Results Both lubiprostone formulations significantly improved SBM count (sprinkle, 4.82 ± 3.66, P = 0.002; capsule, 5.74 ± 3.79, P

The proliferation of wearable technology presents a novel opportunity for perioperative activity monitoring; however, the association between perioperative activity level and readmission remains underexplored. This study sought to determine whether physical activity data captured by wearable technology before and after colorectal surgery can be used to predict 30-day readmission. In this prospective observational cohort study of adults undergoing elective major colorectal surgery (January 2018 to February 2019) at a single institution, participants wore an activity monitor 30 days before and after surgery. The primary outcome was return to baseline percentage, defined as step count on the day before discharge as a percentage of mean preoperative daily step count, among readmitted and non-readmitted patients. 94 patients had sufficient data available for analysis, of which 16 patients (17.0%) were readmitted within 30 days following discharge. Readmitted patients achieved a lower return to baseline percentage compared to patients who were not readmitted (median 15.1% vs. 31.8%; P = 0.004). On multivariable analysis adjusting for readmission risk and hospital length of stay, an absolute increase of 10% in return to baseline percentage was associated with a 40% decreased risk of 30-day readmission (odds ratio 0.60; P = 0.02). Analysis of the receiver operating characteristic curve identified 28.9% as an optimal return to baseline percent threshold for predicting readmission. Achieving a higher percentage of an individual’s preoperative baseline activity level on the day prior to discharge after major colorectal surgery is associated with decreased risk of 30-day hospital readmission.

Background Harvard Pilgrim Health Care expanded coverage for non-invasive prenatal testing (NIPT) to include all pregnant, single-gestation women aged

COVID19 is caused by a newly identified severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) that affects pregnant women equally to the general population. How SARS-CoV2 affects the mothers, the neonates and the placental pathology remain controversial.To explore the effects of maternal SARS-CoV2 infection on the neonates and placental pathology in comparison to those from the normal pregnancies.Maternal, neonatal and placental pathology data were collected from medical records between March and August 2020 from New York Presbyterian- Brooklyn Methodist Hospital. The data from a total 142 neonates and 101 placentas from SARS-CoV2 positive mothers were compared with those from SARS-CoV2 negative mothers.There were 142 SARS-CoV2 positive mothers within the study group, and 43 (36%) of them showed various degrees of COVID19 related clinical symptoms including fever (13.8%), cough (5.7%), loss of taste/smell (anosmia)(5.6%), shortness of breath (2.4%), muscle ache (2.4%), headache (1.6%) and pneumonia (0.8%). A total 142 neonates were born to the SARS-CoV-2 positive mothers, and only 1 neonate tested positive for SARS-CoV2 in the first 24 h. Two additional neonates were initially tested negative in first 24 h, and later tested positive on day 7 and the 1 month visit, and all these neonates were asymptomatic and had no sequelae. There was no increase of pre-term labor and delivery or NICU admissions from SARS-CoV2 positive mothers. Examination of 101 placentas from SARS-CoV2 positive mothers and 121 placentas from SARS-CoV2 negative mothers revealed no increase of placental pathologic features. There were more vaginal deliveries and more meconium stain of fetal membranes from the SARS-CoV2 positive mothers. Previous reports of more maternal vascular malperfusion and fetal vascular malperfusion were not demonstrated in our current data.Although SARS-CoV2 is a significant risk to the pregnant women (mothers) and general population, there is no increased risk for neonates. Vertical transmission is rare, and perinatal transmission can also occur. There is no increased frequency of placental abnormalities in both maternal and fetal circulation.

Electrical injury has low incidence but is associated with high morbidity and mortality. Variability in diagnosis and management among clinicians can lead to unnecessary testing. This study examines the utility of an electrical injury treatment algorithm by comparing the incidence of testing done on a cohort of patients before and after implementation. Demographics, injury characteristics, and treatment information were collected for patients arriving to a regional burn center with the diagnosis of electrical injury from January 2013 to September 2018. Results were compared for patients admitted before and after the implementation of an electrical injury treatment algorithm in July 2015. There were 56 patients in the pre-algorithm cohort and 38 in the post-algorithm cohort who were of similar demographics. The proportion of creatine kinase (82% vs 47%, P < .0006), troponin (79% vs 34%, P < .0001), and urinary myoglobin (80% vs 45%, P < .0007) testing in the pre-algorithm cohort was significantly higher compared to post-algorithm cohort. There were more days of telemetry monitoring (median [IQR], 1 [1–5] vs 1 [1-1] days, P = .009) and greater ICU length of stays (4 [1–5] vs 1 [1-1] days, P = .009), prior to algorithm implementation. There were no significant differences in total hospital lengths of stay, incidence of ICU admissions, in-hospital mortality, or 30-day readmissions. This study demonstrates an electrical injury evaluation and treatment algorithm suggests a mode of triage to cardiac monitoring and hospital admission where necessary. Use of this algorithm allowed for reduction in testing and health care costs without increasing mortality or readmission rates.