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Abstract Introduction Many evidence‐based programs (EBPs) have been determined in randomized controlled trials to be effective, but few studies explore the real‐world effectiveness of EBPs implemented in the natural community setting. Our study evaluated whether a novel linked infrastructure would enable such insights and continuous improvement as part of a learning healthcare‐community bridged “wellcare” ecosystem. Methods We created a secure, web‐based data entry and storage platform with a network of Minnesota community‐based organizations to record EBP participants' demographics and attendance, and program details. We then linked participant's information to their Rochester Epidemiology Project (REP) medical records. With this infrastructure, we conducted a proof of concept, retrospective cohort study by matching EBP participants to REP controls and comparing medical record‐documented outcomes over 1 year follow‐up. Results We successfully linked EBP participant records with medical records in 77.6% of cases, and the infrastructure proved feasible and scalable. Still, key challenges remain in obtaining participant consent for data sharing. Upfront resource investments and the availability of REP‐like warehouses limit generalizability. Optimal learning will be improved by enhancements that better track program fidelity. Our pilot study established a proof‐of‐concept, but sample sizes (n = 99 for falls prevention and n = 97 chronic disease/pain management EBP completers) were too small to detect significant differences in hospital admittance as compared to matched controls for either EBP group, (OR = 0.66[0.36, 1.19]) and (OR = 0.81[0.43, 1.54]), respectively. Events were too rare to gather meaningful information about effects on fall rates. Conclusions Our pilot demonstrates the feasibility of developing an online infrastructure that connects information from community leaders with medical record documented health outcomes, bridging the knowledge gap between community programs and the health care system. Insights gleaned from our infrastructure can be used to continuously shape community program delivery to reduce the need for formal health care services.

Objectives: According to the World Health Organization (WHO), an early and consistent international and national response is needed to control a pandemic's spread. In this analysis, we evaluate the coordination of Canada's early response to the coronavirus (COVID-19) pandemic in terms of public health interventions and policies implemented in each province and territory.Methods: Retrospective data was obtained from publicly accessible websites maintained by federal, provincial and territorial governmental agencies. Consistent with WHO's spreading of the disease pandemic action, individual and community-based public health interventions and policies were the focus. Time of intervention or policy, and COVID-19 cases per million at time of intervention was recorded for each province and territory.Results: Most public health interventions and policies demonstrated wide time ranges of implementation across individual provinces and territories. At time of implementation, there were also wide variations in the number of positive COVID-19 cases in these jurisdictions. Cases per million per implemented day were also not similar across interventions or policy, suggesting that other factors may have been preferentially considered.Conclusions: Whether an earlier and more structured national approach would have lessened the pandemic's burden is uncertain, calls for greater federal coordination and leadership should to examined.

Abstract Background There are currently limited data for the use of specific antiviral therapies for the treatment of Ebola virus disease (EVD). While there is anecdotal evidence that supportive care may be effective, there is a paucity of direct experimental data to demonstrate a role for supportive care in EVD. We studied the impact of ICU-level supportive care interventions including fluid resuscitation, vasoactive medications, blood transfusion, hydrocortisone, and ventilator support on the pathophysiology of EVD in rhesus macaques infected with a universally lethal dose of Ebola virus strain Makona C07. Methods Four NHPs were infected with a universally lethal dose Ebola virus strain Makona, in accordance with the gold standard lethal Ebola NHP challenge model. Following infection, the following therapeutic interventions were employed: continuous bedside supportive care, ventilator support, judicious fluid resuscitation, vasoactive medications, blood transfusion, and hydrocortisone as needed to treat cardiovascular compromise. A range of physiological parameters were continuously monitored to gage any response to the interventions. Results All four NHPs developed EVD and demonstrated a similar clinical course. All animals reached a terminal endpoint, which occurred at an average time of 166.5 ± 14.8 h post-infection. Fluid administration may have temporarily blunted a rise in lactate, but the effect was short lived. Vasoactive medications resulted in short-lived improvements in mean arterial pressure. Blood transfusion and hydrocortisone did not appear to have a significant positive impact on the course of the disease. Conclusions The model employed for this study is reflective of an intramuscular infection in humans (e.g., needle stick) and is highly lethal to NHPs. Using this model, we found that the animals developed progressive severe organ dysfunction and profound shock preceding death. While the overall impact of supportive care on the observed pathophysiology was limited, we did observe some time-dependent positive responses. Since this model is highly lethal, it does not reflect the full spectrum of human EVD. Our findings support the need for continued development of animal models that replicate the spectrum of human disease as well as ongoing development of anti-Ebola therapies to complement supportive care.

Continuous renal replacement therapy (CRRT) has become a pillar of care in pediatric intensive care units (PICUs) over the past few decades. Quality indicators (QIs) have been evaluated that reflect safe and accountable CRRT. However, there is a paucity of data on outcomes and QIs in smaller-volume CRRT programming. The purpose of this retrospective study was to evaluate the efficiencies, effectiveness, and outcomes of a small-volume CRRT program. Eighty-two patients received CRRT over a 13-year period, and 79% survived to discharge. Sepsis or nonseptic shock (n = 11 (22%) versus n = 6 (50%); p value = 0.004) and time to CRRT initiation after PICU admission (1.1 versus 5.0 days; p value = 0.005) were independent predictors for mortality. The program also had positive outcomes for QIs related to CRRT efficiency and time of initiation, dosing delivery, and rate of adverse events. This study is important as it illustrates the opportunity that smaller centers have to initiate CRRT programming and provide safe and effective care.

Abstract Critical care needs have been rising in recent decades as populations age and comorbidities increase. Sepsis-related admissions to critical care contribute up to 50% of volume and septic shock carries a 35–54% fatality rate. Improvements in sepsis-related care and mortality would have a significant impact of a resource-intensive area of health care delivery. Unfortunately, research has been hampered by the lack of an animal model that replicates the complex care provided to humans in an intensive care unit (ICU). We developed a protocol to provide full ICU type supportive care to Rhesus macaques. This included mechanical ventilation, continuous sedation, fluid and electrolyte management and vasopressor support in response to Ebolavirus-induced septic shock. The animals accurately recapitulated human responses to a full range of ICU interventions (e.g. fluid resuscitation). This model can overcome current animal model limitations by accurately emulating the complexity of ICU care and thereby provide a platform for testing new interventions in critical care and sepsis without placing patients at risk.

Titrating ventilator settings to minimize pulmonary arterial pressures and optimize both ventilation and oxygen delivery can be challenging following cardiac arrest. Erroneous ventilator adjustments can lead to unnecessary strain on the right ventricle that may be particularly vulnerable during the acute recovery. We report a child with fulminant myocarditis who was mechanically ventilated using thoracic electrical impedance tomography to optimize regional lung inflation and possibly curtail right ventricular afterload following cardiac arrest.

Abstract Background Ultrasound measurement of optic nerve sheath diameter (ONSD) appears to be a promising, rapid, non-invasive bedside tool for identification of elevated intra-cranial pressure. With improvements in ultrasound technology, machines are becoming smaller; however, it is unclear if these ultra-portable handheld units have the resolution to make these measurements precisely. In this study, we estimate the accuracy of ONSD measurement in a pocket-sized ultrasound unit. Methods Utilizing a locally developed, previously validated model of the eye, ONSD was measured by two expert observers, three times with two machines and on five models with different optic nerve sheath sizes. A pocket ultrasound (Vscan, GE Healthcare) and a standard portable ultrasound (M-Turbo, SonoSite) were used to measure the models. Data was analyzed by Bland–Altman plot and intra-class correlation coefficient (ICC). Results The ICC between raters for the SonoSite was 0.878, and for the Vscan was 0.826. The between-machine agreement ICC was 0.752. Bland–Altman agreement analysis between the two ultrasound methods showed an even spread across the range of sheath sizes, and that the Vscan tended to read on average 0.33 mm higher than the SonoSite for each measurement, with a standard deviation of 0.65 mm. Conclusions Accurate ONSD measurement may be possible utilizing pocket-sized, handheld ultrasound devices despite their small screen size, lower resolution, and lower probe frequencies. Further study in human subjects is warranted for all newer handheld ultrasound models as they become available on the market.

Background: The 2014–2016 Ebola outbreak in West Africa recapitulated that nosocomial spread of Ebola virus could occur and that health care workers were at particular risk including notable cases in Europe and North America. These instances highlighted the need for centers to better prepare for potential Ebola virus cases; including understanding how the virus spreads and which interventions pose the greatest risk. Methods: We created a fully equipped intensive care unit (ICU), within a Biosafety Level 4 (BSL4) laboratory, and infected multiple sedated non-human primates (NHPs) with Ebola virus. While providing bedside care, we sampled blood, urine, and gastric residuals; as well as buccal, ocular, nasal, rectal, and skin swabs, to assess the risks associated with routine care. We also assessed the physical environment at end-point. Results: Although viral RNA was detectable in blood as early as three days post-infection, it was not detectable in the urine, gastric fluid, or swabs until late-stage disease. While droplet spread and fomite contamination were present on a few of the surfaces that were routinely touched while providing care in the ICU for the infected animal, these may have been abrogated through good routine hygiene practices. Conclusions: Overall this study has helped further our understanding of which procedures may pose the highest risk to healthcare providers and provides temporal evidence of this over the clinical course of disease.

Please note that four authors (Logan Banadyga, Alixandra Albietz, Brad Pickering, and Gary Wong) have been erroneously omitted from the author list in the published original article [1].

This report summarizes a case of a 4-year-old girl with poststreptococcal glomerulonephritis and diffuse alveolar hemorrhage, an atypical presentation in this age group and type of vasculitic disease. We propose that her rapid improvement in clinical status was due to her treatment, continuous renal replacement therapy (CRRT). This mechanism would have impacted recovery by removing factors such as endothelial microparticles, superantigens, and immune complexes that have been postulated as the pulmonary-renal link. This may be an interesting avenue of exploration going forward given the lack of evidence in treating such conditions and emergence of CRRT.

Purpose: To evaluate the current evidence in the literature on treatment strategies for degenerative lumbar spine fusion in patients with osteoporosis. Methods: A systematic review of the literature from 1950 to 2015. Results: The review of the literature yielded 15 studies on the effect of treatment options for osteoporosis on lumbar fusion rates. This study evaluated only degenerative lumbar spine conditions and excluded deformity patients. One study demonstrated an association between low bone mass as measured by Hounsfield units and lower fusion rates. Six studies evaluated perioperative medical treatment of osteoporosis and showed higher fusion rates in patients treated with alendronate and teriparatide. The strongest evidence was for perioperative teriparatide. Eight studies evaluated surgical treatment strategies in patients with osteoporosis and showed that cement augmentation of pedicle screws and expandable pedicle screws demonstrated improved fusion rates than traditional pedicle screws. The strongest evidence was for expandable pedicle screws. Conclusion: There are 15 articles evaluating osteoporosis in patients undergoing lumbar fusion and the highest level of evidence is for perioperative use of teriparatide.

Objectives: It remains uncertain whether nonconvulsive seizures and nonconvulsive status epilepticus in pediatric traumatic brain injury are deleterious to the brain and/or impact the recovery from injury. Consequently, optimal electroencephalographic surveillance and management is unknown. We aimed to determine specialists’ opinion regarding the detection and treatment of nonconvulsive seizures or nonconvulsive status epilepticus in pediatric traumatic brain injury, regardless of their practice. Methods: In 2012, 183 surveys were sent to all 93 neurologists, 27 neurosurgeons, and 63 intensivists in the14 tertiary pediatric hospitals across Canada. The survey included an initial scenario of pediatric TBI that evolved into three further scenarios. Each scenario had required responses and an embedded branching logic algorithm ascertaining clinical management. The survey instrument assimilated data about the importance of nonconvulsive status epilepticus and nonconvulsive seizures detection and treatment, and whether they are a cause of brain injury that adversely affects neurologic outcomes. Results: Of the 79 specialists who replied (43% response rate), 68%–78% elected to order an electroencephalographic across all four scenarios, and one-third (31%–36%; scenario dependent) would request an urgent electroencephalographic (within the hour) in the comatose pediatric traumatic brain injury patient. In the absence of pharmacologic paralysis or intracranial pressure spikes, half-hour electroencephalographic (41%–55%) was preferred over ⩾24-h continuous electroencephalographic monitoring (29%–40%). Finally, nonconvulsive status epilepticus (81%–87%) and nonconvulsive seizures (61%–73%) were considered to be a cause of poor neurologic outcomes warranting aggressive pharmacologic management. Conclusion: The Canadian specialists’ opinion is that nonconvulsive seizures and nonconvulsive status epilepticus are biomarkers of brain injury and contribute to worsened outcomes. This suggests the urgency of future outcome-oriented research in the identification and management of nonconvulsive seizures or nonconvulsive status epilepticus.