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John C Jackson, Anthony L Farone, Mary B Farone Biology Department, Middle Tennessee State University, Murfreesboro, Tennessee, USA Purpose: Diarrheal disease is one of the leading causes of morbidity in developing countries. To further understand the epidemiology of diarrheal disease among a rural population surrounding Robillard, Haiti, fecal swabs from patients with diarrhea were screened for the presence of enteropathogenic bacteria. Patients and methods: Fecal swabs were collected from 34 patients with signs and symptoms of diarrhea and stored in BBLTM Cary-Blair transport medium (Becton, Dickinson and Company, Sparks, MD) until transit to the USA. Swab material was inoculated on to different enrichment and selective agars for incubation. Fermenting and nonfermenting bacteria that grew on the enteric selection media were identified by the BBLTM CrystalTM Enteric/Nonferementing Identification system (Becton, Dickinson and Company). Organisms identified as Escherichia coli were further screened for the presence of virulence factors by polymerase chain reaction (PCR). Results: Of 34 patients, no Campylobacter, Shigella, Salmonella, or Vibrio spp. were isolated from swabs transported to the USA for culture. Of 73 E. coli isolates cultured from the swabs, one enteropathogenic strain of E. coli was identified by multiplex PCR. Escherichia fergusonii and Cronobacter sakazakii, both potential gastrointestinal pathogens, were also isolated from patient stools. Conclusion: This study was undertaken to determine if bacterial enteropathogens could be detected in the stools of patients suffering from diarrhea or dysentery and, in the absence of sufficient facilities, rectal swabs could be transported to the USA for culture. Although several genera of overt enteropathogens were not detected, one enteropathogenic E. coli and other pathogenic enterobacteriaceae were successfully cultured and identified. Keywords: Escherichia, Cronobacter, diarrheagenic, stool

Background: Delirium occurs frequently in the intensive care unit (ICU), but its pathophysiology is still unclear. Low levels of insulin-like growth factor 1 (IGF-1), a hormone with neuroprotective properties, have been associated with delirium in some non-ICU studies, but this relationship has not been examined in the ICU. We sought to test the hypothesis that low IGF-1 concentrations are associated with delirium during critical illness.Methods: Mechanically ventilated medical ICU patients were prospectively enrolled, and blood was collected after enrollment for measurement of IGF-1 using radioimmunometric assay. Delirium and coma were identified daily using the Confusion Assessment Method for the ICU and the Richmond Agitation-Sedation Scale, respectively. The association between IGF-1 and delirium was evaluated with logistic regression. In addition, the association between IGF-1 and duration of normal mental state, measured as days alive without delirium or coma, was assessed using multiple linear regression.Results: Among 110 patients, the median age was 65 years (IQR, 52-75) and APACHE II was 27 (IQR, 22 -32). IGF-1 levels were not a risk factor for delirium on the day after IGF-1 measurement (p = 0.97), at which time 65% of the assessable patients were delirious. No significant association was found between IGF-1 levels and duration of normal mental state (p = 0.23).Conclusions: This pilot study, the first to investigate IGF-1 and delirium in critically ill patients, found no association between IGF-1 and delirium. Future studies including serial measurements of IGF-1 and IGF-1 binding proteins are needed to determine whether this hormone has a role in delirium during critical illness. [ABSTRACT FROM AUTHOR]

Objective. There exists uncertainty regarding the role of magnetic resonance imaging in the evaluation of intensive care unit delirious patients. This case series describes preliminary magnetic resonance imaging findings obtained because of delirium, subsequent inhospital clinical decisions, and postdischarge neurocognitive outcomes in intensive care unit survivors. Design. Case series. Setting. Intensive care unit. Participants. Eight patients who underwent magnetic resonance imaging for delirium in the absence of focal neurological findings as part of their intensive care unit clinical care. Measurements. Magnetic resonance imaging findings, clinical decisions following magnetic resonance imaging, and three-month neuropsychological outcomes were obtained. Results. Of the eight patients, six (75%) demonstrated white matter hyperintensities, one (12%) had mild atrophy, and no patient had ischemic/hemorrhagic lesions. Magnetic resonance imaging did not lead to new diagnoses or immediate changes in therapy. All six patients who underwent neuropsychological testing had severe impairments in memory, executive function, and attention at three months, despite the absence of baseline cognitive impairment. Conclusion. Magnetic resonance imaging findings in these delirious intensive care unit patients did not alter the immediate treatment course and these patients had neuropsychological impairments at three months. Future research is warranted to define the role of current and newer magnetic resonance imaging techniques in assessing and managing delirious intensive care unit patients, and to examine relationships between inhospital magnetic resonance imaging findings (i.e. white matter hyperintensities) and short- and longterm neurological outcomes. [ABSTRACT FROM AUTHOR]

Rationale: Studies have shown that reducing sedation of critically ill patients shortens time on the ventilator and in the intensive care unit (ICU). Little is known, however, of how such strategies affect long-term cognitive, psychological, and functional outcomes.Objectives: To determine the long-term effects of a wake up and breathe protocol that interrupts and reduces sedative exposure in the ICU.Methods: In this a priori planned substudy conducted at one tertiary care hospital during the Awakening and Breathing Controlled Trial, a multicenter randomized controlled trial, we assessed cognitive, psychological, and functional/quality-of-life outcomes 3 and 12 months postdischarge among 180 medical ICU patients randomized to paired daily spontaneous awakening trials with spontaneous breathing trials (SBTs) or to sedation per usual care plus daily SBTs.Measurements and Main Results: Cognitive impairment was less common in the intervention group at 3-month follow-up (absolute risk reduction, 20.2%; 95% confidence interval, 1.5-36.1%; P = 0.03) but not at 12-month follow-up (absolute risk reduction, -1.9%; 95% CI, -21.3 to 27.1%; P = 0.89). Composite cognitive scores, alternatively, were similar in the two groups at 3-month and 12-month follow-up (P = 0.80 and 0.61, respectively), as were symptoms of depression (P = 0.59 and 0.82) and posttraumatic stress disorder (P = 0.59 and 0.97). Activities of daily living, functional status, and mental and physical quality of life were similar between groups throughout follow-up.Conclusions: In this trial, management of mechanically ventilated medical ICU patients with a wake up and breathe protocol resulted in similar cognitive, psychological, and functional outcomes among patients tested 3 and 12 months post-ICU. The proven benefits of this protocol, including improved 1-year survival, were not offset by adverse long-term outcomes. Clinical trial registered with www.clinicaltrials.gov (NCT 00097630). [ABSTRACT FROM AUTHOR]

Rationale: Many conferences in the ICU occur with the families of patients with limited English proficiency, requiring a medical interpreter. Despite the importance of medical interpretation, little is known about the alterations that occur and their effect on communication.Objectives: This study characterizes the types, prevalence, and potential effects of alterations in interpretation during ICU family conferences involving end-of-life discussions.Methods: We identified ICU family conferences in two hospitals in which a medical interpreter was used. Ten conferences were audiotaped; 9 physicians led these conferences, and 70 family members participated. Research interpreters different from those attending the conference translated the non-English language portions of the audiotaped conferences. We identified interpretation alterations, grouped them into four types, and categorized their potential effects on communication.Results: For each interpreted exchange between clinicians and family, there was a 55% chance that an alteration would occur. These alterations included additions, omissions, substitutions, and editorializations. Over three quarters of alterations were judged to have potentially clinically significant consequences on the goals of the conference. Of the potentially significant alterations, 93% were likely to have a negative effect on communication; the remainder, a positive effect. The alterations with potentially negative effects included interference with the transfer of information, reduced emotional support, and reduced rapport. Those with potential positive effects included improvements in conveying information and emotional support.Conclusions: Alterations in medical interpretation seem to occur frequently and often have the potential for negative consequences on the common goals of the family conference. Further studies examining and addressing these alterations may help clinicians and interpreters to improve communication with family members during ICU family conferences. [ABSTRACT FROM AUTHOR]

Introduction: The objective of this paper was to examine knowledge about cervical cancer risk factors and traditional health beliefs in relation to Papanicolaou (Pap) testing among Vietnamese women.Methods: A population-based survey was conducted in Seattle (n<352, response rate=82%) during 2002.Results: The proportions of women who knew that older age, not getting regular Pap tests, and Vietnamese ethnicity are associated with an elevated cervical cancer risk were only 53%, 62%, and 23%, respectively. The majority (87%) incorrectly believed poor women's hygiene is a risk factor for cervical cancer. Approximately two-thirds (68%) of the women had received a Pap test during the preceding three years. Knowing that lack of Pap testing increases the risk of cervical cancer was strongly associated (p<0.001) with recent Pap smear receipt.Conclusion: Our results confirm that Vietnamese women have lower levels of cervical cancer screening than non-Latina white women. Intervention programs addressing Pap testing in Vietnamese communities should recognize women's traditional beliefs while encouraging them to adopt biomedical preventive measures into their daily lives. [ABSTRACT FROM AUTHOR]

BACKGROUND: Cervical cancer incidence rates are higher among Vietnamese American women than among any other race/ethnic group in the United States. High rates of cervical cancer are associated with low rates of Papanicolao (Pap) testing adherence. METHODS: Twenty-five qualitative interviews and 5 focus groups were conducted with Vietnamese women. RESULTS: Interviews and focus groups revealed unanticipated information about sociocultural influences on women's beliefs about risk factors for cervical cancer. These data were utilized to develop culturally appropriate outreach materials. CONCLUSIONS: Engaging with the target community enabled the development of culturally appropriate materials addressing cervical cancer risk factors and encouraging Pap testing adherence. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine neuropsychological function, depression, and quality of life 6 months after discharge in patients who received mechanical ventilation in the intensive care unit. DESIGN: Prospective cohort study. SETTING: Tertiary care, medical and coronary intensive care unit of a university-based medical center. STUDY POPULATION: A total of 275 consecutive, mechanically ventilated patients from a medical intensive care unit were prospectively followed. At 6 months, 157 were alive, of whom 41 (26%) returned for extensive follow-up testing. MEASUREMENT AND MAIN RESULTS: Neuropsychological testing and assessment of depression and quality of life were performed at 6-month follow-up. Seven of 41 patients were excluded from further analysis due to preexisting cognitive impairment determined via surrogate interviews using the Modified Blessed Dementia Rating Scale and a review of medical records. On the basis of strict criteria derived from normative data, we found that 11 of 34 patients (32%) were neuropsychologically impaired. Impairment was generally diffuse but occurred primarily in areas of psychomotor speed, visual and working memory, verbal fluency, and visuo-construction. The rate of neuropsychological deficits in the study population was markedly higher than population norms for mild dementia. Scores on the Geriatric Depression Scale-Short Form were significantly more abnormal in the neuropsychologically impaired group than in the nonimpaired group at hospital discharge (p =.04) and at 6-month follow-up (p =.02), and clinically significant depression was found in 27% of impaired subjects at hospital discharge and in 36% at 6-month follow-up. No differences were observed between groups in quality of life as measured with the Short Form Health Survey-12 at discharge or 6-month follow-up. CONCLUSIONS: Prolonged neuropsychological impairment is common among survivors of the medical intensive care unit and occurs with greater than anticipated frequency when compared with relevant normative data. Future investigations are warranted to elucidate the nature of the association between critical illness, neuropsychological impairment, depression, and decreased quality of life. [ABSTRACT FROM AUTHOR]

The objective of the study was to develop a culturally relevant video and a pamphlet for use as a cervical cancer screening educational intervention among North-American Chinese women. The project conducted 87 qualitative interviews and nine focus groups to develop a culturally tailored intervention to improve Pap testing rates. The intervention consisted of an educational/motivational video, a pamphlet, and home visits. Less acculturated Chinese women draw on a rich tradition of herbal knowledge and folk practices historically based on Chinese medical theory, now mixed with new information from the media and popular culture. The video, the pamphlet, and the outreach workers knowledge base were designed using these results and combined with biomedical information to address potential obstacles to Pap testing. Culturally relevant information for reproductive health promotion was easily retrieved through qualitative interviews and used to create educational materials modeling the integration of Pap testing into Chinese women's health practices. [ABSTRACT FROM AUTHOR]

Background: North American Chinese women have lower levels of Papanicolaou (Pap) testing than other population subgroups. We conducted a randomized controlled trial to evaluate the effectiveness of two alternative cervical cancer screening interventions for Chinese women living in North America.Methods: Four hundred and eighty-two Pap testing underutilizers were identified from community-based surveys of Chinese women conducted in Seattle, Washington, and Vancouver, British Columbia. These women were randomly assigned to one of two experimental arms or control status. Several Chinese-language materials were used in both experimental arms: an education-entertainment video, a motivational pamphlet, an educational brochure, and a fact sheet. Women in the first experimental group (outreach worker intervention) received the materials, as well as tailored counseling and logistic assistance, during home visits by trilingual, bicultural outreach workers. Those in the second experimental group (direct mail intervention) received the materials by mail. The control group received usual care. Follow-up surveys were completed 6 months after randomization to ascertain participants' Pap testing behavior. All statistical tests were two-sided.Results: A total of 402 women responded to the follow-up survey (83% response rate). Of these women, 50 (39%) of the 129 women in the outreach group, 35 (25%) of the 139 women in the direct mail group, and 20 (15%) of the 134 women in the control group reported Pap testing in the interval between randomization and follow-up data collection (P<.001 for outreach worker versus control, P =.03 for direct mail versus control, and P =.02 for outreach worker versus direct mail). Intervention effects were greater in Vancouver than in Seattle.Conclusion: Culturally and linguistically appropriate interventions may improve Pap testing levels among Chinese women in North America. [ABSTRACT FROM AUTHOR]

Introduction: Chinese American women have high rates of invasive cervical cancer, compared to the general population. However, little is known about the Pap testing behavior of ethnic Chinese immigrants.Methods: We conducted a community-based survey of Chinese immigrants living in Seattle, Washington, during 1999. Two indicators of cervical cancer screening participation were examined: at least one previous Pap smear and Pap testing in the last 2 years.Results: The overall estimated response rate was 64%, and the cooperation rate was 72%. Our study sample for this analysis included 647 women. Nearly one quarter (24%) of the respondents had never had a Pap test, and only 60% had been screened recently. Factors independently associated with cervical cancer screening use included marital status, housing type, and age at immigration.Conclusion: Our findings confirm low levels of cervical cancer screening among Chinese immigrants to North America. Culturally and linguistically appropriate Pap testing intervention programs for less acculturated Chinese women should be developed, implemented, and evaluated. [ABSTRACT FROM AUTHOR]

Southeast Asian immigrants have lower levels of Yap testing than any other racial/ethnic group in the US, and are particularly unfamiliar with western culture and biomedical concepts of prevention. We completed an ethnographic study (N = 42) focusing on cervical cancer screening among Cambodian American women. We also conducted a community-based survey (N = 413) to examine the generalizability of our qualitative results. This report summarizes the results, and describes how we used our findings to influence the content of a multifaceted intervention program targeting Cambodian immigrants. The following constructs were found to be barriers to cervical cancer control: a traditional orientation to the prevention, causation, and treatment of disease; lack of familiarity with western early detection concepts; low levels of knowledge about cervical cancer; concerns about the Yap testing procedure; and health care access issues. In general, the quantitative results confirmed our ethnographic findings. The intervention program, which is delivered by bicultural outreach workers, includes home visits, presentations at small group meetings, barrier-specific counseling, use of a Khmer-language video, and tailored logistic assistance (e.g., transportation and medical interpretation). Both the video and presentation provide cultural context while simultaneously addressing multiple barriers to screening (e.g., women's fear of surgery and preference for female providers). Outreach workers are trained to counsel women about 10 potential barriers including avoidance of biomedicine, perceptions that gynecologic exams are embarrassing, and lack of English proficiency. Our results reinforce the importance of considering health problems within the context of a population's traditional belief systems and daily routines. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine the incidence of adverse events attributable to exchange transfusion during the past 15 years and compare the incidence of severe complications between healthy and ill infants. DESIGN: Medical records for the past 15 years from two teaching hospitals with neonatal intensive care units were reviewed. Those newborns who underwent exchange transfusions were classified as healthy or ill. Adverse events were analyzed to determine whether they were attributable to the procedure. RESULTS: Of the 106 patients who underwent exchange transfusion, 81 were healthy and had no medical problems other than jaundice. The remaining 25 patients were classified as ill and had medical problems ranging from mild to severe. At least 2 (2%) of the 106 patients died of complications probably attributable to exchange transfusion. None of the 81 healthy infants died, but 1 had severe necrotizing enterocolitis requiring surgery. Of the 25 ill infants, at least 3 (12%) experienced severe complications (including 2 deaths) probably attributable to exchange transfusion. Serious complications from the most common adverse events, hypocalcemia and thrombocytopenia, were limited to the group of infants already ill with other medical problems. CONCLUSIONS: Because of the significantly greater rate of severe complications in ill infants, exchange transfusion should be delayed until the risk of bilirubin encephalopathy is as high as the risks of severe complications from the procedure itself (12%). These results do not support recommendations to use lower exchange levels in ill infants compared with healthy infants. [ABSTRACT FROM AUTHOR]

Background: Among survivors of critical illness, prescription of potentially inappropriate medications (PIM) at hospital discharge is thought to be an important, modifiable patient safety concern. To date, there are little empirical data evaluating this issue., Research Question: The objective of this study was to determine the frequency of PIM prescribed to survivors of acute respiratory failure (ARF) at hospital discharge and explore their association with readmissions or death within 90 days of hospital discharge., Study Design and Methods: Prospective multicenter cohort study of ARF survivors admitted to ICUs and discharged home. Prospective of new PIMs with a high-adverse-effect profile ("high impact") at discharge was the primary exposure. Potential inappropriateness was determined by a structured consensus process using Screening Tool of Older Persons' Prescriptions-Screening Tool to Alert to Right Treatment, Beers' criteria, and clinical context of prescriptions by a multidisciplinary team. Covariate balancing propensity score was used for the primary analysis., Results: Of the 195 Addressing Post Intensive Care Syndrome-01 (APICS-01) patients, 169 (87%) had ≥1 new medications prescribed at discharge, with 154 (91.1%) prescribed with one or more high-impact (HI) medications. Patients were prescribed a median of 5 [3-7] medications, of which 3 [1-4] were HI. Twenty percent of HI medications were potentially inappropriate. Medications with significant central nervous system side-effects were most prescribed potentially inappropriately. Forty-six (30%) patients experienced readmission or death within 90 days of hospital discharge. After adjusting for prespecified covariates, the association between prescription of potentially inappropriate HI medications and the composite primary outcome did not meet the prespecified threshold for statistical significance (risk ratio: 0.54; 0.26-1.13; p = 0.095) or with the constituent endpoints: readmission (risk ratio: 0.57, 0.27-1.11) or death (0.7, 0.05-9.32)., Conclusion: At hospital discharge, most ARF survivors are prescribed medications with a high-adverse-effect profile and approximately one-fifth are potentially inappropriate. Although prescription of such medications was not associated with 90-day readmissions and mortality, these results highlight an area for additional investigation., (Copyright © 2024 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Our aim was to investigate the perception and future expectations of Single-Port (SP) surgery among urology trainees in the United States. A 34-item online survey was distributed to urological residency and fellowship programs across the US, covering demographic profiles, SP training opportunities, perceived educational impact, and future perspectives. Descriptive analysis and multivariable linear regression were used to assess predictors of SP adoption. 201 surveys were completed (28.6% completion rate). Among institutions with an SP platform, about 50% have used it regularly for over 2 years, though often in less than 50% of procedures. While robotic simulators are commonly available, only 17% offer both multi-port and SP simulators, and structured pre-clinical SP training is limited. Approximately 30% of respondents expressed concerns over limited hands-on experience and a steeper learning curve with SP. Around 40% felt that their robotic surgery exposure was negatively impacted by SP's introduction. SP surgery's benefits are seen mostly in the immediate post-operative period and a significant number of respondents foresee a major role for SP in urology. However, proficiency in SP surgery is not seen as crucial for career advancement or job opportunities. Academic job aspirations, SP platform availability, and SP surgery workload are predictors of future SP implementation. Trainees increasingly recognize the clinical benefits of SP procedures but express concerns about the potential negative impact on hands-on experience. Training programs should more systematically integrate SP technology into curricula. There is a correlation between training in high-volume SP centers and future SP adoption., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

The number of intensive care unit (ICU) survivors continues to grow, largely due to the emergence of more sophisticated treatment options. Yet despite this remarkable life-saving progress, far too little attention is paid to the survivor's long-term quality of life after discharge. Post-Intensive Care Syndrome continues to impact many survivors' physical, cognitive, and mental health, as well as their social functioning related to these new impairments. In light of this knowledge, there is room to enhance compassionate care, both in and after the ICU, starting with improved collaboration with the patient, their caregivers, and other providers on the patient's care team., Competing Interests: Disclosures The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The efficacy of serratus anterior plane block for treatment of pain after minimally invasive thoracic surgery remains unclear. This trial assesses the impact of serratus anterior plane block on postoperative opioid consumption and on measures of early recovery after thoracoscopic lung resection., Methods: Patients undergoing minimally invasive anatomic lung resection at a single center were randomized to undergo serratus anterior plane block with 40 ml injectate containing bupivacaine 0.25%, clonidine 100 μg, and dexamethasone 4 mg (serratus anterior plane block group) or sham block with 40 ml normal saline (placebo group) at the conclusion of surgery. The primary outcome was cumulative intravenous morphine equivalents during the first 24 h postoperatively. Secondary outcomes were intravenous morphine equivalents, pain scores at rest and with cough, inspiratory volume on incentive spirometry, incidence of nausea or vomiting during the first 48 h postoperatively, Quality of Recovery-15 score on postoperative day 7, and length of stay., Results: Using the protocol-specified intention-to-treat analysis, the median (interquartile range) intravenous morphine equivalents was 10.6 (5.0 to 27.1) mg in serratus anterior plane block patients (n = 46) versus 18.8 (9.9 to 29.6) mg in placebo patients (n = 46; 32% reduction; ratio, 0.68 [95% CI, 0.44 to 1.06]; P = 0.085). Of the secondary outcomes, only the composite pain with cough scores differed significantly in the serratus anterior plane block group by a coefficient of -0.41 (95% CI, -0.81 to -0.01; P = 0.044). A sensitivity as-treated analysis reported median (interquartile range) intravenous morphine equivalents of 10.0 (5.0 to 27.2) mg in serratus anterior plane block patients (n = 44) versus 19.9 (10.4 to 29.0) mg in placebo patients (n = 48; 36% reduction; ratio, 0.64 [95% CI, 0.41 to 1.00]; P = 0.048)., Conclusions: The protocol-specified intention-to-treat analysis demonstrated that serratus anterior plane block did not result in a significant reduction in opioid consumption when added to a multimodal analgesic regimen after thoracoscopic anatomic lung resection. The sensitivity as-treated analysis showed a significant and modest clinical reduction in the primary outcome that warrants further investigation., (Copyright © 2024 American Society of Anesthesiologists. All Rights Reserved.)

Background: Delirium is common during critical illness and is associated with long-term cognitive impairment and disability. Antipsychotics are frequently used to treat delirium, but their effects on long-term outcomes are unknown. We aimed to investigate the effects of antipsychotic treatment of delirious, critically ill patients on long-term cognitive, functional, psychological, and quality-of-life outcomes., Methods: This prespecified, long-term follow-up to the randomised, double-blind, placebo-controlled phase 3 MIND-USA Study was conducted in 16 hospitals throughout the USA. Adults (aged ≥18 years) who had been admitted to an intensive care unit with respiratory failure or septic or cardiogenic shock were eligible for inclusion in the study if they had delirium. Participants were randomly assigned-using a computer-generated, permuted-block randomisation scheme with stratification by trial site and age-in a 1:1:1 ratio to receive intravenous placebo, haloperidol, or ziprasidone for up to 14 days. Investigators and participants were masked to treatment group assignment. 3 months and 12 months after randomisation, we assessed survivors' cognitive, functional, psychological, quality-of-life, and employment outcomes using validated telephone-administered tests and questionnaires. This trial was registered with ClinicalTrials.gov, NCT01211522, and is complete., Findings: Between Dec 7, 2011, and Aug 12, 2017, we screened 20 914 individuals, of whom 566 were eligible and consented or had consent provided to participate. Of these 566 patients, 184 were assigned to the placebo group, 192 to the haloperidol group, and 190 to the ziprasidone group. 1-year survival and follow-up rates were similar between groups. Cognitive impairment was common in all three treatment groups, with a third of survivors impaired at both 3-month and 12-month follow-up in all groups. More than half of the surveyed survivors in each group had cognitive or physical limitations (or both) that precluded employment at both 3-month and 12-month follow-up. At both 3 months and 12 months, neither haloperidol (adjusted odds ratio 1·22 [95% CI 0·73-2.04] at 3 months and 1·12 [0·60-2·11] at 12 months) nor ziprasidone (1·07 [0·59-1·96] at 3 months and 0·94 [0·62-1·44] at 12 months) significantly altered cognitive outcomes, as measured by the Telephone Interview for Cognitive Status T score, compared with placebo. We also found no evidence that functional, psychological, quality-of-life, or employment outcomes improved with haloperidol or ziprasidone compared with placebo., Interpretation: In delirious, critically ill patients, neither haloperidol nor ziprasidone had a significant effect on cognitive, functional, psychological, or quality-of-life outcomes among survivors. Our findings, along with insufficient evidence of short-term benefit and frequent inappropriate continuation of antipsychotics at hospital discharge, indicate that antipsychotics should not be used routinely to treat delirium in critically ill adults., Funding: National Institutes of Health and the US Department of Veterans Affairs., Competing Interests: Declaration of interests The following declarations of interest are reported outside of the submitted work. MFM reports grants from the National Institutes of Health (NIH) and the US Department of Veterans Affairs. LMB reports grants from the NIH and the American Association of Critical Care Nurses. MNG reports grants from the NIH, the Agency for Healthcare Research and Quality, and the US Centers for Disease Control and Prevention; consulting fees for a role as scientific advisor for Endpoint Health; honoraria for grand rounds presentation at Yale University (New Haven, CT, USA); travel support from the American Thoracic Society executive committee; and participation on the data safety monitoring board for a trial on monoclonal antibodies for COVID-19, funded by Regeneron (NCT04452318). AM reports consulting fees from Zoll, Eli Lilly, LivaNova, and Jazz Pharmaceuticals; and a philanthropic contribution from ResMed to the University of California San Diego (La Jolla, CA, USA). BAK reports grants from the NIH, payment for expert testimony for a medicolegal case in the state of Indiana (USA), payment for participation on a data safety monitoring board for the PANDORA trial, and a leadership role as president of the American Delirium Society. SSC reports grants from the NIH and direct payments for participation on the data safety monitoring board of an NIH-funded study unrelated to delirium. CLH reports grants from the NIH. PR reports grants from the NIH and the US Department of Defense, payment and travel support for a continuing medical education event at the Johns Hopkins School of Medicine, and previous leadership of the Association of Academic Anesthesiology Chairs and Society of Academic Associations of Anesthesiology and Perioperative Medicine. BTP reports leadership as co-chair of the Society of Critical Care Medicine ICU Liberation Committee. PPP reports grants from the NIH. NEB reports grants from the NIH and travel support for the Society of Intensive Care Medicine Singapore annual meeting. CGH reports consulting fees for Sedana Medical. MBP reports grants from CSL Behring, the NIH, and the US Department of Defense; royalties for serving as an associate editor with Elsevier on a surgical textbook; travel support for continuing medical education events with the Eastern Association for the Surgery of Trauma, Society of University Surgeons, and American College of Surgeons; a patent for image-derived prognostic models unrelated to this work; participation on a data safety monitoring board for Liberate Medical; and leadership as treasurer for the Eastern Association for the Surgery of Trauma. JLS reports honoria for presentations for the Society of Critical Care Medicine, American College of Chest Physicians, the Chilean Society of Critical Care Medicine, and the Spanish Society of Hospital Pharmacy; travel support for meetings with the Society of Critical Care Medicine, the Saudi Society of Clinical Pharmacy, and the Chilean Society of Critical Care Medicine; and leadership on committees with the Society of Critical Care Medicine. EWE reports grant support from the NIH and the US Department of Veterans Affairs, honoraria for continuing medical education lectures sponsored by Pfizer, and study support (investigational drug provision, no direct payments) from Eli Lilly. TDG reports grants from the NIH, research funding from Ceribell, and personal fees from Haisco Pharmaceutical and Lungpacer Medical. All other authors declare no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Identification of genetic alleles associated with both Alzheimer's disease (AD) and concussion severity/recovery could help explain the association between concussion and elevated dementia risk. However, there has been little investigation into whether AD risk genes associate with concussion severity/recovery, and the limited findings are mixed. We used AD polygenic risk scores (PRS) and APOE genotypes to investigate any such associations in the NCAA-DoD Grand Alliance CARE Consortium (CARE) dataset. We assessed six outcomes in 931 total participants. The outcomes were two concussion recovery measures (number of days to asymptomatic status, number of days to return to play (RTP)) and four concussion severity measures (scores on SAC and BESS, SCAT symptom severity, and total number of symptoms). We calculated PRS using a published score [1] and performed multiple linear regression (MLR) to assess the relationship of PRS with the outcomes. We also used t-tests and chi-square tests to examine outcomes by APOE genotype, and MLR to analyze outcomes in European and African genetic ancestry subgroups. Higher PRS was associated with longer injury to RTP in the normal RTP (<24 days) subgroup ( p = 0.024), and one standard deviation increase in PRS resulted in a 9.89 hour increase to the RTP interval. There were no other consistently significant effects, suggesting that high AD genetic risk is not strongly associated with more severe concussions or poor recovery in young adults. Future studies should attempt to replicate these findings in larger samples with longer follow-up using PRS calculated from diverse populations.

Objectives: Understanding the long-term effects of severe COVID-19 illness on survivors is essential for effective pandemic recovery planning. Therefore, we investigated impairments among hospitalized adults discharged to long-term acute care hospitals (LTACHs) for prolonged severe COVID-19 illness who survived 1 year., Design: The Recovery After Transfer to an LTACH for COVID-19 (RAFT COVID) study was a national, multicenter, prospective longitudinal cohort study., Setting and Patients: We included hospitalized English-speaking adults transferred to one of nine LTACHs in the United States between March 2020 and February 2021 and completed a survey., Interventions: None., Measurements and Main Results: Validated instruments for impairments and free response questions about recovering. Among 282 potentially eligible participants who provided permission to be contacted, 156 (55.3%) participated (median age, 65; 38.5% female; 61.3% in good prior health; median length of stay of 57 d; 77% mechanically ventilated for a median of 26 d; 42% had a tracheostomy). Approximately two-thirds (64%) had a persistent impairment, including physical (57%), respiratory (49%; 19% on supplemental oxygen), psychiatric (24%), and cognitive impairments (15%). Nearly half (47%) had two or more impairment types. Participants also experienced persistent debility from hospital-acquired complications, including mononeuropathies and pressure ulcers. Participants described protracted recovery, attributing improvements to exercise/rehabilitation, support, and time. While considered life-altering with 78.7% not returning to their usual health, participants expressed gratitude for recovering; 99% returned home and 60% of previously employed individuals returned to work., Conclusions: Nearly two-thirds of survivors of among the most prolonged severe COVID-19 illness had persistent impairments at 1 year that resembled post-intensive care syndrome after critical illness plus debility from hospital-acquired complications., Competing Interests: Dr. Makam’s institution received funding from the University of California, San Francisco Research Evaluation and Allocation Committee Carson and Hampton Research Funds and the National Association of Long Term Hospitals (NALTH). Drs. Makam’s and Covinsky’s institutions received funding from the National Institute on Aging. Drs. Makam, Ely, Jackson, and Convinsky received support for article research from the National Institutes of Health. Dr. Prettyman disclosed that he is President of the NALTH. Dr. Espejo’s institution received funding from the Donaghue Foundation. Dr. Votto received funding from the NALTH; he disclosed that he is the Chief Medical Officer of NALTH. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Germ cell tumor of the testis (GCT) is a curable cancer even when it is widely metastatic; however, outcomes can differ based on tumor histology. Chemo-resistance in certain phenotypes, such as teratoma and yolk sac tumor, contributes to poor clinical outcomes in some patients with GCT. Despite this resistance to S-YSTemic therapy, many of these tumor subtypes remain amenable to surgical resection and possible cure. In this study, we report on a series of seven patients highlighting two chemo-resistant subtypes of nonseminomatous germ cell tumor (NSGCT), sarcomatoid yolk sac tumor (S-YST), and epithelioid trophoblastic tumor (ETT) for which early resection rather than additional salvage chemotherapy or high-dose intense chemotherapy might provide a superior clinical outcome and enhance cure rate.

Acute respiratory distress syndrome (ARDS) is associated with long-term impairments in brain and muscle function that significantly impact the quality of life of those who survive the acute illness. The mechanisms underlying these impairments are not yet well understood, and evidence-based interventions to minimize the burden on patients remain unproved. The NHLBI of the NIH assembled a workshop in April 2023 to review the state of the science regarding ARDS-associated brain and muscle dysfunction, to identify gaps in current knowledge, and to determine priorities for future investigation. The workshop included presentations by scientific leaders across the translational science spectrum and was open to the public as well as the scientific community. This report describes the themes discussed at the workshop as well as recommendations to advance the field toward the goal of improving the health and well-being of ARDS survivors.