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Background: In the lower extremity, studies have suggested an optimal nail diameter to medullary canal diameter (ND/MCD) ratio to minimize postoperative complications. The goal of this study was to determine whether a correlation exists between the occurrence of complications, angulation, and range of motion and the ratio of the ND/MCD in the upper extremity., Methods: A total of 85 radius and ulna fractures treated with flexible intramedullary nails had ND/MCD ratios measured. Random-effects models were developed to determine the association between complications and ND/MCD ratio, angulation and ND/MCD ratio, and range of motion and ND/MCD ratio. The results were reported for unadjusted models and adjusted models., Results: Of the 85 forearm fractures treated with intramedullary nailing, there were 3 complications. The average follow-up was 6 months. The ND/MCD ratios were categorized as <0.50, 0.50 to 0.59, and ≥0.60. There was not a significant association between the different ratios and angulation, or risk of complication. There was an association between the ND/MCD ratio ≥0.60 and decreased pronation of -1.58° (-2.77° to -0.38°) and supination of -2.68° (-4.91° to -0.46°) ( P < .05)., Conclusion: This study found that there was not an association between the nail to canal diameter ratio and postoperative angulation in forearm fractures treated with flexible intramedullary nails. When choosing a flexible nail for forearm fractures, there does not appear to be an optimal ratio; it is therefore reasonable to use the ND that passes more easily., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: One of the authors consults for Axogen and Medartis; has royalties with Springer; and is on committees for Pediatric Orthopaedic Society of North America, American Academy of Pediatrics, American Association for Hand Surgery, American Academy of Orthopaedic Surgeons, and American Society for Surgery of the Hand. The remaining authors declare that they have no conflict of interest.

Objective: Monteggia fracture-dislocation variants have been well documented in adults, but most of the literature in the pediatric population is in the form of case reports. These injuries present differently in children due to the presence of immature radiocapitellar epiphyses and the flexibility of the joint that is more prone to subluxation, contributing to occult presentations and/or misdiagnoses. The purpose of this study is to investigate the outcomes and complications of true Monteggia fracture-dislocations compared with their variants in the pediatric population., Methods: A retrospective review was performed of all patients 17 years of age and younger who sustained a true Monteggia fracture-dislocation or a Monteggia fracture-dislocation variant over a 10-year period. Patient demographics, mechanisms of injury, fracture pattern, Bado and Letts classification, treatment (operative or conservative), and complications were recorded., Results: Of the 89 patients identified, 17 (19.1%) had true Monteggia fracture dislocations, and 72 (80.9%) had a Monteggia fracture-dislocation variant. The most common Monteggia fracture-dislocation variant was an olecranon fracture and concomitant radial neck fracture (65.3%, n = 47). Of the Monteggia fracture-dislocation variants, 83.3% (n = 60) were treated nonoperatively with closed reduction and immobilization or immobilization alone, whereas only 23.5% (n = 4) of the true Monteggia fracture-dislocation injuries were treated nonoperatively with closed reduction and immobilization. Overall, 14 (15.7%) patients had complications during the course of treatment, including 12 (16.7%) Monteggia fracture-dislocation variants and 2 (11.8%) true Monteggia fracture-dislocations. The most common complications were loss of range of motion (n = 6, 42.9%, all of which were nondisplaced variants), loss of reduction (n = 4, 28.6%, including 2 nondisplaced variants, 1 displaced variant, and 1 true Monteggia fracture dislocation), and malunion or nonunion (n = 2, 14.3%, both nondisplaced variants)., Conclusion: Pediatric Monteggia fracture-dislocation variants are much more common than true pediatric Monteggia fracture-dislocations. Monteggia fracture-dislocation variants have similar complication rates to true Monteggia fracture-dislocations overall, however, nondisplaced variants exhibited a higher complication rate when treated operatively. Further studies are warranted to assess specific fracture patterns and their associated treatments that result in varying complication rates., Level of Evidence: Level III-retrospective comparison study., Competing Interests: J.M.A. consults for Axogen, has royalties with Springer and Elsevier, and is on committees for POSNA, AAP, AAHS, AAOS, and ASSH. The remaining authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: While radial bow shape is well characterized in adults, its development in children is not well understood. Previous studies on the radial bow use radiographs, thus, rotational positioning of the forearm could alter bowing measurements. This study used 3D imaging to better assess the pediatric radial bow., Methods: Computed tomography scans from the New Mexico Decedent Image Database were obtained for ages 2 to 16 (females) and 18 (males) (n=152). 3D models were generated using Slicer and Rhino software. Length of the entire radial bow (bicipital tuberosity to sigmoid notch), maximum radial bow, location of the maximum radial bow (bicipital tuberosity to the point of maximum bowing), and distal, middle, and proximal third radial bows were measured., Results: The length of the entire bow increased with age, with a strong correlation with age ( r =0.90, P <0.01). The maximum bow increased with age, with a strong correlation with age ( r =0.78, P <0.01). The maximum bow normalized to the length of the entire bow increased mildly with age, mean 0.059 ± 0.012 ( r =0.24, P =0.0024), but seems to plateau around age 8. The location of the maximum bow increased with age ( r =0.85, P <0.01). The normalized location of the maximum bow remained constant between ages, with a mean of 0.41 ± 0.10 ( r =0.12, P =0.14). The normalized distal third bow mildly increased with age ( r =0.34, P <0.01), the normalized middle third bow mildly increased with age ( r =0.25, P <0.01), and the normalized proximal third bow remained constant between ages ( r =0.096, P =0.24)., Conclusions: Normalized values for maximum, distal third, and middle third radial bow increase with age, while normalized values for location and proximal third radial bow remain relatively constant, suggesting the proportional shape of the radius changes during development, although qualitatively plateaus after age 8., Level of Evidence: Retrospective comparative study, Level-III., Competing Interests: R.W.L. receives royalties paid to his university from Orthopediatrics, and a stipend from the Journal of Pediatric Orthopaedics as a deputy editor. J.M.A. is a paid consultant for Axogen and receives publishing royalties/financial support from Elsevier and Springer. The remaining authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Widening of the scapholunate (SL) interval greater than 2 mm is diagnostic of an injury in adults; however, this absolute number cannot be used for skeletally immature individuals due to the ossification of the carpal bones. The purpose of this study was to determine age-appropriate normative values for the radiographic SL interval in the skeletally immature population., Methods: Normal pediatric wrist radiographs were identified. The radiographic SL interval was measured as the distance between the scaphoid and the lunate at the mid-joint space between the scaphoid and the lunate, and the SL and capitolunate angles were measured on lateral views. An initial inter-rater reliability assessment was completed with strong inter-rater reliability., Results: In all, 529 radiographic series of children (276 male), aged 4 to 17 years, were reviewed. A negative linear correlation between chronological age and distance at the mid-joint space was observed. The average values for the radiographic SL interval ranged from 9.07 to 1.57 mm. The average SL and capitolunate angles were 52.0° and 10.6°, respectively. No linear relationship was found between chronological age and SL or capitolunate angle ( R = 0.07 and 0.03, respectively)., Conclusions: The visible radiographic distance between the scaphoid and the lunate decreases with increasing age as the carpal bones ossify. The normative values defined in this study can be used to determine whether a true widening of the SL interval is present in the pediatric population. No linear relationship exists between chronological age and SL or capitolunate angle., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: J.A.M. consults for Axogen and Medartis, has royalties with Springer, and is on committees for pediatric orthopaedic society of North America (POSNA), American Academy of Pediatrics (AAP), American Association for Hand Surgery (AAHS), American Academy of Orthopaedic Surgeons (AAOS), and American Society for Surgery of the Hand (ASSH). The remaining authors declare that they have no conflicts of interest.

Introduction: Previous literature showed an association between hyperthermia and dexmedetomidine (DEX) use for ongoing sedation in non-obese patients. The purpose of this study is to evaluate DEX's effect on temperature in obese critically ill patients. Methods: This single center, retrospective, cohort study included patients ≥18 years, admitted to a surgical or medical ICU, received DEX for ≥8 hours as a single continuous infusion sedative, and weighed ≥120% of ideal body weight. Patients were excluded if they had a fever (≥38°C) and positive cultures within 48 hours of DEX initiation. The primary endpoint was a fever (Tmax of ≥38°C) within 48 hours of DEX initiation. Results: A total of 186 patients were included for evaluation. Forty-two patients (22.5%) had a fever during the first 48 hours of DEX initiation. Median weight was not different between the febrile and afebrile groups (99.4 [90.6-122.4] vs 97.6 [81.6-114.2] kg, P = .6). Median change from baseline temperature for all patients within 48 hours was an increase of .5 (.1-.8) °C, P < .001. In multiple regression analysis, duration of DEX and baseline temperature were the only significant predictors of fever development with an adjusted odds ratio of 1.041 (95% CI 1.009-1.074, P = .012) and 7.058 (95% CI 3.307-15.064, P < .001), respectively. Conclusions: This study suggests that there is a significant increase in body temperature from baseline for obese patients on DEX. Duration of DEX and baseline temperature were found to be risk factors for fever development in this population. Further studies are warranted., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Dual antiplatelet therapy (DAPT) is commonly employed for neuroendovascular stenting due to the significant risk of thromboembolism. Clopidogrel and aspirin are most often selected as initial DAPTs; however, there is limited literature available to support guidance of DAPT in this setting. The objective of this study was to evaluate safety and efficacy in patients whose final regimen included either DAPT with aspirin and clopidogrel (DAPT-C) or DAPT with aspirin and ticagrelor (DAPT-T)., Methods: This was a multicenter, retrospective cohort of patients who underwent neuroendovascular stenting and received DAPT between July 1, 2017, and October 31, 2020. Study participants were allocated into groups based on discharge DAPT regimen. The primary outcome was incidence of stent thrombosis at 3-6 months on DAPT-C versus DAPT-T, as defined by the presence of thrombus on imaging or new onset stroke. Secondary outcomes included major and minor bleeding and death within 3-6 months after the procedure., Results: Five hundred and seventy patients were screened across 12 sites. Of those, 486 were included (DAPT-C n = 360, DAPT-T n = 126). There was no difference in the primary outcome of stent thrombosis between the DAPT-C and DAPT-T groups (8% vs. 8%, p = 0.97) and no difference in any of the secondary safety outcomes., Conclusions: Using DAPT-C or DAPT-T regimens in a broad population of neuroendovascular stenting procedures appears to have similar safety and efficacy profiles. Further prospective evaluation is warranted to streamline the practice of DAPT selection and monitoring to determine the impact on clinical outcomes., (© 2023. Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society.)

Phalangeal fractures are extremely common in the pediatric and adolescent populations. The incidence of phalangeal fractures peaks in children ages 10 to 14 years, corresponding to the age in which children begin contact sports. Younger children are more likely to experience crush injuries, whereas older children often sustain phalangeal fractures during sports. The physis is particularly susceptible to fracture because of the biomechanically weak nature of the physis compared with the surrounding ligaments and bone. Phalangeal fractures are identified through a thorough physical examination and are subsequently confirmed with radiographic evaluation. Management of pediatric phalangeal fractures is dependent on the age of the child, the severity of the injury, and the degree of fracture displacement. Nondisplaced fractures are often managed nonsurgically with immobilization, whereas unstable, displaced fractures may require surgery, which is often a closed rather than open reduction and percutaneous pinning.

Transphyseal fractures of the distal humerus often occur in children younger than 4 years as a result of birth trauma, nonaccidental trauma, or falls from a low height. It is important to identify and treat these injuries in a timely manner to ensure successful management. Most transphyseal fractures of the distal humerus are treated with closed reduction and percutaneous pinning with the aid of an elbow arthrogram. The most common complication following a fracture is cubitus varus caused by growth arrest, malunion, or osteonecrosis of the medial condyle. Normal carrying angles may be restored through corrective lateral closing wedge osteotomy.

Background: Obstetric brachial plexus injuries (OBPI) can have mental health implications on parents coping with this injury to their newborn. The purpose of this study was to assess the mental health of mothers with newborns with an OBPI and identify resources that can help screen and treat mental health needs., Material and Methods: Three groups of mothers were prospectively given a self-reported survey: 1) Newborns with OBPI; 2) Newborns in the nursery without OBPI; 3) Newborns in the neonatal intensive care unit (NICU). The survey consisted of demographic questions, the PHQ-9 and PCL-S screening tools, and parents' exposure to community violence, family support and use of drugs or alcohol., Results: Fifty-seven mothers were prospectively enrolled, and 30% (17/57) of mothers screened in for post-traumatic stress disorder (PTSD). OBPI mothers had significantly higher rates of PTSD symptoms when compared to mothers of children in the full-term nursery (difference = 36.4%; p < 0.01). No statistically significant difference was found between groups regarding depression symptoms., Conclusions: OBPI can be very difficult to cope with for parents and family members. Forty-two percent of mothers with newborns with OBPI or children in the NICU screened in for PTSD symptoms. OBPI clinics should be staffed similarly to the NICU with clinical social workers to appropriately screen and treat parents with PTSD and depression symptoms., (© 2023 Catherine Miller et al., published by Sciendo.)

BackgroundAll Advanced Pharmacy Practice Experience (APPE) pharmacy rotations at a large academic medical center were converted to virtual experiences during the beginning of the coronavirus disease 2019 (COVID-19) pandemic. Objective: This study aimed to describe information obtained through pre- and post-rotation surveys, implemented to improve experiences for future students who may be required to complete virtual APPE pharmacy rotations. Methods: A single-center, descriptive study was conducted at a 1382-bed academic medical center. A pre- and post-rotation survey was sent to 32 students, and a post-rotation survey was sent to 38 preceptors via email to assess newly implemented virtual rotations. Results: Students' response rate for pre- and post-rotation surveys was 59% and 41%, respectively, and the preceptors' response rate for the post-rotation survey was 37%. A statistically significant improvement in videoconferencing abilities after the rotation was found for students but no differences in other skills were noted. In the post-rotation survey, students rated all of the following areas as being "effective": rotation as a whole, virtual topic and patient discussions; but were "neutral" regarding the utility of the introductory training guide. In the post-rotation survey, preceptors rated all of the following areas as being "effective": rotation as a whole, virtual topic and patient discussions. Conclusion: Abrupt shifts to virtual pharmacy clinical rotations due to COVID-19 have led to many challenges. Both students and preceptors felt that virtual rotations were an effective alternative to in-person experiences; however, further studies are warranted to evaluate actual performance compared to perceived effectiveness.

Background: Emergent neuroendovascular stenting presents challenges for the utilization of antiplatelet agents., Methods: This was a multicenter, retrospective cohort of patients who underwent emergent neuroendovascular stenting. The primary endpoints were thrombotic and bleeding events in relation to the timing of antiplatelet administration, route of administration, and choice of intravenous (IV) agent and the study investigated practice variability in antiplatelet utilization., Results: Five-hundred and seventy patients were screened across 12 sites. Of those, 167 were included for data analysis. For patients who presented with ischemic stroke, artery dissection and emergent internal carotid artery (ICA) stenting who received an antiplatelet agent prior to or during the procedure, 57% were given an IV antiplatelet agent; for patients who were given an antiplatelet agent after the procedure, 96% were given an oral agent. For patients who presented for aneurysm repair and received an antiplatelet agent prior to or during the procedure, 74% were given an IV agent; patients who were given an antiplatelet agent after the completion of the procedure were given an oral antiplatelet agent 90% of the time. In patients who presented with ischemic stroke, artery dissection and emergent ICA stenting who received oral antiplatelet agents post-procedure were more likely to have thrombotic events compared to those who received oral antiplatelet agents prior to or during the procedure (29% vs 9%; p   =  0.04). There were no differences in the primary outcomes observed when comparing other antiplatelet treatment strategies., Conclusion: The optimal timing of antiplatelet administration in relation to stent placement and route of administration of antiplatelet agents is unclear. Timing and route of administration of antiplatelet agents may have an effect on thrombosis in emergent neuroendovascular stenting. Significant practice variation exists in antiplatelet agent utilization in emergent neuroendovascular stenting.

Background: Dexmedetomidine is used in neurocritical care units (NCCUs) due to the light, dose-dependent sedation, and anxiolysis provided. It is unknown how to dose dexmedetomidine in obese patients. The primary objective is to assess the ability to achieve the goal Richmond Agitation Sedation Scale (RASS) measurements in obese patients with a neurological injury who are solely on dexmedetomidine before and after an institutional dosing change from actual body weight (ABW) to adjusted body weight (AdjBW)., Methods: This study included patients admitted to the NCCU with a neurological condition, required dexmedetomidine for at least 8 h as a sole sedative, and weighed ≥120% of ideal body weight. Percentage of RASS measurements within the goal range (-1 to +1) during the first 48 h while on dexmedetomidine were compared between patients dosed on ABW and on AdjBW., Results: Sixty-eight patients in the ABW cohort and 72 patients in the AdjBW cohort were included. There were no statistical differences between the two groups (ABW vs. AdjBW) in the percent of RASS measurements in the goal range (53.2% ± 34.8% vs. 55% ± 37%; P = 0.78), mean weight (99.2 ± 26 vs. 96.8 ± 20.9 kg; P = 0.55), or the average dose of dexmedetomidine required to achieve first goal RASS score (0.4 ± 0.3 vs. 0.4 ± 0.3 mcg/kg/h; P = 0.98)., Conclusions: Dosing dexmedetomidine using AdjBW in obese critically ill neurologically injured patients for ongoing sedation resulted in no statistical difference in the percent of RASS measurements within the goal when compared to ABW dosing. Further studies are warranted., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 International Journal of Critical Illness and Injury Science.)

Background: Dexmedetomidine is a highly selective α 2 -adrenoreceptor agonist that produces dose-dependent sedation, anxiolysis, and analgesia without respiratory depression. Due to these ideal sedative properties, there has been increased interest in utilizing dexmedetomidine as a first-line sedative for critically ill patients requiring light sedation., Objective: To evaluate the ability to achieve goal intensive care unit (ICU) sedation before and after an institutional change of dosing from actual (ABW) to adjusted (AdjBW) body weight in obese patients on dexmedetomidine., Methods: This study included patients ≥ 18 years old, admitted to a surgical or medical ICU, required dexmedetomidine for at least 8 hours as a single continuous infusion sedative, and weighed ≥ 120% of ideal body weight. Percentage of RASS measurements within goal range (-1 to +1) during the first 48 hours after initiation of dexmedetomidine as the sole sedative agent or until discontinuation dosed on ABW compared to AdjBW was evaluated., Results: 100 patients were included in the ABW cohort and 100 in the AdjBW cohort. The median dosing weight was significantly higher in the ABW group (95.9 [78.9-119.5] vs 82.2 [72.1-89.8] kg; p = 0.001). There was no statistical difference in percent of RASS measurements in goal range (61.5% vs 69.6%, p = 0.267) in patients that received dexmedetomidine dosed based on ABW versus AdjBW., Conclusion: Dosing dexmedetomidine using AdjBW in obese critically ill patients for ongoing ICU sedation resulted in no statistical difference in the percent of RASS measurements within goal when compared to ABW dosing. Further studies are warranted.

Background: Nutrition support in critically ill patients with acute brain injury is vitally important because of known hypermetabolism. We aimed to describe energy and protein intake within the first 72 h in a broad neurocritical care population and compare energy intake with the indirect calorimetry (IC) resting energy expenditure (REE) target., Methods: IC data, daily energy, and protein intake were collected through chart review over the first 7 days of hospital admission. We evaluated the type and amount of tube-feed product received, volume of propofol (1.1 kcal/ml) and clevidipine (2 kcal/ml), and amount of supplemental protein received., Results: Ninety-one patients were included, with the majority presenting with either intracerebral hemorrhage (35.2%) or acute ischemic stroke (26.4%). The median day of admission on which IC was completed and enteral nutrition was initiated was day 3 (2-5) and day 1 (1-2), respectively. The difference in kilocalories received compared with IC REE target within the first 72 h was significantly different (2831 kcal [1663-4072] vs 4275 kcal [3450-5811]; Z = -6.469; P < .001). The median kilocalories received as tube feeds during the first 72 h was 88% (55%-99%), and the mean protein received in the first 72 h was 0.7 ± 0.5 g/kg/day., Conclusion: In this population, patients had lower energy intake compared with their energy needs determined by IC during the first 72 h of admission but attained 7-day goals. Future studies should investigate barriers to improve energy delivery in this patient population., (© 2021 American Society for Parenteral and Enteral Nutrition.)

Bleeding related to direct oral anticoagulants accounts for nearly half of emergency department visits annually and until recently there were no reversal antidotes available. As there continues to be a shift in prescribing practices away from warfarin, it is essential to have these reversal agents readily available for the treatment of life-threatening bleeds associated with these anticoagulants. In addition, for agents that continue to lack a targeted reversal agent (eg, low-molecular-weight heparin, antiplatelets, and new antithrombotics), it is imperative that research continues to evaluate improved reversal strategies. This review focuses on target-specific anticoagulation reversal agents currently available in the United States (protamine, idarucizumab, and andexanet alfa) and summarizes agents that are in the pipeline for these anticoagulants and antiplatelets., Competing Interests: The authors declare that they have no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Despite increased research on opioids in the orthopaedic literature, little is known of the prescribing practices of orthopaedic providers based on their level of training. The purpose of this study was to describe the discharge opioid prescribing patterns of orthopaedic providers, stratifying by level of training and orthopaedic subspecialty, within a single medical system., Methods: A retrospective review of orthopaedic surgical encounters was performed over a 1-year period for adults who received a discharge opioid prescription. Patient demographics and prescriber characteristics were collected, including the provider's level of training (attending, fellow, resident, physician assistant [PA], and nurse practitioner [NP]) and surgical subspecialty. Junior residents were postgraduate year 1 to 3, whereas senior residents/fellows were postgraduate year 4 to 6. Discharge opioids were converted to milligram morphine equivalents (MMEs). Overprescribing was defined as a prescribing more than a seven-day supply or >45 MMEs per day. Multivariable linear regression analysis determined the factors associated with discharge MMEs, whereas logistic regression determined the factors associated with overprescribing opioids., Results: Of the 3,786 patients reviewed, 1,500 met the criteria for inclusion in the study. The greatest proportion of opioid prescriptions was written by junior residents (33.9%), followed by NPs (30.1%), PAs (24.1%), senior residents/fellows (10.6%), and attendings (1.2%). Compared with junior residents, senior residents prescribed -59.4 MMEs, NPs prescribed +104 MMEs, and attendings prescribed +168 MMEs (P < 0.05), whereas PAs prescribed similar amounts (P > 0.05). Orthopaedic subspecialty was also predictive of discharge MMEs (P < 0.05). Senior residents and attendings were more likely to prescribe more than seven days of opioids (P < 0.05), whereas NPs and PAs were more likely to prescribe >45 MMEs per day (P < 0.05)., Discussion: This study demonstrates significant variability in opioid prescribing practices according to provider level of training and subspecialty. National guidelines for opioid prescribing practices and educational programs may help reduce such variability., Level of Evidence: Level III, retrospective cohort study., (Copyright © 2021 by the American Academy of Orthopaedic Surgeons.)

Background: Prior studies demonstrated reduced risk for venous thromboembolism (VTE) in neurosurgical patients secondary to prophylaxis with both heparin and low-molecular-weight heparin. The ability to monitor low-molecular-weight heparin by obtaining anti-factor Xa (anti-Xa) serum levels provides an opportunity to evaluate safety and efficacy. The aim of this study was to describe characteristics of patients who have anti-Xa levels outside of the goal range (0.2-0.4/0.5 IU/mL) and investigate incidence of major bleeding and VTE., Methods: A single-center, retrospective, observational study was conducted on neurosurgical patients receiving enoxaparin for VTE prophylaxis between August 2019 and December 2020. Significance testing was conducted via Fisher exact test and independent samples t test., Results: The study included 85 patients. Patients were less likely to have an anti-Xa level in the goal range if they were male, had a higher weight, or were morbidly obese. Three neuroendovascular patients (3.5%) experienced a major bleed. Serum anti-Xa levels were significantly higher in patients who experienced major bleeds compared with patients who did not (0.45 ± 0.16 IU/mL vs. 0.28 ± 0.09 IU/mL, P = 0.003). Patients with a supraprophylactic anti-Xa level (>0.5 IU/mL) were more likely to experience a major bleed (P = 0.005). One VTE event occurred: the patient experienced a pulmonary embolism with anti-Xa level at goal., Conclusions: Anti-Xa-guided enoxaparin dosing for VTE prophylaxis in neurosurgical patients may help prevent major bleeding. These data suggest that a higher anti-Xa level may predispose patients to major bleeding. Further evaluation is needed to identify the goal anti-Xa level for VTE prophylaxis in this population., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Tandem occlusions exist in 17-32% of large vessel occlusion (LVO) strokes. A significant concern is bleeding when carotid stenting is performed in tandem with thrombectomy due the administration of antiplatelet agents such as glycoprotein IIb/IIIa inhibitors (GP2b3aI) after receiving rtPA, but data are limited in this setting., Methods: A mutlicenter, retrospective chart review was conducted at two comprehensive stroke centers to assess the safety and efficacy of using GP2b3aI to facilitate carotid stent placement simultaneously with endovascular thrombectomy in patients who have received rtPA., Results: Overall, 32 patients were included in this study, with average age of 66.3 ± 10.4 years and predominantly male (87.5%). The cause of stroke was mostly large artery atherosclerosis (59.4%) and the thrombectomy target vessels were typically first- or second segment middle cerebral artery (37.5% and 31.3%). Time from symptom onset to rtPA bolus was 1.8 h [interquartile range (IQR) 1.5-2.7], rtPA bolus to first pass was 2 h [IQR 1.5-3.1], rtPA bolus to GP2b3aI bolus was 2 h [IQR 1.6-3.5], and rtPA bolus to aspirin and clopidogrel administration was 4.3 h [IQR 2.6-8.9] and 6.6 h [IQR 4.5-11.6] respectively. No patients had acute in-stent thrombosis or post-op bleeding from the access site. Two patients (6.3%) had significant hemorrhagic conversion., Conclusion: The use of GP2b3aI in the setting of tandem occlusions that required emergent stent placement post-rtPA appears safe and effective. Given the small sample size, these findings should be interpreted cautiously, and need to be confirmed in a larger patient population., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Social media has changed the way individuals communicate and recently multiple articles have been published highlighting the utilization of social media for education. To our knowledge, cross-discipline education utilizing these platforms has not been evaluated. The purpose of this study was to implement a pharmacist-led, social media-based nursing education program and evaluate the perceived value. A curriculum of pharmacy-related issues was developed and topics were posted to the neurocritical care unit (NCCU) Facebook group or emailed to non-Facebook users weekly. A pre- and posteducation survey was sent out evaluating the program's effectiveness. Thirty-seven nurses were members of the NCCU Facebook group and 33 received the education via email. A total of 29% and 19% of nurses completed the pre- and posteducation survey, respectively. Of those who completed the survey, 36% received education via Facebook. As compared with the preeducation survey, there were no statistically significant differences in nursing performance on fact-based questions (P value > .05 on all assessment questions); however, 100% of respondents wanted to continue this education delivery. Utilizing social media as a means of cross-discipline education was well-received; however, the solitary utilization should be used cautiously, as performance did not improve on assessment questions., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Context: The coronavirus disease 2019 (COVID-19) pandemic has created a need for remote blood glucose (BG) monitoring in the intensive care unit (ICU)., Objective: To evaluate feasibility and patient safety of a hybrid monitoring strategy of point-of-care (POC) BG plus continuous glucose monitor (CGM) in the ICU., Design: Retrospective analysis., Setting: ICU of an academic medical center., Patients: Patients with COVID-19 on IV insulin., Intervention: After meeting initial validation criteria, CGM was used for IV insulin titration and POC BG was performed every 6 hours or as needed., Main Outcome Measures: Outcomes included frequency of POC BG, workflow, safety, and accuracy measures., Results: The study included 19 patients, 18 with CGM data, mean age 58 years, 89% on mechanical ventilation, 37% on vasopressors, and 42% on dialysis. The median time to CGM validation was 137 minutes (interquartile range [IQR] 114-206). During IV insulin, the median number of POC values was 7 (IQR 6-16) on day 1, and declined slightly thereafter (71% reduction compared with standard of 24/day). The median number of CGM values used nonadjunctively to titrate IV insulin was 11.5 (IQR 0, 15) on day 1 and increased thereafter. Time in range 70 to 180 mg/dL was 64 ± 23% on day 1 and 72 ± 16% on days 2 through 7, whereas time <70 mg/dL was 1.5 ± 4.1% on day 1 and <1% on days 2 through 7., Conclusions: This study provides data to support that CGM using a hybrid protocol is feasible, accurate, safe, and has potential to reduce nursing and staff workload., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Perturbations in resting energy expenditure (REE) among critically ill stroke patients are ill defined, and guidelines recommend weight-based dosing when indirect calorimetry (IC) is not feasible to estimate daily energy requirements. We aimed to determine whether guideline-recommended weight-based dosing provides adequate energy requirements compared with guidelines recommended IC target., Methods: IC data was collected on stroke patients admitted to a neurocritical care unit. We compared low-weight-based dosing (25 kcal/kg) and high (30 kcal/kg) with the IC REE target. Subsequently, we analyzed the effect of stroke subtype on the differences among these measurements., Results: Seventy-two metabolic studies were performed (45.1% intracerebral hemorrhage [ICH], 18.3% aneurysmal subarachnoid hemorrhage [aSAH], and 36.6% acute ischemic stroke [AIS]). Energy needs, estimated using low-weight-based group, were significantly lower than IC REE target (1496 kcal/day [IQR, 1224-1850] vs 1770 kcal/day [IQR, 1400-2150]; P = .003). High weight-based group energy measurements were similar to IC REE target (1806 kcal/day [IQR, 1530-2236] vs 1770 kcal/day; P = .343). Subgroup analysis showed that low-weight-based calculations were significantly lower than those of IC in ICH and aSAH, but they were similar in AIS (P ≤ .001, .016, and .078, respectively). Linear regression analysis showed that weight, height, and hemorrhagic stroke subtype were associated with IC (P ≤ .001, .024, and .051, respectively)., Conclusion: Important differences between weight-based estimation of energy needs and guideline-recommended IC estimation exist for critically ill stroke patients. Low-weight-based calculations of REE underestimate energy needs in ICH and aSAH patients., (© 2020 American Society for Parenteral and Enteral Nutrition.)

Management of warfarin-associated intracerebral hemorrhage (ICH) necessitates rapid reversal of anticoagulation. Guideline-based management of warfarin-associated ICH includes timely administration of prothrombin complex concentrate (PCC) and intravenous (IV) vitamin K. In 2017, our hospital implemented an order set for warfarin reversal to facilitate computerized provider order entry (CPOE), and the pharmacy department began prospective verification and dispensing of all PCC orders for anticoagulant reversal. We sought to compare the proportion of patients who received timely, guideline-based therapy for warfarin-associated ICH before and after these changes. We conducted a single-center, retrospective cohort study of all warfarin-associated ICH patients who had an order for PCC. A total of 66 patients were included; 32 patients (pre-intervention cohort) were evaluated in the 2 year period prior to the process improvement changes, while 34 patients (post-intervention cohort) were evaluated in the 2 year period following these changes. Baseline characteristics were similar between groups. The proportion of patients receiving timely guideline-based therapy was significantly higher in the post-intervention cohort compared to the pre-intervention cohort (76.5% vs 34.4%, p < 0.001), primarily driven by increased ordering of vitamin K 10 mg IV in conjunction with PCC in the post-intervention cohort. Our results indicate that implementation of an order set to assist with CPOE, in addition to prospective pharmacist verification of PCC orders, leads to increased adherence to guideline-based management of warfarin-associated ICH., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature.)

Objective: We describe our implementation of a continuous glucose monitoring (CGM) guideline to support intravenous insulin administration and reduce point of care (POC) glucose monitoring frequency in the coronavirus disease 2019 medical intensive care unit (MICU) and evaluate nurses' experience with implementation of CGM and hybrid POC + CGM protocol using the Promoting Action on Research in Health Services framework., Methods: A multidisciplinary team created a guideline providing criteria for establishing initial sensor-meter agreement within each individual patient followed by hybrid use of CGM and POC. POC measures were obtained hourly during initial validation, then every 6 hours. We conducted a focus group among MICU nurses to evaluate initial implementation efforts with content areas focused on initial assessment of evidence, context, and facilitation to identify barriers and facilitators. The focus group was analyzed using a qualitative descriptive approach., Results: The protocol was integrated through a rapid cycle review process and ultimately disseminated nationally. The Diabetes Consult Service performed device set-up and nurses received just-in-time training. The majority of barriers centered on contextual factors, including limitations of the physical environment, complex device set-up, hospital firewalls, need for training, and CGM documentation. Nurses' perceived device accuracy and utility were exceptionally high. Solutions were devised to maximize facilitation and sustainability for nurses while maintaining patient safety., Conclusion: Outpatient CGM systems can be implemented in the MICU using a hybrid protocol implementation science approach. These efforts hold tremendous potential to reduce healthcare worker exposure while maintaining glucose control during the COVID-19 pandemic., (Copyright © 2021 AACE. Published by Elsevier Inc. All rights reserved.)

Background: Increasing evidence suggests that large-volume infusions of 0.9% sodium chloride (NaCl) for resuscitation are associated with hyperchloremic metabolic acidosis, renal vasoconstriction, and increased risk of acute kidney injury (AKI). Patients with neurological injury may require hypertonic NaCl for therapeutic hypernatremia, treatment of cerebral salt wasting, hyponatremia, or elevated intracranial pressure. Consequently, this increased exposure to chloride may result in an increased risk for development of AKI. Objective: The primary aim of this study was to describe the risk for development of AKI in neurologically injured patients receiving large volumes of intravenous hypertonic NaCl. Methods: This single-center, retrospective study looked at neurologically injured patients who received hypertonic NaCl and sodium acetate. Data were collected to assess renal function, hyperchloremia, and acidemia. Receiver operating characteristic (ROC) curve analysis was used to determine the predictive association between the amount of daily and overall chloride exposure and development of AKI. Results: A total of 301 patients were screened, and of those, 142 were included. Of the 142 patients included, 13% developed AKI, and 38% developed hyperchloremia. Additionally, 32% of patients were switched from NaCl to sodium acetate after an average of 3.4 ± 1.5 days of NaCl therapy. The ROC curve demonstrated that if patients received greater than 2055 mEq of chloride over 7 days, they were more likely to develop AKI (sensitivity 72%, specificity 70%; P = 0.002; area under the curve = 0.7). Conclusion and Relevance: Neurologically injured patients receiving hypertonic sodium therapy with a high chloride load are at risk of developing hyperchloremia and AKI.

Aneurysmal subarachnoid hemorrhage (aSAH) is responsible for 5% to 10% of all strokes in the United States annually and is a neurologic emergency with considerable morbidity and mortality. A common complication of aSAH is cerebral vasospasm (CVS) or narrowing of the cerebral arteries. While nearly 70% of aSAH patients will develop CVS, approximately 30% of those patients will go on to develop delayed cerebral ischemia, defined as symptomatic vasospasm or cerebral infarction demonstrated on imaging. While the pathophysiology of CVS is unclear, the prevention and treatment of this complication are a focus of ongoing research. Despite continued efforts, only one medication, nimodipine, is Food and Drug Administration approved for the improvement of neurologic outcomes by reducing the incidence and severity of ischemic deficits in patients with CVS during aSAH. This review provides nurse practitioners and the bedside nursing staff with a summary of the available literature on the pharmacologic management of CVS. It focuses on oral, intravenous, intra-arterial, and intraventricular medications available in the United States that may be utilized in the management of CVS.

The package insert of 4-factor prothrombin complex concentrate (4F-PCC) contains specific dosing recommendations stating to determine the patients dose based on their INR and weight, capping the weight at 100 kg. However, the mean body mass index (BMI) in the 4F-PCC U.S. approval study was 27 kg/m 2 , and there is a lack of literature identifying the ideal dosing strategy in obesity. We conducted a retrospective analysis of obese patients (BMI ≥ 30 kg/m 2 ) who received 4F-PCC for warfarin associated emergent bleeding reversal. Treatment groups were those that received 4F-PCC on adjusted body weight (AdjBW) and those on actual body weight (ActBW). The primary outcome was the percent of patients achieving coagulopathy reversal, defined as a post-treatment INR < 1.4 for neurologic indications and < 1.5 for all others. A total of 78 obese patients were included (28 AdjBW and 50 ActBW). Baseline INR (3.1 vs. 2.8; p = 0.052) and BMI (33.6 vs. 33.6 kg/m 2 ) were similar between groups. Achievement of goal INR was significantly lower in the AdjBW group (36% vs. 68%; p = 0.006). A majority of patients had intracranial hemorrhage (32% vs. 54%; p = 0.06), and the median dose of 4F-PCC was lower in the AdjBW group (2120 vs. 2500 units; p = 0.02). Dosing 4F-PCC using adjusted body weight in obese patients resulted in a significantly lower rate of coagulopathy reversal. ActBW should be used to dose 4F-PCC in obese patients when the 100 kg dose cap is utilized per the package insert recommendations.

Intracerebral hemorrhage (ICH) is responsible for approximately 15% of strokes annually in the United States, with nearly 1 in 3 of these patients dying without ever leaving the hospital. Because this disproportionate mortality risk has been stagnant for nearly 3 decades, a main area of research has been focused on the optimal strategies to reduce mortality and improve functional outcomes. The acute hypertensive response following ICH has been shown to facilitate ICH expansion and is a strong predictor of mortality. Rapidly reducing blood pressure was once thought to induce cerebral ischemia, though has been found to be safe in certain patient populations. Clinicians must work quickly to determine whether specific patient populations may benefit from acute lowering of systolic blood pressure (SBP) following ICH. This review provides nurses with a summary of the available literature on blood pressure control following ICH. It focuses on intravenous and oral antihypertensive medications available in the United States that may be utilized to acutely lower SBP, as well as medications outside of the antihypertensive class used during the acute setting that may reduce SBP.

Purpose: Results of a study to evaluate medication storage, distribution, and safety outcomes after addition of 23.4% sodium chloride to a hospital formulary and development of a novel distribution process incorporating safeguards allowing for urgent medication removal from an automated dispensing cabinet (ADC) are reported., Summary: A retrospective review of 23.4% sodium chloride injection doses dispensed during a 38-month period was performed at an academic medical center to evaluate times from order entry to pharmacist verification, dispensing, and administration; adverse events related to dispensing or administration; and other outcomes. Seventy doses of 23.4% sodium chloride injection were administered to 60 patients during the study period. The mean times from order entry to pharmacist verification, medication removal from an ADC, and administration were 8, 25, and 43 minutes, respectively, when the ADC override function was not used. After 23.4% sodium chloride injection's addition to the ADC override list, 16 of 30 doses were removed "on override," with order entry performed retrospectively for 9 of these doses. There were no documented adverse events related to medication distribution and 2 adverse effects possibly related to medication administration., Conclusion: Novel storage and distribution processes for 23.4% sodium chloride injection were implemented at a large academic medical center to optimize safety related to the medication-use process. A retrospective review of 70 administered doses found the process of maintaining this medication in ADCs to be a safe and efficient method of storing and dispensing a high-alert medication., (© American Society of Health-System Pharmacists 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Previous reports note that in a mixed patient population, vancomycin doses >4 g/day are associated with increased rates of acute kidney injury (AKI)., Objective: The objective of the study is to determine if vancomycin regimens >4 g/day are associated with a higher incidence of AKI in neurocritical care unit (NCCU) and trauma/burn Intensive Care Unit (TBICU) patients., Materials and Methods: This single-centered, retrospective study enrolled adult patients initiated on vancomycin in the NCCU and TBICU at an academic medical center during 2016. Based on maximum steady-state dose exposure, patients were separated into two groups: ≤4 g/day and >4 g/day. The primary outcome of incidence of AKI was defined by the AKI Network criteria., Results: A total of 284 patients were screened for eligibility; 165 patients met inclusion criteria, 98 patients received ≤4 g/day and 67 patients received >4 g/day. The >4 g/day group had a lower mean age (32.6±11.1 vs. 47.8±16.2, P < 0.001), included more male patients (81% vs. 60%, P = 0.008), were more often treated for a central nervous system infection (31% vs. 11%, P = 0.001), had, on average, more concomitant use of nephrotoxic drugs (2.2±1.2 vs. 1.8±0.9, P = 0.02) and had a higher exposure to contrast (94% vs. 79%, P < 0.001). The primary outcome of AKI occurred in 14 patients receiving ≤4 g/day and five patients receiving >4 g/day which was not statistically significant (14% vs. 7%, P = 0.22)., Conclusions: Our results indicate that administering >4 g/day of vancomycin to achieve therapeutic vancomycin troughs does not appear to lead to an increased incidence of AKI in a mixed NCCU and TBICU population., Competing Interests: There are no conflicts of interest.

Background: Patients with subarachnoid hemorrhage (SAH) typically exhibit hyperdynamic cardiovascular hemodynamics, which may lead to increased medication clearance. The aims of this study were to evaluate the actual creatinine clearance (CrClA) in an aneurysmal SAH population and the effect of the development of cerebral vasospasm (CV) along with its treatment to better understand if this population exhibits augmented renal clearance (ARC)., Methods: This was a prospective, single-center study in a neurosciences ICU at a university hospital. A total of 20 patients were consented and provided a 24-h urine sample to measure the CrClA. If patients experienced CV, a 24-h urine collection was repeated during vasospasm treatment. CrClA was measured using a modified Jaffe assay., Results: Among the 20 patients enrolled, the mean SAH CrClA was 325.93 ± 135.20 ml/min 1.73 m(2) and this differed significantly from the SAH estimated creatinine clearance (CrClE) 144.93 ± 42.82 ml/min 1.73 m(2) (p < 0.001). Four patients developed CV; the mean CV CrClA was 558.43 ± 356.12 ml/min 1.73 m(2) and there was no significant difference when compared to those patients' mean SAH CrClA (246.91 ± 84.14 ml/min 1.73 m(2), p = 0.16)., Conclusions: ARC was present in 100 % of the patients with recent SAH enrolled. Although ARC remained present in the patients who experienced CV, their creatinine clearance was not significantly further augmented. Further work is needed to clarify the impact of such clearances on renally excreted medications and how the development and treatment of CV further augment these findings.

Paroxysmal sympathetic hyperactivity (PSH) affects approximately 10% of survivors of acquired brain injury and is associated with substantial morbidity. The most effective maintenance therapies include oral β-blockers and α-2 antagonists. We report the use of rectal propranolol for symptomatic control of PSH in a critically ill patient with an altered gastrointestinal tract for whom oral intake was contraindicated. A 15-year-old Caucasian male with no past medical history was admitted status post all-terrain vehicle rollover with multiple intra-abdominal injuries. On hospital day 40, the patient experienced cardiac arrest with a subsequent anoxic brain injury, which was complicated by the development of PSH on post-arrest day 1. Because of his altered gastrointestinal tract, he was symptomatically managed with propranolol 40 mg per rectum every 6 hours in the form of specially prepared suppositories, intravenously infused morphine and dexmedetomidine, and a transdermal clonidine patch. The patient improved clinically during this treatment and was transferred to a rehabilitation facility. This is the first case report to describe successful use of propranolol suppositories in a clinical environment. This case supports the use of propranolol suppositories as a potential alternative route when oral administration is not possible., (© 2015 Pharmacotherapy Publications, Inc.)

The effect of the anthropogenic complexing agent EDTA on thorium transport in groundwater has been studied using sand-packed columns and flow rates in the range of 20-100 m y⁻¹. The concentrations injected into the columns were in the range of 0.4-4 mM for Th and 4-40 mM for EDTA, and with EDTA:Th ratios in the range 1:1 to 10:1. The results show that EDTA can significantly increase Th transport, but two very different behaviours are observed at Th concentrations of 0.4 and 4 mM. At the lower concentration, Th breakthrough is retarded with respect to a conservative tracer, with a peak width that is consistent with a single K(d) value, followed by a longer tail, and the behaviour is very sensitive to the flow rate. However at 4 mM Th, the breakthrough peak appears near to that of the tracer, and the width of the peak is consistent with a distribution of K(d) values and/or a larger dispersivity than the tracer. Speciation and transport modelling have been used to interpret the data, and a model was developed that could explain the 0.4 mM behaviour. This suggests that ternary surface complexes are important in these systems, with at least two different species involved, although the complexity of Th speciation in these systems leads to significant uncertainty in the values of the equilibrium and kinetic parameters. For the 4 mM systems, the rapid transport observed could not be explained by a simple chemical model; instead it is likely that EDTA plays an important role in stabilising and transporting thorium colloids and clusters., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

In Asia, contact between persons and nonhuman primates is widespread in multiple occupational and nonoccupational contexts. Simian foamy viruses (SFVs) are retroviruses that are prevalent in all species of nonhuman primates. To determine SFV prevalence in humans, we tested 305 persons who lived or worked around nonhuman primates in several South and Southeast Asian countries; 8 (2.6%) were confirmed SFV positive by Western blot and, for some, by PCR. The interspecies interactions that likely resulted in virus transmission were diverse; 5 macaque taxa were implicated as a potential source of infection. Phylogenetic analysis showed that SFV from 3 infected persons was similar to that from the nonhuman primate populations with which the infected persons reported contact. Thus, SFV infections are likely to be prevalent among persons who live or work near nonhuman primates in Asia.

Electrospray ionisation-mass spectrometry (ESI-MS) has been used to investigate the speciation of Th in the presence of two common organic complexing agents found in radioactive wastes, EDTA and NTA. These ligands may enhance radionuclide migration from nuclear wastes and contaminated land, and characterisation of the complexes formed will improve our understanding of their environmental mobility. When acetic acid and ammonia were used to adjust the pH, the dominant Th-EDTA species changed from the mixed ligand [ThEDTAac](-) complex to [ThEDTAOH](-) and [ThEDTA(OH)(2)ac](3-) as the pH increased, with all species co-existing, to some extent, over the pH range (2.5-10.8). A previously suggested Th-NTA species, [ThNTA(2)](2-), dominates from pH 6.0-8.5 but at high pH (10.0-10.8) NTA was not able to solubilise Th to a measurable extent. In the presence of both EDTA and NTA, Th formed a mixed ligand complex, [ThEDTANTA](3-) which has also been characterised in independent experiments. The identification of the importance of [ThNTA(2)](2-), [ThEDTANTA](3-) and [ThEDTA(OH)(2)](2-) (with an additional acetate ligand) highlights that these species are not included in current speciation databases and thus may impact on predictions of the environmental mobility of Th. ESI-MS has therefore been used to identify and confirm fundamentally important Th complexes. It has proved to be a useful tool for elucidating radionuclide speciation, adding to our knowledge of Th geochemistry and providing a means of critically examining existing stability constant data.

Objective: We describe the significance of detecting focal areas of hypermetabolism in the breast in patients undergoing PET/CT for reasons other than for breast cancer detection or staging., Conclusion: When evaluated, almost all of the abnormal foci detected in the breast subsequently proved to be breast carcinoma, specifically infiltrating ductal carcinoma.

Human T-cell lymphotropic virus I (HTLV-I) encodes for a 40-kDa protein, Tax, which is important for the immortalization of T cells. Tax has been shown to transactivate several cellular genes. In this study, we show that MIP-1alpha is selectively expressed and secreted in the tax transfected Jurkat cell line upon mitogen stimulation. Expression of MIP-1alpha-R mRNA in these cells suggests an autocrine role for this chemokine in HTLV-I infected T-cells. Induced MIP-1alpha expression and secretion in PMA/PHA stimulated tax transfected cells correlate with the noninduction of MNP-1 transcription factor, which is intimately involved in downmodulating the MIP-1alpha gene., (Copyright 1999 Academic Press.)