Long-Term POTS Outcomes Survey: Diagnosis, Therapy, and Clinical Outcomes

BACKGROUND

Limited data exist on long-term outcomes in individuals with postural orthostatic tachycardia syndrome (POTS). We designed an electronic questionnaire assessing various aspects of outcomes among patients diagnosed and treated in a single-center pediatric POTS clinical program.

METHODS AND RESULTS

The LT-POTS (Long Term POTS Outcomes Survey) included questions about quality of life, symptoms, therapies, education, employment, and social impact of disease. Patients age≤18 years at POTS diagnosis who were managed in the Children's Hospital of Philadelphia POTS Program were included. A total of 227 patients with POTS responded with sufficient data for interpretation. The mean age of respondents was 21.8±3.5 years. The median age of symptom onset was 13 (interquartile range 11-14) years, with mean 9.6±3.4 years symptom duration. Multiple cardiovascular, neurologic, and gastrointestinal symptoms were reported. Symptom prevalence and severity were worse for female patients, with 99% of patients reporting ongoing symptoms. Quality of life showed moderate function and limitation, with more severe limitations in energy/fatigue and general health. Nearly three quarters of patients had diagnostic delays, and over half were told that their symptoms were "in their head." Multiple medications were used and were felt to be effective, whereas fewer nonpharmacologic interventions demonstrated efficacy. Nearly 90% of patients required continued nonpharmacologic therapy to control symptoms.

CONCLUSIONS

POTS is a chronic disorder leading to significant disability with a range of multisystem problems. Although symptoms can be modifiable, it rarely spontaneously resolves. Improved understanding of POTS presentation and therapeutic approaches may inform provider education, improve diagnostic success, and help patients self-advocate for appropriate medical management approaches.

Health education intervention and its impact on patients with unilateral vestibular dysfunction: An information-motivation-behavioral model approach

Unilateral vestibular dysfunction is a one-sided impairment of vestibular function in one ear. Incorporating health education in treatment and rehabilitation plans can improve vestibular function, keep negative emotions at bay, and reduce the extent of the condition. This letter investigates the impact of the information-motivation-behavioral skills model as a medium for health education on patient outcomes. While offering encouraging observations, there are certain limitations, such as the study's retrospective design, small sample size, use of subjective measures, and lack of longer follow-ups that challenge the cogency of the study. The study is a step toward transforming vestibular dysfunction treatment through health education.

Evaluation of teplizumab's efficacy and safety in treatment of type 1 diabetes mellitus: A systematic review and meta-analysis

BACKGROUND

Islets of Langerhans beta cells diminish in autoimmune type 1 diabetes mellitus (T1DM). Teplizumab, a humanized anti-CD3 monoclonal antibody, may help T1DM. Its long-term implications on clinical T1DM development, safety, and efficacy are unknown.

AIM

To assess the effectiveness and safety of teplizumab as a therapeutic intervention for individuals with T1DM.

METHODS

A systematic search was conducted using four electronic databases (PubMed, Embase, Scopus, and Cochrane Library) to select publications published in peer-reviewed journals written in English. The odds ratio (OR) and risk ratio (RR) were calculated, along with their 95%CI. We assessed heterogeneity using Cochrane Q and I² statistics and the appropriate P value.

RESULTS

There were 8 randomized controlled trials (RCTs) in the current meta-analysis with a total of 1908 T1DM patients from diverse age cohorts, with 1361 patients receiving Teplizumab and 547 patients receiving a placebo. Teplizumab was found to have a substantial link with a decrease in insulin consumption, with an OR of 4.13 (95%CI: 1.72 to 9.90). Teplizumab is associated with an improved C-peptide response (OR 2.49; 95%CI: 1.62 to 3.81) and a significant change in Glycated haemoglobin A1c (HbA1c) levels in people with type 1 diabetes [OR 1.75 (95%CI: 1.03 to 2.98)], and it has a RR of 0.71 (95%CI: 0.53 to 0.95).

CONCLUSION

In type 1 diabetics, teplizumab decreased insulin consumption, improved C-peptide response, and significantly changed HbA1c levels with negligible side effects. Teplizumab appears to improve glycaemic control and diabetes management with good safety and efficacy.

Pseudocarcinomatous Hyperplasia of the Nose and Necrotic Tracheitis Associated with Acute Myeloid Leukemia

A 29-year-old woman who had been diagnosed with acute myeloid leukemia presented with persistent grade-4 febrile neutropenia (FN) after initial chemotherapy with idarubicin and cytarabine. Despite intensive treatment, FN persisted. Subsequently, her nose became reddish and swollen, obstructing the nasal cavities. Computed tomography revealed swelling of the nostrils and an irregular tracheal surface. Debridement of the nasal lesion and a bronchoscopic biopsy of the tracheal lesion were also performed. A histopathological examination revealed pseudocarcinomatous hyperplasia (PCH) of the nose and necrotizing tracheitis. Both nasal PCH and necrotizing tracheitis ameliorated when the patient recovered from leukocytopenia.

Ruthenibacterium lactatiformans isolated from a human blood culture: a first report

BACKGROUND

Ruthenibacterium lactatiformans, a Gram-stain-negative, rod-shaped, obligate anaerobic bacterium of the Oscillospiraceae family, has not been previously reported in human infections. This study reports the first case of bacteraemia and potential vertebral osteomyelitis caused by Ruthenibacterium lactatiformans.

CASE PRESENTATION

An 82-year-old man with a history of diabetes, chronic renal failure, and prior spinal surgery for spondylolisthesis and spinal stenosis presented with fever and lower back pain. Magnetic resonance imaging revealed multiple vertebral osteomyelitis lesions. Initial blood cultures identified methicillin-resistant Staphylococcus aureus (MRSA), which prompted vancomycin treatment. However, repeated blood cultures not only confirmed persistent MRSA, but also detected Gram-negative bacilli (GNB). Despite surgical removal of the spinal hardware and antimicrobial therapy, the patient's osteomyelitis worsened, necessitating transfer for further management. Subsequent analysis using 16S rRNA gene sequencing identified the GNB as Ruthenibacterium lactatiformans.

CONCLUSIONS

This is the first documented instance of human infection with Ruthenibacterium lactatiformans, signifying its pathogenic potential in vertebral osteomyelitis. The involvement of anaerobic bacteria and the possibility of polymicrobial infections complicate the diagnosis and treatment of vertebral osteomyelitis. This report underscores the need for caution when identifying the causative organism and selecting an appropriate treatment.

Identification of gaps in the delivery of high-quality care of patients with eosinophilic esophagitis

Quality indicators (QIs) are standardized metrics that can be used to quantify health care delivery and identify important areas for practice improvement. Nine QIs pertaining to the diagnosis and management of eosinophilic esophagitis (EoE) were recently established. We therefore aimed to identify existing gaps in care using these QIs. This is a retrospective, multicenter study utilizing recently established EoE QIs to evaluate practice patterns among adult gastroenterologists in the diagnosis and management of EoE. Three patient cohorts of 30 patients each presenting with dysphagia, food impaction, and new diagnosis of EoE, respectively, were obtained, yielding 120 patients per site to assess for every QI. Summary statistics were reported across two main themes: diagnosis and management. Subsequent analysis of gaps in care was then performed. The domain of diagnosis of EoE (QI 1 and 2) had the most notable gap in care with only 55% of the presenting patients undergoing appropriate evaluation for EoE. The domain of management of EoE had overall higher QI fulfillment-however it also contained significant intra-category variation in care. Notably, while 79% of patients had clinical follow-up within 1 year from remission, only 54% underwent surveillance endoscopy within 2 years of remission. In contrast, 100% of patients with symptomatic strictures independent of histologic response underwent endoscopic dilation (QI 4). Management approaches for EoE are evolving and variation in care delivery exists. We identified significant gaps in both diagnosis of EoE especially amongst patients presenting with index food impaction and long term management of EoE, when retrospectively evaluating care patterns using newly established QIs. This is the first study of its kind to utilize these previously established QIs to objectively identify care gaps that exist in EoE amongst several institutions. These findings also highlight the importance of QIs and standardization of management of complex chronic diseases like EoE to help bridge these gaps and provide a framework to measure adherence to these best practices.

Dose-response relationship between physical activity and frailty: A systematic review and meta-analysis

Objective

Frailty is a significant public health issue facing aging societies and can be reduced by physical activity (PA), but the dose-response relationship between PA and frailty is not clear. This systematic review and dose-response meta-analysis aimed to assess the effect of PA on frailty in adults by aggregating data from observational studies.

Methods

PubMed, Embase, Web of Science, Cochrane Library, Scopus, SAGE Reference Online, SinoMed, CINAHL and CNKI were retrieved for articles published before May 2024. After quality evaluation, data on PA and the risk of frailty were extracted. Stata/MP 17.0 was used for dose-response meta-analysis.

Results

A total of 15 articles were included, involving 34,754 participants, including 4250 subjects with frailty or pre-frailty. The consequence of the dose-response meta-analysis revealed that compared with those who were not active at all, a 22 % (95 % CI, 16 %-28 %) reduction in the risk of frailty in individuals with 11.25 MET h/week of cumulative activity and a 55 % (95 % CI, 44 %-63 %) reduction in the risk of frailty in those with 22.5 MET h/week of cumulative activity; for higher activity levels (36.75 MET h/week), the risk of frailty was reduced by 68 % (95 % CI, 58 %-76 %) and continued to be reduced as PA volum increased.

Conclusions

There is a non-linear dose-response relationship between PA and frailty risk. Even small amounts of PA could reduce the risk of frailty. Meeting the minimum recommended PA target could reduce some risks, and doubling the recommended PA volumes could reduce most risks, which continue to increase as the volum of PA accumulates.

Stereotactic radiosurgery versus combined stereotactic radiosurgery and bevacizumab for recurrent glioblastoma; a systematic review and meta-analysis of survival

Recurrent glioblastoma (rGBM) is a brain tumor that is resistant to standard treatments. Although stereotactic radiosurgery (SRS) is a non-invasive radiation technique, it cannot fully prevent tumor recurrence and progression. Bevacizumab blocks tumor blood supply and has been approved for rGBM. However, the best way to combine SRS and bevacizumab is still unclear. We did a systematic review and meta-analysis of studies comparing SRS alone and SRS plus bevacizumab for rGBM. We searched three databases for articles published until June 2023. All statistical analysis was performed by STATA v.17. Our meta-analysis included 20 studies with 926 patients. We found that the combination therapy had a significantly lower rate of overall survival (OS) than SRS alone at 6-month 0.77[95%CI:0.74-0.85] for SRS alone and (100%) for SRS plus bevacizumab. At 1-year OS, 0.39 [95%CI: 0.32-0.47] for SRS alone and 0.61 [95%CI:0.44-0.77] for SRS plus bevacizumab (P-value:0.02). However, this advantage was not seen in the long term (18 months and two years). Additionally, the combination therapy had lower chances of progression-free survival (PFS) than SRS alone at the 6-month and 1-year time points, but the differences were insignificant. Our study indicates that incorporating bevacizumab with SRS may lead to a short-term increase in OS for rGBM patients but not long-term. Additionally, the PFS rate did not show significant improvement in the group receiving combination therapy. Further clinical trials are necessary to validate the enhanced overall survival with combination therapy for rGBM.

Bilateral renal agenesis: fetal intervention and outcomes

Bilateral renal agenesis (BRA) is a fetal anomaly which leads to anhydramnios and resultant pulmonary hypoplasia. Historically, this anomaly was universally fatal early in the neonatal period due to the severity of the associated lung disease. Over the last 30 years, innovations in fetal therapies-specifically, serial amnioinfusions-have led to instances of infant pulmonary survival and initiation of postnatal dialysis, raising the possibility that early neonatal death may not be inevitable. Amnioinfusions are not without risk, and maternal complications can include prelabor rupture of membranes, preterm labor, infection, and bleeding. The data detailing neonatal outcomes are still limited and actively being collected. Two case series and one non-randomized clinical trial have supplied most of the known outcome data for infants with BRA after prenatal amnioinfusion. Although there are survivors reported in the literature, mortality remains high, with many deaths in infancy due to dialysis-associated sepsis. In addition, previously unknown morbidities have been documented in these infants, including neurologic injury. These challenges, in addition to the mechanical difficulties of providing dialysis to extremely small infants, can result in significant burdens for patients and their caregivers and moral distress for the health care team. The present review aims to explain the pathophysiology of BRA, detail the historical context and rationale for serial amnioinfusions to treat the pulmonary insufficiency associated with BRA, describe the available data regarding outcomes of infants born following prenatal amnioinfusions, discuss ethical issues surrounding this fetal intervention, and describe critical aspects of prenatal counseling for patients considering the intervention.

Results of the RVA Breathes randomized controlled trial

OBJECTIVE

This study tested a randomized controlled trial of RVA Breathes, a community asthma program, in reducing asthma-related healthcare utilization among children living in an area with a high poverty rate.

METHODS

Participants included 250 caregivers (78% African American/Black; 73.3% household income<$25,000/year) and their children with asthma (5-11 years). Inclusion criteria included an asthma-related emergency department (ED) visit, hospitalization, unscheduled doctor's visit, or systemic steroids in the past 2 years. Families were randomized to a full active intervention (asthma education with community health workers [CHWs], home remediation with home assessors, and a school nurse component; n = 118), partial active intervention (asthma education and home remediation; n = 69), or a control group (n = 63) for 9 months. Measures on healthcare utilization and asthma-related factors were collected. Follow-up assessments occurred across a 9-month period.

RESULTS

Although we did not find any significant effects, there was a trend toward significance for a group by time effect with objective healthcare utilization as the outcome (F4,365 = 2.28, p = .061). The full intervention group experienced a significant decrease from baseline to 9-month follow-up compared with the other groups (p < .001). Only the full intervention group experienced a significant increase in reported asthma action plans across time (no significant group effect).

CONCLUSIONS

In the context of the unprecedented COVID-19 pandemic, which led to a substantial global decrease in healthcare utilization, the study's main hypotheses were not supported. Nevertheless, findings support the benefit of community asthma programs that integrate care across multiple settings and connect families with CHWs.

Healthcare utilization disparities among children with high-risk neuroblastoma treated on Children's Oncology Group clinical trials

INTRODUCTION

Disparities in relapse and survival from high-risk neuroblastoma (HRNBL) persist among children from historically marginalized groups even in highly standardized clinical trial settings. Research in other cancers has identified differential treatment toxicity as one potential underlying mechanism. Whether racial and ethnic disparities in treatment-associated toxicity exist in HRNBL is poorly understood.

METHODS

This is a retrospective study utilizing a previously assembled merged cohort of children with HRNBL on Children's Oncology Group (COG) post-consolidation immunotherapy trials ANBL0032 and ANBL0931 at Pediatric Health Information System (PHIS) centers from 2005 to 2014. Race and ethnicity were categorized to reflect historically marginalized populations as Hispanic, non-Hispanic Black (NHB), non-Hispanic other (NHO), and non-Hispanic White (NHW). Associations between race-ethnicity and intensive care unit (ICU)-level care utilization as a proxy for treatment-associated toxicity were examined with log binomial regression and summarized as risk ratio (RR) and corresponding 95% confidence interval (CI).

RESULTS

The analytic cohort included 370 children. Overall, 88 (23.8%) patients required ICU-level care for a median of 3.0 days (interquartile range [IQR]: 1.0-6.5 days). Hispanic children had nearly three times the risk of ICU-level care (RR 3.1, 95% CI: 2.1-4.5; fully adjusted RR [aRR] 2.5, 95% CI: 1.6-3.7) compared to NHW children and the highest percentage of children requiring cardiovascular-driven ICU-level care.

CONCLUSION

Children of Hispanic ethnicity with HRNBL receiving clinical trial-delivered therapy were more likely to experience ICU-level care compared to NHW children. These data suggest that further investigation of treatment-related toxicity as a modifiable mechanism underlying outcome disparities is warranted.

Factors Related to Clinical Performance in Spine Surgery Fellowship: Can We Predict Success

INTRODUCTION

The factors most important in the spine fellowship match may not ultimately correlate with quality of performance during fellowship. This study examined the spine fellow applicant metrics correlated with high application rank compared with the metrics associated with the strongest clinical performance during fellowship.

METHODS

Spine fellow applications at three academic institutions were retrieved from the San Francisco Match database (first available to 2021) and deidentified for application review. Application metrics pertaining to research, academics, education, extracurriculars, leadership, examinations, career interests, and letter of recommendations were extracted. Attending spine surgeons involved in spine fellow selection at their institutions were sent a survey to rank (1) fellow applicants based on their perceived candidacy and (2) the strength of performance of their previous fellows. Pearson correlation assessed the associations of application metrics with theoretical fellow rank and actual performance.

RESULTS

A total of 37 spine fellow applications were included (Institution A: 15, Institution B: 12, Institution C: 10), rated by 14 spine surgeons (Institution A: 6, Institution B: 4, Institution C: 4). Theoretical fellow rank demonstrated a moderate positive association with overall research, residency program rank, recommendation writer H-index, US Medical Licensing Examination (USMLE) scores, and journal reviewer positions. Actual fellow performance demonstrated a moderate positive association with residency program rank, recommendation writer H-index, USMLE scores, and journal reviewer positions. Linear regressions identified journal reviewer positions (ß = 1.73, P = 0.002), Step 1 (ß = 0.09, P = 0.010) and Step 3 (ß = 0.10, P = 0.002) scores, recommendation writer H-index (ß = 0.06, P = 0.029, and ß = 0.07, P = 0.006), and overall research (ß = 0.01, P = 0.005) as predictors of theoretical rank. Recommendation writer H-index (ß = 0.21, P = 0.030) and Alpha Omega Alpha achievement (ß = 6.88, P = 0.021) predicted actual performance.

CONCLUSION

Residency program reputation, USMLE scores, and a recommendation from an established spine surgeon were important in application review and performance during fellowship. Research productivity, although important during application review, was not predictive of fellow performance.

LEVEL OF EVIDENCE

III.

STUDY DESIGN

Cohort Study.

Asymptomatic Ophthalmomyiasis Interna Posterior with Central Pigment Accumulation in the Inner Retina

PURPOSE

To report a case of ophthalmomyiasis interna posterior which was asymptomatic and had pigment clumps in the inner retina at the macula.

METHODS

Single-centre, observational, retrospective case report.

RESULTS

A routine refractive error check-up for an asymptomatic 52-year-old Asian Indian woman, who had relied on glasses for 8 years, unfolded a captivating narrative within her retina. This coloured fundus photo unveils mid-peripheral retinal disease with multiple outer retinal atrophic tracts, circumlinear patterns, and intricately intertwined RPE atrophic tracts. These were hyper-autofluorescent on blue autofluorescence. The inferonasal periphery had two-disc diameters of pigmented retinal-choroidal atrophic scar. The macula revealed a collection of black intraretinal pigments in parafoveal areas. The distinct clinical presentation, marked by multiple tracts and unilateral manifestation without disc pallor, hinted at the intriguing possibility of self-resolved "Ophthalmomyiasis interna posterior."

CONCLUSION

The course of disease in ophthalmomyiasis interna posterior can be self-limiting and asymptomatic. The presence of inner retinal pigments at foveal and parafoveal areas, possibly due to pigment migration from the peripheral outer retinal tracts, is a rare presentation.

Etiopathology, Epidemiology, Diagnosis, and Treatment of Fungal Keratitis

Fungal keratitis (FK) is a severe ocular condition resulting from corneal infection that is prevalent in tropical countries, particularly in developing regions of Asia and Africa. Factors like corneal lens misuse, inappropriate steroid use, and diagnostic challenges have provoked the epidemic. FK causes significant vision impairment, scarring, and ocular deformities. Accurate pathological diagnosis is crucial for effective therapeutic intervention. Topical antifungal therapy with surface healing medications proves effective in preventing fungal-borne ulcers. Managing FK requires a comprehensive understanding of fungal pathogenesis, guiding formulation strategies and preventive measures to curb global ocular blindness. This review provides in-depth insights into FK, covering etiology, epidemiology, pathogenesis, therapeutic interventions, antifungal resistance, limitations, prevention, and future perspectives on ocular surface disease management.

Granulicatella adiacens Bacterial Infection After Pancreatectomy Whipple's Procedure

Background: Granulicatella adiacens inhabits the oral cavity, urogenital, and gastrointestinal tracts and is a typical commensal of human mucosal surfaces. It rarely causes disease. Identification of these gram-positive cocci can be challenging. Case Report: In a 58-year-old male in an oncology center, we report the first occurrence of bacterial infection caused by G. adiacens. After a precise diagnosis of the infection, the patient received effective treatment. Conclusion: Owing to a lack of sufficient diagnostic tools, G. adiacens may be a more notable pathogen than has been previously identified. Sensitivity testing standards are desperately needed.

Changes in health-related quality of life in common variable immunodeficiency: an eight-year journey, including the COVID-19 pandemic

BACKGROUND

Personalized medicine requires the assessment of the impact of health care interventions on Health-Related Quality of Life.

RESEARCH DESIGN AND METHODS

We run an observational study of HRQoL in 140 CVID patients with biannual assessments over 8  years using a disease-specific tool, the CVID_QoL, and the GHQ questionnaires. Factors influencing changes in HRQoL scores were identified using multiple linear regression models with a stepwise procedure.

RESULTS

Infections frequency, female gender, and chronic enteropathy were associated with worse global CVID_QoL scores. The presence of permanent organ damage and older age contributed to the perception of being at risk of health deterioration, while chronic enteropathy was associated with fatigue. The presence of permanent organ damage was also associated with perceived difficulties in usual activities. The frequency of infections was the main risk factor for difficulties in long-term planning and perceptions of vulnerability. Before COVID-19, improved HRQoL scores were associated with reduced respiratory infections and changes in immunoglobulin replacement route and setting. The COVID-19 pandemic caused a sudden deterioration in all HRQoL dimensions, and a further deterioration in the emotional dimension was observed during the pandemic period. Patients who died during the study had worse CVID_QoL scores at all time points, confirming that HRQoL performance is strongly related to patient outcome.

CONCLUSIONS

Periodic HRQoL assessments are needed to capture relevant issues that change over time in patients affected by long-term chronic conditions such CVID, possibly identifying areas of intervention.

Material, Psychological, and Behavioral Financial Hardship Among Lesbian, Gay, and Bisexual Cancer Survivors in the United States

PURPOSE

Driven by anti-LGBTQ+ stigma, emerging literature suggests that lesbian, gay, and bisexual (LGB) cancer survivors experience financial hardship (FH) more frequently than heterosexual survivors. However, few studies have used nationally representative samples to estimate this inequity.

METHODS

National Health Interview Survey data from 2019 to 2022 were pooled and weighted. Outcomes included material, psychological, and behavioral FH. The behavioral domain was further broken down into subdomains including medical care, prescription medications, and mental health care. Multivariable logit models controlling for a variety of factors were used to generate LGB and heterosexual predicted probabilities and differential effects for each FH outcome. Stratified estimates were generated by sex and age groups.

RESULTS

A total of N = 374 LGB and N = 12,757 heterosexual cancer survivors were included in this analysis. In adjusted analyses, LGB cancer survivors had significantly higher material (19%, 95% CI, 15 to 24 v 12%, 95% CI, 11 to 13; P = .004), psychological (44%, 95% CI, 38 to 51 v 37%, 95% CI, 36 to 38; P = .035), and behavioral (23%, 95% CI, 18 to 28 v 13%, 95% CI, 13 to 14; P < .0001) FH than heterosexual survivors. LGB cancer survivors also had higher medical behavioral (11%, 95% CI, 7 to 15 v 7%, 95% CI, 6 to 7; P = .030), prescription medication behavioral (14%, 95% CI, 10 to 19 v 10%, 95% CI, 9 to 10; P = .032), and mental health behavioral (9%, 95% CI, 6 to 13 v 3%, 95% CI, 3 to 4; P < .0001) FH than heterosexual survivors. Stratified estimates revealed young LGB cancer survivors had the highest probability of each outcome (material: 31%, 95% CI, 23 to 40; psychological: 58%, 95% CI, 50 to 66; behavioral: 45%, 95% CI, 36 to 53).

CONCLUSION

In this nationally representative analysis, LGB cancer survivors experience substantial inequities in all FH outcomes. It is crucial that future FH interventional work should prioritize populations at the highest risk of FH, such as LGB cancer survivors.

Multimodal prehabilitation and postoperative outcomes in upper abdominal surgery: systematic review and meta-analysis

The impact of multimodal prehabilitation on postoperative complications in upper abdominal surgeries is understudied. This review analyzes randomized trials on multimodal prehabilitation with patient and hospital outcomes. MEDLINE, Embase, CINAHL, and Cochrane CENTRAL were searched for trials on prehabilitation before elective (non-emergency) abdominal surgery. Two reviewers independently screened studies, extracted data, and assessed study quality. Primary outcomes of interest were postoperative pulmonary complications (PPCs) and all-cause complications; secondary outcomes included hospital and intensive care length of stay. A meta-analysis with random-effect models was performed, and heterogeneity was evaluated with I-square and Cochran's Q test. Dichotomous variables were reported in log-odds ratio and continuous variables were presented as mean difference. Ten studies (total 1503 patients) were included. Odds of developing complications after prehabilitation were significantly lower compared to various control groups (- 0.38 [- 0.75- - 0.004], P = 0.048). Five studies described PPCs, and participants with prehabilitation had decreased odds of PPC (- 0.96 [- 1.38- - 0.54], P < 0.001). Prehabilitation did not significantly reduce length of stay, unless exercise was implemented; with exercise, hospital stay decreased significantly (- 0.91 [- 1.67- - 0.14], P = 0.02). Multimodal prehabilitation may decrease complications in upper abdominal surgery, but not necessarily length of stay; research should address heterogeneity in the literature.

Interventions to improve primary healthcare in rural settings: A scoping review

BACKGROUND

Residents of rural areas have poorer health status, less healthy behaviours and higher mortality than urban dwellers, issues which are commonly addressed in primary care. Strengthening primary care may be an important tool to improve the health status of rural populations.

OBJECTIVE

Synthesize and categorize studies that examine interventions to improve rural primary care.

ELIGIBILITY CRITERIA

Experimental or observational studies published between January 1, 1996 and December 2022 that include an historical or concurrent control comparison.

SOURCES OF EVIDENCE

Pubmed, CINAHL, Cochrane Library, Embase.

CHARTING METHODS

We extracted and charted data by broad category (quality, access and efficiency), study design, country of origin, publication year, aim, health condition and type of intervention studied. We assigned multiple categories to a study where relevant.

RESULTS

372 papers met our inclusion criteria, divided among quality (82%), access (20%) and efficiency (13%) categories. A majority of papers were completed in the USA (40%), Australia (15%), China (7%) or Canada (6%). 35 (9%) papers came from countries in Africa. The most common study design was an uncontrolled before-and-after comparison (32%) and only 24% of studies used randomized designs. The number of publications each year has increased markedly over the study period from 1-2/year in 1997-99 to a peak of 49 papers in 2017.

CONCLUSIONS

Despite substantial inequity in health outcomes associated with rural living, very little attention is paid to rural primary care in the scientific literature. Very few studies of rural primary care use randomized designs.

Maternal Morbidity following Trial of Labor after Cesarean in Women Experiencing Antepartum Fetal Death

This study aims to investigate whether trial of labor after cesarean delivery (TOLAC) in women with antepartum fetal death, is associated with an elevated risk of maternal morbidity. A retrospective multicenter. TOLAC of singleton pregnancies following a single low-segment incision were included. Maternal adverse outcomes were compared between women with antepartum fetal death and women with a viable fetus. Controls were matched with cases in a 1:4 ratio based on their previous vaginal births and induction of labor rates. Univariate analysis was followed by multiple logistic regression modeling. During the study period, 181 women experienced antepartum fetal death and were matched with 724 women with viable fetuses. Univariate analysis revealed that women with antepartum fetal death had significantly lower rates of TOLAC failure (4.4% vs. 25.1%, p < 0.01), but similar rates of composite adverse maternal outcomes (6.1% vs. 8.0%, p = 0.38) and uterine rupture (0.6% vs. 0.3%, p = 0.56). Multivariable analyses controlling for confounders showed that an antepartum fetal death vs. live birth isn't associated with the composite adverse maternal outcomes (aOR 0.96, 95% CI 0.21-4.44, p = 0.95). TOLAC in women with antepartum fetal death is not associated with an increased risk of adverse maternal outcomes while showing high rates of successful vaginal birth after cesarean (VBAC).

Sociobehavioral Risk Factors and Clinical Implications of Late Presentation Among People Living with HIV in the Brazilian Amazon Region

This study aimed to analyze the prevalence, sociobehavioral factors and clinical-laboratory consequences of late presentation among people living with HIV (PLHIV) in the Brazilian Amazon region. In total, 402 HIV + individuals treated at reference units in Belém city (Pará, Brazil) between 2018 and 2019 were evaluated. Late presentation was defined as a first-collection LTCD4+ count below 350 cells/µL. Sociodemographic, behavioral and clinical data were obtained from questionnaires or medical records. Th1, Th2 and Th17 cytokine profiles were evaluated by flow cytometry. Longitudinal data on viral load, T lymphocytes, and antiretroviral therapy administration were obtained from control and logistic databases. Approximately 52.73% of the participants were late presenters and sought medical care 7-12 + months after their primary HIV diagnosis. Sociobehavioral factors associated with late presentation included illicit drug use for more than 5 years, polyamory, no alcohol consumption, homosexuality, and sexual inactiveness after HIV diagnosis. Clinically, late presentation was associated with coinfection rate; polysymptomatology; high IFN-ɣ, IL-6 and IL-10 levels; nonresponse to antiretroviral therapy; and virological failure- and tuberculosis coinfection-motivated changes to therapy. In summary, the prevalence of late presentation in Pará in the Brazilian Amazon region is high. Delays in seeking specialized care after a primary HIV diagnosis cause medium/long-term changes in the life expectancy and health of PLHIV.

Application of triboelectric nanogenerator (TENG) in cancer prevention and adjuvant therapy

Cancer is a malignant tumor that kills about 940,000 people worldwide each year. In addition, about 30-77 % of cancer patients will experience cancer metastasis and recurrence, which can increase the cancer mortality rate without prompt treatment. According to the US Food and Drug Administration, wearable devices can detect several physiological indicators of patients to reflect their health status and adjuvant cancer treatment. Based on the triboelectric effect and electrostatic induction phenomenon, triboelectric nanopower generation (TENG) technology can convert mechanical energy into electricity and drive small electronic devices. This article reviewed the research status of TENG in the areas of cancer prevention and adjuvant therapy. TENG can be used for cancer prevention with advanced sensors. At the same time, electrical stimulation generated by TENG can also be used to help inhibit the growth of cancer cells to reduce the proliferation, recurrence, and metastasis of cancer cells. This review will promote the practical application of TENG in healthcare and provide clean and sustainable energy solutions for wearable bioelectronic systems.

Diagnostic and therapeutic considerations in cases of civilian intravascular ballistic embolism: a review of case reports

Background

Ballistic embolism (BE) is a rare complication of firearm injuries notoriously associated with a vexing clinical picture in the trauma bay. Unless considered early, the associated confusion can lead to needless delay in the management of the patient with a gunshot wound. Despite this known entity, there is a relative paucity of high-grade evidence regarding complications, management, and follow-up in these patients.

Methods

An electronic database literature search was conducted to identify cases of acute intravascular BE in pediatric and adult civilians occurring during index hospitalization, filtered to publications during the past 10 years. Exclusion criteria included non-vascular embolization, injuries occurring in the military setting, and delayed migration defined as occurring after discharge from the index hospitalization.

Results

A total of 136 cases were analyzed. Nearly all cases of BE occurred within 48 hours of presentation. Compared with venous emboli, arterial emboli were significantly more likely to be symptomatic (71% vs. 7%, p<0.001), and 43% of patients developed symptoms attributable to BE in the trauma bay. In addition, arterial emboli were significantly less likely to be managed non-invasively (19% vs. 49%, p<0.001). Open retrieval was significantly more likely to be successful compared with endovascular attempts (91% vs. 29%, p<0.001). Patients with arterial emboli were more likely to receive follow-up (52% vs. 39%) and any attempt at retrieval during the hospitalization was significantly associated with outpatient follow-up (p=0.034). All but one patient remained stable or had clinically improved symptoms after discharge.

Conclusion

Consideration for BE is reasonable in any patient with new or persistent unexplained signs or symptoms, especially during the first 48 hours after a penetrating firearm injury. Although venous BE can often be safely observed, arterial BE generally necessitates urgent retrieval. Patients who are managed non-invasively may benefit from follow-up in the first year after injury.

Inhibitors of the Structural and Nonstructural Proteins of Alphaviruses

The Alphavirus genus includes viruses that cause encephalitis due to neuroinvasion and viruses that cause arthritis due to acute and chronic inflammation. There is no approved therapeutic for alphavirus infections, but significant efforts are ongoing, more so in recent years, to develop vaccines and therapeutics for alphavirus infections. This review article highlights some of the major advances made so far to identify small molecules that can selectively target the structural and the nonstructural proteins in alphaviruses with the expectation that persistent investigation of an increasingly expanding chemical space through a variety of structure-based design and high-throughput screening strategies will yield candidate drugs for clinical studies. While most of the works discussed are still in the early discovery to lead optimization stages, promising avenues remain for drug development against this family of viruses.

Breastfeeding in US working mothers: A systematic review

BACKGROUND

Previous studies demonstrate that exclusive breastfeeding has positive long-term health effects on the mother and infant, but research has shown that nearly 50% of mothers do not breastfeed for the recommended amount of time.

OBJECTIVE

This article systematizes previous quantitative research on the impact of work on breastfeeding practices to identify the factors that correlate to the cessation of breastfeeding in working mothers.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statements, we performed a systematic review that screened PubMed, CINAHL, PsycINFO, and Academic Search Complete databases for articles relating to maternal employment and breastfeeding.

RESULTS

Of the 13,106 articles assessed for eligibility, 21 studies met all requirements and were included in this systematic review. The 21 articles were divided into study type and methods, participant demographics, study outcomes, and additional factors that included stressors and stress levels, factors that increased or decreased rates of breastfeeding, and feeding methods. Articles outside of the United States were excluded due to differences in maternity leave policies of other countries impacting the data.

CONCLUSION

Cessation of breastfeeding and breastfeeding outcomes were seen to have a strong association with maternal employment, specifically with the policies and employer support in the workplace. Other factors such as race, level of education, and stress were also shown to relate to breastfeeding outcomes and are important to consider in future public health interventions and workplace policies.

Melanometry for objective evaluation of skin pigmentation in pulse oximetry studies

Pulse oximetry enables real-time, noninvasive monitoring of arterial blood oxygen levels. However, results can vary with skin color, thus detecting disparities during clinical validation studies requires an accurate measure of skin pigmentation. Recent clinical studies have used subjective methods such as self-reported color, race/ethnicity to categorize skin. Melanometers based on optical reflectance may offer a more effective, objective approach to assess pigmentation. Here, we review melanometry approaches and assess evidence supporting their use as clinical research tools. We compare performance data, including repeatability, robustness to confounders, and compare devices to each other, to subjective methods, and high-quality references. Finally, we propose best practices for evaluating melanometers and discuss alternate optical approaches that may improve accuracy. Whilst evidence indicates that melanometers can provide superior performance to subjective approaches, we encourage additional research and standardization efforts, as these are needed to ensure consistent and reliable results in clinical studies.

Pathogenomics analysis of high-risk clone ST147 multidrug-resistant Klebsiella pneumoniae isolated from a patient in Egypt

BACKGROUND

The emergence of multi-drug-resistant Klebsiella pneumoniae (MDR-KP) represents a serious clinical health concern. Antibiotic resistance and virulence interactions play a significant role in the pathogenesis of K. pneumoniae infections. Therefore, tracking the clinical resistome and virulome through monitoring antibiotic resistance genes (ARG) and virulence factors in the bacterial genome using computational analysis tools is critical for predicting the next epidemic.

METHODS

In the current study, one hundred extended spectrum β-lactamase (ESBL)-producing clinical isolates were collected from Mansoura University Hospital, Egypt, in a six-month period from January to June 2022. One isolate was selected due to the high resistance phenotype, and the genetic features of MDR-KP recovered from hospitalized patient were investigated. Otherwise, the susceptibility to 25 antimicrobials was determined using the DL Antimicrobial Susceptibility Testing (AST) system. Whole genome sequencing (WGS) using Illumina NovaSeq 6000 was employed to provide genomic insights into K. pneumoniae WSF99 clinical isolate.

RESULTS

The isolate K. pneumoniae WSF99 was phenotypically resistant to the antibiotics under investigation via antibiotic susceptibility testing. WGS analysis revealed that WSF99 total genome length was 5.7 Mb with an estimated 5,718 protein-coding genes and a G + C content of 56.98 mol%. Additionally, the allelic profile of the WSF99 isolate was allocated to the high-risk clone ST147. Furthermore, diverse antibiotic resistance genes were determined in the genome that explain the high-level resistance phenotypes. Several β-lactamase genes, including blaCTX-M-15, blaTEM-1, blaTEM-12, blaSHV-11, blaSHV-67, and blaOXA-9, were detected in the WSF99 isolate. Moreover, a single carbapenemase gene, blaNDM-5, was predicted in the genome, positioned within a mobile cassette. In addition, other resistance genes were predicted in the genome including, aac(6')-Ib, aph(3')-VI, sul1, sul2, fosA, aadA, arr-2, qnrS1, tetA and tetC. Four plasmid replicons CoIRNAI, IncFIB(K), IncFIB(pQil), and IncR were predicted in the genome. The draft genome analysis revealed the occurrence of genetic mobile elements positioned around the ARGs, suggesting the ease of dissemination via horizontal gene transfer.

CONCLUSIONS

This study reports a comprehensive pathogenomic analysis of MDR-KP isolated from a hospitalized patient. These findings could be relevant for future studies investigating the diversity of antimicrobial resistance and virulence in Egypt.

Effectiveness of personalized rehabilitation in adults suffering from persistent concussion symptoms as compared to usual care: a randomized control trial protocol

BACKGROUND

Symptoms reported by patients who sustain a concussion are non-specific. As such, clinicians are better able to manage patients when a standardized clinical exam is performed to sub-type the driver(s) of symptoms. Aerobic exercise and multimodal rehabilitation have consistently shown to be a possibly effective means to manage this population; however, the optimal training prescription is unclear. Thus, there is a need to further examine the effectiveness of personalized rehabilitative treatments. Our primary aim is to evaluate the response to personalized therapy on recovery, as measured by The Rivermead Post-concussion Symptoms Questionnaire (RPQ) when compared to an active control.

METHODS

We will conduct a multi-center 12-week case-crossover randomized controlled trial. 50 participants will be recruited from out-patient University Health Network clinics and community-based clinical practices around the greater Toronto area. Participants will be randomized at baseline to Group A: a personalized care program followed by an active control or Group B: an active control followed by a personalized care program. Participants will be included should they be 21 years of age and older and have symptoms that have persisted beyond 4 weeks but less than 1 year. Participants will undergo 6-weeks of care in their respective streams. After 6-weeks, participants will undergo a re-examination. They will then crossover and undertake the alternative treatment for 6 weeks. At the end of 12 weeks, participants will undertake the endpoint examinations. The primary outcome will be the Rivermead Postconcussion Questionnaire (RPQ). The secondary outcomes will be changes in standardized clinical examination, Neck Disability Index (NDI), Patient Health Questionnaire (PHQ-9) and an electroencephalography (EEG) via NeuroCatch™. The statistical analysis to be performed is composed of an adjusted model using an analysis of variance, specifically using an unpaired t-test to test for associations between variables and outcomes.

DISCUSSION

Given the recommendations from reviews on the topic of rehabilitation for adults with persistent concussion symptoms, we are undertaking a controlled trial. The documented high costs for patients seeking care for persistent symptoms necessitate the need to evaluate the effectiveness of a personalized rehabilitative program compared to the current standard of care.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT06069700.

Management of Acute Wounds-Expert Panel Consensus Statement

Significance: The Wound Healing Foundation recognized the need for consensus-based unbiased recommendations for the treatment of wounds. As a first step, a consensus on the treatment of chronic wounds was developed and published in 2022. The current publication on acute wounds represents the second step in this process. Acute wounds may result from any number of conditions, including burns, military and combat operations, and trauma to specific areas of the body. The management of acute wounds requires timely and evidence-driven intervention to achieve optimal clinical outcomes. This consensus statement provides the clinician with the necessary foundational approaches to the causes, diagnosis, and therapeutic management of acute wounds. Presented in a structured format, this is a useful guide for clinicians and learners in all patient care settings. Recent Advances: Recent advances in the management of acute wounds have centered on stabilization and treatment in the military and combat environment. Specifically, advancements in hemostasis, resuscitation, and the mitigation of infection risk through timely initiation of antibiotics and avoidance of high-pressure irrigation in contaminated soft tissue injury. Critical Issues: Critical issues include infection control, pain management, and the unique considerations for the management of acute wounds in pediatric patients. Future Directions: Future directions include new approaches to preventing the progression and conversion of burns through the use of specific gel formulations. Additionally, the use of three-dimensional bioprinting and photo-modulation for reconstruction is a promising area for continued discovery.

Posttraumatic stress disorder in the aftermath of the Turkey earthquake: exploring the role of demographics, level of exposure, and personality traits

BACKGROUND AND OBJECTIVES

Post-Traumatic Stress Disorder (PTSD) is an important mental disorder that can develop after mass traumas such as earthquakes. In our study, we aimed to investigate the development of PTSD after the Turkey earthquake (6 February 2023) and its association with some demographic variables, personality traits, and psychological vulnerability.

METHOD

547 participants completed assessments of personality, disaster exposure, and PTSD symptoms. Multiple regression analyses were used to identify predictors of PTSD symptoms.

RESULTS

PTSD scores were higher in women, single people, those with low educational level, those who witnessed someone else's injury or death, those who were injured, and those whose homes were destroyed. Physical injury, conscientiousness, marital status, income, and agreeableness predicted PTSD. Among these variables, physical injury was the strongest predictor of PTSD.

CONCLUSIONS

Psychological vulnerability, conscientiousness, physical injury, employment, witnessing someone else's injury, gender, and emotional stability predicted PTSD score in a significant way. Physical injury, conscientiousness, marital status, income, agreeableness predicted PTSD in a significant way.

Immuno-inflammatory pathogenesis in ischemic heart disease: perception and knowledge for neutrophil recruitment

Ischemic heart disease (IHD) can trigger responses from the innate immune system, provoke aseptic inflammatory processes, and result in the recruitment and accumulation of neutrophils. Excessive recruitment of neutrophils is a potential driver of persistent cardiac inflammation. Once recruited, neutrophils are capable of secreting a plethora of inflammatory and chemotactic agents that intensify the inflammatory cascade. Additionally, neutrophils may obstruct microvasculature within the inflamed region, further augmenting myocardial injury in the context of IHD. Immune-related molecules mediate the recruitment process of neutrophils, such as immune receptors and ligands, immune active molecules, and immunocytes. Non-immune-related molecular pathways represented by pro-resolving lipid mediators are also involved in the regulation of NR. Finally, we discuss novel regulating strategies, including targeted intervention, agents, and phytochemical strategies. This review describes in as much detail as possible the upstream molecular mechanism and external intervention strategies for regulating NR, which represents a promising therapeutic avenue for IHD.

The impact of discharge letter content on unplanned hospital readmissions within 30 and 90 days in older adults with chronic illness - a mixed methods study

BACKGROUND

Care transitions are high-risk processes, especially for people with complex or chronic illness. Discharge letters are an opportunity to provide written information to improve patients' self-management after discharge. The aim of this study is to determine the impact of discharge letter content on unplanned hospital readmissions and self-rated quality of care transitions among patients 60 years of age or older with chronic illness.

METHODS

The study had a convergent mixed methods design. Patients with chronic obstructive pulmonary disease or congestive heart failure were recruited from two hospitals in Region Stockholm if they were living at home and Swedish-speaking. Patients with dementia or cognitive impairment, or a "do not resuscitate" statement in their medical record were excluded. Discharge letters from 136 patients recruited to a randomised controlled trial were coded using an assessment matrix and deductive content analysis. The assessment matrix was based on a literature review performed to identify key elements in discharge letters that facilitate a safe care transition to home. The coded key elements were transformed into a quantitative variable of "SAFE-D score". Bivariate correlations between SAFE-D score and quality of care transition as well as unplanned readmissions within 30 and 90 days were calculated. Lastly, a multivariable Cox proportional hazards model was used to investigate associations between SAFE-D score and time to readmission.

RESULTS

All discharge letters contained at least five of eleven key elements. In less than two per cent of the discharge letters, all eleven key elements were present. Neither SAFE-D score, nor single key elements correlated with 30-day or 90-day readmission rate. SAFE-D score was not associated with time to readmission when adjusted for a range of patient characteristics and self-rated quality of care transitions.

CONCLUSIONS

While written summaries play a role, they may not be sufficient on their own to ensure safe care transitions and effective self-care management post-discharge.

TRIAL REGISTRATION

Clinical Trials. giv, NCT02823795, 01/09/2016.

Profiling deutetrabenazine extended-release tablets for tardive dyskinesia and chorea associated with Huntington's disease

INTRODUCTION

Tardive dyskinesia (TD) and Huntington's disease (HD)-associated chorea are persistent and disabling hyperkinetic disorders that can be treated with vesicular monoamine transporter type 2 (VMAT2) inhibitors, including the recently approved once-daily (QD) formulation of deutetrabenazine (DTBZ ER). While its efficacy and safety profile have not been directly investigated, currently available data confirms bioequivalence and similar bioavailability to the twice-daily formulation (DTBZ BID).

AREAS COVERED

The authors briefly review the pivotal trials establishing efficacy of DTBZ for TD and HD-associated chorea, the pharmacokinetic data for bioequivalence between QD and BID dosing of DTBZ, as well as dose proportionality evidence, titration recommendations, and safety profile for DTBZ ER.

EXPERT OPINION

Long-term data show that DTBZ is efficacious and well tolerated for the treatment of TD and HD-associated chorea. DTBZ ER likely demonstrates therapeutic equivalence with no new safety signals. Due to the lack of comparative clinical trial data, no evidence-based recommendation about choice of VMAT2 inhibitor or switching between VMAT2 inhibitors can be made about best practice. Ultimately, QD dosing may offer the chance of improved medication adherence, an important consideration in patients with complex treatment regimens and/or patients with cognitive decline.

Oxidative stress induces ferroptosis in tendon stem cells by regulating mitophagy through cGAS-STING pathway

Tendinopathy is one of the most prevalent sports injury diseases in orthopedics. However, there is no effective treatment or medicine. Recently, the discovery of tendon stem cells (TSCs) provides a new perspective to find new therapeutic methods for Tendinopathy. Studies have shown that oxidative stress will inevitably cause TSCs injury during tendinopathy, but the mechanism has not been fully elucidated. Here, we report the oxidative damage of TSCs induced by H2O2 via ferroptosis, as well, treatment with H2O2 raised the proportion of mitochondria engulfed by autophagosomes in TSCs. The suppression of mitophagy by Mdivi-1 significantly attenuates the H2O2-induced ferroptosis in TSCs. Mechanically, H2O2 actives the cGAS-STING pathway, which can regulate the level of mitophagy. Interfering with cGAS could impair mitophagy and the classical ferroptotic events. In the rat model of tendinopathy, interference of cGAS could relieve tendon injury by inhibiting ferroptosis. Overall, these results provided novel implications to reveal the molecular mechanism of tendinopathy, by which pointed to cGAS as a potential therapeutic target for the treatment of tendinopathy.

DISPLACE study shows poor quality of transcranial doppler ultrasound for stroke risk screening in sickle cell anemia

ABSTRACT

Children with sickle cell anemia (SCA) are at increased risk of stroke when compared with their age-based counterparts. The Stroke Prevention Trial in Sickle Cell Anemia (STOP) previously demonstrated that with the use of transcranial Doppler ultrasound (TCD; Sickle Stroke Screen) and chronic red cell transfusion, the risk of stroke is reduced by over 90%. The STOP criteria detailed the type and method of measurement required; the time-averaged mean maximum velocity (TAMMV). Unfortunately, it has been difficult to adhere to the appropriate TAMMV measurements. The objectives of this study were to assess the quality of TCD and transcranial Doppler imaging (TCDi) reports to determine the report quality and accuracy. This is a subanalysis of the DISPLACE (Dissemination and Implementation of Stroke Prevention Looking at the Care Environment) study. Over 12 000 TCD/TCDi reports were collected during this study from 28 institutions; 391 TCDs were reviewed for this subanalysis. There were significant variations in the vessels being assessed, the velocities used to define abnormal results, and who was interpreting the scans. In 52% of reports, it was impossible to identify whether the TAMMV was what was measured. Similarly, it was only clear in 42% of reports that the TAMMV was used to interpret the examination as normal/abnormal. Given this inconsistency, we strongly recommend standardization of TCD/TCDi reporting, specialized training for those performing and interpreting the scans in the use of TCD/TCDi in patients with SCA, internal quality assurance, and institutional quality improvement work to ensure appropriate use of this potentially lifesaving technology.

Once or consecutive administration of inhaled salbutamol in children with acute asthma exacerbation: Is an additional dose beneficial?

BACKGROUND

Although international guidelines generally recommend the back to back use of short-acting β-agonizts (SABA) within a short time in the management of acute wheezing in children with asthma, there is still uncertainty in the evidence of short term outcome. Thus, this study aimed to investigate the efficacy of back to back and single use of inhaled SABA by lung function testing.

METHODS

This was a prospective, double-blinded, placebo controlled study conducted in children ≥6 years of age with a history of asthma. Children who presented with an acute asthma exacerbation (AAE) with a forced expiratory volume in 1 s (FEV1) between 40% to 60% were enrolled in the study if they had a first dose to SABA response of FEV1 ≥ 12%. All children were then randomly assigned either to receive two additional doses of inhaled SABA (300 µg per dose) or placebo. Spirometric analysis included forced vital capacity (FVC), FEV1, FEV1/FVC, PEF, and FEF25-75 at baseline, 15, 30, and 45 min for each group. Oxygen saturation and heart rate were monitored during the study period.

RESULTS

A total of 93 patients (inhaled SABA group; n = 48 vs. placebo group; n = 45) out of 110 enrolled patients completed the study. Baseline demographic characteristics of patients include age, gender, age of diagnosis, parental asthma, history of allergic rhinitis and atopic dermatitis, current asthma treatment, IgE and skin prick test were similar among groups. (p > .05) When lung function parameters were compared at each time interval during the study period, there were no statistical significance found in FVC, FEV1, FEV1/FVC, PEF and forced expiratory flow between 25% and 75% (FEF25-75) among groups. (p > .05) There were also no differences between groups for changes in heart rate and oxygen saturation. (p > .05) CONCLUSION: A single dose of inhaled SABA provides similar short term bronchodilator effect as back to back administration of inhaled SABA in children with AAE who showed an initial response to SABA of FEV1 ≥ 12%.

Everyday Clinical Ethics: Essential Skills and Educational Case Scenarios

Bioethics conjures images of dramatic healthcare challenges, yet everyday clinical ethics issues unfold regularly. Without sufficient ethical awareness and a relevant working skillset, clinicians can feel ill-equipped to respond to the ethical dimensions of everyday care. Bioethicists were interviewed to identify the essential skills associated with everyday clinical ethics and to identify educational case scenarios to illustrate everyday clinical ethics. Individual, semi-structured interviews were conducted with a convenience sample of bioethicists. Bioethicists were asked: (1) What are the essential skills required for everyday clinical ethics? And (2) What are potential educational case scenarios to illustrate and teach everyday clinical ethics? Participant interviews were analyzed using qualitative content analysis. Twenty-five (25) bioethicists completed interviews (64% female; mean 14.76 years bioethics experience; 80% white). Five categories of general skills and three categories of ethics-specific skills essential for everyday clinical ethics were identified. General skills included: (1) Awareness of Core Values and Self-Reflective Capacity; (2) Perspective-Taking and Empathic Presence; (3) Communication and Relational Skills; (4) Cultural Humility and Respect; and (5) Organizational Understanding and Know-How. Ethics-specific skills included: (1) Ethical Awareness; (2) Ethical Knowledge and Literacy; and (3) Ethical Analysis and Interaction. Collectively, these skills comprise a Toolbox of Everyday Clinical Ethics Skills. Educational case scenarios were identified to promote everyday ethics. Bioethicists identified skills essential to everyday clinical ethics. Educational case scenarios were identified for the purpose of promoting proficiency in this domain. Future research could explore the impact of integrating educational case scenarios on clinicians' ethical competencies.

The Effect of Rifapentine and Rifampicin on Serum Voriconazole Levels Persist for 5 Days and 7 Days or More After Discontinuation in Tuberculosis Patients with Chronic Pulmonary Aspergillosis

Purpose

Voriconazole, a first-line therapeutic agent for chronic pulmonary aspergillosis, is metabolized by the cytochrome 450 enzymes, specifically CYP2C19 and CYP3A4. Rifampicin and rifapentine act as inducers of the cytochrome P450 enzyme. The current study explored the potential drug interactions arising from the co-administration of voriconazole with either rifampicin or rifapentine, as well as the duration of this effect on serum voriconazole levels after discontinuation of rifampicin or rifapentine.

Patients and Methods

A retrospective study was conducted in tuberculosis patients with chronic pulmonary aspergillosis. These patients underwent a combination therapy involving voriconazole and rifampicin or rifapentine, or they were treated with voriconazole after discontinuation of rifampicin or rifapentine. The serum concentrations of voriconazole at steady-state were monitored. Data on demographic characteristics and the serum voriconazole levels were used for statistical analyses.

Results

A total of 124 serum voriconazole concentrations from 109 patients were included in the study. The average serum concentration of voriconazole fell below the effective therapeutic range in patients treated with both voriconazole and rifampicin or rifapentine. Notably the co-administration of rifapentine led to a substantial (>70%) decrease in serum voriconazole levels in two patients. Moreover, this interfering effect persisted for at least 7 days following rifampicin discontinuation, while it endured for 5 days or more after discontinuation of rifapentine.

Conclusion

Concomitant use of voriconazole and rifampicin or rifapentine should be avoided, and it is not recommended to initiate voriconazole therapy within 5 or 7 days after discontinuation of rifapentine or rifampicin. Therapeutic drug monitoring not only provides a basis for the adjustment of clinical dose, but also serves as a valuable tool for identifying drug interactions.

Vaccine effectiveness and impact of meningococcal vaccines against gonococcal infections: A systematic review and meta-analysis

OBJECTIVES

To systematically review and synthesis the evidence of vaccine effectiveness (VE) and impact (VI) of meningococcal vaccines in preventing gonorrhoea.

METHODS

We systematically evaluated studies. Literature searches were conducted in PubMed, Embase, Cochrane Library, CINAHL, Google Scholar, clinical trial registries, and major health and immunisation conferences. Meta-analysis was performed with the DerSimonian-Laird random-effects model to estimate the pooled VE.

RESULTS

Twelve studies met the criteria for inclusion. VE of meningococcal B (MenB) outer membrane vesicle (OMV) vaccines was evaluated in nine studies, with one study evaluating a non-OMV vaccine, MenB-FHbp. The majority of studies targeted individuals aged 15-30 years. Adjusted VE for OMV vaccines against gonorrhoea ranged from 22% to 46%. MenB-FHbp did not show protection against gonorrhoea. The pooled VE estimates of OMV vaccines against any gonorrhoea infection following the full vaccine series were 33-34%. VI was assessed for 4CMenB in Canada and Australia, for VA-MENGOC-BC in Cuba; and for MenBvac in Norway. VI ranged from a 30% to 59% reduction in gonorrhoea incidence.

CONCLUSIONS

4CMenB and other MenB-OMV vaccines show moderate effectiveness against gonorrhoea. Further research is required to explore the factors associated with vaccine protection, informing more effective vaccination strategies for the management of gonococcal infections.

The cutoff values of functional independence measure scores for predicting discharge destination in the early stroke phase

This study aimed to determine cutoff values of functional independence measure (FIM) scores to predict the discharge destinations of patients with acute stroke. The sample included 318 patients with acute stroke (mean age, 72.0 years; women, 39%). The discharge destination was categorized into three groups: home, postacute rehabilitation (hospital with convalescent rehabilitation wards), and postacute care (institution without convalescent rehabilitation wards). We assessed FIM after lifting bed restriction. Multinomial logistic regression analyses were used to estimate odds ratios (OR) and 95% confidence intervals (CI) of the FIM scores for predicting discharge destinations, with postacute rehabilitation as a reference. Cutoff values of motor and cognitive FIM scores for distinguishing home from postacute rehabilitation and postacute care from postacute rehabilitation were determined using receiver operating characteristic curves. The proportion of home, postacute rehabilitation, and postacute care were 34.6%, 41.8%, and 23.6%, respectively. After adjustments for clinical variables, the ORs (95% CIs) for motor and cognitive FIM scores for home versus postacute rehabilitation were 1.08 (1.04-1.11) and 1.05 (0.98-1.12). Furthermore, those for postacute care versus postacute rehabilitation were 1.01 (0.98-1.04) and 0.92 (0.87-0.98). The cutoff values of the motor and cognitive FIM scores for distinguishing home from postacute rehabilitation were 37.5 (sensitivity: 0.92; specificity: 0.64) and 23.5 (sensitivity: 0.78; specificity: 0.67). Furthermore, those for distinguishing postacute care from postacute rehabilitation were 15.5 (sensitivity, 0.81; specificity, 0.51) and 12.5 (sensitivity, 0.74; specificity, 0.64). The identified cutoff values may serve as early indicators for predicting discharge destinations from acute stroke care.

Workplace Violence Against Primary Care Clinicians: A Narrative Review

Workplace violence (WPV) is a commonly reported occupational hazard in healthcare and its prevalence is increasing. WPV occurs in all types of practice settings, but little is known about WPV in primary care settings in the United States (US). Because primary care practice settings differ from the inpatient settings, further examination of WPV in primary care is warranted. Our objective was to summarize the available literature highlight important gaps. We conducted a search using Pubmed and OVID for US studies of WPV in US-based adult primary care practices. Studies including only pediatric populations were excluded. Due to the lack of available literature conducted in US primary care settings, we expanded our search to include international studies. We identified 70 studies of which 5 were US based. Due to the lack of significant numbers of US-based studies, we opted to conduct a narrative review of all available studies. The evidence shows that WPV is a common occurrence in primary care settings in many countries and that the majority of primary care clinicians have experienced at least some form of non-physical violence in their careers. Most of the studies conducted were cross-sectional in design and reported on both non-physical and physical forms of WPV. There was not a consistent trend between genders in experiencing the major forms of WPV, but women were consistently more likely to be subjected to sexual harassment. Potential root causes for WPV could generally be categorized as patient-level, clinician-level, clinical encounter specific, and operational root causes. While most WPV was found to be non-physical, it still had significant emotional and job-related impacts on clinicians. These troubling results highlight the need for further studies to be conducted in the US.

Virtual Interviews in the Post-COVID-19 Emergency Era: Insights from the Gastroenterology Fellowship Applicants and Programs

BACKGROUND

Virtual interviews are still recommended for fellowship applications, 3 years after the beginning of the COVID-19 pandemic. Improving equity by reducing the cost for the applicants has been the most important reason for continuing virtual interviews. However, some argue that important information may be missed in a virtual setting. Our objective was to assess the perspective of Gastroenterology (GI) fellowship interviewers and applicants toward virtual interviews.

METHODS

We designed two different anonymous surveys directed at GI programs and GI applicants who were interviewed for GI fellowship programs from 2020 to 2022 and matched to a GI program. Survey links were emailed to the Program Directors (PDs) and Program Coordinators via the AGA listserv starting in January 2023. A descriptive analysis was performed using Excel, and Fisher's exact tests were performed using R version 4.3.1.

RESULTS

Sixty-one applicants and 79 interviewers responded to our survey. More than 80% of applicants strongly agreed (n = 36; 59%) and agreed (n = 14; 23%) that they would prefer in-person interviews if money was not an issue. When applicants were asked about the interview format in order of their preference, "in-person, hybrid, virtual" was the most popular answer (n = 16; 26.2%). Most interviewers (n = 47; 59.5%) do not prefer virtual interviews over in-person interviews. Furthermore, some interviewers were rarely able to judge the applicants' interpersonal (n = 17; 21.5%) and ethical skills (n = 16; 20.3%). These results differed according to the type of interviewer (p = 0.013 and 0.018, respectively).

CONCLUSION

Based on our survey, most programs still prefer in-person interviews. Despite the several advantages of virtual interviews, the majority of applicants would prefer an in-person setting if the financial burden was not a factor. Nonetheless, many applicants think that the cost savings outweigh all the disadvantages associated with virtual interviews. The lack of empathy, personal connections, and engagement may impact the ability of interviewers to judge and ultimately rank a candidate. The virtual interview is here to stay, and we need input from the applicants and the interviewers to make the process more productive.

Long COVID Brain Fog Treatment: Findings from a Pilot Randomized Controlled Trial of Constraint-Induced Cognitive Therapy

Purpose

Long COVID brain fog is often disabling. Yet, no empirically-supported treatments exist. This study's objectives were to evaluate feasibility and efficacy, provisionally, of a new rehabilitation approach, Constraint-Induced Cognitive Therapy (CICT), for post-COVID-19 cognitive sequelae.

Design

Sixteen community-residents ≥ 3-months post-COVID-19 infection with mild cognitive impairment and dysfunction in instrumental activities of daily living (IADL) were enrolled. Participants were randomized to Immediate-CICT or treatment-as-usual (TAU) with crossover to CICT. CICT combined behavior change techniques modified from Constraint-Induced Movement Therapy with Speed of Processing Training, a computerized cognitive-training program. CICT was deemed feasible if (a) ≥80% of participants completed treatment, (b) the same found treatment highly satisfying and at most moderately difficult, and (c) <2 study-related, serious adverse-events occurred. The primary outcome was IADL performance in daily life (Canadian Occupational Performance Measure). Employment status and brain fog (Mental Clutter Scale) were also assessed.

Results

Fourteen completed Immediate-CICT ( n =7) or TAU ( n =7); two withdrew from TAU before their second testing session. Completers were [ M (S D )]: 10 (7) months post-COVID; 51 (13) years old; 10 females, 4 males; 1 African American, 13 European American. All the feasibility benchmarks were met. Immediate-CICT, relative to TAU, produced very large improvements in IADL performance ( M =3.7 points, p<.001, d =2.6) and brain fog ( M =-4 points, p<.001, d =-2.9). Four of five non-retired Immediate-CICT participants returned-to-work post-treatment; no TAU participants did, p =.048.

Conclusions

CICT has promise for reducing brain fog, improving IADL, and promoting returning-to-work in adults with Long COVID. Findings warrant a large-scale RCT with an active-comparison group.

IMPACT

Brain fog in adults with Long COVID is often associated with dysfunction in everyday activities and unemployment. Yet, there are no empirically supported treatments targeting cognition in this population. Findings from this small-scale, pilot randomized controlled trial (RCT) suggest that a novel intervention, i.e., Constraint-Induced Cognitive Therapy, is a feasible cognitive rehabilitation method in adults with Long COVID cognitive sequelae with promise of (a) improving performance of cognition-based tasks in daily life and (b) promoting return-to-work. Further studies with larger sample sizes are warranted.Speed of Processing Training (SOPT) has been shown to increase processing speed in older adults without neurological disorders but has not been applied to adults with brain fog due to Long COVID, in whom slowing of cognitive processing speed is common. The results of this pilot RCT suggest that SOPT, in conjunction with behavior change techniques, may increase cognitive processing speed in this brain-injured population.

When to feed after percutaneous endoscopic gastrostomy: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Initiation of feeding after percutaneous endoscopic gastrostomy (PEG) placement has been debated. Randomized controlled trials (RCTs) have been performed on early feeding compared with delayed feeding after PEG placement with varying results. Therefore, a meta-analysis was conducted examining early vs delayed feeding after placement of a PEG.

METHODS

A comprehensive search of databases was conducted in January 2024. Peer-reviewed published RCTs comparing early feeding (≤4 h) with delayed feeding (>4 h) were identified and included in the meta-analysis. Meta-analysis was completed using pooled estimates of overall complications, individual complications, mortality ≤72 h, and number of day 1 significant gastric residual volumes.

RESULTS

Six RCTs (n = 467) were included in the analysis. Comparison of early feeding with delayed feeding after PEG showed no statistically significant differences for overall complications (P = 0.18), mortality ≤72 h (P = 0.3), and number of day 1 significant gastric residual volumes (P = 0.05). No differences were also noted for individual complications, including vomiting, wound infection, bleeding, or diarrhea.

CONCLUSION

Feeding ≤4 h after PEG have no differences in minor and major complications compared with that of delayed feeding. Early feeding ≤4 h is safe and should be recommended in future guidelines.

Associations Between PTSD Features and Firearm Ownership and Storage: Results From the PRImary Care Screening Methods (PRISM) Study

INTRODUCTION

Veterans and active duty service members are significantly more likely to die by suicide using firearms compared to the general population. Not-secure firearm storage (e.g., keeping guns loaded/in an unlocked location) is associated with greater risk for suicide and a third of veteran firearm owners store at least 1 personal firearm unsecured. Veterans and active duty service members are also significantly more likely to be diagnosed with posttraumatic stress disorder (PTSD) than the general population. Symptoms of PTSD are divided into 4 criteria: reexperiencing, avoidance, negative affect, and hyperarousal. Research has suggested that endorsement of hyperarousal symptoms is positively associated with unsecure firearm storage and that avoidance symptoms might be negatively associated with unsecure storage practices. The present study examined the relationship between self-reported firearm ownership and storage practices among each item from the Primary Care PTSD Screening for DSM-IV-TR (PC-PTSD-IV) to explore associations between PTSD features and firearm ownership and storage.

MATERIALS AND METHODS

Participants were recruited from primary care clinics across 5 military installations in the United States as part of a larger study (Mage = 45.4, SD = 16.9). Among participants (n = 2,685), most of our sample identified as male (51.3%) and white (67.3%) with 61.6% currently serving in the military, 16.8% retirees, and 21.6% family members. PTSD symptoms were assessed using the PC-PTSD-IV and a quarter met the clinical threshold for PTSD. Binomial and multinomial logistic regression analyses were used.

RESULTS

Among completed responses, 989 (38.1%) people reported owning guns; among gun owners, 386 (39.0%) reported that they were loaded, and 352 (35.6%) reported they were loaded and unlocked. Endorsement of specific items on the PC-PTSD-IV, including those specific to hyperarousal and avoidance, was not significantly associated with storing firearms loaded and/or in nonsecure locations when controlling for military service. Non-responses to items around firearm storage practices were significantly associated with those individuals meeting the clinical threshold for PTSD according to the PC-PTSD-IV and participants currently serving had higher odds of storing at least 1 personal firearm loaded and both loaded and unlocked.

CONCLUSIONS

Results from our study highlight similarities and departures from the previous literature on the connection between PTSD and non-secure firearm storage practices. Further research may examine (1) the relation between PTSD symptoms and firearm storage between active duty service members, retirees, and family members and (2) whether non-response to items regarding firearm ownership is systematic.

Advancing thalamic neuromodulation in epilepsy: Bridging adult data to pediatric care

Thalamic neuromodulation has emerged as a treatment option for drug-resistant epilepsy (DRE) with widespread and/or undefined epileptogenic networks. While deep brain stimulation (DBS) and responsive neurostimulation (RNS) depth electrodes offer means for electrical stimulation of the thalamus in adult patients with DRE, the application of thalamic neuromodulation in pediatric epilepsy remains limited. To address this gap, the Neuromodulation Expert Collaborative was established within the Pediatric Epilepsy Research Consortium (PERC) Epilepsy Surgery Special Interest Group. In this expert review, existing evidence and recommendations for thalamic neuromodulation modalities using DBS and RNS are summarized, with a focus on the anterior (ANT), centromedian(CMN), and pulvinar nuclei of the thalamus. To-date, only DBS of the ANT is FDA approved for treatment of DRE in adult patients based on the results of the pivotal SANTE (Stimulation of the Anterior Nucleus of Thalamus for Epilepsy) study. Evidence for other thalamic neurmodulation indications and targets is less abundant. Despite the lack of evidence, positive responses to thalamic stimulation in adults with DRE have led to its off-label use in pediatric patients. Although caution is warranted due to differences between pediatric and adult epilepsy, the efficacy and safety of pediatric neuromodulation appear comparable to that in adults. Indeed, CMN stimulation is increasingly accepted for generalized and diffuse onset epilepsies, with recent completion of one randomized trial. There is also growing interest in using pulvinar stimulation for temporal plus and posterior quadrant epilepsies with one ongoing clinical trial in Europe. The future of thalamic neuromodulation holds promise for revolutionizing the treatment landscape of childhood epilepsy. Ongoing research, technological advancements, and collaborative efforts are poised to refine and improve thalamic neuromodulation strategies, ultimately enhancing the quality of life for children with DRE.

The impact of abortion restrictions on American mental health

The overturning of Roe v. Wade has led to numerous states enacting new abortion restrictions. However, limited empirical evidence exists regarding the general mental health impact of these bans. Leveraging the nationwide Household Pulse Survey, we evaluate the impact of emergent gestational limits and outright bans on self-reported mental health status between July 2021 and June 2023 using a difference in difference approach. Responses indicate a significant increase in reports of mental distress after the institution of such restrictions. These effects appear to persist at least 4 months following a ban and are moderated by household income and education but not by sex, race, age, marital status, or sexual orientation. Less educated and less wealthy subjects reported greater mental health distress compared to wealthier, more educated groups. These results suggest that the institution of abortion restrictions has had broad negative implications for the mental health of people living in the US, particularly those of lower education and personal wealth.

Therapeutic challenges and unmet needs in the management of myasthenia gravis: an Italian expert opinion

Myasthenia gravis (MG) is a rare, autoimmune, neurological disorder. Most MG patients have autoantibodies against acetylcholine receptors (AChRs). Some have autoantibodies against muscle-specific tyrosine kinase (MuSK) or lipoprotein-receptor-related protein 4 (LRP4), and some are seronegative. Standard of care, which includes anti-cholinesterase drugs, thymectomy, corticosteroids (CS), and off-label use of non-steroidal immunosuppressive drugs (NSISTs), is bounded by potential side effects and limited efficacy in refractory generalized MG (gMG) patients. This highlights the need for new therapeutic approaches for MG. Eculizumab, a monoclonal antibody that inhibits the complement system, has been recently approved in Italy for refractory gMG. A panel of 11 experts met to discuss unmet therapeutic needs in the acute and chronic phases of the disease, as well as the standard of care for refractory patients. Survival was emphasized as an acute phase outcome. In the chronic phase, persistent remission and early recognition of exacerbations to prevent myasthenic crisis and respiratory failure were considered crucial. Refractory patients require treatments with fast onset of action, improved tolerability, and the ability to slow disease progression and increase life expectancy. The Panel agreed that eculizumab would presumably meet the therapeutic needs of many refractory gMG patients. The panel concluded that the unmet needs of current standard of care treatments for gMG are significant. Evaluating new therapeutic options accurately is essential to find the best balance between efficacy and tolerability for each patient. Collecting real-world data on novel molecules in routine clinical practice is necessary to address unmet needs.