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Tian Z, Shofer FS, Fan M, Sandroni AZ, Yao L, Han L, Qin L, Enomoto-Iwamoto M, Zhang Y. ADAM8 inactivation retards intervertebral disc degeneration in mice. Genes Dis 2024; 11:101059. [PMID: 38292194 PMCID: PMC10825293 DOI: 10.1016/j.gendis.2023.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 03/17/2023] [Accepted: 06/27/2023] [Indexed: 02/01/2024] Open
Affiliation(s)
- Zuozhen Tian
- Department of Physical Medicine & Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19146, USA
| | - Frances S. Shofer
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Mingyue Fan
- School of Biomedical Engineering, Science & Health Systems, Drexel University, Philadelphia, PA 19104, USA
| | - Alec Z. Sandroni
- Department of Physical Medicine & Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19146, USA
| | - Lutian Yao
- Department of Orthopedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Orthopedics/Sports Medicine and Joint Surgery, the First Hospital of China Medical University, Shenyang, Liaoning 110001, China
| | - Lin Han
- School of Biomedical Engineering, Science & Health Systems, Drexel University, Philadelphia, PA 19104, USA
| | - Ling Qin
- Department of Orthopedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Motomi Enomoto-Iwamoto
- Department of Orthopedics, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Yejia Zhang
- Department of Physical Medicine & Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19146, USA
- Department of Orthopedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Section of Rehabilitation Medicine, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
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Lu J, Tian Z, Shofer FS, Qin L, Sun H, Zhang Y. Tnfaip8 and Tipe2 Gene Deletion Ameliorates Immediate Proteoglycan Loss and Inflammatory Responses in the Injured Mouse Intervertebral Disc. Am J Phys Med Rehabil 2024:00002060-990000000-00471. [PMID: 38630557 DOI: 10.1097/phm.0000000000002488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
OBJECTIVE TNFAIP8 and TIPE2 belong to TNFa-induced protein 8 (TNFAIP8/TIPE) family. They control apoptosis and direct leukocyte migration. Nucleus pulposus (NP) cell loss is a hallmark of intervertebral disc (IVD) degeneration in response to injury, and inflammation may cause pain. Here, we examined the effects of TNFAIP8/TIPE2 deficiency on the IVDs in mice with these genes deleted. DESIGN Tail IVDs in Tnfaip8 or Tipe2 single and double knockout mice (Tnfaip8-/-, Tipe2-/-, and Tnfaip8/Tipe2 dko), and wild type (WT) controls were injured. The spine motion segments were stained with Safranin O to reveal proteoglycans. Macrophages were identified by immunostaining, and selected inflammatory marker and collagen gene expression was examined by Real Time PCR. RESULTS The injured tail IVDs of Tnfaip-/-, Tipe2-/-, and Tnfaip8/Tipe2 dko mice all displayed higher levels of proteoglycans than WT controls. Fewer macrophages were found in the injured IVDs of Tipe2-/- and Tnfaip8/Tipe2 dko mice than WT. Il6, Adam8 and Col1 gene expression was downregulated in the injured IVDs of Tnfip8/Tipe2 dko mice. CONCLUSIONS TNFAIP8 and TIPE2 loss of function ameliorated proteoglycan loss and inflammation in the injured IVDs. They may serve as molecular targets to preserve disc structure and reduce inflammation.
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Affiliation(s)
| | - Zuozhen Tian
- Departments of Physical Medicine & Rehabilitation
| | | | | | - Honghong Sun
- Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania
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Greenwood JC, Talebi FM, Jang DH, Spelde AE, Gordon EK, Horak J, Acker MA, Kilbaugh TJ, Shofer FS, Augoustides JGT, Brenner JS, Muzykantov VR, Bakker J, Abella BS. Anaerobic Lactate Production Is Associated With Decreased Microcirculatory Blood Flow and Decreased Mitochondrial Respiration Following Cardiovascular Surgery With Cardiopulmonary Bypass. Crit Care Med 2024:00003246-990000000-00322. [PMID: 38578158 DOI: 10.1097/ccm.0000000000006289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
OBJECTIVES Quantify the relationship between perioperative anaerobic lactate production, microcirculatory blood flow, and mitochondrial respiration in patients after cardiovascular surgery with cardiopulmonary bypass. DESIGN Serial measurements of lactate-pyruvate ratio (LPR), microcirculatory blood flow, plasma tricarboxylic acid cycle cycle intermediates, and mitochondrial respiration were compared between patients with a normal peak lactate (≤ 2 mmol/L) and a high peak lactate (≥ 4 mmol/L) in the first 6 hours after surgery. Regression analysis was performed to quantify the relationship between clinically relevant hemodynamic variables, lactate, LPR, and microcirculatory blood flow. SETTING This was a single-center, prospective observational study conducted in an academic cardiovascular ICU. PATIENTS One hundred thirty-two patients undergoing elective cardiovascular surgery with cardiopulmonary bypass. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients with a high postoperative lactate were found to have a higher LPR compared with patients with a normal postoperative lactate (14.4 ± 2.5 vs. 11.7 ± 3.4; p = 0.005). Linear regression analysis found a significant, negative relationship between LPR and microcirculatory flow index (r = -0.225; β = -0.037; p = 0.001 and proportion of perfused vessels: r = -0.17; β = -0.468; p = 0.009). There was not a significant relationship between absolute plasma lactate and microcirculation variables. Last, mitochondrial complex I and complex II oxidative phosphorylation were reduced in patients with high postoperative lactate levels compared with patients with normal lactate (22.6 ± 6.2 vs. 14.5 ± 7.4 pmol O2/s/106 cells; p = 0.002). CONCLUSIONS Increased anaerobic lactate production, estimated by LPR, has a negative relationship with microcirculatory blood flow after cardiovascular surgery. This relationship does not persist when measuring lactate alone. In addition, decreased mitochondrial respiration is associated with increased lactate after cardiovascular surgery. These findings suggest that high lactate levels after cardiovascular surgery, even in the setting of normal hemodynamics, are not simply a type B phenomenon as previously suggested.
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Affiliation(s)
- John C Greenwood
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Fatima M Talebi
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - David H Jang
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Audrey E Spelde
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Emily K Gordon
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jiri Horak
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Michael A Acker
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Center for Mitochondrial and Epigenomic Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Frances S Shofer
- Department of Epidemiology & Biostatistics, Department of Emergency Medicine Hospital of the University of Pennsylvania, Philadelphia, PA
| | - John G T Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jacob S Brenner
- Division of Pulmonary, Allergy, & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Vladimir R Muzykantov
- Department of Pharmacology and Center for Translational Targeted Therapeutics and Nanomedicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jan Bakker
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Benjamin S Abella
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Perkison WB, Schaefer CM, Green-McKenzie J, Roy RW, Shofer FS, McCarthy RB. Outcomes for a Heat Illness Prevention Program in Outdoor Workers: A 9-Year Overview. J Occup Environ Med 2024; 66:293-297. [PMID: 38242542 DOI: 10.1097/jom.0000000000003051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
OBJECTIVE To describe the outcomes effect of removing the medical surveillance component from a heat illness prevention program (HIPP) for outdoor workers from a Central Texas municipality. METHODS Heat-related illness (HRI) frequency and workers' compensation (WC) cost were assessed retrospectively in a cohort of 329 workers from 2011-2019. During 2011-2017, the HIPP included training, acclimatization, and medical surveillance. In 2018-2019, a modified (mHIPP) was implemented that included training and acclimatization, but without medical surveillance. RESULTS The HRI rate during HIPP averaged 19.5 per 1000 workers during the first 4 years, dropped to 1.01 per 1,000 workers over the next 3 years, (2015-2017), and increased during mHIPP, to 7.6 per 1,000 workers. DISCUSSION Although the case increase during the mHIPP was small, medical surveillance may be an important component in lowering workforce HRI.
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Affiliation(s)
- William B Perkison
- From the Department of Epidemiology, Human Genetics and Environmental Sciences, Southwest Center for Occupational and Environmental Health, University of Texas Health Science Center, Houston, School of Public Health, Houston, Texas (W.B.P., R.W.R.); Department of Management, Policy, and Community Health, University of Texas Health Science Center, Houston, School of Public Health, Houston, Texas (C.M.S.); Division of Occupational and Environmental Medicine, Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (J.G.-M.); Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (F.S.); and Concentra, Medical Surveillance Services, Irwindale, California (R.S.M.)
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Graves RL, Shofer FS, Kayser JB, Perrone J. First-Year Medical Students' Perceptions of Stigma Toward People With Opioid Use Disorder Before and After an Educational Intervention. Subst Use Addctn J 2024:29767342241236302. [PMID: 38456439 DOI: 10.1177/29767342241236302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND Stigma among medical trainees toward people with opioid use disorder (OUD) compounds the problems associated with opioid addiction. People with OUD who experience overt and implicit stigma from healthcare providers are less likely to seek and receive treatment, further restricting their access to already limited resources. The objective of our study was to assess an educational strategy to mitigate stigma toward people with OUD among first-year medical students. METHODS This study assessed perceptions of stigma toward people with OUD among first-year medical students using an adaptation of a brief, validated opioid stigma scale before and after an educational intervention. The intervention consisted primarily of a recorded panel in which people with a history of OUD shared their experiences with stigma followed by small group discussions. RESULTS After the educational intervention, students were more likely to respond that (1) they believed most people held negative beliefs about people with OUD and (2) they personally disagreed with negative statements about people with OUD. CONCLUSIONS Educational interventions addressing stigma toward people with OUD are potentially effective and should be integrated into medical curricula. Such interventions are a crucial part of the effort to improve the medical care of people with OUD.
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Affiliation(s)
- Rachel L Graves
- Department of Anesthesiology, Wake Forest University, Winston-Salem, NC, USA
| | - Frances S Shofer
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua B Kayser
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care, Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeanmarie Perrone
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Medicine Center for Addiction Medicine and Policy, Philadelphia, PA, USA
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Mavroudis CD, Lewis A, Greenwood JC, Kelly M, Ko TS, Forti RM, Shin SS, Shofer FS, Ehinger JK, Baker WB, Kilbaugh TJ, Jang DH. Investigation of Cerebral Mitochondrial Injury in a Porcine Survivor Model of Carbon Monoxide Poisoning. J Med Toxicol 2024; 20:39-48. [PMID: 37847352 PMCID: PMC10774472 DOI: 10.1007/s13181-023-00971-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/30/2023] [Accepted: 09/08/2023] [Indexed: 10/18/2023] Open
Abstract
INTRODUCTION Carbon monoxide (CO) is a colorless and odorless gas that is a leading cause of environmental poisoning in the USA with substantial mortality and morbidity. The mechanism of CO poisoning is complex and includes hypoxia, inflammation, and leukocyte sequestration in brain microvessel segments leading to increased reactive oxygen species. Another important pathway is the effects of CO on the mitochondria, specifically at cytochrome c oxidase, also known as Complex IV (CIV). One of the glaring gaps is the lack of rigorous experimental models that may recapitulate survivors of acute CO poisoning in the early phase. The primary objective of this preliminary study is to use our advanced swine platform of acute CO poisoning to develop a clinically relevant survivor model to perform behavioral assessment and MRI imaging that will allow future development of biomarkers and therapeutics. METHODS Four swine (10 kg) were divided into two groups: control (n = 2) and CO (n = 2). The CO group received CO at 2000 ppm for over 120 min followed by 30 min of re-oxygenation at room air for one swine and 150 min followed by 30 min of re-oxygenation for another swine. The two swine in the sham group received room air for 150 min. Cerebral microdialysis was performed to obtain semi real-time measurements of cerebral metabolic status. Following exposures, all surviving animals were observed for a 24-h period with neurobehavioral assessment and imaging. At the end of the 24-h period, fresh brain tissue (cortical and hippocampal) was immediately harvested to measure mitochondrial respiration. RESULTS While a preliminary ongoing study, animals in the CO group showed alterations in cerebral metabolism and cellular function in the acute exposure phase with possible sustained mitochondrial changes 24 h after the CO exposure ended. CONCLUSIONS This preliminary research further establishes a large animal swine model investigating survivors of CO poisoning to measure translational metrics relevant to clinical medicine that includes a basic neurobehavioral assessment and post exposure cellular measures.
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Affiliation(s)
- Constantine D Mavroudis
- Divisions of Cardiothoracic Surgery, The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, 19104, USA
| | - Alistair Lewis
- Divisions of Cardiothoracic Surgery, The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, 19104, USA
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Anesthesia and Critical Care Medicine Mitochondrial Unit (ACMU), The Children's Hospital of Philadelphia (CHOP), Lab 6200, Colket Translational Research Building, 3501 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - John C Greenwood
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Matthew Kelly
- Divisions of Cardiothoracic Surgery, The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, 19104, USA
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Anesthesia and Critical Care Medicine Mitochondrial Unit (ACMU), The Children's Hospital of Philadelphia (CHOP), Lab 6200, Colket Translational Research Building, 3501 Civic Center Blvd, Philadelphia, PA, 19104, USA
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Emergency Medicine, University of Alabama, Birmingham, AL, USA
| | - Tiffany S Ko
- Anesthesia and Critical Care Medicine Mitochondrial Unit (ACMU), The Children's Hospital of Philadelphia (CHOP), Lab 6200, Colket Translational Research Building, 3501 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Rodrigo M Forti
- Anesthesia and Critical Care Medicine Mitochondrial Unit (ACMU), The Children's Hospital of Philadelphia (CHOP), Lab 6200, Colket Translational Research Building, 3501 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Samuel S Shin
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Frances S Shofer
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Johannes K Ehinger
- Otorhinolaryngology, Head and Neck Surgery, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Mitochondrial Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Otorhinolaryngology, Head and Neck Surgery, Skåne University Hospital, Lund, Sweden
| | - Wesley B Baker
- Anesthesia and Critical Care Medicine Mitochondrial Unit (ACMU), The Children's Hospital of Philadelphia (CHOP), Lab 6200, Colket Translational Research Building, 3501 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Todd J Kilbaugh
- Anesthesia and Critical Care Medicine Mitochondrial Unit (ACMU), The Children's Hospital of Philadelphia (CHOP), Lab 6200, Colket Translational Research Building, 3501 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - David H Jang
- Anesthesia and Critical Care Medicine Mitochondrial Unit (ACMU), The Children's Hospital of Philadelphia (CHOP), Lab 6200, Colket Translational Research Building, 3501 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
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Lu J, Tian Z, Shofer FS, Yao L, Sandroni AZ, Sun H, Qin L, Zhang Y. Tnfa , Il6 , Cxcl1 , and Adam8 Genes Are the Early Markers After Mouse Tail Intervertebral Disc Injury. Am J Phys Med Rehabil 2023; 102:1063-1069. [PMID: 37208807 PMCID: PMC10618411 DOI: 10.1097/phm.0000000000002278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
OBJECTIVES The early molecular events after intervertebral disc injury remain unclear. In this study, we aimed to compare inflammatory markers from 1 day to 4 wks after injury to have a comprehensive understanding of the intervertebral disc response to injury. DESIGN Mouse tail intervertebral disc injury was induced by a needle puncture. Inflammatory marker gene expression and morphological changes were recorded at 1 day, 1 wk, and 4 wks after injury. RESULTS Tnfa , Il6 , and Cxcl1 gene expression peaked at day 1 post-needle puncture of the mouse intervertebral disc, Adam8 gene expression peaked at 1-wk time point, while Tipe2 gene expression was upregulated at week 4 postinjury. F4/80 positive cells, likely to be macrophages, are present as early as day 1 in the injured intervertebral discs and consistently present at week 4 postinjury. Loss of Safranin O staining and increased histological scores of the injured intervertebral discs are consistent with progressive degeneration after injury. CONCLUSIONS Inflammatory cytokines including Tnfa precede Tipe2 , suggesting that Tipe2 is likely induced by Tnfa . Upregulation of Adam8 and Cxcl1 gene expression persisted at week 4, suggesting that they play a role in the transition to chronic phase of intervertebral disc degeneration.
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Affiliation(s)
- Jiawei Lu
- Department of Orthopedic Surgery, Perelman School of Medicine, University of Pennsylvania
- Department of Spine Surgery, Shanghai East Hospital, Tongji University School of Medicine, 150 Jimo Rd, Shanghai, 200120, China
| | - Zuozhen Tian
- Department of Physical Medicine & Rehabilitation, Perelman School of Medicine, University of Pennsylvania
| | - Frances S. Shofer
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Lutian Yao
- Department of Orthopedic Surgery, Perelman School of Medicine, University of Pennsylvania
| | - Alec Z. Sandroni
- Department of Physical Medicine & Rehabilitation, Perelman School of Medicine, University of Pennsylvania
| | - Honghong Sun
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Ling Qin
- Department of Orthopedic Surgery, Perelman School of Medicine, University of Pennsylvania
| | - Yejia Zhang
- Department of Physical Medicine & Rehabilitation, Perelman School of Medicine, University of Pennsylvania
- Section of Rehabilitation Medicine, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA
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Engel-Rebitzer E, Dolan A, Shofer FS, Schapira MM, Hess EP, Rhodes KV, Bellamkonda VR, Msw EG, Bell J, Schwarz L, Schiller E, Lewis-Salley D, McCollum S, Zyla M, Becker LB, Graves RL, Meisel ZF. The association between specific narrative elements and patient perspectives on acute pain treatment. Am J Emerg Med 2023; 74:84-89. [PMID: 37797399 PMCID: PMC10924766 DOI: 10.1016/j.ajem.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 09/05/2023] [Accepted: 09/12/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Narratives are effective tools for communicating with patients about opioid prescribing for acute pain and improving patient satisfaction with pain management. It remains unclear, however, whether specific narrative elements may be particularly effective at influencing patient perspectives. METHODS This study was a secondary analysis of data collected for Life STORRIED, a multicenter RCT. Participants included 433 patients between 18 and 70 years-old presenting to the emergency department (ED) with renal colic or musculoskeletal back pain. Participants were instructed to view one or more narrative videos during their ED visit in which a patient storyteller discussed their experiences with opioids. We examined associations between exposure to individual narrative features and patients' 1) preference for opioids, 2) recall of opioid-related risks and 3) perspectives about the care they received. RESULTS Participants were more likely to watch videos featuring storytellers who shared their race or gender. We found that participants who watched videos that contained specific narrative elements, for example mention of prescribed opioids, were more likely to recall having received information about pain treatment options on the day after discharge (86.3% versus 72.9%, p = 0.02). Participants who watched a video that discussed family history of addiction reported more participation in their treatment decision than those who did not (7.6 versus 6.8 on a ten-point scale, p = 0.04). CONCLUSIONS Participants preferentially view narratives featuring storytellers who share their race or gender. Narrative elements were not meaningfully associated with patient-centered outcomes. These findings have implications for the design of narrative communication tools.
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Affiliation(s)
- Eden Engel-Rebitzer
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia, PA, USA; Brigham and Women's Hospital, Boston, MA, USA.
| | - Abby Dolan
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia, PA, USA; Urban Health Lab at the Penn Medicine Center for Health Justice, Perelman School of Medicine at the University of Pennsylvania, USA; Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Frances S Shofer
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia, PA, USA; Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Marilyn M Schapira
- Center for Health Equity Research and Promotion (CHERP), Philadelphia VA Medical Center, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; University of Pennsylvania Department of General and Internal Medicine, Philadelphia, PA, USA
| | - Erik P Hess
- Department of Emergency Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA; Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, TN, USA
| | - Karin V Rhodes
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Venkatesh R Bellamkonda
- Department of Emergency Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Erica Goldberg Msw
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey Bell
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia, PA, USA
| | - Linda Schwarz
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia, PA, USA
| | - Elise Schiller
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia, PA, USA
| | - Dena Lewis-Salley
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia, PA, USA
| | - Sharon McCollum
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael Zyla
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia, PA, USA
| | - Lance B Becker
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Rachel Lynn Graves
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia, PA, USA
| | - Zachary F Meisel
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia, PA, USA; Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA 19104, USA
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9
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Greenwood JC, Talebi FM, Jang DH, Spelde AE, Gordon EK, Horak J, Acker MA, Kilbaugh TJ, Shofer FS, Augoustides JGT, Bakker J, Brenner JS, Muzykantov VR, Abella BS. Low postoperative perfused vessel density is associated with increased soluble endothelial cell adhesion molecules during circulatory shock after cardiac surgery. Microvasc Res 2023; 150:104595. [PMID: 37619889 PMCID: PMC10530427 DOI: 10.1016/j.mvr.2023.104595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/11/2023] [Accepted: 08/21/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION Microcirculatory dysfunction after cardiovascular surgery is associated with significant morbidity and worse clinical outcomes. Abnormal capillary blood flow can occur from multiple causes, including cytokine-mediated vascular endothelial injury, microthrombosis, and an inadequate balance between vasoconstriction and vasodilation. In response to proinflammatory cytokines, endothelial cells produce cellular adhesion molecules (CAMs) which regulate leukocyte adhesion, vascular permeability, and thus can mediate tissue injury. The relationship between changes in microcirculatory flow during circulatory shock and circulating adhesion molecules is unclear. The objective of this study was to compare changes in plasma soluble endothelial cell adhesion molecules (VCAM-1, ICAM-1, and E-Selectin) in patients with functional derangements in microcirculatory blood flow after cardiovascular surgery. METHODS Adult patients undergoing elective cardiac surgery requiring cardiopulmonary bypass who exhibited postoperative shock were enrolled in the study. Sublingual microcirculation imaging was performed prior to surgery and within 2 h of ICU admission. Blood samples were taken at the time of microcirculation imaging for biomarker analysis. Plasma soluble VCAM-1, ICAM-1, and E-selectin in addition to plasma cytokines (IL-6, IL-8, and IL-10) were measured by commercially available enzyme-linked immunoassay. RESULTS Of 83 patients with postoperative shock who were evaluated, 40 patients with clinical shock had a postoperative perfused vessel density (PVD) >1 SD above (High PVD group = 28.5 ± 2.3 mm/mm2, n = 20) or below (Low PVD = 15.5 ± 2.0 mm/mm2, n = 20) the mean postoperative PVD and were included in the final analysis. Patient groups were well matched for comorbidities, surgical, and postoperative details. Overall, there was an increase in postoperative plasma VCAM-1 and E-Selectin compared to preoperative levels, but there was no difference between circulating ICAM-1. When grouped by postoperative microcirculation, patients with poor microcirculation were found to have increased circulating VCAM-1 (2413 ± 1144 vs. 844 ± 786 ng/mL; p < 0.0001) and E-Selectin (242 ± 119 vs. 87 ± 86 ng/mL; p < 0.0001) compared to patients with increased microcirculatory blood flow. Microcirculatory flow was not associated with a difference in plasma soluble ICAM-1 (394 ± 190 vs. 441 ± 256; p = 0.52). CONCLUSIONS Poor postoperative microcirculatory blood flow in patients with circulatory shock after cardiac surgery is associated with increased plasma soluble VCAM-1 and E-Selectin, indicating increased endothelial injury and activation compared to patients with a high postoperative microcirculatory blood flow. Circulating endothelial cell adhesion molecules may be a useful plasma biomarker to identify abnormal microcirculatory blood flow in patients with shock.
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Affiliation(s)
- John C Greenwood
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Fatima M Talebi
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - David H Jang
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Audrey E Spelde
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Emily K Gordon
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jiri Horak
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael A Acker
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Center for Mitochondrial and Epigenomic Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Frances S Shofer
- Department of Epidemiology & Biostatistics, Department of Emergency Medicine Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - John G T Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jan Bakker
- Division of Pulmonary, Allergy, and Critical Care Medicine, New York University, New York, NY, USA; Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jacob S Brenner
- Division of Pulmonary, Allergy, & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Vladimir R Muzykantov
- Department of Pharmacology and Center for Translational Targeted Therapeutics and Nanomedicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin S Abella
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Kather C, Shofer FS, Park JI, Bogen D, Pierce SR, Kording K, Nilan KA, Zhang H, Prosser LA, Johnson MJ. Quantifying interaction with robotic toys in pre-term and full-term infants. Front Pediatr 2023; 11:1153841. [PMID: 37928351 PMCID: PMC10622661 DOI: 10.3389/fped.2023.1153841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 08/29/2023] [Indexed: 11/07/2023] Open
Abstract
Infants born pre-term are at an increased risk for developmental, behavioral, and motor delay and subsequent disability. When these problems are detected early, clinical intervention can be effective at improving functional outcomes. Current methods of early clinical assessment are resource intensive, require extensive training, and do not always capture infants' behavior in natural play environments. We developed the Play and Neuro Development Assessment (PANDA) Gym, an affordable, mechatronic, sensor-based play environment that can be used outside clinical settings to capture infant visual and motor behavior. Using a set of classification codes developed from the literature, we analyzed videos from 24 pre-term and full-term infants as they played with each of three robotic toys designed to elicit different types of interactions-a lion, an orangutan, and an elephant. We manually coded for frequency and duration of toy interactions such as kicking, grasping, touching, and gazing. Pre-term infants gazed at the toys with similar frequency as full-term infants, but infants born full-term physically engaged more frequently and for longer durations with the robotic toys than infants born pre-term. While we showed we could detect differences between full-term and pre-term infants, further work is needed to determine whether differences seen were primarily due to age, developmental delays, or a combination.
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Affiliation(s)
- Collin Kather
- Rehabilitation Robotics Lab, Department of Physical Medicine and Rehabilitation, University of Pennsylvania, Philadelphia, PA, United States
| | - Frances S. Shofer
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Jeong Inn Park
- Rehabilitation Robotics Lab, Department of Physical Medicine and Rehabilitation, University of Pennsylvania, Philadelphia, PA, United States
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, United States
| | - Daniel Bogen
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, United States
| | - Samuel R. Pierce
- Department of Physical Therapy, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Konrad Kording
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, United States
| | - Kathleen A. Nilan
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Huayan Zhang
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Neonatology, Guangzhou Women’s and Children’s Medical Center, Guangzhou, China
| | - Laura A. Prosser
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, United States
- Division of Rehabilitation Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Michelle J. Johnson
- Rehabilitation Robotics Lab, Department of Physical Medicine and Rehabilitation, University of Pennsylvania, Philadelphia, PA, United States
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, United States
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Kao SH, Shofer FS, Greenwood JC, Alomaja O, Ranganathan A, Piel S, Mesaros C, Shin SS, Ehinger JK, Kilbaugh TJ, Jang DH. Cell-Free DNA as a Biomarker in a Rodent Model of Chlorpyrifos Poisoning Causing Mitochondrial Dysfunction. J Med Toxicol 2023; 19:352-361. [PMID: 37523031 PMCID: PMC10522542 DOI: 10.1007/s13181-023-00956-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 08/01/2023] Open
Abstract
INTRODUCTION Organophosphates (OPs) are a major public health problem worldwide due to ease of access and high toxicity lacking effective biomarkers and treatment. Cholinergic agents such as OPs and carbamates are responsible for many pesticide-related deaths. While the inhibition of AChE is thought to be the main mechanism of injury, there are other important pathways that contribute to the overall toxicity of OPs such as mitochondrial dysfunction. An existing gap in OP poisoning are biomarkers to gauge severity and prognosis. Cell-free DNA (cfDNA) are novel biomarkers that have gained increased attention as a sensitive biomarker of disease with novel use in acute poisoning. This study investigates alterations in cerebral mitochondrial function in a rodent model of chlorpyrifos poisoning with the use of cfDNA as a potential biomarker. METHODS Twenty rodents were divided into two groups: Control (n = 10) and Chlorpyrifos (n = 10). Chlorpyrifos was administered through the venous femoral line with a Harvard Apparatus 11 Elite Syringe pump (Holliston, MA, USA) at 2 mg/kg. Animals were randomized to receive chlorpyrifos versus the vehicle (10% DMSO) for 60 min which would realistically present an acute exposure with continued absorption. At the end of the exposure (60 min), isolated mitochondria were measured for mitochondrial respiration along with measures of acetylcholinesterase activity, cfDNA, cytokines and western blot. RESULTS The Chlorpyrifos group showed a significant decrease in heart rate but no change in the blood pressure. There was a significant increase in bulk cfDNA concentrations and overall decrease in mitochondrial respiration from brain tissue obtained from animals in the Chlorpyrifos group when compared to the Control group with no difference in acetylcholinesterase activity. In addition, there was a significant increase in both IL-2 and IL-12 in the Chlorpyrifos group. CONCLUSIONS In our study, we found that the total cfDNA concentration may serve as a more accurate biomarker of OP exposure compared to acetylcholinesterase activity. In addition, there was an overall decrease in cerebral mitochondrial function in the Chlorpyrifos group when compared to the Control group.
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Affiliation(s)
- Shih-Han Kao
- The Children's Hospital of Philadelphia, The Resuscitation Science Center, Philadelphia, PA, 19104, USA
| | - Frances S Shofer
- Department of Emergency Medicine, Perelman School of Medicine, The Resuscitation Science Center (RSC), Lab 814F, University of Pennsylvania, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - John C Greenwood
- Department of Emergency Medicine, Perelman School of Medicine, The Resuscitation Science Center (RSC), Lab 814F, University of Pennsylvania, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Oladunni Alomaja
- Department of Emergency Medicine, Perelman School of Medicine, The Resuscitation Science Center (RSC), Lab 814F, University of Pennsylvania, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Abhay Ranganathan
- The Children's Hospital of Philadelphia, The Resuscitation Science Center, Philadelphia, PA, 19104, USA
| | - Sarah Piel
- The Children's Hospital of Philadelphia, The Resuscitation Science Center, Philadelphia, PA, 19104, USA
| | - Clementina Mesaros
- Department of Pharmacology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Samuel S Shin
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Johannes K Ehinger
- Mitochondrial Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Otorhinolaryngology, Head and Neck Surgery, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Otorhinolaryngology, Head and Neck Surgery, Skåne University Hospital, Lund, Sweden
| | - Todd J Kilbaugh
- The Children's Hospital of Philadelphia, The Resuscitation Science Center, Philadelphia, PA, 19104, USA
| | - David H Jang
- Department of Emergency Medicine, Perelman School of Medicine, The Resuscitation Science Center (RSC), Lab 814F, University of Pennsylvania, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA.
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Green-McKenzie J, Shofer FS, Lappin M, Cohen E, O'Connor D, Kuter BJ. Perceptions of the Availability of Personal Protective Equipment and Its Association With Burnout Among US Healthcare Personnel During the SARS-CoV-2 Pandemic, 2020-2021. J Occup Environ Med 2023; 65:e619-e625. [PMID: 37464275 DOI: 10.1097/jom.0000000000002926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
OBJECTIVE The aim of the study is to explore associations among personal protective equipment (PPE) availability, workplace environment, and burnout among US healthcare personnel during the COVID-19 pandemic. METHODS The study used an online healthcare provider (HCP) survey (December 2020-February 2021) regarding PPE confidence, availability, burnout, and workplace environment. RESULTS Lack of appropriate PPE was reported by 27% of 799 US HCP surveyed. Burnout, reported by 77% of HCP, was more likely among females, those with fewer years of professional experience, and those with a higher desire to quit, and less likely for those who perceived PPE was adequate or their employer took all steps to minimize workplace risks. CONCLUSIONS This study suggests that lack of adequate PPE can lead to HCP burnout, which may result in employees quitting. A pandemic preparedness plan that includes adequate PPE is essential for HCP well-being, patient health, and employer fiscal health.
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Affiliation(s)
- Judith Green-McKenzie
- From the Division of Occupational Medicine, Department of Emergency Medicine, University of PennsylvaniaPerelman School of Medicine, Philadelphia, Pennsylvania (J.G.M., F.S.S., M.L., E.C., D.O.); Leonard Davis Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (J.G.M.); Department of Physical Medicine and Rehabilitation, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (F.S.S.); Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, Pennsylvania (F.S.S.); and Vaccine Education Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (B.J.K.)
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Green-McKenzie J, Shofer FS, Kruse G, Momplaisir F, Brennan PJ, Kuter BJ. COVID-19 vaccine uptake before and after a vaccine mandate at a major academic hospital: Trends by race/ethnicity and level of patient contact. Vaccine 2023; 41:5441-5446. [PMID: 37517911 DOI: 10.1016/j.vaccine.2023.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 07/14/2023] [Accepted: 07/14/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVES To assess vaccine coverage rates before and after implementation of a COVID-19 vaccine mandate among Health care Personnel (HCP) and demographic characteristics associated with vaccine uptake Design, Setting, and Participants: Cohort study conducted among 10,889 hospital employees followed from Dec 16, 2020 - October 31, 2021, at a large academic hospital in Philadelphia. MAIN OUTCOME AND MEASURES Time to COVID-19 vaccination and vaccine series completion rates before and after implementation of a COVID-19 vaccine mandate based on age, gender, race/ethnicity, and level of patient contact/occupational group. RESULTS The vaccination series completion rate was 86.0% prior to mandate announcement, and increased to 98.7% after mandate implementation. Rates before mandate announcement were highest among Asians (96.2%), Whites (94.0%), males (89.7%), employees ≥ 65 years of age (95.2%), and employees with direct patient care (physicians, 99.0%, and nurses, 93.3%). Hospital educational initiatives (including Town Halls and discussions with Black and Hispanic employees with the lowest vaccination rates) appeared to improve uptake. The largest increase in series completion after mandate announcement occurred among Blacks, those of other/multiracial backgrounds, and Hispanics (35.6%, 22.4%, and 10.8%, respectively) as well as those with some or no direct patient contact (24.5% and 18.3%, respectively). Medical or religious exemptions were approved for 64 (<0.6%) employees and 38 (<0.4%) left their positions (8 voluntary, 30 involuntary) specifically due to the COVID-19 vaccine mandate. No clinically meaningful differences by age, gender, or race/ethnicity for those who were vaccinated under the mandate versus those who left their positions were noted. CONCLUSIONS AND RELEVANCE These results suggest that while mandates may be challenging to institutions and enforcement unpopular, they play an important role in reducing hesitancy and securing high vaccination rates among HCP, a group at high risk of COVID-19 given their employment and who can be a source of disease transmission to patients.
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Affiliation(s)
- Judith Green-McKenzie
- Professor & Chief, Division of Occupational Medicine, Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, United States; Leonard Davis Institute, University of Pennsylvania Perelman School of Medicine, United States.
| | - Frances S Shofer
- Director & Adjunct Professor of Epidemiology & Biostatistics, Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, United States
| | - Gregory Kruse
- Associate Vice President of Strategic Operations, University of Pennsylvania Perelman School of Medicine, United States
| | - Florence Momplaisir
- Leonard Davis Institute, University of Pennsylvania Perelman School of Medicine, United States; Assistant Professor, University of Pennsylvania, Perelman School of Medicine, Department of Medicine, Division of Infectious Diseases, United States
| | - Patrick J Brennan
- Chief Medical Officer and Senior Vice President, University of Pennsylvania Health System, United States
| | - Barbara J Kuter
- Visiting Research Scientist, Vaccine Education Center, Children's Hospital of Philadelphia, United States
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14
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Alomaja O, Shofer FS, Greenwood JC, Piel S, Clayman C, Mesaros C, Kao SH, Shin SS, Ehinger JK, Kilbaugh TJ, Jang DH. Alteration in Cerebral Metabolism in a Rodent Model of Acute Sub-lethal Cyanide Poisoning. J Med Toxicol 2023; 19:196-204. [PMID: 36757579 PMCID: PMC10050286 DOI: 10.1007/s13181-022-00928-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/20/2022] [Accepted: 12/29/2022] [Indexed: 02/10/2023] Open
Abstract
INTRODUCTION Cyanide exposure can occur in various settings such as industry and metallurgy. The primary mechanism of injury is cellular hypoxia from Complex IV (CIV) inhibition. This leads to decreased ATP production and increased reactive oxygen species production. The brain and the heart are the organs most affected due to their high metabolic demand. While the cardiac effects of cyanide are well known, the cerebral effects on cellular function are less well described. We investigated cerebral metabolism with a combination of brain respirometry, microdialysis, and western blotting using a rodent model of sub-lethal cyanide poisoning. METHODS Twenty rodents were divided into two groups: control (n = 10) and sub-lethal cyanide (n = 10). Cerebral microdialysis was performed during a 2 mg/kg/h cyanide exposure to obtain real-time measurements of cerebral metabolic status. At the end of the exposure (90 min), brain-isolated mitochondria were measured for mitochondrial respiration. Brain tissue ATP concentrations, acyl-Coenzyme A thioesters, and mitochondrial content were also measured. RESULTS The cyanide group showed significantly increased lactate and decreased hypotension with decreased cerebral CIV-linked mitochondrial respiration. There was also a significant decrease in cerebral ATP concentration in the cyanide group and a significantly higher cerebral lactate-to-pyruvate ratio (LPR). In addition, we also found decreased expression of Complex III and IV protein expression in brain tissue from the cyanide group. Finally, there was no change in acyl-coenzyme A thioesters between the two groups. CONCLUSIONS The key finding demonstrates mitochondrial dysfunction in brain tissue that corresponds with a decrease in mitochondrial function, ATP concentrations, and an elevated LPR indicating brain dysfunction at a sub-lethal dose of cyanide.
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Affiliation(s)
- Oladunni Alomaja
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Frances S Shofer
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - John C Greenwood
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Sarah Piel
- The Children's Hospital of Philadelphia , The Resuscitation Science Center, Philadelphia, PA, 19104, USA
| | - Carly Clayman
- The Children's Hospital of Philadelphia , The Resuscitation Science Center, Philadelphia, PA, 19104, USA
| | - Clementina Mesaros
- Department of Pharmacology, Perelman School of Medicine,, University of Pennsylvania,, Philadelphia, PA, 19104, USA
| | - Shih-Han Kao
- The Children's Hospital of Philadelphia , The Resuscitation Science Center, Philadelphia, PA, 19104, USA
| | - Samuel S Shin
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, PA, 19104, Philadelphia, USA
| | - Johannes K Ehinger
- Mitochondrial Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Otorhinolaryngology, Head and Neck Surgery, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Todd J Kilbaugh
- The Children's Hospital of Philadelphia , The Resuscitation Science Center, Philadelphia, PA, 19104, USA
| | - David H Jang
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
- The Children's Hospital of Philadelphia , The Resuscitation Science Center, Philadelphia, PA, 19104, USA.
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Lewis A, Forti RM, Alomaja O, Mesaros C, Piel S, Greenwood JC, Talebi FM, Mavroudis CD, Kelly M, Kao SH, Shofer FS, Ehinger JK, Kilbaugh TJ, Baker WB, Jang DH. Correction to: Preliminary Research: Application of Non-Invasive Measure of Cytochrome c Oxidase Redox States and Mitochondrial Function in a Porcine Model of Carbon Monoxide Poisoning. J Med Toxicol 2023; 19:53. [PMID: 36508082 DOI: 10.1007/s13181-022-00913-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Alistair Lewis
- Department of Chemistry, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Division of Neurology, The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, 19104, USA
| | - Rodrigo M Forti
- Division of Neurology, The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, 19104, USA
| | - Oladunni Alomaja
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Clementina Mesaros
- Department of Systems Pharmacology and Translational Therapeutics (SPATT), University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Sarah Piel
- Resuscitation Science Center of Emphasis, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia Research Institute, Philadelphia, PA, 19104, USA
| | - John C Greenwood
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Fatima M Talebi
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Constantine D Mavroudis
- Division of Neurology, The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, 19104, USA
| | - Matthew Kelly
- Department of Emergency Medicine, The University of Alabama at Birmingham, 701 20th Street South, Birmingham, 35233, AB, UK
| | - Shih-Han Kao
- Resuscitation Science Center of Emphasis, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia Research Institute, Philadelphia, PA, 19104, USA
| | - Frances S Shofer
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Johannes K Ehinger
- Otorhinolaryngology, Head and Neck Surgery, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Mitochondrial Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Todd J Kilbaugh
- Resuscitation Science Center of Emphasis, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia Research Institute, Philadelphia, PA, 19104, USA
| | - Wesley B Baker
- Division of Neurology, The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, 19104, USA
| | - David H Jang
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
- Resuscitation Science Center of Emphasis, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia Research Institute, Philadelphia, PA, 19104, USA.
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Greenwood JC, Talebi FM, Jang DH, Spelde AE, Tonna JE, Gutsche JT, Horak J, Acker MA, Kilbaugh TJ, Shofer FS, Augoustides JGT, Bakker J, Brenner JS, Muzykantov VR, Abella BS. Topical nitroglycerin to detect reversible microcirculatory dysfunction in patients with circulatory shock after cardiovascular surgery: an observational study. Sci Rep 2022; 12:15257. [PMID: 36088474 PMCID: PMC9464203 DOI: 10.1038/s41598-022-19741-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 09/02/2022] [Indexed: 11/09/2022] Open
Abstract
AbstractPersistent abnormalities in microcirculatory function are associated with poor clinical outcomes in patients with circulatory shock. We sought to identify patients with acutely reversible microcirculatory dysfunction using a low-dose topical nitroglycerin solution and handheld videomicroscopy during circulatory shock after cardiac surgery. Forty subjects were enrolled for the study, including 20 preoperative control and 20 post-operative patients with shock. To test whether microcirculatory dysfunction is acutely reversible during shock, the sublingual microcirculation was imaged with incident dark field microscopy before and after the application of 0.1 mL of a 1% nitroglycerin solution (1 mg/mL). Compared to the control group, patients with shock had a higher microcirculation heterogeneity index (MHI 0.33 vs. 0.12, p < 0.001) and a lower microvascular flow index (MFI 2.57 vs. 2.91, p < 0.001), total vessel density (TVD 22.47 vs. 25.90 mm/mm2, p = 0.005), proportion of perfused vessels (PPV 90.76 vs. 95.89%, p < 0.001) and perfused vessel density (PVD 20.44 vs. 24.81 mm/mm2, p < 0.001). After the nitroglycerin challenge, patients with shock had an increase in MFI (2.57 vs. 2.97, p < 0.001), TVD (22.47 vs. 27.51 mm/mm2, p < 0.009), PPV (90.76 vs. 95.91%, p < 0.001), PVD (20.44 vs. 26.41 mm/mm2, p < 0.001), venular RBC velocity (402.2 vs. 693.9 µm/s, p < 0.0004), and a decrease in MHI (0.33 vs. 0.04, p < 0.001. Thirteen of 20 patients showed a pharmacodynamic response, defined as an increase in PVD > 1.8 SD from shock baseline. Hemodynamics and vasoactive doses did not change during the 30-min study period. Our findings suggest a topical nitroglycerin challenge with handheld videomicroscopy can safely assess for localized recruitment of the microcirculatory blood flow in patients with circulatory shock and may be a useful test to identify nitroglycerin responsiveness.
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Calandra JM, Shofer FS, Chao AM, Swanson RL. Nutrition Education, Understanding, and Counseling Practices Among Physiatrists: A Survey Study. Cureus 2022; 14:e28756. [PMID: 36211094 PMCID: PMC9531699 DOI: 10.7759/cureus.28756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2022] [Indexed: 11/05/2022] Open
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Greenwood JC, Talebi FM, Jang DH, Spelde AE, Kilbaugh TJ, Shofer FS, Acker MA, Augoustides JGT, Bakker J, Meyer NJ, Brenner JS, Muzykantov VR, Abella BS. Protocol for the MicroRESUS study: The impact of circulatory shock and resuscitation on microcirculatory function and mitochondrial respiration after cardiovascular surgery. PLoS One 2022; 17:e0273349. [PMID: 36018848 PMCID: PMC9417024 DOI: 10.1371/journal.pone.0273349] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/05/2022] [Indexed: 11/26/2022] Open
Abstract
Background Despite current resuscitation strategies, circulatory shock and organ injury after cardiac surgery occur in 25–40% of patients. Goal-directed resuscitation after cardiac surgery has generated significant interest, but clinical practice to normalize hemodynamic variables including mean arterial pressure, cardiac filling pressures, and cardiac output may not reverse microcirculation abnormalities and do not address cellular dysoxia. Recent advances in technology have made it possible to measure critical components of oxygen delivery and oxygen utilization systems in live human tissues and blood cells. The MicroRESUS study will be the first study to measure microcirculatory and mitochondrial function in patients with circulatory shock and link these findings with clinical outcomes. Methods and analysis This will be a prospective, observational study that includes patients undergoing elective cardiovascular surgery with cardiopulmonary bypass (CPB). Microcirculation will be quantified with sublingual incident dark field videomicroscopy. Mitochondrial respiration will be measured by performing a substrate–uncoupler–inhibitor titration protocol with high resolution respirometry on peripheral blood mononuclear cells at baseline and serial timepoints during resuscitation and at recovery as a possible liquid biomarker. Plasma samples will be preserved for future analysis to examine endothelial injury and other mechanisms of microcirculatory dysfunction. Thirty-day ventilator and vasopressor-free days (VVFDs) will be measured as a primary outcome, along with sequential organ failure assessment scores, and other clinical parameters to determine if changes in microcirculation and mitochondrial respiration are more strongly associated with clinical outcomes compared to traditional resuscitation targets. Discussion This will be the first prospective study to examine both microcirculatory and mitochondrial function in human patients with circulatory shock undergoing cardiac bypass and address a key mechanistic knowledge gap in the cardiovascular literature. The results of this study will direct future research efforts and therapeutic development for patients with shock.
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Affiliation(s)
- John C. Greenwood
- Division of Critical Care Medicine, Department of Emergency Medicine, Department of Anesthesiology and Critical Care, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
- * E-mail:
| | - Fatima M. Talebi
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
| | - David H. Jang
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
| | - Audrey E. Spelde
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
| | - Todd J. Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Center for Mitochondrial and Epigenomic Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Frances S. Shofer
- Department of Epidemiology & Biostatistics, Department of Emergency Medicine Hospital of the University of Pennsylvania, Philadelphia, PA, United States of America
| | - Michael A. Acker
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
| | - John G. T. Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
| | - Jan Bakker
- Division of Pulmonary, Allergy, and Critical Care Medicine, New York University, New York, NY, United States of America
| | - Nuala J. Meyer
- Division of Pulmonary and Critical Care, Department of Medicine, Perelman School of Medicine, Philadelphia, PA, United States of America
| | - Jacob S. Brenner
- Division of Pulmonary and Critical Care, Department of Medicine, Perelman School of Medicine, Philadelphia, PA, United States of America
| | - Vladimir R. Muzykantov
- Department of Pharmacology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Benjamin S. Abella
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
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Tian Z, Shofer FS, Sandroni AZ, Zhao L, Scanzello CR, Zhang Y. Expression of Human Interleukin 8 in Mice Alters Their Natural Behaviors. J Inflamm Res 2022; 15:2413-2424. [PMID: 35444450 PMCID: PMC9013918 DOI: 10.2147/jir.s355669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 04/04/2022] [Indexed: 02/05/2023] Open
Abstract
Objective To examine the effects of human interleukin (IL) 8 expression on mouse behavior. Methods A mouse line expressing human IL8 in the intervertebral discs (IVD) and cartilaginous tissues (hIL8+ ) was generated. Mouse spontaneous behaviors, including locomotion, climbing, rearing, grooming, eating, drinking, and immobility were recorded with a fully automatic, non-invasive platform. Results Distance traveled by the hIL8+ mice declined with age compared with control littermates, and male hIL8+ mice traveled a shorter distance than male controls and females of either genotype (p <0.05). The hIL8+ mice also spent less time in locomotion than control mice (p <0.01), and male hIL8+ mice spent the least amount of time and had lowest count in locomotion compared with the other 3 groups at 12 weeks of age or greater (p <0.05). The hIL8+ mice spent less time climbing than controls, and male mice spent less time climbing than female mice of the same genotype (p <0.01). The hIL8+ mice spent more time eating and less time drinking than controls, and all mice spent less time eating and more time drinking with increasing age. Finally, hIL8+ mice spent more time immobile than controls, and male hIL8+ mice spent more time immobile than any other group (p <0.05). Conclusion The hIL8+ mice, especially hIL8+ males, showed reduced ambulation and climbing. Mice showed age-related decrease in eating and increase in drinking and grooming time that was also influenced by expression of hIL8. These changes in natural behaviors in control mice are consistent with functional decline with age. Effects of hIL8 superimposed on the natural aging process could involve systemic (e.g., on the brain) and local (e.g., in the spine and joint tissues) mechanisms. Future exploration of these mechanisms might be productive.
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Affiliation(s)
- Zuozhen Tian
- Department of Physical Medicine & Rehabilitation, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Frances S Shofer
- Department of Physical Medicine & Rehabilitation, Hospital of the University of Pennsylvania, Philadelphia, PA, USA,Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alec Z Sandroni
- Department of Physical Medicine & Rehabilitation, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Lan Zhao
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Carla R Scanzello
- Division of Rheumatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Section of Rheumatology, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Yejia Zhang
- Department of Physical Medicine & Rehabilitation, Hospital of the University of Pennsylvania, Philadelphia, PA, USA,Section of Rehabilitation Medicine, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA,Correspondence: Yejia Zhang, Department of Physical Medicine & Rehabilitation, Hospital of the University of Pennsylvania, Philadelphia, PA, USA, Email ;
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20
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Khatri UG, Lee K, Lin T, D'Orazio JL, Patel MS, Shofer FS, Perrone J. A Brief Educational Intervention to Increase ED Initiation of Buprenorphine for Opioid Use Disorder (OUD). J Med Toxicol 2022; 18:205-213. [PMID: 35415804 PMCID: PMC9004452 DOI: 10.1007/s13181-022-00890-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 03/07/2022] [Accepted: 03/10/2022] [Indexed: 11/26/2022] Open
Abstract
Background Despite the evidence in support of the use of buprenorphine in the treatment of OUD and increasing ability of emergency medicine (EM) clinicians to prescribe it, emergency department (ED)-initiated buprenorphine is uncommon. Many EM clinicians lack training on how to manage acute opioid withdrawal or initiate treatment with buprenorphine. We developed a brief buprenorphine training program and assessed the impact of the training on subsequent buprenorphine initiation and knowledge retention. Methods We conducted a pilot randomized control trial enrolling EM clinicians to receive either a 30-min didactic intervention about buprenorphine (standard arm) or the didactic plus weekly messaging and a monetary inducement to administer and report buprenorphine use (enhanced arm). All participants were incentivized to complete baseline, immediate post-didactic, and 90-day knowledge and attitude assessment surveys. Our objective was to achieve first time ED buprenorphine prescribing events in clinicians who had not previously prescribed buprenorphine in the ED and to improve EM-clinician knowledge and perceptions about ED-initiated buprenorphine. We also assessed whether the incentives and reminder messaging in the enhanced arm led to more clinicians administering buprenorphine than those in the standard arm following the training; we measured changes in knowledge of and attitudes toward ED-initiated buprenorphine. Results Of 104 EM clinicians enrolled, 51 were randomized to the standard arm and 53 to the enhanced arm. Clinical knowledge about buprenorphine improved for all clinicians immediately after the didactic intervention (difference 19.4%, 95% CI 14.4% to 24.5%). In the 90 days following the intervention, one-third (33%) of all participants reported administering buprenorphine for the first time. Clinicians administered buprenorphine more frequently in the enhanced arm compared to the standard arm (40% vs. 26.3%, p = 0.319), but the difference was not statistically significant. The post-session knowledge improvement was not sustained at 90 days in the enhanced (difference 9.6%, 95% CI − 0.37% to 19.5%) or in the standard arm (difference 3.7%, 95% CI − 5.8% to 13.2%). All the participants reported an increased ability to recognize patients with opioid withdrawal at 90 days (enhanced arm difference .55, 95% CI .01–1.09, standard arm difference .85 95% CI .34–1.37). Conclusions A brief educational intervention targeting EM clinicians can be utilized to achieve first-time prescribing and improve knowledge around buprenorphine and opioid withdrawal. The use of weekly messaging and gain-framed incentivization conferred no additional benefit to the educational intervention alone. In order to further expand evidence-based ED treatment of OUD, focused initiatives that improve clinician competence with buprenorphine should be explored. Trial Registration ClinicalTrials.gov Identifier: NCT03821103. Supplementary Information The online version contains supplementary material available at 10.1007/s13181-022-00890-7.
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Affiliation(s)
- Utsha G Khatri
- National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA, USA.
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, New York, NY, 10029, USA.
| | - Kathleen Lee
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Medicine Center for Digital Health, Center for Health Care Innovation, Perelman School of Medicine, Philadelphia, PA, USA
| | - Theodore Lin
- Penn Medicine Center for Digital Health, Center for Health Care Innovation, Perelman School of Medicine, Philadelphia, PA, USA
| | - Joseph L D'Orazio
- Department of Emergency Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Mitesh S Patel
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Health Care Management, Wharton School, University of Pennsylvania, Philadelphia, PA, USA
- Penn Medicine Nudge Unit, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Frances S Shofer
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Epidemiology & Biostatistics, Center for Public Health, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Medicine Center for Addiction Medicine and Policy, Philadelphia, PA, USA
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21
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Green-McKenzie J, Shofer FS, Matthei J, Biester R, Deibler M. Clinical and Psychological Factors Associated With Return to Work Among United States Diplomats Who Sustained a Work-Related Injury While on Assignment in Havana, Cuba. J Occup Environ Med 2022; 64:212-217. [PMID: 34873135 PMCID: PMC8887843 DOI: 10.1097/jom.0000000000002450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine factors associated with return to work in US diplomats injured during a work assignment in Cuba. METHODS In this case series work ability was determined at each visit. Questionnaires used included the Symptom Score Questionnaire, Beck Anxiety Inventory, Beck Depression Inventory, Quality-of-Life Inventory, and Patient Health Questionnaire. RESULTS Of the 45 employees referred to Occupational Medicine, the mean age was 42.5 years, 60% were men, 68% were never out of work, 22% were out of work for some period, and 15% remain out of work. Vestibular, cognitive, hearing, sleep, and visual symptoms, and a higher initial symptom score were significantly associated with work inability while psychiatric symptoms were not. CONCLUSIONS This exposure resulted in prolonged illness with cognitive impairment and other clinical manifestations associated with work inability.
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Affiliation(s)
- Judith Green-McKenzie
- Division of Occupational Medicine, Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine; Center of Excellence in Environmental Toxicology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania (Dr Green-McKenzie); Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine (Dr Shofer); SHARP Rees-Stealy Medical Group, San Diego, California (Dr Matthei);University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (Dr Matthei); Department of Physical Medicine and Rehabilitation, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (Dr Biester); Rehabilitation Medicine Service, Corporal Michael Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania (Dr Biester); The Center or Emotional Health of Greater Philadelphia, Philadelphia, Pennsylvania (Dr Deibler)
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22
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Prosser LA, Aguirre MO, Zhao S, Bogen DK, Pierce SR, Nilan KA, Zhang H, Shofer FS, Johnson MJ. Infants at risk for physical disability may be identified by measures of postural control in supine. Pediatr Res 2022; 91:1215-1221. [PMID: 34175891 PMCID: PMC8710181 DOI: 10.1038/s41390-021-01617-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 04/29/2021] [Accepted: 05/20/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Early detection of delay or impairment in motor function is important to guide clinical management and inform prognosis during a critical window for the development of motor control in children. The purpose of this study was to investigate the ability of biomechanical measures of early postural control to distinguish infants with future impairment in motor control from their typically developing peers. METHODS We recorded postural control from infants lying in supine in several conditions. We compared various center of pressure metrics between infants grouped by birth status (preterm and full term) and by future motor outcome (impaired motor control and typical motor control). RESULTS One of the seven postural control metrics-path length-was consistently different between groups for both group classifications and for the majority of conditions. CONCLUSIONS Quantitative measures of early spontaneous infant movement may have promise to distinguish early in life between infants who are at risk for motor impairment or physical disability and those who will demonstrate typical motor control. Our observation that center of pressure path length may be a potential early marker of postural instability and motor control impairment needs further confirmation and further investigation to elucidate the responsible neuromotor mechanisms. IMPACT The key message of this article is that quantitative measures of infant postural control in supine may have promise to distinguish between infants who will demonstrate future motor impairment and those who will demonstrate typical motor control. One of seven postural control metrics-path length-was consistently different between groups. This metric may be an early marker of postural instability in infants at risk for physical disability.
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Affiliation(s)
- Laura A. Prosser
- grid.25879.310000 0004 1936 8972Department of Pediatrics, University of Pennsylvania, Philadelphia, PA USA ,grid.239552.a0000 0001 0680 8770Division of Rehabilitation Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Maria Ovando Aguirre
- grid.25879.310000 0004 1936 8972Department of Bioengineering, University of Pennsylvania, Philadelphia, PA USA
| | - Susan Zhao
- grid.25879.310000 0004 1936 8972Department of Bioengineering, University of Pennsylvania, Philadelphia, PA USA
| | - Daniel K. Bogen
- grid.25879.310000 0004 1936 8972Department of Bioengineering, University of Pennsylvania, Philadelphia, PA USA
| | - Samuel R. Pierce
- grid.239552.a0000 0001 0680 8770Department of Physical Therapy, The Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Kathleen A. Nilan
- grid.239552.a0000 0001 0680 8770Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Huayan Zhang
- grid.239552.a0000 0001 0680 8770Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, PA USA ,Department of Neonatology, Guangzhou Women’s and Children’s Medical Center, Guangzhou, Guangdong China
| | - Frances S. Shofer
- grid.25879.310000 0004 1936 8972Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Michelle J. Johnson
- grid.25879.310000 0004 1936 8972Department of Bioengineering, University of Pennsylvania, Philadelphia, PA USA ,grid.25879.310000 0004 1936 8972Department of Physical Medicine and Rehabilitation, University of Pennsylvania, Philadelphia, PA USA
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23
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Mansfield B, Shofer FS, Green-McKenzie J. The Effect of Introduction of Motorized Stretchers on Hospital-Based Patient Transporter Injuries and Resultant Workers' Compensation Costs. J Occup Environ Med 2021; 63:1078-1080. [PMID: 34860204 DOI: 10.1097/jom.0000000000002319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Manual stretchers cause more injuries than hydraulic stretchers in workers who transport patients. OBJECTIVE To evaluate the impact of introducing motorized stretchers on transporter injuries and resultant workers' compensation costs. METHODS The number of transporters who sustained injuries related to stretcher manipulation, and associated workers' compensation costs, before and after the introduction of motorized stretchers, was determined. The Wilcoxon Rank Sum test was used to examine costs and lost and restricted workdays. RESULTS The number of injuries and restricted work days decreased after motorized stretchers were introduced. Transporters incurred less lost work days (median 24.5 vs 7 days, P = 0.050). CONCLUSIONS Motorized stretchers were associated with decreased injuries and lost work days.
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Affiliation(s)
- Blythe Mansfield
- Occupational Medicine at Kelsey-Seybold Clinic, Texas (Dr Mansfield); University of Pennsylvania Perelman School of Medicine, Philadelphia (Dr Mansfield); Epidemiology & Biostatistics, Department of Emergency Medicine at the University of Pennsylvania Perelman School of Medicine, Philadelphia (Dr Shofer); Division of Occupational Medicine and Residency Program, The University of Pennsylvania Perelman School of Medicine, Philadelphia (Dr Green-McKenzie)
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24
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Green-McKenzie J, Shofer FS, Momplaisir F, Kuter BJ, Kruse G, Bialal U, Behta M, O’Donnell J, Al-Ramahi N, Kasbekar N, Sullivan P, Okala P, Brennan PJ. Factors Associated With COVID-19 Vaccine Receipt by Health Care Personnel at a Major Academic Hospital During the First Months of Vaccine Availability. JAMA Netw Open 2021; 4:e2136582. [PMID: 34851399 PMCID: PMC8637254 DOI: 10.1001/jamanetworkopen.2021.36582] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 09/28/2021] [Indexed: 11/25/2022] Open
Abstract
Importance Several COVID-19 vaccines have been authorized in the US, yet preliminary evidence suggests high levels of vaccine hesitancy and wide racial, ethnic, and socioeconomic disparities in uptake. Objective To assess COVID-19 vaccine acceptance among health care personnel (HCP) during the first 4 months of availability in a large academic hospital, compare acceptance with previously measured vaccine hesitancy, and describe racial, ethnic, and socioeconomic disparities in vaccine uptake. Design, Setting, and Participants This cross-sectional study included 12 610 HCP who were offered COVID-19 vaccination at a major academic hospital in Philadelphia between December 16, 2020, and April 16, 2021. Exposures For each HCP, data were collected on occupational category, age, sex, race and ethnicity (Asian or Pacific Islander, Black or African American [Black], Hispanic, White, and multiracial), and social vulnerability index (SVI) at the zip code of residence. Main Outcomes and Measures Vaccine uptake by HCP at the employee vaccination clinic. Results The study population included 4173 men (34.8%) and 7814 women (65.2%) (623 without data). A total of 1480 were Asian or Pacific Islander (12.4%); 2563 (21.6%), Black; 452 (3.8%), Hispanic; 7086 (59.6%), White; and 192 (1.6%), multiracial; 717 had no data for race and ethnicity. The mean (SD) age was 40.9 (12.4) years, and 9573 (76.0%) received at least 1 vaccine dose during the first 4 months of vaccine availability. Adjusted for age, sex, job position, and SVI, Black (relative risk [RR], 0.69; 95% CI, 0.66-0.72) and multiracial (RR, 0.80; 95% CI, 0.73-0.89) HCP were less likely to receive vaccine compared with White HCP. When stratified by job position, Black nurses (n = 189; 62.8%), Black HCP with some patient contact (n = 466; 49.9%), and Black HCP with no patient contact (n = 636; 56.3%) all had lower vaccine uptake compared with their White and Asian or Pacific Islander counterparts. Similarly, multiracial HCP with some (n = 26; 52.0%) or no (n = 48; 58.5%) patient contact had lower vaccine uptake. In contrast, Black physicians were just as likely to receive the vaccine as physicians of other racial and ethnic groups. Conclusions and Relevance In this cross-sectional study, more than two-thirds of HCP at a large academic hospital in Philadelphia received a COVID-19 vaccine within 4 months of vaccine availability. Although racial, ethnic, and socioeconomic disparities were seen in vaccine uptake, no such disparities were found among physicians. Better understanding of factors driving these disparities may help improve uptake.
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Affiliation(s)
- Judith Green-McKenzie
- Leonard Davis Institute, Division of Occupational Medicine, Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Frances S. Shofer
- Epidemiology and Biostatistics Research, Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Florence Momplaisir
- Leonard Davis Institute, Department of Infectious Disease, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Barbara J. Kuter
- Vaccine Education Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Gregory Kruse
- University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Usama Bialal
- Urban Health Collaborative and Department of Epidemiology and Biostatistics, Drexel Dornsife School of Public Health, Philadelphia, Pennsylvania
| | - Maryam Behta
- University of Pennsylvania Health System, Philadelphia
| | - Judith O’Donnell
- Infection Control, Penn Presbyterian Medical Center, Division of Infectious Diseases, Clinical Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Nida Al-Ramahi
- Office of the Chief Medical Officer and Chief Quality Officer, University of Pennsylvania Health System, Philadelphia
| | | | | | - Philip Okala
- University of Pennsylvania Health System, Philadelphia
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25
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Fernández‐Penny FE, Jolkovsky EL, Shofer FS, Hemmert KC, Valiuddin H, Uspal JE, Sands NA, Abella BS. COVID-19 vaccine hesitancy among patients in two urban emergency departments. Acad Emerg Med 2021; 28:1100-1107. [PMID: 34403539 PMCID: PMC8441923 DOI: 10.1111/acem.14376] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 08/14/2021] [Accepted: 08/16/2021] [Indexed: 01/31/2023]
Abstract
Background Widespread vaccination is an essential component of the public health response to the COVID‐19 pandemic, yet vaccine hesitancy remains pervasive. This prospective survey investigation aimed to measure the prevalence of vaccine hesitancy in a patient cohort at two urban emergency departments (EDs) and characterize underlying factors contributing to hesitancy. Methods Adult ED patients with stable clinical status (Emergency Severity Index 3–5) and without active COVID‐19 disease or altered mental status were considered for participation. Demographic elements were collected as well as reported barriers/concerns related to vaccination and trusted sources of health information. Data were collected in person via a survey instrument proctored by trained research assistants. Results A total of 1,555 patients were approached, and 1,068 patients completed surveys (completion rate = 68.7%). Mean (±SD) age was 44.1 (±15.5) years (range = 18–93 years), 61% were female, and 70% were Black. A total of 31.6% of ED patients reported vaccine hesitancy. Of note, 19.7% of the hesitant cohort were health care workers. In multivariable regression analysis, Black race (odds ratio [OR] = 4.24, 95% confidence interval [CI] = 2.62 to 6.85) and younger age (age 18–24 years—OR = 4.57, 95% CI = 2.66 to 7.86; age 25–35 years—OR = 5.71, 95% CI = 3.71 to 8.81) were independently associated with hesitancy, to a greater degree than level of education (high school education or less—OR = 2.27, 95% CI = 1.23 to 4.19). Hesitant patients were significantly less likely to trust governmental sources of vaccine information than nonhesitant patients (39.6% vs. 78.9%, p < 0.001); less difference was noted in the domain of trust toward friends/family (51.1% vs. 61.0%, p = 0.004). Hesitant patients also reported perceived vaccine safety concerns and perceived insufficient research. Conclusions Vaccine hesitancy is common among ED patients and more common among Black and younger patients, independent of education level. Hesitant patients report perceived safety concerns and low trust in government information sources but less so friends or family. This suggests that strategies to combat hesitancy may need tailoring to specific populations.
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Affiliation(s)
| | - Eliana L. Jolkovsky
- Department of Emergency Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Frances S. Shofer
- Department of Emergency Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Keith C. Hemmert
- Department of Emergency Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Hisham Valiuddin
- Department of Emergency Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Julie E. Uspal
- Department of Emergency Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Nathaniel A. Sands
- Department of Emergency Medicine University of Pennsylvania Philadelphia Pennsylvania USA
- Penn Acute Research Collaboration University of Pennsylvania Philadelphia Pennsylvania USA
| | - Benjamin S. Abella
- Department of Emergency Medicine University of Pennsylvania Philadelphia Pennsylvania USA
- Penn Acute Research Collaboration University of Pennsylvania Philadelphia Pennsylvania USA
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26
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Greenwood JC, Jang DH, Spelde AE, Gutsche JT, Horak J, Acker MA, Kilbaugh TJ, Shofer FS, Augoustides JG, Bakker J, Abella BS. Low Microcirculatory Perfused Vessel Density and High Heterogeneity are Associated With Increased Intensity and Duration of Lactic Acidosis After Cardiac Surgery with Cardiopulmonary Bypass. Shock 2021; 56:245-254. [PMID: 33394972 PMCID: PMC9887933 DOI: 10.1097/shk.0000000000001713] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Lactic acidosis after cardiac surgery with cardiopulmonary bypass is common and associated with an increase in postoperative morbidity and mortality. A number of potential causes for an elevated lactate after cardiopulmonary bypass include cellular hypoxia, impaired tissue perfusion, ischemic-reperfusion injury, aerobic glycolysis, catecholamine infusions, and systemic inflammatory response after exposure to the artificial cardiopulmonary bypass circuit. Our goal was to examine the relationship between early abnormalities in microcirculatory convective blood flow and diffusive capacity and lactate kinetics during early resuscitation in the intensive care unit. We hypothesized that patients with impaired microcirculation after cardiac surgery would have a more severe postoperative hyperlactatemia, represented by the lactate time-integral of an arterial blood lactate concentration greater than 2.0 mmol/L. METHODS We measured sublingual microcirculation using incident darkfield video microscopy in 50 subjects on intensive care unit admission after cardiac surgery. Serial measurements of systemic hemodynamics, blood gas, lactate, and catecholamine infusions were recorded each hour for the first 6 h after surgery. Lactate area under the curve (AUC) was calculated over the first 6 h. The lactate AUC was compared between subjects with normal and low perfused vessel density (PVD < 18 mm/mm2), high microcirculatory heterogeneity index (MHI > 0.4), and low vessel-by-vessel microvascular flow index (MFIv < 2.6). RESULTS Thirteen (26%) patients had a low postoperative PVD, 20 patients (40%) had a high MHI, and 26 (52%) patients had a low MFIv. Patients with low perfused vessel density had higher lactate AUC compared with subjects with a normal PVD (22.3 [9.4-31.0] vs. 2.6 [0-8.8]; P < 0.0001). Patients with high microcirculatory heterogeneity had a higher lactate AUC compared with those with a normal MHI (2.5 [0.1-8.2] vs. 13.1 [3.7-31.1]; P < 0.001). We did not find a difference in lactate AUC when comparing high and low MFIv. CONCLUSION Low perfused vessel density and high microcirculatory heterogeneity are associated with an increased intensity and duration of lactic acidosis after cardiac surgery with cardiopulmonary bypass.
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Affiliation(s)
- John C. Greenwood
- Division of Critical Care Medicine, Department of Emergency Medicine, Department of Anesthesiology and Critical Care, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David H. Jang
- Division of Medical Toxicology and Critical Care Medicine, Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Audrey E. Spelde
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jacob T. Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jiri Horak
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael A. Acker
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Todd J. Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Center for Mitochondrial and Epigenomic Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Frances S. Shofer
- Department of Epidemiology and Biostatistics, Department of Emergency Medicine Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John G.T. Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jan Bakker
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Intensive Medicine, The Pontifical Catholic University of Chile, Santiago, Región Metropolitana, Chile
| | - Benjamin S. Abella
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Sinnenberg L, Umscheid CA, Shofer FS, Leri D, Meisel ZF. Communicating Guideline Recommendations Using Graphic Narrative Versus Text-based Broadcast Screensavers. JMIR Hum Factors 2021; 8:e27171. [PMID: 34264197 PMCID: PMC8713086 DOI: 10.2196/27171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 05/22/2021] [Accepted: 07/04/2021] [Indexed: 11/28/2022] Open
Abstract
Background The use of graphic narratives, defined as stories that use images for narration, is growing in health communication. Objective The aim of this study was to describe the design and implementation of a graphic narrative screensaver (GNS) to communicate a guideline recommendation (ie, avoiding low-value acid suppressive therapy [AST] use in hospital inpatients) and examine the comparative effectiveness of the GNS versus a text-based screensaver (TBS) on clinical practice (ie, low-value AST prescriptions) and clinician recall. Methods During a 2-year period, the GNS and the TBS were displayed on inpatient clinical workstations. The numbers of new AST prescriptions were examined in the four quarters before, the three quarters during, and the one quarter after screensavers were implemented. Additionally, an electronic survey was sent to resident physicians 1 year after the intervention to assess screensaver recall. Results Designing an aesthetically engaging graphic that could be rapidly understood was critical in the development of the GNS. The odds of receiving an AST prescription on medicine and medicine subspecialty services after the screensavers were implemented were lower for all four quarters (ie, GNS and TBS broadcast together, only TBS broadcast, only GNS broadcast, and no AST screensavers broadcast) compared to the quarter prior to implementation (odds ratio [OR] 0.85, 95% CI 0.78-0.92; OR 0.89, 95% CI 0.82-0.97; OR 0.87, 95% CI 0.80-0.95; and OR 0.81, 95% CI 0.75-0.89, respectively; P<.001 for all comparisons). There were no statistically significant decreases for other high-volume services, such as the surgical services. These declines appear to have begun prior to screensaver implementation. When surveyed about the screensaver content 1 year later, resident physicians recalled both the GNS and TBS (43/70, 61%, vs 54/70, 77%; P=.07) and those who recalled the screensaver were more likely to recall the main message of the GNS compared to the TBS (30/43, 70%, vs 1/54, 2%; P<.001). Conclusions It is feasible to use a graphic narrative embedded in a broadcast screensaver to communicate a guideline recommendation, but further study is needed to determine the impact of graphic narratives on clinical practice.
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Affiliation(s)
| | - Craig A Umscheid
- University of Chicago Medicine and Biological Sciences Division, Chicago, US.,Center for Healthcare Delivery Science and Innovation, University of Chicago Medicine, Chicago, US
| | - Frances S Shofer
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, US.,Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia, US
| | - Damien Leri
- Penn Medicine Center for Health Care Innovation, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, US
| | - Zachary F Meisel
- Center for Emergency Care Policy and Research, University of Pennsylvania, Ravdin Ground3400 Spruce Street, Philadelphia, US.,Department of Emergency Medicine, University of Pennsylvania, Philadelphia, US
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Engel-Rebitzer E, Dolan AR, Aronowitz SV, Shofer FS, Nguemeni Tiako MJ, Schapira MM, Perrone J, Hess EP, Rhodes KV, Bellamkonda VR, Cannuscio CC, Goldberg E, Bell J, Rodgers MA, Zyla M, Becker LB, McCollum S, Meisel ZF. Patient Preference and Risk Assessment in Opioid Prescribing Disparities: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2118801. [PMID: 34323984 PMCID: PMC8322998 DOI: 10.1001/jamanetworkopen.2021.18801] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Although racial disparities in acute pain control are well established, the role of patient analgesic preference and the factors associated with these disparities remain unclear. OBJECTIVE To characterize racial disparities in opioid prescribing for acute pain after accounting for patient preference and to test the hypothesis that racial disparities may be mitigated by giving clinicians additional information about their patients' treatment preferences and risk of opioid misuse. DESIGN, SETTING, AND PARTICIPANTS This study is a secondary analysis of data collected from Life STORRIED (Life Stories for Opioid Risk Reduction in the ED), a multicenter randomized clinical trial conducted between June 2017 and August 2019 in the emergency departments (EDs) of 4 academic medical centers. Participants included 1302 patients aged 18 to 70 years who presented to the ED with ureter colic or musculoskeletal back and/or neck pain. INTERVENTIONS The treatment arm was randomized to receive a patient-facing intervention (not examined in this secondary analysis) and a clinician-facing intervention that consisted of a form containing information about each patient's analgesic treatment preference and risk of opioid misuse. MAIN OUTCOMES AND MEASURES Concordance between patient preference for opioid-containing treatment (assessed before ED discharge) and receipt of an opioid prescription at ED discharge. RESULTS Among 1302 participants in the Life STORRIED clinical trial, 1012 patients had complete demographic and treatment preference data available and were included in this secondary analysis. Of those, 563 patients (55.6%) self-identified as female, with a mean (SD) age of 40.8 (14.1) years. A total of 455 patients (45.0%) identified as White, 384 patients (37.9%) identified as Black, and 173 patients (17.1%) identified as other races. After controlling for demographic characteristics and clinical features, Black patients had lower odds than White patients of receiving a prescription for opioid medication at ED discharge (odds ratio [OR], 0.42; 95% CI, 0.27-0.65). When patients who did and did not prefer opioids were considered separately, Black patients continued to have lower odds of being discharged with a prescription for opioids compared with White patients (among those who preferred opioids: OR, 0.43 [95% CI, 0.24-0.77]; among those who did not prefer opioids: OR, 0.45 [95% CI, 0.23-0.89]). These disparities were not eliminated in the treatment arm, in which clinicians were given additional data about their patients' treatment preferences and risk of opioid misuse. CONCLUSIONS AND RELEVANCE In this secondary analysis of data from a randomized clinical trial, Black patients received different acute pain management than White patients after patient preference was accounted for. These disparities remained after clinicians were given additional patient-level data, suggesting that a lack of patient information may not be associated with opioid prescribing disparities. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03134092.
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Affiliation(s)
- Eden Engel-Rebitzer
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
| | - Abby R. Dolan
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Frances S. Shofer
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Max Jordan Nguemeni Tiako
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Yale School of Medicine, New Haven, Connecticut
| | - Marilyn M. Schapira
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of General and Internal Medicine, University of Pennsylvania, Philadelphia
| | - Jeanmarie Perrone
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Penn Center for Addiction Medicine and Policy, Philadelphia, Pennsylvania
| | - Erik P. Hess
- Department of Emergency Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Karin V. Rhodes
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Venkatesh R. Bellamkonda
- Department of Emergency Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Carolyn C. Cannuscio
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Public Health Initiatives, University of Pennsylvania, Philadelphia
| | - Erica Goldberg
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
| | - Jeffrey Bell
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
| | - Melissa A. Rodgers
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- College of Education, University of Texas at Austin, Austin
| | - Michael Zyla
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
| | - Lance B. Becker
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Sharon McCollum
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
| | - Zachary F. Meisel
- Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Penn Injury Science Center, University of Pennsylvania, Philadelphia
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Teran F, Centeno C, Lindqwister AL, Hunckler WJ, Landis WP, Moodie KL, Shofer FS, Abella BS, Paradis NA. Epinephrine plus chest compressions is superior to epinephrine alone in a hypoxia-induced porcine model of pseudo-pulseless electrical activity. Resusc Plus 2021; 6:100110. [PMID: 34223370 PMCID: PMC8244467 DOI: 10.1016/j.resplu.2021.100110] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/04/2021] [Accepted: 03/05/2021] [Indexed: 01/25/2023] Open
Abstract
Aim Pseudo-pulseless electrical activity (pseudo-PEA) is a global hypotensive ischemic state with retained coordinated myocardial contractile activity and an organized ECG with no clinically detectable pulses. The role of standard external chest compressions (CPR) and its associated intrinsic hemodynamics remains unclear in the setting of pseudo-PEA. We undertook an experimental trial to compare epinephrine alone versus epinephrine with CPR in the treatment of pseudo-PEA. Methods Using a porcine model of hypoxic pseudo-PEA, we randomized 12 Yorkshire male swine to resuscitation with epinephrine only (control) (0.0015 mg/kg) versus epinephrine plus standard CPR (intervention). Animals who achieved return of spontaneous circulation (ROSC) were stabilized, fully recovered to hemodynamic and respiratory baseline, and rearrested up to 6 times. Primary outcome was ROSC defined as a sustained systolic blood pressure (SBP) of 60 mmHg for 2 min. Secondary outcomes included time to ROSC, coronary perfusion pressure (CoPP), and end-tidal carbon dioxide (ETCO2). Results Among 47 events of pseudo-PEA in 12 animals, we observed significantly higher proportion of ROSC when treatment included CPR (14/21 – 67%) compared to epinephrine alone (4/26 – 15%) (p = 0.0007). CoPP, aortic pressures and ETCO2 were significantly higher, and right atrial pressures were lower in the intervention group. Conclusions In a swine model of hypoxia-induced pseudo-PEA, epinephrine plus CPR was associated with improved intra-arrest hemodynamics and higher probability of ROSC. Thus, epinephrine plus CPR may be superior to epinephrine alone in the treatment of patients with pseudo-PEA.
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Affiliation(s)
- Felipe Teran
- Center for Resuscitation Science, University of Pennsylvania School of Medicine, University of Pennsylvania Blockley Hall, 423 Guardian Drive, Room 414A, Philadelphia, PA 19104, USA.,Department of Emergency Medicine, University of Pennsylvania School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Claire Centeno
- Department of Emergency Medicine, University of Pennsylvania School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | | | - William J Hunckler
- Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, NH 03775, USA
| | - William P Landis
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia & University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Karen L Moodie
- Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, NH 03775, USA
| | - Frances S Shofer
- Department of Emergency Medicine, University of Pennsylvania School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Benjamin S Abella
- Center for Resuscitation Science, University of Pennsylvania School of Medicine, University of Pennsylvania Blockley Hall, 423 Guardian Drive, Room 414A, Philadelphia, PA 19104, USA.,Department of Emergency Medicine, University of Pennsylvania School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Norman A Paradis
- Department of Emergency Medicine, Dartmouth Hitchcock Medical Center, 1 Medical Center Dr #4B, Lebanon, NH 03756, USA
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Kemmler CB, Sangal RB, Rothenberg C, Li SX, Shofer FS, Abella BS, Venkatesh AK, Foster SD. Delays in antibiotic redosing: Association with inpatient mortality and risk factors for delay. Am J Emerg Med 2021; 46:63-69. [PMID: 33735698 DOI: 10.1016/j.ajem.2021.02.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 02/15/2021] [Accepted: 02/21/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Although timely administration of antibiotics has an established benefit in serious bacterial infection, the majority of studies evaluating antibiotic delay focus only on the first dose. Recent evidence suggests that delays in redosing may also be associated with worse clinical outcome. In light of the increasing burden of boarding in Emergency Departments (ED) and subsequent need to redose antibiotic in the ED, we examined the association between delayed second antibiotic dose administration and mortality among patients admitted from the ED with a broad array of infections and characterized risk factors associated with delayed second dose administration. METHODS We performed a retrospective cohort study of patients admitted through five EDs in a single healthcare system from 1/2018 through 12/2018. Our study included all patients, aged 18 years or older, who received two intravenous antibiotic doses within a 30-h period, with the first dose administered in the ED. Patients with end stage renal disease, cirrhosis and extremes of weight were excluded due to a lack of consensus on antibiotic dosing intervals for these populations. Delay was defined as administration of the second dose at a time-point greater than 125% of the recommended interval. The primary outcome was in-hospital mortality. RESULTS A total of 5605 second antibiotic doses, occurring during 4904 visits, met study criteria. Delayed administration of the second dose occurred during 21.1% of visits. After adjustment for patient characteristics, delayed second dose administration was associated with increased odds of in-hospital mortality (OR 1.50, 95%CI 1.05-2.13). Regarding risk factors for delay, every one-hour increase in allowable compliance time was associated with a 18% decrease in odds of delay (OR 0.82 95%CI 0.75-0.88). Other risk factors for delay included ED boarding more than 4 h (OR 1.47, 95%CI 1.27-1.71) or a high acuity presentation as defined by emergency severity index (ESI) (OR 1.54, 95%CI 1.30-1.81 for ESI 1-2 versus 3-5). CONCLUSIONS Delays in second antibiotic dose administration were frequent in the ED and early hospital course, and were associated with increased odds of in-hospital mortality. Several risk factors associated with delays in second dose administration, including ED boarding, were identified.
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Affiliation(s)
- Charles B Kemmler
- Department of Emergency Medicine, Prisma Health, University of South Carolina School of Medicine Greenville, 701 Grove Rd, Greenville, SC 29605, USA.
| | - Rohit B Sangal
- Department of Emergency Medicine, Yale University, 464 Congress Ave, New Haven, CT 06510, USA.
| | - Craig Rothenberg
- Department of Emergency Medicine, Yale University, 464 Congress Ave, New Haven, CT 06510, USA.
| | - Shu-Xia Li
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, 1 Church St #200, New Haven, CT 06510, USA.
| | - Frances S Shofer
- Department of Emergency Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA.
| | - Benjamin S Abella
- Department of Emergency Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA.
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale University, 464 Congress Ave, New Haven, CT 06510, USA; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, 1 Church St #200, New Haven, CT 06510, USA.
| | - Sean D Foster
- Department of Emergency Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA.
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Bui KD, Wamsley CA, Shofer FS, Kolson DL, Johnson MJ. Robot-Based Assessment of HIV-Related Motor and Cognitive Impairment for Neurorehabilitation. IEEE Trans Neural Syst Rehabil Eng 2021; 29:576-586. [PMID: 33534709 PMCID: PMC7987220 DOI: 10.1109/tnsre.2021.3056908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
There is a pressing need for strategies to slow or treat the progression of functional decline in people living with HIV. This paper explores a novel rehabilitation robotics approach to measuring cognitive and motor impairment in adults living with HIV, including a subset with stroke. We conducted a cross-sectional study with 21 subjects exhibiting varying levels of cognitive and motor impairment. We tested three robot-based tasks – trajectory tracking, N-back, and spatial span – to assess if metrics derived from these tasks were sensitive to differences in subjects with varying levels of executive function and upper limb motor impairments. We also examined how well these metrics could estimate clinical cognitive and motor scores. The results showed that the average sequence length on the robot-based spatial span task was the most sensitive to differences between various cognitive and motor impairment levels. We observed strong correlations between robot-based measures and clinical cognitive and motor assessments relevant to the HIV population, such as the Color Trails 1 (rho = 0.83), Color Trails 2 (rho = 0.71), Digit Symbol – Coding (rho = 0.81), Montreal Cognitive Assessment – Executive Function subscore (rho = 0.70), and Box and Block Test (rho = 0.74). Importantly, our results highlight that gross motor impairment may be overlooked in the assessment of HIV-related disability. This study shows that rehabilitation robotics can be expanded to new populations beyond stroke, namely to people living with HIV and those with cognitive impairments.
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Jang DH, Piel S, Greenwood JC, Kelly M, Mazandi VM, Ranganathan A, Lin Y, Starr J, Hallowell T, Shofer FS, Baker WB, Lafontant A, Andersen K, Ehinger JK, Kilbaugh TJ. Alterations in cerebral and cardiac mitochondrial function in a porcine model of acute carbon monoxide poisoning. Clin Toxicol (Phila) 2021; 59:801-809. [PMID: 33529085 DOI: 10.1080/15563650.2020.1870691] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The purpose of this study is the development of a porcine model of carbon monoxide (CO) poisoning to investigate alterations in brain and heart mitochondrial function. DESIGN Two group large animal model of CO poisoning. SETTING Laboratory. SUBJECTS Ten swine were divided into two groups: Control (n = 4) and CO (n = 6). INTERVENTIONS Administration of a low dose of CO at 200 ppm to the CO group over 90 min followed by 30 min of re-oxygenation at room air. The Control group received room air for 120 min. MEASUREMENTS Non-invasive optical monitoring was used to measure cerebral blood flow and oxygenation. Cerebral microdialysis was performed to obtain semi real time measurements of cerebral metabolic status. At the end of the exposure, both fresh brain (cortical and hippocampal tissue) and heart (apical tissue) were immediately harvested to measure mitochondrial respiration and reactive oxygen species (ROS) generation and blood was collected to assess plasma cytokine concentrations. MAIN RESULTS Animals in the CO group showed significantly decreased Complex IV-linked mitochondrial respiration in hippocampal and apical heart tissue but not cortical tissue. There also was a significant increase in mitochondrial ROS generation across all measured tissue types. The CO group showed a significantly higher cerebral lactate-to-pyruvate ratio. Both IL-8 and TNFα were significantly increased in the CO group compared with the Control group obtained from plasma. While not significant there was a trend to an increase in optically measured cerebral blood flow and hemoglobin concentration in the CO group. CONCLUSIONS Low-dose CO poisoning is associated with early mitochondrial disruption prior to an observable phenotype highlighting the important role of mitochondrial function in the pathology of CO poisoning. This may represent an important intervenable pathway for therapy and intervention.
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Affiliation(s)
- David H Jang
- Department of Emergency Medicine, Division of Medical Toxicology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Sarah Piel
- Resuscitation Science Center, Philadelphia, PA, USA
| | - John C Greenwood
- Department of Anesthesiology and Critical Care Medicine, Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Matthew Kelly
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - Yuxi Lin
- Resuscitation Science Center, Philadelphia, PA, USA
| | | | | | - Frances S Shofer
- Department of Emergency Medicine, Division of Medical Toxicology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Wesley B Baker
- Department of Pediatric Neurology, The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, USA
| | - Alec Lafontant
- Department of Pediatric Neurology, The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, USA
| | - Kristen Andersen
- Department of Pediatric Neurology, The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, USA
| | - Johannes K Ehinger
- Mitochondrial Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Department of Otorhinolaryngology, Head and Neck Surgery, Skåne University Hospital, Lund University, Malmo, Sweden
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Chukwulebe SB, Gaieski DF, Bhardwaj A, Mulugeta-Gordon L, Shofer FS, Dean AJ. Early hemodynamic assessment using NICOM in patients at risk of developing Sepsis immediately after emergency department triage. Scand J Trauma Resusc Emerg Med 2021; 29:23. [PMID: 33509242 PMCID: PMC7842048 DOI: 10.1186/s13049-021-00833-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 01/12/2021] [Indexed: 11/10/2022] Open
Abstract
Background One factor leading to the high mortality rate seen in sepsis is the subtle, dynamic nature of the disease, which can lead to delayed detection and under-resuscitation. This study investigated whether serial hemodynamic parameters obtained from a non-invasive cardiac output monitor (NICOM) predicts disease severity in patients at risk for sepsis. Methods Prospective clinical trial of the NICOM device in a convenience sample of adult ED patients at risk for sepsis who did not have obvious organ dysfunction at the time of triage. Hemodynamic data were collected immediately following triage and 2 hours after initial measurement and compared in two outcome groupings: (1) admitted vs. dehydrated, febrile, hypovolemicdischarged patients; (2) infectious vs. non-infectious sources. Receiver operator characteristic (ROC) curves were calculated to determine whether the NICOM values predict hospital admission better than a serum lactate. Results 50 patients were enrolled, 32 (64 %) were admitted to the hospital. Mean age was 49.5 (± 16.5) years and 62 % were female. There were no significant associations between changes in hemodynamic variables and patient disposition from the ED or diagnosis of infection. Lactate was significantly higher in admitted patients and those with infection (p = 0.01, p = 0.01 respectively). The area under the ROC [95 % Confidence Intervals] for lactate was 0.83 [0.64–0.92] compared to 0.59 [0.41–0.73] for cardiac output (CO), 0.68 [0.49–0.80] for cardiac index (CI), and 0.63 [0.36–0.80] for heart rate (HR) for predicting hospital admission. Conclusions CO and CI, obtained at two separate time points, do not help with early disease severity differentiation of patients at risk for severe sepsis. Although mean HR was higher in those patients who were admitted, a serum lactate still served as a better predictor of patient admission from the ED.
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Affiliation(s)
- Steve B Chukwulebe
- Department of Emergency Medicine, Advocate Sherman Hospital, Elgin, IL, USA
| | - David F Gaieski
- Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, 1025 Walnut Street; 300 College Building, 19107, Philadelphia, PA, USA.
| | - Abhishek Bhardwaj
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Lakeisha Mulugeta-Gordon
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Frances S Shofer
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anthony J Dean
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Greenwood JC, Jang DH, Hallisey SD, Gutsche JT, Horak J, Acker MA, Bermudez CA, Zhou VL, Chatterjee S, Shofer FS, Kilbaugh TJ, Augoustides JGT, Meyer NJ, Bakker J, Abella BS. Severe Impairment of Microcirculatory Perfused Vessel Density Is Associated With Postoperative Lactate and Acute Organ Injury After Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 35:106-115. [PMID: 32505603 PMCID: PMC7666105 DOI: 10.1053/j.jvca.2020.04.045] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/20/2020] [Accepted: 04/27/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Resuscitation after cardiac surgery needs to address multiple pathophysiological processes that are associated with significant morbidity and mortality. Functional microcirculatory derangements despite normal systemic hemodynamics have been previously described but must be tied to clinical outcomes. The authors hypothesized that microcirculatory dysfunction after cardiac surgery would include impaired capillary blood flow and impaired diffusive capacity and that subjects with the lowest quartile of perfused vessel density would have an increased postoperative lactate level and acute organ injury scores. DESIGN Prospective, observational study. SETTING A single, tertiary university cardiovascular surgical intensive care unit. PARTICIPANTS 25 adults undergoing elective cardiac surgery requiring cardiopulmonary bypass. INTERVENTION Sublingual microcirculation was imaged using incident dark field microscopy before and 2 to 4 hours after surgery in the intensive care unit. MEASUREMENTS AND MAIN RESULTS Compared with baseline measurements, postoperative vessel-by-vessel microvascular flow index (2.9 [2.8-2.9] v 2.5 [2.4-2.7], p < 0.0001) and perfused vessel density were significantly impaired (20.7 [19.3-22.9] v 16.3 [12.8-17.9], p < 0.0001). The lowest quartile of perfused vessel density (<12.8 mm/mm2) was associated with a significantly increased postoperative lactate level (6.0 ± 2.9 v 1.8 ± 1.2, p < 0.05), peak lactate level (7.6 ± 2.8 v 2.8 ± 1.5, p = 0.03), and sequential organ failure assessment (SOFA) score at 24 and 48 hours. CONCLUSION In patients undergoing cardiac surgery, there was a significant decrease in postoperative microcirculatory convective blood flow and diffusive capacity during early postoperative resuscitation. Severely impaired perfused vessel density, represented by the lowest quartile of distribution, is significantly related to hyperlactatemia and early organ injury.
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Affiliation(s)
- John C Greenwood
- Division of Critical Care Medicine, Department of Emergency Medicine, Department of Anesthesiology and Critical Care, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - David H Jang
- Division of Medical Toxicology and Critical Care Medicine, Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Stephen D Hallisey
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - Jacob T Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jiri Horak
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Michael A Acker
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Christian A Bermudez
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Victoria L Zhou
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Shampa Chatterjee
- Department of Physiology, Institute for Environmental Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Frances S Shofer
- Epidemiology and Biostatistics, Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Center for Mitochondrial and Epigenomic Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - John G T Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Nuala J Meyer
- Division of Pulmonary and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jan Bakker
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, NY; Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Intensive Medicine, The Pontifical Catholic University of Chile
| | - Benjamin S Abella
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Fasina AA, Dean AJ, Panebianco NL, Shofer FS, Ali O, Yahya M, Ismail S, Henwood PC. Evaluation of Diagnostic Imaging Capacity and the Role for Point-of-Care Ultrasound (POCUS) within the Zanzibar Health System. POCUS J 2021; 6:45-50. [PMID: 36895506 PMCID: PMC9979903 DOI: 10.24908/pocus.v6i1.14763] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background: The Zanzibar Ministry of Health identified access to ultrasound (US) as a system priority due to limited diagnostic imaging capacity and consequent impact on patient care and requested a needs assessment in this regard. As a result, the objective of this study was to assess diagnostic imaging capacity focusing on ultrasound in Zanzibar, including health care providers’ (HCPs) current training, use, and barriers to implementation. Methods: A previously published ultrasound needs assessment survey was modified and administered on-site at the eight public hospitals in Zanzibar among a convenience sample of HCPs. Demographics, perceived US needs, current training and practice, and availability of specialty support were assessed. HCPs also completed focused personal interviews (FPIs) to explore experience with training, interests, and barriers to ultrasound. On-site diagnostic imaging modalities were assessed. Results: There were nine ultrasound machines present at six of the eight public hospitals assessed. All had x-ray, but only one had a CT scanner and a radiologist. There was no MRI capacity at the hospitals assessed at the time of the study. Survey data among 40 participants revealed that prior experience with POCUS was limited with only 10% reporting any prior ultrasound training or experience. The majority of those surveyed (72%), indicated a ‘high’ interest in learning ultrasound. Of those reporting interest in POCUS applications, obstetrics was the most often cited (70%). Lack of ultrasound machines (40%) and educators (28%) were identified as the greatest barriers. Conclusion: HCPs in Zanzibar have limited access to diagnostic imaging, including ultrasound, and expressed a high level of interest in learning point-of-care ultrasound. A shortage of machines and educators are the main barriers to widespread use. Obstetrics is the application for which ultrasound is currently most used and is the application HCPs are most interested in learning. Equipment and educational support for a POCUS program could improve care by increasing access to diagnostic imaging.
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Affiliation(s)
- Abiola A Fasina
- Emergency Healthcare Consultants Lagos Nigeria.,Point-of-care Ultrasound in Resource-limited Environments Philadelphia, PA USA
| | - Anthony J Dean
- Department of Emergency Medicine, University of Pennsylvania Hospital Philadelphia, PA USA.,Point-of-care Ultrasound in Resource-limited Environments Philadelphia, PA USA
| | - Nova L Panebianco
- Department of Emergency Medicine, University of Pennsylvania Hospital Philadelphia, PA USA
| | - Frances S Shofer
- Department of Emergency Medicine, University of Pennsylvania Hospital Philadelphia, PA USA
| | | | - Mwajuma Yahya
- Department of Radiology, Mnazi Moja Hospital Unguja Zanzibar
| | - Salim Ismail
- Department of Radiology, Mnazi Moja Hospital Unguja Zanzibar
| | - Patricia C Henwood
- Point-of-care Ultrasound in Resource-limited Environments Philadelphia, PA USA.,Department of Emergency Medicine, Thomas Jefferson University Hospital Philadelphia, PA USA
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Takakuwa KM, Shofer FS, Schears RM. Letter to the Editor: A National Survey of U.S. Emergency Medicine Physicians on Their Knowledge Regarding State and Federal Cannabis Laws. Cannabis Cannabinoid Res 2021; 5:337-339. [PMID: 33381647 DOI: 10.1089/can.2019.0073] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Frances S Shofer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Raquel M Schears
- Department of Emergency Medicine, University of Central Florida, Orlando, Florida, USA
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Abstract
There is a pressing need for strategies to slow or treat the progression of functional decline in people living with HIV. This paper explores a novel rehabilitation robotics approach to measuring cognitive and motor impairment in adults living with HIV, including a subset with stroke. We conducted a cross-sectional study with 21 subjects exhibiting varying levels of cognitive and motor impairment. We developed three robot-based tasks – trajectory tracking, N-back, and spatial span – to assess if metrics derived from these tasks were sensitive to differences in subjects with varying levels of executive function and upper limb motor impairments. We also examined if these metrics could estimate clinical cognitive and motor scores. The results showed that the average sequence length on the robot-based spatial span task was the most sensitive to differences between subjects’ cognitive and motor impairment levels. We observed strong correlations between robot-based measures and clinical cognitive and motor assessments relevant to the HIV population, such as the Color Trails 1 (rho = 0.83), Color Trails 2 (rho = 0.71), Digit Symbol – Coding (rho = 0.81), Montreal Cognitive Assessment – Executive Function subscore (rho = 0.70), and Box and Block Test (rho = 0.74). Importantly, our results highlight that gross motor impairment may be overlooked in the assessment of HIV-related disability. This study shows that rehabilitation robotics can be expanded to new populations beyond stroke, namely to people living with HIV and those with cognitive impairments.
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Affiliation(s)
- Kevin D Bui
- Rehabilitation Robotics Lab and Department of Bioengineering, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Carol A Wamsley
- Penn Institute for Rehabilitation Medicine, Philadelphia, PA 19146 USA
| | - Frances S Shofer
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Dennis L Kolson
- Department of Neurology, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Michelle J Johnson
- Rehabilitation Robotics Lab, Department of Physical Medicine and Rehabilitation, and Department of Bioengineering, University of Pennsylvania, Philadelphia, PA 19104 USA
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Meisel ZF, Goldberg EB, Dolan AR, Bansal E, Rhodes KV, Hess EP, Cannuscio CC, Schapira MM, Perrone J, Rodgers MA, Zyla MM, Bell JJ, McCollum S, Shofer FS. Stories to Communicate Individual Risk for Opioid Prescriptions for Back and Kidney Stone Pain: Protocol for the Life STORRIED Multicenter Randomized Clinical Trial. JMIR Res Protoc 2020; 9:e19496. [PMID: 32969832 PMCID: PMC7545334 DOI: 10.2196/19496] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/07/2020] [Accepted: 07/21/2020] [Indexed: 11/13/2022] Open
Abstract
Background Prescription opioid misuse in the United States is a devastating public health crisis; many chronic opioid users were originally prescribed this class of medication for acute pain. Video narrative–enhanced risk communication may improve patient outcomes, such as knowledge of opioid risk and opioid use behaviors after an episode of acute pain. Objective Our objective is to assess the effect of probabilistic and narrative-enhanced opioid risk communication on patient-reported outcomes, including knowledge, opioid use, and patient preferences, for patients who present to emergency departments with back pain and kidney stone pain. Methods This is a multisite randomized controlled trial. Patients presenting to the acute care facilities of four geographically and ethnically diverse US hospital centers with acute renal colic pain or musculoskeletal back and/or neck pain are eligible for this randomized controlled trial. A control group of patients receiving general risk information is compared to two intervention groups: one receiving the risk information sheet plus an individualized, visual probabilistic Opioid Risk Tool (ORT) and another receiving the risk information sheet plus a video narrative–enhanced probabilistic ORT. We will study the effect of probabilistic and narrative-enhanced opioid risk communication on the following: risk awareness and recall at 14 days postenrollment, reduced use or preferences for opioids after the emergency department episode, and alignment with patient preference and provider prescription. To assess these outcomes, we administer baseline patient surveys during acute care admission and follow-up surveys at predetermined times during the 3 months after discharge. Results A total of 1302 patients were enrolled over 24 months. The mean age of the participants was 40 years (SD 14), 692 out of 1302 (53.15%) were female, 556 out of 1302 (42.70%) were White, 498 out of 1302 (38.25%) were Black, 1002 out of 1302 (76.96%) had back pain, and 334 out of 1302 (25.65%) were at medium or high risk. Demographics and ORT scores were equally distributed across arms. Conclusions This study seeks to assess the potential clinical role of narrative-enhanced, risk-informed communication for acute pain management in acute care settings. This paper outlines the protocol used to implement the study and highlights crucial methodological, statistical, and stakeholder involvement as well as dissemination considerations. Trial Registration ClinicalTrials.gov NCT03134092; https://clinicaltrials.gov/ct2/show/NCT03134092 International Registered Report Identifier (IRRID) DERR1-10.2196/19496
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Affiliation(s)
- Zachary F Meisel
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Erica B Goldberg
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Abby R Dolan
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Esha Bansal
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Karin V Rhodes
- Department of Population Health Management, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
| | - Erik P Hess
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Carolyn C Cannuscio
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Marilyn M Schapira
- Department of General and Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Jeanmarie Perrone
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Melissa A Rodgers
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Michael M Zyla
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Jeffrey J Bell
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sharon McCollum
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Frances S Shofer
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Takakuwa KM, Hergenrather JY, Shofer FS, Schears RM. The Impact of Medical Cannabis on Intermittent and Chronic Opioid Users with Back Pain: How Cannabis Diminished Prescription Opioid Usage. Cannabis Cannabinoid Res 2020; 5:263-270. [PMID: 32923663 DOI: 10.1089/can.2019.0039] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objective: To determine if cannabis may be used as an alternative or adjunct treatment for intermittent and chronic prescription opioid users. Design: Retrospective cohort study. Setting: A single-center cannabis medical practice site in California. Patients: A total of 180 patients who had a chief complaint of low back pain were identified (International Classification of Diseases, 10th Revision, code M54.5). Sixty-one patients who used prescription opioids were analyzed. Interventions: Cannabis recommendations were provided to patients as a way to mitigate their low back pain. Outcome Measures: Number of patients who stopped opioids and change in morphine equivalents. Results: There were no between-group differences based on demographic, experiential, or attitudinal variables. We found that 50.8% were able to stop all opioid usage, which took a median of 6.4 years (IQR=1.75-11 years) after excluding two patients who transitioned off opioids by utilizing opioid agonists. For those 29 patients (47.5%) who did not stop opioids, 9 (31%) were able to reduce opioid use, 3 (10%) held the same baseline, and 17 (59%) increased their usage. Forty-eight percent of patients subjectively felt like cannabis helped them mitigate their opioid intake but this sentiment did not predict who actually stopped opioid usage. There were no variables that predicted who stopped opioids, except that those who used higher doses of cannabis were more likely to stop, which suggests that some patients might be able to stop opioids by using cannabis, particularly those who are dosed at higher levels. Conclusions: In this long-term observational study, cannabis use worked as an alternative to prescription opioids in just over half of patients with low back pain and as an adjunct to diminish use in some chronic opioid users.
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Affiliation(s)
| | | | - Frances S Shofer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Raquel M Schears
- Department of Emergency Medicine, University of Central Florida, Orlando, Florida
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40
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Mudan A, Love JS, Greenwood JC, Stickley C, Zhou VL, Shofer FS, Jang DH. The management of the poisoned patient using a novel emergency department-based resuscitation and critical care unit (ResCCU). Am J Emerg Med 2020; 38:2070-2073. [PMID: 33142177 DOI: 10.1016/j.ajem.2020.06.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 06/17/2020] [Accepted: 06/22/2020] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVES The Resuscitation & Critical Care Unit (ResCCU) is a novel ED-based ICU designed to provide early critical care services. This study sought to identify characteristics of poisoned patients treated in the ResCCU. METHODS We conducted a retrospective, single-center case study of poisoned patients over the age of 18 years old over a 16-month period. Patient demographics, drug concentrations, and severity of illness scores were extracted from electronic medical records. Patients were divided into two groups, those who required short term ICU level care (< 24 h) and prolonged ICU care (> 24 h). RESULTS A total of 58 ED visits with a tox-related illness were analyzed. There were 24 women (41%) and 34 men (59%). There were 42 patients (72%) who required short term ICU level care and 16 patients (28%) who required prolonged ICU care. In the short-term ICU group, 13 patients (31%) were discharged home directly from the ResCCU, 29 patients (69%) were sent to the inpatient floor, and 1 of the admitted floor patients expired. There were no patients admitted to the floor that required a step-up to the inpatient ICU. 56 patients (97%) were alive at post-admit day 7 and 28, and only 8 (14%) were re-admitted within 30 days. CONCLUSIONS Patients who were treated in the ED-based ICU for toxicology-related illnesses were frequently able to be either discharged home or admitted to a regular floor after their initial stabilization and treatment, and none that were sent to the floor required an ICU step-up.
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Affiliation(s)
- Anita Mudan
- Department of Emergency Medicine, University of California San Francisco, United States
| | - Jennifer S Love
- Department of Emergency Medicine, Oregon Health & Science University, United States
| | - John C Greenwood
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States; Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Carolyn Stickley
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Victoria L Zhou
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Frances S Shofer
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - David H Jang
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States.
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Tian Z, Shofer FS, Yao L, Sun H, Zhang H, Qin L, Chen YH, Zhang Y. TNFAIP8 family gene expressions in the mouse tail intervertebral disc injury model. JOR Spine 2020; 3:e1093. [PMID: 32613168 PMCID: PMC7323467 DOI: 10.1002/jsp2.1093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/25/2020] [Accepted: 05/08/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The TNF-α-induced protein-8 (TNFAIP8, also known as TIPE) family of molecules comprises four members: TNFAIP8 and TIPEs1-3. Since the first description of these proteins, their roles in fine-tuning inflammation and in directing leukocyte migration have been described in several organ systems. However, their relationship with intervertebral disc (IVD) is unknown. MATERIALS AND METHODS Here, we describe the expression of TNFAIP8 family genes in the nucleus pulposus (NP) and annulus fibrosus (AF) of the normal adult murine IVD. We further describe the expression of these genes in the injured male and female murine IVD. RESULTS Tnfaip8 gene expression was decreased, and Tipe1 gene expression was essentially unchanged, in response to injury. Tipe2 and Tipe3 gene expression was markedly elevated in response to IVD injury, along with those encoding known inflammatory markers (ie, Tnfa, Il6, Cxcl1, and Adam8). Additionally, sex-related differences were also observed for some of these genes in intact and injured mouse IVDs. Future studies include examining tissue distribution of TNFAIP8 family proteins and identifying cells that produce them. In addition, examining mice that are deficient in TNFAIP8 molecules, in relation to gene expression, tissue morphology and mouse behavior, may further delineate the roles of these molecules in IVD inflammation and degeneration.
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Affiliation(s)
- Zuozhen Tian
- Department of Physical Medicine & RehabilitationUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Frances S. Shofer
- Department of Emergency MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Lutian Yao
- Department of Orthopaedic SurgeryUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Orthopaedics/Sports Medicine and Joint Surgery, First Affiliated HospitalChina Medical UniversityShenyangLiaoningChina
| | - Honghong Sun
- Pathology and Laboratory Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Hongtao Zhang
- Pathology and Laboratory Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Ling Qin
- Department of Emergency MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Youhai H. Chen
- Pathology and Laboratory Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Yejia Zhang
- Department of Physical Medicine & RehabilitationUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Orthopaedic SurgeryUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Translational Musculoskeletal Research Center (TMRC)Corporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPennsylvaniaUSA
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Brent JM, Tian Z, Yao L, Huang J, Markova DZ, Shofer FS, Brice AK, Qin L, Scanzello CR, Vitale F, Chen D, Zhang Y. Functional Deficits in Mice Expressing Human Interleukin 8. Comp Med 2020; 70:205-215. [PMID: 32312361 DOI: 10.30802/aalas-cm-19-000049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We showed previously that inflammatory mediators, including IL8, in intervertebral disc tissues from patients with discogenic back pain may play a key role in back pain. To investigate the molecular mechanism of IL8 signaling in back pain, we generated a mouse model that conditionally expresses human (h) IL8. We hypothesized that hIL8 levels affect mouse activity and function. Briefly, hIL8 cDNA was inserted into the pCALL2 plasmid, linearized, and injected into mouse embryos. Resulting pCALL2-hIL8 mice were then bred with GDF5-Cre mice to express the transgene in cartilage and intervertebral disc (IVD) tissues. Functional capacities including nest-making and other natural behaviors were measured. Both male and female mice expressing hIL8 showed lower nesting scores than did littermates that did not express hIL8 (n = 14 to 16 per group). At 28 wk of age, mice expressing hIL8 (n = 35) spent more time immobile and eating during each night than littermate controls (n = 33). Furthermore, hIL8-expressing mice traveled shorter distances and at a lower average speed than littermate controls. Thus, in an initial effort to investigate the relationship between this chemokine and mouse behavior, we have documented changes in normal activities in mice conditionally expressing hIL8.
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Affiliation(s)
- Julie Michelle Brent
- University Laboratory Animal Resources, University of Pennsylvania, Philadelphia, Pennsylvania;,
| | - Zuozhen Tian
- Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania
| | - Lutian Yao
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania; Department of Orthopaedics-Sports Medicine and Joint Surgery, First Affiliated Hospital, China Medical University, Shenyang, Liaoning, China
| | - Jian Huang
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Dessislava Z Markova
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Frances S Shofer
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Angela K Brice
- University Laboratory Animal Resources, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ling Qin
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania
| | - Carla R Scanzello
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania; Department of Rheumatology, Perelman School of Medicine, University of Pennsylvania; Corporal Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Flavia Vitale
- Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania; Department of Neurology, Perelman School of Medicine, University of Pennsylvania; Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, Pennsylvania; Corporal Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Di Chen
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Yejia Zhang
- Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania; Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania; Corporal Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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Owiredu S, Ranganathan A, Eckmann DM, Shofer FS, Hardy K, Lambert DS, Kelly M, Jang DH. Ex vivo use of cell-permeable succinate prodrug attenuates mitochondrial dysfunction in blood cells obtained from carbon monoxide-poisoned individuals. Am J Physiol Cell Physiol 2020; 319:C129-C135. [PMID: 32374677 DOI: 10.1152/ajpcell.00539.2019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The purpose of this study was to evaluate a new pharmacological strategy using a first-generation succinate prodrug, NV118, in peripheral blood mononuclear cells (PBMCs) obtained from subjects with carbon monoxide (CO) poisoning and healthy controls. We obtained human blood cells from subjects with CO poisoning and healthy control subjects. Intact PBMCs from subjects in the CO and Control group were analyzed with high-resolution respirometry measured in pmol O2 per second per 10-6 PBMCs. In addition to obtaining baseline respiration, NV118 (100 μM) was injected, and the same parameters of respiration were obtained for comparison in PBMCs. We measured mitochondrial dynamics with microscopy with the same conditions. We enrolled 37 patients (17 in the CO group and 20 in the Control group for comparison) in the study. PMBCs obtained from subjects in the CO group had overall significantly lower respiration compared with the Control group (P < 0.0001). There was a significant increase in respiration with NV118, specifically with an increase in maximum respiration and respiration from complex II and complex IV (P < 0.0001). The mitochondria in PBMCs demonstrated an overall increase in net movement compared with the Control group. Our results of this study suggest that the therapeutic compound, NV118, increases respiration at complex II and IV as well as restoration of mitochondrial movement in PBMCs obtained from subjects with CO poisoning. Mitochondrial-directed therapy offers a potential future strategy with further exploration in vivo.
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Affiliation(s)
- Shawn Owiredu
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Abhay Ranganathan
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David M Eckmann
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Frances S Shofer
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kevin Hardy
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David S Lambert
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew Kelly
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David H Jang
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Brent JM, Tian Z, Shofer FS, Martin JT, Yao L, Acharte C, Chen YH, Qin L, Enomoto-Iwamoto M, Zhang Y. Influence of Genetic Background and Sex on Gene Expression in the Mouse ( Mus musculus) Tail in a Model of Intervertebral Disc Injury. Comp Med 2020; 70:131-139. [PMID: 32156324 PMCID: PMC7137552 DOI: 10.30802/aalas-cm-19-000034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 05/08/2019] [Accepted: 07/26/2019] [Indexed: 11/05/2022]
Abstract
To facilitate rational experimental design and fulfill the NIH requirement of including sex as a biologic variable, we examined the influences of genetic background and sex on responses to intervertebral disc (IVD) injury in the mouse tail. The goal of this study was to compare gene expression and histologic changes in response to a tail IVD injury (needle puncture) in male and female mice on the DBA and C57BL/6 (B6) backgrounds. We hypothesized that extracellular matrix gene expression in response to IVD injury differs between mice of different genetic backgrounds and sex. Consistent changes were detected in gene expression and histologic features after IVD injury in mice on both genetic backgrounds and sexes. In particular, expression of col1a1 and adam8 was higher in the injured IVD of DBA mice than B6 mice. Conversely, col2a1 expression was higher in B6 mice than DBA mice. Sex-associated differences were significant only in B6 mice, in which col2a1 expression was greater in male mice than in female. Histologic differences in response to injury were not apparent between DBA and B6 mice or between males and females. In conclusion, mouse tail IVD showed sex- and strain-related changes in gene expression and histology after needle puncture. The magnitude of change in gene expression differed with regard to genetic background and, to a lesser degree, sex.
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Affiliation(s)
- Julie M Brent
- University Laboratory Animal Resources, University of Pennsylvania, Philadelphia, Pennsylvania;,
| | - Zuozhen Tian
- Departments of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Frances S Shofer
- Departments of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John T Martin
- Departments of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Translational Musculoskeletal Research Center, Corporal Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Lutian Yao
- Departments of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Orthopaedics-Sports Medicine and Joint Surgery, First Affiliated Hospital, China Medical University, Shenyang, Liaoning, China
| | - Christian Acharte
- Departments of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Youhai H Chen
- Departments of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ling Qin
- Departments of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Motomi Enomoto-Iwamoto
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Yejia Zhang
- Departments of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Departments of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Translational Musculoskeletal Research Center, Corporal Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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45
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Sangal RB, Shofer FS, Blutinger EJ, Mamtani M. Nursing updates as a means to improve patient satisfaction. Am J Emerg Med 2020; 38:404-406. [DOI: 10.1016/j.ajem.2019.158388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 07/31/2019] [Accepted: 08/05/2019] [Indexed: 11/30/2022] Open
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46
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Takakuwa KM, Shofer FS, Schears RM. The practical knowledge, experience and beliefs of US emergency medicine physicians regarding medical Cannabis: A national survey. Am J Emerg Med 2020; 38:1952-1954. [PMID: 32067838 DOI: 10.1016/j.ajem.2020.01.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 01/28/2020] [Accepted: 01/29/2020] [Indexed: 10/25/2022] Open
Affiliation(s)
- Kevin M Takakuwa
- Society of Cannabis Clinicians, Sebastopol, CA, United States of America.
| | - Frances S Shofer
- University of Pennsylvania, Philadelphia, PA, United States of America
| | - Raquel M Schears
- University of Central Florida, Orlando, FL, United States of America
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47
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Abstract
In 1350 client-owned dogs in North America, the association of calculus, gingival inflammation and periodontal bone loss with diet (dry food only, or other than dry food only), and with access to other chewing materials was analyzed. There were few apparent differences seen in dogs fed dry food only compared with those fed other than dry food only. There was progressively less accumulation of calculus, less gingival inflammation and less periodontal bone loss in dogs that were given access to more types of chewing materials (rawhides, bones, biscuits, chew toys) compared with dogs given access to fewer or no chewing materials. When the effects of individual chewing materials were analyzed, access to rawhides overall had the greatest apparent periodontal protective effect, and this effect was more apparent in dogs fed dry food only compared with those fed other than dry food only.
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Affiliation(s)
- Colin E. Harvey
- From the Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, 3900 Delancey Street, Philadelphia, PA 19104–6010
| | - Frances S. Shofer
- From the Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, 3900 Delancey Street, Philadelphia, PA 19104–6010
| | - Larry Laster
- From the Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, 3900 Delancey Street, Philadelphia, PA 19104–6010
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48
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Abstract
Thirteen hundred and fifty dogs were examined under anesthesia at veterinary hospitals in the USA and Canada. Periodontal health was recorded in detail. Teeth were frequently absent (particularly lower third molar, upper and lower first premolars, and incisor teeth). Calculus was most extensive on the upper fourth premolar and molar teeth. Missing teeth, mobility of remaining teeth, extent of calculus and gingival inflammation, and furcation exposure and attachment loss all were more common in small dogs compared with larger dogs, and in older dogs compared with younger dogs.
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Affiliation(s)
- Colin E. Harvey
- Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, 3900 Delancey Street, Philadelphia, PA 19104-6010
| | - Frances S. Shofer
- Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, 3900 Delancey Street, Philadelphia, PA 19104-6010
| | - Larry Laster
- Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, 3900 Delancey Street, Philadelphia, PA 19104-6010
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49
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Mamtani M, Shofer FS, Sackeim A, Conlon L, Scott K, Mills AM. Feedback With Performance Metric Scorecards Improves Resident Satisfaction but Does Not Impact Clinical Performance. AEM Educ Train 2019; 3:323-330. [PMID: 31637349 PMCID: PMC6795364 DOI: 10.1002/aet2.10348] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/27/2019] [Accepted: 03/27/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES The Emergency Medicine Milestone Project, a framework for assessing competencies, has been used as a method of providing focused resident feedback. However, the emergency medicine milestones do not include specific objective data about resident clinical efficiency and productivity, and studies have shown that milestone-based feedback does not improve resident satisfaction with the feedback process. We examined whether providing performance metric reports to resident physicians improves their satisfaction with the feedback process and their clinical performance. METHODS We conducted a three-phase stepped-wedge randomized pilot study of emergency medicine residents at a single, urban academic site. In phase 1, all residents received traditional feedback; in phase 2, residents were randomized to receive traditional feedback (control group) or traditional feedback with performance metric reports (intervention group); and in phase 3, all residents received monthly performance metric reports and traditional feedback. To assess resident satisfaction with the feedback process, surveys using 6-point Likert scales were administered at each study phase and analyzed using two-sample t-tests. Analysis of variance in repeated measures was performed to compare impact of feedback on resident clinical performance, specifically patient treatment time (PTT) and patient visits per hour. RESULTS Forty-one residents participated in the trial of which 21 were randomized to the intervention group and 20 in the control group. Ninety percent of residents liked receiving the report and 74% believed that it better prepared them for expectations of becoming an attending physician. Additionally, residents randomized to the intervention group reported higher satisfaction (p = 0.01) with the quality of the feedback compared to residents in the control group. However, receiving performance metric reports, regardless of study phase or postgraduate year status, did not affect clinical performance, specifically PTT (183 minutes vs. 177 minutes, p = 0.34) or patients visits per hour (0.99 vs. 1.04, p = 0.46). CONCLUSIONS While feedback with performance metric reports did not improve resident clinical performance, resident physicians were more satisfied with the feedback process, and a majority of residents expressed liking the reports and felt that it better prepared them to become attending physicians. Residency training programs could consider augmenting feedback with performance metric reports to aide in the transition from resident to attending physician.
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Affiliation(s)
- Mira Mamtani
- Department of Emergency MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Frances S. Shofer
- Department of Emergency MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Alexander Sackeim
- Department of Emergency MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Lauren Conlon
- Department of Emergency MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Kevin Scott
- Department of Emergency MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Angela M. Mills
- Department of Emergency MedicineColumbia University College of Physician and SurgeonsNew YorkNY
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50
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Baumann BM, Greenwood JC, Lewis K, Nuckton TJ, Darger B, Shofer FS, Troeger D, Jung SY, Kilgannon JH, Rodriguez RM. Combining qSOFA criteria with initial lactate levels: Improved screening of septic patients for critical illness. Am J Emerg Med 2019; 38:883-889. [PMID: 31320214 DOI: 10.1016/j.ajem.2019.07.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/20/2019] [Accepted: 07/02/2019] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To determine if the addition of lactate to Quick Sequential Organ Failure Assessment (qSOFA) scoring improves emergency department (ED) screening of septic patients for critical illness. METHODS This was a multicenter retrospective cohort study of consecutive adult patients admitted to the hospital from the ED with infectious disease-related illnesses. We recorded qSOFA criteria and initial lactate levels in the first 6 h of ED stay. Our primary outcome was a composite of hospital death, vasopressor use, and intensive care unit stay ≤72 h of presentation. Diagnostic test characteristics were determined for: 1) lactate levels ≥2 and ≥4; 2) qSOFA scores ≥1, ≥2, and =3; and 3) combinations of these. RESULTS Of 3743 patients, 2584 had a lactate drawn ≤6 h of ED stay and 18% met the primary outcome. The qSOFA scores were ≥1, ≥2, and =3 in 59.2%, 22.0%, and 5.3% of patients, respectively, and 34.4% had a lactate level ≥2 and 7.9% had a lactate level ≥4. The combination of qSOFA ≥1 OR Lactate ≥2 had the highest sensitivity, 94.0% (95% CI: 91.3-95.9). CONCLUSIONS The combination of qSOFA ≥1 OR Lactate ≥2 provides substantially improved sensitivity for the screening of critical illness compared to isolated lactate and qSOFA thresholds.
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Affiliation(s)
- Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, One Cooper Plaza Camden, NJ 08103, United States of America.
| | - John C Greenwood
- Departments of Emergency Medicine and Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States of America.
| | - Kristin Lewis
- Department of Emergency Medicine, University of California San Francisco, 533 Parnassus Avenue, San Francisco, CA 94143-0749, United States of America.
| | - Thomas J Nuckton
- Department of Medicine, Sutter Eden Medical Center, 20103 Lake Chabot Road Castro Valley, CA 94546, United States of America.
| | - Bryan Darger
- Department of Emergency Medicine, University of California San Francisco, 533 Parnassus Avenue, San Francisco, CA 94143-0749, United States of America.
| | - Frances S Shofer
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States of America.
| | - Dawn Troeger
- Department of Medicine, Sutter Eden Medical Center, 20103 Lake Chabot Road Castro Valley, CA 94546, United States of America.
| | - Soo Y Jung
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States of America.
| | - J Hope Kilgannon
- Department of Emergency Medicine, Cooper Medical School of Rowan University, One Cooper Plaza Camden, NJ 08103, United States of America.
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California San Francisco, 533 Parnassus Avenue, San Francisco, CA 94143-0749, United States of America.
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