Prone Zone 3 REBOA Rescue for Postoperative Hemorrhagic After Sacrococcygeal Tumor Resection

In this report, we describe a 41-year-old man who underwent resection of a large chordoma. During his post-operative recovery, he experienced delayed-onset non-compressive pelvic hemorrhage in the surgical resection bed resulting in nerve root compression. Zone 3 REBOA was prepositioned intra-operatively prior to placing the patient in the prone position for hematoma evacuation and exploration for surgical hemostasis. The balloon was completely inflated to facilitate exposure to the site of hemorrhage in this patient with a high risk for neurologic injury during this operative re-exploration.

The Rapid Implementation of Ad Hoc Tele-Critical Care Respiratory Therapy (eRT) Service in the Wake of the COVID-19 Surge

A 24/7 telemedicine respiratory therapist (eRT) service was set up as part of the established University of Pennsylvania teleICU (PENN E-LERT^®) service during the COVID-19 pandemic, serving five hospitals and 320 critical care beds to deliver effective remote care in lieu of a unit-based RT. The eRT interventions were components of an evidence-based care bundle and included ventilator liberation protocols, low tidal volume protocols, tube patency, and an extubation checklist. In addition, the proactive rounding of patients, including ventilator checks, was included. A standardized data collection sheet was used to facilitate the review of medical records, direct audio–visual inspection, or direct interactions with staff. In May 2020, a total of 1548 interventions took place, 93.86% of which were coded as “routine” based on established workflows, 4.71% as “urgent”, 0.26% “emergent”, and 1.17% were missing descriptors. Based on the number of coded interventions, we tracked the number of COVID-19 patients in the system. The average intervention took 6.1 ± 3.79 min. In 16% of all the interactions, no communication with the bedside team took place. The eRT connected with the in-house respiratory therapist (RT) in 66.6% of all the interventions, followed by house staff (9.8%), advanced practice providers (APP; 2.8%), and RN (2.6%). Most of the interaction took place over the telephone (88%), secure text message (16%), or audio-video telemedicine ICU platform (1.7%). A total of 5115 minutes were spent on tasks that a bedside clinician would have otherwise executed, reducing their exposure to COVID-19. The eRT service was instrumental in several emergent and urgent critical interventions. This study shows that an eRT service can support the bedside RT providers, effectively monitor best practice bundles, and carry out patient–ventilator assessments. It was effective in certain emergent situations and reduced the exposure of RTs to COVID-19. We plan to continue the service as part of an integrated RT service and hope to provide a framework for developing similar services in other facilities.

Characteristics, Outcomes, and Trends of Patients With COVID-19-Related Critical Illness at a Learning Health System in the United States

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic continues to surge in the United States and globally.

OBJECTIVE

To describe the epidemiology of COVID-19-related critical illness, including trends in outcomes and care delivery.

DESIGN

Single-health system, multihospital retrospective cohort study.

SETTING

5 hospitals within the University of Pennsylvania Health System.

PATIENTS

Adults with COVID-19-related critical illness who were admitted to an intensive care unit (ICU) with acute respiratory failure or shock during the initial surge of the pandemic.

MEASUREMENTS

The primary exposure for outcomes and care delivery trend analyses was longitudinal time during the pandemic. The primary outcome was all-cause 28-day in-hospital mortality. Secondary outcomes were all-cause death at any time, receipt of mechanical ventilation (MV), and readmissions.

RESULTS

Among 468 patients with COVID-19-related critical illness, 319 (68.2%) were treated with MV and 121 (25.9%) with vasopressors. Outcomes were notable for an all-cause 28-day in-hospital mortality rate of 29.9%, a median ICU stay of 8 days (interquartile range [IQR], 3 to 17 days), a median hospital stay of 13 days (IQR, 7 to 25 days), and an all-cause 30-day readmission rate (among nonhospice survivors) of 10.8%. Mortality decreased over time, from 43.5% (95% CI, 31.3% to 53.8%) to 19.2% (CI, 11.6% to 26.7%) between the first and last 15-day periods in the core adjusted model, whereas patient acuity and other factors did not change.

LIMITATIONS

Single-health system study; use of, or highly dynamic trends in, other clinical interventions were not evaluated, nor were complications.

CONCLUSION

Among patients with COVID-19-related critical illness admitted to ICUs of a learning health system in the United States, mortality seemed to decrease over time despite stable patient characteristics. Further studies are necessary to confirm this result and to investigate causal mechanisms.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality.

Crop-to-weed introgression has impacted allelic composition of johnsongrass populations with and without recent exposure to cultivated sorghum

Sorghum halepense L. (johnsongrass) is one of the world's most noxious weeds, and a paradigm for the potential dangers of crop-weed hybridization. Introduced into the southeastern United States about 200 years ago, S. halepense is a close relative of cultivated sorghum (Sorghum bicolor). Both artificial crossing and experimental field studies have demonstrated the potential for S. halepensex S. bicolor hybrid formation, but no prior study has addressed the long-term persistence of sorghum genes in johnsongrass populations. We surveyed 283 loci (on all 10 sorghum linkage groups) to identify 77 alleles at 69 loci that are found in US sorghum cultivars but are absent from a worldwide sampling of johnsongrass genotypes. These putatively cultivar-specific alleles were present in up to 32.3% of individuals in johnsongrass populations adjacent to long-term sorghum production fields in Texas and Nebraska. Lower frequencies of cultivar-specific alleles at smaller numbers of loci are found in johnsongrass populations from New Jersey and Georgia with no recent exposure to cultivated sorghum, suggesting that introgressed sorghum alleles may be dispersed across long distances. The number of cultivar-specific alleles and extensive multilocus patterns of cultivar-specific allelic composition observed at both linked and unlinked loci in the johnsongrass populations, are inconsistent with alternatives to introgression such as convergence, or joint retention of ancestral polymorphisms. Naturalized johnsongrass populations appear to provide a conduit by which transgenes from sorghum could become widely disseminated.

Heterologous expression of cry2 gene from a local strain of Bacillus thuringiensis isolated in Nigeria

A cry2 gene encoding a larvicidal crystal protein was isolated from a strain of Bacillus thuringiensis found in soil samples in Nigeria. This gene was cloned into plasmid pUC19 and subcloned into both pBluescript (sk(+/-)) and pPICZ alpha B placed under a T7/AOXI (alcohol oxidase I) promoter respectively and transformed into Escherichia coli and Pichia pastoris. Clones were induced for expression, and the cellular proteins extracted and analysed by SDS/PAGE. Integration of an insert into the yeast chromosome was confirmed by PCR amplification using AOXI primers designed to monitor the intactness of the insertion into the chromosome. The expression cassettes constructed were both expressed in E. coli strain (XL1-blue) and P. pastoris (SMD1168) respectively. An approximately 70 kDa recombinant toxin was obtained both in P. pastoris and E. coli in different quantities. Expression was confirmed by Northern-blot analysis of 2.0 kb transcripts, obtained from clones induced for RNA transcripts, which hybridized with a [(32)P]dCTP-labelled probe prepared from a 641 bp fragment of restriction-endonuclease- Hae II-digested PCR product of the cry2 gene.

The impact of osteoporosis on quality-of-life: the OFELY cohort

Although the long-term outcomes of osteoporosis (Op) such as fracture, kyphosis, and pain are well known, the physical, psychological, and social consequences, beyond fracture and pain, are less clear. The Osteoporosis-targeted Quality-of-life (OPTQoL) questionnaire aimed at assessing the physical difficulty, fears, and adaptations to one's daily life was developed as a cross-sectional instrument to characterize the burden of Op within a community. The purpose of this study was to assess the impact of Op and related factors on community women participating in the OFELY study in France. Femoral neck bone mineral density (BMD) and OPTQoL questionnaire data were collected from women randomly selected from a large insurance company. Data were obtained for 756 women (mean age 59 years, range 36-92), most of whom were white. Women were classified into five groups based on the extent of physical manifestations and family history of Op. Women who had prior fractures, height loss, and/or kyphosis or both reported greater physical difficulty, more adaptations to their lives, and greater fears than women reporting no such changes. Scores on the Physical Difficulty domain, however, did not differ significantly based on BMD alone (BMD T score <or=2.5), after controlling for age and self-reported arthritis. The negative impact of Op on quality-of-life (QoL) seems to be more related to the physical manifestations of Op than to bone density levels. Recognition of the impact of Op-related factors on QoL may help health-care providers more fully appreciate the importance of prevention and treatment.

Low bone mineral density and risk of fracture in white female nursing home residents

CONTEXT

Low bone mineral density (BMD) is a strong risk factor for fracture in community-dwelling white women, but the relationship in white female nursing home residents, for whom fracture rates are highest, is less clear.

OBJECTIVE

To assess the relative contribution of low BMD to fracture risk in nursing home residents.

DESIGN

Prospective cohort study with baseline data collected April 1995 to June 1997, with 18 months of follow-up.

SETTING

Forty-seven randomly selected nursing homes in Maryland.

PATIENTS

A total of 1427 white female nursing home residents aged 65 years or older.

MAIN OUTCOME MEASURE

Documented osteoporotic fracture occurring during follow-up as a function of baseline BMD measurements higher vs lower than the median, and after controlling for demographic, functional, cognitive, psychosocial, and medical factors.

RESULTS

A total of 223 osteoporotic fractures occurred among 180 women. Low BMD and transfer independence were significant independent risk factors for fracture in this nursing home sample (P<.001) and the 2 factors acted synergistically (P =.06) to further increase fracture risk. Compared with women whose BMD was higher than the median (0. 296 g/cm(2)), those whose BMD was lower than the median had an unadjusted hazard ratio for risk of fracture of 2.1 (95% confidence interval [CI], 1.5-2.8); women who were independent in transfer had a hazard ratio of 1.6 (95% CI, 1.2-2.2) compared with women dependent in transfer. Among residents independent in transfer, those with BMD below the median had a more than 3-fold increase in fracture risk compared with those with higher BMD (unadjusted hazard ratio, 3.1; 95% CI, 2.2-4.4). Among residents dependent in transfer, those with BMD below the median had a 60% increase in fracture risk (unadjusted hazard ratio, 1.6; 95% CI, 1.1-2.3). Adjustment for covariates did not alter the BMD-fracture relationship.

CONCLUSIONS

Our data indicate that low BMD and independence in transfer are significant predictors of osteoporotic fracture in white female nursing home residents. JAMA. 2000;284:972-977

Spinal-flexibility-plus-aerobic versus aerobic-only training: effect of a randomized clinical trial on function in at-risk older adults

BACKGROUND

As exercise is associated with favorable health outcomes, impaired older adults may benefit from specialized exercise interventions to achieve gains in function. The purpose of this study was to determine the added benefit of a spinal flexibility-plus-aerobic exercise intervention versus aerobic-only exercise on function among community-dwelling elders.

METHODS

We employed a randomized clinical trial consisting of 3 months of supervised exercise followed by 6 months of home-based exercise with telephone follow-up. A total of 210 impaired males and females over age 64 enrolled in this study. Of these, 134 were randomly assigned to either spinal flexibility-plus-aerobic exercise or aerobic-only exercise, with 116 individuals completing the study. Primary outcomes obtained at baseline, after 3 months of supervised exercise, and after 6 months of home-based exercise included: axial rotation, maximal oxygen uptake (VO2max); functional reach, timed-bed-mobility; and the Physical Function Scale (PhysFunction) of the Medical Outcomes Study SF-36.

RESULTS

Differences between the two interventions were minimal. Overall change scores for both groups combined indicated significant improvement for: axial rotation (p=.001), VO2max (p=.0001), and PhysFunction (p=.0016). Secondary improvements were noted for overall health (p=.0025) and reduced symptoms (p=.0008). Differences between groups were significant only for VO2max (p=.0014) at 3 months with the aerobic-only group improving twice as much in aerobic capacity as the spinal flexibility-plus-aerobic group. Repeated measures indicated both groups improved during the supervised portion of the intervention but tended to return toward baseline following the home-based portion of the trial.

CONCLUSIONS

Gains in physical functioning and perceived overall health are obtained with moderate aerobic exercise. No differential improvements were noted for the spinal flexibility-plus-aerobic intervention.

Measurement of distal forearm bone mineral density: can different forearm segments be used interchangeably ?

Many different forearm sites have been used for the measurement of bone mineral density (BMD) and prediction of risk of future fracture among community dwelling populations. In populations where bone densitometry of peripheral sites may be the most cost effective and practical means of measuring BMD, such as the nursing home population, knowing the characteristics of forearm BMD measures would be beneficial. The purpose of this study was to assess the relationship of four common commercially available measures to each other and to estimate the inter- and intrarater reliability of the measures in a sample of nursing home residents as a first step toward identifying appropriate forearm measurement sites. These sites were the distal radius, the distal ulna, a composite of the distal radius and distal ulna, and the ultra distal radius. BMD measurements on 48 nursing home patients were obtained using single X-ray absorptiometry. Inter- and intrarater reliability was excellent at all four sites (interclass correlation coefficients > 0. 85). Moderate to high correlations (0.84-0.91) between the distal radius and ultra distal radius sites of the forearm suggest that these measures may be interchangeable. Although not directly assessed here, differences in bone composition among forearm sites may partially explain moderate rather than high correlations between sites and may affect the ability of each site to predict future fractures. Thus, different forearm sites may be used interchangeably for diagnostic purposes; however, the prognostic value of each site remains unknown.

Different subcellular distribution of caspase-3 and caspase-7 following Fas-induced apoptosis in mouse liver

Caspases plays a key role in the execution phase of apoptosis. "Initiator" caspases, such as caspase-8, activate "effector" caspases, such as caspase-3 and -7, which subsequently cleave cellular substrates thereby precipitating the dramatic morphological changes of apoptosis. Following treatment of mice with an agonistic anti-Fas antibody to induce massive hepatocyte apoptosis, we now demonstrate a distinct subcellular localization of the effector caspases-3 and -7. Active caspase-3 is confined primarily to the cytosol, whereas active caspase-7 is associated almost exclusively with the mitochondrial and microsomal fractions. These data suggest that caspases-3 and -7 exert their primary functions in different cellular compartments and offer a possible explanation of the presence of caspase homologs with overlapping substrate specificities. Translocation and activation of caspase-7 to the endoplasmic reticulum correlates with the proteolytic cleavage of the endoplasmic reticular-specific substrate, sterol regulatory element-binding protein 1. Liver damage, induction of apoptosis, activation and translocation of caspase-7, and proteolysis of sterol regulatory element-binding protein 1 are all blocked by the caspase inhibitor, benzyloxycarbonyl-Val-Ala-Asp fluoromethyl ketone (Z-VAD. fmk). Our data demonstrate for the first time the differential subcellular compartmentalization of specific effector caspases following the induction of apoptosis in vivo.

Is lower extremity strength gain associated with improvement in physical performance and disability in frail, community-dwelling elders?

BACKGROUND

Strength loss is strongly associated with functional decline and is reversible with exercise. The effect of increased strength on function has not been clearly established. The purpose of this study was to determine whether strength gain is associated with improvement in physical performance and disability.

METHODS

One hundred functionally impaired community-dwelling men and women (77.6 +/- 7.6 yrs) were tested at baseline and outcome for lower extremity strength, physical performance, and disability. After random group assignment, exercise participants received strengthening exercises in their homes three times a week for 10 weeks while control subjects continued their normal activities. Using multiple regression techniques, the relationship between strength gain and improvement in physical performance and disability was assessed, controlling for age, depression, and baseline strength.

RESULTS

A significant impact of strength gain on mobility skills (p = .0009) was found. The impact of strength gain on chair rise performance was significant in participants who were more impaired (p = .04). Strength gain was associated with gain in gait speed (p = .02) and in falls efficacy (p = .05), but not with other balance, endurance, or disability measures.

CONCLUSIONS

Lower extremity strength gain is associated with gains in chair rise performance, gait speed, and in mobility tasks such as gait, transfers, stooping, and stair climbing, but not with improved endurance, balance, or disability. Strength gain is also associated with improvement in confidence in mobility. Factors that may influence the ability of strength gain to affect function are initial level of frailty and specificity of exercise. These results support the idea that strength training is an intervention that can potentially improve physical health status in many frail elders.

Reliability of an Osteoporosis-Targeted Quality of Life Survey Instrument for use in the community: OPTQoL

A brief Osteoporosis-Targeted Quality of Life (OPTQoL) questionnaire was previously developed as a cross-sectional survey instrument to assess the community impact of osteoporosis on quality of life in women. The initial development process involving item generation through focus groups, item reduction, and content and construct validation yielded a 36-item questionnaire with three domains (physical difficulty, adaptations and fears) and 10 health-related questions. In the present study, test-retest reliability and internal consistency of the questionnaire were assessed in a mail-based study with two clinical sites. Two hundred women (50 with severe osteoporosis, 50 with osteopenia, 50 with normal bone mineral density (BMD) and 50 with osteoarthritis and normal BMD), aged 43-84 years, completed the self-administered questionnaire initially and again about 2 weeks later. Using weighted kappas, agreement between questionnaire administrations ranged from 0.60 to 0.80 for most of the individual items. Intraclass correlation coefficients to assess reliability for the domain scores were 0.93 (physical difficulty), 0.82 (adaptations) and 0.88 (fears). Internal consistency of each of the domains was also high, with Cronbach's alpha coefficients ranging from 0.89 to 0.91. Four items were dropped from the 36-item questionnaire due to high percentage of 'not applicable' responses. Results of the analyses support the validity and reliability of this instrument as a cross-sectional survey tool for assessing the impact of osteoporosis on quality of life in women living in the community. The questionnaire has been translated and culturally adapted into seven languages to allow cross-cultural studies of the community impact of osteoporosis.

Activation of CPP32 and Mch3 alpha in wild-type p53-induced apoptosis

DNA-damaging agents induce apoptosis primarily by a p53-dependent pathway. LTR6 cells containing a temperature-sensitive p53 were used to dissect further the mechanisms of p53-induced apoptosis. Apoptosis was accompanied by the processing and activation of CPP32 and Mch3 alpha, together with the cleavage of poly(ADP-ribose) polymerase and lamin B1. These results demonstrate a critical role for the activation of interleukin-1 beta-converting enzyme-like proteases in p53-induced apoptosis.

Exercise to improve physiologic and functional performance in old age

The purpose of this article is to evaluate the impact of exercise in elderly men and women. The type and intensity of exercise, the health status of the participants, and the outcomes measured vary widely across studies. In general, studies of exercise interventions in older adults show positive physiologic effects in persons of all ages. Musculoskeletal and cardiovascular systems, regardless of age, can respond to both resistance and aerobic training as measured by impairments such as strength and maximum oxygen uptake. The magnitude of physiologic effect may be dampened in frailer individuals in response to lower intensity exercise stimuli. In the most impaired elders, exercise may help to forestall further decline in physiologic reserve rather than produce significant gains. The extent to which exercise programs impact performance and disability is less clear. Exercise programs in frailer individuals appear to have greater effect on gait speed and chair rise time than similar programs in healthier individuals. The impact of exercise on measures of disability has not been widely reported. Studies reviewed in this article suggest that exercise training in elders is a potential means of reducing the burden of impairments and ultimately improving function.

The relationship of postural sway to sensorimotor function, functional performance, and disability in the elderly

OBJECTIVE

To examine the relationship of postural sway to sensorimotor impairment, functional performance, and self-reported disability.

DESIGN

Cross-sectional cohort.

SETTING

Department of Veterans' Affairs Medical Center.

PATIENTS

One hundred community-dwelling elderly unable to climb stairs step over step.

MAIN OUTCOME MEASURES

Postural sway (area of ellipse and path length, eyes open and closed), sensorimotor (strength, sensation, range of motion, central processing time), functional performance (functional reach, timed gait, mobility skills, endurance), and disability (MOS-SF36, Falls Efficacy Scale [FES]).

RESULTS

Postural sway area measures correlated with sensorimotor measures: (1) During eyes-closed conditions, increased sway occurs in individuals with sensory deficits (p < .05); (2) Sway was positively correlated with tibialis anterior latency (p < .05); (3) Sway area measures increased with increased strength (p < .05). The sway/strength relationship may be explained by week subjects improving their stability by limiting rather than increasing sway. Sway was not significantly correlated with any measures of physical performance. Sway was correlated with some measures of disability: (1) Eyes-closed measures of postural sway were correlated with FES scores (p < .05); (2) Sway was not correlated with the MOS-36 physical functioning question. When controlling for functional measures, eyes-closed measures of sway significantly predicted FES scores (p < .03).

CONCLUSIONS

Measures of postural sway are more likely capturing sensorimotor deficits rather than differentiating functional performance abilities, and the relationship between postural sway and self-reported disability is inconsistent.

Postural responses to platform perturbation: kinematics and electromyography

Dynamic postural control may be studied using feedback paradigms which disturb standing balance. In this study the kinematics and electromyography of the reaction to an unexpected slip were examined simultaneously in 16 young, healthy volunteers to characterize the response to postural perturbation in the context of the perturbation characteristics. Kinematically, results showed ankle plantarflexion, knee flexion, hip extension, and shoulder flexion. Electromyographically, sequences of activation of the postural muscles of the leg were primarily anterior distal. Data is presented that supports a new model of the reaction to perturbation which incorporates the timing and type of muscular activity, the type of motion (active or passive), and the perturbation characteristics. RELEVANCE--:Understanding the interplay of the neurophysiological and biomechanical aspects of dynamic postural control gives insight into balance reactions. Simultaneous consideration of the kinematics, muscle activation, and perturbation characteristics allows a more comprehensive view of recovery of balance.

Balance performance on the postural stress test: comparison of young adults, healthy elderly, and fallers

The purpose of this study was to compare the postural responses of three groups of individuals--healthy young adults (n = 42; age, 20-40 years); healthy, community-dwelling, elderly individuals (n = 66; age, 60-102 years), and elderly individuals with a history of frequent falls (n = 10; age, 66-95 years)--using the postural stress test (PST). The PST is a simple, clinically applicable, quantitative measure of an individual's ability to withstand a series of graded destabilizing forces applied at the level of the subject's waist. Elderly fallers tend to score lower on the PST than elderly nonfallers, but age-related differences in postural responses during the PST have not been established. Each subject underwent the PST using a method and scoring procedure described previously. Results of this study confirm previous findings that elderly fallers score significantly lower on the PST than either young adult or nonfalling elderly individuals. This study also showed that there was no difference in balance strategy scores between the young adults and the healthy elderly subjects. Therefore, it appears that poor performance on the PST cannot be attributed to age alone, but may be predictive of pathological processes that predispose an individual to frequent falls.

The effects of methadone on maternal-fetal interactions in the rat

Female Sprague-Dawley rats received methadone (25 mg/kg/day) by gavage throughout gestation. Water-gavaged rats served as controls. Fetuses were delivered by cesarean section when parturition was imminent. Our results indicate that methadone may interfere with fetal development and maternal-fetal interactions to some degree. The observed alterations were as follows: fetal growth retardation, an interference with the triggering of parturition once normal delivery size is attained and possible positional malformations.