Managing "socially admitted" patients in hospital: a qualitative study of health care providers' perceptions

BACKGROUND

Emergency departments are a last resort for some socially vulnerable patients without an acute medical illness (colloquially known as "socially admitted" patients), resulting in their occupation of hospital beds typically designated for patients requiring acute medical care. In this study, we aimed to explore the perceptions of health care providers regarding patients admitted as "social admissions."

METHODS

This qualitative study was informed by grounded theory and involved semistructured interviews at a Nova Scotia tertiary care centre. From October 2022 to July 2023, we interviewed eligible participants, including any health care clinician or administrator who worked directly with "socially admitted" patients. Virtual or in-person individual interviews were audio-recorded and transcribed, then independently and iteratively coded. We mapped themes on the 5 domains of the Quintuple Aim conceptual framework.

RESULTS

We interviewed 20 nurses, physicians, administrators, and social workers. Most identified as female (n = 11) and White (n = 13), and were in their mid to late career (n = 13). We categorized 9 themes into 5 domains: patient experience (patient description, provision of care); care team well-being (moral distress, hierarchy of care); health equity (stigma and missed opportunities, prejudices); cost of care (wait-lists and scarcity of alternatives); and population health (factors leading to vulnerability, system changes). Participants described experiences caring for "socially admitted" patients, perceptions and assumptions underlying "social" presentations, system barriers to care delivery, and suggestions of potential solutions.

INTERPRETATION

Health care providers viewed "socially admitted" patients as needing enhanced care but identified individual, institutional, and system challenges that impeded its realization. Examining perceptions of the people who care for "socially admitted" patients offers insights to guide clinicians and policy-makers in caring for socially vulnerable patients.

A Case of Persistent Junctional Reciprocating Tachycardia Coincident With Cor Triatriatum Sinister

Persistent junctional reciprocating tachycardia is a rare form of refractory atrioventricular reentrant tachycardia that accounts for <1% of supraventricular tachycardia in pediatrics. The accessory pathways are generally isolated with few reported underlying structural heart defects. We present a case of a five-month-old male with refractory tachyarrhythmia found to have cor triatriatum sinister, which to our knowledge, is the first reported case of these two rare anomalies coexisting.

Osteoblastoma of the frontal sinus: A rare case presenting with seizures and pneumocephalus

Key Clinical Message

Osteoblastoma of the frontal sinus, although rare, can manifest with seizures and pneumocephalus, underscoring the importance of thorough evaluation and complete surgical excision to prevent serious complications and ensure optimal patient outcomes.

Abstract

Osteoblastoma is an infrequent bone tumor, with origins typically in the vertebrae and long bones. While craniofacial involvement is rare, it may occur in regions such as the paranasal sinuses. We present a case of osteoblastoma located in the frontal sinus, an exceptionally uncommon site, resulting in seizures secondary to pneumocephalus. A 21-year-old male presented with a generalized tonic-clonic seizure and postictal confusion. Imaging studies revealed a well-defined lesion in the left frontal sinus causing cortical breach, destruction of the posterior wall, and pneumocephalus. A total surgical excision was performed through bifrontal craniotomy. Histopathological analysis confirmed the diagnosis of osteoblastoma. Postoperative recovery was uneventful, with a follow-up CT scan showing complete lesion excision. Osteoblastomas, especially in the cranial sinuses, are rare entities that may present asymptomatically but can lead to severe complications. The risk of recurrence underscores the importance of complete surgical resection for optimal patient outcomes.

Right Atrial Enlargement on Electrocardiogram in Previously Healthy Young Patients

OBJECTIVES

To assess whether right atrial enlargement (RAE) on electrocardiogram (ECG) correlates with true RAE on echocardiogram in previously healthy young patients and to understand which patients with RAE on ECG may warrant additional testing.

STUDY DESIGN

A single-center, retrospective review of previously healthy young patients with (1) ECGs that were read as RAE by a pediatric cardiologist and (2) echocardiograms obtained within 90 days of the ECG. ECGs were reviewed to confirm RAE and determine which leads met criteria. The echocardiograms were then reviewed and RA measurements with z scores obtained. A z score >2 was considered positive for RAE on echocardiogram.

RESULTS

In total, 162 patients with median age 10.8 years were included in the study. A total of 23 patients had true RAE on echocardiogram, giving a positive predictive value (PPV) of 14%. In patients <1 year of age, the PPV increased to 35%. In patients older than 1 year, the PPV was low at 7%. Patients with true RAE were more likely to meet criteria for RAE in the anterior precordial leads (V1-V3) (48% vs 5%, P < .001) and meet criteria for right ventricular hypertrophy (22% vs 6%, P = .023).

CONCLUSION

Our findings show that RAE on ECG has a low PPV for RAE on echocardiogram in previously healthy young patients. The highest yield for RAE on echocardiogram was observed in patients who were <1 year of age, had RAE in the anterior precordial leads, or displayed right ventricular hypertrophy on ECG.

Communication and Social Determinants of Cancer Preventive Behaviors in Adolescents From Low Socio-Economic Backgrounds in India: A Cross-Sectional Study

PURPOSE

Promoting cancer preventive behaviors among adolescents, especially those from lower socioeconomic backgrounds, is crucial due to the significant impact of health behaviors in adolescence on disease risk in adulthood. With India witnessing a rise in cancer incidence and mortality, adolescence becomes a pivotal stage for establishing healthy habits, emphasizing the need for early cancer prevention efforts.

METHODS

This cross-sectional study used survey data from 2242 adolescents attending public schools of Mumbai, India. Multiple logistic regression was conducted to determine the associations between cancer preventive behaviors and: (1) the individual and social determinants of health, and (2) media exposure.

FINDINGS

Merely 21.5% of the adolescents ate fruits and vegetables daily, 50% of the adolescents exercised 3 or more times a week, and 20% of the adolescents admitted having used tobacco and/or supari. Girls were found to have lower odds of exercising, as well as using tobacco and/or supari. Wealth and father's education were positively associated with all 3 cancer preventive behaviors. Media exposure was negatively associated, with television exposure linked to reduced fruits and vegetables consumption, while movies and social media exposure were associated with increased tobacco and/or supari use.

INTERPRETATION

Our findings suggest that individual and social determinants of health and media exposure can influence cancer preventive health behaviors in low socio-economic status (SES) adolescents. Efforts to increase awareness to promote cancer preventive behaviors among the adolescents, particularly low SES adolescents, a population more vulnerable to poor health outcomes, is critical.

Identifying predictors of cognitive decline in long-term care: a scoping review

BACKGROUND

Cognitive impairment can cause social, emotional, and financial burdens on individuals, caregivers, and healthcare providers. This is especially important in settings such as long-term care (LTC) homes which largely consist of vulnerable older adults. Thus, the objective of this study is to review and summarize current research examining risk factors of cognitive decline in older adults within LTC.

METHODS

This scoping review includes primary observational research studies assessing within-person change in cognition over time in LTC or equivalent settings in high resource countries. A mean participant age of ≥ 65 years was required. Searches were conducted in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PyscInfo on June 27th, 2022 and included articles published during or after the year 2000. Title, abstract, and full-text screening was performed by two independent reviewers using Covidence. Specific predictors along with their associated relation with cognitive decline were extracted by a team of reviewers into a spreadsheet.

RESULTS

Thirty-eight studies were included in this review. The mean sample size was 14 620. Eighty-seven unique predictors were examined in relation to cognitive decline. Dementia was the most studied predictor (examined by 9 of 38 studies), and the most conclusive, with eight of those studies identifying it as a risk factor for cognitive decline. Other predictors that were identified as risk factors included arterial stiffness (identified by 2 of 2 studies), physical frailty (2 of 2 studies), sub-syndromal delirium (2 of 2 studies), and undergoing the first wave of COVID-19 lockdowns (2 of 2 studies). ADL independence was the most conclusive protective factor (3 of 4 studies), followed by social engagement (2 of 3 studies). Many remaining predictors showed no association and/or conflicting results.

CONCLUSIONS

Dementia was the most common risk factor, while ADL independence was the most common protective factor associated with cognitive decline in LTC residents. This information can be used to stratify residents by risk severity and provide better personalized care for older adults through the targeted management of cognitive decline.

Access to legal cannabis market in Canada over the four years following non-medical cannabis legalisation

INTRODUCTION

An increasing number of countries are inthe process of legalising non-medical cannabis. We described how the legal market has changed over the first 4 years following legalisation in Canada.

METHODS

We collected longitudinal data on operating status and location of all legal cannabis stores in Canada for the first 4 years following legalisation. We examined per capita stores and sales, store closures, and the drive time between stores and each neighbourhood in Canada. We compared measures between public and private retail systems.

RESULTS

Four years after legalisation, there were 3305 cannabis stores open in Canada (10.6 stores per 100,000 individuals aged 15+ years). Canadians spent $11.85CAD a month on cannabis per individual aged 15+ years, and 59% of neighbourhoods were within a 5-minute drive of a cannabis store. Over 4 years, per capita stores and per capita sales increased each year by an average of 122.3% and 91.7%, respectively, with larger increases in private versus public systems (4.01 times greater for per capita stores and 2.46 times greater for per capita sales). The annual increase in per capita stores and sales during the first 3 years was 6.0 and 15.5 times greater, respectively, than the increase in the fourth year following legalisation. Over 4 years, 7% of retail store locations permanently closed.

DISCUSSION AND CONCLUSION

The legal cannabis market in Canada expanded enormously over the first 4 years following legalisation, with considerable variation in access between jurisdictions. The rapid retail expansion has implications for evaluation of health impacts of non-medical legalisation.

The Use of Automated Atrial CMR Measures and a Novel Atrioventricular Coupling Index for Predicting Risk in Repaired Tetralogy of Fallot

Atrial size and function have been recognized as markers of diastolic function, and diastolic dysfunction has been identified as a predictor of adverse outcomes in repaired tetralogy of Fallot (rTOF). This was a retrospective single-center study with the objective of investigating the use of atrial measurements obtained via CMR for predicting outcomes in rTOF patients. Automated contours of the left and right atria (LA and RA) were performed. A novel parameter, termed the Right Atrioventricular Coupling Index (RACI), was defined as the ratio of RA end-diastolic volume to right ventricle (RV) end-diastolic volume. Patients were risk-stratified using a previously validated Importance Factor Score for the prediction of life-threatening arrhythmias in rTOF. Patients with a high-risk Importance Factor Score (>2) had a significantly larger minimum RA volume (p = 0.04) and RACI (p = 0.03) compared to those with scores ≤2. ROC analysis demonstrated RACI to be the best overall predictor of a high-risk Importance Factor Score (AUC 0.73, p = 0.03). Older age at the time of repair and a diagnosis of pulmonary atresia were associated with a larger RACI. Automated atrial CMR measurements are easily obtained from standard CMRs and have the potential to serve as noninvasive predictors of adverse outcomes in rTOF.

Lyme carditis presenting as paroxysmal junctional tachycardia and complete atrioventricular block in an adolescent

We describe a case of a previously healthy adolescent who presented with junctional tachycardia and complete atrioventricular (AV) block due to Lyme carditis. The simultaneous presence of these findings suggested significant inflammation of the AV junction. Junctional tachycardia, particularly if seen in a patient with conduction abnormalities and potential tick exposure, should increase suspicion for Lyme carditis.

Electrocardiogram changes in pediatric patients with myocarditis

BACKGROUND

It is traditionally taught that pediatric patients with myocarditis almost always have an abnormal electrocardiogram (ECG) at presentation. However, there has never been a study to objectively evaluate ECG changes in pediatric myocarditis patients compared to healthy controls or explore if specific ECG changes correlate with clinical outcomes.

METHODS

Pediatric patients diagnosed with acute myocarditis were age and sex matched 1:2 with healthy controls in this retrospective case-control study spanning a seven-year period. ECGs from presentation through discharge were interpreted by electrophysiologists blinded to the patients' diagnoses.

RESULTS

Thirty-nine patients with myocarditis were identified. Twenty-eight (72%) had an abnormal ECG at presentation, 11 (28%) had a completely normal ECG. In this second group, six patients had an abnormal ECG at some point during their hospital course for a total of 34 (88%). Myocarditis patients who had an abnormal ECG at presentation spent more time in the hospital, 5 (2-19) versus 2 ((1-3) days (p < 0.01), and in the ICU, 1 (0-6) versus 0 (0-1) days (p < 0.01). Myocarditis patients were more likely to have ST elevation on their ECG compared to control patients (41% versus 17%, p < 0.01). Patients with ST elevation at presentation had a higher peak troponin level, 18.4 (5.8-31.0) versus 7.7 (0-19.1) ng/ml, (p < 0.01).

CONCLUSIONS

Over a quarter of patients with myocarditis had a normal ECG at presentation to the emergency department. Patients with an abnormal ECG at presentation spent more time in the hospital. The presenting ECG, particularly the presence of ST elevation, may correlate with other clinical markers and help direct early management decisions.

Adverse events and Breakthrough infections associated with COVID-19 vaccination in the Indian population

Vaccines against COVID‐19 provide immunity to deter severe morbidities associated with the infection. However, it does not prevent infection altogether in all exposed individuals. Furthermore, emerging variants of SARS‐CoV‐2 impose a threat concerning the competency of the vaccines in combating the infection. This study aims to determine the variability in adverse events and the extent of breakthrough infections in the Indian population. A retrospective study was conducted using a pre‐validated questionnaire encompassing social, demographic, general health, the status of SARS‐CoV‐2 infection, vaccination, associated adverse events, and breakthrough infections in the Indian population. Informed consent and ethical approval were obtained as per Indian Council of Medical Research (ICMR) guidelines. Participants, who provided the complete information, were Indian citizens, above 18 years, and if vaccinated, administered with either Covishield or Covaxin, were considered for the study. Data have been compiled in Microsoft Excel and analyzed for statistical differences using STATA 11. The responses from 2051 individuals fulfilling the inclusion criteria were analyzed. Among 2051, 1119 respondents were vaccinated and 932 respondents were non‐vaccinated. Among 1119 vaccinated respondents, 7 were excluded because of missing data. Therefore, out of 1112 vaccinated, 413 experienced adverse events with a major fraction of younger individuals, age 18–40 years, getting affected (74.82%; 309/413). Furthermore, considerably more females than males encountered adverse consequences to vaccination (p < 0.05). Among vaccinated participants, breakthrough infections were observed in 7.91% (88/1112; 57.96% males and 42.04% females) with the older age group, 61 years and above (odds ratio, 3.25 [1.32–8.03]; p = 0.011), and males were found to be at higher risk. Further research is needed to find the age and sex‐related factors in determining vaccine effectiveness and adverse events.

Significant higher adverse events following COVID‐19 vaccination in females in comparison to males.

Breakthrough infections among Indian population was found to be 7.91%.

Older people and males were found to be at high risk for getting breakthrough infections.

Extreme rainfall deficits were not the cause of recurring colonial era famines of southern Indian semi-arid regions

Using information contained in the eighteenth to twentieth century British administrative documents, preserved in the National Archives of India (NAI), we present a 218-year (1729–1947 AD) record of socioeconomic disruptions and human impacts (famines) associated with ‘rain failures’ that affected the semi-arid regions (SARs) of southern India. By mapping the southern Indian famine record onto long-term spatiotemporal measures of regional rainfall variability, we demonstrate that the SARs of southern India repeatedly experienced famines when annual rainfall reduced by ~ one standard deviation (1 SD), or more, from long-term averages. In other words, ‘rain failures’ listed in the colonial documents as causes of extreme socioeconomic disruptions, food shortages and human distress (famines) in the southern Indian SARs were fluctuations in precipitation well within the normal range of regional rainfall variability and not extreme rainfall deficits (≥ 3 SD). Our study demonstrates that extreme climate events were not necessary conditions for extreme socioeconomic disruptions and human impacts rendered by the colonial era famines in peninsular India. Based on our findings, we suggest that climate change risk assessement should consider the potential impacts of more frequent low-level anomalies (e.g. 1 SD) in drought prone semi-arid regions.

Effect of methadone on QTc in infants

OBJECTIVE

Methadone has been associated with prolongation of the QTc interval (QTc) on electrocardiogram (ECG). In infants, the effects of methadone on the QTc are not well described. Our study's objective is to evaluate the QTc in infants being treated with methadone.

METHODS

We conducted a retrospective study in infants receiving methadone. We collected demographic data, methadone dose, and QTc. A blinded-to-disease-state pediatric electrophysiologist determined the QTc. Baseline ECG was defined as an ECG obtained while not on methadone therapy, and QTc on baseline ECG was compared with treatment QTc. A significant change was defined as any absolute QTc greater than 500 or a QTc greater than 460 with an increase from baseline of greater than 40 ms.

RESULTS

A total of 44 infants comprised the study population. The mean gestational age was 32.3 ± 5.51 weeks. The median age of initiation was 66 days. The median dose was 0.52 mg/kg/day in oral methadone equivalents. Nine patients were on high dose methadone (>1 mg/kg/day in oral methadone equivalents). The mean baseline QTc was 421 ± 27 and the mean change on methadone was -2 ms. No patient had a QTc greater than 500 on methadone. One patient had a QTc of 467 and 46 ms change from baseline, with no clinically significant impact.

CONCLUSION

In our study population, methadone did not significantly prolong the QTc. Further prospective study is warranted to determine the utility and frequency of ECGs in infants receiving methadone.

Incessant Focal Atrial Tachycardia Leading to Tachycardiomyopathy

A 22-year-old man presented with severe left ventricular (LV) dysfunction and progressive heart failure. The 12-lead electrocardiogram showed short runs of supraventricular tachycardia suggestive of focal atrial tachycardia. The patient underwent successful radiofrequency ablation. There was a complete recovery of symptoms and LV function at six months of follow-up. We discuss the importance of identifying tachycardiomyopathy as a reversible cause of heart failure.

Iron Chelation in Local Infection

Iron is an essential element in multiple biochemical pathways in humans and pathogens. As part of the innate immune response in local infection, iron availability is restricted locally in order to reduce overproduction of reactive oxygen species by the host and to attenuate bacterial growth. This physiological regulation represents the rationale for the therapeutic use of iron chelators to support induced iron deprivation and to treat infections. In this review paper we discuss the importance of iron regulation through examples of local infection and the potential of iron chelation in treating infection.

Detailed Morphometry and Morphology of Bicipital Groove of Humerus among North Indian Population

Introduction: Bicipital Groove (BG) represents an indentation on the proximal humerus which lodges tendon of Long Head of Biceps (LHB) brachii with synovial sheath. It’s medial and lateral walls are formed by lesser and greater tubercles respectively and the transverse humeral ligament converts it into a tunnel. Aim: To find a detailed morphometry attributing to morphological classification of BG among North Indian population. Materials and Methods: The present observational study was conducted over a period of one year on 100 adult intact dry humerii of unknown sexes obtained from Osteology Museum, Department of Anatomy, Shree Guru Gobind Singh Tricentenary (SGT) University, Gurugram, Haryana, India for several morphometric parameters like length, width, depth, length of medial and lateral walls as per descriptive statistics using Statistical Package for the Social Sciences (SPSS) version 21.0. The BG was classified according to the depth, opening angle and medial wall angles. Morphological features like Supratubercular Ridge (STR) of Meyer’s, bony spur on the floor of the groove or thickening of the walls were also observed and the frequency distribution was presented and Independent t-test was applied to compare the parameters on both sides. Results: Out of 100 sample, the mean of each parameter was length 72.98±7.54 mm, width 9.12±2.18.mm, depth 5.49±1.56 mm, medial wall and lateral wall length 54.83±8.62 mm and 60.82±8.01 mm respectively, opening angle 72.27±18.12º and medial angle 65.27±10.71º. Mostly BG had a depth of 4-6 mm with an incidence of 48%. Opening angle of BG was small (<95º) in 84% of humerus and maximum belonged to type 1 (90º to 75º) variety. Around 34% bones were showing morphological changes, out of which STR was 47.05%, bony spur on the floor of BG was 20.58% with wall thickening in 32.35% of total humerus. Conclusion: The detailed morphometry and classification of BG will serve as a reference base for North Indian population. It will be also useful for the clinicians as they should be well verged with the various morphological appearances of BG among dry bones and radiographs for proper diagnosis and treatment.

Comparison of Cardiopulmonary Fitness among Obese and Non Obese School Children

Introduction: Childhood obesity is now rising as a significant health problem. In India, some studies showed a rising trend in the prevalence of overweight and obesity in children. This shocking rise in childhood obesity often accounts for increased intake of high calorie foods and decreased physical activity. In addition, non communicable diseases like diabetes mellitus, cardiovascular diseases and cancer are more common in obesity. Aim: To assess the relationship between cardiopulmonary fitness and Body Mass Index (BMI) in school going adolescents between 12 to 16 years. Materials and Methods: This study was a cross-sectional observational study conducted from March 2018 to March 2019. The study included 60 healthy students (between 12 to 16 years) full sample size divided into two groups and four subgroups. After the general physical examination and history taking, participants’ selection made in line with pre-defined inclusion and exclusion criteria. Anthropometric and body composition parameters were recorded. Using the modified Harvard’s Step test, cardiopulmonary fitness parameters like Physical Fitness Index (PFI) and Maximal oxygen consumption (VO2max) of each subject were calculated by applying the concerned formulae. All statistical analysis has been done by using Statistical Package for the Social Sciences (SPSS) software version 16.0. Results: Total 60 apparently healthy students included 30 males and 30 females. Mean age was 14.93±0.96 years in Group I (normal weight boys, n=15) and 14.47±1.41 years in Group II (overweight/obese boys, n=15). Also mean age was 14.93±0.59 years in Group III (normal weight girls, n=15) and 15.27±0.59 years in Group IV (overweight/obese girls, n=15). Pearson correlation showed a significant negative correlation between BMI and PFI (r=-0.504, p-value <0.001) also between BMI and VO2max (r=-0.459, p-value <0.001). Conclusion: Appropriate measures should be taken to enhance cardiopulmonary fitness among school children who are the wealth of the country at the school and community levels.

Impact of prolotherapy in temporomandibular joint disorder: a quality of life assessment

Chronic pain and functional impairment associated with temporomandibular joint (TMJ) disorders (TMD) considerably reduce oral health-related quality of life (OHRQoL). In the present study we have assessed the influence of prolotherapy in patients with TMD by the subjective measurement of QoL using the Oral Health Impact Profile-14 (OHIP-14). Twenty-five patients diagnosed with TMD (mean (range) age 38 (18 - 70) years) were included. They had all undergone dextrose prolotherapy to the TMJ at regular time intervals (four times at intervals of two weeks) using the method suggested by Hemwall-Hackett. They were asked to answer the OHIP-14 questionnaire before and two years after prolotherapy. Seven domains of OHRQoL were rated on a 5-point Likert scale from 0 (never) to 4 (very often). Domain scores and total OHIP-14 scores were compared using inferential statistics (chi squared and Wilcoxon signed rank tests). Prolotherapy was effective over time, as all the domains' mean scores decreased considerably after treatment. The total mean score before prolotherapy was 21.20, which was extensively reduced to 13.08 after prolotherapy (p=0.001). There was statistically significant improvement in all domains, including functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap (p≤0.005 in all cases). We concluded that prolotherapy has a promising role in the improvement of OHRQoL of patients with TMD, and its beneficial effects persist at least two years after treatment.

∑3 Twin Boundaries in Gd2Ti2O7 Pyrochlore: Pathways for Oxygen Migration

Understanding the chemistry at twin boundaries (TB) is a well-recognized challenge, which could enable the capabilities to manipulate the functional properties in complex oxides. The study of this atomic imperfection becomes even more important, as the presence of twin boundaries has been widely observed in materials, regardless of the dimensionalities, due to the complexities in growth methods. In the present study, we provide atomic-scale insights into a ∑3(111̅) ⟨11̅0⟩ twin boundary present in pyrochlore-structured Gd₂Ti₂O₇ using atomic-resolution electron microscopy and atomistic modeling. The formation of the observed TB occurs along (111̅) with a 71° angle between two symmetrically arranged crystals. We observe distortions (∼3 to 5% strain) in the atomic structure at the TB with an increase in Gd-Gd (0.66 ± 0.03 nm) and Ti-Ti (0.65 ± 0.02 nm) bond lengths in the (11̅0) plane, as compared to 0.63 nm in the ordered structure. Using atomistic modeling, we further calculate the oxygen migration barrier for vacancy hopping at 48f-48f sites in the pyrochlore structure, which is the primary diffusion pathway for fast oxygen transport. The mean migration barrier is lowered by ∼25% to 0.9 eV at the TB as compared to 1.23 eV in the bulk, suggesting the ease in oxygen transport through the ∑3 twin boundaries. Overall, these results offer a critical understanding of the atomic arrangement at the twin boundaries in pyrochlores, leading to control of the interplay between defects and properties.

Anesthetic management of a patient with Sheehan's syndrome and twin pregnancy while undergoing a cesarean section

Sheehan's syndrome (SS) is caused by infarction of the pituitary gland usually precipitated by hypotension due to massive uterine hemorrhage during the peripartum period. Once SS develops, it becomes a major comorbidity for the young females and predisposes them to further medical, obstetric, and anesthetic complications. Herein, we report the perioperative anesthetic management of a 28-year-old female, already diagnosed with SS precipitated by urosepsis and septicemic shock in a previous pregnancy, now presenting with twin pregnancy for elective cesarean section. Her magnetic resonance imaging brain revealed pituitary apoplexy and she had hypothyroidism with gestational diabetes mellitus. The overall successful perioperative management of the patient is described along with an emphasis on aggressive management of hypotension due to any cause in the peripartum period to prevent infarction/necrosis of anterior pituitary gland.

Efficacy of buffered local anaesthetics in head and neck infections

Lignocaine is one of the most commonly-used agents to anaesthetise an area preoperatively. It can, however, cause undesirable effects such as burning on injection, relatively slow onset, and unreliable, or lack of, numbness when injected into infected tissues as a result of the acidic pH of commercial preparations (the pH is between 3.5 and 7.0 compared with the physiological pH, which is between 7.35 and 7.45). The aim of this comparative study was to evaluate the efficacy of buffered local anaesthetic on infected areas by altering the pH with 8.4% sodium bicarbonate, to measure the pain before and after the injection, and to record the time of onset of anaesthesia. All 60 patients were given 2% lignocaine hydrochloride with adrenaline 1:80,000 and 30 patients were randomly allocated to have 10:1 dilution of 8.4% sodium bicarbonate (study group). Pain was assessed on a visual analogue scale and a verbal rating scale. There was a significant difference in the amount of pain between control and study groups (p=0.025). The mean (SD) time (minutes) to onset of local anaesthesia in the study group was 1.06 (0.25) compared with 2.96 (0.81) in the control group (p<0.001). Our results confirm the efficacy of the buffered local anaesthetic solution in reducing pain on injection and resulting in quicker onset of anaesthesia. Increasing the pH of lignocaine solutions with bicarbonate immediately before use, therefore, should be considered when treating various acute infections of the head and neck.

Utility and safety of adenosine challenge for subtle ventricular pre-excitation in the pediatric population

INTRODUCTION

Adenosine challenge (AC) can be used to evaluate possible Wolff-Parkinson-White (WPW) pattern on an electrocardiogram (ECG). Despite the use of this technique, there is a paucity of studies in the pediatric population evaluating the efficacy, safety, and outcomes of this testing modality.

METHODS AND RESULTS

All ACs performed from January 2009 to June 2017 were retrospectively reviewed. Patient demographics, adenosine dosing, results, adverse effects, and outcomes including results of electrophysiology studies (EPS) were reviewed. Analysis was conducted between AC positive and negative cohorts. ECG criteria of shortest PR interval, longest QRS duration, and the number of suspected pre-excited leads were evaluated for inter-rater reliability and correlation to positive AC. Fifty-six AC (n = 51) were performed (median age, 13.8; range, 0.3-20 years). Forty-one AC were pre-EPS and 15 post-EPS due to concern for recurrent WPW. Thirty-one (76%) pre-EPS AC were negative, 9 (22%) positive, and 1 (2%) equivocal. EPS was performed following seven positive AC revealing 5 (71%) left posterior and 2 (29%) right posteroseptal AP. The 15 post-EPS AC were all found to be negative. Mean effective adenosine dose was 0.2 ± 0.11 mg/kg. No adverse events were reported. Mean follow up duration after AC was 314 ± 482 days with no documented arrhythmias.

CONCLUSION

Adenosine challenge is an effective and safe testing modality for subtle WPW in the pediatric population. In our population, there were no adverse events or documented arrhythmias in patients following a negative study.

Paroxysmal complete atrioventricular block in pediatric heart transplant recipients following cardiac catheterization: A case series

Late-onset paroxysmal AVB has been described as a rare complication after HT and has been associated with AR or CAV. We describe 4 pediatric HT recipients who developed paroxysmal AVB hours after routine cardiac catheterization in the absence of AR, CAV, or underlying conduction system disease. Four pediatric HT recipients who were >1 year post-transplant had episodes of paroxysmal AVB hours after surveillance cardiac catheterization with EMB. Telemetry demonstrated high-grade block, ranging from 2:1 AVB to complete AVB without ventricular escape for several seconds. None of the patients had significant AR or rapidly progressive CAV. Supplemental testing did not reveal underlying conduction system disease. Three of the 4 patients received permanent pacemakers, although subsequent interrogations showed minimal ventricular pacing. These pediatric HT recipients had paroxysmal AVB hours after cardiac catheterization in the absence of significant AR, CAV, or underlying conduction system disease. Subsequent pacemaker interrogations showed minimal ventricular pacing, suggesting these were isolated episodes. These cases suggest that mechanisms in addition to AR and CAV may cause paroxysmal AVB in pediatric HT recipients, warranting further investigation.

Marked First-Degree Atrioventricular Block and Pseudo-Pacemaker Syndrome in a Pediatric Patient

We describe a 17-year-old female who presented with 3 weeks of abdominal pain, exercise intolerance, and an episode of altered mental status found to have marked first-degree atrioventricular block. Exercise stress test and cardiac catheterization demonstrated pseudo-pacemaker syndrome, and a permanent pacemaker was placed. Following placement, she has resolution of symptoms and markedly improved exercise tolerance.

Resource utilization at the time of prostacyclin initiation in children in pulmonary arterial hypertension: a multicenter analysis

There are limited data investigating the epidemiology and resource utilization associated with parenteral prostacyclin use in children. We sought to examine national trends in treatment practices and resource utilization during prostacyclin initiation for pulmonary arterial hypertension (PAH) at children’s hospitals in the United States. Patients with PAH initiated on parenteral epoprostenol and treprostinil (2004–2014) were identified using a nationwide administrative database. Demographics, clinical characteristics, and resource utilization were compared between epoprostenol and treprostinil groups. Costs were indexed in 2014 US dollars. Among 1448 children admitted with a primary or secondary diagnosis of PAH, 280 (19%) were initiated on parenteral prostacyclins (epoprostenol n = 195 and treprostinil n = 85). Epoprostenol predominated early (97% of initiations in 2005); however, treprostinil predominated recently (52–67% of initiations/year). Children initiated on treprostinil had shorter ICU stays (1 [IQR = 0–4] vs. 4 [0–10] days, P < 0.001), shorter total lengths of stay (4 [2–9] vs. 8 [4–18] days, P = 0.001), and lower in-hospital mortality (1 vs. 12%, P = 0.001) with no difference in 30-day (13 vs. 19%, P = 0.19) or one-year readmission rates (56 vs. 61%, P = 0.41). Inpatient costs were lower for treprostinil initiation ($23,779 [11,830–39,535] vs. $32,976 [11,904–94,082], P = 0.03), with a greater difference in the recent era (2009–2013). Though significant variation exists regarding prostacyclin use for PAH across US centers, prostacyclins are common among children with PAH. Treprostinil initiation has been increasing and is associated with less resource utilization and lower cost compared to epoprostenol initiation. Post-discharge outcome data are needed to fully inform decision-making about the relative benefits of parental prostacyclin drug choice.

Adenosine-sensitive Wolff-Parkinson-White: Longer time across the atrioventricular groove

BACKGROUND

Successful ablation sites in Wolff-Parkinson-White syndrome (WPW) are characterized by short atrioventricular (AV) intervals. Approximately 15% of patients with WPW have adenosine-sensitive accessory pathways (APs). We sought to determine if local AV intervals of adenosine-sensitive APs are different from those of adenosine-insensitive APs in patients with WPW.

METHODS

Patients ≤21 years with WPW and adenosine-sensitive APs who underwent successful ablation over a 9-year period were included. Patients with WPW and adenosine-insensitive APs were matched by age and weight in a 1:2 case-control design. AP location, antegrade and retrograde conduction properties, supraventricular tachycardia (SVT) inducibility, local AV interval, interval from delta wave onset to local ventricular activation (del-V), and time to loss of preexcitation were reviewed.

RESULTS

Fourteen patients with adenosine-sensitive APs and 28 with adenosine-insensitive APs were included. Patients with adenosine-sensitive APs had minimum 1:1 antegrade AP conduction at a longer median paced cycle length (380, interquartile range [IQR] 295 to 585 ms vs 290, IQR 250 to 330 ms, P = 0.046), were less likely to have inducible SVT (35.7% vs 75.0%, P = 0.035), and had a longer median local AV interval (40.5, IQR 30.8 to 58.3 ms vs 32.0, IQR 29.3 to 37.8 ms, P = 0.029) when compared to those with adenosine-insensitive APs.

CONCLUSION

Patients with WPW and adenosine-sensitive APs have 1:1 antegrade AP conduction at longer cycle lengths, lower likelihood of SVT induction, and longer local AV intervals when compared to those with adenosine-insensitive APs. In patients with WPW, it may be important to consider adenosine response when selecting appropriate ablation targets.

Galectin-3: an emerging biomarker in stroke and cerebrovascular diseases

The carbohydrate-binding molecule galectin-3 has garnered significant attention recently as a biomarker for various conditions ranging from cardiac disease to obesity. Although there have been several recent studies investigating its role in stroke and other cerebrovascular diseases, awareness of this emerging biomarker in the wider neurology community is limited. We performed a systematic search in PubMed, Embase, Scopus, CINAHL, Clinicaltrials.gov and the Cochrane library in November and December 2016 for articles related to galectin-3 and cerebrovascular disease. We included both human and pre-clinical studies in order to provide a comprehensive view of the state of the literature on this topic. The majority of the relevant literature focuses on stroke, cerebral ischemia and atherosclerosis, but some recent attention has also been devoted to intracranial and subarachnoid hemorrhage. Higher blood levels of galectin-3 correlate with worse outcomes in atherosclerotic disease as well as in intracranial and subarachnoid hemorrhage in human studies. However, experimental evidence supporting the role of galectin-3 in these phenotypes is not as robust. It is likely that the role of galectin-3 in the inflammatory cascade within the central nervous system following injury is responsible for many of its effects, but its varied physiological functions and multiple sites of expression mean that it may have different effects depending on the nature of the disease condition and the time since injury. In summary, experimental and human research raises the possibility that galectin-3, which is closely linked to the inflammatory cascade, could be of value as a prognostic marker and therapeutic target in cerebrovascular disease.

Acute Management of Refractory and Unstable Pediatric Supraventricular Tachycardia

OBJECTIVE

To characterize the management of acute pediatric supraventricular tachycardia (SVT), placing special emphasis on infants, patients refractory to adenosine (refractory SVT), and patients with hypotension, poor perfusion, or altered mental status (unstable SVT).

STUDY DESIGN

Retrospective cohort study of patients 0-18 years of age without congenital heart disease who presented to our pediatric hospital from January 2003 to December 2012 for the treatment of acute SVT. Multiple logistic regression was applied to identify whether age was a risk factor for different SVT therapies. Model fit and residuals also were examined.

RESULTS

We identified 179 episodes for SVT. First dose of adenosine was effective in 72 (56%) episodes, and a second dose was effective in 27 of 54 (50%) episodes, leaving 27 (15%) episodes with refractory SVT. The response to the first dose of adenosine increased proportionally with age (OR 1.13, 95% CI 1.05-1.2). Only 1 of 17 episodes in infants responded to the first dose of adenosine. Refractory SVT was more frequent in infants vs older children (χ² = 5.9 [1 df], P = .01). Unstable SVT was present in 13 episodes and was treated with adenosine and antiarrhythmics. Synchronized cardioversion was performed on 3 patients, 2 patients with unstable SVT, and 1 with refractory SVT.

CONCLUSION

In children with SVT, young age is associated with decreased response to the first dose of adenosine and increased odds of adenosine-refractory SVT. In the treatment of unstable SVT, medical management with various antiarrhythmics before cardioversion may have a role in a subset of patients. Synchronized cardioversion rarely is performed for acute SVT.

The Presence of Phage Orthologous Genes in Helicobacter pylori Correlates with the Presence of the Virulence Factors CagA and VacA

BACKGROUND

The bacterium Helicobacter pylori is associated with ulcers and the development of gastric cancer. Several genes, including cytotoxin-associated gene A (CagA) and vacuolating cytotoxin A (VacA), are associated with increased gastric cancer risk. Some strains of H. pylori also contain sequences related to bacteriophage phiHP33; however, the significance of these phage-related sequences remains unknown.

MATERIALS AND METHODS

We assessed the extent to which phiHP33-related sequences are present in 335 H. pylori strains using homology searches then mapped shared genes between phiHP33 and H. pylori strains onto an existing phylogeny.

RESULTS

One hundred and twenty-one H. pylori strains contain phage orthologous sequences, and the presence of the phage-related sequences correlates with the presence of CagA and VacA. Mapping of the phage orthologs onto a phylogeny of H. pylori is consistent with the hypothesis that these genes were acquired by horizontal gene transfer.

CONCLUSIONS

phiHP33 phage orthologous sequences might be of significance in understanding virulence of different H. pylori strains.

Accelerated Idioventricular Rhythm in a Child With Status Asthmaticus

Acute asthma exacerbations occur relatively frequently in children. We present the case of a 4-year-old boy who was admitted to our hospital in status asthmaticus and found to have a wide complex rhythm while being treated with inhaled albuterol and intravenous methylprednisolone. This rhythm was diagnosed as accelerated idioventricular rhythm (AIVR), which carries a benign prognosis. It resolved as the medications used to treat his asthma exacerbation were weaned. There was no ventricular ectopy seen on a 24-hour Holter monitor performed 3 months after his hospitalization, suggesting that the AIVR was related to the medications the patient was receiving at the time. This case suggests that albuterol may be a risk factor for the development of AIVR and highlights the importance of recognizing this rhythm to avoid unnecessary and potentially harmful therapies.

Discovery of a novel Kv7 channel opener as a treatment for epilepsy

Facilitating activation, or delaying inactivation, of the native Kv7 channel reduces neuronal excitability, which may be beneficial in controlling spontaneous electrical activity during epileptic seizures. In an effort to identify a compound with such properties, the structure-activity relationship (SAR) and in vitro ADME for a series of heterocyclic Kv7.2-7.5 channel openers was explored. PF-05020182 (2) demonstrated suitable properties for further testing in vivo where it dose-dependently decreased the number of animals exhibiting full tonic extension convulsions in response to corneal stimulation in the maximal electroshock (MES) assay. In addition, PF-05020182 (2) significantly inhibited convulsions in the MES assay at doses tested, consistent with in vitro activity measure. The physiochemical properties, in vitro and in vivo activities of PF-05020182 (2) support further development as an adjunctive treatment of refractory epilepsy.

Ventricular ectopy in children without known heart disease

OBJECTIVE

To describe the presentation and clinical course of patients with ventricular ectopy (VE) without known heart disease seen at a single institution.

STUDY DESIGN

Patients with VE were identified from the cardiology database. Patients with known hemodynamically significant heart disease or systemic diseases were excluded.

RESULTS

A total of 219 patients constitute the study population, with 59% male and median age of diagnosis 11.3 years. A total of 138 patients had follow-up data. Median duration of follow-up was 3.1 years (n = 138, range 0-21 years) for a total of 587 patient-years. Simple VE was found in 83%, and 17% had ventricular tachycardia. Most patients were asymptomatic at presentation (77%) At presentation, echocardiograms were performed in 164 patients, with 98% normal. Of the 36 patients with sequential echocardiograms, 32 (88%) remained normal, 3 (9%) had abnormal echocardiograms which normalized, and 1 (3%) had progressive left ventricular dysfunction. On sequential Holter data (n = 48), 54% showed stable or decreased VE, 40% showed resolution, and 6% showed worsening. No cases of death or resuscitated sudden death occurred.

CONCLUSIONS

Most patients were asymptomatic. There were rare cases of progression of VE and development of left ventricular dysfunction but the majority had stable findings. No deaths occurred.

Evidence for horizontal gene transfer between Chlamydophila pneumoniae and Chlamydia phage

Chlamydia-infecting bacteriophages, members of the Microviridae family, specifically the Gokushovirinae subfamily, are small (4.5–5 kb) single-stranded circles with 8–10 open-reading frames similar to E. coli phage ϕX174. Using sequence information found in GenBank, we examined related genes in Chlamydophila pneumoniae and Chlamydia-infecting bacteriophages. The 5 completely sequenced C. pneumoniae strains contain a gene orthologous to a phage gene annotated as the putative replication initiation protein (PRIP, also called VP4), which is not found in any other members of the Chlamydiaceae family sequenced to date. The C. pneumoniae strain infecting koalas, LPCoLN, in addition contains another region orthologous to phage sequences derived from the minor capsid protein gene, VP3. Phylogenetically, the phage PRIP sequences are more diverse than the bacterial PRIP sequences; nevertheless, the bacterial sequences and the phage sequences each cluster together in their own clade. Finally, we found evidence for another Microviridae phage-related gene, the major capsid protein gene, VP1 in a number of other bacterial species and 2 eukaryotes, the woodland strawberry and a nematode. Thus, we find considerable evidence for DNA sequences related to genes found in bacteriophages of the Microviridae family not only in a variety of prokaryotic but also eukaryotic species.

Medical management of fecal incontinence in challenging populations: a review

Fecal incontinence (FI) is a common and growing problem in the United States. Although there are multiple emerging novel interventions for the treatment of FI, the mainstay of initial therapy remains medical management. In this article, we review the available literature on the medical management of FI, with a special focus on patients with multiple sclerosis, diabetes mellitus, and the elderly.

Bifurcated intraarticular long head of biceps tendon

Though rare, many anomalous origins of long head of the biceps tendon (LHBT) have been reported in the literature. Anatomic variations commonly explained are a third humeral head, anomalous insertion, congenital absence and adherence to the rotator cuff. We report a rare case who underwent shoulder arthroscopy with impingement symptoms where in LHBT was found to be bifurcated with a part attached to superior labrum and the other part to the posterior capsule of joint. Furthermore, intraarticular portion of LHBT was adherent to the undersurface of the supraspinatus tendon. Awareness of such an anatomical aberration during the shoulder arthroscopy is of great importance as it can potentially avoid unnecessary confusion and surgery.

ABO blood groups and oral premalignancies: A clinical study in selected Indian population

Background: The ABO blood group antigens are present on the surface of red blood cells and various epithelial cells. As the majority of human cancers are derived from epithelial cells, changes in blood group antigens constitute an important aspect of human cancers. The aim of the study was to establish clinical usefulness of ABO blood group as a predisposing factor in early diagnosis and management of patients with oral precancerous lesions/conditions. Materials and Methods: The study sample consisted of 50 control and 50 oral precancer (25 leukoplakia and 25 Oral Submucous Fibrosis) confirmed by histopathologic examination. All samples were subjected to blood group testing and their prevalence was compared by Z-test using STATA version 8. Results: The "A" blood group was prevalent among the precancerous group. Significant differences on prevalences of blood groups were found (P < 0.05) between control versus leukoplakia and OSMF. Interestingly, 24% gutka chewers who had higher number of grades of dysplasia were falling in "A" blood group. Conclusion: Blood group type should be considered along with other risk factors to understand the individual patient's risk and further studies in larger samples with inclusion of Rh factor is needed to elucidate the relationship with ABO blood group types.