Clinical Interventions Research Articles

UNVEILING THE VEIN

Cerebrospinal fluid (CSF)-venous fistula represents a formidable yet often overlooked neurosurgical dilemma. Despite its disabling consequences, it remains significantly underdiagnosed. This abstract sheds light on the clinical intricacies, diagnostic challenges, and therapeutic interventions associated with CSF-venous fistula. Early diagnosis is paramount, yet hindered by its rarity and diverse and often unspecific clinical presentations. The importance of heightened awareness among clinicians and radiologists for timely detection and management cannot be overstated. This presentation will draw upon a review of clinical cases operated in the Royal Hallamshire Hospital, supplemented by a concise surgical video which is focused on surgical technique and benefit of microscope mediated augmented reality.

Gene expression profiling reveals host defense strategies for restricting Candida albicans invasion and gastritis to the limiting ridge of the murine stomach

ABSTRACT Candida albicans is a fungal constituent of the human gastrointestinal microbiota that can tolerate acidic environments like the stomach, where it can be associated with ulcers and chronic gastritis. In mice, C. albicans induces gastritis without concurrent intestinal inflammation, suggesting that the stomach is particularly prone to fungal infection. We previously showed that C. albicans invasion in the limiting ridge does not extend to or elicit an inflammatory response in the adjacent glandular region, indicating regionalized gastritis in the murine stomach. However, the molecular pathways involved in the host response to C. albicans specifically in the limiting ridge have not been investigated. Here, we found that gastric dysbiosis was associated with C. albicans limiting ridge colonization and gastritis. We isolated the limiting ridge and evaluated the expression of over 90 genes involved in mucosal responses. C. albicans infection triggered a type 3 immune response marked by elevated Il17a , Il17f , Il1b , Tnf , and Il36g , as well as an upregulation of Il12a , Il4 , Il10 , and l13 . Chemokine gene induction (including Ccl2 , Ccl3 , Ccl4 , Ccl1l , Cxcl1 , Cxcl2 , Cxcl9 , and Cxcl10 ) coincided with an influx of neutrophils, monocytes/macrophages, and eosinophils. Hyphal invasion caused tissue damage, epithelial remodeling, and upregulation of genes linked to epithelium signaling and antimicrobial responses in the limiting ridge. Our findings support a need for continued exploration into the interactions between the immunological milieu, the host microbiota, and clinical interventions such as the use of antibiotics and immunotherapeutic agents and their collective impact on invasive candidiasis risk.

Identification of Molecular Subtypes and Prognostic Traits Based on Chromosomal Instability Phenotype-Related Genes in Lung Adenocarcinoma

Lung adenocarcinoma (LUAD) exhibits significant molecular heterogeneity; however, previous studies have not fully explored its classification into distinct molecular subtypes. Here, we identified LUAD-significant chromosomal instability (CIN) phenotype genes (n = 24) using a TCGA-LUAD cohort (n = 592) and evaluated their ability to predict pathologic grade. Unsupervised clustering and principal component analysis revealed that LUAD patients could be classified into CIN phenotype-related subtypes (GroupLow, GroupModerate, and GroupHigh), each exhibiting distinct transcriptomic patterns. Notably, the GroupHigh showed significantly poor overall survival [OS; hazard ratio (HR) = 1.43, p-value < 10−3] and disease-free survival (DFS; HR = 1.27, p-value < 10−3). Univariate and multivariate analysis confirmed that its expression status was an independent prognostic predictor (p-value < 10−3, HR = 2.18, 95% C.I = 1.26–3.76) of the clinical outcomes, outperforming pathologic grade (p-value < 10−3, HR = 1.2, 95% C.I = 1.08–1.33). Moreover, analysis of surfactant metabolism-related genes revealed higher expression in the GroupLow, which was associated with a favorable prognosis. By integrating multiple independent cohorts (n = 779), we validated these findings and confirmed that CIN phenotype gene status serves as a critical prognostic marker in LUAD. Furthermore, genomic profiling showed that the GroupHigh exhibited frequent mutations in key genes such as KEAP1, LYST, SETD2, and TP53, with oncogenes in this group preferentially showing copy number gains. Our study highlights the significance of CIN phenotype gene status as a predictor of LUAD prognosis and its association with transcriptomic and genomic alterations, paving the way for further clinical validation and potential therapeutic interventions.

Clinical Acceptability of a Quality Improvement Program for Reducing Cardiovascular Disease Risk in People With Chronic Kidney Disease in Australian General Practice: Qualitative Study

Abstract Background Future Health Today (FHT) is a technology program that integrates with general practice clinical software to provide point of care (PoC) clinical decision support and a quality improvement dashboard. This qualitative study looks at the use of FHT in the context of cardiovascular disease risk in chronic kidney disease (CKD). Objective This study aims to explore factors influencing clinical implementation of the FHT module focusing on cardiovascular risk in CKD, from the perspectives of participating general practitioner staff. Methods Practices in Victoria were recruited to participate in a pragmatic cluster randomized controlled trial using FHT, of which 19 practices were randomly assigned to use FHT’s cardiovascular risk in CKD program. A total of 13 semistructured interviews were undertaken with a nominated general practitioner (n=7) or practice nurse (n=6) from 10 participating practices. Interview questions focused on the clinical usefulness of the tool and its place in clinical workflows. Qualitative data were coded by 2 researchers and analyzed using framework analysis and Clinical Performance Feedback Intervention Theory. Results All 13 interviewees had used the FHT PoC tool, and feedback was largely positive. Overall, clinicians described engaging with the tool as a “prompt” or “reminder” system. Themes reflected that the tool’s goals and clinical content were aligned with clinician’s existing priorities and knowledge, and the tool’s design facilitated easy integration into existing workflows. The main barrier to implementation identified by 2 clinicians was notification fatigue. A total of 7 interviewees had used the FHT dashboard tool. The main barriers to use were its limited integration into clinical workflows, such that some participants did not know of its existence; clinicians’ competing clinical priorities; and limited time to learn and use the tool. Conclusions This study identified many facilitators for the successful use of the FHT PoC program, in the context of cardiovascular risk in CKD, and barriers to the use of the dashboard program. This work will be used to inform the wider implementation of FHT, as well as the development of future modules of FHT for other risk or disease states.

The co-expression of the depolarizing and hyperpolarizing mechanosensitive ion channels in mammalian retinal neurons

IntroductionThe elevation of the intraocular and extraocular pressures is associated with various visual conditions, including glaucoma and traumatic retinal injury. The retina expresses mechanosensitive channels (MSCs), but the role of MSCs in retinal physiology and pathologies has been unclear.MethodsUsing immunocytochemistry, confocal microscopy, and patch-clamp recording techniques, we studied the co-expression of K+-permeable (K-MSCs) TRAAK and big potassium channel BK with the epithelial sodium channel ENaC and transient receptor potential channel vanilloid TPRV4 and TRPV2 favorably permeable to Ca2+ than Na+ (together named N-MSCs), and TRPV4 activity in the mouse retina.ResultsTRAAK immunoreactivity (IR) was mainly located in Müller cells. Photoreceptor outer segments (OSs) expressed BK and ENaCα intensively and TRAAK, TRPV2, and TRPV4 weakly. Somas and axons of retinal ganglion cells (RGCs) retrograde-identified clearly expressed ENaCα, TRPV4, and TRPV2 but lacked TRAAK and BK. Rod bipolar cells (RBCs) showed TRPV4-IR in somas and BK-IR in axonal globules. Horizontal cells were BK-negative, and some cone BCs lacked TRPV4-IR. TRPV4 agonist depolarized RGCs, enhanced spontaneous spikes and excitatory postsynaptic currents, reduced the visual signal reliability (VSR = 1-noise/signal) by ~50%, and resulted in ATP crisis, which could inactivate voltage-gated sodium channels in RGCs.ConclusionIndividual neurons co-express hyperpolarizing K-MSCs with depolarizing N-MSCs to counterbalance the pressure-induced excitation, and the level of K-MSCs relative to N-MSCs (RK/N ratio) is balanced in the outer retina but low in RGCs, bringing out novel determinants for the pressure vulnerability of retinal neurons and new targets for clinical interventions.

Delayed Lactogenesis II in High-Risk Pregnancies: What Should We Care

Background: The timely initiation of lactogenesis II is crucial for postpartum women, with delays having significant clinical implications. This study aimed to evaluate the determinants of delayed lactogenesis II (DOL II) in high-risk pregnant women to guide clinical interventions and postnatal care protocols. Methods: We conducted a study involving high-risk pregnant women who gave birth and were admitted to our hospital’'s obstetric intensive care unit for postpartum surveillance and treatment from February 1, 2023, to April 30, 2024. We utilized Pearson correlation analysis and logistic regression to determine factors linked to DOL II. Results: Our study included 206 high-risk pregnant women, with 85 (41.26%) experiencing DOL II. Pearson correlation analysis indicated strong associations between DOL II and maternal age (r = 0.452), gestational hypertension (r = 0.514), gestational diabetes (r = 0.487), and delayed colostrum secretion (r = 0.506), all statistically significant ( p < 0.05). Logistic regression analysis identified age 35 years or older (OR = 2.115, 95%CI: 1.785–2.466), gestational hypertension (OR = 2.404, 95%CI: 2.125–3.107), gestational diabetes (OR = 2.556, 95%CI: 2.008–2.879), and colostrum secretion later than one hour postpartum (OR = 3.126, 95%CI: 2.682–3.605) as independent risk factors for DOL II, all with p < 0.05. Conclusions: The incidence of DOL II is significantly elevated in high-risk pregnant women, especially those aged 35 or older, those with gestational diabetes and hypertension, and those who delay the initiation of breastfeeding. It is imperative that clinical practices prioritize enhanced prenatal care and health education, robust lactation support, and improved lactation awareness among postpartum women to reduce the prevalence of DOL II.

Evaluating the causal association between circulating plasma proteins, 731 immune cell phenotypes, and atopic dermatitis: A mediation Mendelian randomization study

Introduction: Atopic dermatitis (AD) is a chronic inflammatory skin disease characterized by eczematous lesions and severe itching. However, its pathogenesis has not yet been fully elucidated. The aim of this study was to investigate the causal relationship between plasma proteins and AD, as well as to identify and quantify the potential roles of immune cell phenotypes as mediators. Methods: We utilized summary-level data from genome-wide association studies and conducted a two-sample Mendelian randomization (MR) analysis involving 4907 circulating plasma proteins, 731 immune cell phenotypes, and AD. Initially, we conducted bidirectional univariate MR analyses to forecast causal effects linking circulating plasma proteins and AD. Subsequently, we employed a two-step MR analysis to scrutinize the immune cell phenotypes that could mediate these effects. The inverse variance weighted was the main method employed for MR analysis, while the Cochran’s Q test and MR-Egger intercept test were used to assess the presence of heterogeneity and pleiotropy, respectively. We then determined whether our results could be influenced by individual single-nucleotide polymorphisms using the “leave-one-out” test. Results: Positive correlations were observed between KRT1, IL18R1, and SEMA6A and the risk of AD, whereas BDH2, ADAMTS3, ANKRD1, TIAM1, MID2, and IFNA16 all showed negative correlations with the risk of AD. Mediation analysis indicated that CD8 on CM CD8br cells acted as a mediator between IFNA16 and AD, with a mediation effect proportion of 11.2%. In addition, sensitivity analyses did not reveal significant heterogeneity or level pleiotropy. Conclusion: Our findings indicated the presence of a one-way causal relationship between the circulating plasma protein IFNA16 and AD. This study also explored immune cell phenotypes that may serve as mediators, offering novel insights into the etiology, pathogenesis, and potential clinical interventions in AD. Nevertheless, these findings need to be validated by clinical and laboratory studies.

Are rates of clinical interventions during pregnancy and childbirth different for refugees and asylum seekers in high-income countries? A scoping review

Abstract Background Adequate maternity care and appropriate clinical interventions during labour and delivery can reduce adverse perinatal outcomes, but unnecessary interventions may cause harm. While studies have shown that refugees and asylum seekers face important barriers when accessing maternity care, there is a lack of high-quality quantitative data on perinatal health interventions, such as induction of labour or caesarean sections, among refugees and asylum seekers and the findings reported in the literature tend to be inconsistent. Our goal was to examine and synthesise the evidence regarding the rates of intrapartum clinical interventions in women who are refugees and asylum seekers in high-income countries compared to other population groups. Methods We conducted a scoping review of peer-reviewed studies published in English since 2011 that report original quantitative findings regarding intrapartum clinical interventions among refugees and asylum seekers in high-income countries compared to those in non refugee, non asylum seeker populations. We examined reported rates of clinical pain relief, labour induction and augmentation, episiotomies, instrumental deliveries, and caesarean sections. Results Twenty-five papers were included in the review. Findings indicate that refugees and asylum seekers were less likely to receive pain relief, with 16 out of 20 data points showing unadjusted ORs ranging from 0.20 (CI: 0.10–0.60) to 0.96 (CI: 0.70–1.32). Similarly, findings indicate lower odds of instrumental delivery among refugees and asylum seekers with 14 of 21 data points showing unadjusted ORs between 0.25 (CI: 0.15–0.39) and 0.78 (CI: 0.47–1.30); the remaining papers report no statistically significant difference between groups. There was no discernable trend in rates of labour induction and episiotomies across studies. Conclusions The studies included in this review suggest that asylum seekers and refugees are less likely to receive clinical pain relief and experience instrumental delivery than non-refugee groups in high-income countries. This review strengthens our understanding of the links between immigration status and maternity care, ultimately informing policy and practice to improve perinatal health and the provision of care for all.

Abstract 4137820: Extreme heat and cardiovascular disease in a changing climate: An urgent need for risk management and health research

Background: Extreme heat can trigger or exacerbate cardiovascular disease (CVD) through ischemia or thrombosis, and its deleterious impacts are inclined to worsen as increased heat exposure and heightened vulnerability from climate change interacted with natural and social environment. Research Questions: Previous studies have primarily focused on quantifying the increased risk of CVD due to heat exposure, while lacking a comprehensive understanding of the association, underlying mechanisms, and vulnerability in CVD patients. Consequently, there is a scarcity of clinical and public health interventions aimed at preventing the convergence of extreme heat exposure and the risk of CVD within the context of climate change. Methods: We conducted a systematic search in PubMed, Embase, and Web of Science from inception to December, 2023, and we retrieved articles which assessed the effects of extreme heat or climate change on CVD. Results: In this review, we outline the existing evidence on the epidemiology and pathophysiological mechanisms that elucidate how extreme heat affects the risk of CVD. Extreme heat is associated with increased risks for CVD morbidity and mortality, where older persons, low socioeconomic status, pre-existing medical conditions, and unfavorable living environments confer greater susceptibility to heat. The adverse effects of extreme heat on cardiovascular system involved a wide range of complex mechanisms between different organs and regulatory pathways (Figure 1). Additionally, we identify the factors that contribute to the vulnerability of CVD patients to heat exposure. The discrepancy in heat-related risk can be attributed to individual susceptibility, sociocultural factors, population temperature adaptations, and environmental factors. Future climate change is projected to exacerbate the burden of extreme heat, particularly due to the interaction of air pollution, population aging, and urbanization (Figure 2). Conclusions: Addressing extreme heat should be within the framework of the prevention of CVD. Health professionals and scientists are responsible for mitigating the cardiovascular effects mediated by extreme heat, with an emphasis on engaging in risk management tactics and health research to implement preventive strategies. As CVD is a climate sensitive disease, evidence-based interventions during heat extremes are urgently needed to cope with the cardiovascular risks associated with the inevitable trajectory of climate change.

Abstract 4136277: The Lay Public Misconceives Characteristics of Acute Coronary Syndrome-Related Chest Pain

Introduction: The most common acute coronary syndrome (ACS) symptom is chest pain. Chest pain is an umbrella term more precisely described using words like pressure or tightness. Previous studies have not explored the lay public’s conceptions of ACS-related chest pain. Misconceptions about chest pain make it difficult for individuals to recognize this symptom if they were to experience it, delaying care seeking. Research Question: How does the lay public conceive of ACS-related chest pain? Methods: Participants from across the U.S. were recruited in May and June 2023. Participants completed an online survey including the Chest Pain Conception Questionnaire. Descriptive statistics were used to characterize conceptions of chest pain quality, timing, intensity, and distress. Conceptions of men and women were compared using the independent-samples t -test and Chi-square test. Results: Participants (n=597) were mostly women (n=355; 59.5%) with a mean age of 54.0 years (SD = 11.5). The sample was diverse: White (n=414, 69.2%), Black (n=101; 16.9%), Hispanic or Latina/o/e/x (n=96; 16.1%), and Asian (n=67; 11.2%). Participants often thought of pressure (78.9%), tightness (77.4%), squeezing (75.5%), gripping (72.9%), and heaviness (72.5%) as possible descriptors of ACS-related chest pain. They less often thought of discomfort (48.7%), fullness (16.8%), and indigestion (13.4%). Participants expected ACS-related chest pain to be “intense” and to bother them “a lot,” both with median scores of 4.0 on a 5-point Likert scale. Participants felt that ACS-related chest pain would “often” (median 4.0) occur with activity and “sometimes” (median 3.0) occur at rest. Women were more likely to rate specific descriptors of chest pain (i.e., pressure, tightness) and general descriptors of chest pain (i.e., discomfort, pain) as more likely ACS-related chest pain descriptors than men, (all ps ≤ .05). Women (n=58; 16.3%) were about twice as likely as men (n=22; 9.2%) to endorse indigestion as a possible descriptor of ACS-related chest pain, ( p = .013, OR = 0.52 [95% CI = 0.31-0.87]). Conclusions: As many as 1 in 5 participants did not endorse common descriptors such as pressure and tightness as potentially characterizing ACS-related chest pain. Most believed this symptom would be intense and bother them a lot. They also more often associated ACS-related chest pain with activity than with rest. Clinical and research interventions can target the misconceptions identified in this study.

Unraveling the Nexus: The Role of Collapsin Response Mediator Protein 2 Phosphorylation in Neurodegeneration and Neuroregeneration

AbstractNeurodegenerative disease characterized by the progressive damage of the nervous system, and neuropathies caused by the neuronal injury are both led to substantial impairments in neural function and quality of life among geriatric populations. Recovery from nerve damage and neurodegenerative diseases present a significant challenge, as the central nervous system (CNS) has limited capacity for self-repair. Investigating mechanism of neurodegeneration and regeneration is essential for advancing our understanding and development of effective therapies for nerve damage and degenerative conditions, which can significantly enhance patient outcomes. Collapsin response mediator protein 2 (CRMP2) was first identified as a key mediator of axonal growth and guidance is essential for neurogenesis and neuroregeneration. Phosphorylation as a primary modification approach of CRMP2 facilitates its involvement in numerous physiological processes, including axonal guidance, neuroplasticity, and cytoskeleton dynamics. Prior research on CRMP2 phosphorylation has elucidated its involvement in the mechanisms of neurodegenerative diseases and nerve damage. Pharmacological and genetic interventions that alter CRMP2 phosphorylation have shown the potential to influence neurodegenerative diseases and promote nerve regeneration. Even with decades of research delving into the intricacies of CRMP2 phosphorylation, there remains a scarcity of comprehensive literature reviews addressing this topic. This absence of synthesis and integration of findings hampers the field’s progress by preventing a holistic understanding of CRMP2’s implications in neurobiology, thereby impeding potential advancements in clinical treatments and interventions. This review intends to compile investigations focused on the role of CRMP2 phosphorylation in both neurodegenerative disease models and injury models to summarizing impacts and offer novel insight for clinical therapies.

Abstract 4113951: Calcification Alters Luminal Surface Complexity in Cadaveric Left Anterior Descending Arteries

Background: Understanding the intricacies of luminal surface topographic changes in pathologic coronary arteries may yield insight not only on the efficacy of existing clinical interventions (e.g. impact of surface changes on stent anchoring), but also on the subsequent hemodynamic changes and pathophysiology of thrombus formation. In this study, we aim to detect and quantify luminal surface alterations induced by the presence of calcification in cadaveric left anterior descending arteries (LADs) using a novel approach–surface metrology. Methods: LADs (n=10) were harvested from cadaveric hearts using a systematic dissection approach, scanned using the Bruker Skyscan 1173 microCT scanner, and then underwent threshold-based image segmentation on Dragonfly by Object Research Systems to quantify the total calcium volume present throughout the vessel. Each specimen was then splayed open and up to 15 scans were performed at 20X magnification using the Sensofar S Neox optical profiler. Each scan subsequently underwent surface metrologic scale-sensitive fractal analyses in SensoMap 10. Results: Extent of calcification was standardized and expressed using the following ratio: total calcium volume by total vessel length (TC/VL). We considered a TC/VL ratio of 0-0.25 as low calcification and 0.26-0.5 as high calcification. Interestingly, our findings demonstrated statistically significant increases in smooth-rough crossover (SRC) and scale of maximum complexity (Smfc) with positive correlation, but reductions in fractal complexity (Lsfc) and fractal dimension (Dls) with negative correlation, in highly calcified compared to lowly calcified LADs. Conclusions: Our data suggests that the presence of calcium in the walls of LADs may translate to increased roughness in luminal surfaces generally, but smoothness over calcified plaques, locally. Our proposed mechanism is increased endothelial tension directly over areas of calcification, thus reducing surface complexity. Future studies will involve modeling blood flow using smooth particle hemodynamics (SPH) based on complete luminal and surface topographical geometries to evaluate the impact of these surface changes on hemodynamics.

Reducing the Brace Correction Stress on the Secondary Lumbar Curve Results in Excellent Muscle, Bone, and Disc Mechanical Performance: A Musculoskeletal Finite Element Simulation of AIS Patient With Rigo A3

ABSTRACTObjectivesThe biomechanical mechanism of brace intervention on bone, muscle, and disc should be comprehensively considered for AIS patients. We aimed to developmentally construct a musculoskeletal finite element model of adolescent idiopathic scoliosis to simulate the coupling of corrective forces and analyze the mechanical properties of bone, muscle, and disc. Investigateing, more effective clinical interventions to break the vicious cycle of patients during growth.MethodsA finite element model, including muscle, bone, and disc, was established using computed tomography data of a patient with RigoA3 adolescent idiopathic scoliosis. The three‐point force coupling, antigravity, and bending effects of the Chêneau brace were simulated, and the correction force of the secondary lumbar bend was gradually reduced while observing the mechanical characteristics of bone, muscle, and disc. The correction force in line with symmetrical spine growth was comprehensively evaluated.ResultsThe correction rate of the main thoracic (MT) curve, the intervertebral space height on the concave side of the vertebrae at the apex, and the stress ratio of the intervertebral discs were optimal when the maximum corrective pressure threshold was reached. However, the proximal thoracic (PT) curve was aggravated and the axial forces on the concave side were unbalanced. At this time, the biomechanical performance of the model is also not optimal. The correction rate of the Cobb Angle of the MT curve decreased with the decrease of the correction pressure in the lumbar region. When reduced to 25% of the maximum threshold, the convex side of disc stress, intervertebral space, and muscle axial force is more in line with the biomechanical mechanism of correction and can avoid sacrificing the PT curve.ConclusionsDownward adjustment of the corrective force to the secondary lumbar curve, using the Chêneau brace, results in better primary thoracic curvature mechanics in the musculoskeletal finite element model, suggesting that breaking the vicious cycle of scoliosis progression to guide benign spinal growth is beneficial.

Comparison of six natural language processing approaches to assessing firearm access in Veterans Health Administration electronic health records

Abstract Objective Access to firearms is associated with increased suicide risk. Our aim was to develop a natural language processing approach to characterizing firearm access in clinical records. Materials and Methods We used clinical notes from 36 685 Veterans Health Administration (VHA) patients between April 10, 2023 and April 10, 2024. We expanded preexisting firearm term sets using subject matter experts and generated 250-character snippets around each firearm term appearing in notes. Annotators labeled 3000 snippets into three classes. Using these annotated snippets, we compared four nonneural machine learning models (random forest, bagging, gradient boosting, logistic regression with ridge penalization) and two versions of Bidirectional Encoder Representations from Transformers, or BERT (specifically, BioBERT and Bio-ClinicalBERT) for classifying firearm access as “definite access”, “definitely no access”, or “other”. Results Firearm terms were identified in 36 685 patient records (41.3%), 33.7% of snippets were categorized as definite access, 9.0% as definitely no access, and 57.2% as “other”. Among models classifying firearm access, five of six had acceptable performance, with BioBERT and Bio-ClinicalBERT performing best, with F1s of 0.876 (95% confidence interval, 0.874-0.879) and 0.896 (95% confidence interval, 0.894-0.899), respectively. Discussion and Conclusion Firearm-related terminology is common in the clinical records of VHA patients. The ability to use text to identify and characterize patients’ firearm access could enhance suicide prevention efforts, and five of our six models could be used to identify patients for clinical interventions.

Abstract Su303: Afferent Rapid Response Limb Failure Prior to Non-ICU In-Hospital Cardiac Arrest and Associated In-Hospital Mortality

Introduction/Background: Rapid Response Teams (RRT) have been widely implemented to recognize and manage clinical deterioration outside of the intensive care unit (ICU). Hospital systems frequently rely on individual healthcare provider’s skill and attention to identify early deterioration and activate the appropriate clinical resources. This is referred to as the afferent limb, or triggering mechanism, of the Rapid Response system. Hypothesis: Afferent limb failure leads to delayed clinical intervention and potentially worse outcomes for patients that progress to in-hospital cardiac arrest (IHCA). Goals/Aims: The aim of this retrospective study was to identify if afferent limb failure, defined as failure to recognize two or more standardized early warning criteria in the 24 hours prior to non-ICU IHCA, is associated with increased in-hospital mortality when compared to patients with zero to one standardized early warning criteria. Methods: Non-ICU IHCAs over a 6-year period (January 1 st , 2018, to December 31 st , 2023) at a large academic medical center were reviewed using standardized criteria to determine 1) if any RRT activation criteria had been met in the 24 hours prior to non-ICU IHCA, 2) how many RRT criteria were met, 3) whether an RRT activation occurred, and 4) in-hospital mortality. Statistical analysis included a Chi-Square analysis and Pearson Correlation Coefficient. Results: We identified 386 adult non-ICU IHCAs, with 214 (55.4%) meeting at least two RRT criteria in the 24 hours preceding their non-ICU IHCA. In patients without a preceding RRT activation (N=313), there was significantly higher in-hospital mortality in patients who met two or more RRT criteria prior to their non-ICU IHCA than patients who met one or zero criteria (91/151, 60.2% vs 114/162, 70.3%, p < 0.05). We also found a weak but statistically significant correlation between the total number of RRT criteria met prior to IHCA and in-hospital mortality (r=0.1331, p < 0.05). Conclusion: Afferent limb failure is associated with higher in-hospital mortality in patients with multiple markers of clinical deterioration prior to non-ICU IHCA. There is also an association between in-hospital mortality and the total number of clinical deterioration criteria met prior to non-ICU IHCA.

OUTCOME OF BURIED VERSUS EXPOSED KIRCHNER WIRES IN TERMS OF INFECTION IN FRACTURE OF PHALANGES AND METACARPAL BONE OF HAND

Kirschner wire (K-wire) fixation is a common technique for treating phalangeal and metacarpal fractures due to its cost-effectiveness and efficiency. However, the risk of infection associated with exposed K-wires remains a significant concern. This study aimed to compare infection rates and clinical outcomes in hand fractures treated with buried versus exposed K-wires. Objective: To assess and compare infection rates, clinical interventions, and patient comfort between buried and exposed K-wires in phalangeal and metacarpal fractures. Method: This study was conducted at Bolan Medical Complex Hospital, Quetta, with 110 patients divided into two groups: Group A (55 patients with buried K-wires) and Group B (55 patients with exposed K-wires). Infection rates were evaluated by categorizing infections as superficial or deep. Clinical outcomes, including the need for antibiotics, K-wire removal, and patient comfort, were assessed for both groups. Results: Group A (buried K-wires) had significantly lower infection rates, with 3.6% of patients developing superficial infections and 1.8% deep infections. In contrast, Group B (exposed K-wires) had higher infection rates, with 10.9% experiencing superficial infections and 5.4% deep infections. Additionally, exposed K-wire patients required more clinical interventions, including increased antibiotic use and K-wire removal. Conclusion: Buried K-wires provide a safer and more comfortable alternative for hand fracture management, with significantly lower infection rates and reduced need for further medical intervention compared to exposed K-wires. Therefore, the use of buried K-wires is preferable for reducing infection risk and enhancing patient comfort.

Qualitative analysis of clinical pharmacy interventions in an inpatient leukemia service

Introduction Leukemia, a complex hematological malignancy, requires a multidisciplinary treatment approach, with clinical pharmacists playing a crucial role. However, their involvement in clinical practice is not well-documented in the literature. This study aimed to examine the characteristics of clinical pharmacy interventions (CPIs) reported by clinical pharmacists. Method This retrospective study involved extraction of CPIs entered into a pharmacy documentation database “Quantifi®” between January 2019 and June 2023. These CPIs included direct clinical pharmacist interventions (DCPIs), detected medication errors (MEs) and adverse drug reactions (ADRs). Results A total of 6286 CPIs were extracted, of which DCPIs, MEs and ADRs accounted for 5701 (90.7%), 357 (5.7%) and 228 (3.6%) reports, respectively. The most prevalent DCPIs were drug therapy discontinuation (n = 1080, 18.9%). Antimicrobials were the most common medications associated with DCPIs (n = 1991, 34.9%). Physicians accepted 99.4% of DCPIs and 64.1% (n = 3656) of direct interventions were considered significant. Among detected MEs, antimicrobials were the most reported medications (n = 158, 44.3%), with pharmacy internal errors being the most prevalent cause of the events (n = 172, 48.2%). Among the reported ADRs, hematological reactions were the most common (n = 81, 35.5%), and antineoplastic agents were the most frequently associated medications with ADRs (n = 164, 71.9%). Conclusion This study highlights the crucial role of clinical pharmacists in managing leukemia patients, emphasizing their key interventions and ability to identify MEs and ADRs. Further research is needed to explore the clinical outcomes and financial impact of their involvement.

Association between within-target risk factors and life expectancy free from cardiovascular disease, cancer, and dementia in individuals with type 2 diabetes in New Zealand between 1994 and 2018: a multi-ethnic cohort study

BackgroundThe extent to which type 2 diabetes (T2D) reduces life expectancy depends on the risk of complications. We aimed to characterise the relationship between risk factors for diabetes complications and life expectancy, in individuals with T2D, free from major chronic disease, in a regional database linked with national New Zealand health databases.MethodsA prospective cohort study design was employed, analysing data from individuals with T2D drawn from the comprehensive Diabetes Care Support Service database (1994–2018). Participants with known values for all five within-target risk factors (WTRF +) including blood pressure, glycaemia, and LDL cholesterol, alongside being non-smoking with normal renal function at baseline, were included. Life expectancy free from cardiovascular disease (CVD), cancer, and dementia at age 50 years was estimated using multistate life tables, adjusting for demographics and clinical metrics.ResultsWomen and men with no WTRF + at enrolment had a life expectancy free from CVD, cancer, or dementia of 13.1 (95% confidence interval: 9.1–19.0) and 11.2 (6.7–18.6) years, respectively. For the most socioeconomically deprived groups or Māori with no WTRF + at baseline, life expectancies were markedly lower. Life expectancies were 23.7 (18.9–29.7) years for women and 23.2 years (17.2–31.4) years for men with four or five WTRF + at baseline, respectively. While an increasing number of WTRF + at baseline was significantly associated with improved outcomes in men and certain subgroups (e.g. Other ethnicity group), this trend was not statistically significant for women overall or in most subgroups.ConclusionsHaving multiple WTRF + at baseline is associated with a considerable increase in life expectancy free from major chronic disease among individuals with T2D. This highlights the importance of lifestyle and clinical interventions in the management of T2D and in the prevention and management of associated chronic conditions.

Pregnant Women's Care Needs During Early Labor–A Scoping Review

ABSTRACTIntroductionPregnant women face the challenge of managing early labor on their own until they feel the need to seek professional support. However, professional support during such a vulnerable stage of labor may sometimes be insufficient. This study aims to understand pregnant women's care needs during early labor in order to improve the quality of care provided at the onset of labor.MethodsA scoping review was conducted following a systematic search strategy in May 2021 and in August 2022 concentrating on pregnant women in early labor with spontaneous onset of labor. A sensitive search strategy was used with five different databases. The articles were screened by two independent researchers. Data were extracted and mapped to answer the research question.Results52 articles were included. Major reasons for seeking professional help are to receive reassurance and get advice and information on how to cope with early labor. Furthermore, many women express the need for professional guidance. Several articles demonstrated women's preferences for hospital admission or a continuous care model. While some women want empowerment and empathy from a midwife, others require clear instructions on helpful measures or even clinical interventions within the process.ConclusionsManaging early labor without professional support creates a major challenge for pregnant women and nurtures insecurities and anxiety. Protecting women from unnecessary interventions is a well‐intentioned plan, yet a lack of support in early labor may sometimes jeopardize a positive birth experience. New ways need to be elaborated to support women‐centred and individualized approaches to providing early labor care.

Severe alcohol withdrawal during pregnancy or early postpartum: maternal and fetal outcomes

Abstract Objective Alcohol withdrawal syndrome (AWS) during pregnancy is under-researched despite growing concerns about increased alcohol use among pregnant women. This study aims to explore the severity of AWS and its impact on maternal and fetal outcomes. Methods This retrospective study reviewed the medical records of patients admitted to the Mayo Clinic who underwent the CIWA-Ar protocol for AWS from June 2019 through June 2022. Pregnant women identified in this cohort had their pregnancy, labor, and neonatal data analyzed for alcohol-related complications and outcomes. Results Out of the medical records reviewed, 8 cases involved pregnant women experiencing AWS. These cases showed a high severity of withdrawal symptoms, with a median peak CIWA-Ar score of 17 (IQR = 14). Maternal complications included a high rate of ICU admissions (37.5%; n = 3) and significant rates of miscarriage and stillbirth (37.5%; n = 3). Fetal outcomes were concerning, with 1 out of 5 (20%) neonates requiring NICU admission and experiencing conditions such as respiratory failure and neonatal abstinence syndrome. Developmental problems were noted in 2 out of 5 (40%) newborns. Conclusions The findings highlight the severe implications of AWS during pregnancy, impacting both maternal and fetal health. The severity of AWS requires attentive clinical management and preventative interventions. Future research should focus on larger, prospective studies to better understand and address the risks associated with AWS in pregnant women and to improve health outcomes for mothers and their children. Article Highlights • Severe AWS during pregnancy leads to high ICU admissions and adverse neonatal outcomes. • 37.5% of pregnant women with AWS experienced miscarriage or stillbirth. • 20% of newborns from mothers with AWS required NICU admission for serious conditions; 40% of newborns had developmental problems. • Findings underscore the need for specialized treatment protocols to improve outcomes for pregnant women and their newborns.