Laboratory Testing Monitoring Research Articles

Uric acid to HDL ratio: A marker for predicting incidence of metabolic syndrome in patients with type II diabetes

Background and aimMetabolic syndrome (MetS) refers to existence of a set of risk factors for developing cardiovascular disease and diabetes. Recently, uric acid to HDL ratio has attracted attention in predicting development of diabetes and incidence of metabolic syndrome in diabetic individuals. This study was performed to investigate UHR in patients with type II diabetes as a predicting factor for metabolic syndrome. Methods and resultsThis descriptive-analytical study examined 300 patients with type II diabetes referring to diabetes clinic of Ali-Ibn Abi-Talib hospital, Rafsanjan city in 2021, selected through convenient sampling. Data were collected by a research-made checklist (including demographic, clinical and laboratory parameters) and analyzed by SPSS 24 and chi-square, Fisher exact test, independent paired t-test, one-way analysis of variance (ANOVA), Mann-Whitney U, and receiver operating characteristic (ROC). The findings revealed that 74.33 % (95 % CI: 69 to 79.18 %) of the patients had metabolic syndrome. Further, patients with metabolic syndrome demonstrated a significantly higher mean UHR ratio and triglyceride levels compared to their counterparts without the syndrome (p = 0.002 and p < 0.001, respectively). The ROC analysis identified a UHR threshold of 8.118 % with a sensitivity of 70.32 % and specificity of 55.08 % for diagnosing metabolic syndrome development in type II diabetes (AUC: 0.621, P = 0.001, 95%CI: 0.549–0.694). ConclusionThe results of the present study revealed that the prevalence of metabolic syndrome was high in diabetic patients. UHR showed good sensitivity in the diagnosis of metabolic syndrome in type II diabetes. Thus, regular monitoring of laboratory tests is recommended in patients with diabetes.

Micromechanics and Ultrasonic Propagation in Consolidated Earthen-Site Soils.

Although nondestructive ultrasonic technologies have been applied in laboratory and field tests in the field of heritage conservation, few studies have quantified the relationship among the real microstructures, micromechanical properties, and macroscopic acoustic responses of earthen-site soils. This paper develops a micromechanics-based multiscale model for quantitatively exploring the ultrasonic propagation characteristics of elastic waves in untreated and consolidated earthen-site soils. Scanning electron microscope images and image processing technology are integrated into the finite-element simulation. The effects of microstructure and wave features on the acoustic characteristics of soils are quantitatively investigated under pulsive loading. The simulation results of untreated and consolidated soils are efficiently compared to ultrasonic test data. It is demonstrated that the integration of microstructure image processing and multiscale modeling can predict the ultrasonic pulse velocity well, which improves the accuracy of laboratory testing and field monitoring and better serves the evaluation and implementation of engineering practice in the field of heritage conservation.

Comparing patient reported and medical record data of adverse drug reactions to anti-seizure drugs.

Anti-seizure drugs (ASDs) can potentially cause serious adverse drug reactions (ADRs). Patient self-reporting can increase the rate of ADR detection, but studies examining patient self-reporting of ADRs caused by ASDs are lacking. To determine the characteristics of ADRs reported by patients receiving ASDs, assess laboratory data and medical record confirmation of patient-reported ADRs, and explore factors associated with laboratory data and medical record confirmation. A self-reporting questionnaire was distributed to patients prescribed ASDs at outpatient clinics. Patients assessed the causality of suspected ADRs using Causality Assessment Tool. Naranjo's algorithm was used by researchers for causality assessment. Medical records were used to gather information on ADR symptoms, ASD medication, and abnormal laboratory data. From 478 distributed questionnaires, 93.1% completed the questionnaire and 67.4% of respondents reported at least one ADR. The most common ADRs were drowsiness (50.7%), dizziness (9.7%), and ataxia (4.3%). For causality, suspected ADRs were classified as possible in 52.3% of cases and probable in 46.3% of cases by patients, and possible in 64.7% of cases and probable in 25.7% of cases by researchers. Only 12.7% of patients had laboratory data and/or medical record confirmation of suspected ADRs. The psychiatry clinic was less likely to confirm suspected ADRs compared to the epilepsy clinic (OR = 0.412, p = 0.022). Confirmation of patient-reported ADRs with either laboratory data or medical records was uncommon. Recording patient-reported ADRs in patients' medical history and monitoring laboratory tests related to patient-reported symptoms should be promoted to increase the safety of ASD treatment.

Association between non-dipping blood pressure pattern and different glucometabolic profile during oral glucose tolerance test

It is known that, a not physiological blood pressure (BP) circadian pattern has been associated with increased risk of organ damage and cardiovascular (CV) event. The aim of this study was to assess the association between circadian BP pattern and glucometabolic phenotypes occurring after oral glucose tolerance test (OGTT). We recruited 810 hypertensive Caucasian patients. All participants underwent to OGTT, laboratory test and 24-h ambulatory BP monitoring (ABPM). The analysis of collected data allowed classifying patients based on nocturnal BP profiles into four categories: dippers, non-dippers, extreme dippers, and reverse dippers. Considering the dipping pattern, the proportion of non-dippers in normal glucose tolerance patients with 1-h glucose ≥ 155 mg/dL (NGT ≥ 155) (36.4%) was higher than NGT < 155 (29.6%) and impaired glucose tolerance (IGT) (34.8%), but lower than type 2 diabetes group (T2DM) (52.6%) (p = 0.001). The proportion of dippers was lower in NGT ≥ 155 (47%) and T2DM (34.6%), when compared with NGT < 155 (53.8%) and IGT (51.2%) (p = 0.017). From logistic regression analysis, 1-h glucose ≥ 155 increased the risk of a pathological nocturnal drop in BP by 74%, (OR = 1.740, 95% CI 1.254–2.415, p < 0.0001). In addition, the improvement in 1 unit of Matsuda was responsible for a 3.5% risk decrease (OR = 0.965, 95% CI 0.958–0.971, p < 0.0001), while e-GFR determined a 0.9% risk reduction of nocturnal BP drop (OR = 0.991, 95% CI 0.984–0.999, p = 0.020). Our data demonstrated the existence, in newly diagnosed hypertensive patients, of an association between circadian BP profile and altered glycemic response during OGTT, in particular NGT ≥ 155 subjects are associated with a non-dipper BP pattern, this is clinically relevant because may explain, at least in part, the increased CV risk in this setting of patients.

Multicomponent Pharmacist Intervention Did Not Reduce Clinically Important Medication Errors for Ambulatory Patients Initiating Direct Oral Anticoagulants.

Anticoagulants including direct oral anticoagulants (DOACs) are among the highest-risk medications in the United States. We postulated that routine consultation and follow-up from a clinical pharmacist would reduce clinically important medication errors (CIMEs) among patients beginning or resuming a DOAC in the ambulatory care setting. To evaluate the effectiveness of a multicomponent intervention for reducing CIMEs. Randomized controlled trial. Ambulatory patients initiating a DOAC or resuming one after a complication. Pharmacist evaluation and monitoring based on the implementation of a recently published checklist. Key elements included evaluation of the appropriateness of DOAC, need for DOAC affordability assistance, three pharmacist-initiated telephone consultations, access to a DOAC hotline, documented hand-off to the patient's continuity provider, and monitoring of follow-up laboratory tests. Coupons and assistance to increase the affordability of DOACs. Anticoagulant-related CIMEs (Anticoagulant-CIMEs) and non-anticoagulant-related CIMEs over 90days from DOAC initiation; CIMEs identified through masked assessment process including two physician adjudication of events presented by a pharmacist distinct from intervention pharmacist who reviewed participant electronic medical records and interview data. Incidence and incidence rate ratio (IRR) of CIMEs (intervention vs. control) using multivariable Poisson regression modeling. A total of 561 patients (281 intervention and 280 control patients) contributed 479 anticoagulant-CIMEs including 31 preventable and ameliorable ADEs and 448 significant anticoagulant medication errors without subsequent documented ADEs (0.95 per 100 person-days). Failure to perform required blood tests and concurrent, inappropriate usage of a DOAC with aspirin or NSAIDs were the most common anticoagulant-related CIMEs despite pharmacist documentation systematically identifying these issues when present. There was no reduction in anticoagulant-related CIMEs among intervention patients (IRR 1.17; 95% CI 0.98-1.42) or non-anticoagulant-related CIMEs (IRR 1.05; 95% CI 0.80-1.37). A multi-component intervention in which clinical pharmacists implemented an evidence-based DOAC Checklist did not reduce CIMEs. NCT04068727.

Anticoagulation with Intravenous Direct Thrombin Inhibitors in Pediatric Extracorporeal Membrane Oxygenation: A Systematic Review of the Literature.

Although intravenous (IV) direct thrombin inhibitors (DTI) have gained interest in pediatric extracorporeal membrane oxygenation (ECMO), dosing and safety information is limited. The objective of this systematic review was to characterize DTI types, dosing, monitoring, and outcomes (bleeding and thromboembolic) in pediatric ECMO patients managed with IV DTIs. We conducted searches of MEDLINE (Ovid) and Embase (Elsevier) from inception through December 2022. Case reports, retrospective studies, and prospective studies providing per-patients or summary data for patient(s) <18 years of age receiving IV DTI for ECMO anticoagulation were included. Study selection and data extraction were conducted independently by two reviewers. A total of 28 studies: 14 case reports, 13 retrospective studies, and 1 prospective study were included, totaling 329 patients. Bivalirudin was utilized in 318 (96.7%), argatroban in 9 (2.7%), and lepirudin in 2 (0.6%) patients. Infusion dosing included: bivalirudin 0.14 ± 0.37 mg/kg, argatroban 0.69 ± 0.73 µg/kg/min, lepirudin 0.14 ± 0.02 mg/kg/h. Laboratory monitoring tests utilized were the activated clotting time, activated partial thromboplastin time (aPTT), diluted thrombin time, and thromboelastography measures. The aPTT was utilized in most patients (95%). Thromboembolism, bleeding, or death were observed in 17%, 17%, and 23% of bivalirudin, argatroban, and lepirudin patients, respectively. Bivalirudin appears to be the most frequently used DTI in pediatric ECMO. Dosing and laboratory monitoring varied, and bleeding and thromboembolic events were reported in 17% of patients. Prospective studies are warranted to establish dosing, monitoring, safety, and efficacy of bivalirudin and other IV DTI in pediatric ECMO.

A guide to conducting systematic reviews of clinical laboratory tests.

Clinical laboratory professionals have an instrumental role in supporting clinical decision making with theoptimal use of laboratory testing for screening, risk stratification, diagnostic, prognostic, treatment selection and monitoring of different states of health and disease. Delivering evidence-based laboratory medicine relies on review of available data and literature. The information derived, supports many national policies to improve patient care through clinical practice guidelines or best practice recommendations. The quality, validity and bias of this literature is variable. Hence, there is a need to collate similar studies and data and analyse them critically. Systematic review, thus, becomes the most important source of evidence. A systematic review, unlike a scoping or narrative review, involves a thorough understanding of the procedure involved and a stepwise methodology. There are nuances that need some consideration for laboratory medicine systematic reviews. The purpose of this article is to describe theprocess of performing a systematic review in the field oflaboratory medicine, describing the available methodologies, tools and software packages that can be used to facilitate this process.

Permanent Deformation Monitoring and Remaining Life Prediction of Asphalt Pavement Combining Full-Scale Accelerated Pavement Testing and FEM

Permanent deformation (rutting) is one of the typical failure modes of asphalt pavement with a semirigid base in high-temperature areas. To address issues of pavement structure deformation and remaining life prediction, a method of combining accelerated pavement testing and finite element (FE) simulation was proposed. A modified Burgers model considering creep parameter damage was obtained using strain monitoring data and laboratory test values, which was performed in the FE model to analyze rutting development. The results showed that high temperature and heavy axle loads greatly influenced rutting development: the tested road was loaded 360,000 times at high temperature, contributing 50% to accumulated rutting; rutting increased by 90.7% under the condition of 50% overload under high-temperature seasons from the simulated results. Then, the ratio of the bulge area to the depression area (KR) was proposed to define the rutting deformation mechanism. The KR analysis results illustrated that rutting development was a transition process from compaction rutting to flow rutting. Finally, the relationship between the action times of axle load in the tested and in-service roads was established based on the rutting equivalence principle. When the action times of axle load reach approximately 25 million times (insufficient remaining life) for the investigated Hu-Ning highway, necessary maintenance measures should be taken to treat rutting deformation.

Optimal laboratory testing protocol for patients with acne taking oral isotretinoin

Isotretinoin is a widely prescribed drug for various dermatological conditions, especially acne. Blood tests are routinely performed to monitor its side effects. However, the optimal testing schedule remains controversial. To evaluate the laboratory monitoring tests and schedules of patients with acne taking isotretinoin to determine the most efficient testing regimen. We retrospectively reviewed electronic medical records from the Dermatology Department of Dongguk University Ilsan Hospital from 2005 to 2020 for patients prescribed isotretinoin for acne who underwent monthly blood tests. Aspartate aminotransferase (AST), alanine aminotransferase (ALT), and triglyceride (TG) levels significantly changed between 5 and 6 mo when the total prescription period and dose variables were considered altogether. The high-density lipoprotein level also significantly changed between 5 and 6 mo. However, low-density lipoprotein (LDL) and total cholesterol levels significantly changed between 1 and 2 mo. We recommend testing AST, ALT, and TG levels once every 5 to 6 mo. We also suggest testing LDL and total cholesterol levels during the first and second months.

The features of clinical manifestations of acute stroke associated with COVID-19

The most severe course of COVID-19 is observed in patients with vascular comorbidity (more than 3 cardiovascular diseases). At the same time, a large number of complications from various organs and systems are recorded in this group of patients, with acute stroke being one of the most severe. Stroke in patients with COVID-19 is characterized by a severe clinical course, with a high rate of deaths and poor rehabilitation prognosis in the early and late recovery period. The cohort combined retrospective-prospective study included 80 patients. All subjects were divided into groups: 1) patients with stroke and COVID-19; 2) stroke patients without COVID-19; 3) COVID-19 patients without stroke. All patients underwent complex clinical and laboratory monitoring, including general and biochemical blood tests, assessment of hemostasis and the level of pro-inflammatory cytokines, and MSCT of the brain and lungs. As a result of the study, it was found that patients with stroke and COVID-19 have a more severe course of the disease with a high incidence of multiple organ dysfunction syndrome (MODS) and deaths at the hospital stage.

Vision-based real-time structural vibration measurement through deep-learning-based detection and tracking methods

Structural vibration measurement is crucial in structural health monitoring and structural laboratory tests. Traditional contact type sensors are usually required to be attached to the test specimens, which may be difficult to install, and may affect the structural properties and response. Non-contact type wireless sensors are usually expensive and require specialized workers to install and operate. In recent years, vision-based tracking methods for structural vibration measurement have gained increasing interests due to their high accuracy, non-contact feature and low cost. However, traditional vision-based tracking algorithms are susceptible to external environmental conditions such as illumination and background noise. In this paper, two real-time methods, YOLOv3-tiny and YOLOv3-tiny-KLT, are proposed to track structural motions. In the first method, YOLOv3-tiny is established based on the YOLOv3 architecture to localize customized markers where structural displacements are directly determined from the bounding boxes generated. The second method, YOLOv3-tiny-KLT, is a more advanced method which combines the YOLOv3-tiny detector and the traditional KLT tracking algorithm. The pretrained YOLOv3-tiny is deployed to localize the targets automatically, which will then be tracked by Kanade‐Lucas‐Tomasi algorithm. YOLOv3-tiny is intended to provide baseline vibration measurement when the KLT tracking gets lost. The proposed methods were implemented for the videos of shake table tests on a two-storey steel structure. Parametric studies were conducted for the YOLOv3-tiny-KLT method to examine its sensitivity to the tracking parameters. The results show that the proposed method is capable of achieving real-time speed and high accuracy, when compared with the traditional displacement sensors including linear variable differential transducer (LVDT) and String Pots. It is also found that the combined YOLOv3-tiny-KLT approach achieves higher accuracy than YOLOv3-tiny only method, and higher robustness than KLT only method against illumination changes and background noise.

Usefulness of Routine Laboratory Tests for Follow up of Patients Receiving Outpatient Parenteral Antimicrobial Therapy Run by Infectious Diseases Fellows

The infectious disease society of America (IDSA) recommends routine laboratory tests for all patients receiving outpatient parenteral antimicrobial therapy (OPAT) to monitor for adverse events. There are no data to support how often patients should take monitoring laboratory tests. In addition, the relevance of different laboratory tests commonly used for OPAT follow up is not clearly known. We conducted a retrospective observational cohort study over a 7-year study interval (1 January 2014 to 31 December 2021). Clinical data were obtained to identify the risk factors associated with abnormal laboratory tests and determine if abnormal laboratory tests led to antibiotic change or hospital readmission. Two hundred and forty-six patients met the inclusion criteria for this study. In our multivariate analysis, the Charlson comorbidity index (CCI) of 0-4 (aOR 0.39, 95%Cl 0.18-0.86), the use of ceftriaxone without vancomycin (aOR 0.47, 95%Cl 0.24-0.91) and an OPAT duration of 2-4 weeks (aOR 0.47, 95%Cl 0.24-0.91) were associated with a lower risk of OPAT complications. A CCI of 5 or more (aOR 2.5, 95%Cl (1.1-5.7)) and an OPAT duration of 5 or more weeks (aOR 2.7, 95% Cl 1.3-5.6) were associated with a higher risk of OPAT complications. An abnormal complete metabolic panel or vancomycin levels, but not an abnormal complete blood count, were associated with antibiotic change or readmission. Patients with fewer comorbidities, ceftriaxone and short OPAT durations are at lower risk for OPAT complications. These patients could be followed with less frequent laboratory monitoring.

Assessing challenges and opportunities of treating breast cancer in Lesotho

Background: It has been estimated that, more than 60% of the new breast cancer cases and 70% of related deaths will be seen in Low-Middle Income Countries in the coming 20 years. In Lesotho, out of 228 women, 177 had heard about breast cancer while 72.9% had heard of breast cancer screening. Given limited treatment facilities and options in Lesotho, many patients die soon after diagnosis, before they are able to access treatment; to date this cannot be quantified. Another challenge that affects breast cancer management is treatment and travel-related costs, particularly for those not living close to the medical centre. Most patients are coming with advanced disease stage and are sent home for home-based care, some of which could have been prevented with early screening. Aim: The aim of study is to determine challenges faced by breast cancer patients, the cost to the health system and the opportunities this may bring to the country. Methods: A quantitative cross-sectional, prospective and retrospective study was conducted on 45 breast cancer patients who were initiated chemotherapy at the only cancer treatment centre in Lesotho; Senkatana oncology clinic located at the Botshabelo complex in Maseru. Results: The majority of patients were facing challenges of arranging transport to the doctor (83.3%, n=15), of being far from the healthcare facilities even if transportation was available (77.8%, n=14), paying for healthcare (83.3%, n=15), paying for transport (77.8%, n=14) and paying for diagnostic test (88.9%, n=16) in all ages. Majority of patients who presented for care and treatment late faced challenges more than those who presented earlier. Diagnostic and monitoring laboratory test constituted 64.5% of total direct medical costs followed by 24.7 % from chemotherapy. Conclusion: The challenges faced by breast cancer patients are of financial and practical nature and they get higher for patients who presented at advanced stage for care and treatment. In order to improve breast cancer care and treatment outcome at lower costs efforts for breast cancer awareness need to be intensified so that patients presented early at the health centers. In term of direct medical cost, the largest cost came from the diagnostic and monitoring laboratory tests.

Clinical Decision Support systems: A step forward in establishing the clinical laboratory as a decision maker hub - A CDS system protocol implementation in the clinical laboratory

BackgroundNew tools for health information technology have been developed in recent times, such as Clinical Decision Support (CDS) systems, which are any digital solutions designed to help healthcare professionals when making clinical decisions. The study aimed to show how we have adopted a CDS system in the San Juan de Alicante Clinical Laboratory and facilitate the implementation of our protocol in other clinical laboratories. We have user experience and the motivation to improve healthcare tools. The improvement, measurement, and monitoring of interventions and laboratory tests has been our motto for years. Materials and methodsA descriptive research was conducted. All stages in the design of the project are as follows: 1. Set up a multidisciplinary workgroup. 2. Review patients’ data. 3. Identify relevant data from main sources. 4. Design the likely outcomes. 5. Define a complete integration scenario. 6. Monitor and track the impact. To set up this protocol, two new software systems were implemented in our laboratory: AlinIQ CDS v8.2 as Rule Engine, and AlinIQ AIP Integrated Platform v1.6 as Business Intelligence (BI) tool. ResultsOur protocol shows the workflow and actions that can be done with a CDS system and also how it could be integrated with other monitoring systems, as well as some examples of KPIs and their outcomes. ConclusionsCDS could be a great strategic asset for clinical laboratories to improve the integration of care, optimize the use of laboratory tests, and add more clinical value to physicians in the interpretation of results.

The impact of clinical pharmacist integration in a community rheumatology clinic.

To describe the benefits of pharmacist integration into a community rheumatology clinic in terms of clinical outcomes, patient and provider satisfaction, and clinic time efficiency. A 6-month study was conducted at a community rheumatology clinic to compare clinical and patient and provider satisfaction outcomes before and after a clinical pharmacist (CP) was integrated into the clinic staff to assist with providing medication counseling, ordering and monitoring laboratory tests, monitoring adverse effects and medication adherence, and titrating medication doses. The primary outcome was the change in Routine Assessment of Patient Index Data 3 (RAPID-3) scores from baseline to 3 and 6 months after CP integration. Secondary outcomes included the change in monthly pain scores from baseline to 6 months, the change in patient satisfaction scores from baseline to 6 months, and time saved for the rheumatology providers after pharmacist integration into the clinic. The mean difference in RAPID-3 scores from baseline to 3 months (N = 55) was an improvement of 5.58 points (P < 0.001), while the mean change in weighted RAPID-3 scores was an improvement of 1.87 (P < 0.001). The mean change in RAPID-3 scores from baseline to 6 months (n = 25) was an improvement of 5.13 (P = 0.003), and the mean change in weighted RAPID-3 scores was 1.78 (P = 0.003). The results of this quality improvement project suggest that the integration of a CP in the rheumatology clinic improved patient-reported outcomes, as quantified by patients' pain scores and RAPID-3 scores. The integration of the CP also appeared to enhance patient and provider satisfaction.

Laporan Kasus : Neonatal Dengue

Background : Dengue fever in late pregnancy puts the fetus at great risk because fewer maternal-specific antibodies cross the placenta, leading to a high probability of neonatal dengue infection. We followed a patient in the pediatric health department of the Bali Mandara Hospital. &#x0D; Case Persentation : A 9-day-old baby boy complained of fever for 3 days up to a temperature of 39℃; the fever rose up and fell, but the fever did not go down to normal temperature. On physical examination, the baby was found to be less active, crying enough, suction reflex (+), pulse 135x/minute, breathing: 44 x/minute, temperature: 38.8 (axillary), SpO2: 93%, jaundice (+), lower extremities: warm acral (+), left petechiae (+), CRT &lt;2'', jaundice skin of Kramer 2-3. Laboratory test result’s showed the platelets (69.000), hematocrit(52.2), positive dengue NS1 antigen, and positive dengue IgG and IgM. The patient was diagnosed with neonatal dengue and admitted to Perinatology. Optimal management is needed to treat neonatal dengue.&#x0D; Conclussion : It is Importance to know the transmission of dengue infection to infants, especially in endemic areas. Considering the complication that may occur, early recognition of dengue will significantly reduce infant mortality. Careful monitoring and proper laboratory tests can lead to a smooth recovery.&#x0D; Key word : Neonatal dengue, Platelets, Placenta

Thrombosis-Related Loss of Arterial Lines in the First Wave of COVID-19 and Non-COVID-19 Intensive Care Unit Patients.

Patients with coronavirus disease 2019 (COVID-19) can present with severe respiratory distress requiring intensive care unit (ICU)-level care. Such care often requires placement of an arterial line for monitoring of pulmonary disease progression, hemodynamics, and laboratory tests. During the first wave of the COVID-19 pandemic in March 2020, experienced physicians anecdotally reported multiple attempts, decreased insertion durations, and greater need for replacement of arterial lines in patients with COVID-19 due to persistent thrombosis. Because invasive procedures in patients with COVID-19 may increase the risk for caregiver infection, better defining difficulties in maintaining arterial lines in COVID-19 patients is important. We sought to explore the association between COVID-19 infection and arterial line thrombosis in critically ill patients. In this primary exploratory analysis, a multivariable Fine-Gray subdistribution hazard model was used to retrospectively estimate the association between critically ill COVID-19 (versus sepsis/acute respiratory distress syndrome [ARDS]) patients and the risk of arterial line removal for thrombosis (with arterial line removal for any other reason treated as a competing risk). As a sensitivity analysis, we compared the number of arterial line clots per 1000 arterial line days between critically ill COVID-19 and sepsis/ARDS patients using multivariable negative binomial regression. We retrospectively identified 119 patients and 200 arterial line insertions in patients with COVID-19 and 54 patients and 68 arterial line insertions with non-COVID ARDS. Using a Fine-Gray subdistribution hazard model, we found the adjusted subdistribution hazard ratio (95% confidence interval [CI]) for arterial line clot to be 2.18 (1.06-4.46) for arterial lines placed in COVID-19 patients versus non-COVID-19 sepsis/ARDS patients ( P = .034). Patients with COVID-19 had 36.3 arterial line clots per 1000 arterial line days compared to 19.1 arterial line clots per 1000 arterial line days in patients without COVID-19 (adjusted incidence rate ratio [IRR] [95% CI], 1.78 [0.94-3.39]; P = .078). Our study suggests that arterial line complications due to thrombosis are more likely in COVID-19 patients and supports the need for further research on the association between COVID-19 and arterial line dysfunction requiring replacement.

Using the Electronic Medical Record to Increase Laboratory Test Monitoring in Ocular Inflammation Patients: A Quality Improvement Study.

Treatment of chronic, noninfectious ocular inflammation includes corticosteroids, disease-modifying antirheumatic medications, and biologics. To mitigate adverse effects associated with the use of these medications, routine laboratory test monitoring is recommended throughout treatment. We evaluated the effectiveness of an alert added to the electronic medical record (EMR) to aid in laboratory test monitoring for patients prescribed these high-risk medications. A prospective, interventional study assessed the effect of the alert within the EMR on laboratory test ordering at the Division of Ocular Immunology at the Wilmer Eye Institute. The primary outcome measure was the change in number of ordered laboratory tests at 3, 6, and 12 months after the alert activation compared with pre-intervention levels and overall through the study period. The laboratory tests that were monitored included complete blood count, comprehensive metabolic panel, dual-energy x-ray absorptiometry (DXA) scanning, fasting lipid panel, and interferon gamma release assays. The laboratory test orders for 153 patients on high risk medications were analyzed. Only the frequency of ordering the DXA and interferon gamma release assays increased significantly, compared with baseline, throughout the study. Conversely, there was a significant decrease in the frequency of ordering of fasting lipid profiles and hemoglobin A 1c at each time point and for complete blood count and comprehensive metabolic panel at the 6-month time point. An EMR alert results in increased laboratory test ordering initially for tests drawn on a yearly basis, but the effect on more frequently ordered tests wanes with time if the alert can be silenced by the provider. Nonetheless, it provides a novel mechanism to increase laboratory ordering in patients on high-risk medications that can be adapted for use in other EMR software. Future studies are needed to assess whether physician laboratory test ordering behavior is altered throughout the study period with the use of a non-silencable alert.

Enhancing Anticoagulation Monitoring and Therapy in Patients Undergoing Microvascular Reconstruction in Maxillofacial Surgery: A Prospective Observational Trial.

Background: In reconstructive surgery, loss of a microvascular free flap due to perfusion disorders, especially thrombosis, is a serious complication. In recent years, viscoelastic testing (VET) has become increasingly important in point-of-care (POC) anticoagulation monitoring. This paper describes a protocol for enhanced anticoagulation monitoring during maxillofacial flap surgery. Objective: The aim of the study will be to evaluate, in a controlled setting, the predictive value of POC devices for the type of flap perfusion disorders due to thrombosis or bleeding. VET, Platelet monitoring (PM) and standard laboratory tests (SLT) are comparatively examined. Methods/Design: This study is an investigator-initiated prospective trial in 100 patients undergoing maxillofacial surgery. Patients who undergo reconstructive surgery using microvascular-free flaps will be consecutively enrolled in the study. All patients provide blood samples for VET, PM and SLT at defined time points. The primary outcome is defined as free flap loss during the hospital stay. Statistical analyses will be performed using t-tests, including the Bonferroni adjustment for multiple comparisons. Discussion: This study will help clarify whether VET can improve individualized patient care in reconstruction surgery. A better understanding of coagulation in relation to flap perfusion disorders may allow real-time adaption of antithrombotic strategies and potentially prevent flap complications.

Out-of-sync heat and gas generation in landfill and its effect on slope stability

Heat and gas generation from the degradation of municipal solid waste affects landfill slope stability. Currently, the differences between heat and gas generation are understood, and landfill slope stability analyses considering these differences are required. In this study, the conducted laboratory and field monitoring tests indicated that heat generation peaked earlier than gas generation. The relationship between the heat and gas generation was then considered in a landfill slope stability analysis. The earlier the temperature and gas generation peaked, the lower the safety factor and the earlier the minimum safety factor appeared. The minimum safety factor generally occurred when gas generation peaked. The minimum safety factors obtained with consideration of the out-of-sync heat and gas generation were up to 1.25% greater than those obtained when the temperature or gas generation rate was maintained at a peak value. The later the temperature peaked, and the earlier the gas generation rate peaked, a higher leachate level resulted in a larger difference between the minimum safety factors obtained with and without consideration of the out-of-sync heat and gas generation. Landfill slope instability is more likely to occur in the initial stage of landfilling.