Supplemental Use Research Articles

Prevalence of pulmonary artery dilation in non-cystic fibrosis bronchiectasis: a computed tomography analysis from a cohort of the US Bronchiectasis and Nontuberculous Mycobacteria Research Registry.

Although pulmonary artery (PA) dilation is independently associated with significant morbidity and mortality in patients with pulmonary diseases irrespective of diagnosed pulmonary hypertension, its relationship with nontuberculous mycobacteria (NTM) is unknown. The Bronchiectasis and NTM Research Registry is a multicenter registry created to foster research in non-cystic fibrosis (CF) bronchiectasis and NTM lung disease. The majority of patients with non-CF bronchiectasis at Oregon Health & Science University have NTM infections. To determine the prevalence of PA dilation in these patients and its association with supplemental oxygen use, severity of bronchiectasis, tobacco use, and NTM in the sputum culture, we evaluated the chest computed tomography (CT) scans from 321 patients in a cross-sectional analysis. We measured the severity of bronchiectasis by applying modified Reiff criteria and measured the diameters of the PA and aorta (Ao), with PA dilation defined as a PA:Ao ratio >0.9. In our cohort, the mean age was 67.3 years and 83.2% were female. The mean modified Reiff score was 7.1, indicating moderate disease severity. Forty-two patients (13.1%) were found to have PA dilation. PA dilation was positively associated with the use of supplemental oxygen (P<0.001), but there was no association between PA dilation and NTM infection.

Suspension of Sonchus arvensis L Leaves Ethanolic Extract Affects Blood Creatinine and Urea Levels in Streptozotocin-Induced Wistar Male Rats

The study focused on analyzing the secondary metabolites present in the ethanol extract of Sonchus arvensis L. leaves (SALEE) and their impact on creatinine and urea levels when administered in suspension form at different doses. Phytochemical screening of SALEE identified alkaloids, flavonoids, phenols, saponins, and tannins. In the experiment, twenty-five white male rats were divided into five groups: a healthy control group (Group I), a negative control group (Group II), and three test groups (Groups III, IV, and V) receiving SALEE at doses of 200, 300, and 400 mg/kg BW, respectively. After inducing diabetes with streptozotocin and a 21-day follow-up period, creatinine and urea levels were assessed. The results demonstrated that SALEE administration significantly reduced creatinine levels and increased urea levels. Notably, the 200 mg/kg BW dose of SALEE exhibited a consistent and long-term effect. It was observed that blood urea levels fluctuated even in healthy and negative control groups during the 21-day observation period. In the group receiving the highest dose of SALEE (400 mg/kg BW), blood urea levels increased significantly on days 14 and 21, indicating a potential increase in the rats' appetite rather than renal function failure. Overall, the findings suggest that SALEE has promising potential to regulate creatinine and urea levels in the blood of individuals with diabetes, highlighting its potential for therapeutic and supplemental use.

Potential Usefulness a Coronal View using an Automated Breast Ultrasound System in Detecting Breast Lesions.

An automated breast ultrasound system (ABUS) combined with screening mammography has increased cancer detection rates; however, supplemental ABUS use has increased recall rates. In this study, we aimed to identify an accurate and efficient method of ABUS interpretation and evaluate the potential usefulness of its coronal view versus the conventional transverse view. This retrospective observer study included comprised 114 ABUS cases (40 normal, 35 benign, 39 malignant). Ten physicians from multiple institutions interpreted the anonymized coronal and transverse views independently. The observers scored their confidence in the lesion detection for each case using a continuous scale and recorded reading times for each coronal and transverse view interpretation. Free-response receiver operating characteristic analysis was employed to compare detection accuracies between views; a paired t-test was used to compare the average reading times. Detection accuracy did not differ significantly between the coronal and transverse views (figure of merit=0.740 and 0.745, respectively; p = 0.72). However, the average reading time for the coronal view was significantly shorter than that for the transverse view (149.7 vs. 200.3 seconds per case, p = 0.003). The coronal view obtained with the ABUS was useful for interpretation and associated with significantly shorter reading times compared with the conventional transverse view while maintaining breast lesion detection accuracy.

Severe Acute Exacerbations of Chronic Obstructive Pulmonary Disease: Are There Significant Differences Between Hospitalized and Emergency Department Patients?

Current guidelines define a severe acute exacerbation of chronic obstructive pulmonary disease (AECOPD) as an increase in symptoms requiring hospital admission or emergency department (ED) visit. Little is known about whether or not subjects requiring hospitalization and those needing only ED care have similar patient profiles and if their clinical outcomes appear comparable. The main goals of this study were to compare the demographic and clinical characteristics of patients treated for an AECOPD with an inpatient admission versus an ED visit and to review if hospital resource utilization was different between the 2 groups after discharge. Subjects treated in 2022 at Montfort Hospital for an AECOPD were reviewed. Patient demographic information was collected in addition to spirometry results and blood eosinophil counts on file. Supplemental oxygen use and medication lists were also recorded. Patients with an initial hospital admission were compared to those requiring only ED care with univariate and multivariate analyses. We also assessed if subjects were again treated for an AECOPD up to 6 months post initial discharge, and if so, the type of hospital visits (hospitalization or ED). A total of 135 individuals necessitated hospitalization and 79 received ED care for the treatment of an AECOPD. On univariate analysis, patients requiring an inpatient stay appeared older and were more likely to have spirometry results on file. A greater proportion of hospitalized individuals were on supplemental oxygen and prescribed at least one long-acting inhaled medication. These studied variables remained significant after multivariate logistic regression analysis. Subjects with an initial inpatient admission were also more likely to require hospitalization upon repeat presentation for a severe AECOPD. Given the important differences observed in both patient characteristics and hospital resource utilization, this study supports considering an AECOPD requiring inpatient admission versus an ED visit as distinct categories of events.

Incidence Of Acute Kidney Injury In Mild, Moderate And Severe Cases Of Coronavirus Disease

Objective: The purpose of this research was to determine the incidence of Acute Kidney Injury (AKI) in COVID-19-affected patients Methods: This retrospective cohort study was conducted at Ziauddin Hospital Clifton Campus from June to December 2020. Adult patients with AKI or acute-on-chronic kidney disease (ACKD) were included in a retrospective study. Patients infected with SARS-CoV2 and renal involvement were directed towards the ICU/Nephrology departments which have the expertise to perform laboratory analysis, radiography and institution of treatment. Supplemental oxygen use was documented. The research also assessed information about therapy (antivirals, immunomodulators, RRT) and results (renal function recovery or death). Results: After excluding patients with obstructive AKI, a total of 180 (mean age 50.1 years) of 104 males and 76 females were included in the research. 120 patients were found to have prerenal, and 60 had intrinsic AKI with significant differences between mild, moderate, and severe cases (p=0.004). Acute kidney injury (AKI) survivors had a complete recovery rate of 70%, a partial recovery rate of 22%, and a hemodialysis dependency rate of 8%. Conclusion: Patients with severe COVID-19 infection often develop more severe AKI, and those in the severe or critical stages often exhibit proteinuria and dipstick hematuria. Long-term follow-up for COVID-19 patients should be done to evaluate its influence on renal outcome, and larger samples are required to elucidate the association between COVID-19 and renal damage. Keywords: Coronavirus Disease, Renal Replacement Therapy, proteinuria, dipstick hematuria

Discovery of Transfer Factors in Plant-Derived Proteins and an In Vitro Assessment of Their Immunological Activities.

Repeated exposure to pathogens leads to evolutionary selection of adaptive traits. Many species transfer immunological memory to their offspring to counteract future immune challenges. Transfer factors such as those found in the colostrum are among the many mechanisms where transfer of immunologic memory from one generation to the next can be achieved for an enhanced immune response. Here, a library of 100 plants with high protein contents was screened to find plant-based proteins that behave like a transfer factor moiety to boost human immunity. Aqueous extracts from candidate plants were tested in a human peripheral blood mononuclear cell (PBMC) cytotoxicity assay using human cancerous lymphoblast cells-with K562 cells as a target and natural killer cells as an effector. Plant extracts that caused PBMCs to exhibit enhanced killing beyond the capability of the colostrum-based transfer factor were considered hits. Primary screening yielded an 11% hit rate. The protein contents of these hits were tested via a Bradford assay and Coomassie-stained SDS-PAGE, where three extracts were confirmed to have high protein contents. Plants with high protein contents underwent C18 column fractionation using methanol gradients followed by membrane ultrafiltration to isolate protein fractions with molecular weights of <3 kDa, 3-30 kDa, and >30 kDa. It was found that the 3-30 kDa and >30 kDa fractions had high activity in the PBMC cytotoxicity assay. The 3-30 kDa ultrafiltrates from the top two hits, seeds from Raphanus sativus and Brassica juncea, were then selected for protein identification by mass spectrometry. The majority of the proteins in the fractions were found to be seed storage proteins, with a low abundance of proteins involved in plant defense and stress response. These findings suggest that Raphanus sativus or Brassica juncea extracts could be considered for further characterization and immune functional exploration with a possibility of supplemental use to bolster recipients' immune response.

905. Epidemiology of Enterovirus D68 in the US: New Vaccine Surveillance Network, 2017–2022

Abstract Background Provisional US data indicated that enterovirus D68 (EV-D68) circulated during summer 2022. However, in contrast to 2018 (a previous high circulation year), EV-D68 circulation in 2022 was associated with unusual increases in asthma-specific healthcare visits and a lack of concomitant increases in acute flaccid myelitis (AFM). To explore these distinctions by year, we characterized respiratory EV-D68 circulation in 2022 and compared patient characteristics in 2022 to 2018. Methods We enrolled children aged &amp;lt; 18 years with acute respiratory illness (ARI) seeking care in an emergency department (ED) or as an inpatient (IP) across 7 US medical centers in the New Vaccine Surveillance Network (NVSN). Data sources included parent interview, medical chart review, and collection of a respiratory swab for molecular virus testing. Swabs were tested for EV-D68 from Jul–Nov 2017–2020, and year-round from Jul 2021. A convenience sample of EV-D68-positive swabs was sequenced. We assessed monthly EV-D68 percent positivity among children with ARI. We examined demographics, underlying conditions, and severity markers among children with EV-D68 in 2018 and 2022, by care setting (ED vs IP) and used 0.05 as a threshold of statistical significance. Results Between 2017–2022, there were 994 ED and IP EV-D68 detections at NVSN sites, with distinct peaks during the Jul-Nov testing periods in 2018 and 2022 (Figure). All viruses sequenced in 2018 and 2022 were lineage B3. Compared to 2018, IPs with EV-D68 in 2022 less frequently reported any underlying medical condition or a history of asthma, yet more frequently required supplemental oxygen or intubation (Table). Supplemental oxygen use was also more common among ED patients in 2022 than 2018 (13% vs 6%; p=0.028). Asthma exacerbation was a common primary discharge diagnosis among IPs but was less common in 2022 than 2018 (43% vs 53%; p=0.030). Conclusion EV-D68 circulation was high in 2018, appeared to be disrupted in 2020, and returned with early and high circulation in 2022. Compared to 2018, EV-D68 may have caused more severe respiratory disease in 2022, including in otherwise healthy children. The lack of AFM observed in 2022 despite high EV-D68 circulation needs further investigation. Disclosures Mary A. Staat, MD, MPH, CDC: Grant/Research Support|Cepheid: Grant/Research Support|Merck: Grant/Research Support|NIH: Grant/Research Support|Pfizer: Grant/Research Support|Up-To-Date: Honoraria Elizabeth P. Schlaudecker, MD, MPH, Pfizer: Grant/Research Support|Sanofi Pasteur: Advisor/Consultant Rangaraj Selvarangan, BVSc, PhD, D(ABMM), FIDSA, FAAM, Abbott: Honoraria|Altona Diagnostics: Grant/Research Support|Baebies Inc: Advisor/Consultant|BioMerieux: Advisor/Consultant|BioMerieux: Grant/Research Support|Bio-Rad: Grant/Research Support|Cepheid: Grant/Research Support|GSK: Advisor/Consultant|Hologic: Grant/Research Support|Lab Simply: Advisor/Consultant|Luminex: Grant/Research Support Natasha B. Halasa, MD, MPH, Merck: Grant/Research Support|Quidell: Grant/Research Support|Quidell: donation of kits|Sanofi: Grant/Research Support|Sanofi: vaccine support Marian G. Michaels, MD, MPH, Merck: Grant/Research Support|Viracor: Grant/Research Support Geoffrey A. Weinberg, MD, Merck &amp; Co: Honoraria Janet A. Englund, MD, Ark Biopharma: Advisor/Consultant|AstraZeneca: Advisor/Consultant|AstraZeneca: Grant/Research Support|GlaxoSmithKline: Grant/Research Support|Meissa Vaccines: Advisor/Consultant|Merck: Grant/Research Support|Moderna: Advisor/Consultant|Moderna: Grant/Research Support|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support|Sanofi Pasteur: Advisor/Consultant

Association Between the Neutrophil-to-Lymphocyte Ratio and Adverse Outcomes in Children Aged &amp;lt;2 Years with Respiratory Syncytial Virus

Abstract Background Respiratory syncytial virus (RSV) is a leading cause of hospitalization in children &amp;lt;2 years old. The neutrophil-to-lymphocyte ratio (NLR) is a readily available marker of inflammation that has been studied as a prognostic marker in various infectious diseases. However, its utility in children with RSV remains underexplored. We aimed to determine the association between NLR and adverse outcomes in children &amp;lt;2 years old with RSV. Methods We retrieved records for all clinician-ordered multiplex respiratory viral panel tests for common respiratory pathogens (including RSV) at Vanderbilt University Medical Center between 01/01/2018 and 12/01/2022. We identified RSV-positive children &amp;lt;2 years old who had a complete blood count (CBC) performed with absolute lymphocyte count (ALC) ≥2.00×103/μL and absolute neutrophil count (ANC) ≥1.70×103/μL. Any child with a medical encounter &amp;gt;14 days following a previous encounter was considered a distinct case. We used logistic regression to assess the association between (log-transformed) NLR and adverse outcomes defined as hospitalization, supplemental oxygen use, intensive care unit (ICU) admission, and intubation. Results Of 2,395 RSV-positive children &amp;lt;2 years old, 446 (18.6%) had a CBC performed. Of those, 349 (78.3%) met the stated thresholds for ALC and ANC. The median age of the cohort was 3.7 months (IQR, 1.6–11.6 months), 178 (51.0%) were male, and 269 (77.1%) were hospitalized. Of those hospitalized, 185 (68.8%) received supplemental oxygen, 113 (42.0%) were admitted to the ICU, and 45 (16.7%) were intubated. The odds ratio associated with a two-fold difference in NLR was significant for hospitalization (OR, 1.46; 95% CI, 1.13–1.91; p=0.005) and ICU admission (OR, 1.38; 95% CI, 1.07–1.78; p=0.013) but not for supplemental oxygen use (OR, 1.14; 95% CI, 0.87–1.49; p=0.34) or intubation (OR, 1.32; 95% CI, 0.96–1.83; p=0.092; Table 1). Conclusion Higher NLR was associated with hospitalization and ICU admission in children &amp;lt;2 years with RSV. These findings suggest that NLR has prognostic value in children with RSV.

Prostaglandin-E1 infusion in persistent pulmonary hypertension of the newborn.

Neonates with persistent pulmonary hypertension of the newborn (PPHN) can present with hypoxia and right ventricular dysfunction with resultant inadequate oxygen delivery and end-organ damage. This study describes the use of prostaglandin-E1 (PGE) for ductal patency to preserve right ventricular systolic function and limit afterload in newborns with PPHN. This is a retrospective cohort study that follows the hemodynamics, markers of end-organ perfusion, length of therapeutics, and echocardiographic variables of 57 newborns who used prostglandin-E1 in the setting of PPHN. Tachycardia, lactic acidosis, and supplemental oxygen use improved following PGE initiation. Fractional area change (FAC), to assess right ventricular systolic function, and pulmonary arterial acceleration time indexed to right ventricular ejection time (PAAT/RVET), to assess right ventricular afterload, also improved over three time points relative to PGE use (before, during, and after). Overall, we described the safety and utility of PGE in newborns with severe PPHN for stabilization while allowing natural disease progression.

Provider Perceptions of Oxygenation Strategies for Critically Ill Trauma Patients With and Without Moderate-to-Severe Traumatic Brain Injury.

Hypoxia and hyperoxia (pulse oximetry [SpO2] > 96%) are associated with increased mortality in critically ill patients. However, provider practices regarding oxygenation in traumatic brain injury (TBI) patients are unknown. This study assesses views on oxygenation of critically ill trauma patients with and without TBI and how this varies between Neurological ICU (NeuroICU) and Surgical-Trauma ICU (STICU) providers. This is a cross-sectional survey of Level I trauma center's NeuroICU and STICU providers. We used Likert scales, yes-no questions, and multiple-choice case-based scenarios to characterize provider views on oxygenation with descriptive statistics to characterize responses. Significant differences regarding TBI and non-TBI patients or NeuroICU and STICU providers were determined using Fisher's exact test and a P-value of .05. A total of 83 providers initiated the survey, and 53 providers completed it. Most providers identified a threshold SpO2 < 92% for the administration of supplemental oxygen in critically ill TBI patients. A total of 9% of providers "somewhat or completely agreed" that they were more likely to give supplemental oxygen to a critically ill trauma patient with TBI than one without TBI and the same SpO2. A total of 48% of providers selected an SpO2 < 90% as the point at which supplemental oxygen should be initiated in patients without TBI, compared to 27% of providers in patients with TBI (P < .01). This threshold for supplemental oxygen use varied by provider type for non-TBI patients, but not for TBI patients (30% NeuroICU and 69% STICU providers selected SpO2 < 90% in non-TBI, P < .05; 30% NeuroICU and 35% STICU providers selected SpO2 < 90% in TBI, P = .85). Critical care providers at UCHealth University of Colorado Hospital approach the oxygenation of critically ill trauma patients with and without TBI differently. Specifically, critical care respondents accepted a different lower oxygen saturation threshold for TBI and non-TBI patients. NeuroICU and STICU respondents differed in their threshold for the down-titration of supplemental oxygen. Targeted education for critical care providers may reduce these discrepancies and optimize oxygen use.

An absence of imperfections: A proposed framework for defining, assessing, and achieving skin glow.

Skin glow is a subcomponent of skin quality. It has become entrenched in the cosmeceuticals and aesthetics lexicons as a synonym for health and youth, but is not well-defined as a scientific metric. To examine the concept of skin glow and determine if it is an objective concept that can be defined and quantified. Literature review was used to develop a survey on current concepts relating to skin quality. The survey results were analyzed descriptively and presented to a focus group comprising five dermatologists and four aesthetic physicians. This group then discussed the concept of skin glow, how to define it and what metrics could be used to assess it. Surveyed practitioners (n = 38) ranked skin quality as the fourth most important factor related to a person's overall aesthetic first impression. Almost all (95%) respondents reported routinely assessing skin quality, citing serial photography (83%), and visual inspection (67%) as the main means of achieving this. The focus group defined skin glow as even reflectance from an unaffected papillary and reticular dermal collagen layer, which is created only when skin does not exhibit any characteristics that detract from this even reflectance. Due to its complexity, the focus group proposed a hierarchal framework for assessment, encompassing patient self-rating, practitioner severity rating, and supplemental use of validated measurement devices. Skin glow can be defined and quantified. More work is warranted to develop a practical skin glow assessment tool suitable for use in the clinic setting.

Disturbance mitigation of thiencarbazone-methyl·isoxaflutole on bacterial communities through nitrification inhibitor and attapulgite

There is a knowledge gap in the interaction between the effects of herbicide thiencarbazone-methyl·isoxaflutole on soil microflora and environmental parameters, which leads to a lack of measures in mitigating damage to bacterial communities from the herbicide use. The impacts of thiencarbazone-methyl·isoxaflutole and soil parameters on the diversity, structure and functions of soil bacterial communities were clarified, and the effects and potential mitigation mechanisms of nitrapyrin and modified attapulgite with bacterial function intervention on bacterial communities were explored through incubation and field experiments. The results showed that as thiencarbazone-methyl·isoxaflutole application increased, the stress on soil bacterial community structure and diversity also increased. The relative abundance of bacteria including Aridibacter and GP7 and functional annotations including “nitrate_reduction” were significantly negatively correlated with thiencarbazone-methyl·isoxaflutole residues in soils. The remarkable toxic effects on the Adhaeribacter bacteria were detected at the recommended dose of thiencarbazone-methyl·isoxaflutole application. The residue of isoxaflutole (one of the effective ingredients of thiencarbazone-methyl·isoxaflutole) directly and more strongly affected the diversity of soil bacterial communities than thiencarbazone-methyl. Increasing soil pH was recognised as an important factor in improving the diversity and structure of soil microflora based on the results of the Mantel test and canonical correspondence analysis. Supplemental use of nitrapyrin or modified attapulgite was found to increase soil pH, and further improve the expression of “manganese oxidation” function annotation. This contributed to the increased bacterial diversity (Shannon index). Therefore, the disturbance of soil microflora caused by thiencarbazone-methyl·isoxaflutole application can be mitigated by the use of nitrapyrin and modified attapulgite through raising soil pH.

Diagnostic yield of bronchoscopy in children with leukemia or post hematopoietic stem cell transplant.

The utility of bronchoscopy with bronchoalveolar lavage (BAL) in immunocompromised children is not well understood. We aim to describe the bronchoscopy diagnostic yield and complications and to investigate factors associated with diagnostic yield. This is a single-center, retrospective cohort study of 60 children with leukemia or post-hematopoietic stem cell transplant who had a bronchoscopy with BAL between 2017 and 2021. Comparisons were done with regression analysis. Of the 60 bronchoscopies performed, 46 (77%) revealed diagnostic information: 39 (65%) identified a pathogen, 14 (23.3%) found secretions/mucus plugging, and 6 (10%) found pulmonary hemorrhage. BAL results changed antimicrobial therapy in 27 (45%) cases. Bronchoscopies were performed in the intensive care unit (27/60) or operating room (33/60), with the former having a higher diagnostic yield (96% vs. 60%, p = 0.001). Half (50%) of bronchoscopies found a new infectious diagnosis. Respiratory symptoms (n = 58, 97%), supplemental oxygen use (n = 39, 65%), and antibiotic use (n = 56, 93%) before bronchoscopy were all common. The median volume of fluid instilled during bronchoscopy was 1.3 mL/kg (interquatile range [IQR]: 0.7, 2.6). None of these factors were associated with the diagnostic yield. Complications were rare and minor with only one child having self-resolved bleeding and four children, previously in room air requiring a nasal cannula. For the 27 (45%) children on mechanical ventilation when the bronchoscopy was performed, there was no difference in ventilator settings pre- and post-bronchoscopy. Bronchoscopies with BAL are useful, safe, and important in the diagnostic management of pulmonary complications in this cohort of children.

Adverse life events in patients with functional seizures: Assessment in clinical practice and association with long-term outcome

BackgroundA history of adverse life events (ALE) is a risk factor for functional seizures (FS). Their influence on long-term outcome remains unclear. International guidelines recommend assessing ALE in patients presenting with associated disorders. It is not clear to what extent patients evaluated for FS are regularly asked about ALE. ObjectivesWe hypothesised that the presence of ALE would relate to worse outcome at follow-up and, that the rate of detection of ALE in clinical work-up would be inferior to that based on self-report questionnaires. Methods53 patients with FS from the National Centre for Epilepsy in Norway, aged 16–62 years were included. Symptom severity, health-related quality of life (HRQoL), and antecedent ALE were assessed at baseline. Medical records were examined for disclosure of ALE. At a mean of 70.45 (SD 29.0, range 22–130) months after inclusion, participants were inquired about FS status, FS-related health care utilization and HRQoL.Findings: A history of emotional abuse documented in the medical record was an independent risk factor for worse HRQoL at follow-up. Prevalence of ALE documented in medical records was lower compared with rates measured by a self-report questionnaire. ConclusionsThese findings indicate an association between antecedent ALE and HRQoL years after diagnosis. A substantial proportion of the adverse life events by a self-report questionnaire had not been documented in the clinical records. Clinical implicationsThe supplemental use of a self-report questionnaire in the diagnostic work-up of patients with FS may be valuable for detecting ALE.

Oxygen Therapy During Activities of Daily Living Rehabilitation and Outcome in Patients With Severe-to-critical COVID-19

ObjectiveTo primarily study the duration of supplemental oxygen use while performing ADLs (activities of daily living) and associations leading to a more prolonged oxygen therapy during these tasks. Secondary objectives include (1) studying the presence of COVID-19 related complications during inpatient rehabilitation and after discharge and (2) describing functional outcomes of participants after supplemental oxygen liberation and hospital discharge. DesignExplorative prospective observational cohort study. SettingRehabilitation center within a tertiary hospital, caring for post-COVID patients. ParticipantsTwenty-three (N=23) community-dwelling persons with severe-to-critical COVID-19 disease and ongoing oxygen therapy needs. There was a preponderance of men (69.6%), with mean age of 69.5 (range 46-85) years. InterventionsInpatient pulmonary rehabilitation. Main Outcome MeasuresThe primary outcome was the duration of supplemental oxygen use (from initiation till wean) for ambulation, toileting, dressing, and showering. Secondary outcomes included the presence of COVID-19 related complications (during rehabilitation and after discharge) and post-discharge functional status. ResultsAfter rehabilitation center transfer, all subjects only required oxygen therapy during task(s) performance, and not at rest. ADLs that took the shortest and longest time for supplemental oxygen weaning were dressing (mean 38.4±SD 17.1 days) and showering (mean 47.7±SD 18.1 days), respectively. The mean duration of oxygen therapy application was 48.6±SD 18.3 days. On multivariable analysis, mechanical ventilation and exertional desaturation were significantly associated with prolonged duration for oxygen therapy in all ADLs. ConclusionThe duration of needful oxygen therapy was dissimilar for different ADLs. Showering, which required the longest duration of supplemental oxygen wean, might prove to be the rate-limiting ADL for discharge home.

Pediatric Characteristics Associated With Higher Rates of Monitor Alarms.

Background: Continuous physiologic monitoring commonly is used in pediatric medical-surgical (med-surg) units and is associated with high alarm burden for clinicians. Characteristics of pediatric patients generating high rates of alarms on med-surg units are not known. Objective: To describe the demographic and clinical characteristics of pediatric med-surg patients associated with high rates of clinical alarms. Methods: We conducted a cross-sectional, single-site, retrospective study using existing clinical and alarm data from a children's hospital. Continuously monitored patients from med-surg units who had available alarm data were included. Negative binomial regression models were used to test the association between patient characteristics and the rate of clinical alarms per continuously monitored hour. Results: Our final sample consisted of 1,569 patients with a total of 38,501 continuously monitored hours generating 265,432 clinical alarms. Peripheral oxygen saturation (SpO2) low alarms accounted for 57.5% of alarms. Patients with medical complexity averaged 11% fewer alarms per hour than those without medical complexity (P < 0.01). Patients older than 5 years had up to 30% fewer alarms per hour than those who were younger than 5 years (P < 0.01). Patients using supplemental oxygen averaged 39% more alarms per hour compared with patients who had no supplemental oxygen use (P < 0.01). Patients at high risk for deterioration averaged 19% more alarms per hour than patients who were not high risk (P = 0.01). Conclusion: SpO2 alarms were the most common type of alarm in this study. The results highlight patient populations in pediatric medical-surgical units that may be high yield for interventions to reduce alarms. Most physiologic monitor alarms in pediatric medical-surgical (med-surg) units are not informative and likely could be safely eliminated to reduce noise and alarm fatigue.1-3 However, identifying and sustaining successful alarm-reduction strategies is a challenge. Research shows that 25% of patients in pediatric med-surg units produce almost three-quarters of all alarms.4 These patients are a potential high-yield target for alarm-reduction strategies; however, we are not aware of studies describing characteristics of pediatric patients generating high rates of alarms. The patient populations seen on pediatric med-surg units are diverse. Children of all ages are cared for on these units, with diagnoses ranging from acute respiratory infections, to management of chronic conditions, and to psychiatric conditions. Not all patients on pediatric med-surg units have physiologic parameters continuously monitored,4 but among those who do, understanding patient characteristics associated with high rates of alarms may help clinicians, healthcare technology management (HTM) professionals, and others working on alarm management strategies to develop targeted interventions. We conducted an exploratory retrospective study to describe patient characteristics associated with high rates of alarms in pediatric med-surg units.

Supplemental Optoacoustic Imaging of Breast Masses: A Cost-Effectiveness Analysis

To evaluate the cost-effectiveness of utilizing supplemental optoacoustic ultrasound (OA/US) versus gray-scale ultrasound (US) alone to differentiate benign and malignant breast masses in a diagnostic setting. We created a decision-tree model to compare the cost-effectiveness of OA/US and US from the perspective of the UShealthcare system. We utilized diagnostic test performance parameters from the PIONEER-01(NCT01943916) clinical trial and cost parameters (USD) from the Truven Health MarketScanDatabases. Utility (quality adjusted life year,QALY) values were determined following published patient-reported outcomes. Cost-effectiveness was calculated through incremental cost-effectiveness ratio (USD/QALY, ICER) and net monetary benefit (NMB) in a Markov chain model. Deterministic and probabilistic sensitivity analyses were performed to determine the significance of variation in input parameters. A willingness-to-pay (WTP) threshold of $100,000/QALY was used for the study. OA/US had an estimated cumulative cost of $16,617.36 and the outcome of 16.85 QALYs in the 25-year period. The incremental NMB for OA/US was $1495.36, and the ICER was -$31,715.82/QALY, indicating that supplemental use of OA/US was more cost-effective than US alone. In the deterministic sensitivity analysis, when the cost of OA/US exceeded $1030.61 or the sensitivity of OA/US fell below 79.7%, or the specificity fell below 30.5%, the US alone strategy yielded higher NMB values compared to supplemental OA/US. According to probabilistic sensitivity analysis, OA/US was the better strategy in 98.69% of 10,000 iterations. OA/US is more cost-effective than US to differentiate benign or malignant breast masses in the diagnostic setting. It can reduce costs while improving patients' quality of life, primarily by reducing false-positive results with consequent benign biopsies.

Functional Recovery of COVID-19 Patients Admitted to a Cardiopulmonary Inpatient Rehabilitation Unit

Introduction: With changes in treatments, precautions, and the virus itself, the continued evaluation of post-COVID-19 patient rehabilitation needs is essential. Methods: Demographics, comorbidities, functional assessments, quality of life, and rehabilitation outcomes for 98 patients admitted to inpatient rehabilitation during New York’s most recent major COVID-19 hospitalization surge were analyzed. Patients were contacted at 6 months to evaluate functional improvement, post-COVID-19 symptoms, vaccination status, and quality of life. Results: Inpatient rehabilitation addressed significant limitations in lung capacity, mobility, and self-care. Median mobility scores improved significantly from admission (16) to discharge (34) and follow-up (42). Sixty-six percent of patients reported overall quality of life improvement during their rehabilitation stay; at follow-up, a more modest percentage (35%) reported additional gains. Continued improvement in supplemental oxygen use was observed in 49% of patients who completed the follow-up assessment. Consistent with previous studies on severe disease, post-COVID-19 condition features were exhibited by 86% of patients at follow-up; vaccinated individuals displayed fewer symptoms associated with post-COVID-19 condition than their unvaccinated counterparts. Conclusions: Individuals recovering from severe COVID-19, including previously ventilated patients, made significant functional and quality of life gains during inpatient rehabilitation. While functional independence continued to improve post-discharge, patients exhibited greater improvement from admission to discharge than from discharge to 6-month follow-up. Inpatient rehabilitation represents a crucial component for recovery from severe COVID-19.

Energy Transition Scenarios in Off-grid Communities using SOFC-CHP/Battery Hybrid Systems

Today, most communities are connected to large energy infrastructures that constitute the electricity and gas grids. But these infrastructures may not be present in extremely low populated regions or regions that are difficult to access, thus considered as off-grid islands or remote regions. Currently, the electricity in these communities is still mostly supplied by centralized or decentralized diesel generators, even though the supplemental use of renewable energy from water, wind and solar is increasingly part of their energy mix. Additionally, centralized or decentralized furnaces, also based on fossil fuels or regenerative fuels (as wood), may be used to supply heat needed for room heating and domestic hot water.The first step for energy transitions towards low emissions in this specific application scenario has the goal to implement prime mover that have higher electrical efficiencies. Consequently, the amount of primary energy (fuel) and the associated CO2 emissions are reduced. Secondly, the efficiency of fuel utilization shall be increased by using the waste heat for room heating, thus representing a typical combined heat and power (CHP) system.While diesel generators are very load flexible, available in different power ranges at reasonable costs their electrical efficiency is limited to 40% or less due to the thermodynamic cycle with several energy conversion steps. Due to the low number of conversions steps in fuel cells, higher electrical efficiencies up to 65% are possible for Solid Oxide Fuel Cell systems specifically. Furthermore, Solid Oxide Fuel Cell systems have a high fuel variety due to operation at high temperatures and enables the CHP operational mode. The overall efficiency of CHP SOFC systems ranges to more than 90%. The main drawback for this technology is the limited flexibility to adapt to load variations, especially regarding start/stop cycles and associated power degradation. To overcome this drawback, batteries in conjunction with SOFC systems may be used for the off-grid scenario.In this regard, SOFC-/Battery Hybrid systems are investigated in an annual simulation analysis for diffent scenarios and 3 different sized example communities. In each scenario waste heat from the SOFC combined with decentralized furnaces is used to fulfill the heat demand.Figure 1 shows the shares of the electrical and the thermal power supplied with a 2.8 MWel SOFC system, the operational states of the system as well as the battery State of Charge (SOC) over one year. It is visible how the battery is charged and discharged and when back-up diesel gensets are necessary to supply sufficient electricity.Based on the annual simulations, the performance and the benefit of using such hybrid systems can be shown in terms of primary energy saving and reduction of CO2 emissions, as well as in terms of system configurations and operation patterns. The analysis also gives information about the necessary sizes of the SOFC systems and the battery capacity to be installed.Figure 1: Exemplary simulation of the SOFC-CHP / Battery Hybrid system with a battery capacity of 2.5 MWh Figure 1

Improving Certified Registered Nurse Anesthetists’ Adherence to a Standardized Intraoperative Lung Protective Ventilation Protocol

The use of lung protective ventilation (LPV) during general anesthesia is an effective strategy among certified registered nurse anesthetists (CRNAs) to reduce and prevent the incidence of postoperative pulmonary complications. The purpose of this project was to implement a LPV protocol, assess CRNA provider adherence, and investigate differences in ventilation parameters and postoperative oxygen requirements. This quality improvement project was conducted using a pre- and postimplementation design. Sixty patients undergoing robotic laparoscopic abdominal surgery and 35 CRNAs at a community hospital participated. An evidence-based intraoperative LPV protocol was developed, CRNA education was provided, and the protocol was implemented. Pre- and postimplementation, CRNA knowledge, and confidence were assessed. Ventilation data were collected at 1-minute intervals intraoperatively and oxygen requirements were recorded in the postanesthesia care unit (PACU). Use of intraoperative LPV strategies increased 2.4%. Overall CRNA knowledge (P=.588), confidence (P=.031), and practice (P < .001) improved from pre- to postimplementation. Driving pressures decreased from pre- to postimplementation (P < .001). Supplemental oxygen use on admission to the PACU decreased from 93.3% to 70.0%. Educational interventions and implementation of a standardized protocol can improve the use of intraoperative LPV strategies and patient outcomes.