Rates of Lapidus Procedures in the US Military Before and After the Advent of and Advocacy for Tri-Plane Lapidus Corrective Surgery.

Tri-plane corrective Lapidus surgery has been described as advantageous with respect to its anatomic basis and outcomes. Because the procedure has been broadly publicized, changes in overall Lapidus procedure rates due to increased numbers of patients opting for the tri-plane approach could have occurred. Data supporting this possibility appears lacking. We employed official personnel and health records of the total active-duty US military to conduct a retrospective cohort study of Lapidus surgery rates before and after the advent of the tri-plane corrective Lapidus procedure. Least-squares and locally-weighted scatterplot smoother regression functions were used to confirm time trends. Sociodemographic and occupational traits of Lapidus patients were compared using 2-sided t tests and chi square tests. Lapidus surgery rates among hallux valgus patients decreased during 2014 to 2016 and increased during 2017 to 2021. While multiple factors might explain these trends, they coincide with the advent of and advocacy for tri-plane Lapidus surgery. The results support the possibility that its rise influenced overall Lapidus rates in this population. As these findings represent limited evidence of such an influence, further research is required to confirm a causal link. If such a link is found, and if the ongoing research suggests that superior outcomes are associated with tri-plane Lapidus surgery, substantial implications could exist for this population. Benefits might include enhanced medical readiness due to the importance of lower extremity function during military duties. Additional research is needed to confirm the impact of the procedure and to determine whether Lapidus surgery rate patterns in civilian populations mirror these findings.

A diagnostic conundrum: case of acute appendiceal abscess mimicking multisystem inflammatory syndrome in children in a toddler

Case Report: Patients with Multisystem Inflammatory Syndrome in Children (MIS-C) can commonly present with gastrointestinal symptoms of abdominal pain, vomiting, or diarrhea. These symptoms along with high fever and elevated inflammatory markers can often mask underlying gastrointestinal inflammation and lead to a diagnostic dilemma. Case Presentation: We report a case of a 16-month-old with a history of exposure to SARS-Cov-2 virus, who presented with fever, cough, vomiting, and decreased activity. Her initial workup showed neutrophil-predominant leukocytosis with elevated CRP, ferritin, NTProBNP, and fibrinogen. Serology was positive for COVID-19 IgG antibodies, strongly favoring a diagnosis of MIS-C. Initial CT of the abdomen showed findings consistent with mild enteritis. Intravenous immunoglobulin was not administered as leukocytosis and all inflammatory markers except CRP improved during the course of her hospital stay with parenteral antibiotics, but she remained febrile with worsening abdominal symptoms. She then developed classic symptoms of peritonitis with tenderness and rigidity. Ultrasound of abdomen was inconclusive due to overlying bowel gas. Repeat CT of the abdomen showed multiple intra-abdominal abscesses with the largest rim enhancing lesion in the right lower quadrant. Her presentation was consistent with acute appendiceal abscess due to perforated appendix that improved with CT guided drainage and three weeks of intravenous antibiotics. She was then discharged and planned for an interval appendectomy after two weeks. [Figure presented] Conclusion(s): Symptoms of appendiceal abscess can mimic MIS-C. This case underscores the importance of considering appendicitis in the differential diagnosis in patients with MIS-C. Appendicitis can be missed in toddlers. Hence, clinical suspicion and repeat imaging is key for early diagnosis in this age group. CT Abdomen and Pelvis with intravenous and oral contrast showing findings of perforated, complicated acute appendicitis, with multiple abscesses. Copyright © 2023 Southern Society for Clinical Investigation.

The effects of preconception and early gestation SARS-CoV-2 infection on pregnancy outcomes and placental pathology.

OBJECTIVE: To evaluate if peri-pregnancy timing of a PCR+ test for SARS-CoV-2 RNA affects pregnancy outcomes and placental pathology. METHODS: This is a retrospective cohort study conducted in a tertiary center. Pregnancy outcomes and placental pathology were compiled for women who tested positive for SARS-CoV-2 RNA from a nasopharyngeal swab assessed by RT-PCR. The population comprised four groups that were PCR+ preconception (T0) or in the 1st (T1), 2nd (T2), or 3rd (T3) trimester of pregnancy. A fifth, control group (TC) tested PCR- for SARS-CoV-2 before delivery. RESULTS: Seventy-one pregnancies were studied. The T0 group exhibited lower gestational ages at delivery, had infants with the lowest birth weights, the highest rate of pregnancy loss before 20 weeks. Features of maternal vascular malperfusion and accelerated villous maturation were prominent findings in the histopathology of placentas from women PCR+ for SARS-CoV-2 RNA, especially in the T0 and the T1 groups. CONCLUSION: Women at highest risk for pregnancy complications are those who test PCR+ for viral RNA preconception or during first trimester of pregnancy.

The Effect of Covid-19 on Spontaneous Pneumothorax

RATIONALE: SARS-COV-2 (COVID-19) has presented challenges to hospitals from its initial onset in 2020. Physicians at Lakeland Regional Medical Center (LRH) suspected an increase of spontaneous pneumothorax (PTX) in patients admitted with COVID-19 through the emergency department (LRH has 220,000 ED-visits per year). The suspicion was supported by a small body of literature reporting COVID-19's association with PTX (mainly in the form of small case series or reports). The purpose of this study was to examine the effect that COVID-19 has on PTX incidence on a much larger scale. METHODS : We conducted a retrospective chart review extracting data on admitted patients between March 2020 and December 2021. Data included age, sex, COVID-19 positivity status, intubation (at any time during hospitalization), and PTX occurrence. We compared PTX rates between COVID-19 positive/negative patients and between patients who were intubated or not. A series of chi-square tests (alpha at < .05) were used for comparisons, as well as to calculate odds ratios (OR). Lastly, a binomial logistic regression was conducted to examine the effect of COVID-19 positivity, intubation status, and the interaction of COVID-19 positivity and intubation status, while controlling for age and sex, on odds for developing PTX. RESULTS : There were 50,456 patients included in our analyses. PTX incidence was 2.3% for COVID-19 positive versus 0.62% for COVID-19 negative. There was a significant association (p<0.0001) and 366% increased odds of developing PTX if patients were COVID-19 positive (95% CI [2.99, 4.46]). Intubation in itself had a significant association (p < 0.0001) and OR of 10.35 (95% CI [8.90, 12.04]) for developing PTX, but results of logistic regression revealed a strong interaction between COVIDpositivity and intubation status. Using COVID-19 negative and intubated patients as our reference group, we found that COVID-19 positive and intubated patients were at 6.56 increased odds of developing a PTX. COVID-19 positivity did not appear to have a significant association with PTX in the non-intubated patients. CONCLUSIONS : PTX is a rare, serious potential complication of COVID-19. This complication has considerable morbidity, especially in patients requiring intubation and should require strong clinical suspicion in COVID-19 positive patients. Research is needed to identify other key factors (i.e. underlying pulmonary disease, oxygen requirements, illness severity) that influence outcomes of patients with COVID-19.

Student sustainability knowledge gained from classroom and field experience

This chapter presents an overview of a course designed for undergraduate students, in which they learn about integral changes required for sustainability. The logistics for adapting to changing environmental conditions from global warming and mitigating virus epidemics, like the novel coronavirus, are covered. To develop the course necessitates a well-designed approach towards student learning with knowledge retention for proactive problem solving, enabling them to work towards social and environmental harmony. The process embeds a holistic application of Corporate Social Responsibility, incorporating dimensions of economic, environmental and social, in tandem with Circular Economy. There seems to be a knowledge gap between those who understand issues brought about by global warming and those who don’t, which was exacerbated when the novel coronavirus evolved into a global pandemic. Because of this gap, all communities need to understand the necessity of continuously working proactively for mitigating virus outbreaks and adapting to social and environmental needs brought about by climate change. © Mark Starik and Patricia Kanashiro 2021.

Home Blood Pressure Monitoring in Women with Severe Hypertension Utilizing Audio-Only and In-Person Postpartum Encounters

Objective: Prompt postpartum follow-up for women with hypertension is recommended. We hypothesized that use of home blood pressure monitoring may be beneficial to improve engagement. Our aim was to utilize home blood pressure monitoring with in-person and audio-only virtual visits in women with severe hypertension. Study Design: From March 2020 – September 2020 women with severe hypertension requiring oral antihypertensive therapy postpartum were provided a blood pressure cuff at time of hospital discharge and taught to take home measurements twice daily. Follow-up was scheduled within 10 days. Due to the COVID pandemic, audio-only virtual visits were prioritized, but left to the discretion of the discharge provider. Home blood pressure logs were reviewed at each encounter and documented in the medical record. Severe hypertension was defined as 160/110 mmHg or greater. Subsequent in-person or virtual visits were determined by the provider. Follow-up data and blood pressure values up to 6 weeks postpartum were retrospectively obtained. Statistical analysis included χ2 and McNemar’s test, with a P value <.05 considered significant. Results: Blood pressure cuffs were given to 206 women. Ten (5%) women on antihypertensive therapy represented to the hospital for hypertension. Ten women were lost to follow up after discharge from the hospital, leaving 196 women (95%) who presented for at least 1 postpartum visit. Systolic and diastolic values at the first visit were significantly lower at the last postpartum visit when compared to the first. Additionally, by the last postpartum visit, women were are on less blood pressure medications than at time of discharge from the hospital (P=.048). Composite blood pressure ranges above 140/90, 150/100, and 160/110 mmHg were significantly lower at the last visit when compared to the first, except for severe diastolic values (Figure 1). Conclusion: Use of audio-only virtual visits with in person follow-up for women with severe hypertension allowed for decreased oral antihypertensive medications and a reduction in blood pressure 140/90mmHg or greater. [Formula presented] [Formula presented]

Postpartum Audio-Only Virtual Visits Versus In-Person Follow-up in Women with Severe Hypertension

Objective: Postpartum follow-up within 10 days is currently recommended for women with hypertension, though many women do not complete this visit. Methods beyond in-person visits may be necessary to achieve this. Our goal was to explore the use of home blood pressure monitoring with audio-only virtual visits and in-person postpartum visits for women with severe hypertension. Study Design: From March 2020 – September 2020 women with severe hypertension requiring oral antihypertensive therapy postpartum were provided a blood pressure cuff at time of hospital discharge and taught to take home measurements twice daily. Follow-up was scheduled within 10 days. Due to the COVID pandemic, audio-only virtual visits were prioritized, but left to the discretion of the discharge provider. Demographic and follow-up data up to six weeks postpartum were compiled retrospectively from the medical record. Severe hypertension was defined as blood pressure 160/110 mmHg or greater. Statistical analysis included χ2 and Student-t test, with P value <.05 considered significant. Results: Blood pressure cuffs were given to 206 women: 181 women with severe hypertension in the immediate postpartum period, and 25 who were re-admitted to the hospital with delayed-onset hypertension. Table 1 shows their demographics. Sixty-seven (32%) had pre-existing hypertension. There were 196 (95%) who had one postpartum visit, 165 (80%) had two visits. Average number of days to completion of follow-up appointment was 9 ± 6 days, with 146 (71%) following up at 10 days or less. Ten (5%) women did not return after discharge. Sixty-nine women had their first visit in-person, and 137 women had a virtual encounter. Virtual visits were more likely to be completed within 10 days (118/137 (86%) v 28/69 (41%), p<.001), and had less loss to follow-up after discharge (2/137 (1%) v 8/69 (12%), p<.001). Conclusion: In women with severe hypertension, follow-up within 10 days was more likely with audio-only virtual visits compared to clinic visits, offering an appropriate point of access to postpartum care. [Formula presented] [Formula presented]

A model of the innate immune response to SARS-CoV-2 in the alveolar epithelium.

We present a differential equation model of the innate immune response to SARS-CoV-2 within the alveolar epithelium. Critical determinants of the viral dynamics and host response, including type I and type II alveolar epithelial cells, interferons, chemokines, toxins and innate immune cells, are included. We estimate model parameters, compute the within-host basic reproductive number, and study the impacts of therapies, prophylactics, and host/pathogen variability on the course of the infection. Model simulations indicate that the innate immune response suppresses the infection and enables the alveolar epithelium to partially recover. While very robust antiviral therapy controls the infection and enables the epithelium to heal, moderate therapy is of limited benefit. Meanwhile interferon therapy is predicted to reduce viral load but exacerbate tissue damage. The deleterious effects of interferon therapy are especially apparent late in the infection. Individual variation in ACE2 expression, epithelial cell interferon production, and SARS-CoV-2 spike protein binding affinity are predicted to significantly impact prognosis.

Post-covid recovery: Chronically critically ill patients admitted to a long-term acute Care Hospital

INTRODUCTION: Barlow Respiratory Hospital (BRH) is a 105-bed, not for profit, long-term acute care (LTAC) hospital serving chronically critically ill (CCI) and complex patients transferred from the ICUs of hospitals in southern California. Herein, we report patient characteristics of our first series of COVID-19 survivors admitted to the post-acute venue of an LTAC. METHODS: Single-center descriptive report of patients recovering from acute infectious complications of COVID-19 pneumonia. The Barlow performance improvement database and transferring hospital documentations were queried for selected patient demographics, admission characteristics, diagnoses, and co-morbidities. RESULTS: From 4/28/2020-7/7/2020, 30 post-COVID patients admitted to BRH. All tested negative for COVID-19 prior to transfer. Pre-morbid location home: 63%. Ethnicity: 47% Caucasian, 30% Hispanic, 10% Asian, 6% African American. Acute care course: 90% mechanically ventilated, 43% ARDS, 43% sepsis, 63% AKI/ARF, 37% heart failure. COVID-19 risk factors: 60% type 2 DM, 73% HTN, 33% CAD, 33% HLD, 47% BMI ≥ 30. On BRH admission: age 74.5 [44-99] years, 60% male;length of stay at transferring facility 40 [8-77] days;73% with pressure injury ≥ stage 2, 47% with multiple pressure injuries;30% on hemodialysis, 80% with tracheostomy, 53% on mechanical ventilation, 80% with feeding tube, 47% with central line, 33% with indwelling urinary catheter. Lab: Mean (SD): Hematocrit 30.2% (5.9), Albumin 2.9 g/dl (0.59), BUN 41.8 mg/dl (27.4), Creatinine 1.7 mg/dl (2.1), Glucose 143 mg/dl (50.6). CONCLUSIONS: This is the first report to characterize post-COVID patients transferred to an LTAC. Patients are largely elderly, with known risk factors, spent an average 6 weeks in ICU, with mechanical ventilation via tracheostomy. Overall, these early findings suggest that these CCI patients will continue to require considerable medical interventions and treatments, owing to the numerous sequelae of the infection, and the burden of acute-on-chronic diseases. As ICU survival rates improve, this survey further emphasizes the important role of LTAC in responding to the COVID-19 crisis. LTAC hospitals not only relieve acute care hospitals from the enormous patient burden but also provide high-level care for complex chronic medical conditions caused by COVID-19.

Histopathology of Third Trimester Placenta from SARS-CoV-2-Positive Women.

Background: This study aims to investigate whether maternal SARS-CoV-2 status affects placental pathology. Methods: A retrospective case-control study was conducted by reviewing charts and slides of placentas delivered between April 1 to July 24, 2020. Clinical history of "COVID-19" was searched in Pathology Database (CoPath). Controls were matched with SARS-CoV-2-negative women with singleton deliveries in the 3rd-trimester. Pathological features were extracted from placental pathology reports. Results: Twenty-one 3rd trimester placentas from SARS-CoV-2-positive women were identified and compared to 20 placentas from SARS-CoV-2-negative women. There were no significant differences in individual or group gross or microscopic pathological features. Within the SARS-CoV-2+ group, there are no differences between symptomatic and asymptomatic women. Conclusion: Placentas from SARS-CoV-2-positive women do not demonstrate a specific pathological pattern. Pregnancy complicated with COVID-19 during the 3rd trimester does not have a demonstrable effect on placental structure and pathology.