Early Ventilator Management for Infants With Congenital Diaphragmatic Hernia: Impact of a Standardized Clinical Practice Guideline.

BACKGROUND: Infants with congenital diaphragmatic hernia (CDH) experience high morbidity and mortality due to pulmonary arterial hypertension and hypoplasia. Mechanical ventilation is a central component of CDH management. Our objective was to evaluate the impact of a standardized clinical practice guideline (implemented in January 2012) on ventilator management for infants with CDH, and associate management changes with short-term outcomes, specifically extracorporeal membrane oxygenation (ECMO) utilization and survival to discharge. METHODS: We conducted a retrospective pre-post study of 103 CDH infants admitted from January 2007-July 2021, divided pre- (n = 40) and post-guideline (n = 63). Clinical outcomes, ventilator settings, and blood gas values in the first 7 days of mechanical ventilation were compared between the pre- and post-guideline cohorts. RESULTS: Post-guideline, ECMO utilization decreased (11% vs 38%, p = 0.001) and survival to discharge improved (92% vs 68%, p = 0.001). More post-guideline patients remained on conventional mechanical ventilation without need for escalation to high-frequency ventilation or ECMO, and had higher pressures and PaCO2 with lower FiO2 and PaO2 (p < 0.05). CONCLUSIONS: Standardized ventilator management optimizing pressures for adequate lung expansion and minimizing oxygen toxicity improves outcomes for infants with CDH. LEVEL OF EVIDENCE: III.

Skincare from the inside out: a pilot project addressing social determinants of health through dermatology.

Background: Many women's shelters across the nation have programs that emphasize and empower women through career workshops and skills training. However, what is not typically addressed is their dermatological and mental health needs, which are equally important. Objective: Through this pilot project, we aim to address the diverse interrelated issues concerning the whole woman and her body/mind systems including skin cancer awareness, skincare, healthy sun habits, self-esteem, mental health, and stress management. By addressing the woman holistically, we hope to positively impact the way she views and values herself. Methods: We partnered with a local women's shelter to host a seminar focused on dermatological and mental health education. Pre- and post-seminar surveys were collected from participants. Surveys were anonymous and aimed to evaluate the success and efficiency of the workshop to guide and improve future seminars. The seminar had three workshops: skin cancer and sun protection, skincare, and mental health and wellness. Upon completion of the seminar, the attendees were provided with the opportunity to receive free skin examinations by two board-certified dermatologists, and referrals were made to Northeast Ohio Medical University's Student-Run Free Clinic. Upon completion of the seminar, attendees were provided with items such as sunscreen, skincare, and mental health resources. Results: The "Skincare from the Inside Out" pilot project proved to be beneficial to residents of both Norma Herr Women's Shelter. Limitations: Limitations of this study were the small sample size (n = 15), due to participation limitations during the COVID-19 pandemic. Conclusion: Ultimately, to reduce the morbidity and mortality of dermatologic conditions associated with homelessness, it is imperative to address upstream social determinants of health. Future development of this pilot project will aim toward educating medical professionals on the unique and complex dermatologic and mental health needs of women experiencing homelessness.

Impact of a standardized management guideline for infants with CDH: A single-center experience.

BACKGROUND: Infants with congenital diaphragmatic hernia (CDH) are at high risk of death, even despite extracorporeal membrane oxygenation (ECMO) support. In January 2012 we implemented a standardized clinical practice guideline (CPG) to manage infants with CDH. We hypothesized that infants with CDH managed with CPG had better clinical outcomes, less ECMO utilization, and increased survival to discharge. METHODS: We conducted a retrospective pre-post study of infants with CDH admitted between January 2007 and July 2021 (n = 133). Patients were divided into Cohort 1, pre-CPG (January 2007 to December 2011, n = 54), and Cohort 2, post-CPG (January 2012 to July 2021, n = 79). RESULTS: More patients in Cohort 1 were small for gestational age than in Cohort 2. No other patient demographics were different between cohorts. Cohort 2 had significantly lower ECMO utilization as compared to Cohort 1 (18% vs 50%, p<0.001). Cohort 2 had significantly higher survival to discharge compared to Cohort 1 (85% vs 57%, p<0.001). Survival for ECMO-treated patients in Cohort 2 was significantly higher than in Cohort 1 (71% vs 26%, p = 0.005). In Cohort 1, 70% of the non-survivors were repaired, of which 81% were repaired on ECMO. In Cohort 2, 8% of the non-survivors were repaired, none on ECMO. Only 3% in Cohort 2 were discharged with pulmonary hypertension medication. CONCLUSIONS: A standardized CPG to manage patients with CDH decreased ECMO utilization and improved clinical outcomes including survival to discharge. Refinement of management strategies, implementation of new interventions, and meticulous care can improve outcomes in patients with CDH.

Motivating medical students by utilizing dermatology-oriented online quizzes.

BACKGROUND: Online quiz competitions can facilitate extra-classroom interactions between faculty and medical students. Owing to decreased class attendance nationwide, teaching faculty might revamp their approach to medical education by providing online resources and methods for communication. OBJECTIVE: To explore if the use of online quizzes and social media can result in improved interactions between faculty and students. METHODS: A pilot study conducted from April 7th, 2015 to June 11th, 2015 at Northeast Ohio Medical University (NEOMED) among participants from the second year medical school class. Ten one-question quizzes created using Google Forms were announced over Twitter and email at the rate of one quiz per week. The first correct responder of each quiz chose a five-dollar coffee shop gift card, movie ticket, or a meeting with a NEOMED faculty person as their prize. RESULTS: An average of 23.8% of the second year medical student class at NEOMED participated per quiz. A total of 80 individuals (55.9%) submitted 340 responses during the competition. LIMITATIONS: This is a single-center study with a limited sample size. CONCLUSIONS AND RELEVANCE: This study presents a process evaluation for the use of online quiz competitions amongst medical students. Optional online quizzes with small incentives may foster motivational competition among medical students, increase online interactions with faculty, and serve as study material for exams.

Requisite Role of Kv1.5 Channels in Coronary Metabolic Dilation.

RATIONALE: In the working heart, coronary blood flow is linked to the production of metabolites, which modulate tone of smooth muscle in a redox-dependent manner. Voltage-gated potassium channels (Kv), which play a role in controlling membrane potential in vascular smooth muscle, have certain members that are redox-sensitive. OBJECTIVE: To determine the role of redox-sensitive Kv1.5 channels in coronary metabolic flow regulation. METHODS AND RESULTS: In mice (wild-type [WT], Kv1.5 null [Kv1.5(-/-)], and Kv1.5(-/-) and WT with inducible, smooth muscle-specific expression of Kv1.5 channels), we measured mean arterial pressure, myocardial blood flow, myocardial tissue oxygen tension, and ejection fraction before and after inducing cardiac stress with norepinephrine. Cardiac work was estimated as the product of mean arterial pressure and heart rate. Isolated arteries were studied to establish whether genetic alterations modified vascular reactivity. Despite higher levels of cardiac work in the Kv1.5(-/-) mice (versus WT mice at baseline and all doses of norepinephrine), myocardial blood flow was lower in Kv1.5(-/-) mice than in WT mice. At high levels of cardiac work, tissue oxygen tension dropped significantly along with ejection fraction. Expression of Kv1.5 channels in smooth muscle in the null background rescued this phenotype of impaired metabolic dilation. In isolated vessels from Kv1.5(-/-) mice, relaxation to H2O2 was impaired, but responses to adenosine and acetylcholine were normal compared with those from WT mice. CONCLUSIONS: Kv1.5 channels in vascular smooth muscle play a critical role in coupling myocardial blood flow to cardiac metabolism. Absence of these channels disassociates metabolism from flow, resulting in cardiac pump dysfunction and tissue hypoxia.

MRI assessment of basal ganglia iron deposition in Parkinson's disease.

PURPOSE: To estimate the levels of basal ganglia iron levels in Parkinson's disease (PD) using the PRIME MR sequence at 3.0 Tesla, in relation to patients' motor symptom severity. MATERIALS AND METHODS: Seventy patients with PD and 10 healthy controls underwent assessment of movement and MR imaging. Mean R2' relaxation rates were recorded in the substantia nigra, frontal white matter and in the rostral, mid, and caudal putamen. RESULTS: R2' relaxation rates were significantly higher in patients with PD than in healthy controls. R2' in the most affected substantia nigra correlated with PD patients' motor symptom severity, but not with disease duration. Neuroradiological observation revealed a rostral to caudal "gradient" of putaminal hypointensity. This was substantiated by the finding that the mid and caudal putamen showed significantly higher R2' relaxation rates, consistent with higher iron levels in PD relative to the healthy controls. CONCLUSION: MRI at 3.0 Tesla suggests that substantia nigra iron levels are increased and linked to the severity of motor symptoms experienced in PD. Findings consistent with increased iron levels in the PD putamen are shown, in a region-specific rostral to caudal gradient.