Assessment and Validation of Anterior Humeral Line for Diagnosing Supracondylar Humerus Fractures in the Pediatric Population.

INTRODUCTION: Pediatric supracondylar humerus fractures are commonly evaluated using the anterior humeral line (AHL) on a lateral radiograph. Rotational variations in radiographic projection are common due to child discomfort and could lead to changes in management based on where the AHL intersects the capitellum. The purpose of this study was to establish whether rotational variations in elbow rotation leads to significant changes in AHL position and whether drawing the AHL based on the distal humerus versus shaft is more tolerant to rotation. METHODS: Fifty children with nonoperative supracondylar humerus fractures were identified with sub optimally positioned injury and well positioned follow-up lateral radiographs. The proportion of the bone anterior to the intersection of the AHL and the capitellum was measured using the humeral shaft versus distal humerus to guide position of the AHL. This process was repeated on ten pediatric humerus dry cadaveric specimens which were imaged in 5-degree rotational increments along the axis of the humeral shaft from -20 to +20 degrees. RESULTS: AHL position correlated poorly when measured on rotated lateral radiographs of clinical patients versus non-rotated lateral radiographs when using the distal humerus as a guide (intraclass correlation coefficient 0.14), compared with when using the humeral shaft as a guide (intraclass correlation coefficient 0.81). When assessing the pediatric humerus dry cadavers between the 2 techniques, there was greater statistically significant variation in rotated positions compared with the neutral position in the distal humerus AHL measurement approach compared with the humeral shaft AHL measurement approach, with the mean AHL within the central third of the capitellum for more rotational positions when using the shaft compared with the distal humerus. CONCLUSIONS: With rotated lateral elbow radiographs in supracondylar humerus fractures, utilizing the humeral shaft provides more consistent AHL measurements than utilizing the distal humerus, and thus drawing the line starting at the shaft of the humerus is recommended for surgical decision making.

Implementation of a standardized pregnancy screening process to address gender disparities in radiology turn-around-time and ED length of stay.

OBJECTIVE: The objective of this initiative was to quantify and intervene upon suspected gender disparities in CT turn-around-time and emergency department (ED) length of stay. METHODS: This was a single-site before-after quality improvement initiative including patients aged 12-50 who underwent CT chest and/or abdomen/pelvis. The intervention included protocolization of the pregnancy screening process in triage. Primary outcomes included the difference between women of childbearing age and similarly aged men in regards to CT turn-around-time and ED length of stay. Pre- and post-intervention data were analyzed, including an "intensive intervention period" subanalysis. RESULTS: CT turn-around-time for women of childbearing age was 19 min longer than for similarly aged men at baseline and did not change significantly post-intervention. ED length of stay was 27 min longer for women of childbearing age compared to similarly aged men at baseline and 7 min longer post-intervention, although this was still a significant difference. During the intensive intervention period, CT turn-around-time for women of childbearing age was 15 min longer than similarly aged men but the difference in ED length of stay of 10 min was no longer significant. CONCLUSIONS: There is gender disparity in CT turn-around-time and ED length of stay in our ED, highlighting an important area for improvement to promote equitable care. A quality improvement initiative that aimed to protocolize pregnancy testing in triage did not show sustainable improvement in these outcomes but did result in increased pregnancy testing.

RéSUMé: OBJECTIF: L'objectif de cette initiative était de quantifier et d'intervenir sur les disparités présumées entre les sexes dans le délai d'exécution du scanner et la durée du séjour au service des urgences. MéTHODES: Il s'agissait d'une initiative d'amélioration de la qualité à un seul site avant-après, incluant les patients âgés de 12 à 50 ans qui ont subi une TDM thoracique et/ou abdominale/bassin. L'intervention comprenait la protocolisation du processus de dépistage de la grossesse lors du triage. Les résultats primaires comprenaient la différence entre les femmes en âge de procréer et les hommes du même âge en ce qui concerne le délai d'exécution du scanner et la durée du séjour aux urgences. Les données avant et après l'intervention ont été analysées, y compris une sous-analyse de la "période d'intervention intensive". RéSULTATS: Le temps d'exécution de la TDM chez les femmes en âge de procréer était 19 minutes de plus que chez les hommes de même âge au départ et n'a pas changé de façon significative après l'intervention. La durée de séjour aux urgences était de 27 minutes de plus pour les femmes en âge de procréer par rapport aux hommes du même âge au départ et de 7 minutes de plus après l'intervention, bien que cette différence reste significative. Au cours de la période d'intervention intensive, le temps de passage au scanner des femmes en âge de procréer était de 15 minutes plus long que celui des hommes du même âge, mais la différence de 10 minutes dans la durée de séjour aux urgences n'était plus significative. CONCLUSIONS: Il existe une disparité entre les sexes en ce qui concerne le délai d'exécution du scanner et la durée de séjour dans nos urgences, ce qui met en évidence un domaine important à améliorer pour promouvoir des soins équitables. Une initiative d'amélioration de la qualité visant à protocoliser le test de grossesse au triage n'a pas montré d'amélioration durable de ces résultats mais a entraîné une augmentation des tests de grossesse.

A Comparison of Methylprednisolone and Dexamethasone in Intensive Care Patients With COVID-19.

OBJECTIVES: This study retrospectively compares the effectiveness of methylprednisolone to dexamethasone in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19) requiring intensive care. DESIGN: This is an institutional review board approved cohort study in patients with COVID-19 requiring intensive care unit (ICU) admission. Patients admitted and requiring oxygen supplementation were treated with no steroids, methylprednisolone, or dexamethasone. SETTING: This study takes place in the ICU's at a large, tertiary, public teaching hospital serving a primarily low-income community in urban Los Angeles. PATIENTS: All eligible patients admitted to the ICU for COVID-19 respiratory failure from March 1 to July 31, 2020 were included in this study. INTERVENTIONS: A total of 262 patients were grouped as receiving usual care (n = 75), methylprednisolone dosed at least at 1mg/kg/day for ≥ 3 days (n = 104), or dexamethasone dosed at least at 6 mg for ≥7 days (n = 83). MEASUREMENTS AND MAIN RESULTS: All-cause mortality within 50 days of initial corticosteroid treatment as compared to usual care was calculated. The mortality effect was then stratified based on levels of respiratory support received by the patient. In this cohort of 262 patients with severe COVID-19, all-cause mortalities in the usual care, methylprednisolone, and dexamethasone groups were 41.3%, 16.4% and 26.5% at 50 days (P < 0.01) respectively. In patients requiring mechanical ventilation, mortality was 42% lower in the methylprednisolone group than in the dexamethasone group (hazard ratio 0.48, 95% CI: 0.235-0.956, P = 0.0385). CONCLUSIONS: In COVID-19 patients requiring mechanical ventilation, sufficiently dosed methylprednisolone can lead to a further decreased mortality as compared to dexamethasone.

Use of Incident Command System for Disaster Preparedness: A Model for an Emergency Department COVID-19 Response.

The COVID-19 pandemic has placed unprecedented demands on health systems, where hospitals have become overwhelmed with patients amidst limited resources. Disaster response and resource allocation during such crises present multiple challenges. A breakdown in communication and organization can lead to unnecessary disruptions and adverse events. The Federal Emergency Management Agency (FEMA) promotes the use of an incident command system (ICS) model during large-scale disasters, and we hope that an institutional disaster plan and ICS will help to mitigate these lapses. In this article, we describe the alignment of an emergency department (ED) specific Forward Command structure with the hospital ICS and address the challenges specific to the ED. Key components of this ICS include a hospital-wide incident command or Joint Operations Center (JOC) and an ED Forward Command. This type of structure leads to a shared mental model with division of responsibilities that allows institutional adaptations to changing environments and maintenance of specific roles for optimal coordination and communication. We present this as a model that can be applied to other hospital EDs around the country to help structure the response to the COVID-19 pandemic while remaining generalizable to other disaster situations.

Acculturative stress, disability, and health treatment utilization among Asian and Latin American immigrants in the United States.

PURPOSE: Empirical research has largely ignored the potential links between immigration-related stress and disability as well as immigration-related stress and health service utilization despite increasing scholarship on the association between acculturative stress and health. This study examined the associations between acculturative stress, disability, and health treatment utilization among Asian and Latin American immigrants in the United States. METHODS: Data were from the National Latino and Asian American Study (NLAAS), a nationally representative survey of Asians and Latinos living in the United States. The analytic sample contained 2653 immigrants. We utilized multivariable logistic regression and negative binomial regression analyses to examine the associations between acculturative stress and disability domains. We also examined the association between acculturative stress and treatment utilization, as this may have implications for how to best intervene to address any functional disability related to acculturative stress. RESULTS: Acculturative stress was significantly associated with self-reported disability across five domains: self-care, cognition, mobility, time out of role, and social interaction. Additionally, acculturative stress was significantly associated with a greater frequency of disability domains. Acculturative stress was not significantly associated with utilization of services from mental health or general health sectors, but was significantly and positively associated with utilization of non-health care services. The findings were robust regarding the inclusion of everyday discrimination as well as demographic and socioeconomic covariates. CONCLUSIONS: Acculturative stress may be an important yet overlooked correlate of disability among immigrants in the United States. Non-health care services may provide an effective pathway for intervening for these individuals.

Church-Based Sleep Screenings to Detect Mental Health Problems Among Korean-Americans.

Korean-American mental health is poorly understood, and screening for sleep disturbances may be an effective means of identifying at-risk individuals. In partnership with a Korean-American church in Los Angeles, an online survey was administered. The study was conducted at a Korean-American church in Los Angeles, California. The sample consisted of 137 Korean-Americans drawn from the church congregation. Sleep disturbances were measured using a single ordinal variable, and mental health outcomes included nonspecific psychological distress, perceived stress, loneliness, suicidal ideation, hazardous drinking, treatment seeking behaviors, and perceived need for help. Multivariable logistic regression was used to estimate the associations between sleep disturbances and mental health outcomes, adjusting for age and sex. Results are presented as odds ratios (OR) and 95% confidence intervals. Almost a third of the sample reported moderate or severe sleep disturbances. After adjusting for age and sex, sleep disturbances were associated with greater odds of reporting probable mental illness, perceived need for treatment, and treatment-seeking behaviors. Sleep disturbances were also associated with higher levels of perceived stress and loneliness, but were not significantly associated with suicidal ideation or hazardous drinking. Sleep disturbances are associated with mental health problems and may be an important idiom of distress for Korean-Americans. Primary care providers and informal providers in the community (specifically churches) should work together to screen for sleep problems and refer at-risk individuals to appropriate levels of care.

Perioperative antibiotic use in diabetic patients: A retrospective review of 670 surgeries.

PURPOSE: Carpal tunnel syndrome (CTS) has a high incidence in diabetic patients, with a reported incidence up to 21%. In severe cases of CTS, patients may undergo carpal tunnel release (CTR) surgery, which involves the risk of infection and other complications. To decrease the risk of infection, some physicians provide prophylactic antibiotics. Our study examines the effects of prophylactic antibiotic use, especially in a high-risk, diabetic population. METHODS: A total of 469 CTR surgeries performed by plastic surgery specialists were reviewed for diabetic status at the time of surgery and perioperative antibiotic use. Postoperative infections occurring at the surgical site were recorded. Associations between perioperative antibiotic use and infection in diabetics and nondiabetics were then analyzed. RESULTS: No significant decrease in infection rate was seen in those who were given perioperative antibiotic use. This relationship held true for diabetics as well. CONCLUSIONS: No benefit of antibiotic use during CTR surgery was seen. There was, however, a trend toward a protective effect in patients with uncontrolled diabetes mellitus, suggesting that such patients may benefit from perioperative antibiotic use. LEVEL OF EVIDENCE: III (Retrospective cohort study), Therapeutic.

High-Fat Diet-Induced Complement Activation Mediates Intestinal Inflammation and Neoplasia, Independent of Obesity.

Obesity and related metabolic disturbances are closely associated with pathologies that represent a significant burden to global health. Epidemiological and molecular evidence links obesity and metabolic status with inflammation and increased risk of cancer. Here, using a mouse model of intestinal neoplasia and strains that are susceptible or resistant to diet-induced obesity, it is demonstrated that high-fat diet-induced inflammation, rather than obesity or metabolic status, is associated with increased intestinal neoplasia. The complement fragment C5a acts as the trigger for inflammation and intestinal tumorigenesis. High-fat diet induces complement activation and generation of C5a, which in turn induces the production of proinflammatory cytokines and expression of proto-oncogenes. Pharmacological and genetic targeting of the C5a receptor reduced both inflammation and intestinal polyposis, suggesting the use of complement inhibitors for preventing diet-induced neoplasia. IMPLICATIONS: This study characterizes the relations between diet and metabolic conditions on risk for a common cancer and identifies complement activation as a novel target for cancer prevention. Mol Cancer Res; 14(10); 953-65. ©2016 AACR.

A Randomized Prospective Study Of The Use Of Ipads In Reducing Anxiety During Cast Room Procedures.

BACKGROUND: Cast room procedures can be a source of anxiety for children. Various techniques, including music therapy, have been evaluated as a way to ease this anxiety. The use of iPads as a form of distraction during cast room procedures has not previously been evaluated and was the purpose of the current study. METHODS: 146 children and adolescents who underwent cast room procedures during June- August 2015 were randomly assigned to one of three groups: no-iPad, iPad with video, or iPad with game. Patient heart rates were measured using a pulse oximeter in the waiting room, before the procedure, during the procedure, and after the procedure. Mean values for each group were calculated at each time interval and compared both between groups and within groups over time. RESULTS: There were no significant differences in baseline (waiting room) heart rate between the no-iPad and iPad groups. When compared with the no-iPad group, there was a trend toward decreased heart rate in the video group (p=0.13) and a significant increase in heart rate in the game group (p=0.026) before the procedure. There were no significant decreases in heart rate within any of the groups when comparing the waiting room heart rates with the during procedure heart rates. There was a significant difference between the no-iPad and video groups (p=0.047) when comparing the change in heart rate from baseline to before the procedure, with a decreased heart rate observed in the video group. CONCLUSIONS: The results of this study show a significant decrease in heart rate when transitioning from the waiting room to the cast room while watching videos on the iPad. iPad-based video delivery appears to decrease anxiety prior to cast room procedures. iPad-based game play is difficult to assess as elevations in heart rate prior to the procedure are presumed to be related to game play and confound the observed effect it may have on anxiety related to the procedure.

Effect of remote ischemic postconditioning on patients undergoing living donor liver transplantation.

The aim of this study was to evaluate the protective effect of remote ischemic postconditioning (RIPostC) on graft function and acute kidney injury (AKI) after living donor liver transplantation (LT). Recipients undergoing elective living donor LT were randomly assigned to either the RIPostC group or the control group. Immediately after reperfusion, 4 cycles of ischemia and reperfusion lasting for 5 minutes each were performed on 1 upper limb in the RIPostC group. Graft function was assessed through evaluations of the serum levels of total bilirubin and liver enzymes and the prothrombin time for 28 days after surgery. The incidence of AKI, as defined by the Risk, Injury, Failure, Loss, and End-Stage Kidney Disease classification, was evaluated within 28 days of the operation. In addition, the incidences of graft dysfunction, acute cellular rejection, and major complications; the 1-, 3-, and 6-month mortality rates; the length of stay in the intensive care unit; and the length of hospital stay were also investigated. In all, 78 patients were enrolled in the analysis (n = 39 in each group). No differences in graft function or clinical outcomes were observed between the groups. The incidences of postoperative AKI were 38% (n = 15) in the RIPostC group and 72% (n = 28) in the control group (P = 0.006). Despite no improvements in postoperative graft function, RIPostC decreased the incidence of postoperative AKI after living donor LT in this study. However, no other clinical benefits with respect to the complication rate, length of hospital stay, or short-term mortality rate were observed. Thus, further studies will be needed to evaluate the clinical efficacy of RIPostC in LT fully.

Systematic analysis of enhancer and critical cis-acting RNA elements in the protein-encoding region of the hepatitis C virus genome.

Hepatitis C virus (HCV) causes chronic hepatitis, cirrhosis, and liver cancer. cis-acting RNA elements of the HCV genome are critical for translation initiation and replication of the viral genome. We hypothesized that the coding regions of nonstructural proteins harbor enhancer and essential cis-acting replication elements (CRE). In order to experimentally identify new cis RNA elements, we utilized an unbiased approach to introduce synonymous substitutions. The HCV genome coding for nonstructural proteins (nucleotide positions 3872 to 9097) was divided into 17 contiguous segments. The wobble nucleotide positions of each codon were replaced, resulting in 33% to 41% nucleotide changes. The HCV genome containing one of each of 17 mutant segments (S1 to S17) was tested for genome replication and infectivity. We observed that silent mutations in segment 13 (S13) (nucleotides [nt] 7457 to 7786), S14 (nt 7787 to 8113), S15 (nt 8114 to 8440), S16 (nt 8441 to 8767), and S17 (nt 8768 to 9097) resulted in impaired genome replication, suggesting CRE structures are enriched in the NS5B region. Subsequent high-resolution mutational analysis of NS5B (nt 7787 to 9289) using approximately 51-nucleotide contiguous subsegment mutant viruses having synonymous mutations revealed that subsegments SS8195-8245, SS8654-8704, and SS9011-9061 were required for efficient viral growth, suggesting that these regions act as enhancer elements. Covariant nucleotide substitution analysis of a stem-loop, JFH-SL9098, revealed the formation of an extended stem structure, which we designated JFH-SL9074. We have identified new enhancer RNA elements and an extended stem-loop in the NS5B coding region. Genetic modification of enhancer RNA elements can be utilized for designing attenuated HCV vaccine candidates.