Paravertebral anesthetic nerve block for pain control after peroral endoscopic myotomy.

BACKGROUND: Excess post-operative opioid medication use can delay recovery and is associated with long-term misuse, addiction, and overdose. We aimed to explore the effect of pre-procedural thoracic paravertebral nerve block (PNB) on pain-related outcomes after POEM. METHODS: In this retrospective cohort study, consecutive patients who did and did not receive a PNB prior to POEM were compared. The outcomes were peak and cumulative pain scores, total opioid use during hospitalization, and length of stay. After adjusting for confounders, the associations between nerve block and the outcomes of interest were explored. RESULTS: Forty-nine consecutive patients were enrolled; 25 patients received a block whereas the subsequent 24 did not. There were no differences in baseline characteristics between the study groups. In unadjusted analyses, there was no significant difference between patients who did and did not undergo PNB in peak pain score (7.8 vs. 8.7, p=0.14), cumulative pain score in the first 12 hours (area under curve 66.5 vs. 75.8, p=0.22), median total opioid use (38.9 mg morphine equivalent dosing vs. 42, p=1.00), and median length of hospitalization (26.5 hours vs. 24, p=0.35). In multivariable regression models, PNB was not associated with a reduction in pain scores, opioid use, or hospitalization. There were no adverse events related to the block. CONCLUSIONS: In this exploratory, observational study, paravertebral nerve block immediately before POEM did not result in a statistically significant reduction in pain-related outcomes or hospitalization. Additional observational studies may elucidate whether higher anesthetic doses or longer acting formulations would be of value.

Factors associated with pediatric drowning admissions and outcomes at a trauma center, 2010-2017.

BACKGROUND: Drowning is a leading cause of preventable mortality and morbidity in children. Its high fatality rate and frequent severe sequelae (e.g. brain damage and permanent loss of functioning) place a premium on preventive efforts. METHODS: A retrospective analysis of patients ≤21 years of age admitted between 2010 and 2017 to a pediatric trauma center was conducted to identify factors associated with drowning admissions, fatal drowning, and severe outcome (ventilator use, ICU admission, or death). Outcomes were modeled and estimated by use of logistic regression and Poisson regression. RESULTS: Drowning accounted for 153/4931 (3.1%) trauma admissions between 2010 and 2017. The risk of death (13.1% vs. 1.5%, p < .01), and severe outcome (24.8% vs. 7.8%, p < .01) was significantly higher for drownings vs. other causes. All 20 drowning deaths occurred among children left unattended. In Poisson regression analysis, weekends, summer breaks, and hotter days were independently associated with a higher probability of drowning admissions. Additionally, in analyses excluding indicators of severity, the odds of severe outcome were higher for children age ≤ 2 years [adjusted odds ratio (AOR) = 3.88 95% CI (1.58, 9.53)], and injury downtime of >5 min or unknown length [AOR = 6.66 95% CI (2.74-16.15)]. Immediate intervention after the discovery was associated with ~70% lower odds of a severe outcome. CONCLUSIONS: Drowning admissions were both more severe and more often fatal compared to other pediatric injury causes of admission. Enhanced and targeted educational messages for parents of young children, focused on prevention behaviors on high-risk days and immediate bystander intervention, may reduce the occurrence and severity of these tragic accidents. TABLE OF CONTENTS SUMMARY: A retrospective multi-year cohort study to identify modifiable factors associated with drowning admissions, severe complications, and death from a large trauma registry database. WHAT'S KNOWN ON THIS SUBJECT: Drowning is a leading cause of unintentional injury that results in severe morbidity and a high rate of mortality. Children are disproportionately affected by drowning and have a higher risk of long term sequelae and death. WHAT THIS STUDY ADDS: This study identified high-risk populations and periods for drowning, the importance of supervision, and the effectiveness of immediate intervention in reducing unfavorable outcomes after drowning. It also highlights a need for heightened local intervention for drowning prevention.

Temporal trends in patient characteristics, injury mechanisms and outcomes in pediatric trauma admissions between 2010 and 2017.

INTRODUCTION: Injuries are a leading cause of preventable morbidity and mortality in children. Mechanisms of injuries and presentations are diverse in pediatric injuries and require special attention. Dedicated pediatric trauma care centers are ideal for management of children with injuries simultaneously serving as sources of research data. The objective of the current study was to identify changes in injury mechanisms, modifiable risk factors, and outcomes independently associated with admissions at a large pediatric trauma center in Tampa, Florida. METHODS: We conducted retrospective analysis of 8-years (2010-2017) of pediatric trauma admissions to a large trauma center. Demographic factors and injury characteristics were examined for temporal trends over two year increments. Temporal changes in admissions with major trauma, admission to ICU, and length of stay were examined using logistic regression analysis, and factors associated with independent temporal trends were identified using ordinal logistic regression modeling. RESULTS: During the study period, there were 4,934 trauma admissions with a predominance of falls (45.1%) and traffic injuries (20.5%). Trends were observed with less frequent head injuries (2010-2011: 35.7% vs 2016-2017: 28.3%, p < .01) and abdominal injuries (2010-2011:10.3% vs 2016-2017: 8.2%, p = .03), and more frequent chest injuries (2010-2011: 9.0% vs 2016-2017: 11.4%, p < .01). Over the study period, evaluated in 2-year increments, higher use of private insurance (Adjusted Odds Ratio (AOR)=1.44, 95% Confidence Interval (CI) 95% CI: 1.29-1.61) and helicopter transport (AOR=1.91, 95% CI: 1.58 -2.30) was observed. Admissions for drownings (AOR=1.50, 95% CI: 1.10 -2.02) and animal bites (AOR=1.99, 95% CI: 1.46 -2.71) increased during the study period. Improvement in patient outcomes (adjusted for injury severity) were observed with shorter, ≤1 day length of stay (LOS) (AOR=1.19, 95% CI: 1.06 -1.33), reduction in complications (AOR=0.47, 95% CI: 0.33 -0.66), and more admissions without an intensive care unit (ICU) stay (AOR=1.6 95% CI = 1.36 -1.88). CONCLUSIONS: Significant reductions in LOS, ICU stay, and complications were temporally observed despite an increase in admissions with higher use of helicopter transport. These results can most likely be attributed to dedicated pediatric trauma experts and resources available at an integrated pediatric trauma center.

Adherence to Appropriate Nutrition in Acute Alcoholic Hepatitis is Low.

Malnutrition is a common cause of impeding recovery in patients with acute alcoholic hepatitis (AAH). Previous reports have shown that appropriate nutritional supplementation reduce short and long-term mortality in patients with AAH. Despite these clear recommendations, the element of nutrition in AAH is often neglected. We designed a quality improvement project to evaluate and improve compliance with appropriate nutrition in patients presenting with AAH at our institution. Patients admitted with AAH between December 2015 to December 2016 were included. Our primary outcome was compliance with appropriate nutrition. Secondary outcomes included nutrition consultation and hepatology consultation. A total of fifty-four patients were included. Nine of the 53 patients (17%) received high calorie and high protein diets. Hepatology was consulted in 72% (38/53) of the patients, and 21% (8/38) of these patients received appropriate nutrition as compared to only 8.3% (1/12) in whom hepatology was not consulted. Nutrition was consulted in 55% (29/53) of these patients and 67% (19/28) of those patients received appropriate nutrition. In conclusion, our compliance of appropriate nutrition in AAH is low. Our initial investigation suggests that hepatology and nutrition consultation improved compliance with appropriate nutrition. The next step will be to implement protocolized care for appropriate nutrition in AAH by incorporating consultation of hepatology and nutrition services, assess the effect on adherence to appropriate nutrition, and determine the impact on patient outcomes.

Nuclear trafficking of the HIV-1 pre-integration complex depends on the ADAM10 intracellular domain.

Previously, we showed that ADAM10 is necessary for HIV-1 replication in primary human macrophages and immortalized cell lines. Silencing ADAM10 expression interrupted the HIV-1 life cycle prior to nuclear translocation of viral cDNA. Furthermore, our data indicated that HIV-1 replication depends on the expression of ADAM15 and γ-secretase, which proteolytically processes ADAM10. Silencing ADAM15 or γ-secretase expression inhibits HIV-1 replication between reverse transcription and nuclear entry. Here, we show that ADAM10 expression also supports replication in CD4(+) T lymphocytes. The intracellular domain (ICD) of ADAM10 associates with the HIV-1 pre-integration complex (PIC) in the cytoplasm and immunoprecipitates and co-localizes with HIV-1 integrase, a key component of PIC. Taken together, our data support a model whereby ADAM15/γ-secretase processing of ADAM10 releases the ICD, which then incorporates into HIV-1 PIC to facilitate nuclear trafficking. Thus, these studies suggest ADAM10 as a novel therapeutic target for inhibiting HIV-1 prior to nuclear entry.