Fever and hypothermia do not affect the all-cause 30-day hospital readmission.

BACKGROUND: One of the goals of the Affordable Care Act is to decrease hospital readmissions. While widely adhered to, there is no published research to support the practice of delaying discharge if patients exhibit fever or hypothermia in the preceding 24 h, which is the focus of our study. METHODS: Retrospective analysis of the minimal (Tmin) and maximal (Tmax) body temperatures collected during the last 24 h before discharge of 19,038 inpatients. Fever was defined as Tmax >99.5F (+1SD from the mean Tmax) or >100.2F (+2SDs), and hypothermia as Tmin <97.1F (-1SD from the mean Tmin) or <96.7F (-2SDs). RESULTS: The overall readmission rate was 10.2% (highest for General Medicine and Pediatrics). The rate of readmission was not different between normothermic patients and those with abnormal body temperature, except for higher readmission rate (12.2%) for patients with fever at 1SD from Tmax compared with normothermic patients (9.96%). Neither fever nor hypothermia was associated with shorter time to readmission, except for fever at 2 SDs from Tmax (10.6 days) compared with normothermic patients (12.6 days). Surprisingly, univariate analysis revealed that higher Tmax and older age were associated with lower readmission probability. Both uni- and multivariate analysis showed that the presence of fever is associated with lower readmission probability. Evaluating 200 individual cases, the most common explanation for body temperature abnormality was infection and 90% of the preventable readmissions were due to infection. CONCLUSIONS: Abnormal body temperature 24 h prior to discharge was not useful for predicting the probability of readmission.

Disruption of the Body Temperature Circadian Rhythm in Hospitalized Patients.

BACKGROUND: Dysregulation of the circadian rhythm is linked to immune response deficiencies. Diurnal temperature variation-a surrogate for the circadian rhythm, exists in humans, yet its preservation during illness is not well understood. MATERIALS AND METHODS: Temperatures measured within one-half hour of 8 am, 12 pm, 4 pm, 8 pm, 12 am, and 4 am from 16,245 hospitalized patients were statistically analyzed. RESULTS: Although we found a diurnal pattern when analyzing the ensemble of temperatures from all patients, stratified by measurement site, the trough-to-peak difference was only 0.2°F, while that for healthy volunteers had been in the 0.5°F to 1.9°F range. The peaks occurred at 8 pm for all patients, regardless of age or sex, which is similar to healthy people. However, the troughs were shifted to later times compared with the 6 am in healthy people-for young patients (age 20-30 years) the trough was at 8 am and for elderly patients (age 70-80 years), at 12 pm, again regardless of patients' sex. Analysis of individual patients showed that less than 20% of patients exhibited diurnal variation and among those showing variation, the trend was present only on the minority of hospitalization days. The presence or absence of an infectious process or fever did not influence the proportion of patients showing diurnal variation. CONCLUSIONS: Hospitalization is associated with disruption in the circadian rhythm as reflected by patients' body temperature. Since abnormality in body temperature is known to affect patient outcomes, an understanding of the diurnal cycle during hospitalization is the first step towards devising approaches to re-establish the circadian rhythm.

Comprehensive Analysis of Temperature in Hospitalized Patients.

BACKGROUND: Human body temperature is believed to be linked to clinical diagnoses. However, most of the available data stems from healthy individuals, with no large-scale studies addressing body temperature in the inpatient setting, which is the focus of our study. MATERIALS AND METHODS: This is a retrospective analysis of a total of 695,107 temperature readings from 16,245 patients hospitalized over a 1-year period at a tertiary medical center, ages 0-105 years, 50% female, with rectal, monotherm, axillary, oral, temporal and tympanic measurement sites. The average temperature (Tave) per patient and per measurement site was used in all calculations. Descriptive statistics, Student's t-test, and Pearson's correlation were used, where appropriate, with statistical significance set at P < 0.05. RESULTS: Tave from all measurement sites was 98.13 ± 0.48(SD)F(36.74 ± 0.27°C). Tave varied by the site of measurement, in decreasing order highest-to-lowest being rectal, monotherm, axillary, oral, temporal, and tympanic, all of which were higher than the available reported averages for healthy subjects. Tave decreased as patients' age increased. There was only slight and likely clinically insignificant difference between the sexes. There were differences in Tave between the intensive care units (ICUs), listed from highest-to-lowest: Neuro ICU, Pediatric ICU, Surgical ICU, Cardiac ICU and Medical ICU. However, there was no difference between all ICU and non-ICU patients. CONCLUSIONS: Our inpatient data demonstrate that previously identified body temperature trends among healthy subjects are preserved, to an extent, in the inpatient setting. To our knowledge, ours is the first study that evaluates the temperatures of all hospitalized patients at a large tertiary medical center.

Normal Body Temperature: A Systematic Review.

PubMed was searched from 1935 to December 2017 with a variety of search phrases among article titles. The references of the identified manuscripts were then manually searched. The inclusion criteria were as follows: (1) the paper presented data on measured normal body temperature of healthy human subjects ages 18 and older, (2) a prospective design was used, and (3) the paper was written in or translated into the English language. Thirty-six articles met the inclusion criteria. This comprised 9227 measurement sites from 7636 subjects. The calculated ranges (mean ± 2 standard deviations) were 36.32-37.76 (rectal), 35.76-37.52 (tympanic), 35.61-37.61 (urine), 35.73-37.41 (oral), and 35.01-36.93 (axillary). Older adults (age ≥60) had lower temperature than younger adults (age <60) by 0.23°C, on average. There was only insignificant gender difference. Compared with the currently established reference point for normothermia of 36.8°C, our means are slightly lower but the difference likely has no physiological importance. We conclude that the most important patient factors remain site of measurement and patient's age.

Delusional Parasitosis Impeding Delivery of Acute Care in a Cancer Patient.

Taking care of patients with delusional parasitosis can be challenging. This report illustrates the added management complexity and ethical dilemmas surrounding a patient who was newly diagnosed with an incurable lung cancer, while at the same time was suffering from delusional parasitosis. Her delusion was so profound that she blamed flukes for her respiratory failure and refused treatment of her cancer. This paper emphasizes making the right decision with the greater good in mind, even if this meant "yielding" to a patient's delusion and treating the non-existing parasitosis in order for her to allow us to also treat the cancer.

Actin filaments partition primary cilia membranes into distinct fluid corrals.

Physical properties of primary cilia membranes in living cells were examined using two independent, high-spatiotemporal-resolution approaches: fast tracking of single quantum dot-labeled G protein-coupled receptors and a novel two-photon super-resolution fluorescence recovery after photobleaching of protein ensemble. Both approaches demonstrated the cilium membrane to be partitioned into corralled domains spanning 274 ± 20 nm, within which the receptors are transiently confined for 0.71 ± 0.09 s. The mean membrane diffusion coefficient within the corrals, Dm1 = 2.9 ± 0.41 µm2/s, showed that the ciliary membranes were among the most fluid encountered. At longer times, the apparent membrane diffusion coefficient, Dm2 = 0.23 ± 0.05 µm2/s, showed that corral boundaries impeded receptor diffusion 13-fold. Mathematical simulations predict the probability of G protein-coupled receptors crossing corral boundaries to be 1 in 472. Remarkably, latrunculin A, cytochalasin D, and jasplakinolide treatments altered the corral permeability. Ciliary membranes are thus partitioned into highly fluid membrane nanodomains that are delimited by filamentous actin.

The Complexities of Negative Dysphotopsia.

The appearance of a dark shadow in the temporal periphery, otherwise known as negative dysphotopsia, continues to be a problem for some patients after routine uncomplicated cataract surgery. Etiologies include type and design of intraocular lens (IOL), anatomical features and dimensions of the eye, pupil size, angle kappa, relationship of the optic to the anterior capsule, and the position of the optic/haptic junction of the IOL. Although the primary etiology remains controversial, it is clear that the cause is multifactorial. All of the factors should be considered when attempting to prevent or treat this phenomenon.

Untangling ciliary access and enrichment of two rhodopsin-like receptors using quantitative fluorescence microscopy reveals cell-specific sorting pathways.

Resolution limitations of optical systems are major obstacles for determining whether proteins are enriched within cell compartments. Here we use an approach to determine the degree of membrane protein ciliary enrichment that quantitatively accounts for the differences in sampling of the ciliary and apical membranes inherent to confocal microscopes. Theory shows that cilia will appear more than threefold brighter than the surrounding apical membrane when the densities of fluorescently labeled proteins are the same, thus providing a benchmark for ciliary enrichment. Using this benchmark, we examined the ciliary enrichment signals of two G protein-coupled receptors (GPCRs)-the somatostatin receptor 3 and rhodopsin. Remarkably, we found that the C-terminal VxPx motif, required for efficient enrichment of rhodopsin within rod photoreceptor sensory cilia, inhibited enrichment of the somatostatin receptor in primary cilia. Similarly, VxPx inhibited primary cilium enrichment of a chimera of rhodopsin and somatostatin receptor 3, where the dual Ax(S/A)xQ ciliary targeting motifs within the third intracellular loop of the somatostatin receptor replaced the third intracellular loop of rhodopsin. Rhodopsin was depleted from primary cilia but gained access, without being enriched, with the dual Ax(S/A)xQ motifs. Ciliary enrichment of these GPCRs thus operates via distinct mechanisms in different cells.

New preventative approach for negative dysphotopsia.

PURPOSE: To evaluate whether positioning the intraocular lens (IOL) to decrease the entry of inferotemporal light would decrease the incidence of negative dysphotopsia. SETTING: Private practices, Boston and Chelmsford, Massachusetts, USA. DESIGN: Prospective randomized case study. METHODS: Patients had cataract surgery with implantation of either a silicone IOL inferotemporally or vertically (randomly assigned) or a 1-piece acrylic IOL with the optic-haptic junction inferotemporally or vertically (randomly assigned). Other patients received acrylic IOLs bilaterally and inferotemporally without randomization. Patients were asked about negative dysphotopsia symptoms postoperatively. Data were analyzed using the z test and a chi-square test for comparing the incidence of negative dysphotopsia between the 3 groups. RESULTS: The study comprised 305 patients (418 eyes). A silicone IOL was implanted inferotemporally in 39 eyes and vertically in 60 eyes. An acrylic IOL was implanted with the optic-haptic junction inferotemporally in 163 eyes and with the junction vertical in 114 eyes. Forty-two eyes had bilateral inferotemporal implantation of an acrylic IOL. For the acrylic IOL on the first postoperative day, the incidence of negative dysphotopsia was smaller for the inferotemporal IOL orientation (6%) than in the control group (14%) (P = .026). The rate of persistent negative dysphotopsia decreased in both groups over time, and the difference 1 month after surgery was no longer statistically significant. The negative dysphotopsia rate for the silicone IOL was 0%. CONCLUSIONS: Positioning the optic-haptic junction of an acrylic IOL inferotemporally resulted in a 2.3-fold decrease in the incidence of negative dysphotopsia after cataract surgery. When implanted in the vertical position, Acrylic IOLs seemed to lead to a higher incidence of negative dysphotopsia than silicone IOLs. FINANCIAL DISCLOSURE: Dr. Henderson is a consultant to Abbott Medical Optics, Inc., Alcon Laboratories, Inc., and Bausch & Lomb, Inc. None of the other authors has a financial or proprietary interest in any material or method mentioned.

Photobiomodulation for the treatment of retinal diseases: a review.

Photobiomodulation (PBM), also known as low level laser therapy, has recently risen to the attention of the ophthalmology community as a promising new approach to treat a variety of retinal conditions including age-related macular degeneration, retinopathy of prematurity, diabetic retinopathy, Leber's hereditary optic neuropathy, amblyopia, methanol-induced retinal damage, and possibly others. This review evaluates the existing research pertaining to PBM applications in the retina, with a focus on the mechanisms of action and clinical outcomes. All available literature until April 2015 was reviewed using PubMed and the following keywords: "photobiomodulation AND retina", "low level light therapy AND retina", "low level laser therapy AND retina", and "FR/NIR therapy AND retina". In addition, the relevant references listed within the papers identified through PubMed were incorporated. The literature supports the conclusion that the low-cost and non-invasive nature of PBM, coupled with the first promising clinical reports and the numerous preclinical-studies in animal models, make PBM well-poised to become an important player in the treatment of a wide range of retinal disorders. Nevertheless, large-scale clinical trials will be necessary to establish the PBM therapeutic ranges for the various retinal diseases, as well as to gain a deeper understanding of its mechanisms of action.

Negative dysphotopsia: A perfect storm.

UNLABELLED: The objective of this review was to provide a summary of the peer-reviewed literature on the etiologies of negative dysphotopsia that occurs after routine cataract surgery. A search of PubMed, Google Scholar, and Retina Medical identified 59 reports. Negative dysphotopsia has been associated with many types of intraocular lenses (IOLs), including hydrophobic and hydrophilic acrylic, silicone, and 1-piece and 3-piece designs. Proposed etiologies include edge design, edge smoothness, edge thickness, index of refraction of the IOL, pupil size, amount of functional nasal retina, edema from the clear corneal incision, distance between the iris and IOL, amount of pigmentation of the eye, corneal shape, prominent globe and shallow orbit, and interaction between the anterior capsulorhexis and IOL. Treatments include a piggyback IOL, reverse optic capture, dilation of the pupil, constriction of the pupil, neodymium:YAG capsulotomy of the nasal portion of the anterior capsule, IOL exchange with round-edged optics, and time alone. This review summarizes the findings. FINANCIAL DISCLOSURE: Dr. Henderson is a consultant to Alcon Laboratories, Inc., Abbott Medical Optics, Inc., Bausch & Lomb, and Genzyme Corp. Neither author has a financial or proprietary interest in any material or method mentioned.