Envisioning Better Healthcare Systems: A Unique and Innovative Journey From Community Hospital to Academic Medical Center.

The transformation from a community hospital to an academic medical center (AMC) presents a unique set of challenges and opportunities. This editorial provides an in-depth analysis of the barriers encountered and solutions developed within a large community hospital in Florida as it embarked on this transition, with a focus on the global relevance of issues experienced such as competition with major markets, the ongoing COVID-19 pandemic, the development of multiple Accreditation Council for Graduate Medical Education (ACGME) programs and balancing the complexities of the United States healthcare system. In alignment with the call for submissions, this editorial highlights the personal experiences of healthcare providers, researchers, and policymakers involved in this transition and explores how the lessons learned can inform the development of better healthcare systems worldwide.

Impact of Outpatient Antihypertensive Medication Use on Epinephrine Resistance in Anaphylaxis.

BACKGROUND: There has been an increase in allergy-related emergency department (ED) visits over the past several years. Underlying cardiovascular disease or respiratory disease and concurrent beta blocker or angiotensin-converting enzyme inhibitor use have been identified as potential risk factors for severe or refractory anaphylactic reactions. Conflicting evidence exists regarding the association between antihypertensive (AH) use and the incidence of refractory anaphylaxis. OBJECTIVE: The purpose of this study was to determine the incidence of refractory anaphylaxis in patients presenting to the ED while prescribed select AH medications outpatient. METHODS: This was a retrospective cohort study of all adult and pediatric patients presenting to the ED between February 16, 2021, and August 31, 2021, with a diagnosis of anaphylaxis. The primary objective was to compare the proportion of patients experiencing refractory anaphylaxis that were prescribed versus not prescribed AH medications in the outpatient setting. RESULTS: A total of 101 patients were treated for anaphylaxis in the ED during the study timeframe with 13 patients in the AH group and 88 patients in the no AH group. There was no difference in the incidence of refractory anaphylaxis between groups (0% vs 9%; p=0.48). Significantly fewer patients in the AH group required any epinephrine doses compared to the no AH group (38% vs 88%; p<0.001). CONCLUSIONS: Outpatient use of select AH medications was not associated with an increased incidence of refractory anaphylaxis in patients presenting to the ED.

Association of Type of Vaccination Center With Time to Emergency Department Presentation for Acute COVID-19 Infection: An Exploratory Analysis.

Objective The objective of this study was to identify potential associations between coronavirus disease 2019 (COVID-19) vaccination center reception location and time to presentation to the emergency department for acute COVID-19 infection. The a priori hypothesis was that there are significant differences in the outcome based on vaccination administration center type. Methods This was a cross-sectional, observational study conducted within a hospital in Lakeland, Florida, between October 2021 and May 2022. Participants were at least 18 years old with confirmed severe acute respiratory syndrome coronavirus 2 (SARS­CoV­2) infection and at least two COVID-19 symptoms at enrollment. Patients with prior confirmed COVID-19 diagnosis and hospitalization within 10 days of screening were excluded. Participants were sampled from within the emergency department of the institution. The primary outcome was time to presentation to the emergency department for acute COVID-19 infection since the last vaccination dose from each sampled COVID-19 vaccination center location. Results A total of 93 participants were analyzed. Of these, 48 (52%) participants received COVID-19 vaccination. Participants vaccinated at vaccine clinics demonstrated a significantly longer mean survival time (288.2 (29.9)) compared to other sites. Significant predictors of hospitalization were age (aOR, 1.09, 95%CI 1.02-1.16, p < 0.01), sex (aOR: 10.05, 95%CI 1.52-66.54, p < 0.05), physical function (aOR, 0.90, 95%CI 0.83-0.97, p < 0.01) and number of medications (aOR, 1.34, 95%CI 1.14-1.58, p < 0.001).  Conclusions This exploratory analysis highlights the need for further investigation into both characteristics of healthcare institutions and individual-level factors that may play a role in the prolonged prevention of emergency department presentations due to COVID-19 infection. Increased transparency of data regarding practices related to the administration of COVID-19 vaccines across various institutions may be beneficial in further understanding the role of COVID-19 vaccinations in preventing symptomatic disease across local and global communities.

Use of Casirivimab and Imdevimab for the Treatment of COVID-19.

The authors present three cases of unvaccinated coronavirus disease 2019 (COVID-19) patients who exhibited symptoms of fever, sore throat, nausea, diarrhea, congestion, and headache. Although they refused COVID-19 vaccination, they presented for the casirivimab and imdevimab monoclonal antibody cocktail, which resulted in the resolution of all symptoms. The authors describe the mechanisms and importance of monoclonal antibody treatment for high-risk and unvaccinated patients infected with SARS-CoV-2.

Multisystem Inflammatory Syndrome Presenting as Early Acute Appendicitis.

An 11-year-old male presented to the pediatric emergency department with a one-day history of peri-umbilical pain with nausea, anorexia, and scant vomiting. On examination, he had moderate tenderness in the right upper quadrant with moderate guarding and rebound tenderness. Imaging showed concern for early acute appendicitis. The patient was admitted and underwent laparoscopic appendectomy. Despite the appendectomy, the patient continued to have fevers and abdominal pain. Four days after the initial presentation, the patient decompensated and was diagnosed with multisystem inflammatory syndrome. This case is interesting because the patient never met diagnostic criteria for multisystem inflammatory syndrome in children (MIS-C) prior to his decompensation. If a patient's symptoms continue or worsen despite seemingly appropriate management, the patient must be reassessed for other causes of pathology. Surgeons must have a high index of suspicion for MIS-C in patients with recent COVID-19 diagnoses, and this case demonstrates that MIS-C can present in phases and not all at once.

What Do Spanish Speakers Think of the Andar, Hablar, Ojos, Rostro, Ambos Brazos o Piernas (AHORA) Stroke Tool?

AHORA (Andar, Hablar, Ojos, Rostro, Ambos Brazos o Piernas) is a Spanish language tool to identify stroke symptoms. A survey of 300 primarily Spanish-speaking, non-medical professionals was conducted to assess the acceptance of the tool, specifically about ease of understanding and ability to implement it. The overwhelming majority of respondents reacted very positively to the tool, finding it quite easy to learn, teach, and understand. Respondent feedback, pitfalls, and questions for further research are presented.

Dyspnea in the Elderly.

This article discusses the evaluation and management of stable and unstable elderly patients with dyspnea. Several of the changes in the elderly that alter cardiopulmonary physiology are discussed. A review of common presenting illnesses and their evaluation and management are highlighted. The reader should be left with a better understanding of this unique population and the overall evaluation and treatment.

Assessment of recombinant porcine follicle-stimulating hormone receptor using a novel polyclonal ectodomain antibody.

Follicle-stimulating hormone (FSH) receptors (FSHR) are critically involved in mediating the responses of granulosa cells and Sertoli cells to FSH. The dynamic changes in cell surface FSH receptors (FSHR) in response to FSH remain unclear in part because of the heavy reliance on ligand-binding methodologies. This study was designed to determine the molecular and cellular properties of recombinant porcine FSHR using a novel, high-affinity purified polyclonal antibody to the ectodomain of the pFSHR. A full-length porcine FSHR cDNA was cloned and sequenced and recombinant pFSHR protein was stably expressed in a clonal cell line of Chinese hamster ovary cells (pFSHR-CHO). Recombinant receptor was stably expressed in an ovarian cell line with a density similar to that of porcine ovarian cells. A specific polyclonal antibody was generated in chickens to a 100-amino acid fragment of the pFSHR ectodomain. Immunoblotting, immunoprecipitation, indirect immunofluorescence cytochemistry and immunoelectron microscopy were performed using affinity-purified antibody to identify recombinant pFSHR in pFSHR-CHO cells. Immunoblotting of solubilized pFSHR-CHO proteins and immunoprecipitation of pFSHR-CHO protein metabolically labeled with 35S identified a single 74-kDa band in pFSHR-CHO cells; no bands were visualized in mock-transfected CHO cells. Indirect immunofluorescent labeling revealed the presence of pFSHR in pFSHR-CHO cells but not in mock-transfected CHO cells. Immunoelectron microscopy revealed the highest density of pFSHR associated with the plasma membrane and no pFSHR in mock-transfected CHO cells. The chicken anti-pFSHR antibody is a valuable tool for detecting and monitoring of FSHR using a variety of methodologies.

Antisense oligodeoxynucleotide inhibits expression of recombinant porcine follicle-stimulating hormone receptor.

Follicle-stimulating hormone (FSH) regulates folliculogenesis in the ovary and spermatogenesis in the testis via specific, high affinity membrane-bound receptors (FSHR). To assess the role of FSHR gene expression in regulating expression of FSHR protein in the plasma membrane, the effects of a porcine FSHR cDNA antisense oligodeoxynucleotide (ODN) on FSHR mRNA levels and (125)I-FSH binding were determined in Chinese hamster ovary cells stably expressing recombinant porcine FSHR (pFSHR-CHO cells). An 18-mer phosphorothioated antisense ODN corresponding to the region surrounding the translation initiation codon of the porcine FSHR cDNA was synthesized. An 18-mer phosphorothioated nonsense sequence of identical nucleotide composition was synthesized for use as a control. pFSHR-CHO cells were cultured in the absence or presence of 1-20 microM antisense or nonsense ODN for 24 hr and then assayed for porcine FSHR mRNA, using quantitative reverse transcription and competitive polymerase chain reaction, and for (125)I-FSH binding activity. Treatment with 10 microM antisense ODN caused a paradoxical increase in porcine FSHR mRNA. Nonsense ODN had no effect on porcine FSHR mRNA. Antisense, but not nonsense, ODN (10 microM ) inhibited membrane binding of (125)I-FSH by 13.6 +/- 0.8% (mean +/- SEM, n = 3, P < 0.05) in 24 hr. Treatment of cells with antisense ODN (10 microM) for 48 hr resulted in a 76 +/- 1.5% (P < 0.05) inhibition of (125)I-FSH binding. These results indicate that an FSHR antisense ODN effectively inhibits porcine FSHR synthesis and inhibition of receptor synthesis causes a decrease in functional membrane-bound FSHR.