Impact of an Individualized Pain Plan to Treat Sickle Cell Disease Vaso-occlusive Episodes in the Emergency Department.

To address acute vaso-occlusive episodes (VOEs), the leading cause of Emergency Department (ED) visits among individuals with sickle cell disease (SCD), we conducted the clinical study, An Individualized Pain Plan with Patient and Provider Access for Emergency Department care of SCD (ALIGN), across eight sites. We hypothesized an improvement of 0.5 standard deviations in perceived quality of ED pain treatment of a VOE after implementing individualized pain plans (IPPs) accessible to both patients and providers. Patients with SCD were 18-45, owned a cell phone, and had an ED VOE visit within 90 days prior. Patients completed perceived quality of care surveys at baseline and within 96 hours after a VOE ED visit. Providers completed surveys regarding comfort managing VOEs at baseline and after managing an enrolled patient. Most of the 153 patients were African American (95.4%), female (64.7%) and had Hb SS/Sß0 genotype (71.9%). The perceived quality of ED pain treatment was high at both baseline and post implementation of IPPs; our primary outcome hypothesis was not met, as no statistically significant change in patient perceived quality ED treatment ocurred. A total of 135 providers completed baseline and follow-up surveys. On a scale of 1-7, with 7 being extremely comfortable managing VOEs, 60.5% reported a score ≥6 post IPP implementation vs. 57.8% at baseline. Almost all (97.6%) ordered the recommended medication, and 94.7% intend to use IPPs. In this implementation protocol, all sites successfully implemented IPPs . Patients and ED providers both endorsed the use of IPPs.

Enriched Environment Contributes to the Recovery from Neurotoxin-Induced Parkinson's Disease Pathology.

Parkinson's disease (PD) is a neurological disorder that affects dopaminergic neurons. The lack of understanding of the underlying molecular mechanisms of PD pathology makes treating it a challenge. Several pieces of evidence support the protective role of enriched environment (EE) and exercise on dopaminergic neurons. The specific aspect(s) of neuroprotection after exposure to EE have not been identified. Therefore, we have investigated the protective role of EE on dopamine dysregulation and subsequent downregulation of DJ1 protein using in vitro and in vivo models of PD. Our study for the first time demonstrated that DJ1 expression has a direct correlation with dopamine downregulation in PD models and exposure to EE has a significant impact on improving the behavioral changes in PD mice. This research provides evidence that exercise in EE has a positive effect on PD without interfering with the current line of therapy.

A Case of Atraumatic Angular Vein Thrombosis.

Angular vein thrombosis is a rare vascular disorder marked by the occlusion of the angular vein by a blood clot. We report the case of a 70-year-old woman who presented with a visible bulge near her left nasojugal groove for one week and had no other associated symptoms or pertinent medical history. Subsequent maxillofacial CT scans with contrast revealed left angular vein thrombosis with dilation of the facial vein inferiorly. Despite its rarity, angular vein thrombosis poses a diagnostic challenge due to overlapping symptoms with other vascular and nonvascular pathologies. This case highlights the importance of early identification to prevent complications such as facial venous circulation obstruction and clot migration to the cavernous sinus.

Gastroesophageal reflux disease: 2021 guideline updates and clinical pearls.

ABSTRACT: In 2021, the American College of Gastroenterology updated its diagnosis and treatment guideline for gastroesophageal reflux disease (GERD). This article provides a summary of noteworthy changes to the guideline and describes clinical pearls that are pertinent to the diagnosis and treatment of GERD in primary care.

Longitudinal Analysis of Urinary Cytokines and Biomarkers in COVID-19 Patients with Subclinical Acute Kidney Injury.

In hospitalized COVID-19 patients, disease progression leading to acute kidney injury (AKI) may be driven by immune dysregulation. We explored the role of urinary cytokines and their relationship with kidney stress biomarkers in COVID-19 patients before and after the development of AKI. Of 51 patients, 54.9% developed AKI. The principal component analysis indicated that in subclinical AKI, epidermal growth factor (EGF) and interferon (IFN)-α were associated with a lower risk of AKI, while interleukin-12 (IL-12) and macrophage inflammatory protein (MIP)-1ß were associated with a higher risk of AKI. After the manifestation of AKI, EGF and IFN-α remained associated with a lower risk of AKI, while IL-1 receptor (IL-1R), granulocyte-colony stimulating factor (G-CSF), interferon-gamma-inducible protein 10 (IP-10) and IL-5 were associated with a higher risk of AKI. EGF had an inverse correlation with kidney stress biomarkers. Subclinical AKI was characterized by a significant up-regulation of kidney stress biomarkers and proinflammatory cytokines. The lack of EGF regenerative effects and IFN-α antiviral activity seemed crucial for renal disease progression. AKI involved a proinflammatory urinary cytokine storm.

Role of Urinary Kidney Stress Biomarkers for Early Recognition of Subclinical Acute Kidney Injury in Critically Ill COVID-19 Patients.

A high proportion of critically ill patients with COVID-19 develop acute kidney injury (AKI) and die. The early recognition of subclinical AKI could contribute to AKI prevention. Therefore, this study was aimed at exploring the role of the urinary biomarkers NGAL and [TIMP-2] × [IGFBP7] for the early detection of AKI in this population. This prospective, longitudinal cohort study included critically ill COVID-19 patients without AKI at study entry. Urine samples were collected on admission to critical care areas for determination of NGAL and [TIMP-2] × [IGFBP7] concentrations. The demographic information, comorbidities, clinical, and laboratory data were recorded. The study outcomes were the development of AKI and mortality during hospitalization. Of the 51 individuals that were studied, 25 developed AKI during hospitalization (49%). Of those, 12 had persistent AKI (23.5%). The risk factors for AKI were male gender (HR = 7.57, 95% CI: 1.28-44.8; p = 0.026) and [TIMP-2] × [IGFBP7] ≥ 0.2 (ng/mL)2/1000 (HR = 7.23, 95% CI: 0.99-52.4; p = 0.050). Mortality during hospitalization was significantly higher in the group with AKI than in the group without AKI (p = 0.004). Persistent AKI was a risk factor for mortality (HR = 7.42, 95% CI: 1.04-53.04; p = 0.046). AKI was frequent in critically ill COVID-19 patients. The combination of [TIMP-2] × [IGFBP7] together with clinical information, were useful for the identification of subclinical AKI in critically ill COVID-19 patients. The role of additional biomarkers and their possible combinations for detection of AKI in ritically ill COVID-19 patients remains to be explored in large clinical trials.

Acute kidney injury in patients with severe COVID-19 in Mexico.

INTRODUCTION: Some patients with COVID-19 pneumonia present systemic disease involving multiple systems. There is limited information about the clinical characteristics and events leading to acute kidney injury (AKI). We described the factors associated with the development of AKI and explored the relation of AKI and mortality in Mexican population with severe COVID-19. METHODS: We retrospectively reviewed the medical records of individuals with severe pneumonia caused by SARS-CoV-2 hospitalized at the largest third-level reference institution for COVID-19 care in Mexico between March and April 2020. Demographic information, comorbidities, clinical and laboratory data, dates of invasive mechanical ventilation (IMV) and hospitalization, mechanical-ventilator settings and use of vasoactive drugs were recorded. RESULTS: Of 99 patients studied, 58 developed AKI (58.6%). The risk factors for AKI were older age (OR = 1.07, 95% CI = 1.01-1.13, p = 0.024); obesity (OR = 6.58, 95% CI = 1.8-24.05, p = 0.040); and the need for IMV (OR = 6.18, CI = 1.29-29.58, p = 0.023). The risk factors for mortality were obesity (OR = 5.57, 95% CI = 1.48-20.93, p = 0.011); requirement of vasoactive drugs on admission (OR = 5.35, 95% CI = 1.16-24.61, p = 0.031); and AKI (OR = 8.61, 95% CI = 2.24-33.1, p = 0.002). In-hospital mortality was significantly higher in patients with AKI stage 3 (79.3%) and AKI stage 2 (68.7%) compared with those with AKI stage 1 (25%; p = 0.004). Fifty-three patients underwent the furosemide stress test (FST) to predict progression to AKI stage 3. Of those, 12 progressed to AKI stage 3 (22%). The ROC curve for the FST had an AUC of 0.681 (p = 0.009); a sensitivity of 81.6% and a specificity of 54.5%. CONCLUSIONS: AKI was common in our cohort of patients with severe pneumonia caused by SARS-CoV-2 infection. The risk factors for AKI were older age, obesity and the need for of IMV on admission. The risk factors for mortality were obesity, requirement of vasoactive drugs on admission and AKI. Mortality was more frequent in patients with AKI stages 2-3. The FST had an acceptable predictive capacity to identify patients progressing to AKI stage 3.

Identification and Management of Obese Patients in a Pediatric Orthopaedic Clinic.

BACKGROUND: Childhood obesity is a complex healthcare problem that affects all aspects of a child's health. The American Academy of Pediatrics and the Expert Committee recommends that all children be evaluated for current medical conditions including the risk for obesity by identifying elevated body mass index (BMI), physical activity habits, and diet. Childhood obesity is defined as a BMI of 95th percentile or greater on standardized age-based growth charts. Abdominal and visceral fat mass has a negative effect on bone formation during childhood and adolescence. Effective interventions are aimed at prevention and treatment and include collection and assessment of obesity, eating habits, physical activity, and family history. At a local outpatient pediatric orthopaedic practice, few patients had a diagnosis of childhood obesity and weight management varied by providers. PURPOSE: The purpose of this quality improvement project was to improve identification of obese children and increase referrals to a weight management program. METHODS: Setting: A hospital-affiliated pediatric orthopaedic clinic staffed with 3 orthopaedic surgeons and 2 nurse practitioners. POPULATION: 6- to 18-year-olds with a BMI of greater than 95th percentile (N = 239). DATA COLLECTION: Electronic medical record chart review for documented obesity and referral to weight management program: Intervention: Provider educational in-service reviewing management guidelines and referral process. RESULTS: Average percentages of documented obesity diagnosis increased from 11% to 53%. The number of referrals to Heart Healthy weight management program increased by 400%. CONCLUSION: An educational-based intervention in a pediatric orthopaedic clinic was effective in increasing the number of patients with a diagnosis of obesity and referred to a weight management program.

Biofilm-derived Legionella pneumophila evades the innate immune response in macrophages.

Legionella pneumophila, the causative agent of Legionnaire's disease, replicates in human alveolar macrophages to establish infection. There is no human-to-human transmission and the main source of infection is L. pneumophila biofilms established in air conditioners, water fountains, and hospital equipments. The biofilm structure provides protection to the organism from disinfectants and antibacterial agents. L. pneumophila infection in humans is characterized by a subtle initial immune response, giving time for the organism to establish infection before the patient succumbs to pneumonia. Planktonic L. pneumophila elicits a strong immune response in murine, but not in human macrophages enabling control of the infection. Interactions between planktonic L. pneumophila and murine or human macrophages have been studied for years, yet the interface between biofilm-derived L. pneumophila and macrophages has not been explored. Here, we demonstrate that biofilm-derived L. pneumophila replicates significantly more in murine macrophages than planktonic bacteria. In contrast to planktonic L. pneumophila, biofilm-derived L. pneumophila lacks flagellin expression, do not activate caspase-1 or -7 and trigger less cell death. In addition, while planktonic L. pneumophila is promptly delivered to lysosomes for degradation, most biofilm-derived bacteria were enclosed in a vacuole that did not fuse with lysosomes in murine macrophages. This study advances our understanding of the innate immune response to biofilm-derived L. pneumophila and closely reproduces the natural mode of infection in human.

Resuscitation great. Karel Wenckebach: the story behind the block.

The first documentation of a human atrioventricular (AV) block dates back to 1873, when A.L. Galabin reported a 34-year-old patient using an apexcardiogram. This was followed the same year by Luciani, recording 2nd degree AV blocks while studying frogs. In 1899, Karel F. Wenckebach provided the cardiology field with the criteria of what he called "Luciani periods", what we now know as Wenckebach Periodicity or Mobitz I AV block. The classic electrocardiographic presentation of Mobitz I/Wenckebach periodicity is characterized by progressive prolongation of the PR interval on the electrocardiogram (EKG) on consecutive beats followed by a blocked P wave. This clinical entity is the first and most common of two types of 2nd degree AV block. This manuscript reviews the life of Karel F. Wenckebach and the events that led this great Dutch physician to make one of the most important contributions to the field of cardiology.