Hypertonic Saline for Severe Traumatic Brain Injury With Herniation: A Military Prehospital Case Report.

Severe traumatic brain injury (sTBI) is a devastating injury with limited prehospital therapies available. The Joint Trauma System (JTS) Clinical Practice Guidelines recommend hypertonic saline (HTS) for casualties with sTBI and signs of impending or ongoing herniation (IOH), but its use by combat medics has never been reported in the literature. This report details the management of a pregnant patient with sTBI and signs of IOH, including the use of HTS, by US Air Force pararescumen in an austere prehospital setting. Treatment with HTS was followed by improvement in the patient's neurologic exam and successful evacuation to definitive care where her child was delivered alive. Additionally, we review the pathophysiology and signs of herniation, the mechanism of action of hyperosmotic therapies, and the rationale behind the use of HTS in the combat setting.

Pathophysiology and Treatment of Burns.

Management of burn patients in the prehospital and prolonged field care environments presents complex patient care and logistical challenges. The authors discuss the pathophysiology, diagnostics, longitudinal concerns, and treatment involved in the care of such patients.

Active Surveillance for Early Stage Lung Cancer.

OBJECTIVES: Data describing outcomes for patients with early stage lung cancer who undergo expectant management is lacking, despite evidence of a sub-population with indolent malignancies. We used the National Cancer Data Base (NCDB) to identify factors associated with active surveillance for early stage lung cancer. Additionally, we sought to describe outcomes of three different care plans: active surveillance, no treatment, and Stereotactic Body Radiation Therapy (SBRT). METHODS: Patients diagnosed in 2010 to 2017 with early stage lung cancer who underwent active surveillance, no treatment, and SBRT were retrospectively identified in the NCDB. Multinomial logistic regression was used to assess care plan selection. Kaplan Meier analysis was used to assess overall survival (OS). RESULTS: We identified 30,107 patients that met our inclusion criteria: 838 (3%) underwent active surveillance, 6388 patients (21%) received no treatment, and 22,881 (76%) underwent SBRT. Black race (relative risk ratio (RRR): 1.66) and older age (RRR: 1.02) were significant positive predictors of active surveillance selection. Conversely, higher tumor stage (RRR: 0.26) and squamous cell carcinoma (RRR: 0.35) were significant negative predictors of active surveillance selection. Kaplan Meier analysis revealed a longer median OS associated with active surveillance compared to no treatment at 49.3 months versus 26.5 months, respectively. SBRT OS was 43.1 months. CONCLUSIONS: We identified a population of lung cancer patients who underwent expectant management with favorable outcomes. Additionally, we identified factors associated with active surveillance selection. The selection of active surveillance over no treatment was associated with significantly longer OS.

Evaluating perceptions of social determinants of health and Part D star performance of Medicare Advantage-contracted primary care providers serving a South Texas market.

BACKGROUND: Socioeconomic factors can have a significant impact on a patient's health status and could be responsible for as much as 70%-80% of a patient's overall health. These factors, called the social determinants of health (SDoH), define a patient's day-to-day experiences. While the influence of such factors is well recognized, who ultimately is responsible for addressing SDoH in health care remains unclear. Physicians and other clinicians are suitably placed to assess SDoH factors that can impact clinical decision making. Understanding Medicare Advantage (MA)-contracted primary care provider (PCP) SDoH perceptions has yet to be fully explored. OBJECTIVES: To (a) understand MA-contracted PCP perceptions of SDoH and (b) investigate correlations between PCP perceptions and their CMS Part D star performances, as well as their hospital admissions and emergency room admissions. METHODS: Survey data were collected from MA-contracted PCPs serving a South Texas market during 2019. An 8-item survey consisting of short answer, ranking, and multiple-choice questions was deployed at attendance-mandatory provider meetings from August to October. Analyses were conducted to understand the providers' SDoH perceptions. PCP responses were first summarized as frequencies and percentages. Baseline descriptive characteristics of the providers were compared by Medicare star ratings using chi-square tests (for categorical variables) and t-tests (for continuous variables). Group differences in physician beliefs on how SDoH affects patients' overall health (question 1), as well as provider beliefs regarding how SDoH affects patients' medication adherence practices (question 2), were assessed using chi-square and t-tests. Associations of provider SDoH perceptions with hospital admissions and emergency room admissions were also assessed. A Fischer's chi-square test was used to examine associations between how PCPs answered the question regarding lack of consistent transportation (question 3) and emergency room admissions. The relationships between PCP perceptions of whose job it is to address SDoH (question 7) and hospital admissions were also evaluated. RESULTS: The response rate for returned surveys was 89%. Analysis revealed that the top 3 barriers were financial insecurity (24.87%), low health literacy (18.65%), and social isolation (15.03%). However, about 36% of PCPs felt they should be the primary addressor of SDoH. There was a significant association between years of practice and CMS Part D star ratings (P = 0.005). A significant association between responses in belief towards patients' overall health and CMS Part D star ratings was examined (P = 0.047). There was a statistically significant difference in mean hospital admissions with PCP perception of who should address SDOH (P = 0.03). Emergency room admissions was significantly associated with perceptions regarding lack of consistent transportation (P = 0.04). No differences with star ratings were observed. CONCLUSIONS: Previous literature recognize safety and food insecurity as key SDoH barriers. However, they were not among the top SDoH barriers in our survey. Future research should examine patient perceptions of SDoH in this population to identify ways providers can better serve their patients. DISCLOSURES: Funding for this study was provided by CareAllies, a Cigna business. Statistical analysis was completed in partnership with the University of Houston. Payne, Esse, Qian, Serna, Villarreal, and Becho-Dominguez are employees of CareAllies. Mohan and Abughosh are employed by the University of Houston College of Pharmacy. Abughosh reports grants from Valeant and Regeneron/Sanofi, unrelated to this work. Vadhariya has nothing to disclose. This research was presented virtually at the AMCP Pharmacist Virtual Learning Days event, April 2020, as well as the American College of Clinical Pharmacy Virtual Poster Symposium, May 26-27, 2020.

Influence of a genomic classifier on post-operative treatment decisions in high-risk prostate cancer patients: results from the PRO-ACT study.

OBJECTIVE: To assess the effect of an individualized genomic classifier (GC) test, for predicting metastasis following radical prostatectomy (RP), on urologists' adjuvant treatment decisions when caring for high-risk patients. PATIENTS AND METHODS: Data were submitted by US board-certified urologists in community practices (n = 15), who ordered the GC test for 146 prostate cancer patients with adverse pathologic features following RP (i.e., pathologic stage pT3 or positive surgical margins). Treatment recommendations were reported using an electronic data collection instrument, before and after reviewing the GC test report. Physicians also completed a Decision Conflict Scale (DCS), a decisional conflict measure, to assess their confidence with their treatment recommendations. RESULTS: Over 60% of high-risk patients were re-classified as low risk after review of the GC test results. Overall, adjuvant treatment recommendations were modified for 30.8% (95% CI = 23-39%) of patients. With GC test results, 42.5% of patients who were initially recommended adjuvant therapy were subsequently recommended observation. Although the number of patients recommended adjuvant therapy remained the same before and after review of the GC test results, it did influence patient treatment strategies. Multivariable analysis confirmed GC risk was the only significant predictor of treatment recommendations (OR = 4.04; 95% CI = 2.36, 6.92; p < 0.0001). Decisional conflict with regard to adjuvant treatment decisions was significantly less with the use of the GC test (p < 0.0001). CONCLUSIONS: Information on individualized metastasis risk based on a patient's tumor biology, with use of the GC test, significantly changed urologists' adjuvant treatment recommendations for post-operative patients with prostate cancer, who were at high risk of metastasis. Namely, the results of this study provide evidence for the utility of the GC test, and show it may guide use of adjuvant radiation.

Endoscopic ablation of Hunner's lesions in interstitial cystitis patients.

INTRODUCTION: We report our experience with endoscopic ablation of Hunner's lesions in women with interstitial cystitis (IC). METHODS: A chart review was performed on 14 patients with IC symptoms who were identified to have bladder lesions and underwent endoscopic ablation. A Hunner's lesion was identified as an area of erythema that reproduced the patients' pain when touched by the cystoscope. Pathology reports were reviewed and improvement in pain was used as the main outcome measure. RESULTS: Of the 14 patients, 12 had more than 50% symptomatic improvement and 8 patients reported 100% improvement. Mean improvement was 76%. In all patients who improved, the biopsy specimen showed inflammatory cystitis, often with epithelial denudation. Four patients had symptomatic recurrence, but all had improvement after repeat ablation. CONCLUSION: Endoscopic ablation of Hunner's lesions improves symptoms in IC patients. Recurrence of symptoms should prompt repeat cystoscopy to identify recurrent lesions, as repeat ablation offers symptomatic improvement.

Clinical telehealth across the disciplines: lessons learned.

Videoconferencing technologies can vastly expand the reach of healthcare practitioners by providing patients (particularly those in rural/remote areas) with unprecedented access to services. While this represents a fundamental shift in the way that healthcare professionals care for their patients, very little is known about the impact of these technologies on clinical workflow practices and interprofessional collaboration. In order to better understand this, we have conducted a focused literature review, with the aim of providing policymakers, administrators, and healthcare professionals with an evidence-based foundation for decision-making. A total of 397 articles focused on videoconferencing in clinical contexts were retrieved, with 225 used to produce this literature review. Literature in the fields of medicine (including general and family practitioners and specialists in neurology, dermatology, radiology, orthopedics, rheumatology, surgery, cardiology, pediatrics, pathology, renal care, genetics, and psychiatry), nursing (including hospital-based, community-based, nursing homes, and home-based care), pharmacy, the rehabilitation sciences (including occupational and physical therapy), social work, and speech pathology were included in the review. Full utilization of the capacity of videoconferencing tools in clinical contexts requires some basic necessary technical conditions to be in place (including basic technological infrastructure, site-to-site technological compatibility, and available technical support). The available literature also elucidates key strategies for organizational readiness and technology adoption (including the development of a change management and user training plan, understanding program cost and remuneration issues, development of organizational protocols for system use, and strategies to promote interprofessional collaboration).

Hemiparesis of bladder caused by tethered cord.

Conventional teaching has maintained that the detrusor musculature is well-coupled and unilateral innervation should prompt a coordinated detrusor contraction. We present the case of a 17-year-old girl with a tethered spinal cord, unilateral neurologic symptoms and fluoroscopic evidence of ipsilateral hemiparesis of the bladder unresponsive to cord detethering. This adds to a small body of evidence that the bladder smooth muscle is less well-coupled than once believed.

Bacillus Calmette-Guerin inhibits apoptosis in human urothelial carcinoma cell lines in response to cytotoxic injury.

PURPOSE: By inducing cell cycle arrest at the G1/S transition bacillus Calmette-Guerin has been shown to have a direct antiproliferative effect on urothelial carcinoma cell lines. In other systems cell cycle arrest has been shown to confer a relative state of apoptotic resistance. We assessed the effect of bacillus Calmette-Guerin on the susceptibility of urothelial carcinoma cells to apoptotic stimuli. MATERIALS AND METHODS: The human UC cell lines T24 and 253J (American Type Cell Culture, Rockville, Maryland) were used to evaluate the effect of bacillus Calmette-Guerin or antibody mediated alpha5beta1cross-linking on apoptosis and apoptotic sensitivity. Following treatment baseline apoptosis and the response to the apoptotic inducing agent camptothecin was evaluated using assays for caspase 3 activation and DNA fragmentation. Pharmacological blockade of signaling pathways known to be activated in response to bacillus Calmette-Guerin/alpha5beta1 cross-linking was used to assess the role of these pathways in the bacillus Calmette-Guerin apoptotic response. A final series of experiments used the MTT assay to study the impact of bacillus Calmette-Guerin pretreatment on the cytotoxicity of the antineoplastic agent mitomycin C. RESULTS: Treatment with bacillus Calmette-Guerin failed to induce apoptosis, as measured by caspase 3 activation or DNA laddering. Bacillus Calmette-Guerin pretreatment significantly inhibited the induction of apoptosis in response to camptothecin. These effects were reproduced by antibody mediated cross-linking of alpha5beta1 integrin. Pharmacological inhibition of nuclear factor kappaB and/or AP1 signaling pathways reversed the anti-apoptotic effect of bacillus Calmette-Guerin. Mitomycin C cytotoxicity was significantly decreased by bacillus Calmette-Guerin pretreatment. CONCLUSIONS: Bacillus Calmette-Guerin exerts a direct anti-apoptotic effect on human urothelial carcinoma cell lines. The ability of antibody mediated cross-linking to reproduce the effect and the ability of signal transduction inhibitors to block it are consistent with a mechanism involving integrin mediated signaling. Apoptotic resistance represents a therapeutic target for modulating the response to bacillus Calmette-Guerin and it may have clinical implications in the sequencing of intravesical therapies.