STAT: Mobile app helps clinicians manage inpatient emergencies.

In response to the unprecedented surge of patients with COVID-19, Massachusetts General Hospital created both repurposed and de-novo COVID-19 inpatient general medicine and intensive care units. The clinicians staffing these new services included those who typically worked in these care settings (e.g., medicine residents, hospitalists, intensivists), as well as others who typically practice in other care environments (e.g., re-deployed outpatient internists, medical subspecialists, and other physician specialties). These surge clinicians did not have extensive experience managing low frequency, high acuity emergencies, such as those that might result from COVID-19. Physician-innovators, in collaboration with key hospital stakeholders, developed a comprehensive strategy to design, develop, and distribute a digital health solution to address this problem. MGH STAT is an intuitive mobile application that empowers clinicians to respond to medical emergencies by providing immediate access to up-to-date clinical guidelines, consultants, and code-running tools at the point-of-care. 100% of surveyed physicians found STAT to be easy to use and would recommend it to others. Approximately 1100 clinicians have downloaded the app, and it continues to enjoy consistent use over a year after the initial COVID-19 surge. These results suggest that STAT has helped clinicians manage life threatening emergencies during and after the pandemic, although formal studies are necessary to evaluate its direct impact on patient care.

A case of chronic hypomagnesemia in a cancer survivor.

OBJECTIVES: Hypomagnesemia is common among hospitalized patients, particularly those who are critically ill. It can be associated with a number of potentially life-threatening cardiovascular, neurological and behavioral manifestations. As opposed to acute, chronic hypomagnesemia is often underdiagnosed and underreported and as such may pose a diagnostic and therapeutic problem. CASE PRESENTATION: We describe a case of magnesium wasting in a middle-aged woman with head and neck cancer who presented with recurrent syncopal episodes complicated by a femur fracture 4 months after completing a course of carboplatin-containing chemotherapy. Fractional excretion of magnesium of 16% was consistent with renal wasting of magnesium. After ruling out all common causes of hypomagnesemia, it was concluded that she sustained carboplatin-induced renal tubular damage making her relatively resistant to magnesium supplementation. CONCLUSION: Several antineoplastic agents have been linked to chronic hypomagnesemia including anti-epidermal growth factor receptor agents such as cetuximab and panitumumab, cyclosporine, and the platinum-based agents cisplatin and carboplatin. The example case presented here illustrates the importance of chronic hypomagnesemia and its possible debilitating effects following carboplatin-containing chemotherapy. A growing numbers of cancer survivors are treated with these antineoplastic agents, and are hospitalized for non-cancer-related problems. These patients may have prolonged hypomagnesemia, and hence pose a diagnostic dilemma. We review the pathophysiology, etiology, diagnosis, clinical manifestations, monitoring and treatment of hypomagnesemia, with special attention to mechanisms of renal damage caused by platinum-containing chemotherapeutic agents.

It is possible: availability of lymphedema case management in each health facility in Togo. Program description, evaluation, and lessons learned.

Lymphatic filariasis (LF) is a vector-borne parasitic disease that can clinically manifest as disabling lymphedema. Although the LF elimination program aims to reduce disability and to interrupt transmission, there has been a scarcity of disease morbidity management programs, particularly on a national scale. This report describes the implementation of the first nationwide LF lymphedema management program. The program, which was initiated in Togo in 2007, focuses on patient behavioral change. Its goal is two-fold: to achieve a sustainable program on a national-scale, and to serve as a model for other countries. The program has five major components: 1) train at least one health staff in lymphedema care in each health facility in Togo; 2) inform people with a swollen leg that care is available at their dispensary; 3) train patients on self-care; 4) provide a support system to motivate patients to continue self-care by training community health workers or family members and providing in home follow-up; and 5) integrate lymphedema management into the curriculum for medical staff. The program achieved the inclusion of lymphedema management in the routine healthcare package. The evaluation after three years estimated that 79% of persons with a swollen leg in Togo were enrolled in the program. The adherence rate to the proposed World Health Organization treatment of washing, exercise, and leg elevation was more than 70% after three years of the program, resulting in a stabilization of the lymphedema stage and a slight decrease in reported acute attacks among program participants. Health staff and patients consider the program successful in reaching and educating the patients. After the external funding ended, the morbidity management program is maintained through routine Ministry of Health activities.

A microchip approach for practical label-free CD4+ T-cell counting of HIV-infected subjects in resource-poor settings.

Simple affordable CD4 cell counting is urgently needed to stage and monitor HIV-infected patients in resource-limited settings. To address the limitations of current approaches, we designed a simple, label-free, and cost-effective CD4 cell counting device using microfluidic technology. We previously described the fabrication of a microfluidic system for high-efficiency isolation of pure populations of CD4+ T cells based on cell affinity chromatography operated under controlled flow. Here, we compare the performance of a microfluidic CD4 cell counting device against standard flow cytometry in 49 HIV-positive subjects over a wide range of absolute CD4 cell counts. We observed a close correlation between CD4 cell counts from the microchip device and measurements by flow cytometry, using unprocessed whole blood from HIV-positive adult subjects. Sensitivities for distinguishing clinically relevant thresholds of 200, 350, and 500 cells/microL are 0.86, 0.90, and 0.97, respectively. Specificity is 0.94 or higher at all thresholds. This device can serve as a functional cartridge for fast, accurate, affordable, and simple CD4 cell counting in resource-limited settings.

Kinetic measurements of protein conformation in a microchip.

This paper presents a microchip-based system for collecting kinetic time-based information on protein refolding and unfolding. Dynamic protein conformational change pathways were studied in microchannel flow using a microfluidic device. We present a protein-conserving approach for quantifying refolding by dynamically varying the concentration of the chemical denaturants, guanidine hydrochloride and urea. Short diffusion distances in the microchannel result in rapid equilibrium between protein and titrating solutions. Dilutions on the chip were tightly regulated using pressure controls rather than syringe-based flow, as verified with extensive on-chip tracer dye controls. To validate this protein assay method, folding transition experiments were performed using two well-characterized proteins, human serum albumin (HSA) and bovine carbonic anhydrase (BCA). Transition events were monitored through fluorescence intensity shifts of the protein dye 8-anilino-1-naphthalenesulfonic acid (ANS) during dilutions of protein from urea or guanidine hydrochloride solutions. The enzymatic activity of refolded BCA was measured by UV absorption through the conversion of p-nitrophenyl acetate (p-NPA). The microchip protein refolding transitions using ANS were well-correlated with conventional plate-based experiments. The microfluidic platform enables refolding studies to identify rapidly the optimal folding strategy for a protein using small quantities of material.