The 2018 Nigerian Lassa fever season saw the largest ever recorded upsurge of cases, raising concerns over the emergence of a strain with increased transmission rate. To understand the molecular ...epidemiology of this upsurge, we performed, for the first time at the epicenter of an unfolding outbreak, metagenomic nanopore sequencing directly from patient samples, an approach dictated by the highly variable genome of the target pathogen. Genomic data and phylogenetic reconstructions were communicated immediately to Nigerian authorities and the World Health Organization to inform the public health response. Real-time analysis of 36 genomes and subsequent confirmation using all 120 samples sequenced in the country of origin revealed extensive diversity and phylogenetic intermingling with strains from previous years, suggesting independent zoonotic transmission events and thus allaying concerns of an emergent strain or extensive human-to-human transmission.
Abstract Objectives The objective is of the study to evaluate the effect of antihypertensive therapy in emergency department (ED) patients with markedly elevated blood pressure (BP) but no ...signs/symptoms of acute target organ damage (TOD). Methods This is a retrospective cohort study of ED patients age 18 years and older with an initial BP greater than or equal to 180/100 mm Hg and no acute TOD, who were discharged with a primary diagnosis of hypertension. Patients were divided based on receipt of antihypertensive therapy and outcomes (ED revisits and mortality) and were compared. Results Of 1016 patients, 435 (42.8%) received antihypertensive therapy, primarily (88.5%) oral clonidine. Average age was 49.2 years, and 94.5% were African American. Treated patients more often had a history of hypertension (93.1% vs 84.3%; difference = − 8.8; 95% confidence interval CI, − 12.5 to − 4.9) and had higher mean initial systolic (202 vs 185 mm Hg; difference = 16.9; 95% CI, − 19.7 to − 14.1) and diastolic (115 vs 106 mm Hg; difference = − 8.6; 95% CI, − 10.3 to − 6.9) BP. Emergency department revisits at 24 hours (4.4% vs 2.4%; difference = − 2.0; 95% CI, − 4.5 to 0.3) and 30 days (18.9% vs 15.2%; difference = − 3.7; 95% CI, − 8.5 to 0.9) and mortality at 30 days (0.2% vs 0.2%; difference = 0; 95% CI, − 1.1 to 0.8) and 1 year (2.1% vs 1.6%; difference = − 0.5; 95% CI, − 2.5 to 1.2) were similar. Conclusions Revisits and mortality were similar for ED patients with markedly elevated BP but no acute TOD, whether they were treated with antihypertensive therapy, suggesting relative safety with either approach.
Background In recent years, increasing emphasis has been placed on value-based health care delivery. Dermatology must develop performance measures to judge the quality of services provided. The ...implementation of a national complication registry is one such method of tracking surgical outcomes and monitoring the safety of the specialty. Objective The purpose of this study was to define critical outcome measures to be included in the complications registry of the American College of Mohs Surgery (ACMS). Methods A Delphi process was used to reach consensus on the complications to be recorded. Results Four major and one minor complications were selected: death, bleeding requiring additional intervention, functional loss attributable to surgery, hospitalization for an operative complication, and surgical site infection. Limitations This article addresses only one aspect of registry development: identifying and defining surgical complications. Conclusion The ACMS Registry aims to gather data to monitor the safety and value of dermatologic surgery. Determining and defining the outcomes to be included in the registry is an important foundation toward this endeavor.
Background
Perforated peptic ulcer disease (PPUD) has a prevalence of 0.004–0.014% with mortality of 23.5% (Tarasconi et al. in World J Emerg Surg 15(PG-3):3, 2020). In this single center study, we ...examined the impact associated with patient transfer from outside facilities to our center for definitive surgical intervention (exploratory laparotomy).
Methods
Using EPIC report workbench, we identified 27 patients between 2018 and 2021 undergoing exploratory laparotomy with a concurrent diagnosis of peptic ulcer disease, nine of which were transferred to our institution for care. We queried this population for markers of disease severity including mortality, length of stay, intensive care unit (ICU) length of stay, and readmission rates. Manual chart reviews were performed to examine these outcomes in more detail and identify patients who had been transferred to our facility for surgery from an outside hospital.
Results
A total of 27 patients were identified undergoing exploratory laparotomy for definitive treatment of PPUD. The majority of patients queried underwent level A operations, the most urgent level of activation. In our institution, a Level A operation needs to go to the operating room within one hour of arrival to the hospital. Average mortality for this patient population was 14.8%. The readmission rate was 40.1%, and average length of ICU stay post-operatively was 16 days, with 83% of non-transfer patients requiring ICU admission and 100% of transfer patients requiring ICU admission, although this was not found to be statistically significant. Average length of hospital stay was 27 days overall. For non-transfer patients and transfer patients, LOS was 20 days and 41 days, respectively, which was statistically significant by one-sided
t
-test (
p
= 0.05).
Conclusion
Patients transferred for definitive care of PPUD in a population otherwise notable for high mortality and high readmission rates: their average length of stay compared to non-transfer patients was over twice the length, which was statistically significant. Transferred patients also had higher rates of ICU care requirement although this was not statistically significant. Further inquiry to identify modifiable variables to facilitate the care of transferred patients is warranted, especially in the context of improving quality metrics known to enhance patient outcomes, satisfaction, and value.
Graphical abstract
Objective To conduct a retrospective, theoretical comparison of actual pediatric intensive care unit (PICU) screening for abusive head trauma (AHT) vs AHT screening guided by a previously validated ...4-variable clinical prediction rule (CPR) in datasets used by the Pediatric Brain Injury Research Network to derive and validate the CPR. Study design We calculated CPR-based estimates of abuse probability for all 500 patients in the datasets. Next, we demonstrated a positive and very strong correlation between these estimates of abuse probability and the overall diagnostic yields of our patients' completed skeletal surveys and retinal examinations. Having demonstrated this correlation, we applied mean estimates of abuse probability to predict additional, positive abuse evaluations among patients lacking skeletal survey and/or retinal examination. Finally, we used these predictions of additional, positive abuse evaluations to extrapolate and compare AHT detection (and 2 other measures of AHT screening accuracy) in actual PICU screening for AHT vs AHT screening guided by the CPR. Results Our results suggest that AHT screening guided by the CPR could theoretically increase AHT detection in PICU settings from 87%-96% ( P < .001), and increase the overall diagnostic yield of completed abuse evaluations from 49%-56% ( P = .058), while targeting slightly fewer, though not significantly less, children for abuse evaluation. Conclusions Applied accurately and consistently, the recently validated, 4-variable CPR could theoretically improve the accuracy of AHT screening in PICU settings.
Abstract Objective Bovine carotid artery (BCA) grafts have been described as a possibly superior alternative to expanded polytetrafluoroethylene hemoaccess grafts. However, published experience ...remains limited, and patency rates for nonautogenous arteriovenous grafts remain unsatisfactory. We report herein the largest published experience with the current generation of BCA grafts for dialysis access and analyze subgroups to determine whether obesity, gender, or prior access surgery influences patency. Methods We retrospectively reviewed 134 BCA grafts (Artegraft, North Brunswick, NJ) implanted for hemodialysis access in the upper extremities of 126 patients between January 2012 and May 2015. Patients had a mean of 1.8 prior access operations. Primary, primary assisted, and secondary patency rates were calculated using the Kaplan-Meier method, and longitudinal infection risk was tabulated. Patency differences were calculated using the log-rank method. Results For the entire group, 1-year primary patency was 32%, primary assisted patency was 49%, and secondary patency was 78%. Ten of 133 grafts (7%) developed infection requiring graft excision between 1 and 9 months after implantation. There was no statistical difference between men and women in primary or secondary patency ( P = .88, P = .69). There was no difference in primary patency or secondary patency for patients with body mass index >30 or <30 ( P = .85, P = .54). Patients who had a BCA graft as their first access attempt had a higher primary and primary assisted patency than that of patients who had the graft placed after prior access failure ( P = .039, P = .024). Conclusions This represents the largest published series of BCA grafts for arteriovenous grafts in the modern era. The primary patency of BCA grafts in this series was lower than that reported in a smaller randomized study. However, primary assisted and secondary patency were similar. Infection rates in this series appear to be somewhat lower than polytetrafluoroethylene infection rates reported in the literature. BCA grafts are a satisfactory alternative to expanded polytetrafluoroethylene for hemodialysis access, but larger controlled studies are needed to determine whether superior primary patency previously reported is a reproducible finding.
A new project is underway at the National Ignition Facility with the goal of applying a seed magnetic field to the fusion fuel in an indirect drive hohlraum implosion and quantifying the effect on ...the hot-spot temperature, shape and neutron yield. Magnetizing fusion fuel is calculated to reduce heat loss from the implosion core by constraining the motion of electrons and fusion-generated alpha particles; this can improve the chances of achieving high-gain fusion in a laboratory plasma. We describe the goals of this project and the significant scientific and technological challenges which must be overcome for this project to succeed.
PDF
