Transitioning to Medical School: An Innovative Pre-matriculation Program

Medical schools use pre-matriculation programs consisting of knowledge-based curricula to prepare at-risk students. There is limited evidence showing the direct benefit of these programs with long-term success. We propose a pre-matriculation program focused on professional development and wellness to facilitate student acclimation and, in turn, academic success.

Prevalence and effects of acute myocardial infarction on hospital outcomes among COVID-19 patients

BACKGROUND

Acute myocardial infarction (AMI) is one of the most lethal complications of COVID-19 hospitalization. In this study, we looked for the occurrence of AMI and its effects on hospital outcomes among COVID-19 patients.

METHODS

Data from the 2020 California State Inpatient Database was used retrospectively. All COVID-19 hospitalizations with age ≥ 18 years were included in the analyses. Adverse hospital outcomes included in-hospital mortality, prolonged length of stay (LOS), vasopressor use, mechanical ventilation, and ICU admission. Prolonged LOS was defined as any hospital LOS ≥ 75th percentile. Multivariate logistic regression analyses were used to understand the strength of associations after adjusting for cofactors.

RESULTS

Our analysis had 94 114 COVID-19 hospitalizations, and 1548 (1.6%) had AMI. Mortality (43.2% vs. 10.8%, P  < 0.001), prolonged LOS (39.9% vs. 28.2%, P  < 0.001), vasopressor use (7.8% vs. 2.1%, P  < 0.001), mechanical ventilation (35.0% vs. 9.7%, P  < 0.001), and ICU admission (33.0% vs. 9.4%, P  < 0.001) were significantly higher among COVID-19 hospitalizations with AMI. The odds of adverse outcomes such as mortality (aOR 3.90, 95% CI: 3.48-4.36), prolonged LOS (aOR 1.23, 95% CI: 1.10-1.37), vasopressor use (aOR 3.71, 95% CI: 3.30-4.17), mechanical ventilation (aOR 2.71, 95% CI: 2.21-3.32), and ICU admission (aOR 3.51, 95% CI: 3.12-3.96) were significantly more among COVID-19 hospitalizations with AMI.

CONCLUSION

Despite the very low prevalence of AMI among COVID-19 hospitalizations, the study showed a substantially greater risk of adverse hospital outcomes and mortality. COVID-19 patients with AMI should be aggressively treated to improve hospital outcomes.

Effect of Frailty on Hospital Outcomes Among Pediatric Cancer Patients in the United States: Results From the National Inpatient Sample

BACKGROUND

Studies on frailty among pediatric patients with cancer are scarce. In this study, we sought to understand the effects of frailty on hospital outcomes in pediatric patients with cancer.

METHODS

This retrospective study used data collected and stored in the Nationwide Inpatient Sample (NIS) between 2005 and 2014. These were hospitalized patients and hence represented the sickest group of patients. Frailty was measured using the frailty definition diagnostic indicator by Johns Hopkins Adjusted Clinical Groups.

RESULTS

Of 187,835 pediatric cancer hospitalizations included in this analysis, 11,497 (6.1%) were frail. The average hospitalization costs were $86,910 among frail and $40,358 for nonfrail patients. In propensity score matching analysis, the odds of in-hospital mortality (odds ratio, 2.08; 95% CI, 1.71-2.52) and length of stay (odds ratio, 3.76; 95% CI, 3.46-4.09) were significantly greater for frail patients. The findings of our study suggest that frailty is a crucial clinical factor to be considered when treating pediatric cancer patients in a hospital setting.

CONCLUSIONS

These findings highlight the need for further research on frailty-based risk stratification and individualized interventions that could improve outcomes in frail pediatric cancer patients. The adaptation and validation of a frailty-defining diagnostic tool in the pediatric population is a high priority in the field.

A Rare Cause of Low Back Pain

This is the case of a 60-year-old man with no known medical history who presented with progressively worsening lumbar pain and was found to have idiopathic dorsal epidural lipomatosis. The patient's condition improved significantly with pain management. Therefore, no surgical intervention was warranted at the time, but the patient was advised to keep close follow-up as an outpatient. Being familiar with this potential cause of lumbar pain is vital, as it can lead to severe morbidity if left unrecognized.

832 Groin Hernia Should Remain A Clinical Diagnosis -- An Evidence-Based Study

Introduction

British Hernia Society (BHS) 2013 guidelines1 suggest that groin hernia diagnostic investigation should not be done at the primary care level. Nevertheless, General Practitioners refer patients with a positive ultrasound finding of groin hernia to secondary care. As a result, patients have false hopes that their symptoms would resolve if the ultrasound finding is addressed. The study aims to find the positive predictive value (PPV) for groin ultrasound for hernia and should the primary care physicians request the scan before referral to secondary care.

Method

A retrospective audit of outcome of patients referred to a general surgical department for groin hernia treatment. The study looked at elective groin hernia referrals for the period between June and August 2019.

Results

127 patients were electively treated for groin hernia in secondary care. 40% of the patients had ultrasounds before treatment. The GP requested 78% of the ultrasounds. A positive finding was the reason for the referral. Two patients (5%) in this group had negative operative findings. 24 herniograms over 57 months for patients referred with positive ultrasound and negative clinical findings showed only 2 had positive findings (8%). None of the negative patients returned to the same hospital for groin hernia treatment until date.

Conclusions

It is recommended that the diagnostic tests for groin hernia be requested by the operating surgeon as per the BHS guidelines. Patients should not be subjected to hernia operations based on ultrasound findings as the PPV for this investigation is very low for patients who have negative clinical findings.2

Mechanisms and perceived mental health changes after a livelihood intervention for HIV-positive Kenyans: Longitudinal, qualitative findings

While food insecurity and poverty worsen mental health outcomes among people living with HIV/AIDS (PLHIV), few intervention studies have targeted poverty and food insecurity as a way to improve mental health. Among HIV-positive patients, addressing such upstream determinants may prove crucial to ensure better mental health and HIV clinical outcomes. We integrated longitudinal, qualitative research into a randomized trial of a livelihood intervention to understand processes and mechanisms for how the intervention may affect mental health among HIV-infected Kenyan adults. In-depth interviews were conducted with intervention participants (n = 45) and control participants (n = 9) at two time-points (after intervention start and upon intervention end). Interviews (n = 85) were translated, double-coded, and analyzed thematically using an inductive-deductive team approach. Participants reported numerous mental health improvements post-intervention including reduced stress, fewer symptoms of anxiety, improved mood, lower depressive symptoms, fewer repetitive and ruminating thoughts, and more hopefulness for the future. Improvements in mental health appear to occur via several mechanisms including: 1) better food security and income; 2) increased physical activity and ability to create fruitful routines around farm work; and, 3) improved sense of self as an active member of the community. Qualitative, longitudinal interviews may help identify intervention mechanisms for improved mental health, but additional research is required to confirm self-reports of mental health changes. These findings suggest that livelihood interventions may improve mental health in multi-faceted ways, and help PLHIV better integrate with their communities. Trial registered at ClinicalTrials.gov: NCT01548599.

Solar-powered oxygen delivery: proof of concept

SETTING

A resource-limited paediatric hospital in Uganda.

OBJECTIVE

Pneumonia is a leading cause of child mortality worldwide. Access to life-saving oxygen therapy is limited in many areas. We designed and implemented a solar-powered oxygen delivery system for the treatment of paediatric pneumonia.

DESIGN

Proof-of-concept pilot study. A solar-powered oxygen delivery system was designed and piloted in a cohort of children with hypoxaemic illness.

RESULTS

The system consisted of 25 × 80 W photovoltaic solar panels (daily output 7.5 kWh [range 3.8-9.7kWh]), 8 × 220 Ah batteries and a 300 W oxygen concentrator (output up to 5 l/min oxygen at 88% [±2%] purity). A series of 28 patients with hypoxaemia were treated with solar-powered oxygen. Immediate improvement in peripheral blood oxygen saturation was documented (median change +12% [range 5-15%], P < 0.0001). Tachypnoea, tachycardia and composite illness severity score improved over the first 24 h of hospitalisation (P < 0.01 for all comparisons). The case fatality rate was 6/28 (21%). The median recovery times to sit, eat, wean oxygen and hospital discharge were respectively 7.5 h, 9.8 h, 44 h and 4 days.

CONCLUSION

Solar energy can be used to concentrate oxygen from ambient air and oxygenate children with respiratory distress and hypoxaemia in a resource-limited setting.

Phase Ib/II pharmacokinetic/pharmacodynamic (PK/PD) study of combination voreloxin and cytarabine in relapsed or refractory AML patients

7005

Background: Voreloxin is a naphthyridine analog that intercalates DNA and inhibits topoisomerase II, inducing apoptosis. Clinical activity is observed in ovarian cancer and AML. Voreloxin combined with cytarabine (Ara-C) show supra-additive activity preclinically. Interim results from a phase Ib/II study in relapsed or refractory AML are reported. Methods: Dose-escalation in relapsed/refractory AML patients (pts) with ≤ 3 prior induction regimens; phase II expansion in first-relapse pts (CR1 ≥ 3 months) at MTD. Voreloxin given d1 and d4, combined with: A) continuous infusion 400 mg/m2/d x 5d Ara-C (CIV), or B) bolus 1 g/m2/d IV x 5d Ara-C. Voreloxin starting dose: A) 10 mg/m2/dose; B) 70 mg/m2/dose. Treatment: induction, reinduction if needed, and up to 2 courses for consolidation. DLT, PK, and PD were assessed in cycle 1. Pts’ PBMC were evaluated for induction of DNA damage response markers. Ex vivo sensitivity of pt BMA to voreloxin and Ara-C were evaluated by CellTiter-Glo proliferation assay. Results: 52 pts treated to date (A: 41 pts, dose-escalation; 5 pts Phase 2; B: 6 pts dose-escalation). A) MTD is 80 mg/m2/dose voreloxin. Infections are the most common G3 or higher toxicity. Voreloxin PK were dose proportional to 50 mg/m2, then plateaued. Evaluation of PBMC pre- and posttreatment suggests modulation of pDNA-PKcs and pChk2 may reflect response. Ex vivo BMA assay results suggest that voreloxin is the primary contributor to the majority of CRs observed. Phase Ib: 9 CRs + CRp were observed in multiply relapsed or 1° refractory pts. B) 70 mg/m2/dose voreloxin, no DLT; too early to evaluate activity. Conclusions: Voreloxin in combination with CIV Ara-C is generally well-tolerated, with CR in relapsed/refractory pts. Enrollment continues: A) phase II; B) phase Ib. Ex vivo activity assay results suggest that voreloxin is the primary contributor to the majority of CR. Induction of pDNA-PKcs and pChk2 in PBMCs from treated pts may reflect response.

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Prevalences and correlates of non-viral injecting-related injuries and diseases in a convenience sample of Australian injecting drug users

BACKGROUND

The prevalences and correlates of non-viral injecting-related injuries and diseases (IRIDs) in Australian injecting drug users (IDUs) remain unknown.

METHODS

A cross-sectional survey of IDUs was conducted in six sites across Australia's eastern states to investigate IRID experience among Australian IDU. Correlates of IRIDs were explored using logistic and negative binomial regression analyses.

RESULTS

393 IDUs were recruited. Lifetime experience of non-serious IRIDs was common (e.g., 'dirty hit' 68%); potentially serious and serious IRIDs were less commonly experienced (e.g., abscess 16%; gangrene <1%). Factors independently associated with potentially serious or serious IRIDs in the previous 12 months were: injecting in sites other than arms (Adjusted Odds Ratio 3.0, 95% confidence interval 1.7-5.4), injecting non-powder drug forms (5.0, 2.2-11.2), unstable accommodation (2.0, 1.1-3.5), being aged 25 years or older (4.3, 1.7-10.6) and not always washing hands before injection (9.3, 2.1-41.8). Factors independently associated with multiple IRIDs in the preceding 12 months were using three or more injecting sites (Adjusted Incidence Rate Ratio 1.5, 95% CI 1.1-2.0), injecting in sites other than arms (1.7, 1.3-2.2), using non-powder drug forms (1.9, 1.4-2.5), injecting daily or more often (1.7, 1.3-2.2), current pharmacotherapy experience (1.5, 1.1-1.9), and not always washing hands before injecting (1.9, 1.2-2.9).

DISCUSSION

Some IRIDs are widespread among Australian IDUs. Observed associations, particularly the protective effect of handwashing, have useful public health implications.

Outcome of infants born to hepatitis C infected women

BACKGROUND

Hepatitis C virus (HCV) can be transmitted vertically from mother to infant, either late in pregnancy or at delivery.

AIMS

To determine the outcome of infants born to HCV infected women, to characterise epidemiology and to design an appropriate infant monitoring schedule.

METHODS

Three hundred and fourteen infants, born to 296 HCV positive women between 1994 and 1999 were monitored for a median of 18 months (range 1-52).

RESULTS

Forty per cent of infants were small for age and 46% had neonatal abstinence syndrome (NAS). Of 173 infants of defined status, 11 were infected (vertical transmission rate [VTR] 6.4%, 95% CI 2.8-10). Infected infants were diagnosed at a median of three months (range 0.5-10). Liver transaminases elevation was documented in 8% of uninfected infants. A negative HCV PCR test before one month of age did not exclude infection but all infected patients had detectable HCV RNA when next tested (range 2-10 months).

CONCLUSIONS

94% of infants born to HCV antibody positive women are not HIV infected. Liver transaminase elevation in exposed infants is not always indicative of infection. A minimum monitoring schedule of testing (PCR and antibody) at six to eight weeks, six and 18 months allows early diagnosis while detecting late seroconversions.

Hepatitis C infection in an Irish antenatal population

BACKGROUND

Hepatitis C infection (HCV) has an estimated seroprevalence of 1-2% in women of child-bearing age and vertical transmission rate of 5-15%.

AIMS

To characterise the current trends of HCV in an Irish antenatal population.

METHODS

Infants of HCV seropositive women, born 1994 to 1999, were referred to the Paediatric Infectious Diseases service. Maternal details were collected retrospectively.

RESULTS

296 HCV seropositive women were studied. 244 (82%) were infected through intravenous drug use (IVDU), 25 (8%) through heterosexual contact and 13 (7%) via blood products. Nine women had no identifiable risk factors. Coinfection with other blood borne viruses was uncommon (4.7% HIV, 3.4% hepatitis B). Of 84 women tested for HCV-RNA, 46 (55%) were positive. Eighty three (26%) delivered prematurely; the caesarean section rate was 11%.

CONCLUSIONS

HCV is increasingly detected in antenatal clinics. Heterosexual contact is a mode of spread. Maternal HCV viraemia can be variable in pregnancy. Further study of HCV in pregnancy is needed to define the impact of pregnancy on HCV, accurately predict infant outcome and selectively target interventions to women at greatest risk of transmission.

Risk of hepatitis C infection in neonates transfused with blood from donors infected with hepatitis C

This look-back study was undertaken to identify newborn infants who had been infected with the hepatitis C virus (HCV) as a result of transfusions received before the introduction of routine screening in 1991 and to determine the transmission rates and persistence of transfusion-transmitted HCV infection acquired in the neonatal period. A total of 24 infants, transfused between 1980 and 1991, were identified as having received potentially infected blood from 11 blood donors. Ten of the donors had been administered batches of anti-D in 1977 known to have transmitted HCV genotype 1b infection. HCV RNA was detected in five of these donors when tested in 1994-95; the past donations of five of the donors, who had received anti-D immunoglobulin and had serological evidence of previous HCV infection but who were PCR negative when tested in 1994-95, were considered of lower risk. The source and time of acquisition of HCV infection for the one remaining donor in the study was not determined. Twenty-one (88%) of the 24 children were living at time of lookback. The median age at transfusion was 12 days. The median age at time of testing was 6.3 years. One child, who tested negative, was excluded from further analysis of HCV transmission, due to incomplete transfusion records. Overall, 12 of 20 (60%) children tested were positive for anti-HCV and seven (35%) were HCV RNA positive. Twelve (71%) of the 17 recipients of viraemic blood were ELISA positive and seven (41%) were PCR positive. Resolved HCV infection, as determined by ELISA pos, RIBA pos or indeterminate and PCR negativity, occurred in five of 12 (42%). In many instances there was more than one recipient per HCV infected donation. All of the reported children are clinically asymptomatic. However, the duration of HCV infection is relatively short and there is evidence of a degree of hepatitis in five of the seven children who are HCV RNA positive as judged by mildly elevated transaminase levels. The three who have undergone liver biopsy show mild hepatitis. The lower rates of persistence of HCV infection in this study may be due to the young age at exposure or to the source of infection which for all but one of the children was linked to one HCV genotype from female donors. Sharing of units of blood among multiple infants should be discouraged.

Biochemical polymorphisms in the South African springbok (Antidorcas marsupialis)

An attempt was made to use polymorphic markers in the genetic taxonomy of springbok populations. Three independent free ranging springbok populations could be identified on the basis of albumin and transferrin gene frequencies. Even if most of the enzyme markers appeared to be monomorphic it can be stated that in any comparative study of this kind, cryptic genetic markers are of greater use than other environmentally sensitive taxonomic criteria. From the given data and others mentioned it can be stated that little support exists for the continued application of the subspecific status in the species Antidorcas marsupialis. It is shown that the use of environmentally sensitive parameters in the springbok are both misleading and highly unsatisfactory. Biochemical polymorphism can be utilized better than other parametres but here also there are several limitations. Basically, only the albumin and transferrin types can be used when blood samples are available and only IDH and 6-PGD polymorphisms are of value when liver samples can be utilized for the genetic differentiation.