The Association of Hypertensive Disorders of Pregnancy with Infant Mortality, Preterm Delivery, and Small for Gestational Age

Gestational hypertension, preeclampsia, eclampsia, and chronic hypertension (CHTN) are associated with adverse infant outcomes and disproportionately affect minoritized race/ethnicity groups. We evaluated the relationships between hypertensive disorders of pregnancy (HDP) and/or CHTN with infant mortality, preterm delivery (PTD), and small for gestational age (SGA) in a statewide cohort with a diverse racial/ethnic population. All live, singleton deliveries in South Carolina (2004-2016) to mothers aged 12-49 were evaluated for adverse outcomes: infant mortality, PTD (20 to less than <37 weeks) and SGA (<10th birthweight-for-gestational-age percentile). Logistic regression models adjusted for sociodemographic, behavioral, and clinical characteristics. In 666,905 deliveries, mothers had superimposed preeclampsia (HDP + CHTN; 1.0%), HDP alone (8.0%), CHTN alone (1.8%), or no hypertension (89.1%). Infant mortality risk was significantly higher in deliveries to women with superimposed preeclampsia, HDP, and CHTN compared with no hypertension (relative risk [RR] = 1.79, 1.39, and 1.48, respectively). After accounting for differing risk by race/ethnicity, deliveries to women with HDP and/or CHTN were more likely to result in PTD (RRs ranged from 3.14 to 5.25) or SGA (RRs ranged from 1.67 to 3.64). As CHTN, HDP and superimposed preeclampsia confer higher risk of adverse outcomes, prevention efforts should involve encouraging and supporting mothers in mitigating modifiable cardiovascular risk factors.

Social support in relation to posttraumatic stress disorder symptoms among patients with violent versus nonviolent injury

OBJECTIVE

Violent injuries have become increasingly more common in the United States. Individuals experiencing violent injury are at increased risk for the development of posttraumatic stress disorder (PTSD) as compared to those experiencing nonviolent injury. Social support is touted as a protective factor against various psychiatric symptoms (i.e., PTSD), though little is known about the relation between PTSD symptoms and social support in traumatic injury populations. The aims of the present paper were twofold: (1) examine the prevalence of PTSD as a function of injury type (2) explore differences in levels of social support as a function of injury type and (3) explore the association between injury type and later PTSD symptoms as moderated by baseline social support.

METHOD

Participants were 553 adults from a level-one trauma center in the Southeast United States who experienced a violent injury or nonviolent injury and completed measures of social support at baseline as well as PTSD symptoms at the 30-day follow-up timepoint. The study utilized data from both the baseline timepoint (i.e., upon admission to the trauma surgery unit), as well as a 30-day follow-up timepoint.

RESULTS

Results demonstrated that those endorsing nonviolent injury reported lower levels of social support and PTSD symptoms. Social support predicted later PTSD symptoms until injury type was included as a covariate in the model. Social support did not moderate the relationship between injury type and later PTSD symptoms.

CONCLUSIONS

Findings highlight the interrelatedness of key risk variables (i.e., injury type) with protective factors in influencing the trajectory of psychopathology postinjury. Violence intervention and interruption programs may have the capacity to fill patient needs when social support networks are insufficient. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Hypertensive Disorders of Pregnancy and Pre-Pregnancy Hypertension with Subsequent Incident Venous Thromboembolic Events

Hypertensive disorders of pregnancy (HDP) and pre-pregnancy hypertension contribute to maternal morbidity and mortality. We examined the association of HDP and pre-pregnancy hypertension with subsequent venous thromboembolic (VTE) events. The retrospective cohort study included 444,859 women with ≥1 live, singleton birth in South Carolina (2004-2016). Hospital and emergency department visit and death certificate data defined incident VTE, HDP, and pre-pregnancy hypertension. Birth certificate data also defined the exposures. Adjusted Cox proportional hazards methods modeled VTE events risk. Of the cohort, 2.6% of women had pre-pregnancy hypertension, 5.8% had HDP, 2.8% had both pre-pregnancy hypertension and HDP (both conditions), and 88.8% had neither condition. The risk of incident VTE events within one year of delivery was higher in women with HDP (hazard ratio [HR] = 1.62, 95% confidence interval [CI]: 1.15-2.29) and both conditions (HR = 2.32, 95% CI: 1.60-3.35) compared to those with neither condition as was the risk within five years for women with HDP (HR = 1.35, 95% CI: 1.13-1.60) and for women with both conditions (HR = 1.82, 95% CI: 1.50-2.20). One- and five-year risks did not differ in women with pre-pregnancy hypertension compared to women with neither condition. Compared to non-Hispanic White (NHW) women with neither condition, the incident VTE event risk was elevated within five years of delivery for NHW (HR = 1.29, 95% CI: 1.02-1.63; HR = 1.59, 95% CI: 1.16-2.17) and non-Hispanic Black (NHB; HR = 1.51, 95% CI: 1.16-2.96; HR = 2.08, 95% CI: 1.62-2.66) women with HDP and with both conditions, respectively, and for NHB women with pre-pregnancy hypertension (HR = 1.50, 95% CI: 1.09-2.07). VTE event risk was highest in women with HDP, and the event rates were higher in NHB women than in NHW women in the same exposure group.

Anaesthesia cart standardisation expedites supply retrieval: A simulation study with patient safety implications

BACKGROUND

Anaesthesia providers often work at a variety of perioperative and procedural locations. However, the layout of anaesthesia supplies and equipment is often inconsistent from operating theatre to operating theatre. This lack of standardisation may create delays in identification and retrieval of supplies. The primary goal of this study was to compare the duration of time required by anaesthesia providers to identify and retrieve a list of anaesthesia supplies prior to and after standardisation of the location for anaesthesia supplies.

METHODS

In this observational simulation study, a pre-set list of ten items that may be rapidly needed when caring for patients was created. Volunteer anaesthesia providers were then timed retrieving these in two different operating theatres before and after anaesthesia cart standardisation. Cumulative time to retrieve all items was recorded in seconds. Participants were evaluated regarding mean time to compete the task before and after supply standardisation. Paired t-test were used to assess mean time to retrieve the ten items both before and after standardisation and between the two operating theatre locations. Providers were also evaluated on their familiarity with the operating theatre location, and this was assessed by chi-square tests of homogeneity. Multivariable generalised linear modelling was used to evaluate the impact of covariables on the change in time.

RESULTS

Data from 18 anaesthesia providers was collected. Mean (95% confidence interval) time in seconds to retrieve items was decreased by 45% after supply standardisation (105.3 [88.6, 121.9 vs 57.1 [50.8, 63.5]; p < 0.001) with a mean (95% confidence interval) reduction of 48.1 seconds (30.6, 65.6; p < 0.001). Providers who worked primarily at that location also had faster times to complete the task. In a multivariable regression model that considered both the provider's familiarity with the location and the simulation attempt (Operating theatre 1 or Operating theatre 2), the mean time to retrieve all items remained reduced by 48.1 seconds (95% confidence interval: 31.9-64.4) after supply standardisation (p < 0.001).

CONCLUSION

Standardisation of the location for anaesthesia supplies decreased the time for on-demand item retrieval. Retrieval times were most improved after standardisation for providers in an unfamiliar area. Supply standardisation of anaesthesia carts across perioperative and procedural sites could result in more timely interventions in patient care and efficiency.

A Trial of Adding Lung Protective Strategies to Existing Enhanced Recovery After Surgery Protocols and Its Effect on Improving Postoperative Lung Function

Background

With this rising popularization of enhanced recovery after surgery (ERAS) protocols, it is important to ask if the current and developing pathways are fully comprehensive for the patient's perioperative experience. Many current pathways discuss aspects of care including fluid management, pain management, and anti-emetic medication regiments, but few delineate recommendations for lung protective strategies. The hypothesis was that intraoperative lung protective strategies would results in improved postoperative lung function.

Methods

One hundred patients at the Medical University of South Carolina undergoing hepatobiliary and colorectal surgeries were randomized to receive intraoperative lung protective techniques or a standard intraoperative ventilation management. Three maximum vital capacity breaths were recorded preoperatively, and postoperatively 30 min, 1 h, and 2 h after anesthesia stop time. Average maximum capacity breaths from all four data collection interactions were analyzed between both study and control cohorts.

Results

There was no significant difference in the preoperative inspiratory capacity between the control and the ERAS group (2,043.3 ± 628.4 mL vs. 2,012.2 ± 895.2 mL; P = 0.84). Additional data analysis showed no statistically significant difference between ERAS and control groups: total average of the inspiratory capacity volumes (1,253.5 ± 593.7 mL vs. 1,390.4 ± 964.9 mL; P = 0.47), preoperative oxygen saturation (97.76±2.3% vs. 98.04±1.7%; P = 0.50), the postoperative oxygen saturation (98.51±1.4% vs. 96.83±14.2%; P = 0.40), and change in inspiratory capacity (95% confidence interval (CI) (-211.2 - 366.6); P = 0.60).

Conclusions

No statistically significant difference in postoperative inspiratory capacities were seen after the implementation of intraoperative lung protective strategies. The addition of other indicators of postoperative lung function like pneumonia incidence or length of inpatient stay while receiving oxygen treatment could provide a fuller picture in future studies, but a higher power will be needed.

Abstract 16: Maternal Coronary Heart Disease and Mortality Within 5 Years of Delivery Among Women With Hypertensive Disorders of Pregnancy and/or Diabetes

Introduction: Pre-pregnancy hypertension (HTN), hypertensive disorders of pregnancy (HDP), and diabetes are linked to increased risk of post-pregnancy coronary heart disease (CHD) and all-cause mortality, but the cumulative impact of pre-pregnancy HTN, HDP, and diabetes has yet to be fully investigated. We aimed to examine associations between HDP and diabetes with CHD and mortality ≤5 years of delivery stratified by race/ethnicity.

Methods: This retrospective cohort study included women aged 12-49 with ≥1 singleton, live birth in South Carolina (2004-2016). After exclusions, 431,839 women remained: non-Hispanic White [NHW; 58.8%], non-Hispanic Black [NHB; 31.7%], and Hispanic [9.5%]. Birth certificates defined pre-pregnancy HTN, HDP (preeclampsia, eclampsia, gestational hypertension), and diabetes (pre-pregnancy, gestational); hospitalization/ED visit data also defined pre-pregnancy HTN and HDP. Hospitalization/ED visit data and death certificates defined incident CHD and all-cause mortality. Cox proportional hazard models adjusted for covariates assessed associations by condition and race/ethnicity.

Results: Incident CHD risk was increased ≤5 years of delivery for women with diabetes (HR=1.79, CI: 1.40-2.29), HDP (HR=2.91, CI: 1.98-2.65), diabetes and HDP (HR=3.95 CI:3.09-5.05), pre-pregnancy HTN and HDP (HR=3.94, CI: 3.11-5.00), and all three conditions (HR=5.78, CI: 4.41-8.06) compared to none. All-cause mortality risk was increased for HDP (HR=1.31, CI: 1.08-1.58), diabetes and HDP (HR=1.93, CI: 1.30-2.87), pre-pregnancy HTN and HDP (HR=2.20, CI: 1.54-3.15), and all three conditions (HR=2.88, CI: 1.61-5.16), but not with diabetes. The table shows overall and race/ethnic-specific event rates and model results.

Discussion: Women with HDP (regardless of pre-pregnancy HTN) and/or diabetes experienced higher incident CHD and all-cause mortality risk ≤5 years of delivery. Event rates were highest for women with two or three conditions, with all event rates higher for NHB than NHW women.

Hypertensive Disorders of Pregnancy With and Without Prepregnancy Hypertension Are Associated With Incident Maternal Kidney Disease Subsequent to Delivery

BACKGROUND

Maternal morbidity and mortality are related to prepregnancy hypertensive disease and hypertensive disorders of pregnancy (HDP) including preeclampsia (41.1% of HDP), eclampsia (1.3% of HDP), and gestational hypertension (39.9% of HDP). Less information is available on the risk of maternal kidney disease and potential racial/ethnic differences following a hypertensive condition during pregnancy. Our objective was to examine the relationships between HDP and prepregnancy hypertension with maternal incident kidney disease subsequent to delivery (up to 3, 5, and 14 years) with consideration of racial/ethnic differences.

METHODS

In a retrospective cohort study, 391 838 women 12 to 49 years of age had a live birth in South Carolina between 2004 and 2016; 35.1% non-Hispanic Black (NHB) and 64.9% non-Hispanic White (NHW). Hospitalization, emergency department, and birth certificate data defined prepregnancy hypertension and HDP. Hospitalization and death certificate data identified incident kidney disease.

RESULTS

317 006 (80.8%) women experienced neither condition, 1473 (0.4%) had prepregnancy hypertension, 64 050 (16.3%) had HDP, and 9662 (2.5%) had both conditions (prepregnancy hypertension with superimposed HDP, ie, preeclampsia). Five years after delivery, incident kidney disease risk was increased for NHB and NHW women with HDP (NHB: hazard ratio, 2.30 [95% CI, 1.94-2.73]; NHW: hazard ratio, 1.97 [95% CI, 1.64-2.37]) and with both conditions (NHB: hazard ratio, 3.88 [95% CI, 3.05-4.93]; NHW: hazard ratio, 1.86 [95% CI, 1.20-2.87]) compared with counterparts with neither condition after adjustment (P value for race/ethnicity interaction=0.003).

CONCLUSIONS

Increased kidney disease risk 5 years after delivery was observed for women with HDP and with both compared with neither condition, with associated risk higher in NHB than NHW women.

Preoperative Quadratus Lumborum Block Reduces Opioid Requirements in the Immediate Postoperative Period Following Hip Arthroscopy: A Randomized, Blinded Clinical Trial

PURPOSE

To examine acute postoperative opioid consumption in patients undergoing hip arthroscopy and randomized to either receive a preoperative lateral quadratus lumborum block or sham injection.

METHODS

This trial randomized 46 subjects undergoing hip arthroscopy with a single surgeon to receive a preoperative lateral quadratus lumborum block (40 mL, ropivacaine 0.25%) or sham injection. The primary outcome was postoperative opioid consumption in patients with and without a block. All opioid medications were converted to morphine milligram equivalents for comparisons. Categorical data were compared with χ² tests and Fisher exact tests where appropriate. Continuous data were compared with 2-sided t-test and Wilcoxon rank-sum tests.

RESULTS

Forty-six subjects scheduled for elective hip arthroscopy were successfully consented and randomized. Demographic and clinical characteristics did not differ. Postoperative opioid consumption decreased 28.3% in patients who received a preoperative lateral quadratus lumborum block (P = .04). Total perioperative opioid consumption (intraoperative and postoperative combined) was reduced 20% in the block group; however, this did not achieve statistical significance (P = .05). Three subjects in the sham group (12.5%) required unblinding for a rescue block in the postoperative anesthetic care unit (PACU) for uncontrolled pain despite systemic analgesics. While cold sensation was decreased postoperatively over the abdomen (P < .001) and anterior thigh (P = .03) in the block group, other PACU variables did not differ, including VAS pain scores, motor function, side effects, PACU duration, and patient satisfaction.

CONCLUSIONS

Opioid consumption was reduced in patients who received a preoperative lateral quadratus lumborum block combined with a standardized, multimodal protocol as compared with patients who did not receive a block. Our findings support the growing evidence that quadratus lumborum blocks are an effective component of multimodal analgesia options for patients undergoing elective hip arthroscopy.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Preoperative Quadratus Lumborum Block Reduces Initial Postoperative Opioid Consumption Following Hip Arthroscopy: A Retrospective Analysis

Compare postoperative opioid consumption following hip arthroscopy in patients who received a preoperative, lateral quadratus lumborum block versus those who did not. Patients were retrospectively identified. The primary outcome was postoperative opioid consumption (IV morphine milligram equivalents) in patients with and without a block. Comparisons between groups were conducted with Chi-square tests and Fisher Exact Tests where appropriate. Continuous data were compared with two-sided t-tests and Wilcoxon rank-sum tests. Data were collected on 100 patients. Mean (95% confidence interval) postoperative opioid consumption was reduced in patients with a quadratus lumborum block compared to those without a block (6.6 [5.2 - 8.1] vs 11.8 [10.2 - 13.4]; p < 0.0001; respectively). Eleven percent of patients with a preoperative quadratus lumborum block did not consume any opioids in the post anesthesia care unit. Opioid consumption in the immediate postoperative period was significantly reduced in patients that received a preoperative quadratus lumborum block. Level of Evidence: Level III - Retrospective Cohort Study. (Journal of Surgical Orthopaedic Advances 31(1):017-021, 2022).

Incident Heart Failure Within the First and Fifth Year after Delivery Among Women With Hypertensive Disorders of Pregnancy and Prepregnancy Hypertension in a Diverse Population

Background Hypertensive disorders of pregnancy (HDP) and pre-pregnancy hypertension are associated with increased morbidity and mortality for the mother. Our aim was to investigate the relationships between HDP and pre-pregnancy hypertension with maternal heart failure (HF) within 1 and 5 years of delivery and to examine racial/ethnic differences. Methods and Results We conducted a retrospective cohort study in South Carolina (2004-2016) involving 425 649 women aged 12 to 49 years (58.9% non-Hispanic White [NHW], 31.5% non-Hispanic Black [NHB], 9.6% Hispanic) with a live, singleton birth. Incident HF was defined by hospital/emergency department visit and death certificate data. Pre-pregnancy hypertension and HDP (preeclampsia, eclampsia, or gestational hypertension) were based on hospitalization/emergency department visit and birth certificate data (i.e., gestational hypertension for HDP). The 425 649 women had pre-pregnancy hypertension without superimposed HDP (pre-pregnancy hypertension alone; 0.4%), HDP alone (15.7%), pre-pregnancy hypertension with superimposed HDP (both conditions; 2.2%), or neither condition in any pregnancy (81.7%). Incident HF event rates per 1000 person-years were higher in NHB than NHW women with HDP (HDP: 2.28 versus 0.96; both conditions: 4.30 versus 1.22, respectively). After adjustment, compared with women with neither condition, incident HF risk within 5 years of delivery was increased for women with pre-pregnancy hypertension (HR,2.55, 95% CI: 1.31-4.95), HDP (HR,4.20, 95% CI: 3.66-4.81), and both conditions (HR,5.25, 95% CI: 4.24-6.50). Conclusions Women with HDP and pre-pregnancy hypertension were at higher HF risk (highest for superimposed preeclampsia) within 5 years of delivery. NHB women with HDP had higher HF risk than NHW women, regardless of pre-pregnancy hypertension.

Plasma Sphingolipid Profile Associated With Subclinical Atherosclerosis and Clinical Disease Markers of Systemic Lupus Erythematosus: Potential Predictive Value

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that affects females more than males, with African Americans developing more severe manifestation of the disease. SLE patients are at increased risk for cardiovascular disease (CVD), and SLE women 35-44 years old have 50 fold the incidence rate of CVD. Because SLE patients do not follow the typical age and gender pattern for CVD, but instead an accelerated disease course, the traditional biomarkers of elevated LDL and total cholesterol levels do not accurately assess their CVD risk. Recently, we have reported that African American SLE patients had higher ceramide, hexosylceramide, sphingosine and dihydrosphingosine 1-phosphate levels compared to their healthy controls, and those with atherosclerosis had higher sphingomyelin and sphingoid bases levels than those without (PLoS One. 2019; e0224496). In the current study, we sought to identify sphingolipid species that correlate with and pose the potential to predict atherosclerosis severity in African American SLE patients. Plasma samples from a group of African American predominantly female SLE patients with well-defined carotid atherosclerotic plaque burden were analyzed for sphingolipidomics using targeted mass spectroscopy. The data demonstrated that at baseline, plaque area and C3 values correlated inversely with most lactoceramide species. After one-year follow-up visit, values of the change of plaque area correlated positively with the lactoceramide species. There was no correlation between LDL-C concentrations and lactoceramide species. Taken together, lactocylcermide levels may have a ‘predictive’ value and sphingolipidomics have an added benefit to currently available tools in early diagnosis and prognosis of African American SLE patients with CVD.

Abstract 050: Maternal Risk Of Incident Embolism Following Hypertensive Disorders Of Pregnancy Or Pre-pregnancy Hypertension In South Carolina

Introduction: Hypertensive disorders of pregnancy (HDP) and pre-pregnancy hypertension are associated with increased maternal morbidity and mortality, and information on racial/ethnic disparities is lacking. The association of HDP and pre-pregnancy hypertension with incident maternal embolism was examined within five years of delivery and for the study period (≤14 years) overall and by race/ethnicity.

Methods: Women with a live, singleton birth in South Carolina (2004-2016) aged 12-49 years were included in a retrospective cohort study (n=433,625; non-Hispanic white [NHW; 58.7%], non-Hispanic black [NHB; 31.8%)] and Hispanic [9.5%]). HDP were defined by hospitalization/emergency department (ED) visit data (pre-eclampsia, eclampsia, gestational hypertension) or birth certificates (gestational hypertension). Pre-pregnancy hypertension was also defined by these data sources. Hospitalization/ED visit data and death certificates defined fatal and non-fatal incident embolism. Cox proportional hazards models were used with covariate adjustment.

Results: In women with ≥1 pregnancy, 81.6% never experienced pre-pregnancy hypertension or HDP, 0.4% had pre-pregnancy hypertension without superimposed HDP, 15.7% had HDP alone, and 2.3% had pre-pregnancy hypertension with superimposed HDP. Incident embolism risk was elevated ≤14 years after delivery for women with HDP alone (HR=1.21, 95% CI: 1.12-1.30) and with pre-pregnancy hypertension with superimposed HDP (HR=1.44, 95% CI: 1.26-1.65) compared to neither condition. Pre-pregnancy hypertension alone was not associated with incident embolism risk (HR=1.23, 95% CI: 0.84-1.80). The table shows the joint impact of racial/ethnicity and the exposure categories.

Discussion: Fatal and non-fatal embolism up to 14 years after delivery was increased for HDP regardless of pre-pregnancy hypertension suggesting a long-term impact. Incident embolism event rates were highest for NHB women and lowest for Hispanic women across all HDP exposure categories.

Maternal Coronary Heart Disease, Stroke, and Mortality Within 1, 3, and 5 Years of Delivery Among Women With Hypertensive Disorders of Pregnancy and Pre-Pregnancy Hypertension

Background Pre-pregnancy hypertension and hypertensive disorders of pregnancy (HDP; preeclampsia, eclampsia, gestational hypertension) are major health risks for maternal morbidity and mortality. However, it is unknown if racial/ethnic differences exist. We aimed to determine the impact of HDP and pre-pregnancy hypertension on maternal coronary heart disease, stroke, and mortality risk ≤1, 3, and 5 years post-delivery and by race/ethnicity ≤5 years. Methods and Results This retrospective cohort study included women aged 12 to 49 years with a live, singleton birth between 2004 to 2016 (n=254 491 non-Hispanic White; n=137 784 non-Hispanic Black; n=41 155 Hispanic). Birth and death certificates and International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification (ICD-9-CM and ICD-10-CM) diagnosis codes in hospitalization/emergency department visit data defined HDP, pre-pregnancy hypertension, incident coronary heart disease and stroke, and all-cause mortality. During at least 1 pregnancy of the 433 430 women, 2.3% had pre-pregnancy hypertension with superimposed HDP, 15.7% had no pre-pregnancy hypertension with HDP, and 0.4% had pre-pregnancy hypertension without superimposed HDP, whereas 81.6% had neither condition. Maternal deaths from coronary heart disease, stroke, and all causes totaled 2136. Within 5 years of delivery, pre-pregnancy hypertension, and HDP were associated with all-cause mortality (hazard ratio [HR], 2.21; 95% CI, 1.61-3.03), incident coronary heart disease (HR, 3.79; 95% CI, 3.09-4.65), and incident stroke (HR, 3.10; 95% CI, 2.09-4.60). HDP alone was related to all outcomes. Race/ethnic differences were observed for non-Hispanic Black and non-Hispanic White women, respectively, in the associations of pre-pregnancy hypertension and HDP with all-cause mortality within 5 years of delivery (HR, 2.34 [95% CI, 1.58-3.47]; HR, 2.11 [95% CI, 1.23-3.65]; P interaction=0.001). Conclusions Maternal cardiovascular outcomes including mortality were increased ≤5 years post-delivery in HDP, pre-pregnancy hypertension, or pre-pregnancy hypertension with superimposed HDP. The race/ethnic interaction for all-cause mortality ≤5 years of delivery warrants further research.

The Utility of Carbohydrate-Deficient Transferrin in Identifying Chronic Alcohol Users in the Injured Patient: Expanding the Toolkit

BACKGROUND

Alcohol use remains abundant in patients with traumatic injury. Previous studies have suggested that serum carbohydrate-deficient transferrin (%dCDT) levels, relative to blood alcohol levels (BALs), may better differentiate episodic binge drinkers from sustained heavy consumers in admitted patients with traumatic injury. We characterized %dCDT levels and BAL levels to differentiate binge drinkers from sustained heavy consumers in admitted trauma patients and their associations with outcomes.

METHODS

This prospective, cross-sectional, observational study assessed %dCDT and BAL levels in admitted male and female patients with traumatic injury (≥18 y) at an American College of Surgeons Committee on Trauma level-1 center from July 2014 to June 2016. We designated patients with %dCDT levels ≥1.7% (CDT+) as chronic alcohol users and dichotomized acutely intoxicated patients using three different BAL-level thresholds. Primary outcomes included in-hospital complications, along with prolonged ventilation and intensive care unit length of stay, both defined as the top decile. Secondary outcomes included rates of drug or alcohol withdrawal and all-cause mortality. Analyses were adjusted for clinical factors.

RESULTS

We studied 715 patients (77.5% men, 60.6% ≤ 40 y of age, median Injury Severity Score: 14, 41.7% motor vehicle crashes, 17.9% gunshot wounds, 11.1% falls). While 31.0% were CDT+, 48.7% were BAL>0. After adjusting for CDT levels, BAL levels >0, >100, or >200 were not associated with adverse outcomes. However, CDT+ relative to patients with CDT were associated with complications (adjusted odds ratio: 1.96 [1.24-3.09]), prolonged ventilation days (3.23 [1.08-9.65]), and prolonged intensive care unit stays (2.83 [1.20-6.68]).

CONCLUSIONS

In this 2-year prospective, cross-sectional, and observational study, we found that %dCDT levels, relative to BAL levels, may better stratify admitted patients with traumatic injury into acute versus chronic alcohol users, identifying those at higher risk for in-hospital complications.

Train-the-trainer: Pilot trial for ebola virus disease simulation training

BACKGROUND

Highly infectious but rare diseases require rapid dissemination of safety critical skills to health-care workers (HCWs). Simulation is an effective method of education; however, it requires competent instructors. We evaluated the efficacy of an internet-delivered train-the-trainer course to prepare HCWs to care for patients with Ebola virus disease (EVD).

METHODS

Twenty-four individuals without prior EVD training were recruited and divided into two groups. Group A included nine trainees taught by three experienced trainers with previous EVD training. Group B included 15 trainees taught by five novice trainers without previous EVD training who completed the train-the-trainer course. We compared the efficacy of the train-the-trainer course by examining subject performance, measured by time to complete 13 tasks and the proportion of steps per task flagged for critical errors and risky and positive actions. Trainees' confidence in their ability to safely care for EVD patients was compared with a self-reported survey after training.

RESULTS

Overall trainees' confidence in ability to safely care for EVD patients did not differ by group. Participants trained by the novice trainers were statistically significantly faster at waste bagging (P = 0.002), lab specimen bagging (P = 0.004), spill clean-up (P = 0.01), and the body bagging (P = 0.008) scenarios compared to those trained by experienced trainers. There were no significant differences in the completion time in the remaining nine training tasks. Participants trained by novice and experienced trainers did not differ significantly with regard to the proportion of steps in a task flagged for critical errors, risky actions, or positive actions with the exception of the task "Man Down in Gown" (12.5% of steps graded by experienced trainers compared to 0 graded by novice trainers, P = 0.007).

DISCUSSION

The online train-the-trainer EVD course is effective at teaching novices to train HCWs in protective measures and can be accomplished swiftly.

Earlier re-initiation of enteral feeding after necrotizing enterocolitis decreases recurrence or stricture: a systematic review and meta-analysis

OBJECTIVE

To assess the effects of earlier vs. later re-initiation of enteral feeds after necrotizing enterocolitis (NEC).

STUDY DESIGN

We reviewed the literature to assess timing of enteral feeding after NEC using fixed effects models.

RESULTS

Three studies met inclusion criteria; no randomized trials. After removal of Bell's Stage I infants, the earlier refeeding group (<5-7 or median 4 days) included 79 infants and later refeeding group (≥5-7 or median 10 days) included 119 infants. Pooled analysis revealed earlier re-initiation reduced the incidence in the composite outcome of recurrent NEC and/or post-NEC stricture (OR = 0.27; 95% Cl = 0.10-0.75; p = 0.012). Individually, NEC recurrence (pooled OR = 0.34; 95% Cl = 0.09-1.29; p = 0.112) or stricture (OR = 0.34; 95% Cl = 0.09-1.26; p = 1.06) did not differ between groups.

CONCLUSIONS

There was no increase in negative outcomes with earlier refeeding after NEC. Earlier initiation of enteral feeds resulted in a significantly lower risk for the combined outcome of recurrent NEC and/or post-NEC stricture.

Race disparity in blood sphingolipidomics associated with lupus cardiovascular comorbidity

Systemic lupus erythematous (SLE) is a chronic multi-organ autoimmune disease. Genetic and environmental factors contribute to disease onset and severity. Sphingolipids are signaling molecules involved in regulating cell functions and have been associated with multiple genetic disease processes. African-Americans are more likely to suffer from SLE morbidity than Whites. The Medical University of South Carolina has banked plasma samples from a well-characterized lupus cohort that includes African-Americans and Whites. This study examined the influence of race on plasma sphingolipid profiles in SLE patients and association of sphingolipid levels with comorbid atherosclerosis and SLE disease activity. Mass spectrometry revealed that healthy African-Americans had higher sphingomyelin levels and lower lactosylcermide levels compared to healthy Whites. SLE patients, irrespective of race, had higher levels of ceramides, and sphingoid bases (sphingosine and dihydrosphingosine) and their phosphates compared to healthy subjects. Compared to African-American controls, African-American SLE patients had higher levels of ceramides, hexosylceramides, sphingosine and dihydrosphingosine 1-phosphate. Compared to White controls, White SLE patients exhibited higher levels of sphingoid bases and their phosphates, but lower ratios of C16:0 ceramide/sphingosine 1-phosphate and C24:1 ceramide/sphingosine 1-phosphate. White SLE patients with atherosclerosis exhibited lower levels of sphingoid bases compared to White SLE patients without atherosclerosis. In contrast, African-American SLE patients with atherosclerosis had higher levels of sphingoid bases and sphingomyelins compared to African-American SLE patients without atherosclerosis. Compared to White SLE patients with atherosclerosis, African-American SLE patients with atherosclerosis had higher levels of select sphingolipids. Plasma levels of sphingosine, C16:0 ceramide/sphingosine 1-phosphate ratio and C24:1 ceramide/sphingosine 1-phosphate ratio significantly correlated with SLEDAI in the African-American but not White SLE patients. The C16:0 ceramide/sphingosine 1-phosphate ratio in SLE patients, and levels of C18:1 and C26:1 lactosylcermides, C20:0 hexosylceramide, and sphingoid bases in SLE patients with atherosclerosis could be dependent on race. Further ethnic studies in SLE cohorts are necessary to verify use of sphingolipidomics as complementary diagnostic tool.

Safety and Tolerability of Thrombin Inhibition in Scleroderma-Associated Interstitial Lung Disease

Objective

Interstitial lung disease (ILD) is a frequent complication of systemic sclerosis (SSc) (scleroderma) and the leading cause of scleroderma‐related deaths. There exists an unmet need for a new drug therapy for ILD‐complicated SSc. Substantial evidence supports an important role for thrombin in the pathogenesis of SSc‐associated ILD (hereafter SSc‐ILD), and targeting thrombin with a direct thrombin inhibitor could prove to be a novel and effective treatment strategy. As a first step toward designing a clinical trial to test the efficacy of thrombin inhibition in SSc‐ILD, we conducted this study to test the safety and tolerability of dabigatran in patients with SSc‐ILD.

Methods

We performed a prospective, single‐center, open‐label treatment trial with the direct thrombin inhibitor, dabigatran, in patients with SSc‐ILD. Any patient with a history of gastrointestinal hemorrhage or gastric antral vascular ectasia was excluded. Blood monitoring was performed monthly, and patient‐reported outcomes, pulmonary function tests, and skin scores were obtained at baseline and at 3‐ and 6‐month visits. Bronchoscopy with bronchoalveolar lavage (BAL) was performed at baseline and at 6 months for measurement of lung thrombin activity.

Results

Of 15 patients with SSc‐ILD, 14 completed 6 months of treatment with dabigatran at 75 mg taken orally twice daily. Adverse events were uncommon and usually mild or unrelated to the study medication. No serious adverse event was observed. Dabigatran was well tolerated, and we observed no significant gastrointestinal, pulmonary, or other safety issues or intolerability. BAL fluid thrombin activity decreased or remained stable in 13 of 14 (92.8%) subjects.

Conclusion

Dabigatran appears to be safe and well tolerated in patients with SSc‐ILD. A larger randomized controlled trial to test the efficacy of direct thrombin inhibition with dabigatran can be considered.

A Pilot Trial of Online Simulation Training for Ebola Response Education

This article describes a pilot trial of an internet-distributable online software package that provides course materials and built-in evaluation tools to train healthcare workers in high-risk infectious disease response. It includes (1) an online self-study component, (2) a "hands-on" simulation workshop, and (3) a data-driven performance assessment toolset to support debriefing and course reporting. This study describes a pilot trial of the software package using a course designed to provide education in Ebola response to prepare healthcare workers to safely function as a measurable, high-reliability team in an Ebola simulated environment. Eighteen adult volunteer healthcare workers, including 9 novices and 9 experienced participants, completed an online curriculum with pre- and posttest, 13 programmed simulation training scenarios with a companion assessment tool, and a confidence survey. Both groups increased their knowledge test scores after completing the online curriculum. Simulation scenario outcomes were similar between groups. The confidence survey revealed participants had a high degree of confidence after the course, with a median confidence level of 4.5 out of 5.0 (IQR = 0.5). This study demonstrated the feasibility of using the online software package for the creation and application of an Ebola response course. Future studies could advance knowledge gained from this pilot trial by assessing timely distribution and multi-site effectiveness with standard education.

Myocardial infarction after epilepsy onset: A population-based retrospective cohort study

INTRODUCTION

Cardiovascular comorbidities of epilepsy such as hypertension, hyperlipidemia, and diabetes are associated with myocardial infarction (MI). Little data on the development of subsequent cardiovascular disease (CVD) in persons with epilepsy (PWE) are available, with inconsistent findings regarding the association between epilepsy and subsequent MI. A higher risk of MI among adults (without prior MI) following epilepsy diagnosis compared with that among controls was hypothesized.

METHODS

This retrospective cohort study used statewide hospital and emergency department (ED) encounter data from 2000-2013 for South Carolina residents aged >18 years without prior MI at the onset of epilepsy, or the first encounter for controls. Persons with epilepsy were compared with 1) persons with migraine (PWM), whose neurological condition has characteristics similar to epilepsy; and 2) persons with isolated lower extremity fracture (PWLF). Subsequent MI was defined as a diagnosis of MI after the first clinical encounter for epilepsy, migraine, or lower extremity fracture (LEF); the association was evaluated with Cox proportional hazard modeling methods.

RESULTS

In this study, 2.2% of PWE, 0.6% of PWM, and 1.2% of PWLF had a subsequent MI. Persons with epilepsy were significantly more likely to be non-Hispanic Black (NHB), be covered by Medicaid, and reside in a rural or low income area compared with PWM and PWLF. Specific cardiovascular disease risk factors were more prevalent in PWE than in PWM and PWLF. After adjustment, the hazard of subsequent MI in PWE was 48% higher than in PWM (hazard ratio (HR) = 1.48; 95% confidence intervals (CI) = 1.31-1.67) and 24% higher than in PWLF (HR = 1.24; 95% CI = 1.10-1.39). The hazard of MI increased with increasing age and number of additional comorbidities and was higher in males, those living in rural areas, and those with specific cardiovascular risk factors.

CONCLUSION

Persons with epilepsy had moderately elevated risk of subsequent MI compared with PWM or PWLF. The association between epilepsy and MI needs to be further investigated, and clinical care of PWE should include evaluation and management of risk factors for MI.

Time to reintroduction of feeding in infants with nonsurgical necrotizing enterocolitis

BACKGROUND

For infants with necrotizing enterocolitis (NEC) treated nonoperatively, no consensus exists on the optimal fasting period prior to reintroducing feeds after NEC. We report our experience with early (<7days) and late (≥7days) refeeding in this population.

METHODS

A chart review of infants with NEC born between 2006 and 2016 was performed. Data elements include demographics, comorbidities, day of diagnosis, Bell's stage, recurrence, strictures, length of stay and mortality, and were grouped into early and late refeeding. T-tests were used for means and chi-squared tests for distribution of proportions. Linear and logistic regressions were used to further evaluate the association of length of stay, stricture, recurrence, and death with time to refeeding.

RESULTS

Of 228 NEC patients, 149(65%) were treated nonoperatively (Bell Stages I, IIA, IIB, IIIA). Eleven patients were excluded owing to never restarting feeds, largely secondary to early death. The early (n=40) and late refeeding (n=98) groups were not significantly different with regard to mean gestational age at birth, race, birth weight, day of life at NEC diagnosis, or cardiac disease. NEC Stage was significantly different (p<0.001). The late group had significantly more Stage IIB patients (p=.02), and the early group had more stage I patients (p=<0.01). After adjusting for Bell's stage, the odds of NEC recurrence, death, and the composite outcome of recurrence or stricture or death were not significantly different between early and late groups.

CONCLUSIONS

No standardized guidelines exist for restarting enteral nutrition following medical NEC. In patients managed nonoperatively, early reintroduction of feeding was not significantly associated with increased NEC recurrence, mortality, or stricture.

LEVEL OF EVIDENCE

Treatment Study - Level III.

Identifying chronic heavy alcohol use in emergency general surgery patients: a pilot study

Background

Chronic heavy alcohol (CHA) use has been associated with perioperative complications. Emergency general surgery (EGS) patients are not routinely screened for CHA. If screened, it is usually for hazardous use of alcohol, using a survey such as the Alcohol Use Disorders Identification Test (AUDIT). This study screened EGS patients for CHA use using serum carbohydrate-deficient transferrin (%dCDT) level, a biomarker that has been validated as an indicator for CHA use, as well as the AUDIT. The purpose of this study was to determine the percent of EGS patients with CHA (as indicated by elevated %dCDT), and the relationship between %dCDT and AUDIT. Secondary aims included comparing the characteristics of EGS patients with and without CHA use, and evaluating the association of CHA use with negative clinical outcomes.

Methods

EGS patients aged 21 and older admitted to the general surgery inpatient service of a tertiary hospital from July 2014 to June 2016 were invited to participate in this study. %dCDT levels above 1.7% were considered positive for CHA use, as were AUDIT scores ≥8.

Results

195 EGS patients were screened for inclusion and 91 (46.7%) agreed to participate. 14 (15.4%) were positive for hazardous alcohol use on AUDIT and 5 (5.5%) were positive for CHA by %dCDT. Positive predictive value of AUDIT for CHA was 21.4%. There was no correlation between positive scores on AUDIT and %dCDT.

Discussion

Identifying at risk patients early on in their hospital course may allow clinicians to institute treatments to mitigate and/or circumvent complications in such patients. This pilot study determined that 17.6% of participating EGS patients were positive for some type of alcohol misuse, but only 5.5% had CHA. Further research is needed to determine whether routine use of %dCDT would be beneficial in reducing perioperative complications in this patient population.

Level of evidence

III (diagnostic test).

Developmental Ethanol-Induced Sleep Fragmentation, Behavioral Hyperactivity, Cognitive Impairment and Parvalbumin Cell Loss are Prevented by Lithium Co-treatment

Developmental ethanol exposure is a well-known cause of lifelong cognitive deficits, behavioral hyperactivity, emotional dysregulation, and more. In healthy adults, sleep is thought to have a critical involvement in each of these processes. Our previous work has demonstrated that some aspects of cognitive impairment in adult mice exposed at postnatal day 7 (P7) to ethanol (EtOH) correlate with slow-wave sleep (SWS) fragmentation (Wilson et al., 2016). We and others have also previously demonstrated that co-treatment with LiCl on the day of EtOH exposure prevents many of the anatomical and physiological impairments observed in adults. Here we explored cognitive function, diurnal rhythms (activity, temperature), SWS, and parvalbumin (PV) and perineuronal net (PNN)-positive cell densities in adult mice that had received a single day of EtOH exposure on P7 and saline-treated littermate controls. Half of the animals also received a LiCl injection on P7. The results suggest that developmental EtOH resulted in adult behavioral hyperactivity, cognitive impairment, and reduced SWS compared to saline controls. Both of these effects were reduced by LiCl treatment on the day of EtOH exposure. Finally, developmental EtOH resulted in decreased PV/PNN-expressing cells in retrosplenial (RS) cortex and dorsal CA3 hippocampus at P90. As with sleep and behavioral activity, LiCl treatment reduced this decrease in PV expression. Together, these results further clarify the long-lasting effects of developmental EtOH on adult behavior, physiology, and anatomy. Furthermore, they demonstrate the neuroprotective effects of LiCl co-treatment on this wide range of developmental EtOH's long-lasting consequences.

Hospitalization in low-level trauma centres after severe traumatic brain injury: review of a population-based emergency department data base

OBJECTIVE

To achieve the best possible recovery, individuals with severe TBI should be treated at Level I/II trauma centres (I/II TC). Increased morbidity and mortality can result when injured patients are admitted to facilities that may not have the appropriate resources or expertise to treat the injury. The purpose of this study was to estimate the proportion of severe TBI visits resulting in hospitalization in lower-level trauma centres (OTH) and evaluate the characteristics associated with such hospitalizations.

METHODS

The 2012 National Emergency Department Sample (NEDS) data set was analysed. Weighted descriptive analysis and multivariable logistic regression were used to describe the association of hospitalization in OTH with demographic, clinical and hospital characteristics.

RESULTS

Of visits for severe TBI, 112 208 were admitted to I/II TC and 43 294 admitted to OTH. The adjusted odds of hospitalization in OTH were higher for isolated TBI, falls, women, in those with ≥3 chronic conditions and increasing age.

CONCLUSIONS

An estimated 19.5% of visits for severe TBI resulted in hospitalization in OTH. These findings show the need to further evaluate the relationship between sex, age and mechanism of injury to inform efforts to appropriately triage individuals with TBI to ensure the best possible recovery.

Behavioral health in young adults with epilepsy: Implications for transition of care

AIM

Neurodevelopmental and behavioral health disorders commonly occur with epilepsy, yet risk for young adults is unknown. The aim of this study was to determine the distribution and risk characteristics of neurodevelopmental and behavior health comorbidities among young adults with epilepsy compared with those among young adults with migraine and healthy controls.

METHOD

A case-control study examining hospital admission, outpatient, and emergency department (ED) visits for young adults with an ICD-9-CM diagnosis of epilepsy, migraine, or lower extremity fracture (LEF) was conducted. The association of epilepsy, migraine, or LEF with comorbidities was evaluated with univariate and multivariate polytomous logistic regression.

RESULTS

From 2000 to 2013, 29,139 young adults ages 19 to 25years were seen in hospitals and EDs for epilepsy (5666), migraine (17,507), or LEF (5966). Young adults with epilepsy had higher proportions of behavioral health comorbidities (51.8%) compared with controls with migraine (37.6%) or LEF (21.6%). In young adults with epilepsy compared with migraine, the increased risk of having any behavioral health comorbidity was 76%, and neurodevelopmental comorbidity was 297%. After adjustment, young adults with epilepsy showed significantly higher odds of each behavioral health comorbidity compared with controls with migraine and LEF.

INTERPRETATION

Young adults with epilepsy are particularly susceptible to behavioral health and neurodevelopmental disorders. Results are discussed within the context of transition to adult care.

Shaping polymersomes into predictable morphologies via out-of-equilibrium self-assembly

Polymersomes are bilayer vesicles, self-assembled from amphiphilic block copolymers. They are versatile nanocapsules with adjustable properties, such as flexibility, permeability, size and functionality. However, so far no methodological approach to control their shape exists. Here we demonstrate a mechanistically fully understood procedure to precisely control polymersome shape via an out-of-equilibrium process. Carefully selecting osmotic pressure and permeability initiates controlled deflation, resulting in transient capsule shapes, followed by reinflation of the polymersomes. The shape transformation towards stomatocytes, bowl-shaped vesicles, was probed with magnetic birefringence, permitting us to stop the process at any intermediate shape in the phase diagram. Quantitative electron microscopy analysis of the different morphologies reveals that this shape transformation proceeds via a long-predicted hysteretic deflation-inflation trajectory, which can be understood in terms of bending energy. Because of the high degree of controllability and predictability, this study provides the design rules for accessing polymersomes with all possible different shapes.

Epidemiology of systemic lupus erythematosus in rural Wisconsin

We investigated the epidemiology of systemic lupus erythematosus (SLE) in the Marshfield Epidemiologic Study Area (MESA), a defined rural region where nearly all residents obtain their health care from a large clinic system. Computerized medical records were searched to identify MESA residents diagnosed with SLE from 1991 through 2001. Medical records were manually reviewed for all selected patients to identify cases of SLE using the 1982 revised American College of Rheumatology criteria. Patients with 4 criteria were classified as definite SLE. Age- and gender- specific SLE incidence rates (1991-2001), the population prevalence rate of SLE on 31 December 2001 and survival rates were calculated. We identified 117 MESA residents with definite SLE. The average age-adjusted incidence of definite SLE was 5.1 per 100 000 per year (95% CI: 3.6, 6.6) and the age-adjusted population prevalence was 78.5 per 100 000 (95% CI: 59.0, 98.0). The mean age at diagnosis among the 44 incident cases was 51.7 years (range: 14-90 years). Positive anti-nuclear antibody (ANA), hematologic abnormalities, arthritis and renal disease were common at diagnosis. Five- and 10-year survival rates were 88% and 76%, respectively. Epidemiologic characteristics of SLE in this rural Caucasian population are generally similar to those reported by other US studies. One notable difference is a relatively high incidence of SLE in older adults.

Plasticity in the Olfactory System: Lessons for the Neurobiology of Memory

We are rapidly advancing toward an understanding of the molecular events underlying odor transduction, mechanisms of spatiotemporal central odor processing, and neural correlates of olfactory perception and cognition. A thread running through each of these broad components that define olfaction appears to be their dynamic nature. How odors are processed, at both the behavioral and neural level, is heavily dependent on past experience, current environmental context, and internal state. The neural plasticity that allows this dynamic processing is expressed nearly ubiquitously in the olfactory pathway, from olfactory receptor neurons to the higher-order cortex, and includes mechanisms ranging from changes in membrane excitability to changes in synaptic efficacy to neurogenesis and apoptosis. This review will describe recent findings regarding plasticity in the mammalian olfactory system that are believed to have general relevance for understanding the neurobiology of memory.

Developmental ethanol exposure-induced sleep fragmentation predicts adult cognitive impairment

Developmental ethanol (EtOH) exposure can lead to long-lasting cognitive impairment, hyperactivity, and emotional dysregulation among other problems. In healthy adults, sleep plays an important role in each of these behavioral manifestations. Here we explored circadian rhythms (activity, temperature) and slow-wave sleep (SWS) in adult mice that had received a single day of EtOH exposure on postnatal day 7 and saline littermate controls. We tested for correlations between slow-wave activity and both contextual fear conditioning and hyperactivity. Developmental EtOH resulted in adult hyperactivity within the home cage compared to controls but did not significantly modify circadian cycles in activity or temperature. It also resulted in reduced and fragmented SWS, including reduced slow-wave bout duration and increased slow-wave/fast-wave transitions over 24-h periods. In the same animals, developmental EtOH exposure also resulted in impaired contextual fear conditioning memory. The impairment in memory was significantly correlated with SWS fragmentation. Furthermore, EtOH-treated animals did not display a post-training modification in SWS which occurred in controls. In contrast to the memory impairment, sleep fragmentation was not correlated with the developmental EtOH-induced hyperactivity. Together these results suggest that disruption of SWS and its plasticity are a secondary contributor to a subset of developmental EtOH exposure's long-lasting consequences.

Neurodevelopmental and mental health comorbidities in children and adolescents with epilepsy and migraine: a response to identified research gaps

AIM

To determine the distribution and risk characteristics of comorbid neurodevelopmental and mental health comorbidities among children and adolescents (6-18y) with epilepsy or migraine (i.e. a neurological condition with shared features and potential etiology) compared with lower extremity fracture (LEF).

METHOD

This case-control study involved a subset analysis of surveillance data in South Carolina, USA. Hospital admission, outpatient, and emergency department visits for individuals with an International Classification of Disease, 9th revision Clinical Modification diagnosis of epilepsy (n=6730; 54.5% females, 45.5% males; mean age [SD] 14y 2mo [4y 5mo]); migraine (n=10 495; 74.5% females, 25.5% males; 15y 6mo [2y 6mo]), or LEF (n=15 305; 40.3% females, 59.7% males; 13y 11mo [2y 11mo]) from January 1 2000 to December 31 2011 were identified. The association of epilepsy, migraine, or LEF with any mental health comorbidity was evaluated with univariate and multivariate polytomous logistic regression.

RESULTS

Comorbidities were highly prevalent in children and adolescents, with epilepsy with a rate of 29.7% (95% confidence interval [CI]: 28.6-30.8) for mental health comorbidities and 30.8% (95% CI: 29.7-31.9) for neurodevelopmental comorbidities. The odds of mental health comorbidity was 2.20 (95% CI: 2.02-2.39) for children and adolescents with epilepsy and 1.60 (95% CI: 1.48-1.73) for migraine, in reference to children and adolescents with LEF after adjusting for potential confounders. Prevalence and risk for specific comorbidities are presented.

INTERPRETATION

Neuropathophysiological and psychosocial factors specific to epilepsy may provide more risk for adolescents with epilepsy compared to migraine.

Premature deaths among children with epilepsy - South Carolina, 2000-2011

Epilepsy is a common childhood neurologic disorder. In 2007, epilepsy affected an estimated 450,000 children aged 0-17 years in the United States. Approximately 53% of children with epilepsy and special health care needs have co-occurring conditions, and only about one third have access to comprehensive care. The few studies of mortality risk among children with epilepsy as compared with the general population generally find a higher risk for death among children with epilepsy with co-occurring conditions but a similar risk for death among children with epilepsy with no co-occurring conditions. However, samples from these mortality studies are often small, limiting comparisons, and are not representative. This highlights the need for expanded mortality surveillance among children with epilepsy to better understand their excess mortality. This report describes mortality among children with epilepsy in South Carolina during 2000-2011 by demographic characteristics and underlying causes of death. The overall mortality rate among children with epilepsy was 8.8 deaths per 1,000 person-years, and the annual risk for death was 0.84%. Developmental conditions, cardiovascular disorders, and injuries were the most common causes of death among children with epilepsy. Team-based care coordination across medical and nonmedical systems can improve outcomes and reduce health care costs for children with special health care needs, but they require more study among children with epilepsy. Ensuring appropriate and timely health care and social services for children with epilepsy, especially those with complications, might reduce the risk for premature death. Health care providers, social service providers, advocacy groups and others can work together to assess whether coordinated care can improve outcomes for children with epilepsy.

Risk of venous thromboembolism in people with epilepsy

OBJECTIVE

Risk of venous thromboembolism (VTE) among people with epilepsy (PWEs) has not been previously reported. Standard VTE prevention methods may increase the risk of complications in this population. This statewide study assessed the risk of VTE in PWEs.

METHODS

Main risk categories were grouped into definite epilepsy (DE), probable epilepsy (PE), and migraine, a comparable neurologic condition. All inpatient, emergency department, and hospital-based outpatient encounters in South Carolina from January 1, 2000 through December 31, 2011, were evaluated for the primary outcome variable of VTE, defined as having a diagnosis of VTE at or after the diagnosis of epilepsy or migraine. Coagulopathies and common comorbidities of epilepsy were enumerated. Differences in VTE proportions were assessed using 95% confidence intervals (CIs). Association of VTE with epilepsy and migraine was evaluated with Cox proportional hazard modeling.

RESULTS

A total of 138,497 people with migraine (PWMs) and 67,900 PWEs (32,186 DE, 35,714 PE) were included. VTE occurred in 2.7% of PWEs (4.2% among DE), and 0.6% of PWMs. The hazard ratio for VTE in DE compared with PWMs was 3.08 (95% CI 2.76-3.42), adjusted for all covariables. Higher numbers of comorbidities were strongly associated with VTE. PWE had higher numbers of comorbidities (52% with 2+ comorbidities versus 23% of PWM), but the impact of comorbidities on VTE risk was larger in PWM.

SIGNIFICANCE

Higher VTE risk in PWE than PWM suggests risk factors associated with epilepsy, independent of chronic neurologic illness. VTE occurrence in PWE is comparable to published rates among people with cancer.

Distinct neurobehavioral dysfunction based on the timing of developmental binge-like alcohol exposure

Gestational exposure to alcohol can result in long-lasting behavioral deficiencies generally described as fetal alcohol spectrum disorder (FASD). FASD-modeled rodent studies of acute ethanol exposure typically select one developmental window to simulate a specific context equivalent of human embryogenesis, and study consequences of ethanol exposure within that particular developmental epoch. Exposure timing is likely a large determinant in the neurobehavioral consequence of early ethanol exposure, as each brain region is variably susceptible to ethanol cytotoxicity and has unique sensitive periods in their development. We made a parallel comparison of the long-term effects of single-day binge ethanol at either embryonic day 8 (E8) or postnatal day 7 (P7) in male and female mice, and here demonstrate the differential long-term impacts on neuroanatomy, behavior and in vivo electrophysiology of two systems with very different developmental trajectories. The significant long-term differences in odor-evoked activity, local circuit inhibition, and spontaneous coherence between brain regions in the olfacto-hippocampal pathway that were found as a result of developmental ethanol exposure, varied based on insult timing. Long-term effects on cell proliferation and interneuron cell density were also found to vary by insult timing as well as by region. Finally, spatial memory performance and object exploration were affected in P7-exposed mice, but not E8-exposed mice. Our physiology and behavioral results are conceptually coherent with the neuroanatomical data attained from these same mice. Our results recognize both variable and shared effects of ethanol exposure timing on long-term circuit function and their supported behavior.

Risk of severe and repetitive traumatic brain injury in persons with epilepsy: a population-based case-control study

BACKGROUND

While traumatic brain injury (TBI) can lead to epilepsy, individuals with preexisting epilepsy or seizure disorder (ESD), depending on the type of epilepsy and the degree of seizure control, may have a greater risk of TBI from seizure activity or medication side effects. The joint occurrence of ESD and TBI can complicate recovery as signs and symptoms of TBI may be mistaken for postictal effects. Those with ESD are predicted to experience more deleterious outcomes either because of having a more severe TBI or because of the cumulative effects of repetitive TBI.

METHODS

We conducted a case-control study of all emergency department visits and hospital discharges for TBI from 1998 through 2011 in a statewide population. The severity of TBI, repetitive TBI, and other demographic and clinical characteristics were compared between persons with TBI with preexisting ESD (cases) and those without (controls). Significant differences in proportions were evaluated with confidence intervals. Logistic regression was used to examine the association of the independent variables with ESD.

RESULTS

During the study period, 236,164 individuals sustained TBI, 5646 (2.4%) of which had preexisting ESD. After adjustment for demographic and clinical characteristics, cases were more likely to have sustained a severe TBI (OR=1.49; 95% CI=1.38-1.60) and have had repetitive TBI (OR=1.54; 95% CI=1.41-1.69).

CONCLUSION

The consequences of TBI may be greater in individuals with ESD owing to the potential for a more severe or repetitive TBI. Seizure control is paramount, and aggressive management of comorbid conditions among persons with ESD and increased awareness of the hazard of repetitive TBI is warranted. Furthermore, future studies are needed to examine the long-term outcomes of cases in comparison with controls to determine if the higher risk of severe or repetitive TBI translates into permanent deficits.

Using syndromic surveillance to estimate baseline rates for healthcare-associated infections in critical care units of small animal referral hospitals

BACKGROUND

Expected rates of healthcare-associated infections (HCAI) have not been established in veterinary hospitals. Baseline rates are critically needed as benchmarks for quality animal care.

OBJECTIVE

To estimate the occurrence of events related to HCAI identified using a standardized syndromic surveillance system in small animals in critical care cases at referral hospitals.

ANIMALS

Weaned dogs and cats (n = 1,951) that were hospitalized in the critical care unit of referral teaching hospitals during a 12-week period.

METHODS

Multicenter, prospective longitudinal study. A survey was completed for all enrolled animals to record basic demographics, information about procedures and treatments that animals received, and to document the occurrence of defined nosocomial syndromes. Data were analyzed to identify risk factors associated with the occurrence of these nosocomial syndromes.

RESULTS

Controlling for hospital of admission, 16.3% of dogs (95% confidence intervals [CI], 14.3-18.5) and 12% of cats (95% CI, 9.3-15.5) were reported to have had ≥ 1 nosocomial syndrome occur during hospitalization. Risk factors found to have a positive association with the development of a nosocomial syndrome were longer hospital stays, placement of a urinary catheter, surgical procedures being performed, and the administration of antiulcer medications and antimicrobial drugs excluding those given perioperatively.

CONCLUSIONS AND CLINICAL IMPORTANCE

Syndromic surveillance systems can be successfully standardized for use across multiple hospitals to effectively collect data pertinent to HCAI rates and risk factors for occurrence.

Incidence of sport-related traumatic brain injury and risk factors of severity: a population-based epidemiologic study

PURPOSE

Few studies of sport-related traumatic brain injury (TBI) are population-based or rely on directly observed data on cause, demographic characteristics, and severity. This study addresses the epidemiology of sport-related TBI in a large population.

METHODS

Data on all South Carolina hospital and emergency department encounters for TBI, 1998-2011, were analyzed. Annual incidence rate of sport-related TBI was calculated, and rates were compared across demographic groups. Sport-related TBI severity was modeled as a function of demographic and TBI characteristics using logistic regression.

RESULTS

A total of 16,642 individuals with sport-related TBI yielded an average annual incidence rate of 31.5/100,000 population with a steady increase from 19.7 in 1998 to 45.6 in 2011. The most common mechanisms of sport-related TBI were kicked in football (38.1%), followed by fall injuries in sports (20.3%). Incidence rate was greatest in adolescents ages 12-18 (120.6/100,000/persons). Severe sport-related TBI was strongly associated with off-road vehicular sport (odds ratio [OR], 4.73; 95% confidence interval [95% CI], 2.92-7.67); repeated head trauma (OR, 4.36; 95% CI, 3.69-5.15); equestrian sport (OR, 2.73; 95% CI, 1.64-4.51); and falls during sport activities (OR, 2.72; 95% CI, 1.67-4.46).

CONCLUSIONS

The high incidence of sport-related TBI in youth, potential for repetitive mild TBI, and its long-term consequences on learning warrants coordinated surveillance activities and population-based outcome studies.

Neurobiology of secure infant attachment and attachment despite adversity: a mouse model

Attachment to an abusive caregiver has wide phylogenetic representation, suggesting that animal models are useful in understanding the neural basis underlying this phenomenon and subsequent behavioral outcomes. We previously developed a rat model, in which we use classical conditioning to parallel learning processes evoked during secure attachment (odor-stroke, with stroke mimicking tactile stimulation from the caregiver) or attachment despite adversity (odor-shock, with shock mimicking maltreatment). Here we extend this model to mice. We conditioned infant mice (postnatal day (PN) 7-9 or 13-14) with presentations of peppermint odor and either stroking or shock. We used (14) C 2-deoxyglucose (2-DG) to assess olfactory bulb and amygdala metabolic changes following learning. PN7-9 mice learned to prefer an odor following either odor-stroke or shock conditioning, whereas odor-shock conditioning at PN13-14 resulted in aversion/fear learning. 2-DG data indicated enhanced bulbar activity in PN7-9 preference learning, whereas significant amygdala activity was present following aversion learning at PN13-14. Overall, the mouse results parallel behavioral and neural results in the rat model of attachment, and provide the foundation for the use of transgenic and knockout models to assess the impact of both genetic (biological vulnerabilities) and environmental factors (abusive) on attachment-related behaviors and behavioral development.

Capacitance and optical studies of elastic and dielectric properties in an organosiloxane tetrapode exhibiting a N(B) phase

Biaxial (N(B)) and uniaxial nematic (N(U)) phase behavior was detected and confirmed for an organosiloxane tetrapode material using capacitance and birefringence measurements. Elastic constants, permittivities at two distinct low frequencies, and birefringencies were determined as a function of temperature over both the N(U) and the N(B) phase ranges. The N(U)-N(B) transition is clearly observed in the birefringencies and conoscopy data. A temperature dependent cross-over frequency is also detected in this material for the permittivities, allowing the electrical switching of both planar and homeotropic aligned samples.

Odor-evoked activity in the mouse lateral entorhinal cortex

The entorhinal cortex is a brain area with multiple reciprocal connections to the hippocampus, amygdala, perirhinal cortex, olfactory bulb and piriform cortex. As such, it is thought to play a large role in the olfactory memory process. The present study is the first to compare lateral entorhinal and anterior piriform cortex odor-evoked single-unit and local field potential activity in mouse. Recordings were made in urethane-anesthetized mice that were administered a range of three pure odors and three overlapping odor mixtures. Results show that spontaneous as well as odor-evoked unit activity was lower in lateral entorhinal versus piriform cortex. In addition, units in lateral entorhinal cortex were responsive to a more restricted set of odors compared to piriform. Conversely, odor-evoked power change in local field potential activity was greater in the lateral entorhinal cortex in the theta band than in piriform. The highly odor-specific and restricted firing in lateral entorhinal cortex suggests that it may play a role in modulating odor-specific, experience- and state-dependent olfactory coding.

Microdistribution and long-term retention of 239Pu (NO3)4 in the respiratory tracts of an acutely exposed plutonium worker and experimental beagle dogs

The long-term retention of inhaled soluble forms of plutonium raises concerns as to the potential health effects in persons working in nuclear energy or the nuclear weapons program. The distributions of long-term retained inhaled plutonium-nitrate [(239)Pu (NO(3))(4)] deposited in the lungs of an accidentally exposed nuclear worker (Human Case 0269) and in the lungs of experimentally exposed beagle dogs with varying initial lung depositions were determined via autoradiographs of selected histologic lung, lymph node, trachea, and nasal turbinate tissue sections. These studies showed that both the human and dogs had a nonuniform distribution of plutonium throughout the lung tissue. Fibrotic scar tissue effectively encapsulated a portion of the plutonium and prevented its clearance from the body or translocation to other tissues and diminished dose to organ parenchyma. Alpha radiation activity from deposited plutonium in Human Case 0269 was observed primarily along the subpleural regions while no alpha activity was seen in the tracheobronchial lymph nodes of this individual. However, relatively high activity levels in the tracheobronchial lymph nodes of the beagles indicated the lymphatic system was effective in clearing deposited plutonium from the lung tissues. In both the human case and beagle dogs, the appearance of retained plutonium within the respiratory tract was inconsistent with current biokinetic models of clearance for soluble forms of plutonium. Bound plutonium can have a marked effect on the dose to the lungs and subsequent radiation exposure has the potential to increase cancer risk.

Global cost of correcting vision impairment from uncorrected refractive error

OBJECTIVE

To estimate the global cost of establishing and operating the educational and refractive care facilities required to provide care to all individuals who currently have vision impairment resulting from uncorrected refractive error (URE).

METHODS

The global cost of correcting URE was estimated using data on the population, the prevalence of URE and the number of existing refractive care practitioners in individual countries, the cost of establishing and operating educational programmes for practitioners and the cost of establishing and operating refractive care facilities. The assumptions made ensured that costs were not underestimated and an upper limit to the costs was derived using the most expensive extreme for each assumption.

FINDINGS

There were an estimated 158 million cases of distance vision impairment and 544 million cases of near vision impairment caused by URE worldwide in 2007. Approximately 47 000 additional full-time functional clinical refractionists and 18 000 ophthalmic dispensers would be required to provide refractive care services for these individuals. The global cost of educating the additional personnel and of establishing, maintaining and operating the refractive care facilities needed was estimated to be around 20 000 million United States dollars (US$) and the upper-limit cost was US$ 28 000 million. The estimated loss in global gross domestic product due to distance vision impairment caused by URE was US$ 202 000 million annually.

CONCLUSION

The cost of establishing and operating the educational and refractive care facilities required to deal with vision impairment resulting from URE was a small proportion of the global loss in productivity associated with that vision impairment.