Headpulse measurement can reliably identify large-vessel occlusion stroke in prehospital suspected stroke patients: Results from the EPISODE-PS-COVID study

BACKGROUND

Large-vessel occlusion (LVO) stroke represents one-third of acute ischemic stroke (AIS) in the United States but causes two-thirds of poststroke dependence and >90% of poststroke mortality. Prehospital LVO stroke detection permits efficient emergency medical systems (EMS) transport to an endovascular thrombectomy (EVT)-capable center. Our primary objective was to determine the feasibility of using a cranial accelerometry (CA) headset device for prehospital LVO stroke detection. Our secondary objective was development of an algorithm capable of distinguishing LVO stroke from other conditions.

METHODS

We prospectively enrolled consecutive adult patients suspected of acute stroke from 11 study hospitals in four different U.S. geographical regions over a 21-month period. Patients received device placement by prehospital EMS personnel. Headset data were matched with clinical data following informed consent. LVO stroke diagnosis was determined by medical chart review. The device was trained using device data and Los Angeles Motor Scale (LAMS) examination components. A binary threshold was selected for comparison of device performance to LAMS scores.

RESULTS

A total of 594 subjects were enrolled, including 183 subjects who received the second-generation device. Usable data were captured in 158 patients (86.3%). Study subjects were 53% female and 56% Black/African American, with median age 69 years. Twenty-six (16.4%) patients had LVO and 132 (83.6%) were not LVO (not-LVO AIS, 33; intracerebral hemorrhage, nine; stroke mimics, 90). COVID-19 testing and positivity rates (10.6%) were not different between groups. We found a sensitivity of 38.5% and specificity of 82.7% for LAMS ≥ 4 in detecting LVO stroke versus a sensitivity of 84.6% (p < 0.0015 for superiority) and specificity of 82.6% (p = 0.81 for superiority) for the device algorithm (CA + LAMS).

CONCLUSIONS

Obtaining adequate recordings with a CA headset is highly feasible in the prehospital environment. Use of the device algorithm incorporating both CA and LAMS data for LVO detection resulted in significantly higher sensitivity without reduced specificity when compared to the use of LAMS alone.

Outpatient COVID-19 convalescent plasma recipient antibody thresholds correlated to reduced hospitalizations within a randomized trial

BACKGROUNDCOVID-19 convalescent plasma (CCP) virus-specific antibody levels that translate into recipient posttransfusion antibody levels sufficient to prevent disease progression are not defined.METHODSThis secondary analysis correlated donor and recipient antibody levels to hospitalization risk among unvaccinated, seronegative CCP recipients within the outpatient, double-blind, randomized clinical trial that compared CCP to control plasma. The majority of COVID-19 CCP arm hospitalizations (15/17, 88%) occurred in this unvaccinated, seronegative subgroup. A functional cutoff to delineate recipient high versus low posttransfusion antibody levels was established by 2 methods: (i) analyzing virus neutralization-equivalent anti-Spike receptor-binding domain immunoglobulin G (anti-S-RBD IgG) responses in donors or (ii) receiver operating characteristic (ROC) curve analysis.RESULTSSARS-CoV-2 anti-S-RBD IgG antibody was volume diluted 21.3-fold into posttransfusion seronegative recipients from matched donor units. Virus-specific antibody delivered was approximately 1.2 mg. The high-antibody recipients transfused early (symptom onset within 5 days) had no hospitalizations. A CCP-recipient analysis for antibody thresholds correlated to reduced hospitalizations found a statistical significant association between early transfusion and high antibodies versus all other CCP recipients (or control plasma), with antibody cutoffs established by both methods-donor-based virus neutralization cutoffs in posttransfusion recipients (0/85 [0%] versus 15/276 [5.6%]; P = 0.03) or ROC-based cutoff (0/94 [0%] versus 15/267 [5.4%]; P = 0.01).CONCLUSIONIn unvaccinated, seronegative CCP recipients, early transfusion of plasma units in the upper 30% of study donors' antibody levels reduced outpatient hospitalizations. High antibody level plasma units, given early, should be reserved for therapeutic use.TRIAL REGISTRATIONClinicalTrials.gov NCT04373460.FUNDINGDepartment of Defense (W911QY2090012); Defense Health Agency; Bloomberg Philanthropies; the State of Maryland; NIH (3R01AI152078-01S1, U24TR001609-S3, 1K23HL151826NIH); the Mental Wellness Foundation; the Moriah Fund; Octapharma; the Healthnetwork Foundation; the Shear Family Foundation; the NorthShore Research Institute; and the Rice Foundation.

COVID-19 convalescent plasma therapy decreases inflammatory cytokines: a randomized controlled trial

IMPORTANCE

This study examined the role that cytokines may have played in the beneficial outcomes found when outpatient individuals infected with SARS-CoV-2 were transfused with COVID-19 convalescent plasma (CCP) early in their infection. We found that the pro-inflammatory cytokine IL-6 decreased significantly faster in patients treated early with CCP. Participants with COVID-19 treated with CCP later in the infection did not have the same effect. This decrease in IL-6 levels after early CCP treatment suggests a possible role of inflammation in COVID-19 progression. The evidence of IL-6 involvement brings insight into the possible mechanisms involved in CCP treatment mitigating SARS-CoV-2 severity.

Outpatient COVID-19 convalescent plasma recipient antibody thresholds correlated to reduced hospitalizations within a randomized trial

BACKGROUND

The COVID-19 convalescent plasma (CCP) viral specific antibody levels that translate into recipient post-transfusion antibody levels sufficient to prevent disease progression is not defined.

METHODS

This secondary analysis correlated donor and recipient antibody levels to hospitalization risk among unvaccinated, seronegative CCP recipients within the outpatient, double blind, randomized clinical trial that compared CCP to control plasma. The majority of COVID-19 CCP arm hospitalizations (15/17, 88%) occurred in this unvaccinated, seronegative subgroup. A functional cutoff to delineate recipient high versus low post-transfusion antibody levels was established by two methods: 1) analyzing virus neutralization-equivalent anti-S-RBD IgG responses in donors or 2) receiver operating characteristic (ROC) analysis.

RESULTS

SARS-CoV-2 anti-S-RBD IgG antibody was diluted by a factor of 21.3 into post-transfusion seronegative recipients from matched donor units. Viral specific antibody delivered approximated 1.2 mg. The high antibody recipients transfused early (symptom onset within 5 days) had no hospitalizations. A CCP recipient analysis for antibody thresholds correlated to reduced hospitalizations found a significant association with Fisher's exact test between early and high antibodies versus all other CCP recipients (or control plasma) with antibody cutoffs established by both methods-donor virus neutralization-based cutoff: (0/85; 0% versus 15/276; 5.6%) p=0.03 or ROC based cutoff: (0/94; 0% versus 15/267; 5.4%) p=0.01.

CONCLUSION

In unvaccinated, seronegative CCP recipients, early transfusion of plasma units corresponding to the upper 30% of all study donors reduced outpatient hospitalizations. These high antibody level plasma units, given early, should be reserved for therapeutic use.Trial registration: NCT04373460.

FUNDING

Defense Health Agency and others.

A comparison of the effect of patient-specific versus weight-based protocols to treat vaso-occlusive episodes in the emergency department

BACKGROUND

Vaso-occlusive crises (VOCs) cause debilitating pain and are a common cause of emergency department (ED) visits, for people with sickle cell disease (SCD). Strategies for achieving optimal pain control vary widely despite evidence-based guidelines. We tested existing guidelines and hypothesized that a patient-specific pain protocol (PSP) written by their SCD provider may be more effective than weight-based (WB) dosing of parenteral opiate medication, in relieving pain.

METHODS

This study was a prospective, randomized controlled trial comparing a PSP versus WB protocol for patients presenting with VOCs to six EDs. Patients were randomized to a PSP or WB protocol prior to an ED visit. The SCD provider wrote their protocol and placed it in the electronic health record for future ED visits with VOC exclusion criteria that included preexisting PSP excluding parenteral opioid analgesia or outpatient use of buprenorphine or methadone or highly suspected for COVID-19. Pain intensity scores, side effects, and safety were obtained every 30 min for up to 6 h post-ED bed placement. The primary outcome was change in pain intensity score from placement in an ED space to disposition or 6 h.

RESULTS

A total of 328 subjects were randomized; 104 participants enrolled (ED visit, target n = 230) with complete data for 96 visits. The study was unable to reach the target sample size and stopped early due to the impact of COVID-19. We found no significant differences between groups in the primary outcome; patients randomized to a PSP had a shorter ED length of stay (p = 0.008), and the prevalence of side effects was low in both groups. Subjects in both groups experienced both a clinically meaningful and a statistically significant decrease in pain (27 mm on a 0- to 100-mm scale).

CONCLUSIONS

We found a shorter ED length of stay for patients assigned to a PSP. Patients in both groups experienced good pain relief without significant side effects.

Early antibody treatment, inflammation, and risk of post-COVID conditions

IMPORTANCE

Approximately 20% of individuals infected with SARS-CoV-2 experienced long-term health effects, as defined PCC. However, it is unknown if there are any early biomarkers associated with PCC or whether early intervention treatments may decrease the risk of PCC. In a secondary analysis of a randomized clinical trial, this study demonstrates that among outpatients with SARS-CoV-2, increased IL-6 at time of infection is associated with increased odds of PCC. In addition, among individuals treated early, within 5 days of symptom onset, with COVID-19 convalescent plasma, there was a trend for decreased odds of PCC after adjusting for other demographic and clinical characteristics. Future treatment studies should be considered to evaluate the effect of early treatment and anti-IL-6 therapies on PCC development.

Dynamics of inflammatory responses after SARS-CoV-2 infection by vaccination status in the USA: a prospective cohort study

BACKGROUND

Cytokines and chemokines play a critical role in the response to infection and vaccination. We aimed to assess the longitudinal association of COVID-19 vaccination with cytokine and chemokine concentrations and trajectories among people with SARS-CoV-2 infection.

METHODS

In this longitudinal, prospective cohort study, blood samples were used from participants enrolled in a multi-centre randomised trial assessing the efficacy of convalescent plasma therapy for ambulatory COVID-19. The trial was conducted in 23 outpatient sites in the USA. In this study, participants (aged ≥18 years) were restricted to those with COVID-19 before vaccination or with breakthrough infections who had blood samples and symptom data collected at screening (pre-transfusion), day 14, and day 90 visits. Associations between COVID-19 vaccination status and concentrations of 21 cytokines and chemokines (measured using multiplexed sandwich immunoassays) were examined using multivariate linear mixed-effects regression models, adjusted for age, sex, BMI, hypertension, diabetes, trial group, and COVID-19 waves (pre-alpha or alpha and delta).

FINDINGS

Between June 29, 2020, and Sept 30, 2021, 882 participants recently infected with SARS-CoV-2 were enrolled, of whom 506 (57%) were female and 376 (43%) were male. 688 (78%) of 882 participants were unvaccinated, 55 (6%) were partly vaccinated, and 139 (16%) were fully vaccinated at baseline. After adjusting for confounders, geometric mean concentrations of interleukin (IL)-2RA, IL-7, IL-8, IL-15, IL-29 (interferon-λ), inducible protein-10, monocyte chemoattractant protein-1, and tumour necrosis factor-α were significantly lower among the fully vaccinated group than in the unvaccinated group at screening. On day 90, fully vaccinated participants had approximately 20% lower geometric mean concentrations of IL-7, IL-8, and vascular endothelial growth factor-A than unvaccinated participants. Cytokine and chemokine concentrations decreased over time in the fully and partly vaccinated groups and unvaccinated group. Log10 cytokine and chemokine concentrations decreased faster among participants in the unvaccinated group than in other groups, but their geometric mean concentrations were generally higher than fully vaccinated participants at 90 days. Days since full vaccination and type of vaccine received were not correlated with cytokine and chemokine concentrations.

INTERPRETATION

Initially and during recovery from symptomatic COVID-19, fully vaccinated participants had lower concentrations of inflammatory markers than unvaccinated participants suggesting vaccination is associated with short-term and long-term reduction in inflammation, which could in part explain the reduced disease severity and mortality in vaccinated individuals.

FUNDING

US Department of Defense, National Institutes of Health, Bloomberg Philanthropies, State of Maryland, Mental Wellness Foundation, Moriah Fund, Octapharma, HealthNetwork Foundation, and the Shear Family Foundation.

Transfusion reactions associated with COVID-19 convalescent plasma in outpatient clinical trials

BACKGROUND

COVID-19 convalescent plasma (CCP) is an important therapeutic option for outpatients at high risk of hospitalization from SARS-CoV-2 infection. We assessed the safety of outpatient CCP transfusions administered during clinical trials.

STUDY DESIGN AND METHODS

We analyzed data pertaining to transfusion-related reactions from two randomized controlled trials in the U.S. that evaluated the efficacy of CCP versus control plasma in various ambulatory settings. Multivariable logistic regression was used to assess whether CCP was associated with transfusion reactions, after adjusting for potential confounders.

RESULTS

The combined study reported 79/1351 (5.9%) adverse events during the transfusion visit, with the majority 62/1351 (4.6%) characterized by mild, allergic-type findings of urticaria, and/or pruritus consistent with minor allergic transfusion reactions; the other reported events were attributed to the patients' underlying disease, COVID-19, or vasovagal in nature. We found no difference in the likelihood of allergic transfusion reactions between those receiving CCP versus control plasma (adjusted odds ratio [AOR], 0.75; 95% CI, 0.43-1.31). Risk of urticaria and/or pruritus increased with a pre-existing diagnosis of asthma (AOR, 2.33; 95% CI, 1.16-4.67). We did not observe any CCP-attributed antibody disease enhancement in participants with COVID-19 or increased risk of infection. There were no life-threatening severe transfusion reactions and no patients required hospitalization related to transfusion-associated complications.

DISCUSSION

Outpatient plasma administration was safely performed for nearly 1400 participants. CCP is a safe therapeutic option for outpatients at risk of hospitalization from COVID-19.

Coronavirus Disease 2019 Convalescent Plasma Outpatient Therapy to Prevent Outpatient Hospitalization: A Meta-Analysis of Individual Participant Data From 5 Randomized Trials

BACKGROUND

Outpatient monoclonal antibodies are no longer effective and antiviral treatments for coronavirus disease 2019 (COVID-19) disease remain largely unavailable in many countries worldwide. Although treatment with COVID-19 convalescent plasma (CCP) is promising, clinical trials among outpatients have shown mixed results.

METHODS

We conducted an individual participant data meta-analysis from outpatient trials to assess the overall risk reduction for all-cause hospitalizations by day 28 in transfused participants. Relevant trials were identified by searching Medline, Embase, medRxiv, World Health Organization COVID-19 Research Database, Cochrane Library, and Web of Science from January 2020 to September 2022.

RESULTS

Five included studies from 4 countries enrolled and transfused 2620 adult patients. Comorbidities were present in 1795 (69%). The virus neutralizing antibody dilutional titer levels ranged from 8 to 14 580 in diverse assays. One hundred sixty of 1315 (12.2%) control patients were hospitalized, versus 111 of 1305 (8.5%) CCP-treated patients, yielding a 3.7% (95% confidence interval [CI], 1.3%-6.0%; P = .001) absolute risk reduction and 30.1% relative risk reduction for all-cause hospitalization. The hospitalization reduction was greatest in those with both early transfusion and high titer with a 7.6% absolute risk reduction (95% CI, 4.0%-11.1%; P = .0001) accompanied by at 51.4% relative risk reduction. No significant reduction in hospitalization was seen with treatment >5 days after symptom onset or in those receiving CCP with antibody titers below the median titer.

CONCLUSIONS

Among outpatients with COVID-19, treatment with CCP reduced the rate of all-cause hospitalization and may be most effective when given within 5 days of symptom onset and when antibody titer is higher.

A novel simulation model for tube thoracostomy

Objective

Tube thoracostomy is a life-saving procedure that must be performed competently and expeditiously by emergency care providers. The primary objective of this project was to develop a simple, easily-reproducible, and realistic simulation model for tube thoracostomy placement by learners of emergency medicine.

Methods

This chest tube simulator utilizes two slabs of pork ribs with associated intercostal muscle and fascial planes to aid learners in identifying anatomic landmarks, palpating intercostal spaces, and performing blunt dissection in a manner that approximates human anatomy. Holes are cut on both sides of a 1.8-bushel capacity rectangular plastic clothing hamper, and rib slabs are secured to the hamper with zip ties or metal wire. A bed pillow with plastic cover is then placed inside of the plastic hamper to simulate lung tissue. The rib-hamper complex is then wrapped with cellophane or elastic compression bandages to further anchor the rib slabs and simulate skin and subcutaneous tissues.

Results

The initial cost of our thoracostomy model is approximately $50, much less than the $1,000-$3,000 cost for a commercial model. Although the hamper and pillow can be reused an indefinite number of times, the other components of our model must be replaced occasionally. Assuming a lifespan of 1,000 uses, our model costs approximately $1.78 per attempt, compared to $4.00 per attempt with the cheapest commercial mannequin system. In fact, assuming a longer useful lifespan for the mannequin does not substantially improve this comparison (e.g. $3.10 versus $1.77 per attempt for a 10,000 attempt lifespan for the commercial mannequin), largely due to the higher cost of commercial replacement skin pads when compared to the components consumed in our model with each attempt.

Conclusions

We describe a porcine thoracostomy model that simulates the look and feel of human ribs for purposes of tube thoracostomy training, although it could also be used for thoracentesis and thoracotomy simulation. This model is relatively cheap (costing around $50) and easy to produce within a few minutes utilizing commonly-available materials. Further study is needed to determine whether an inexpensive model like ours provides the same educational value as more expensive commercial mannequin models.

Current Updates in Rectal Infusion of Fluids and Medications

Purpose of Review

Rectal infusion is a feasible alternative for the immediate administration of medication and fluids when intravenous access is delayed, contraindicated, or unnecessary. Advances in medical device technology have made rectal infusion more practical and easier for medical care providers, and more comfortable for patients. This paper briefly reviews the history of therapeutic rectal infusion, including recent improvements in technology and the existing evidence for the use of this technique.

Recent Findings

While ultrasound-guided peripheral intravenous (PIV) access techniques and other alternatives to landmark-based PIV catheter insertion have recently improved the ability of providers to overcome challenges related to difficult vascular access (DVA), these challenges are increasingly affecting patient outcomes, emergency department throughput, and the cost of medical care. In recent years, waves of parenteral drug, fluid, and supply shortages have affected hospitals. Concurrently, advances in rectal infusion technology have made rectal infusion easier, more comfortable, and more cost-effective than many parenteral options.

Summary

The infusion of resuscitative fluids and medications via the rectal route has previously fallen out of favor due to concurrent improvements in IV access devices. However, this technique demonstrates the potential for a reemergence considering the current challenges facing healthcare providers and systems. Improvements in rectal infusion devices, coupled with an aging population, increased incidence of DVA, shortages in parenteral drugs, fluids, supplies and skilled staff, and the need for care improvements in the post-acute setting have contributed to a greater need for easy, safe and effective alternatives to IV infusion.

Early Treatment, Inflammation and Post-COVID Conditions

Background

Post-COVID conditions (PCC) are common and have significant morbidity. Risk factors for PCC include advancing age, female sex, obesity, and diabetes mellitus. Little is known about early treatment, inflammation, and PCC.

Methods

Among 883 individuals with confirmed SARS-CoV-2 infection participating in a randomized trial of CCP vs. control plasma with available biospecimens and symptom data, the association between early COVID treatment, cytokine levels and PCC was evaluated. Cytokine and chemokine levels were assessed at baseline, day 14 and day 90 using a multiplexed sandwich immuosassay (Mesoscale Discovery). Presence of any self-reported PCC symptoms was assessed at day 90. Associations between COVID treatment, cytokine levels and PCC were examined using multivariate logistic regression models.

Results

One-third of the 882 participants had day 90 PCC symptoms, with fatigue (14.5%) and loss of smell (14.5%) being most common. Cytokine levels decreased from baseline to day 90. In a multivariable analysis including diabetes, body mass index, race, and vaccine status, female sex (adjusted odds ratio[AOR]=2.70[1.93-3.81]), older age (AOR=1.32[1.17-1.50]), and elevated baseline levels of IL-6 (AOR=1.59[1.02-2.47]) were associated with development of PCC.There was a trend for decreased PCC in those with early CCP treatment (≤5 days after symptom onset) compared to late CCP treatment.

Conclusion

Increased IL-6 levels were associated with the development of PCC and there was a trend for decreased PCC with early CCP treatment in this predominately unvaccinated population. Future treatment studies should evaluate the effect of early treatment and anti-IL-6 therapies on PCC development.

Transfusing Convalescent Plasma as Post-Exposure Prophylaxis Against Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection: A Double-Blinded, Phase 2 Randomized, Controlled Trial

BACKGROUND

The efficacy of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) convalescent plasma (CCP) for preventing infection in exposed, uninfected individuals is unknown. CCP might prevent infection when administered before symptoms or laboratory evidence of infection.

METHODS

This double-blinded, phase 2 randomized, controlled trial (RCT) compared the efficacy and safety of prophylactic high titer (≥1:320 by Euroimmun ELISA) CCP with standard plasma. Asymptomatic participants aged ≥18 years with close contact exposure to a person with confirmed coronavirus disease 2019 (COVID-19) in the previous 120 hours and negative SARS-CoV-2 test within 24 hours before transfusion were eligible. The primary outcome was new SARS-CoV-2 infection.

RESULTS

In total, 180 participants were enrolled; 87 were assigned to CCP and 93 to control plasma, and 170 transfused at 19 sites across the United States from June 2020 to March 2021. Two were excluded for screening SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) positivity. Of the remaining 168 participants, 12/81 (14.8%) CCP and 13/87 (14.9%) control recipients developed SARS-CoV-2 infection; 6 (7.4%) CCP and 7 (8%) control recipients developed COVID-19 (infection with symptoms). There were no COVID-19-related hospitalizations in CCP and 2 in control recipients. Efficacy by restricted mean infection free time (RMIFT) by 28 days for all SARS-CoV-2 infections (25.3 vs 25.2 days; P = .49) and COVID-19 (26.3 vs 25.9 days; P = .35) was similar for both groups.

CONCLUSIONS

Administration of high-titer CCP as post-exposure prophylaxis, although appearing safe, did not prevent SARS-CoV-2 infection.

CLINICAL TRIALS REGISTRATION

NCT04323800.

The Effect of a Flipped Classroom Learning Model Versus Traditional Lecture Model on Resident's Knowledge Acquisition for Atraumatic Back Pain in the Emergency Department

Objective

The effectiveness of lecture-based (LB) formats for residency education has recently been challenged as the gold standard. Studies suggest a flipped classroom (FC) lecture improves resident satisfaction, but evidence that showing improved knowledge acquisition is lacking. To determine whether the flipped classroom model improves knowledge acquisition compared to traditional LB model.

Methods

Emergency medicine resident physicians at 2 academic programs were included in December 2019; at Sinai-Grace Hospital, a traditional lecture was the teaching method and at Detroit Receiving Hospital, FC was utilized. Residents completed prelecture and postlecture content tests. The primary outcome was change in test results (pretest to post-test). A noninferiority design comparing the changes between intervention and control groups was utilized (1-sided t-test, noninferiority margin of -0.5; 1-sided alpha = 0.05).

Results

Results were available for 31 residents (17 controls and 14 interventions) out of 83 enrolled. There were 14 postgraduate year 1 (PGY-1), 9 PGY-2, and 8 PGY-3 residents. The mean difference in score was +0.71 (SD 1.38) and +0.77 (SD 1.48) for the FC and LB groups, respectively. This resulted in a mean difference between groups of -0.05 (lower bound of the upper 95% confidence interval -0.93 and therefore crossing the noninferiority margin of -0.05; P = .20).

Conclusions

This study of resident education at 2 training programs was unable to demonstrate noninferiority of an FC format compared to standard lecture. Surprisingly, there was little improvement in test results after both teaching formats. Larger studies are needed to power results.

COVID-19 Convalescent Plasma Outpatient Therapy to Prevent Outpatient Hospitalization: A Meta-analysis of Individual Participant Data From Five Randomized Trials

Background

Monoclonal antibody and antiviral treatments for COVID-19 disease remain largely unavailable worldwide, and existing monoclonal antibodies may be less active against circulating omicron variants. Although treatment with COVID-19 convalescent plasma (CCP) is promising, randomized clinical trials (RCTs) among outpatients have shown mixed results.

Methods

We conducted an individual participant data meta-analysis from all outpatient CCP RCTs to assess the overall risk reduction for all-cause hospitalizations by day 28 in all participants who had transfusion initiated. Relevant trials were identified by searching MEDLINE, Embase, MedRxiv, WHO, Cochrane Library, and Web of Science from January 2020 to September 2022.

Results

Five included studies from four countries enrolled and transfused 2,620 adult patients. Comorbidities were present in 1,795 (69%). The anti-Spike or virus neutralizing antibody titer range across all trials was broad. 160 (12.2%) of 1315 control patients were hospitalized, versus 111 (8.5%) of 1305 CCP-treated patients, yielding a 3.7% (95%CI: 1.3%-6.0%; p=.001) ARR and 30.1% RRR for all-cause hospitalization. The effect size was greatest in those with both early transfusion and high titer with a 7.6% ARR (95%CI: 4.0%-11.1%; p=.0001) accompanied by at 51.4% RRR. No significant reduction in hospitalization was seen with treatment > 5 days after symptom onset or in those receiving CCP with antibody titers below the median titer.

Conclusions

Among outpatients with COVID-19, treatment with CCP reduced the rate of all-cause hospitalization. CCP may be most effective when given within 5 days of symptom onset and when antibody titer is higher.

Key Points

While the outpatient COVID-19 randomized controlled trial meta-analysis indicated heterogeneity in participant risk factors and convalescent plasma, the combined CCP efficacy for reducing hospitalization was significant, improving with transfusion within 5 days of symptom onset and high antibody neutralization levels.

The Effect of Missing Data on the Measurement of Cardiac Arrest Outcomes According to Race

INTRODUCTION

High-quality data are important to understanding racial differences in outcome following out of hospital cardiac arrest (OHCA). Previous studies have shown differences in OHCA outcomes according to both race and socioeconomic status. EMS reporting of data on race is often incomplete. We aim to determine the effect of missing data on the determination of racial differences in outcomes for OHCA patients.

METHODS

We performed a secondary analysis of a data set developed by probabilistically linking the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) and the Michigan Inpatient Database (MIDB). Adult OHCA patients (age >18) who survived to hospital admission between 2014 and 2017 were included. Both datasets recorded patient race and ethnicity with CARES using a single race/ethnicity variable. Patients were categorized as White, Black, other, or missing and only a single choice was allowed. Due to the small number of Hispanic patients and the combined race/ethnicity variable, these patients were excluded. The outcomes of interest were survival to hospital discharge and survival to discharge with Cerebral Performance Category 1 or 2 (good outcome). Outcomes were stratified according to EMS- or hospital-documented race.

RESULTS

We included 3,756 matched patients, after excluding 34 Hispanic patients from analysis. Documentation of patient race was missing in 892 (22.1%) of CARES and 212 (5.6%) of MIDB patients. When both datasets documented Black or White race, agreement in race documentation was excellent (κ=0.83). White patients were more likely to have good outcomes than Black in both the CARES (27.3% vs 14.8%) and MIDB (26.9% vs 16.1%) databases (both p < 0.001), but were not more likely to survive (30.8% vs 27.3% p = 0.22; 30.3% vs 28.1%, p = 0.07). Moreover, we found no significant difference in outcome measures based on race documentation for White vs Black patients (good outcome [27.3 vs 26.9% (MIDB)] and [16.1% vs 14.8% (CARES)] respectively and survival [30.8% vs 30.3% (MIDB)] and [27.3 vs 28.1% (CARES)] respectively).

CONCLUSION

Despite higher rates of missing EMS documentation, we identified statistically similar rates in OHCA outcome measures between databases. Further work is needed to determine the true effect of missing documentation of race on OHCA outcome measures.

Convalescent plasma with a high level of virus-specific antibody effectively neutralizes SARS-CoV-2 variants of concern

The ongoing evolution of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants severely limits available effective monoclonal antibody therapies. Effective drugs are also supply limited. COVID-19 convalescent plasma (CCP) qualified for high antibody levels effectively reduces immunocompetent outpatient hospitalization. The Food and Drug Administration currently allows outpatient CCP for the immunosuppressed. Viral-specific antibody levels in CCP can range 10- to 100-fold between donors, unlike the uniform viral-specific monoclonal antibody dosing. Limited data are available on the efficacy of polyclonal CCP to neutralize variants. We examined 108 pre-δ/pre-ο donor units obtained before March 2021, 20 post-δ COVID-19/postvaccination units, and 1 pre-δ/pre-ο hyperimmunoglobulin preparation for variant-specific virus (vaccine-related isolate [WA-1], δ, and ο) neutralization correlated to Euroimmun S1 immunoglobulin G antibody levels. We observed a two- to fourfold and 20- to 40-fold drop in virus neutralization from SARS-CoV-2 WA-1 to δ or ο, respectively. CCP antibody levels in the upper 10% of the 108 donations as well as 100% of the post-δ COVID-19/postvaccination units and the hyperimmunoglobulin effectively neutralized all 3 variants. High-titer CCP neutralizes SARS-CoV-2 variants despite no previous donor exposure to the variants.

Early Outpatient Treatment for Covid-19 with Convalescent Plasma

BACKGROUND

Polyclonal convalescent plasma may be obtained from donors who have recovered from coronavirus disease 2019 (Covid-19). The efficacy of this plasma in preventing serious complications in outpatients with recent-onset Covid-19 is uncertain.

METHODS

In this multicenter, double-blind, randomized, controlled trial, we evaluated the efficacy and safety of Covid-19 convalescent plasma, as compared with control plasma, in symptomatic adults (≥18 years of age) who had tested positive for severe acute respiratory syndrome coronavirus 2, regardless of their risk factors for disease progression or vaccination status. Participants were enrolled within 8 days after symptom onset and received a transfusion within 1 day after randomization. The primary outcome was Covid-19-related hospitalization within 28 days after transfusion.

RESULTS

Participants were enrolled from June 3, 2020, through October 1, 2021. A total of 1225 participants underwent randomization, and 1181 received a transfusion. In the prespecified modified intention-to-treat analysis that included only participants who received a transfusion, the primary outcome occurred in 17 of 592 participants (2.9%) who received convalescent plasma and 37 of 589 participants (6.3%) who received control plasma (absolute risk reduction, 3.4 percentage points; 95% confidence interval, 1.0 to 5.8; P = 0.005), which corresponded to a relative risk reduction of 54%. Evidence of efficacy in vaccinated participants cannot be inferred from these data because 53 of the 54 participants with Covid-19 who were hospitalized were unvaccinated and 1 participant was partially vaccinated. A total of 16 grade 3 or 4 adverse events (7 in the convalescent-plasma group and 9 in the control-plasma group) occurred in participants who were not hospitalized.

CONCLUSIONS

In participants with Covid-19, most of whom were unvaccinated, the administration of convalescent plasma within 9 days after the onset of symptoms reduced the risk of disease progression leading to hospitalization. (Funded by the Department of Defense and others; CSSC-004 ClinicalTrials.gov number, NCT04373460.).

How do I implement an outpatient program for the administration of convalescent plasma for COVID-19?

Convalescent plasma, collected from donors who have recovered from a pathogen of interest, has been used to treat infectious diseases, particularly in times of outbreak, when alternative therapies were unavailable. The COVID-19 pandemic revived interest in the use of convalescent plasma. Large observational studies and clinical trials that were executed during the pandemic provided insight into how to use convalescent plasma, whereby high levels of antibodies against the pathogen of interest and administration early within the time course of the disease are critical for optimal therapeutic effect. Several studies have shown outpatient administration of COVID-19 convalescent plasma (CCP) to be both safe and effective, preventing clinical progression in patients when administered within the first week of COVID-19. The United States Food and Drug Administration expanded its emergency use authorization (EUA) to allow for the administration of CCP in an outpatient setting in December 2021, at least for immunocompromised patients or those on immunosuppressive therapy. Outpatient transfusion of CCP and infusion of monoclonal antibody therapies for a highly transmissible infectious disease introduces nuanced challenges related to infection prevention. Drawing on our experiences with the clinical and research use of CCP, we describe the logistical considerations and workflow spanning procurement of qualified products, infrastructure, staffing, transfusion, and associated management of adverse events. The purpose of this description is to facilitate the efforts of others intent on establishing outpatient transfusion programs for CCP and other antibody-based therapies.

High Viral Specific Antibody Convalescent Plasma Effectively Neutralizes SARS-CoV-2 Variants of Concern

The ongoing evolution of SARS-Co-V2 variants to omicron severely limits available effective monoclonal antibody therapies. Effective drugs are also supply limited. Covid-19 convalescent plasma (CCP) qualified for high antibody levels effectively reduces immunocompetent outpatient hospitalization. The FDA currently allows outpatient CCP for the immunosuppressed. Viral specific antibody levels in CCP can range ten-to hundred-fold between donors unlike the uniform viral specific monoclonal antibody dosing. Limited data are available on the efficacy of polyclonal CCP to neutralize variants. We examined 108 pre-delta/pre-omicron donor units obtained before March 2021, 20 post-delta COVID-19/post-vaccination units and one pre-delta/pre-omicron hyperimmunoglobulin preparation for variant specific virus (vaccine-related isolate (WA-1), delta and omicron) neutralization correlated to Euroimmun S1 IgG antibody levels. We observed a 2-to 4-fold and 20-to 40-fold drop in virus neutralization from SARS-CoV-2 WA-1 to delta or omicron, respectively. CCP antibody levels in the upper 10% of the 108 donations as well as 100% of the post-delta COVID-19/post-vaccination units and the hyperimmunoglobulin effectively neutralized all three variants. High-titer CCP neutralizes SARS-CoV-2 variants despite no previous donor exposure to the variants.

Key points

All of the post-delta COVID-19/post vaccination convalescent plasma effectively neutralizes the omicron and delta variants.High-titer CCP and hyperimmunoglobulin neutralizes SARS-CoV-2 variants despite no previous donor exposure to the variants.

Evolution of prescribing practices and outcomes in the COVID-19 pandemic in metropolitan areas

INTRODUCTION

We wanted to characterize the evolution of the COVID-19 pandemic in a typical metropolitan area.

METHODS

Data were extracted from the Detroit COVID-19 Consortium database for hospitalized COVID-19 patients treated in Southeast Michigan over the 12-month period from March 2020 to February 2021. Demographic and outcomes data were compared to CDC data.

RESULTS

A total of 4,775 patients were enrolled during the study period. We divided the pandemic into three phases: Phase-1 (Spring Surge); Phase-2 (Summer Lull); and Phase-3 (Fall Spike). Changes in hydroxychloroquine, remdesivir, corticosteroid, antibiotic and anticoagulant use closely followed publication of landmark studies. Mortality in critically-ill patients decreased significantly from Phase-1 to Phase-3 (60.3% vs. 47.9%, Chisq p=0.0110). Monthly mortality of all hospitalized patients ranged between 14.8% - 21.5% during Phase-1 and 9.7 to 13.4% during Phase 3 (NS).

DISCUSSION

The COVID-19 pandemic presented in three unique phases in Southeast Michigan. Medical systems rapidly modified treatment plans, often preceding CDC and NIH recommendations. Despite improved treatment regimens, intubation rates and mortality for hospitalized patients remained elevated.

CONCLUSION

Preventive measures aimed at reducing hospitalizations for COVID-19 should be emphasized.

Imaging Utilization Patterns and Injury Characteristics Associated with Electric Standing Scooters in a Major Urban Area

BACKGROUND

The recent proliferation of electric standing scooters in major urban areas of the United States has been accompanied by injuries of varying severity and nature, representing a growing public health concern.

OBJECTIVE

Our aim was to characterize imaging utilization patterns for injuries associated with electric scooter (e-scooter) use, including their initial emergency department (ED) management.

METHODS

We conducted a retrospective review of the electronic medical record for all patients presenting to affiliated EDs for e-scooter-related injuries between July 2018 and April 2020. Demographics, date and time of presentation, imaging study type, resultant injury, and procedural details were recorded.

RESULTS

Ninety-seven patients were included; mean age was 27.6 years. Of these, 55 patients (57%) had injuries identified on imaging and 40% of all imaging studies were positive. Most identified injuries (61%) were musculoskeletal, with a small number of neurological (2%) and genitourinary (1%) injuries. The highest prevalence of presentations occurred in August; most patients (72%) presented between 3 pm and 1 am and granular peaks were between 12 am and 1 am and 5 pm and 6 pm.

CONCLUSIONS

Patients presenting with e-scooter injuries have a high likelihood of injury to the radial head, nasal bone, and malleoli. Emergency physicians should be especially vigilant for injuries in these areas at presentation. Visceral injuries are uncommon but may be severe enough to warrant surgery.

Randomized Controlled Trial of Early Outpatient COVID-19 Treatment with High-Titer Convalescent Plasma

BACKGROUND

The efficacy of polyclonal high titer convalescent plasma to prevent serious complications of COVID-19 in outpatients with recent onset of illness is uncertain.

METHODS

This multicenter, double-blind randomized controlled trial compared the efficacy and safety of SARS-CoV-2 high titer convalescent plasma to placebo control plasma in symptomatic adults ≥18 years positive for SARS-CoV-2 regardless of risk factors for disease progression or vaccine status. Participants with symptom onset within 8 days were enrolled, then transfused within the subsequent day. The measured primary outcome was COVID-19-related hospitalization within 28 days of plasma transfusion. The enrollment period was June 3, 2020 to October 1, 2021.

RESULTS

A total of 1225 participants were randomized and 1181 transfused. In the pre-specified modified intention-to-treat analysis that excluded those not transfused, the primary endpoint occurred in 37 of 589 (6.3%) who received placebo control plasma and in 17 of 592 (2.9%) participants who received convalescent plasma (relative risk, 0.46; one-sided 95% upper bound confidence interval 0.733; P=0.004) corresponding to a 54% risk reduction. Examination with a model adjusting for covariates related to the outcome did not change the conclusions.

CONCLUSION

Early administration of high titer SARS-CoV-2 convalescent plasma reduced outpatient hospitalizations by more than 50%. High titer convalescent plasma is an effective early outpatient COVID-19 treatment with the advantages of low cost, wide availability, and rapid resilience to variant emergence from viral genetic drift in the face of a changing pandemic.

Trial Registration

ClinicalTrials.gov number, NCT04373460.

Randomized controlled trial transfusing convalescent plasma as post-exposure prophylaxis against SARS-CoV-2 infection

BACKGROUND

The efficacy of SARS-CoV-2 convalescent plasma (CCP) for preventing infection in exposed, uninfected individuals is unknown. We hypothesized that CCP might prevent infection when administered before symptoms or laboratory evidence of infection.

METHODS

This double-blinded, phase 2 randomized, controlled trial (RCT) compared the efficacy and safety of prophylactic high titer (≥1:320) CCP with standard plasma. Asymptomatic participants aged ≥18 years with close contact exposure to a person with confirmed COVID-19 in the previous 120 hours and negative SARS-CoV-2 test within 24 hours before transfusion were eligible. The primary outcome was development of SARS-CoV-2 infection.

RESULTS

180 participants were enrolled; 87 were assigned to CCP and 93 to control plasma, and 170 transfused at 19 sites across the United States from June 2020 to March 2021. Two were excluded for SARS-CoV-2 RT-PCR positivity at screening. Of the remaining 168 participants, 12/81 (14.8%) CCP and 13/87 (14.9%) control recipients developed SARS-CoV-2 infection; 6 (7.4%) CCP and 7 (8%) control recipients developed COVID-19 (infection with symptoms). There were no COVID-19-related hospitalizations in CCP and 2 in control recipients. There were 28 adverse events in CCP and 58 in control recipients. Efficacy by restricted mean infection free time (RMIFT) by 28 days for all SARS-CoV-2 infections (25.3 vs. 25.2 days; p=0.49) and COVID-19 (26.3 vs. 25.9 days; p=0.35) were similar for both groups.

CONCLUSION

In this trial, which enrolled persons with recent exposure to a person with confirmed COVID-19, high titer CCP as post-exposure prophylaxis appeared safe, but did not prevent SARS-CoV-2 infection.

TRIAL REGISTRATION

Clinicaltrial.gov number NCT04323800 .

Prehospital Tibial Intraosseous Drug Administration is Associated with Reduced Survival Following Out of Hospital Cardiac Arrest: A study for the CARES Surveillance Group

BACKGROUND

Recent reports have questioned the efficacy of intraosseous (IO) drug administration for out-of-hospital cardiac arrest (OHCA) resuscitation. Our aim was to determine whether prehospital administration of resuscitative medications via the IO route was associated with lower rates of return of spontaneous circulation (ROSC) and survival to hospital discharge than peripheral intravenous (IV) infusion in the setting of OHCA.

METHODS

We obtained data on all OHCA patients receiving prehospital IV or IO drug administration from the three most populous counties in Michigan over three years. Data was from the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) database. The association between route of drug administration and outcomes was tested using a matched propensity score analysis.

RESULTS

From a total of 10,626 OHCA patients, 6869 received parenteral drugs during their prehospital resuscitation (37.8% by IO) and were included in analysis. Unadjusted outcomes were lower in patients with IO vs. IV access: 18.3% vs. 23.8% for ROSC (p < 0.001), 3.2% vs. 7.6% for survival to hospital discharge (p < 0.001), and 2.0% vs. 5.8% for favorable neurological function (p < 0.001). After adjustment, IO route remained associated with lower odds of sustained ROSC (OR 0.72, 95% CI 0.63-0.81, p < 0.001), hospital survival (OR 0.48, 95% CI 0.37-0.62, p < 0.001), and favorable neurological outcomes (OR 0.42, 95% CI 0.30-0.57, p < 0.001).

CONCLUSION

In this cohort of OHCA patients, the use of prehospital IO drug administration was associated with unfavorable clinical outcomes.

Hospital length of stay, do not resuscitate orders, and survival for post-cardiac arrest patients in Michigan: A study for the CARES Surveillance Group

OBJECTIVE

Current guidelines recommend deferring prognostic decisions for at least 72 h following admission after Out of Hospital cardiac arrest (OHCA). Most non-survivors experience withdrawal of life sustaining therapy (WLST), and early WLST may adversely impact survival. We sought to characterize the hospital length of stay (LOS) and timing of Do Not Resuscitate (DNR) orders (as surrogates for WLST), to assess their relationship to survival following cardiac arrest.

DESIGN

We performed a retrospective cohort study of probabilistically linked cardiac arrest registries (Cardiac Arrest Registry to Enhance Survival (CARES) and Michigan Inpatient Database (MIDB) from 2014 to 2017.

PATIENTS

Adult (≥18 years) patients admitted following OHCA were included. We considered LOS ≤ 3 days (short LOS) and written DNR order with LOS ≤ 3 days (Early DNR) as indicators of early WLST. Our primary outcome was survival to hospital discharge. We utilized multilevel logistic regression clustered by hospital to examine associations of these variables, patient characteristics and survival to hospital discharge.

MEASUREMENT AND MAIN RESULTS

We included 3644 patients from 38 hospitals with >30 patients. Patients mean age was 62.4 years and were predominately male (59.3%). LOS ≤ 3 days (OR_adj = 0.11) and early DNR (OR_adj = 0.02) were inversely associated with survival to discharge. There was a non-significant inverse association between hospital rates of LOS ≤ 3 days and survival (p = 0.11), and Early DNR and survival (p = 0.83). In the multilevel model, using median odd ratios to assess variation in LOS ≤ 3 days and survival, patient characteristics contributed more to variability in surviival than between-hospital variation. However, between-hospital variation contributed more to variability than patient characteristics in the provision of early DNR orders.

CONCLUSIONS

We observed that LOS ≤ 3 days for post-arrest patients was negatively-associated with survival, with both patient characteristics and between-hospital variation associated with outcomes. However, between-hospital variation appears to be more highly-associated with provision of early DNR orders than patient characteristics. Further work is needed to assess variation in early DNR orders and their impact on patient survival.

Benign Presentation Following Massive Deutetrabenazine Overdose

Deutetrabenazine (DTBZ) (Austedo®) is a novel vesicular monoamine transporter 2 (VMAT2) inhibitor, which acts by blocking dopamine release and other monoamines from neuronal vesicles. Although this drug is considered the first-line treatment for tardive dyskinesia (TD), VMAT2 inhibition has also been shown to improve patients’ symptoms with Huntington’s disease-induced chorea. We present the case of a 59-year-old woman with a history of TD, who presented to the emergency department following massive DTBZ ingestion. The relative paucity of other overdose symptoms further supports the manufacturer’s claims of a low side effect profile for this drug in overdose. Although DTBZ demonstrates an excellent safety profile, emergency physicians should be aware of the potential side effect of DTBZ overdose, in addition to other known side effects of this novel drug.

Resident Research in Emergency Medicine: An Introduction and Primer

Training in research methodology represents an important aspect of emergency medicine (EM) resident education, but best methods for design, implementation, and dissemination of resident research remain elusive. Here we describe recommendations and best practices from the existing literature on EM resident research, including helpful tips on how to best implement a resident research program.

Data supporting the use of end-tidal carbon dioxide (ETCO2) measurement to guide management of cardiac arrest: A systematic review

The data presented in this article are related to the research article, "The Use of End-Tidal Carbon Dioxide (ETCO2) Measurement to Guide Management of Cardiac Arrest: A Systematic Review" [1]. This article is a systematic review and meta-analysis of existing data on the subject of whether any level of end-tidal carbon dioxide (ETCO2) measured during cardiopulmonary resuscitation (CPR) correlates with return of spontaneous circulation (ROSC) or survival in adult patients experiencing cardiac arrest in any setting. These data are made publicly available to enable critical or extended analyses.

Blood pressure variability as an indicator of sepsis severity in adult emergency department patients

STUDY OBJECTIVE

Quantify the correlation between blood pressure variability (BPV) and markers of illness severity: serum lactate (LAC) or Sequential Organ Failure Assessment (SOFA) scores.

METHODS

We performed a secondary analysis of data from a prospective, observational study evaluating fluid resuscitation on adult, septic, ED patients. Vital signs and fluid infusion volumes were recorded every 15min during the 3h following ED arrival. BPV was assessed via average real variability (ARV): the average of the absolute differences between consecutive BP measurements. ARV was calculated for the time periods before and after 3 fluid infusion milestones: 10-, 20-, and 30-mL/kg total body weight (TBW). Spearman's rho correlation coefficient analysis was utilized. A p-value<0.05 was considered statistically significant.

RESULTS

Forty patients were included. Mean fluid infusion was 33.7mL/kg TBW (SD 22.1). All patients received fluid infusion≥10mL/kg TBW, 25 patients received fluid infusion>20mL/kg TBW, and 16 patients received fluid infusion>30mL/kg TBW. Mean initial LAC was 4.0mmol/L (SD 3.2). Mean repeat LAC was 3.1mmol/L (SD 3.2), obtained an average of 6.6h (SD 5.3) later. Mean SOFA score was 7.0 (SD 4.4). BPV correlated with both follow-up LAC (r=0.564; p=0.023) and SOFA score (r=0.544; p=0.024) among the cohort that received a fluid infusion>20-mL/kg TBW.

CONCLUSION

With the finding of a positive correlation between BPV and markers of illness severity (LAC and SOFA scores), this pilot study introduces BPV analysis as a real-time, non-invasive tool for continuous sepsis monitoring in the ED.

Intraosseous vascular access: A review

Intraosseous cannulation is an increasingly common means of achieving vascular access for the administration of fluids and medications during the emergent resuscitation of both paediatric and adult patients. Improved tools and techniques for intraosseous vascular access have recently been developed, enabling the healthcare provider to choose from a wide range of devices and insertion sites. Despite its increasing popularity within the adult population, and decades of use in the paediatric population, questions remain regarding the safety and efficacy of intraosseous infusion. Although various potential complications of intraosseous cannulation have been theorized, few serious complications have been reported. This article aims to provide a review of the current literature on intraosseous vascular access, including discussion on the various intraosseous devices currently available in the market, the advantages and disadvantages of intraosseous access compared to conventional vascular access methods, complications of intraosseous cannulation and current recommendations on the use of this approach.

Intraosseous injection of iodinated computed tomography contrast agent in an adult blunt trauma patient

Intraosseous venous access can be life-saving in trauma patients when traditional methods for obtaining venous access are difficult or impossible. Because many blunt trauma patients require expeditious evaluation by computed tomography (CT) scans with intravenous contrast, it is important to evaluate whether intraosseous catheters can be used for administering CT contrast agents in lieu of waiting until secure peripheral intravenous or central venous catheter access can be established. Previous case reports have demonstrated that tibial intraosseous catheters can be used to safely administer CT contrast in the pediatric patient population. Here we report a case in which intraosseous access was the only means of administering intravenous contrast agent in an adult blunt trauma patient. An intraosseous catheter was placed in the standard manner in the right proximal humerus. Intravenous contrast agent was administered through the intraosseous catheter, using the standard blunt trauma protocol at our institution. CT scans were evaluated by a staff radiologist and assessed for the adequacy of diagnosis for blunt traumatic injuries. CT scans of the thorax, abdomen, and pelvis were considered to be adequate for diagnostic purposes and subjectively equivalent to those of studies using traditional central venous access. The intraosseous catheter was discontinued the following day. No complications of intraosseous placement or of contrast administration were identified. Intraosseous catheterization appears to be a feasible and effective alternative to traditional methods of venous access in the administration of iodinated contrast agents for CT evaluation in adult blunt trauma patients. Further study is warranted.

Medical errors education for students of surgery: a pilot study revealing the need for action

BACKGROUND

Medical errors training is an important yet often overlooked aspect of surgical education. In response to a perceived deficiency in medical errors training at our institution, we implemented an educational session on medical errors concepts for the benefit of rotating medical students.

MATERIALS AND METHODS

Medical students completed the same 12-question test before and after the 90-minute educational session. Pretest and posttest scores were compared for evidence of enhanced understanding. No personal identifiers were used, and students were provided unlimited time to complete the tests. Six groups of medical students (who ranged from 5 to 8 students per session) completed the educational session. All sessions were moderated by the same surgical resident and attending surgeon, who used a standard slide presentation. Test scores were analyzed with SPSS statistical software (version 14.0; SPSS Inc., Cary, NC), which employed the paired samples t-test (alpha = 0.05).

RESULTS

Test scores increased significantly from a pretest mean of 27.3% correct (3.28 of 12 possible, SD = 1.57) to a mean posttest score of 70.1% (8.41, SD = 1.52) (p < 0.001).

CONCLUSIONS

This retrospective pilot study demonstrated that a brief educational intervention led to statistically significant improved performance on a general understanding of medical errors. The study also revealed the dearth of baseline knowledge in our participating medical students on the subject. We believe that these results underscore the need for action in providing improved and ongoing education in medical errors concepts to enhance medical student awareness and proactive handling of medical errors.

The cost effectiveness of laparoscopic versus open gastric bypass surgery

BACKGROUND

Over the last decade, laparoscopic gastric bypass (LGBP) has been proven to be a safe and well-tolerated approach to the Roux-en-Y gastric bypass, despite its increased cost when compared to the open approach (OGBP). This increased expense has led many to question whether LGBP is a cost effective alternative to OGBP. The aim of this study is to determine which approach is most cost effective, considering costs associated with the operation itself, perioperative complications, and income lost during convalescence.

METHODS

A PubMed search of the National Library of Medicine online journal database was conducted. Studies that met predetermined criteria for selection were included in the analyses of patient demographics, perioperative complications, length of hospital stay, excess weight loss, and time to recovery. Data on 6,425 OGBP and 5,867 LGBP patients were used to compare the outcomes associated with each approach.

RESULTS

Significant differences were found in the perioperative complication profiles, time to recovery, and overall expense of the two approaches. OGBP was associated with an increased incidence of major perioperative complications, especially extraintestinal complications, and greater perioperative mortality. LGBP was associated with shorter hospital stays, increased incidence of intestinal complications, and a 2.25% incidence of conversion to OGBP. Patient demographics and percent excess weight loss (%EWL) at 3 years follow-up were found to be similar with both OGBP and LGBP.

CONCLUSION

LGBP is a cost effective alternative to OGBP for surgical weight loss. Despite the increased cost of LGBP, patients suffer fewer expensive and lifethreatening perioperative complications.

Interposition of a jejunal segment as an alternative one-stage operation for acute left colon obstruction

PURPOSE

Much debate surrounds the one-stage surgical management of acute left colon obstruction. Many surgeons are still reluctant to perform primary anastomosis in unprepared bowel fearing the risk of anastomotic dehiscence. Although intraoperative lavage and subtotal colectomy have recently proved effective for preventing fecal loading, both of these procedures have drawbacks and the search for additional alternative surgical procedures continues. We conducted an experimental study to examine a new one-stage operation, consisting of the interposition of a jejunal segment to the resection site of the colon, to manage acute left colon obstruction.

METHODS

The colons of 20 domestic pigs were obstructed, and 2 days later, segmental resection and either primary colo-colonic anastomosis or interposition of a jejunal segment was performed. Autopsies were done 6 weeks after the operations and the anastomotic regions were subjected to bursting pressure analysis.

RESULTS

The operating time was longer in the interposition group at 49 +/- 14 vs 38 +/- 12 min ( P < 0.01). There was no mortality or clinical signs of anastomotic dehiscence in either group. A perianastomotic abscess was detected on autopsy in one animal from the primary colo-colonic anastomosis group. The bursting pressures of the jejunocolic anastomoses were significantly higher ( P < 0.001) than those of the primary colo-colonic anastomoses.

CONCLUSIONS

These experimental results suggest that jejunal interposition may be a feasible alternative to primary colonic anastomosis to create intestinal continuity after resection for acute obstruction of the left colon.

Interleukin-6 induces thermotolerance in cultured Caco-2 cells independent of the heat shock response

In recent studies, induction of the heat shock response increased IL-6 production in gut mucosa in vivo and in cultured Caco-2 cells in vitro. The heat shock response is associated with increased survival of cells exposed to otherwise lethal hyperthermia, so called thermotolerance, but the role of IL-6 in the induction of thermotolerance is not known. We tested the hypothesis that treatment of cultured Caco-2 cells with IL-6 results in the development of thermotolerance. Cells were treated with human recombinant IL-6 for 1h followed by 3 h recovery in cytokine-free medium whereafter cells were exposed to heat stress (48 degrees C for 2 h). In untreated cells, the heat stress resulted in an approximately 80% cell death. In cells treated with IL-6, cell viability after heat stress was significantly improved and was doubled at an IL-6 concentration of 20 ng/ml. Treatment of the cells with other cytokines (IL-4, IL-10, IL-1beta, or TNFalpha) did not induce thermotolerance, suggesting that the effect of IL-6 may be specific for this cytokine. The induction of thermotolerance by IL-6 was blocked by an IL-6 receptor antibody, suggesting that the development of thermotolerance was receptor-mediated. Treatment of cells with IL-6 did not induce an heat shock response as suggested by unaltered heat shock protein 70 and 90 levels and unaffected heat shock factor DNA binding activity. In addition, the IL-6-induced thermotolerance was not inhibited by quercetin. The present study provides the first evidence of IL-6-induced thermotolerance and suggests that this effect of IL-6 is independent of the heat shock response.

Interleukin-10 activates the transcription factor C/EBP and the interleukin-6 gene promoter in human intestinal epithelial cells

BACKGROUND

Interleukin (IL)-6 is produced by enterocytes in response to sepsis and after treatment with IL-1beta. The IL-6 promoter contains binding sites for multiple transcription factors, including nuclear factor-kappaB and C/EBP. The anti-inflammatory cytokine IL-10 downregulates nuclear factor-kappaB activity, but its effects on C/EBP activation and IL-6 production in the enterocyte are not known.

METHODS

Caco-2 cells were treated with IL-1beta, IL-10, or a combination of the cytokines. C/EBP DNA binding activity was determined by electrophoretic mobility shift assay and IL-6 levels by enzyme-linked immunosorbent assay. IL-6 promoter activation was assessed by luciferase assay.

RESULTS

IL-10 treatment of cultured Caco-2 cells resulted in increased C/EBP DNA binding activity. Supershift analysis revealed upregulated DNA binding activity of C/EBP-beta but not C/EBP-delta. To examine if the increased DNA binding reflected gene activation, cells were transfected with a wild-type IL-6 promoter luciferase construct or with a mutated C/EBP binding site. IL-10 potentiated IL-1 beta-induced IL-6 promoter activity. Replacing the wild-type promoter with the promoter containing a mutated C/EBP DNA binding sequence blocked the effect of IL-10. When cells were treated with 0.5 ng/mL of IL-1 beta for 24 hours, IL-6 production increased, and this response to IL-1 beta was potentiated several-fold by IL-10.

CONCLUSIONS

IL-10 may activate the IL-6 gene in stimulated enterocytes by upregulating the expression and activity of C/EBP.