Brain dynamics reflecting an intra-network brain state is associated with increased posttraumatic stress symptoms in the early aftermath of trauma

This study examines the association between brain dynamic functional network connectivity (dFNC) and current/future posttraumatic stress (PTS) symptom severity, and the impact of sex on this relationship. By analyzing 275 participants' dFNC data obtained ~2 weeks after trauma exposure, we noted that brain dynamics of an inter-network brain state link negatively with current (r=-0.179, pcorrected= 0.021) and future (r=-0.166, pcorrected= 0.029) PTS symptom severity. Also, dynamics of an intra-network brain state correlated with future symptom intensity (r = 0.192, pcorrected = 0.021). We additionally observed that the association between the network dynamics of the inter-network brain state with symptom severity is more pronounced in females (r=-0.244, pcorrected = 0.014). Our findings highlight a potential link between brain network dynamics in the aftermath of trauma with current and future PTSD outcomes, with a stronger protective effect of inter-network brain states against symptom severity in females, underscoring the importance of sex differences.

Characterizing opioid overdose hotspots for place-based overdose prevention and treatment interventions: A geo-spatial analysis of Rhode Island, USA

OBJECTIVE

Examine differences in neighborhood characteristics and services between overdose hotspot and non-hotspot neighborhoods and identify neighborhood-level population factors associated with increased overdose incidence.

METHODS

We conducted a population-based retrospective analysis of Rhode Island, USA residents who had a fatal or non-fatal overdose from 2016 to 2020 using an environmental scan and data from Rhode Island emergency medical services, State Unintentional Drug Overdose Reporting System, and the American Community Survey. We conducted a spatial scan via SaTScan to identify non-fatal and fatal overdose hotspots and compared the characteristics of hotspot and non-hotspot neighborhoods. We identified associations between census block group-level characteristics using a Besag-York-Mollié model specification with a conditional autoregressive spatial random effect.

RESULTS

We identified 7 non-fatal and 3 fatal overdose hotspots in Rhode Island during the study period. Hotspot neighborhoods had higher proportions of Black and Latino/a residents, renter-occupied housing, vacant housing, unemployment, and cost-burdened households. A higher proportion of hotspot neighborhoods had a religious organization, a health center, or a police station. Non-fatal overdose risk increased in a dose responsive manner with increasing proportions of residents living in poverty. There was increased relative risk of non-fatal and fatal overdoses in neighborhoods with crowded housing above the mean (RR 1.19 [95 % CI 1.05, 1.34]; RR 1.21 [95 % CI 1.18, 1.38], respectively).

CONCLUSION

Neighborhoods with increased prevalence of housing instability and poverty are at highest risk of overdose. The high availability of social services in overdose hotspots presents an opportunity to work with established organizations to prevent overdose deaths.

Relationship of hepatitis C risk to hepatitis C test acceptance among adult patients participating in an ED hepatitis C screening programme

BACKGROUND

It is possible that adult ED patients consider their hepatitis C virus (HCV) risk factor history when deciding whether to accept HCV screening. To help address this question, we examined whether self-reporting any HCV risk was more common among ED patients who agreed than who declined HCV screening. Among ED patients who agreed to HCV screening, we also assessed if self-reporting any HCV risk was more common among those whose HCV antibody (Ab) and HCV viral load (VL) test results were positive.

METHODS

This study was conducted among adult patients ≥18 years old participating in a universal, ED-based HCV screening programme in New York City between 22 January 2019 and 9 April 2020. Participants were surveyed about their HCV risk factors. Differences in the frequencies of self-reporting any HCV risk were compared according to HCV screening acceptance and by HCV Ab and VL status.

RESULTS

Of the 4658 ED patients surveyed, 2846 (61%) accepted and 1812 (39%) declined HCV screening. Among these participants, 38% reported at least one HCV risk factor, most commonly injection drug use. Self-reporting any HCV risk was not more common among those who accepted versus declined HCV screening (40% vs 37%, p<0.7) but was more common among those with HCV Ab positive versus negative test results (36% vs 6%, p<0.001) and HCV VL positive versus negative results (95% vs 5%, p<0.001).

CONCLUSION

HCV risk factors were self-reported by more than one-third of ED patients but were not more commonly present among those who accepted HCV screening.

Opioid Analgesic Use After an Acute Pain Visit: Evidence from a Urolithiasis Patient Cohort

Introduction: Urolithiasis causes severe acute pain and is commonly treated with opioid analgesics in the emergency department (ED). We examined opioid analgesic use after episodes of acute pain. Methods: Using data from a longitudinal trial of ED patients with urolithiasis, we constructed multivariable models to estimate the adjusted probability of opioid analgesic use 3, 7, 30, and 90 days after ED discharge. We used multiple imputation to account for missing data and weighting to account for the propensity to be prescribed an opioid analgesic at ED discharge. We used weighted multivariable regression to compare longitudinal opioid analgesic use for those prescribed vs not prescribed an opioid analgesic at discharge, stratified by reported pain at ED discharge. Results: Among 892 adult ED patients with urolithiasis, 79% were prescribed an opioid analgesic at ED discharge. Regardless of reporting pain at ED discharge, those who were prescribed an opioid analgesic were significantly more likely to report using it one, three, and seven days after the visit in weighted multivariable analysis. Among those who were not prescribed an opioid analgesic, an estimated 21% (not reporting pain at ED discharge) and 30% (reporting pain at discharge) reported opioid analgesic use at day three. Among those prescribed an opioid analgesic, 49% (no pain at discharge) and 52% (with pain at discharge) reported using an opioid analgesic at day three. Conclusion: Urolithiasis patients who received an opioid analgesic at ED discharge were more likely to continue using an opioid analgesic than those who did not receive a prescription at the initial visit, despite the time-limited nature of urolithiasis.

Socio-demographic and trauma-related predictors of depression within eight weeks of motor vehicle collision in the AURORA study

BACKGROUND

This is the first report on the association between trauma exposure and depression from the Advancing Understanding of RecOvery afteR traumA(AURORA) multisite longitudinal study of adverse post-traumatic neuropsychiatric sequelae (APNS) among participants seeking emergency department (ED) treatment in the aftermath of a traumatic life experience.

METHODS

We focus on participants presenting at EDs after a motor vehicle collision (MVC), which characterizes most AURORA participants, and examine associations of participant socio-demographics and MVC characteristics with 8-week depression as mediated through peritraumatic symptoms and 2-week depression.

RESULTS

Eight-week depression prevalence was relatively high (27.8%) and associated with several MVC characteristics (being passenger v. driver; injuries to other people). Peritraumatic distress was associated with 2-week but not 8-week depression. Most of these associations held when controlling for peritraumatic symptoms and, to a lesser degree, depressive symptoms at 2-weeks post-trauma.

CONCLUSIONS

These observations, coupled with substantial variation in the relative strength of the mediating pathways across predictors, raises the possibility of diverse and potentially complex underlying biological and psychological processes that remain to be elucidated in more in-depth analyses of the rich and evolving AURORA database to find new targets for intervention and new tools for risk-based stratification following trauma exposure.

Development of a Deep Learning Network to Classify Inferior Vena Cava Collapse to Predict Fluid Responsiveness

OBJECTIVES

To create a deep learning algorithm capable of video classification, using a long short-term memory (LSTM) network, to analyze collapsibility of the inferior vena cava (IVC) to predict fluid responsiveness in critically ill patients.

METHODS

We used a data set of IVC ultrasound (US) videos to train the LSTM network. The data set was created from IVC US videos of spontaneously breathing critically ill patients undergoing intravenous fluid resuscitation as part of 2 prior prospective studies. We randomly selected 90% of the IVC videos to train the LSTM network and 10% of the videos to test the LSTM network's ability to predict fluid responsiveness. Fluid responsiveness was defined as a greater than 10% increase in the cardiac index after a 500-mL fluid bolus, as measured by bioreactance.

RESULTS

We analyzed 211 videos from 175 critically ill patients: 191 to train the LSTM network and 20 to test it. Using standard data augmentation techniques, we increased our sample size from 191 to 3820 videos. Of the 175 patients, 91 (52%) were fluid responders. The LSTM network was able to predict fluid responsiveness moderately well, with an area under the receiver operating characteristic curve of 0.70 (95% confidence interval [CI], 0.43-1.00), a positive likelihood ratio of infinity, and a negative likelihood ratio of 0.3 (95% CI, 0.12-0.77). In comparison, point-of-care US experts using video review offline and manual diameter measurement via software caliper tools achieved an area under the receiver operating characteristic curve of 0.94 (95% CI, 0.83-0.99).

CONCLUSIONS

We demonstrated that an LSTM network can be trained by using videos of IVC US to classify IVC collapse to predict fluid responsiveness. Our LSTM network performed moderately well given the small training cohort but worse than point-of-care US experts. Further training and testing of the LSTM network with a larger data sets is warranted.

Developing an Accident and Emergency HIV Testing Program in Belize City: Recommendations from Key Stakeholders

With the ultimate goal of developing an accident and emergency (A&E) department HIV testing program in Belize City, Belize, we sought input from key stakeholders on program components and potential facilitators and barriers to HIV testing in emergency care. We conducted semistructured interviews among 4 key stakeholder groups at Karl Heusner Memorial Hospital Authority (KHMHA) in Belize City: (1) 20 A&E patients, (2) 5 A&E physicians, (3) 5 A&E nurses, and (4) 5 KHMHA administrators. We performed a qualitative content analysis of the interview transcripts and isolated important themes. Major themes included: (1) Patient selection: patients preferred to test all A&E patients. All other stakeholder groups preferred testing specific patient groups. (2) Training: Specific training should be completed for staff. (3) Confidentiality: integral for testing. (4) Facilitators and barriers: facilitators included respectful relationships, privacy, resources, coordination, and education. Barriers included stigmatization, patient willingness, inadequate resources, privacy, and testing biases.

Variations in Substance Use Prevalence Estimates and Need for Interventions Among Adult Emergency Department Patients Based on Different Screening Strategies Using the ASSIST

Introduction

Among adult emergency department (ED) patients, we sought to examine how estimates of substance use prevalence and the need for interventions can differ, based on the type of screening and assessment strategies employed.

Methods

We estimated the prevalence of substance use and the need for interventions using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in a secondary analysis of data from two cross-sectional studies using random samples of English- or Spanish-speaking 18–64-year-old ED patients. In addition, the test performance characteristics of three simplified screening strategies consisting of selected questions from the ASSIST (lifetime use, past three-month use, and past three-month frequency of use) to identify patients in need of a possible intervention were compared against using the full ASSIST.

Results

Of 6,432 adult ED patients, the median age was 37 years-old, 56.6% were female, and 61.6% were white. Estimated substance use prevalence among this population differed by how it was measured (lifetime use, past three-month use, past three-month frequency of use, or need for interventions). As compared to using the full ASSIST, the predictive value and accuracy to identify patients in need of any intervention was best for a simplified strategy asking about past three-month substance use. A strategy asking about daily/near-daily use was better in identifying patients needing intensive interventions. However, some patients needing interventions were missed when using these simplified strategies.

Conclusion

Substance use prevalence estimates and identification of ED patients needing interventions differ by screening strategies used. EDs should carefully select strategies to identify patients in need of substance use interventions.

Oral cancer awareness in young South-Asian communities in London

OBJECTIVES

First, to evaluate awareness of oral cancer amongst the young South-Asian community in London and identify any aspects of knowledge about oral cancer that are lacking; and, second, to determine whether demographic factors or health-related behaviours are associated with knowledge of oral cancer.

RESEARCH DESIGN

Cross-sectional questionnaire survey.

PARTICIPANTS

South Asians aged 18-44 years attending community centres or places of worship in London.

MAIN OUTCOME MEASURES

Oral cancer awareness; health-related behaviours.

RESULTS

Respondents (n = 201) were mainly male (61%), Indian (77%) and Hindu (35%). Over half (58%; n = 113) had one or more negative health-related behaviours and only 18% had attended a dentist in the previous two years. Chewing paan with betel nut (OR = 4.08, 95% CI = 1.58-10.59, p < 0.01), and time since last visit to a dentist (OR = 4.90, 95% CI = 2.13-11.28, p < 0.01) were independently associated with respondents level of knowledge of mouth cancer; the former positively and the latter negatively.

CONCLUSIONS

The results suggest that young adults in the South Asian Community are exposed to a number of risk factors for oral cancer yet have poor knowledge of the implications of these health-related behaviours, and ways in which oral cancer can be detected earlier. The survey highlighted specific issues for action.

A successful twin pregnancy in a patient with HbE-β-thalassemia in western India

Improvements in medical facilities have helped a large number of clinically severe hemoglobin E (HbE)-β-thalassemia patients reach adulthood. Consequently, there is a new challenge, that of managing women with HbE-β-thalassemia during pregnancy. In particular, they have a high risk of abortion, preterm delivery, intrauterine growth restriction, and thromboembolism. A 27-year-old HbE-β-thalassemia patient on regular transfusion, who was splenectomized and heptatitis C (HCV)-positive, conceived for the first time without any infertility treatment. However, there was incomplete abortion with heavy bleeding at 3 months of gestation, which required bilateral uterine artery angiography. The angiogram showed the left uterine artery to be moderately hypertrophied. This was embolized with 300-500 micron polyvinyl alcohol (PVA) to stop the bleeding. Soon after, she conceived again with a twin pregnancy, and at 33.3 weeks of gestation, there was a normal delivery of twin girls without any postpartum hemorrhage or perineal tear. Both babies were given prematurity care. The mother and children were both normal up till the last follow-up 18 months after delivery, and both the girls are HbE heterozygous. Thorough monitoring of endocrine functions along with proper management of transfusions and iron overload can help in reducing the complications related to pregnancy in these patients.

Neuraxial block, death and serious cardiovascular morbidity in the POISE trial

BACKGROUND

This post hoc analysis aimed to determine whether neuraxial block was associated with a composite of cardiovascular death, non-fatal myocardial infarction (MI) and non-fatal cardiac arrest within 30 days of randomization in POISE trial patients.

METHODS

A total of 8351 non-cardiac surgical patients at high risk of cardiovascular complications were randomized to β-blocker or placebo. Neuraxial block was defined as spinal, lumbar or thoracic epidural anaesthesia. Logistic regression, with weighting using estimated propensity scores, was used to determine the association between neuraxial block and primary and secondary outcomes.

RESULTS

Neuraxial block was associated with an increased risk of the primary outcome [287 (7.3%) vs 229 (5.7%); odds ratio (OR), 1.24; 95% confidence interval (CI), 1.02-1.49; P=0.03] and MI [230 (5.9%) vs 177 (4.4%); OR, 1.32; 95% CI, 1.07-1.64; P=0.009] but not stroke [23 (0.6%) vs 32 (0.8%); OR, 0.76; 95% CI, 0.44-1.33; P=0.34], death [96 (2.5%) vs 111 (2.8%); OR, 0.87; 95% CI, 0.65-1.17; P=0.37] or clinically significant hypotension [522 (13.4%) vs 484 (12.1%); OR, 1.13; 95% CI, 0.99-1.30; P=0.08]. Thoracic epidural with general anaesthesia was associated with a worse primary outcome than general anaesthesia alone [86 (12.1%) vs 119 (5.4%); OR, 2.95; 95% CI, 2.00-4.35; P<0.001].

CONCLUSIONS

In patients at high risk of cardiovascular morbidity, neuraxial block was associated with an increased risk of adverse cardiovascular outcomes, which could be causal or because of residual confounding.

Impact of nursing home residence on hospital epidemiology of meticillin-resistant Staphylococcus aureus: a perspective from Asia

In a Singapore hospital practising meticillin-resistant Staphylococcus aureus (MRSA) admission screening, the relative risk for MRSA colonization for those admitted from nursing homes was 6.89 (95% confidence interval: 5.74-8.26; 41% of 190 vs 6.0% of 14,849). However, the MRSA burden on admission attributable to nursing home residence was low (6.9%). Risk factors independently associated with MRSA colonization in patients admitted from nursing homes were previous hospital admissions, broken skin, prior use of antibiotics and Chinese ethnicity. Low rates of nursing home use means that the overall impact of nursing home residence on MRSA in our hospital is low.

Nomenclature and definitions for emergency department human immunodeficiency virus (HIV) testing: report from the 2007 conference of the National Emergency Department HIV Testing Consortium

Early diagnosis of persons infected with human immunodeficiency virus (HIV) through diagnostic testing and screening is a critical priority for individual and public health. Emergency departments (EDs) have an important role in this effort. As EDs gain experience in HIV testing, it is increasingly apparent that implementing testing is conceptually and operationally complex. A wide variety of HIV testing practice and research models have emerged, each reflecting adaptations to site-specific factors and the needs of local populations. The diversity and complexity inherent in nascent ED HIV testing practice and research are associated with the risk that findings will not be described according to a common lexicon. This article presents a comprehensive set of terms and definitions that can be used to describe ED-based HIV testing programs, developed by consensus opinion from the inaugural meeting of the National ED HIV Testing Consortium. These definitions are designed to facilitate discussion, increase comparability of future reports, and potentially accelerate wider implementation of ED HIV testing.

Outcome of the treatment for sarcoidosis

The clinical characteristics and pathology of sarcoidosis are well defined; however, the optimal therapy for this disorder remains unclear. Although patients respond, acutely, to corticosteroid therapy, it is not clear that these agents ultimately alter the natural history of this disease. These observations and that corticosteroids have significant side effects suggest that only patients who will clearly benefit from corticosteroid therapy should be treated. In a prospective study of patients' with sarcoidosis (n = 98), we limited our use of corticosteroids to those patients who had objective evidence of recent deterioration in lung function or serious extrapulmonary disease. All patients with sarcoidosis fulfilling these criteria were treated with corticosteroids. Patients were tapered off corticosteroids after they were treated for 1 yr. Of the 98 study subjects, 91 had not received therapy for the disease and 7 were on therapy before entry into the study. Of the 91 previously untreated patients, 55 were observed without therapy and 36 were treated with corticosteroids. Of those who were observed off therapy, only eight deteriorated. Of these latter patients, six responded and stabilized with the administration of corticosteroids for treatment of the underlying disease, to antibiotics for an associated bronchiectasis, or to diuretics for treatment for congestive heart failure; two were lost to follow-up. None of these six patients deteriorated while receiving corticosteroids. Of the 36 patients who deteriorated and were treated with corticosteroids, 20 remained stable and 16 improved clinically. Of the 37 patients who were eventually tapered off corticosteroids, five deteriorated and required reinitiation of corticosteroid therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlation between integrated evoked EMG and respiratory function following atracurium administration in unanaesthetized humans

In six healthy volunteers, integrated evoked electromyography (IEEMG) measured in response to ulnar nerve stimulation was correlated with respiratory function-tidal volume (VT), forced vital capacity (FVC), forced expiratory volume in one second (FEV1), maximum negative inspiratory pressure (NIP), hand grip (HG) and head-lift during steady-state infusion of subparalytic doses of atracurium. Studies were carried out at train-of-four T4/T1 = 0.2 and T4/T1 = 0.6. When T4/T1 = 0.2, all subjects had difficulty with swallowing and phonation, none could sustain any head-lift and HG was 26 per cent of control. However, VT was normal, FVC was 80 per cent, FEV1 was 82 per cent, and NIP was 50 per cent of control. AT T4/T1 = 0.6, all assessments of peripheral strength were normal, and all respiratory measurements were not significantly different from control, except for NIP which was 73 per cent of control (P less than 0.05). We conclude that an IEEMG of 0.6, recorded from the hypothenar muscles, in unanaesthetized subjects is consistent with near normal respiratory function.

Endoscopy in the diagnosis of genital tuberculosis

From 1977 to 1986, endoscopy (laparoscopy, cystoscopy and hysteroscopy) was used in the evaluation of women for pelvic tuberculosis. Among 687 cases of diagnostic laparoscopy, pelvic tuberculosis was suspected in 101 (14.7%) from the appearance alone. The appearance was correlated with other criteria for the diagnosis. Definitive evidence was found in 70 cases. All 101 patients were placed on an antibiotic. Seventy-three patients reported for follow-up for more than two years. Of them, six (8.2%) were judged to be cured. Thirty-eight (52.05%) improved as determined by second-look laparoscopy and/or negative histopathology or hysterosalpingographic evidence. Eleven women (15.06%) had an intrauterine pregnancy; nine delivered normally, and two underwent termination of pregnancy for medical reasons. There were three tubal pregnancies (4.1%). In 15 cases (20.5%) the disease remained stationary.

Cardiopulmonary toxicity of adoptive immunotherapy

Adoptive immunotherapy, the administration of interleukin-2 (IL-2) and interleukin-2 activated cells, leads to tumor regression in some patients with advanced cancer. Although this new therapeutic modality offers hope for the future, at present, a multitude of toxicities limit the total dose and duration of therapy. Among the toxic side effects a purported third space or vascular leak syndrome is the most serious. In this review, we detail the evidence for a third space syndrome (peripheral edema, ascites, oliguria, elevated serum creatinine levels) and cardiopulmonary dysfunction (hypotension, respiratory distress, pulmonary edema, hypoxemia) with adoptive immunotherapy in human and animal studies. We conclude that IL-2 administration is associated with increased pulmonary microvascular permeability, infiltration of the lung parenchyma with large esterase negative lymphoid cells, hypoxemia, systemic hypotension, positive fluid balance and, in animals, transient pulmonary hypertension. These abnormalities do not seem to be caused by IL-2 directly; the causes may be mediated by IL-2 activated lymphocytes or other IL-2 activated cellular mediators.