Intensive Care Admissions: Predicting Palliative Care Needs in the First 24 Hours

PURPOSE: The purpose of this retrospective analysis was to determine the proportion of intensive care admissions that required palliative care services during the same admission assessed by an investigator-developed palliative care screening tool. This study also analyzed the screening tool for the number of criteria producing the highest sensitivity and specificity for a palliative care consult occurring during the same hospital stay. METHODS: Retrospective data collection and analysis were performed by randomly selecting 110 patients records from a report obtained through the electronic health record, Epic. The sample was drawn from patients admitted to a medicine intensive care unit (2A) and neurology/neurosurgical intensive care unit (2B) at Baptist Health in Lexington Kentucky, a community-based tertiary care hospital, between April and August 2017. RESULTS: Screening tool items capturing more than one trigger point produced the highest sensitivity and specificity under a ROC curve (.7/.422) resulting in a palliative care consultation during the same hospital stay. The utilization of palliative consultations when criteria on the tool was triggered was low at 20/79 (25.3%) patients. A palliative consult, when indicated, was carried out a median of 5.5 days after the initial admission to the intensive care unit. Missed opportunities for palliative consults were discovered with 8 out of the remaining 59 patients who warranted, but did not receive a consult, died since the reviewed ICU admission. CONCLUSION: Palliative care consultations within the first twenty-four hours of an intensive care admission are needed but carried out at a low rate. The investigator-developed screening tool was effective in identifying the need for palliative care consultation. Palliative care screening tools need further validity testing as no standardize tool currently exists. Customizing tools for individual facility use is recommended and additional criteria should be considered

EFFECTS OF PITUITARY PARS INTERMEDIA DYSFUNCTION AND PRASCEND\u3csup\u3e®\u3c/sup\u3e TREATMENT ON ENDOCRINE AND IMMUNE FUNCTION IN SENIOR HORSES

Pituitary pars intermedia dysfunction (PPID) is one of the most common endocrine diseases affecting senior horses. PPID causes abnormally high concentrations of adrenocorticotropic hormone (ACTH) in the plasma and a very distinct, long, shaggy haircoat (hypertrichosis). At present, the recommended treatment for PPID is daily oral administration of pergolide mesylate. Due to the increased ACTH levels associated with PPID, it is commonly thought that these horses are immunosuppressed and at increased risk of opportunistic infections, although current research in this area is sparse. Additionally, it is not well-understood how treatment with Prascend® (pergolide tablets) affects endocrine measures other than ACTH and if it also impacts the immune response. To better understand how PPID influences endocrine and immune function in the horse, Non-PPID horses (n=10), untreated PPID horses (n=9), and PRASCEND-treated PPID horses (n=9) were followed over 15 months. Endocrine measures assessed included basal ACTH, ACTH responses to thyrotropin-releasing hormone (TRH) stimulation tests, basal insulin, insulin responses to oral sugar tests (OST), total cortisol, and free cortisol. Systemic immune function measures included basal and stimulated whole blood and peripheral blood mononuclear cell (PBMCs) cytokine and receptor expression, plasma myeloperoxidase levels, and complete blood counts. Localized immune function measures within the lung included cytokine and receptor expression after stimulation of cells obtained via bronchoalveolar lavage (BAL), myeloperoxidase levels in BAL fluid, and BAL fluid cytology. We hypothesized that PPID would affect immune function, but that any alterations would be corrected by treatment with PRASCEND. Results for the endocrine analyses showed that basal ACTH was reduced in the PRASCEND-treated horses to the levels of the Non-PPID horses, but ACTH in response to TRH stimulation was only reduced in the PRASCEND-treated horses at non-fall timepoints. PPID did not affect basal insulin, insulin responses to OSTs, total cortisol, or free cortisol, and PRASCEND treatment did not appear to have an impact on these measures either. These results suggest that PPID and hyperinsulinemia/insulin dysregulation are distinct endocrine conditions, and that the excess ACTH in horses with PPID is inactive, as it is unable to stimulate a normal cortisol response. In the immune function analyses, PPID horses had decreased expression of interferon gamma (IFNγ) from PBMCs stimulated with Rhodococcus equi and Escherichia coli and increased transforming growth factor beta (TGFβ) expression from the E. coli-stimulated PBMCs. TGFβ was also increased in PPID horses in the unstimulated whole blood samples. These results suggest that PPID horses are unable to mount an appropriate Th1 response, and that the regulatory subset of T-lymphocytes may be contributing to this decreased Th1 response. Results for the localized immune function analyses may indicate altered Th2 responses within the lung of PPID horses, although these results were severely limited by the sample size available for analyses. PRASCEND did not appear to affect immune function as measured in this study. In summary, PRASCEND successfully reduces basal ACTH in PPID horses and remains the best choice for veterinarians in monitoring dosage and response to PRASCEND treatment. Insulin, total cortisol, and free cortisol were not affected by PPID status or PRASCEND treatment in this study. Immune function was altered in horses with PPID, and it is likely that these horses are indeed at increased risk of opportunistic infection. PRASCEND treatment did not correct the differences in immune function in this study. Additional research is needed to further understand which mechanisms are driving the alterations in immune function for horses with PPID

The Effect of Exercise, Prewrap, and Athletic Tape on the Maximal Active and Passive Ankle Resistance to Ankle Inversion

This investigation explored alternatives to the null hy potheses that maximal active and passive resistance to inversion developed by a near-maximally inverted and weightbearing ankle is not altered by 1) the use of prophylactic adhesive athletic tape, 2) the use of non- adhesive prewrap (underwrap), or 3) 40 minutes of vigorous exercise. Ten healthy men and 10 healthy women (mean age, 25 ± 3 years) with no recent ankle injuries underwent testing to determine maximal ankle resistance to inversion under unipedal, weightbearing conditions. Tests were performed with and without the support of athletic tape, and before and after 40 min utes of exercise. Half the testing sessions were per formed with prewrap under the tape. At 15° of inver sion, without any external ankle support, healthy young men and women could maximally resist a mean (SD) inversion moment of 52.9 (6.4) N-m and 28.3 (5.8) N-m, respectively. Although use of ankle tape provided a 10% increase in maximal resistance to inversion moments, this increase diminished to insignificant lev els after 40 minutes of vigorous exercise. Use of pre wrap improved maximal resistance to inversion by more than 10%.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/66568/2/10.1177_036354659702500203.pd

Measurement of the pubic portion of the levator ani muscle in women with unilateral defects in 3â D models from MR images

ObjectiveDevelop a method to quantify the crossâ sectional area of the pubic portion of the levator ani muscle, validate the method in women with unilateral muscle defects, and report preliminary findings in those women.MethodMultiâ planar proton density magnetic resonance images of 12 women with a unilateral defect in the pubic portion of their levator ani were selected from a larger study of levator ani muscle anatomy in women with and without genital prolapse. Threeâ dimensional bilateral models of the levator ani were reconstructed (using 3â D Slicer, version 2.1b1) and divided into iliococcygeal and pubic portions. Muscle crossâ sectional areas were calculated at four equally spaced locations perpendicular to a line drawn from the pubic origin to the visceral insertion using the Iâ DEAS® computer modeling software.ResultsThe crossâ sectional area of the muscle on the side with the defect was smaller than the normal side at all the four locations. The average bilateral difference was up to 81% at location 1 (nearest pubic origin). Almost all of the volume difference (13.7%, P = 0.0004) was attributable to a reduction in the pubic portion (24.6%, P < 0.0001), not the iliococcygeal portion (P = 0.64), of the muscle.ConclusionsA method was developed to quantify crossâ sectional area of the pubic portion of the levator ani perpendicular to the intact muscle direction. Significant bilateral crossâ sectional area differences were found between intact and defective muscles in women with a unilateral defect.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135155/1/ijgo234.pd

Association of index finger palpatory assessment of pubovisceral muscle body integrity with MRIâ documented tear

AimsPubovisceral (PV) muscle tears are associated with pelvic floor disorders. The goal of this study was to determine whether index finger palpatory assessment of PV muscle body integrity through the lateral vaginal wall is a reliable indicator of PV muscle tear severity diagnosed by magnetic resonance imaging (MRI).MethodsWe studied 85 women, 7 weeks after vaginal birth. All had at least one risk factor for obstetricâ related PV muscle tear. The ordinal outcome measure of MRIâ documented PV muscle tear was defined as: none, less than 50% unilateral tear, 50% or greater unilateral tear or less than 50% bilateral tear, and 50% or greater bilateral tear. PV muscle body integrity by palpatory assessment was scored on a matrix, with each side scored independently and classified as PV muscle body â presentâ (assuredly felt), â equivocalâ (not sure if felt), or â absentâ (assuredly not felt). Proportional odds models were constructed to estimate the relationship between PV muscle body integrity palpatory assessment and MRIâ documented PV muscle tears.ResultsThirtyâ five percent of study participants exhibited varying degrees of MRIâ documented PV muscle tears. Using palpatory assessment, we identified â PV muscle body present bilaterallyâ in 20%, â equivocal unilaterally or present contralaterallyâ in 8%, â equivocal or absent unilaterallyâ or â equivocal bilaterallyâ in 62%, and â absent bilaterallyâ in 9%. The odds ratio for estimating MRI results from palpatory assessment was 3.62 (95% confidence intervalâ =â 1.70â 7.73, Pâ =â 0.001).ConclusionsA rapid and inexpensive palpatory assessment in the clinic was highly associated with the risk of MRIâ documented PV muscle tear and is a useful component of a clinical assessment.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/149233/1/nau23967_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149233/2/nau23967.pd

Cigarette smoke extract exacerbates hyperpermeability of cerebral endothelial cells after oxygen glucose deprivation and reoxygenation

Cigarette smoking is a risk factor for stroke and is linked to stroke severity. Previous studies have shown that cigarette smoke extract (CSE) triggers endothelial dysfunction in vitro by initiating oxidative stress and/or an inflammatory response. In addition, cerebral endothelial dysfunction (particularly at the level of the blood-brain barrier [BBB]) contributes to stroke pathogenesis. Therefore, we hypothesized that cigarette smoking may influence stroke, at least in part, by exacerbating ischaemia-induced BBB disruption. To test this, we examined the effect of CSE on the permeability of cerebral endothelial cells exposed to oxygen glucose deprivation and reoxygenation (OGD + RO). We found that the loss of BBB integrity following ischaemic/reperfusion-like conditions was significantly worsened by CSE. Despite this being associated with increased mRNA expression of Nox catalytic subunits, reactive oxygen species (ROS) levels were however markedly lower. Furthermore, this occurred in association with elevated expression of antioxidant enzymes (SOD1, SOD2, and Gpx-1), suggesting an antioxidant defence response. Lastly, we found that CSE significantly upregulated mRNA expression of cytokines (IL-6 and TGF-β). Collectively, these results show that acute exposure to CSE worsens BBB disruption caused by OGD + RO, however, this is not linked to elevated ROS levels but may involve inflammatory mechanisms

New perspectives on ACL injury: On the role of repetitive subâ maximal knee loading in causing ACL fatigue failure

In this paper, we review a series of studies that we initiated to examine mechanisms of anterior cruciate ligament (ACL) injury in the hope that these injuries, and their sequelae, can be better prevented. First, using the earliest in vitro model of a simulated singleâ leg jump landing or pivot cut with realistic knee loading rates and transâ knee muscle forces, we identified the worstâ case dynamic knee loading that causes the greatest peak ACL strain: Combined knee compression, flexion, and internal tibial rotation. We also identified morphologic factors that help explain individual susceptibility to ACL injury. Second, using the above knee loading, we introduced a possible paradigm shift in ACL research by demonstrating that the human ACL can fail by a sudden rupture in response to repeated subâ maximal knee loading. If that load is repeated often enough over a short time interval, the failure tended to occur proximally, as observed clinically. Third, we emphasize the value of a physical exam of the hip by demonstrating how limited internal axial rotation at the hip both increases the susceptibility to ACL injury in professional athletes, and also increases peak ACL strain during simulated pivot landings, thereby further increasing the risk of ACL fatigue failure. When training atâ risk athletes, particularly females with their smaller ACL crossâ sections, rationing the number and intensity of worstâ case knee loading cycles, such that ligament degradation is within the ACL’s ability to remodel, should decrease the risk for ACL rupture due to ligament fatigue failure.© 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:2059â 2068, 2016.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135588/1/jor23441.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/135588/2/jor23441_am.pd

Mechanisms of continence and surgical cure in female and male SUI: Surgical research initiatives

Aims To report the conclusions of the Think Tank on mechanisms of incontinence and surgical cure in female and male SUI: surgical research initiatives during the ICI‐RS meeting in 2010. Methods The sub‐group considered five areas for future research in stress urinary incontinence (SUI); (i) epidemiology and public health efforts in SUI, (ii) the basic sciences examining the physiology and pathophysiology of the continence mechanism, (iii) diagnostic techniques and clinical assessment of SUI, (iv) the future of treatment and surgical cure, and (v) the separate issue of male SUI. Results Roadblocks to progress were identified for each of the five directions. Conclusions Future research directions are suggested for each of these areas. Neurourol. Urodynam. 30:704–707, 2011. © 2011 Wiley‐Liss, Inc.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/87181/1/21139_ftp.pd

Which Lower Limb Frontal Plane Sensory and Motor Functions Predict Gait Speed and Efficiency on Uneven Surfaces in Older Persons With Diabetic Neuropathy?

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/146965/1/pmr2726.pd

Antibody responses to nasopharyngeal carriage of Streptococcus pneumoniae in adults: A longitudinal household study

Background. Natural immunity to Streptococcus pneumoniae is thought to be induced by exposure to S. pneumoniae or cross-reactive antigens. No longitudinal studies of carriage of and immune responses to S. pneumoniae have been conducted using sophisticated immunological laboratory techniques.Methods. We enrolled 121 families with young children into this study. Nasopharyngeal (NP) swabs were collected monthly for 10 months from all family members and were cultured in a standard fashion. Cultured S. pneumoniae isolates were serotyped. At the beginning (month 0) and end (month 10) of the study, venous blood was collected from family members 118 years old. Serotype-specific antipolysaccharide immunoglobulin G (IgG) and functional antibody and antibodies to pneumolysin, pneumococcal surface protein A (PspA), and pneumococcal surface antigen A (PsaA) were measured in paired serum samples.Results. Levels of anticapsular IgG increased significantly after carriage of serotypes 9V, 14, 18C, 19F, and 23F by an individual or family member. For serotype 14, a higher level of anticapsular IgG at the beginning of the study was associated with reduced odds of carriage (P = .0006). There was a small (similar to 20%) but significant increase in titers of antibodies to PsaA and pneumolysin but no change in titers of antibody to PspA.Conclusions. Adults respond to NP carriage by mounting anticapsular and weak antiprotein antibody responses, and naturally induced anticapsular IgG can prevent carriage