The emergency department evaluation and outcomes of elderly fallers

BACKGROUND: Approximately one-third of community dwelling elderly people (age ≥65 years) falls each year contributing to over 2 million elderly emergency department (ED) visits for falls annually. The cost of care for fatal falls by elderly patients in the US was $179 million in 2000, and was$19 billion for non-fatal falls. The risk of falling increases with various risk factors including advancing age. Despite the frequency and costs associated with elderly falls, it is not clear what evaluation elderly fallers receive in the ED, after the ED, and the outcomes of the care provided. OBJECTIVES: We sought to examine the ED and post-ED workup of elderly fallers, and to compare this evaluation to that recommended by published ED fall evaluation and treatment guidelines. We also examined the disposition of these patients and the rate of adverse events which occurred within 1 year of discharge. METHODS: This study was a retrospective chart review of elderly ED fall patients from one urban teaching hospital with >90,000 visits per year. Patients aged ≥65 years who had an ED visit in 2012 with fall related ICD-9 codes E880-886, E888 and who had been seen by a primary care physician (PCP) within our hospital network during the past 3 years were included. We excluded patients who were transferred to our hospital and subsequent visits related to the original fall. We randomly selected 350 eligible patients for chart review. We adapted our data collection instrument from published fall evaluation recommendations including the American Geriatric Society. Categorical data were presented as percentages and continuous data were recorded as mean with standard deviation (SD) if normally distributed or medians with inter-quartile ranges (IQR) if non-normally distributed. RESULTS: A random sample of 450 charts were taken, 100 were subsequently excluded for erroneous identification. The average age was 80 (SD±9) years; 124 (35%) were male, with an average Charlson comorbidity index of 7.6 (SD 2.9). In terms of history, 251/350 (72%) took 5 or more medications, 144/350 (41%) had their visual acuity checked in the past 12 months, and 34/350 (10%) had fallen two or more times in the past 3 months. In the physical exam, only 43/350 (12%) had orthostatics done. 168/350 (48%) patients had their extremity strength recorded, of these 16/168 (10%) had decreased muscle strength. Only 128/350 (37%) patients had their gait recorded, of which 108/128 (84%) were noted to have an abnormal gait. Basic chemistry laboratory tests and hematology were sent on 199/350 (57%) of patients in the ED. X-rays were taken of 275/350 (79%) patients, and CTs were taken of 184/350 (53%) patients in the ED. 277/350 (79%) patients were discharged to their place of preadmission residence from the ED, ED observation unit, or hospital while 70/350 (20%) were discharged to a skilled rehab facility, all after being admitted to the hospital. 196/350 (56%) patients returned to the ED for any reason within 1 year of discharge, averaging 2.4 ± 1.9 visits. 161/350 (46%) patients were hospitalized within 1 year after discharge, averaging 2 ± 1.4 hospital admissions. 23 (7%) of patients died within 1 year after discharge. CONCLUSION: The comprehensive evaluation of falls for well-established risk factors and causes appears to be poor in this academic medical center ED. While results may not be generalizable to other EDs, the results suggest that standardized evaluation and treatment guidelines are needed

Revisits within 48 Hours to a Thai Emergency Department

Objective. Emergency department (ED) revisits are a common ED quality measure. This study was undertaken to ascertain the contributing factors of revisits within 48 hours to a Thai ED and to explore physician-related, illness-related, and patient-related factors behind those revisits. Methods. This study was a chart review from one tertiary care, urban Thai hospital from October 1, 2009, to September 31, 2010. We identified patients who returned to the ED within 48 hours for the same or related complaints after their initial discharge. Three physicians classified revisit as physician-related, illness-related, and patient-related factors. Results. Our study included 172 ED patients' charts. 86/172 (50%) were male and the mean age was 38 ± 5.6 (SD) years. The ED revisits contributing factors were physician-related factors [86/172 (5

Revisits within 48 Hours to a Thai Emergency Department

Objective. Emergency department (ED) revisits are a common ED quality measure. This study was undertaken to ascertain the contributing factors of revisits within 48 hours to a Thai ED and to explore physician-related, illness-related, and patient-related factors behind those revisits. Methods. This study was a chart review from one tertiary care, urban Thai hospital from October 1, 2009, to September 31, 2010. We identified patients who returned to the ED within 48 hours for the same or related complaints after their initial discharge. Three physicians classified revisit as physician-related, illness-related, and patient-related factors. Results. Our study included 172 ED patients’ charts. 86/172 (50%) were male and the mean age was 38 ± 5.6 (SD) years. The ED revisits contributing factors were physician-related factors [86/172 (50.0%)], illness-related factors [61/172 (35.5%)], and patient-related factor [25/172 (14.5%)], respectively. Among revisits classified as physician-related factors, 40/86 (46.5%) revisits were due to misdiagnosis and 36/86 (41.9%) were due to suboptimal management. Abdominal pain [27/86 (31.4%)] was the majority of physician-related chief complaints, followed by fever [16/86 (18.6%)] and dyspnea [15/86 (17.4%)]. Conclusion. Misdiagnosis and suboptimal management contributed to half of the 48-hour repeat ED visits in this Thai hospital

Bending rules for animal propulsion

Animal propulsors such as wings and fins bend during motion and these bending patterns are believed to contribute to the high efficiency of animal movements compared with those of man-made designs. However, efforts to implement flexible designs have been met with contradictory performance results. Consequently, there is no clear understanding of the role played by propulsor flexibility or, more fundamentally, how flexible propulsors should be designed for optimal performance. Here we demonstrate that during steady-state motion by a wide range of animals, from fruit flies to humpback whales, operating in either air or water, natural propulsors bend in similar ways within a highly predictable range of characteristic motions. By providing empirical design criteria derived from natural propulsors that have convergently arrived at a limited design space, these results provide a new framework from which to understand and design flexible propulsors

Inhibition of FOXP3 by stapled alpha-helical peptides dampens regulatory T cell function

Despite continuing advances in the development of novel cellular-, antibody-, and chemotherapeutic-based strategies to enhance immune reactivity, the presence of regulatory T cells (Treg cells) remains a complicating factor for their clinical efficacy. To overcome dosing limitations and off-target effects from antibody-based Treg cell deletional strategies or small molecule drugging, we investigated the ability of hydrocarbon stapled alpha-helical (SAH) peptides to target FOXP3, the master transcription factor regulator of Treg cell development, maintenance, and suppressive function. Using the crystal structure of the FOXP3 homodimer as a guide, we developed SAHs in the likeness of a portion of the native FOXP3 antiparallel coiled-coil homodimerization domain (SAH-FOXP3) to block this key FOXP3 protein-protein interaction (PPI) through molecular mimicry. We describe the design, synthesis, and biochemical evaluation of single- and double-stapled SAHs covering the entire coiled-coil expanse. We show that lead SAH-FOXP3s bind FOXP3, are cell permeable and nontoxic to T cells, induce dose-dependent transcript and protein level alterations of FOXP3 target genes, impede Treg cell function, and lead to Treg cell gene expression changes in vivo consistent with FOXP3 dysfunction. These results demonstrate a proof of concept for rationally designed FOXP3-directed peptide therapeutics that could be used as approaches to amplify endogenous immune responsiveness

Measure twice and cut once: Comparing endoscopy and 3D cloacagram for the common channel and urethral measurements in patients with cloacal malformations

© 2019 Elsevier Inc. Introduction: Precise and accurate measurement of the common channel and urethra is a critical determinant prior to the repair of cloacal malformations. Endoscopy and 3D reconstruction cloacagram are two common modalities utilized to help plan the surgical approach, however the consistency between these methods is unknown. Methods: Common channel and urethral lengths obtained by endoscopy and 3D cloacagram of cloaca patients at six pediatric colorectal centers were compared. Data are given as mean (range). Results: 72 patients were included in the study. Common channel measurements determined by 3D cloacagram and endoscopy were equal in 7 cases (10%). Endoscopic measurements of the common channel were longer than 3D cloacagram in 20 (28%) cases and shorter in the remaining 44 (62%) cases. The absolute difference between measurements of the common channel was 7.2 mm (0–2.4 cm). Urethral measurements by both modalities were equal in 8 cases (12%). Endoscopic measurement of the urethra was longer than that by 3D cloacagram in 20 (31%) patients and shorter in 37 (57%) of cases. The absolute difference between measurements of the urethra was 5.1 mm (0–2.0 cm). The reconstruction (e.g. TUM or urogenital separation) that would be performed according to measurements determined by 3D cloacagram and endoscopic measurements differed in 13/62 (21%) patients with each structure identified and common channel measurements of \u3e 1 cm. Conclusion: Significant variation exists in the measurements of the common channel and urethra in patients with cloacal malformations as determined by endoscopy and 3D cloacagram. This variation should be considered as these measurements influence the decision to perform either a TUM or urogenital separation. Based on these findings, 3D cloacagram should be performed in all patients prior to cloaca repair to prevent mischaracterization of the malformation. Level of evidence: Level IV

Single-use duodenoscope for ERCP performed by endoscopists with a range of experience in procedures of variable complexity

Background and Aims: Expert endoscopists previously reported ERCP outcomes for the first commercialized single-use duodenoscope. We aimed to document usability of this device by endoscopists with different levels of ERCP experience.  Methods: Fourteen “expert” (>2000 lifetime ERCPs) and 5 “less-expert” endoscopists performed consecutive ERCPs in patients without altered pancreaticobiliary anatomy. Outcomes included ERCP completion for the intended indication, rate of crossover to another endoscope, device performance ratings, and serious adverse events.   Results: Two hundred ERCPs including 81 (40.5%) with high complexity (American Society for Gastrointestinal Endoscopy grades 3-4) were performed. Crossover rate (11.3% vs 2.5%, P =.131), ERCP completion rate (regardless of crossovers) (96.3% vs 97.5%, P =.999), median ERCP completion time (25.0 vs 28.5 minutes, P =.130), mean cannulation attempts (2.8 vs 2.8, P =.954), and median overall satisfaction with the single-use duodenoscope (8.0 vs 8.0 [range, 1.0-10.0], P =.840) were similar for expert versus less-expert endoscopists, respectively. The same metrics were similar by procedural complexity except for shorter median completion time for grades 1 to 2 versus grades 3 to 4 (P <.001). Serious adverse events were reported in 13 patients (6.5%).   Conclusions: In consecutive ERCPs including high complexity procedures, endoscopists with varying ERCP experience had good procedural success and reported high device performance ratings. (Clinical trial registration number: NCT04223830.

PyBIDS: Python tools for BIDS datasets

Brain imaging researchers regularly work with large, heterogeneous, high-dimensional datasets. Historically, researchers have dealt with this complexity idiosyncratically, with every lab or individual implementing their own preprocessing and analysis procedures. The resulting lack of field-wide standards has severely limited reproducibility and data sharing and reuse.To address this problem, we and others recently introduced the Brain Imaging Data Standard (BIDS; (Gorgolewski et al., 2016)), a specification meant to standardize the process of representing brain imaging data. BIDS is deliberately designed with adoption in mind; it adheres to a user-focused philosophy that prioritizes common use cases and discourages complexity. By successfully encouraging a large and ever-growing subset of the community to adopt a common standard for naming and organizing files, BIDS has made it much easier for researchers to share, reuse, and process their data (Gorgolewski et al., 2017).The ability to efficiently develop high-quality spec-compliant applications itself depends to a large extent on the availability of good tooling. Because many operations recur widely across diverse contexts—for example, almost every tool designed to work with BIDS datasets involves regular file-filtering operations—there is a strong incentive to develop utility libraries that provide common functionality via a standardized, simple API.PyBIDS is a Python package that makes it easier to work with BIDS datasets. In principle, its scope includes virtually any functionality that is likely to be of general use when working with BIDS datasets (i.e., that is not specific to one narrow context). At present, its core and most widely used module supports simple and flexible querying and manipulation of BIDS datasets. PyBIDS makes it easy for researchers and developers working in Python to search for BIDS files by keywords and/or metadata; to consolidate and retrieve file-associated metadata spread out across multiple levels of a BIDS hierarchy; to construct BIDS-valid path names for new files; and to validate projects against the BIDS specification, among other applications.In addition to this core functionality, PyBIDS also contains an ever-growing set of modules that support additional capabilities meant to keep up with the evolution and expansion of the BIDS specification itself. Currently, PyBIDS includes tools for (1) reading and manipulating data contained in various BIDS-defined files (e.g., physiological recordings, event files, or participant-level variables); (2) constructing design matrices and contrasts that support the new BIDS-StatsModel specification (for machine-readable representation of fMRI statistical models); and (3) automated generation of partial Methods sections for inclusion in publications.PyBIDS can be easily installed on all platforms via pip (pip install pybids), though currently it is not officially supported on Windows. The package has few dependencies outside of standard Python numerical and image analysis libraries (i.e., numpy, scipy, pandas, and NiBabel). The core API is deliberately kept minimalistic: nearly all interactions with PyBIDS functionality occur through a core BIDSLayout object initialized by passing in a path to a BIDS dataset. For most applications, no custom configuration should be required.Although technically still in alpha release, PyBIDS is already being used both as a dependency in dozens of other open-source brain imaging packages –e.g., fMRIPrep (Esteban et al.,2019), MRIQC (Esteban et al., 2017), datalad-neuroimaging (https://github.com/datalad/datalad-neuroimaging), and fitlins (https://github.com/poldracklab/fitlins) – and directly in many researchers’ custom Python workflows. Development is extremely active, with bug fixes and new features continually being added (https://github.com/bids-standard/pybids), and major releases occurring approximately every 6 months. As of this writing, 29 people have contributed code to PyBIDS, and many more have provided feedback and testing. The API is relatively stable, and documentation and testing standards follow established norms for open-source scientific software. We encourage members of the brain imaging community currently working in Python to try using PyBIDS, and welcome new contributions