Optimizing outcomes: Impact of palliative care consultation timing in the cardiovascular intensive care unit.

BACKGROUND: ICU patients and their families experience significant stress due to illness severity and prognostic uncertainty, making palliative care (PC) integral for symptom management, family support, and end-of-life care goals. The impact of PC in the Cardiac Intensive Care Unit (CICU) remains unstudied. OBJECTIVE: We explore the impact of early palliative care consultation (PCC) on patient outcomes in the CICU, including mortality, length of stay, and family meeting frequency. METHODS: This retrospective study at MedStar Washington Hospital Center included 209 adult patients admitted to the CICU between December 2021 and June 2022 receiving PCC. We compared outcomes between those receiving early (<72 h) and late (>72 h) PCC, including mortality, length of stay, and family meeting frequency. Statistical analysis included Wilcoxon rank sum tests, Chi-squared tests, Fisher's exact test, and Poisson regression models. RESULTS: The study included 209 patients admitted to the (M age = 68 years, SD = 14; 45 % female; 62 % Black, 30 % White) who received PCC, most (79 %) within 72 h. Early PCC was associated with shorter CICU stays (median, 3 vs. 5.5 days; p = 0.005). Early PCC patients had higher odds of family meetings (IRR=3.59; p < 0.001) and experienced a change in code status sooner (median 1 day vs. 3 days, p < 0.001). Late PCC patients were more likely to undergo tracheostomy (13.6% vs. 2.4 %; p = 0.007), cardioversion (9.1% vs. 1.8 %; p = 0.037), and have PEG tubes placed (13.6% vs. 2.4 %; p = 0.007). CONCLUSIONS: Early PCC in the CICU is associated with shorter CICU stays, fewer procedures, and more frequent family meetings.

Predictors of attrition in a randomized controlled trial of an electronic nicotine delivery system among people interested in cigarette smoking reduction.

BACKGROUND: Mitigating attrition is a key component to reduce selection bias in longitudinal randomized controlled trials (RCTs). Few studies of electronic nicotine delivery systems (ENDS) allow for the examination of long-term retention. This analysis explores the relationship between attrition, baseline measures, and condition assigned for a RCT involving ENDS differing in nicotine delivery over a 24-week intervention period. METHODS: Participants (N = 520) who smoked ≥10 cigarettes per day [CPD] for ≥1 year and reported interest in reducing but not quitting were randomized to 1 of 4 conditions: an ENDS containing 0, 8, or 36 mg/ml liquid nicotine (administered double-blind) or a cigarette-shaped plastic tube. Cox proportional hazards regression models were fit to examine attrition over time and predictors of attrition including baseline characteristics and condition. A stepwise approach was used to determine the final model; alpha was set at 0.05. RESULTS: Attrition did not differ significantly by condition (223/520), and most (69%) were lost-to-follow-up. Only age, education level, and household income were significantly predictive of attrition. For every additional year of age, attrition risk fell by 3%. Holding a bachelor's degree or higher was associated with reduced attrition risk. Those with the lowest income (<$10 K) were more likely to be withdrawn compared to those earning $10 K-39 K, and those with the highest income ($100 K+) were more likely to be withdrawn compared with the latter bracket and those earning $70-99 K. CONCLUSION: ENDS nicotine content did not drive differential attrition in this trial, and targeted retention efforts are needed for specific subgroups. Trial Registration #: NCT02342795.

Presentation and Management of Postpartum Granulation Tissue: A Single-Institution Retrospective Study.

INTRODUCTION: Although the development of postpartum granulation tissue (PPGT) is an expected phase of healing of perineal and vaginal lacerations, the persistence of this tissue can result in delayed wound healing, pain, bleeding, and discharge. There is a paucity of information on the efficacy of the treatments used for pathologic PPGT. The objective of this study was to describe characteristics associated with the development of PPGT and the treatment methods currently used for management. METHODS: This was a retrospective cohort study of 140 patients diagnosed with PPGT within one year of birth from 2012 through 2022 within a single health care system. Patients were identified by International Classification of Diseases and Current Procedural Terminology codes. Demographics, birth characteristics, symptoms, and treatment information were obtained and assessed in frequencies and means. Treatments were compared with 95% CIs and P values. Time to resolution was assessed by the number of weeks and the number of visits. RESULTS: It was the first vaginal birth for 129 (92%) patients in the study cohort. The majority (84.3%) of patients presented with pain. Almost half of all patients (45%) were diagnosed after 6 weeks postpartum. 30.0% of patients were initially treated conservatively. 76.4% of patients were treated with silver nitrate, and 33.6% had an excisional procedure. Successful conservative management had the lowest average number of visits to resolution with 1.39 visits (95% CI, 1.15-1.69), followed by silver nitrate alone with 1.95 visits (95% CI, 1.73-2.19), and excision with or without silver nitrate with 2.40 visits (95% CI, 2.07-2.78). Conservative management was unsuccessful 45% of the time, requiring additional treatment with silver nitrate or excision. 30% of patients treated with silver nitrate or excision continued to report pain even after the resolution of granulation tissue upon examination. CONCLUSION: PPGT is commonly associated with first vaginal births, often presents beyond 6 weeks postpartum, and frequently requires treatment.

Protocol for Evaluating Remote Patient Blood Pressure Monitoring Adapted to Black Women and Birthing Persons.

Cardiovascular disease is the leading cause of maternal death among Black women in the United States. A large, urban hospital adopted remote patient blood pressure monitoring (RBPM) to increase blood pressure monitoring and improve the management of hypertensive disorders of pregnancy (HDP) by reducing the time to diagnosis of HDP. The digital platform integrates with the electronic health record (EHR), automatically inputting RBPM readings to the patients' chart; communicating elevated blood pressure values to the healthcare team; and offers a partial offset of the cost through insurance plans. It also allows for customization of the blood pressure values that prompt follow-up to the patient's risk category. This paper describes a protocol for evaluating its impact. Objective 1 is to measure the effect of the digitally supported RBPM on the time to diagnosis of HDP. Objective 2 is to test the effect of cultural tailoring to Black participants. The ability to tailor digital content provides the opportunity to test the added value of promoting social identification with the intervention, which may help achieve equity in severe maternal morbidity events related to HDP. Evaluation of this intervention will contribute to the growing literature on digital health interventions to improve maternity care in the United States.

Interactive effects of protonated nicotine concentration and device power on ENDS nicotine delivery, puff topography, and subjective effects.

Electronic nicotine delivery systems (ENDSs) produce an aerosol by heating a liquid that often contains nicotine. The nicotine can be protonated that may make the aerosol easier to inhale than freebase nicotine. This study's purpose is to determine, in cigarette smokers and ENDS users, the effects of three concentrations of protonated nicotine aerosolized at two different power settings. Forty-five participants (22 cigarette smokers and 23 ENDS users) completed some or all of six sessions that varied by liquid nicotine concentration (10, 15, or 30 mg/ml protonated nicotine) and device power (15 or 30 W). Participants took 10 puffs from each product and then used each product for 90 min ad libitum. Plasma nicotine concentration, subjective effects, and puff topography were measured. Results showed increases in plasma nicotine concentration in all conditions, with greater plasma nicotine increases in higher watt, higher nicotine concentration conditions, as well as greater nicotine delivery for ENDS users compared to cigarette smokers. For puff topography, puff duration and volume decreased as nicotine concentration and power increased, and ENDS users took longer and larger puffs than cigarette smokers. Participants rated the higher watt, higher nicotine concentration conditions as harsher and with more throat hit. Overall, these results suggest that device characteristics and liquid constituents interact to influence users' plasma nicotine delivery and should be considered together when regulating ENDS. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The baseline risk of multiple febrile seizures in the same febrile illness: a meta-analysis.

The baseline risk for multiple febrile seizures within the same febrile illness is largely unknown. Estimates range from 5 to 30%. Imprecise estimates can lead to incorrectly powering studies investigating the management of febrile seizures. To estimate the risk of multiple febrile seizures in the same febrile illness, we systematically reviewed and conducted a meta-analysis of studies from January 2000 to December 2021 that contained data for the number of children for both simple and complex febrile seizures in the same febrile illness. We searched MEDLINE, EMBASE, and Web of Science for randomized, quasi-randomized, prospective, and retrospective trials that involved children with febrile seizures. A total of 23,131 febrile illnesses with febrile seizures met the inclusion criteria. The estimated baseline risk of multiple febrile seizures in the same febrile illness was 17% (95% CI, 16-19%). However, the 30 cohorts that included both admitted and non-admitted patients had a lower percentage of multiple FSs within the same illness (14%; 95% CI, 12-15%) than the 30 cohorts that enrolled only admitted patients (20%; 95% CI, 16-25%). CONCLUSION: Researchers can use estimates in this paper to design future studies. Taking into the account the substantial heterogeneity between countries and studies, clinicians could cautiously use our estimates in their clinical assessment and be better able to set parental expectations about a child's chances of having another febrile seizure during the current illness. TRIAL REGISTRATION: PROSPERO CRD42020191784. Registered July 18, 2020. WHAT IS KNOWN: • There is renewed interest in the diagnostic workup and prophylactic treatment of febrile seizures to prevent repeat seizures in the same febrile illness. • There is a lack of accurate estimates of the baseline risk for multiple febrile seizures in the same illness to properly design studies investigating management. WHAT IS NEW: • This study provides the most robust estimates for the baseline risk for multiple febrile seizures in the same illness.

Predictors of smell recovery in a nationwide prospective cohort of patients with COVID-19.

OBJECTIVE: To determine which factors (demographic, symptoms, comorbidities, and treatments) are associated with recovery of smell in patients with COVID-19 associated olfactory loss. STUDY DESIGN: Prospective, longitudinal questionnaires. SETTING: National survey. METHODS: A longitudinal web-based nationwide survey of adults with COVID-19 associated smell and taste loss was launched April 10, 2020. After completing an initial entry survey, participants received detailed follow-up questionnaires 14 days, and 1, 3 and 6 months later. RESULTS: As of June 25, 2021, 798 participants met study inclusion criteria and completed 6-month questionnaires. Of demographic characteristics only age <40 years was positively associated with smell recovery (p < .003). Of symptoms, difficulty breathing was negatively associated with smell recovery (p < .004), and nasal congestion positively associated with smell recovery (p < .03). Of pre-existing comorbidities only previous head injury (p < .017) was negatively associated with smell recovery. None of the queried medications used to treat COVID were associated with better rates of smell recovery. CONCLUSIONS: Age <40 and presence of nasal congestion at time of COVID-19 infection were predictive of improved rates of smell recovery, while difficulty breathing at time of COVID-19 infection, and prior head trauma predicted worsened rates of recovery. Further study will be required to identify potential mechanisms for the other observed associations. Such information can be used by clinicians to counsel patients suffering COVID-19 associated smell loss as to prognosis for recovery.

Quality of life and safety impact of COVID-19 associated smell and taste disturbances.

OBJECTIVE: The association between COVID-19 and chemosensory loss has garnered substantial attention, however to date little is known about the real-life consequences of impairment in this unique patient population. The aim of this study is to evaluate the quality of life (QOL) and personal safety deficits experienced by patients with COVID-19 infection. STUDY DESIGN: Prospective, longitudinal questionnaires. SETTING: National survey. METHODS: A longitudinal web-based nationwide survey of adults with COVID-19 and/or a sudden change in smell and taste was launched April 10, 2020. Previously published questions on chemosensory-related QOL and safety events were asked at the 6-month follow-up survey. RESULTS: As of February 10, 2021, 480 eligible respondents took the 6-month questionnaire, of whom 322 were COVID-19 positive. Impact on QOL was substantial with 96% of subjects reporting at least one of the defined deficits, and over 75% reporting at least 3 of these. "Reduced enjoyment of food" was the most common complaint (87%), while 43% of subjects self-reported depression. The prevalence of safety-related issues was common in this population, with over 57% reporting at least one, and 36% reporting 2 or more events. Of the events asked, the inability to smell smoke that others could perceive was the most common at 45%. CONCLUSIONS: COVID-19 associated chemosensory losses have a real and substantial impact on both quality of life and safety, beyond mere inconvenience. The high prevalence of these issues despite a relatively short period of olfactory deficit should alert clinicians to the serious risks to an already vulnerable patient population.