Magnetic Resonance-Guided Focused Ultrasound without Anesthesiologist Support.

INTRODUCTION: Magnetic resonance-guided focused ultrasound (MRgFUS) is an effective treatment option for essential tremor (ET) and tremor dominant Parkinson's disease (TDPD), which is often performed with sedation or in the presence of an anesthesiologist in an effort to minimize adverse events and maximize patient comfort. This study explores the safety, feasibility, and tolerability of performing MRgFUS without an anesthesiologist. METHODS: This is a single academic center, retrospective review of 180 ET and TDPD patients who underwent MRgFUS treatment without anesthesiologist support. Patient demographics, intra-procedural treatment parameters, peri-procedural adverse events, and 3-month Clinical Rating Scale for Tremor Part B (CRST-B) scores were compared to MRgFUS studies that utilized varying degrees of anesthesia. RESULTS: There were no anesthesia related adverse events or unsuccessful treatments. There were no early treatment terminations due to patient discomfort, regardless of skull density ratio. 94.6% of patients would repeat the procedure again. The most common side effects during treatment were facial/tongue paresthesia (26.3%), followed by nausea (22.3%), dysarthria (8.6%), and scalp pain (8.0%). No anxiolytic, pain, or antihypertensive medications were administered. The most common early adverse event after MRgFUS procedure was gait imbalance (58.3%). There was a significant reduction of 83.1% (83.4% ET and 80.5% TDPD) of the mean CRST-B scores of the treated hand when comparing 3-month and baseline scores (1.8 vs. 10.9, n = 109, p < 0.0001). CONCLUSION: MRgFUS without intra-procedural anesthesiologist support is a safe, feasible, and well-tolerated option, without an increase in peri-procedural adverse events.

Fibroblast Stromal Support Model for Predicting Human Papillomavirus-Associated Cancer Drug Responses.

Currently, there are no specific antiviral therapeutic approaches targeting Human papillomaviruses (HPVs), which cause around 5% of all human cancers. Specific antiviral reagents are particularly needed for HPV-related oropharyngeal cancers (HPV+OPCs) whose incidence is increasing and for which there are no early diagnostic tools available. We and others have demonstrated that the estrogen receptor alpha (ERα) is overexpressed in HPV+OPCs, compared to HPV-negative cancers in this region, and that these elevated levels are associated with an improved disease outcome. Utilizing this HPV+ specific overexpression profile, we previously demonstrated that estrogen attenuates the growth and cell viability of HPV+ keratinocytes and HPV+ cancer cells in vitro. Expansion of this work in vivo failed to replicate this sensitization. The role of stromal support from the tumor microenvironment (TME) has previously been tied to both the HPV lifecycle and in vivo therapeutic responses. Our investigations revealed that in vitro co-culture with fibroblasts attenuated HPV+ specific estrogen growth responses. Continuing to monopolize on the HPV+ specific overexpression of ERα, our co-culture models then assessed the suitability of the selective estrogen receptor modulators (SERMs), raloxifene and tamoxifen, and showed growth attenuation in a variety of our models to one or both of these drugs in vitro. Utilization of these SERMs in vivo closely resembled the sensitization predicted by our co-culture models. Therefore, the in vitro fibroblast co-culture model better predicts in vivo responses. We propose that utilization of our co-culture in vitro model can accelerate cancer therapeutic drug discovery.

Human Papillomavirus 16 replication converts SAMHD1 into a homologous recombination factor and promotes its recruitment to replicating viral DNA.

We have demonstrated that SAMHD1 (sterile alpha motif and histidine-aspartic domain HD-containing protein 1) is a restriction factor for the HPV16 life cycle. Here we demonstrate that in HPV negative cervical cancer C33a cells and human foreskin keratinocytes immortalized by HPV16 (HFK+HPV16), SAMHD1 is recruited to E1-E2 replicating DNA. Homologous recombination (HR) factors are required for HPV16 replication and viral replication promotes phosphorylation of SAMHD1, which converts it from a dNTPase to an HR factor independent from E6/E7 expression. A SAMHD1 phosphor-mimic (SAMHD1 T592D) reduces E1-E2 mediated DNA replication in C33a cells and has enhanced recruitment to the replicating DNA. In HFK+HPV16 cells SAMHD1 T592D is recruited to the viral DNA and attenuates cellular growth, but does not attenuate growth in isogenic HFK cells immortalized by E6/E7 alone. SAMHD1 T592D also attenuates the development of viral replication foci following keratinocyte differentiation. The results indicated that enhanced SAMHD1 phosphorylation could be therapeutically beneficial in cells with HPV16 replicating genomes. Protein phosphatase 2A (PP2A) can dephosphorylate SAMHD1 and PP2A function can be inhibited by endothall. We demonstrate that endothall reduces E1-E2 replication and promotes SAMHD1 recruitment to E1-E2 replicating DNA, mimicking the SAMHD1 T592D phenotypes. Finally, we demonstrate that in head and neck cancer cell lines with HPV16 episomal genomes endothall attenuates their growth and promotes recruitment of SAMHD1 to the viral genome. The results suggest that targeting cellular phosphatases has therapeutic potential for the treatment of HPV infections and cancers. Importance: Human papillomaviruses are causative agents in around 5% of all human cancers. The development of anti-viral therapeutics depends upon an increased understanding of the viral life cycle. Here we demonstrate that HPV16 replication converts SAMHD1 into an HR factor via phosphorylation. This phosphorylation promotes recruitment of SAMHD1 to viral DNA to assist with replication. A SAMHD1 mutant that mimics phosphorylation is hyper-recruited to viral DNA and attenuates viral replication. Expression of this mutant in HPV16 immortalized cells attenuates the growth of these cells, but not cells immortalized by the viral oncogenes E6/E7 alone. Finally, we demonstrate that the phosphatase inhibitor endothall promotes hyper-recruitment of endogenous SAMHD1 to HPV16 replicating DNA and can attenuate the growth of both HPV16 immortalized human foreskin keratinocytes and HPV16 positive head and neck cancer cell lines. We propose that phosphatase inhibitors represent a novel tool for combating HPV infections and disease.

Work fatigue during COVID-19 lockdown teleworking: the role of psychosocial, environmental, and social working conditions.

Background: During national lockdowns in response to the COVID-19 pandemic, previously office-based workers who transitioned to home-based teleworking faced additional demands (e.g., childcare, inadequate homeworking spaces) likely resulting in poor work privacy fit. Previous office research suggests poor work privacy fit is associated with lower wellbeing and higher work fatigue. Emerging evidence suggests a relationship between childcare duties during pandemic teleworking and work fatigue. In addition to psychosocial working conditions (job demand, job control, and job change management), which are acknowledged predictors of work fatigue, this poses a significant threat to occupational health during pandemic teleworking. However, the relative effects of aspects of the psychosocial environment (job demands and resources), the home office environment (including privacy fit), and the social environment (childcare) on work fatigue as well as their interactions are under-explored. Objective: This study examined the relationships between the psychosocial, environmental, and social working conditions of teleworking during the first COVID-19 lockdown and work fatigue. Specifically, the study examined teleworkers' physical work environment (e.g., if and how home office space is shared, crowding, and noise perceptions) as predictors of privacy fit and the relationship between privacy fit, childcare, psychosocial working conditions (job demand, job control, and job change management), and work fatigue. Work privacy fit was hypothesized to mediate the relationship between childcare and work fatigue. Methods: An online cross-sectional survey was conducted with teleworkers (n = 300) during the first COVID-19 lockdown in April and May 2020; most participants were in Germany, Switzerland, and the United Kingdom. Results: Path analysis was used to examine the hypothesized relationships. Privacy fit was lower for those reporting greater levels of noise in home-working spaces and those feeling crowded at home. Work fatigue was lower amongst those with greater privacy fit and higher amongst those with high levels of job demand. An indirect relationship was observed between childcare and work fatigue with privacy fit mediating this relationship. Conclusion: The influence of privacy fit has so far been largely neglected in research on teleworking, especially during the pandemic. However, its contribution to workers' wellbeing should be acknowledged in occupational health strategies.

Sharing Clinical Notes while Protecting Adolescent Confidentiality and Maintaining Parental Insight.

BACKGROUND: The 21st Century Cures Act mandates sharing electronic health records (EHRs) with patients. Health care providers must ensure confidential sharing of medical information with adolescents while maintaining parental insight into adolescent health. Given variability in state laws, provider opinions, EHR systems, and technological limitations, consensus on best practices to achieve adolescent clinical note sharing at scale is needed. OBJECTIVES: This study aimed to identify an effective intervention process to implement adolescent clinical note sharing, including ensuring adolescent portal account registration accuracy, across a large multihospital health care system comprising inpatient, emergency, and ambulatory settings. METHODS: A query was built to assess portal account registration accuracy. At a large multihospital health care system, 80.0% of 12- to 17-year-old patient portal accounts were classified as inaccurately registered (IR) under a parent or registration accuracy unknown (RAU). To increase accurately registered (AR) accounts, the following interventions were pursued: (1) distribution of standardized portal enrollment training; (2) patient outreach email campaign to reregister 29,599 portal accounts; (3) restriction of access to remaining IR and RAU accounts. Proxy portal configurations were also optimized. Subsequently, adolescent clinical note sharing was implemented. RESULTS: Distribution of standardized training materials decreased IR and increased AR accounts (p = 0.0492 and 0.0058, respectively). Our email campaign (response rate: 26.8%) was most effective in decreasing IR and RAU accounts and increasing AR accounts (p < 0.002 for all categories). Remaining IR and RAU accounts, 54.6% of adolescent portal accounts, were subsequently restricted. Postrestriction, IR accounts continued declining significantly (p = 0.0056). Proxy portal enhancements with interventions deployed increased proxy portal account adoption. CONCLUSION: A multistep intervention process can be utilized to effectively implement adolescent clinical note sharing at a large scale across care settings. Improvements to EHR technology, portal enrollment training, adolescent/proxy portal settings, detection, and automation in reenrollment of inaccurate portal accounts are needed to maintain integrity of adolescent portal access.

Transportation Burden Associated With Hemodialysis in Canada: A Qualitative Study of Stakeholders.

Rationale & Objective: For patients requiring in-center hemodialysis, suboptimal transportation arrangements are commonly cited as a source of ongoing stress and anxiety and have been associated with a reduced quality of life and increased mortality risk. Transportation-related problems are especially pronounced in Canada given its size, low population density, and long, often snowy winters. We aimed to identify and better understand transportation options for hemodialysis patients in Canada and to describe stakeholder experiences. Study Design: We used a qualitative descriptive research design to explore stakeholder experiences and perspectives of transportation to and from dialysis facilities. Setting & Participants: We recruited participants from a large urban hemodialysis program in Western Canada and included 11 participants from a project group, 45 participants from an open forum, and a survey of 8 social workers. Data collection occurred at a series of project group meetings and an open forum (n=45). In addition, we asked 8 renal social workers based in major cities across Canada to comment on the provision of transport for patients in their area via email or telephone consult. Analytical Approach: We used conventional content analysis to explore stakeholder experiences. Results: Traveling to and from dialysis facilities remains a source of stress and anxiety for many patients and their families. Patients described several factors contributing to these feelings including: the challenges of physically getting to the treatment center, particularly in adverse weather conditions; being a burden on family and friends; difficulties accessing the treatment facility; issues with public transport; and financial worries related to high costs. Limitations: Findings may not be relevant in low- and middle-income countries and those with a warmer climate. Conclusions: Without a concerted and collaborative approach to address the barriers identified here, it is likely that travel to and from in-center hemodialysis will continue to adversely affect patients' quality of life.

Stereotactic Radiosurgery for Spinal Haemangioblastoma: A Retrospective Single-Centre Experience from the United Kingdom.

INTRODUCTION: Haemangioblastoma is a benign, vascular tumour of the central nervous system. Stereotactic radiosurgery (SRS) is increasingly being used as a treatment for spinal lesions to avoid complex surgery, especially in patients with multi-focal tumours associated with von Hippel-Lindau syndrome (VHL). Here, we present the outcomes of patients treated in our centre using a CyberKnife VSI (Accuray, Inc.). METHODS: Retrospective analysis of all patients treated at our institution was conducted. Assessment of radiological response was based upon RANO criteria. Solid and overall tumour progression-free survival (PFS) was calculated using the Kaplan-Meier method. The development of a symptomatic new or enlarging cyst was included in the definition of progression when determining overall PFS. RESULTS: Fourteen tumours in 10 patients were included. Seven patients were male, and nine had VHL. Nine (64%) tumours had an associated cyst. The median (IQR) age at treatment was 45.5 (43.5-53) years. The median gross tumour volume was 0.355cc. Patients received a mean marginal prescribed dose of 9.6 Gy in a single fraction (median maximum dose: 14.3 Gy), which was constrained by spinal cord tolerance. Mean follow-up was 15.4 months. Radiologically, 11 (78.6%) tumours were stable or regressed and three (21.4%) progressed. Eight patients' symptoms improved or were stable, and two worsened, both of which were secondary to cyst enlargement. The 1-year solid-tumour and overall PFS was 92.3% and 75.7%, respectively. All patients were alive at the most recent follow-up. One patient developed grade 1 back pain following treatment. DISCUSSION/CONCLUSION: SRS appears to be a safe and effective treatment for spinal haemangioblastoma. Prospective trials with longer follow-up are required to establish the optimum management.

Prehospital plasma is associated with survival principally in patients transferred from the scene of injury: A secondary analysis of the PAMPer trial.

BACKGROUND: We sought to characterize if prehospital transfer origin from the scene of injury (SCENE) or from a referral emergency department (REF) alters the survival benefit attributable to prehospital plasma resuscitation in patients at risk of hemorrhagic shock. METHODS: We performed a secondary analysis of data from a recently completed prehospital plasma clinical trial. All of the enrolled patients from either the SCENE or REF groups were included. The demographics, injury characteristics, shock severity and resuscitation needs were compared. The primary outcome was a 30-day mortality. Kaplan-Meier analysis and Cox-hazard regression were used to characterize the independent survival benefits of prehospital plasma for transport origin groups. RESULTS: Of the 501 enrolled patients, the REF group patients (n = 111) accounted for 22% with the remaining (n = 390) originating from the scene. The SCENE group patients had higher injury severity and were more likely intubated prehospital. The REF group patients had longer prehospital times and received greater prehospital crystalloid and blood products. Kaplan-Meier analysis revealed a significant 30-day survival benefit associated with prehospital plasma in the SCENE group (P < .01) with no difference found in the REF group patients (P = .36). The Cox-regression verified after controlling for relevant confounders that prehospital plasma was independently associated with a 30-day survival in the SCENE group patients (hazard ratio 0.59; 95% confidence interval 0.39-0.89; P = .01) with no significant relationship found in the REF group patients (hazard ratio 1.03, 95% confidence interval 0.4-3.0). CONCLUSION: Important differences across the SCENE and REF cohorts exist that are essential to understand when planning prehospital studies. Prehospital plasma is associated with a survival benefit primarily in SCENE group patients. The results are exploratory but suggest transfer origin may be an important determinant of prehospital plasma benefit.

Strong, steady and straight: UK consensus statement on physical activity and exercise for osteoporosis.

Exercise and physical activity can improve bone strength and the risk of falls, which may offer benefits in the prevention and management of osteoporosis. However, uncertainty about the types of exercise that are safe and effective instigates lack of confidence in people with osteoporosis and health professionals. Existing guidelines leave some questions unresolved. This consensus statement aimed to determine the physical activity and exercise needed to optimise bone strength, reduce fall and fracture risk, improve posture and manage vertebral fracture symptoms, while minimising potential risks in people with osteoporosis. The scope of this statement was developed following stakeholder consultation. Meta-analyses were reviewed and where evidence was lacking, individual studies or expert opinion were used to develop recommendations. A multidisciplinary expert group reviewed evidence to make recommendations, by consensus when evidence was not available. Key recommendations are that people with osteoporosis should undertake (1) resistance and impact exercise to maximise bone strength; (2) activities to improve strength and balance to reduce falls; (3) spinal extension exercise to improve posture and potentially reduce risk of falls and vertebral fractures. For safety, we recommend avoiding postures involving a high degree of spinal flexion during exercise or daily life. People with vertebral fracture or multiple low trauma fractures should usually exercise only up to an impact equivalent to brisk walking. Those at risk of falls should start with targeted strength and balance training. Vertebral fracture symptoms may benefit from exercise to reduce pain, improve mobility and quality of life, ideally with specialist advice to encourage return to normal activities. Everyone with osteoporosis may benefit from guidance on adapting postures and movements. There is little evidence that physical activity is associated with significant harm, and the benefits, in general, outweigh the risks.

Future Teleworking Inclinations Post-COVID-19: Examining the Role of Teleworking Conditions and Perceived Productivity.

Organisations have implemented intensive home-based teleworking in response to global COVID-19 lockdowns and other pandemic-related restrictions. Financial pressures are driving organisations to continue intensive teleworking after the pandemic. Understanding employees' teleworking inclinations post COVID-19, and how these inclinations are influenced by different factors, is important to ensure any future, more permanent changes to teleworking policies are sustainable for both employees and organisations. This study, therefore, investigated the relationships between the context of home-based teleworking during the pandemic (pandemic-teleworking conditions), productivity perceptions during home-based teleworking, and employees' future teleworking inclinations (FTI) beyond the pandemic. Specifically, the study examined whether pandemic-teleworking conditions related to the job, and the physical and social environments at home, influenced employees' FTI, and if perceptions of improved or reduced productivity mediated these relationships. Data were collected during April and May 2020 with a cross-sectional online survey of teleworkers (n = 184) in Germany, Switzerland, the United Kingdom, and other countries during the first COVID-19 lockdowns. Reported FTI were mixed. Most participants (61%) reported wanting to telework more post-pandemic compared to before the pandemic; however, 18% wanted to telework less. Hierarchical multiple regression analysis revealed that some teleworking conditions (job demands and work privacy fit) were positively associated with FTI. Other teleworking conditions (specifically, job change, job control, home office adequacy, and childcare) were not associated with FTI. Perceived changes in productivity mediated the relationship between work privacy fit and FTI. Findings highlight the role of work privacy fit and job demands in influencing pandemic productivity perceptions and teleworking inclinations post-pandemic. Results raise questions about the suitability and sustainability of home-based teleworking for all staff. As organisations plan to increase the proportion of teleworking post-pandemic, this study suggests there is a need to support employees who perceived their productivity to be poor while home-working during the pandemic.

Impact of Breastfeeding Support Services on Mothers' Breastfeeding Experiences When Provided by an MD/IBCLC in the Pediatric Medical Home.

Addressing breastfeeding issues enables mothers to reach their breastfeeding goals. We embedded a breastfeeding consultation service run by a pediatrician/International Board Certified Lactation Consultant (MD/IBCLC) in a medical home. This mixed-methods study investigated breastfeeding preparedness and the service's perceived benefits. Mothers with breastfeeding issues/concerns identified at well-baby appointments were referred to the service. Telephone interviews and chart reviews were conducted with 28 participating mothers approximately 1 month after the visits. Breastfeeding Self-Efficacy Scale scores improved significantly from the time of the in-person appointment to 1 month later. Most mothers felt unprepared for breastfeeding despite prenatal efforts. Trust in the pediatrician's recommendation, easy access, and insurance coverage were key factors in seeking the service. Reassurance provided by the MD/IBCLC increased mothers' confidence to breastfeed. The COVID-19 pandemic heightened feelings of isolation and anxiety due to lack of hands-on support from friends and family during the birth hospitalization and when at home.

Evaluation of a natural workspace intervention with active design features on movement, interaction and health.

BACKGROUND: There is increasing focus on designing workspaces that promote less sitting, more movement and interaction to improve physical and mental health. OBJECTIVE: This study evaluates a natural intervention of a new workplace with active design features and its relocation to a greener and open space. METHODS: An ecological model was used to understand how organisations implement change. Pre and post survey data from 221 matched cases of workers and accelerometery data (n = 50) were analysed. RESULTS: Results show a decrease in occupational sitting (-20.65 mins/workday, p = 0.001) and an increase in workplace walking (+5.61 mins/workday, p = 0.001) using survey data, and accelerometery data (occupational sitting time: -31.0 mins/workday, p = 0.035, standing time: +22.0 mins/workday, p = 0.022, stepping time: +11.0 mins/workday, p = 0.001). Improvements in interaction, musculoskeletal pain and mental health were reported. CONCLUSIONS: Application of the ecological model shows that the organisation understands how to target the built environment and social/cultural environment but not how to target behaviour change at the individual level.

Wearable Fitness Trackers to Predict Clinical Deterioration in Maintenance Hemodialysis: A Prospective Cohort Feasibility Study.

RATIONALE & OBJECTIVE: People receiving hemodialysis often require urgent care or hospitalizations. It is possible that reductions in a patient's level of physical activity may serve as an "early warning" of clinical deterioration, allowing timely clinical intervention. We explored whether step count could serve as a trigger for deterioration. STUDY DESIGN: Prospective observational cohort feasibility study. SETTING & PARTICIPANTS: We recruited consenting adult participants from outpatient dialysis clinics in Calgary, AB, between June 28, 2019, and October 10, 2019. EXPOSURE AND OUTCOMES: Participants wore a wristband fitness tracker for 4 weeks. Activity data from the trackers were imported weekly into the study database. Demographic, clinical management, functional impairment, and frailty were assessed at baseline. Clinical events (urgent care and emergency department visits and hospitalizations) were monitored during the observation period. ANALYTICAL APPROACH: Box and whisker plots and line plots were used to describe each participant's daily steps. Adjusted rate ratios (and 95 % confidence intervals) were calculated to assess the associations between the number of steps taken each day and potential predictors. RESULTS: Data from 46 patients were included; their median age was 64 years (range, 22 to 85), and 63 % were men. The median number of steps taken per day was 3,133 (range, 248-13,753). Fourteen events among 11 patients were reported. Within patients, step count varied considerably; it was not possible to identify a patient-specific normal range for daily step count. There was no association between step count and the occurrence of clinical events, although the number of events was very small. LIMITATIONS: The number of participants was relatively small, and there were too few events to model to examine whether step count could predict clinical deterioration. CONCLUSIONS: Within-patient variation in daily step count was too high to generate a normal range for patients. However, patient-specific norms over a longer period (3- or 7-day periods) appear potentially worthy of future study in a larger sample and/or over a longer follow-up.

Treating Choroidal Metastases and Improving Vision with Osimertinib in EGFR T790M-Mutated Lung Adenocarcinoma: A Case Report and Review of the Literature.

A 41-year-old never-smoking female was diagnosed with epidermal growth factor receptor (EGFR)-mutated T2bN3M1b lung adenocarcinoma with axillary lymph nodes. She complained of blurred vision in the left eye (2/60) and was subsequently found to have a left choroidal metastasis. Treatment with tyrosine kinase inhibitor (TKI) erlotinib was started, and after 1 year of disease stability, she developed unsteadiness and worsening visual disturbance (1/60). Brain imaging showed 24 new brain metastases, which were treated with Gamma Knife stereotactic radiosurgery. An enlarging axillary lymph node was biopsied, which identified the T790M mutation, and she commenced the novel TKI osimertinib. Three weeks later, her choroidal lesion had regressed from 3.1 mm to 2.2 mm, and after 2 months of osimertinib, her visual acuity had improved to 6/9. At the last follow-up 8 months after initiation of osimertinib, her choroidal metastasis remains stable, and visual acuity has improved to 6/6. Evidence suggests that osimertinib's efficacy in treating cerebral metastases is superior to that of chemotherapy and other EGFR-TKIs (gefitinib and erlotinib); however, the literature is sparse with regards to the use of osimertinib for the treatment of intraocular disease. In this case, the need for intense daily radiation treatment with its associated toxicities was negated, and as such we propose that osimertinib may be a promising treatment for choroidal metastasis secondary to EGFR-mutated lung adenocarcinoma.

COVID-19 in Pediatrics: Characteristics of Hospitalized Children in New Jersey.

OBJECTIVES: Understanding the risk factors, predictors, and clinical presentation of coronavirus disease 2019 (COVID-19) in pediatric patients with severe disease. METHODS: We conducted a retrospective chart review of pediatric patients admitted between March 1, 2020, and May 31, 2020, to a large health network in New Jersey with positive test results for severe acute respiratory syndrome coronavirus 2 on reverse transcriptase polymerase chain reaction, rapid testing, or serum immunoglobulin G testing; we included demographic characteristics, clinical features, and outcomes. RESULTS: A total of 81 patients ≤21 years old were admitted with positive test results for severe acute respiratory syndrome coronavirus 2 on reverse transcriptase polymerase chain reaction and/or serum immunoglobulin testing. Sixty-seven patients (82.7%) were admitted for management of acute COVID-19 infection, whereas 14 (17.3%) were admitted for management of multisystem inflammatory syndrome in children (MIS-C). Of the 81 hospitalized patients, 28 (34.6%) required intensive care. A majority of patients (42 [51.9%]) admitted for both acute COVID-19 infection and MIS-C were Hispanic. Underlying chronic health conditions were not present in most patients. Obesity (mean BMI of 41.1) was noted in the patients with MIS-C requiring ICU care, although not statistically significant. Absolute lymphopenia and elevated levels of inflammatory markers were statistically significant in the patients with MIS-C treated in the ICU. CONCLUSIONS: This study adds to the growing literature of potential risk factors for severe disease in pediatric patients due to COVID-19 infection and MIS-C. Patients of Hispanic ethnicity represented the majority of patients with both acute COVID-19 infection and MIS-C, despite only representing 10% to 20% of the population our hospitals serve. Infants and patients with chronic health conditions were not at increased risk for severe disease. Absolute lymphopenia and elevated levels of inflammatory markers were associated with more severe disease.

Short-Term Outcomes After Multisystem Inflammatory Syndrome in Children Treatment.

This is a retrospective chart review of 20 patients treated with a consensus-driven treatment algorithm in multisystem inflammatory syndrome in children patients across a wide clinical spectrum. Their treatments and clinical status are described as well as their favorable return to functional baseline by 30 days post presentation.

Severe Acute Respiratory Syndrome Coronavirus 2 Clinical Syndromes and Predictors of Disease Severity in Hospitalized Children and Youth.

OBJECTIVE: To characterize the demographic and clinical features of pediatric severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) syndromes and identify admission variables predictive of disease severity. STUDY DESIGN: We conducted a multicenter, retrospective, and prospective study of pediatric patients hospitalized with acute SARS-CoV-2 infections and multisystem inflammatory syndrome in children (MIS-C) at 8 sites in New York, New Jersey, and Connecticut. RESULTS: We identified 281 hospitalized patients with SARS-CoV-2 infections and divided them into 3 groups based on clinical features. Overall, 143 (51%) had respiratory disease, 69 (25%) had MIS-C, and 69 (25%) had other manifestations including gastrointestinal illness or fever. Patients with MIS-C were more likely to identify as non-Hispanic black compared with patients with respiratory disease (35% vs 18%, P = .02). Seven patients (2%) died and 114 (41%) were admitted to the intensive care unit. In multivariable analyses, obesity (OR 3.39, 95% CI 1.26-9.10, P = .02) and hypoxia on admission (OR 4.01; 95% CI 1.14-14.15; P = .03) were predictive of severe respiratory disease. Lower absolute lymphocyte count (OR 8.33 per unit decrease in 109 cells/L, 95% CI 2.32-33.33, P = .001) and greater C-reactive protein (OR 1.06 per unit increase in mg/dL, 95% CI 1.01-1.12, P = .017) were predictive of severe MIS-C. Race/ethnicity or socioeconomic status were not predictive of disease severity. CONCLUSIONS: We identified variables at the time of hospitalization that may help predict the development of severe SARS-CoV-2 disease manifestations in children and youth. These variables may have implications for future prognostic tools that inform hospital admission and clinical management.

Effect of Enhanced Recovery After Surgery Protocol Implementation on Cost and Outcomes by Type of Colectomy Performed.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols are widely utilized for elective colorectal surgery to improve outcomes and decrease costs, but few studies have evaluated the impact of ERAS protocols on cost with respect to anatomic site of resection. This study evaluated the impact of ERAS protocol on elective colon resections by site and longitudinal impact over time. METHODS: A single-center retrospective cohort study of 598 consecutive patients undergoing elective colorectal resection before and after implementation of ERAS protocol from 2013 to 2017 was performed. The primary outcomes were length of stay (LOS) and cost. Comparative and multivariate inferential statistics were used to assess additional outcomes. RESULTS: A total of 598 patients (100 pre-ERAS vs 498 post-ERAS) were evaluated with an overall median LOS of 4 days for right and left colectomies and 3 days for transverse colectomies. When comparing type of resection before and after ERAS protocol introduction, an increased LOS for left hemicolectomies from 3.09 to 4.03 days (P = .047) was noted, with all other comparisons failing to reach statistical significance. Over time, an initial decrease in LOS for MIS approach after protocol introduction was observed; however, this effect diminished in the ensuing years and had no significant effect overall. Total cost of care was significantly increased post-ERAS for all cohorts except transverse colectomies. No further statistically significant differences were found. CONCLUSION: After an initial improvement in outcomes, continued utilization of ERAS protocols demonstrated no improvement in LOS compared to pre-ERAS data and increased cost overall for patients regardless of site of resection.