2023 Clinical Update in Liver Transplantation.

Liver transplantation continues to provide life-saving treatment for patients with end-stage liver disease. Advances in the field of transplant anesthesia continue to support the care of more complex patients. The use of extracorporeal membrane oxygenation has been described in critical care settings and cardiac surgery but may be a valuable option for specific conditions for patients undergoing liver transplantation. Changes to the allocation process for liver grafts now focus on acuity circles to reduce regional disparities. As the number of life-saving transplant surgeries increases, so does the need for specialty knowledge in the anesthetic considerations of these procedures. The specialty of transplant anesthesia continues to grow and develop to meet the demands of complex patients and the increased number of transplants performed. Liver transplantation can be a resource-demanding procedure, and predicting the need for massive transfusion can aid in planning and preparing for significant blood loss.

Prognostic variables and decannulation of tracheostomy in the long-term acute care environment: a case for clinician-driven decision-making.

Purpose: Tracheostomy is a necessary procedure required for prolonged mechanical ventilation in long-term acute care hospitals (LTACH). Many factors influence successful decannulation, or tracheostomy removal, and it is unclear what factors are essential for determining decannulation. The purpose of this study was to determine retrospective performance of single prognostic variables for successful decannulation, like peak expiratory flow measurement, overnight oximetry testing, and blood gas analysis. Methods: A retrospective analysis of a three-year period to investigate the association between peak flow (PF) measurements ≥160 L/min, successful overnight oximetry (ONO), sex, and decannulation success. Average PF measurements, arterial blood gas (ABG), days on mechanical ventilation, LTACH length of stay (LOS), and age were also investigated. Results: We examined the records of 135 patients, 127 of which were successfully decannulated. PF measurements ≥160 L/min (p=0.16), sex (p<0.05) and passing ONO (p<0.05) were significantly different between successfully and unsuccessfully decannulated patients; mean ABG (pH, pCO2, pO2), mechanical ventilation days, LOS, and age were not significantly different (p>0.05). Conclusions: These results suggest no single prognostic variable can predict decannulation outcomes. Rather, clinical judgment of experienced medical professionals appears sufficient to achieve a 94% decannulation success rate. Additional investigation is required to determine what metrics are necessary, or if clinical judgment alone can predict decannulation success.

The association between beta-natriuretic peptide (BNP) serum levels and liberation from mechanical ventilation.

Prolonged time on mechanical ventilation is associated with multiple consequences for both the patient and medical facility. Based on anecdotal evidence that sustained elevation of beta-natriuretic protein (BNP) during a patient's stay in a long-term acute care hospital (LTACH) was associated with failure to wean from prolonged mechanical ventilation, we investigated if there is an association between a decrease in BNP levels during one's stay and successful weaning from prolonged mechanical ventilation. We performed a retrospective study of 66 patient records revealing no correlation between lowering BNP levels and probability of liberating a patient from prolonged mechanical ventilation in an LTACH environment where the probability of liberation from mechanical ventilation is high (> 85%). BNP measurements by itself does not appear to be a helpful tool in the likelihood of liberation from mechanical ventilation AUC = 0.61 (CI: 0.48-0.72). In an LTACH setting with high success rates of liberation from mechanical ventilation, it does not appear to be necessary to trend BNP measurements in attempts to liberate patients from prolonged mechanical ventilation.

Postpartum Migraine Headache Coding in Electronic Health Records of a Large Integrated Health Care System: Validation Study.

BACKGROUND: Migraine is a common neurological disorder characterized by repeated headaches of varying intensity. The prevalence and severity of migraine headaches disproportionally affects women, particularly during the postpartum period. Moreover, migraines during pregnancy have been associated with adverse maternal outcomes, including preeclampsia and postpartum stroke. However, due to the lack of a validated instrument for uniform case ascertainment on postpartum migraine headache, there is uncertainty in the reported prevalence in the literature. OBJECTIVE: The aim of this study was to evaluate the completeness and accuracy of reporting postpartum migraine headache coding in a large integrated health care system's electronic health records (EHRs) and to compare the coding quality before and after the implementation of the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) codes and pharmacy records in EHRs. METHODS: Medical records of 200 deliveries in all 15 Kaiser Permanente Southern California hospitals during 2 time periods, that is, January 1, 2012 through December 31, 2014 (International Classification of Diseases, 9th revision, Clinical Modification [ICD-9-CM] coding period) and January 1, 2017 through December 31, 2019 (ICD-10-CM coding period), were randomly selected from EHRs for chart review. Two trained research associates reviewed the EHRs for all 200 women for postpartum migraine headache cases documented within 1 year after delivery. Women were considered to have postpartum migraine headache if either a mention of migraine headache (yes for diagnosis) or a prescription for treatment of migraine headache (yes for pharmacy records) was noted in the electronic chart. Results from the chart abstraction served as the gold standard and were compared with corresponding diagnosis and pharmacy prescription utilization records for both ICD-9-CM and ICD-10-CM coding periods through comparisons of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), as well as the summary statistics of F-score and Youden J statistic (J). The kappa statistic (κ) for interrater reliability was calculated. RESULTS: The overall agreement between the identification of migraine headache using diagnosis codes and pharmacy records compared to the medical record review was strong. Diagnosis coding (F-score=87.8%; J=82.5%) did better than pharmacy records (F-score=72.7%; J=57.5%) when identifying cases, but combining both of these sources of data produced much greater accuracy in the identification of postpartum migraine cases (F-score=96.9%; J=99.7%) with sensitivity, specificity, PPV, and NPV of 100%, 99.7%, 93.9%, and 100%, respectively. Results were similar across the ICD-9-CM (F-score=98.7%, J=99.9%) and ICD-10-CM coding periods (F-score=94.9%; J=99.6%). The interrater reliability between the 2 research associates for postpartum migraine headache was 100%. CONCLUSIONS: Neither diagnostic codes nor pharmacy records alone are sufficient for identifying postpartum migraine cases reliably, but when used together, they are quite reliable. The completeness of the data remained similar after the implementation of the ICD-10-CM coding in the EHR system.

Immune repertoire analysis of normal Chinese donors at different ages.

OBJECTIVES: This study investigated the characteristics of the immune repertoire in normal Chinese individuals of different ages. MATERIALS AND METHODS: In this study, all seven receptor chains from both B and T cells in peripheral blood of 16 normal Chinese individuals from two age groups were analyzed using high-throughput sequencing and dimer-avoided multiplex PCR amplification. Normal in this study is defined as no chronic, infectious or autoimmune disease within 6 months prior to blood draw. RESULTS: We found that compared with the younger group, the clonal expression of T-cell receptor repertoire increased in the older group, while diversity decreased. In addition, we found that the T-cell receptor repertoire was more significantly affected by age than the B-cell receptor repertoire, including significant differences in the use of the unique TCR-alpha and TCR-beta V-J gene combinations, in the two groups of normal participants. We further analyzed the degree of complementarity determining region 3 sequence sharing between the two groups, and found shared TCR-alpha, TCR-gamma, immunoglobulin-kappa and immunoglobulin-lambda chain complementarity determining region 3 sequences in all subjects. CONCLUSION: Taken together, our study gives us a better understanding of the immune repertoire of different normal Chinese people, and these results can be applied to the treatment of age-related diseases. Immune repertoire analysis also allows us to observe participant's wellness, aiding in early-stage diagnosis.

2021 Clinical Update in Liver Transplantation.

In 2021, the United States performed 9,236 liver transplantations, an increase of 3.7% from 2020. As the specialty of transplant anesthesiologist continues to grow, so does the body of evidence-based research to improve patient care. New technology in organ preservation offers the possibility of preserving marginal organs for transplant or improving the graft for transplantation. The sequalae of end-stage liver disease have wide-ranging consequences that affect neurologic outcomes of patients both during and after transplantation that anesthesiologists should monitor. Obesity presents several challenges for anesthesiologists. As an increasing number of patients with nonalcoholic steatohepatitis are listed for transplant, managing their multiple comorbidities can be challenging. Finally, the rebalanced hemostasis of end-stage liver disease can cause both bleeding and thrombus. Often, bleeding risks predominate as a concern, but anesthesiologists should be aware of risks of intracardiac thrombus and review therapeutic options for prevention and treatment.

An Exploratory Case Study of the Types of Resources Black Boys Use to Support Their Mental Health.

Black adolescent boys experience mental health challenges because of their exposure to a greater frequency and severity of psychosocial stressors. This study used a sample of Black boys at a high school in southeastern Michigan as a case study to understand the types of resources Black boys might use to support their mental health. After conducting a rigorous analysis of the study data using a rapid and an accelerated data reduction technique, four themes helped us answer the question: What kinds of mental health support resources are Black boys using? Four themes emerged from our analysis: online resources, community and trusted individuals, self-reliance, and additional needs. This case study is a springboard for further work to tailor a mental health education and support intervention, such as the YBMen Project, for Black boys and for building additional support amid the multiple crises occurring that impact their mental health and safety. Findings have implications for future research, practice, and policy to improve the mental health of Black boys in high school.

Inhibitory control, working memory and coping with stress: Associations with symptoms of anxiety and depression in adults with Huntington's disease.

OBJECTIVE: Huntington's disease (HD) is an autosomal dominant neurodegenerative disease characterized by neuropsychiatric symptoms (e.g., anxiety and depression), where individuals suffer high levels of stress from the social, physical, and cognitive burden of the disease. The present study examined two factors associated with increased risk for symptoms of anxiety and depression: executive function skills (inhibitory control/attention and working memory) and skills to cope with stress. METHOD: Adults with HD completed the NIH Toolbox measures of inhibitory control/attention and working memory, as well as self-report measures of coping with HD-related stress and symptoms of anxiety and depression. Path analyses were used to test direct and indirect associations among the subtypes of executive functioning, coping, and symptoms. RESULTS: No significant associations were found in the full sample (n = 47), due to a significant portion of the sample with very low executive function abilities. Additional analyses were conducted on a subset of the sample (participants in the top three quartiles on both measures of executive functioning, n = 32). Significant indirect associations emerged among inhibitory control/attention skills, secondary control coping (e.g., acceptance and reappraisal), and symptoms of anxiety and depression in the subsample. Higher inhibitory control/attention skills were associated with greater use of secondary control coping, and greater use of these coping skills was related to lower symptoms of anxiety and depression. No direct or indirect associations were found among working memory skills, coping, and symptoms of anxiety and depression. CONCLUSIONS: Implications for interventions to enhance executive function and coping skills in adults with HD are highlighted. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

2020 Clinical Update in Liver Transplantation.

The gold standard treatment of end-stage liver disease continues to be liver transplantation (LT). The challenges of LT require skilled anesthesiologists to anticipate physiologic changes associated with end-stage liver disease and surgical considerations that affect multiple organ systems. While on the waiting list, patients may be placed on new anticoagulation medications that can confound already complex coagulopathy in LT patients. Pain management often is an afterthought for such a complex procedure, but appropriate medications can help control pain while limiting opioid medications. Surgical stress and medications for immunosuppression can affect perioperative glucose management in ways that have implications for patient and graft survival. The coronavirus disease 2019 pandemic in 2020 provided a new challenge for anesthesiologists. The uncertainty of the novel respiratory virus challenged providers beyond just LT patients.

Gender and Racial Identity Moderate the Effects of Online and Offline Discrimination on Mental Health: Dismantling Systems of Racism and Oppression during Adolescence.

The present study highlights the growing need to examine Black youths' exposure to racial discrimination in online and offline contexts. Using a sample of 353 Black college students, findings indicate that high public regard moderates the positive association between online and offline racial discrimination and psychological consequences (i.e., depression, anxiety, and psychological well-being) among Black women. Additionally, racial centrality moderated the positive association between online and offline racial discrimination and mental health consequences regardless of gender. The findings highlight the importance of considering context, gender, and racial identity when examining the links between Black emerging adults' experiences of discrimination and mental health.

Use of unattended automated office blood pressure in Utah primary care clinics.

AIM: Unattended automated office blood pressure (BP) measurement (u-AOBP) improves office BP measurement accuracy and reduces white-coat BP elevation. u-AOBP is recommended as the preferred office BP measurement technique by multiple hypertension guidelines. This study examines utilization, performance, and potential barriers to implementation of u-AOBP in Utah primary care clinics following 5 years of promotional efforts by the Utah Million Hearts Coalition (UMHC). METHODS: An online questionnaire was administered to 285 Utah primary care clinics to evaluate self-reported use of u-AOBP and u-AOBP technique, interpretation of results, and perceived barriers to implementation. RESULTS: Seventy-nine of 285 clinics (27.7%) completed the full questionnaire. Fifty-nine clinics (74.7%) use u-AOBP. Nearly 65% first learned about u-AOBP through UMHC promotional efforts rather than from the medical literature. One-half of these clinics noted no significant barriers to u-AOBP implementation, and over 80% noted no reduction in medical staff productivity. However, important knowledge deficits concerning correct u-AOBP performance and interpretation of results were apparent from answers to the questionnaire. CONCLUSION: After 5 years of UMHC promotional efforts, at least 20% of the 285 Utah primary care clinics invited to take the questionnaire and 75% of the 79 clinics completing the survey have incorporated u-AOBP and found it feasible in a primary care setting. Ongoing promotion of u-AOBP implementation at the local and regional level is required to extend its utilization. Effective, accessible educational materials and local technical assistance from public health and community partners are needed to correct knowledge and performance deficits to optimize u-AOBP utilization in primary care.

Medicolegal Aspects of Huntington Disease.

Unlawful behaviors have been reported in association with Huntington's disease (HD), although their overall prevalence and clinical significance remain unknown. Recognition of problematic behavior is limited by stigma and lack of routine clinical assessment, as well as the absence of validated screening measures. We performed a retrospective chart review of 289 patients treated for HD at Vanderbilt University Medical Center from 2006 to 2020 to assess the frequency of illegal activity in our HD population. We identified 31 patients with HD who have a documented history of unlawful behavior, comprising 11 percent of the charts reviewed. Physical violence was the most common behavior reported, followed by reckless driving, substance abuse, illegal financial activity, and inappropriate sexual behavior. Mean age at the time of the first offense was 37 years. Patients with criminal offenses were more likely to be male and in the early stages of disease with associated psychiatric symptoms. Our results emphasize that illegal activities are a significant clinical problem in individuals with HD, particularly young adult males with comorbid psychiatric symptoms. These findings highlight the need for improved screening measures to detect high-risk behaviors in individuals with HD, as well as evidence-based protocols to guide triage and management of patients engaging in potentially detrimental activities.

Neurobiological and Psychosocial Correlates of Communication Between Huntington's Disease Patients and Their Offspring.

OBJECTIVE: Huntington's disease (HD) is an autosomal dominant neurodegenerative disease that presents significant challenges to family communication. The investigators examined observations of communication between parents with HD and their offspring talking about the challenges of HD and explored potential correlates of their communication. METHODS: The sample included parents with HD and their adolescent and young-adult offspring (N=64). Parent communication and chorea were independently coded from video recordings. Parents and offspring completed working memory assessments and self-reports of neuropsychiatric symptoms, stress, and coping. RESULTS: Evidence was found for the association of observed parent-offspring communication with disease markers, psychosocial characteristics, and neurocognitive function. For parents, disease markers and working memory were correlates of communication, whereas offspring's psychiatric symptoms, stress, and coping were associated with their communication. CONCLUSIONS: These findings have potential implications for clinical interventions to enhance communication and quality of life for HD families.

Healthcare Delivery and Huntington's Disease During the Time of COVID-19.

BACKGROUND: Safer-at-home orders during the COVID-19 pandemic altered the structure of clinical care for Huntington's disease (HD) patients. This shift provided an opportunity to identify limitations in the current healthcare infrastructure and how these may impact the health and well-being of persons with HD. OBJECTIVE: The study objectives were to assess the feasibility of remote healthcare delivery in HD patients, to identify socioeconomic factors which may explain differences in feasibility and to evaluate the impact of safer-at-home orders on HD patient stress levels. METHODS: This observational study of a clinical HD population during the 'safer-at-home' orders asked patients or caregivers about their current access to healthcare resources and patient stress levels. A chart review allowed for an assessment of socioeconomic status and characterization of HD severity. RESULTS: Two-hundred and twelve HD patients were contacted with 156 completing the survey. During safer-at-home orders, the majority of HD patients were able to obtain medications and see a physician; however, 25% of patients would not commit to regular telehealth visits, and less than 50% utilized an online healthcare platform. We found that 37% of participants were divorced/single, 39% had less than a high school diploma, and nearly 20% were uninsured or on low-income health insurance. Patient stress levels correlated with disease burden. CONCLUSION: A significant portion of HD participants were not willing to participate in telehealth services. Potential explanations for these limitations may include socioeconomic barriers and caregiving structure. These observations illustrate areas for clinical care improvement to address healthcare disparities in the HD community.

A human monoclonal antibody blocks malaria transmission and defines a highly conserved neutralizing epitope on gametes.

Malaria elimination requires tools that interrupt parasite transmission. Here, we characterize B cell receptor responses among Malian adults vaccinated against the first domain of the cysteine-rich 230 kDa gamete surface protein Pfs230, a key protein in sexual stage development of P. falciparum parasites. Among nine Pfs230 human monoclonal antibodies (mAbs) that we generated, one potently blocks transmission to mosquitoes in a complement-dependent manner and reacts to the gamete surface; the other eight show only low or no blocking activity. The structure of the transmission-blocking mAb in complex with vaccine antigen reveals a large discontinuous conformational epitope, specific to domain 1 of Pfs230 and comprising six structural elements in the protein. The epitope is conserved, suggesting the transmission-blocking mAb is broadly functional. This study provides a rational basis to improve malaria vaccines and develop therapeutic antibodies for malaria elimination.

Emergency preparation and mitigation for COVID-19 response in an integrated pharmacy practice model.

PURPOSE: The purpose of this descriptive report is to share experiences in crisis response planning and risk mitigation at a university health system department of pharmacy with an integrated clinical practice model in the early months of the coronarvirus disease 2019 (COVID-19) pandemic. SUMMARY: The department of pharmacy's COVID-19 pandemic response included successful planning and implementation of measures to maintain pharmacy operations and minimize COVID-19 exposure of patients and staff. These measures included ensuring adequate personnel staffing using flexible staffing solutions, ongoing assessment of supply chain integrity, and continuation of integrated clinical pharmacy services 24/7 throughout the initial phase of the COVID-19 pandemic. Information technology (IT) and educational program modifications are also discussed. CONCLUSION: This report describes successful crisis planning and risk mitigation in the setting of COVID-19, which was facilitated by the department of pharmacy's integrated clinical practice model. This model enabled uninterrupted personnel scheduling, supply chain integrity, continued provision of 24/7 integrated clinical services, adaptive use of IT tools, and continuation of educational programs. The experiences described may be instructive to other pharmacy departments in evaluating their response to the COVID-19 pandemic and in planning for similar pandemic or other emergency scenarios.

2019 Clinical Update in Liver Transplantation.

Liver transplantation continues be the standard for treatment of end-stage liver disease, and even with recent advances in organ preservation, the anesthetic management continues to require understanding of multiple organ systems beyond the liver. Multiple factors contribute to hemodynamic changes after reperfusion of the liver graft that anesthesiologists should be aware of before unclamping. Concomitant renal dysfunction in end-stage liver disease is not uncommon, and preparation for continuous renal replacement therapy may need to be considered in certain cases. Cardiac evaluation of liver transplantation patients with an emphasis on arrhythmias, including atrial fibrillation, can help prevent both intraoperative and postoperative complications detrimental to the patient and graft. Finally, combined liver and thoracic organ transplantations may be indicated for certain disease processes that affect multiple organs. These cases require an understanding of the surgical technique and acknowledgment that some goals of the procedures may be in direct opposition to each other.

Virus-induced genetics revealed by multidimensional precision medicine transcriptional workflow applicable to COVID-19.

Precision medicine requires the translation of basic biological understanding to medical insights, mainly applied to characterization of each unique patient. In many clinical settings, this requires tools that can be broadly used to identify pathology and risks. Patients often present to the intensive care unit with broad phenotypes, including multiple organ dysfunction syndrome (MODS) resulting from infection, trauma, or other disease processes. Etiology and outcomes are unique to individuals, making it difficult to cohort patients with MODS, but presenting a prime target for testing/developing tools for precision medicine. Using multitime point whole blood (cellular/acellular) total transcriptomics in 27 patients, we highlight the promise of simultaneously mapping viral/bacterial load, cell composition, tissue damage biomarkers, balance between syndromic biology versus environmental response, and unique biological insights in each patient using a single platform measurement. Integration of a transcriptome workflow yielded unexpected insights into the complex interplay between host genetics and viral/bacterial specific mechanisms, highlighted by a unique case of virally induced genetics (VIG) within one of these 27 patients. The power of RNA-Seq to study unique patient biology while investigating environmental contributions can be a critical tool moving forward for translational sciences applied to precision medicine.

Association of prenatal opiate exposure with youth outcomes assessed from infancy through adolescence.

OBJECTIVE: This study examined acute findings and long-term outcome trajectories between birth and adolescence in children with prenatal opiate exposure. STUDY DESIGN: Ninety children (45 opiate-exposed, 45 non-exposed) completed assessments between 1 month and 15 years of age. Outcome variables (medical, anthropomorphic, developmental, and behavioral) were analyzed at individual time points and using longitudinal statistical modeling. RESULTS: Opiate-exposed infants displayed transient neurologic findings, but no substantial signs or symptoms long term. There were no group differences in growth, cognitive functioning, or behavior at individual time periods; however, the trajectories of outcomes using longitudinal analyses adjusting for variables known to impact outcome demonstrated increased deficits among opiate-exposed children over time with regards to weight, head circumference, cognitive functioning, and behavior. CONCLUSIONS: Findings support concerns that maternal opiate use during pregnancy may negatively impact a child's developmental trajectory, which in turn may impose concerns to society (e.g., increased need for social, medical, and/or educational services).