Influence of ICU Surge and Capacity on COVID Mortality Across U.S. States and Regions During the COVID-19 Pandemic.

BACKGROUND: To describe the influence of COVID-19 caseload surges and overall capacity in the intensive care unit (ICU) on mortality among US population and census divisions. METHODS: A retrospective analysis of the national COVID ActNow database between January 1, 2021 until March 1, 2022. The main outcome used was COVID-19 weekly mortality rates, which were calculated and incorporated into several generalized estimation of effects models with predictor variables that included ICU bed capacity, as well as ICU capacity used by COVID cases while adjusting for ratios of vaccinations in populations, case density, and percentage of the population over the age of 65. RESULTS: Each 1% increase in general ICU capacity is correlated with approximately 5 more weekly deaths from COVID-19 per 100,000 population and each percentage increase in the number of patients with COVID-19 admitted to the ICU resulted in approximately 10 more COVID-19 deaths per week per 100,000 population. Significant differences in ability to handle caseload surges were observed across US census divisions. CONCLUSIONS: A strong association was observed between COVID-19 ICU surges, overall ICU surge, and increased mortality. Further research is needed to reveal best practices and public health measures to prevent ICU overcrowding amidst future pandemics and disaster responses.

Complex Management of AV Nodal Agent Toxicity in Patients with Cardiac Devices: Massive Calcium Channel Antagonist Overdose in a Patient with a Permanent Pacemaker.

We present a unique case of a massive calcium channel antagonist overdose in a patient with a permanent pacemaker. Upon presentation after the acute overdose, the patient's cardiac device was found to be pacing to an adequate rate (75 beats per minute) and she was admitted to the cardiac intensive care unit. Approximately 24 hours after her ingestion, she acutely decompensated and became hypotensive. The patient was started on infusions of norepinephrine, epinephrine, phenylephrine, and vasopressin. Her mean arterial pressure was unresponsive to multi-vasopressor therapy. She was then given a bolus of methylene blue and high-dose insulin euglycemic therapy. Despite these treatments, the patient remained hypotensive Therefore, intralipid emulsion therapy and IV epinephrine pushes were also administered. As a result of her shock and hemodynamic instability, her course was further complicated by hypoxemic respiratory failure for which she required ventilatory support and developed oliguric renal failure for which she was initiated on continuous veno-venous hemofiltration. This case emphasizes the challenges in managing complex physiology associated with nodal agent toxicity and is the first, to our knowledge, to describe management in a patient who already had a pacemaker, though it was ultimately ineffective in avoiding the patient's profound decompensation.

"When Her Visa Expired, the Family Refused to Renew It," Intersections of Human Trafficking and Domestic Violence: Qualitative Document Analysis of Case Examples from a Major Midwest City.

This study aimed to further understand typologies of trafficking that occur in the home, by an individual's intimate partner (IP) or family members and this overlap with extant knowledge on perpetrator manipulation via the Power and Control Wheel. Inductive and deductive techniques were used to analyze secondary data from a federally funded anti-trafficking program in a Midwest metropolitan area recorded between 2008 and 2017. Cases were included if there was indication of sex or labor exploitation initiated by an IP, family member, or other in the domestic setting via elements of abuse; 59 cases of 213 met this criteria. Most cases included the IP as the trafficker, followed by family members, then others in the domestic setting. Abuse was more commonly used than the threat of abuse. From the Power and Control Wheel, the most frequent types of abuse were using privilege, physical abuse, economic abuse, isolation, and sexual abuse. Case typologies included: those with elements of sex trafficking, specifically forced commercial sex by an IP or family member; those with elements of labor trafficking such as domestic servitude (with or without childcare provision abuse), exploitation in a family business by an IP or family member, or work environments by family and non-family; those with elements of sex and labor trafficking included servile partnerships and forced marriage. Trafficking exploitation by an IP, family member, or in the domestic setting is not uncommon. Intimate relationships with a trafficker, psychological coercion, and threats may reduce reporting of abuse, subsequent provision of services, and result in misclassification as victims of IP violence. This study sheds light on various typologies of trafficking and exploitation in the domestic setting, further expanding the anti-trafficking movement's evidence base for intervention and prevention and adding complexity and nuance to the pathways to trafficking exploitation.

A pilot study evaluating a simple cardiac dysfunction score to predict complications and survival among critically-ill patients with traumatic brain injury.

PURPOSE: To describe the frequency of cardiovascular complications and cardiac dysfunction in critically-ill patients with moderate-severe traumatic brain injury (msTBI) and cardiac factors associated with in-hospital survival. METHODS: Retrospective analysis of a prospective cohort study at a single Level-1 trauma center with a dedicated neuro-trauma intensive care unit (ICU). Adult patients admitted to the ICU with msTBI were consecutively enrolled in the prospective OPTIMISM study between November 2009 and January 2017. Cardiac dysfunction was measured using a combination of EKG parameters, echocardiography abnormalities, and peak serum troponin-I levels during the index hospitalization. These items were combined into a cardiac dysfunction index (CDI), ranging from 0 to 3 points and modeled in a Cox regression analysis. RESULTS: A total of 326 patients with msTBI were included. For every one-point increase in the CDI, the multivariable adjusted risk of dying during the patient's acute hospitalization more than doubled (adjusted HR 2.41; 95% CI 1.29-4.53). CONCLUSION: Cardiac dysfunction was common in patients with msTBI and independently associated with more severe brain injury and a reduction in hospital survival in this population. Further research is needed to validate the CDI and create more precise scoring tools.

A systematic review of smartphone applications for smoking cessation.

Tobacco use is the leading cause of preventable disease and death in the USA. However, limited data exists regarding smoking cessation mobile app quality and intervention effectiveness. Innovative and scalable interventions are needed to further alleviate the public health implications of tobacco addiction. The proliferation of the smartphone and the advent of mobile phone health interventions have made treatment more accessible than ever. The purpose of this review was to examine the relation between published scientific literature and available commercial smartphone health apps for smoking cessation to identify the percentage of scientifically supported apps that were commercially available to consumers and to determine how many of the top commercially available apps for smoking cessation were supported by the published scientific literature. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, apps were reviewed in four phases: (1) identified apps from the scientific literature, (2) searched app stores for apps identified in the literature, (3) identified top apps available in leading app stores, and (4) determined which top apps available in stores had scientific support. Seven articles identified six apps with some level of scientific support, three (50%) were available in at least one app store. Conversely, among the top 50 apps suggested by each of the leading app stores, only two (4%) had any scientific support. While half of the scientifically vetted apps remain available to consumers, they are difficult to find among the many apps that are identified through app store searches.

Identification and Treatment of Human Trafficking Victims in the Emergency Department: A Case Report.

BACKGROUND: Human trafficking victims experience extreme exploitation and have unique health needs, yet too often go undetected by physicians and providers in the Emergency Department (ED). We report a clinical case of human trafficking of a white, English-speaking United States citizen and discuss the features of presentation and treatment options for human trafficking victims upon presentation to the ED. CASE REPORT: A 29-year-old woman with a past medical history significant for intravenous drug abuse and recent relapse presented to the ED after a reported sexual assault. The patient was discharged that evening and returned to the ED the following day acutely suicidal. The patient divulged that she had been kidnapped and raped at gunpoint by numerous individuals as a result of a debt owed to her drug dealers. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Many human trafficking victims present to an ED during the course of their exploitation. To that end, EDs provide one of a limited set of opportunities to intervene in the human trafficking cycle of exploitation, and physicians as well as other ED staff should be equipped to respond.