A Multisite Electronic Health Record Integrated Remote Monitoring Intervention for Hypertension Improvement: Protocol for a Randomized Pragmatic Comparative Effectiveness Trial.

BACKGROUND: Hypertension is a major contributor to various adverse health outcomes. Although previous studies have shown the benefits of home blood pressure (BP) monitoring over office-based measurements, there is limited evidence comparing the effectiveness of whether a BP monitor integrated into the electronic health record is superior to a nonintegrated BP monitor. OBJECTIVE: In this paper, we describe the protocol for a pragmatic multisite implementation of a quality improvement initiative directly comparing integrated to nonintegrated BP monitors for hypertension improvement. METHODS: We will conduct a randomized, comparative effectiveness trial at 3 large academic health centers across California. The 3 sites will enroll a total of 660 participants (approximately n=220 per site), with 330 in the integrated BP monitor arm and 330 in the nonintegrated BP control arm. The primary outcome of this study will be the absolute difference in systolic BP in mm Hg from enrollment to 6 months. Secondary outcome measures include binary measures of hypertension (controlled vs uncontrolled), hypertension-related health complications, hospitalizations, and death. The list of possible participants will be generated from a central data warehouse. Randomization will occur after enrollment in the study. Participants will use their assigned BP monitor and join site-specific hypertension interventions. Cross-site learning will occur at regular all-site meetings facilitated by the University of California, Los Angeles Value-Based Care Research Consortium. A pre- and poststudy questionnaire will be conducted to further evaluate participants' perspectives regarding their BP monitor. Linear mixed effects models will be used to compare the primary outcome measure between study arms. Mixed effects logistic regression models will be used to compare secondary outcome measures between study arms. RESULTS: The study will start enrolling participants in the second quarter of 2023 and will be completed by the first half of 2024. Results will be published by the end of 2024. CONCLUSIONS: This pragmatic trial will contribute to the growing field of chronic care management using remote monitoring by answering whether a hypertension intervention coupled with an electronic health record integrated home BP monitor improves patients' hypertension better than a hypertension intervention with a nonintegrated BP monitor. The outcomes of this study may help health system decision makers determine whether to invest in integrated BP monitors for vulnerable patient populations. TRIAL REGISTRATION: ClinicalTrials.gov NCT05390502; clinicaltrials.gov/study/NCT05390502. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/45915.

Effects of neuromuscular electrical stimulation on glycemic control: a systematic review and meta-analysis.

Background: Physical inactivity increases the risk for metabolic diseases such as obesity and type 2 diabetes. Neuromuscular electrical stimulation (NMES) is an effective method to induce muscle contraction, particularly for populations with physical impairments and/or metabolic diseases. However, its effectiveness to improve glycemic control is unclear. This review aimed to determine the effectiveness of NMES on glycemic control. Methods: Electronic search consisted of MEDLINE (PubMed), EMBASE, Cochrane Library, Google Scholar, and Web of Science to identify studies that investigated the effects of NMES on glycemic control for this systematic review. The meta-analysis consists of the studies designed as randomized controlled trials. Effect sizes were calculated as the standardized mean difference (SMD) and meta-analysis was conducted using a random-effects model. Results: Thirty-five studies met the inclusion criteria for systematic review and of those, nine qualified for the meta-analysis. Existing evidence suggested that NMES effectively improves glycemic control predominantly in middle-aged and elderly population with type 2 diabetes, obesity, and spinal cord injury. The meta-analysis is comprised of 180 participants and reported that NMES intervention lowered fasting blood glucose (SMD: 0.48; 95% CI: 0.17 to 0.78; p=0.002; I²=0%). Additional analysis using the primary measures reported by each study to indicate glycemic control (i.e., OGTT, HOMA-IR, and fasting glucose) also confirmed a significant effect of NMES on improving glycemic control (SMD: 0.41; 95% CI, 0.09 to 0.72; p=0.01; I²=11%). NMES protocol varied across studies and requires standardization. Conclusion: NMES could be considered as a therapeutic strategy to improve glycemic control in populations with physical impairments and/or metabolic disorders. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42020192491.

Multimodal Analgesia's Impact on Opioid Use and Adverse Drug Effects in a Multihospital Health System.

Purpose:In addition to opioid abuse and dependency, opioid use can lead to opioid related adverse drug events (ORADEs). ORADEs are associated with increased length of stay, cost of care, 30-day readmission rate, and inpatient mortality. The addition of scheduled non-opioid analgesic medications has shown to be effective in reducing opioid utilization in post-surgical and trauma populations, but evidence in entire hospital patient populations is limited. The objective of this study was to determine the effects of a multimodal analgesia order set on opioid utilization and adverse drug events in adult hospitalized patients. Methods: This retrospective pre/post implementation analysis was conducted at 3 community hospitals and a level II trauma center between January 2016 and December 2019. Patients included were 18 years of age or older, admitted for greater than 24 hours, and had at least one opioid ordered during hospital admission. The primary outcome of this analysis was the average oral morphine milligram equivalents (MME) used on days 1 through 5 of hospitalization. Secondary outcomes included the percentage of hospitalized patients with an opioid ordered for analgesia who received a scheduled non-opioid analgesic medication, the average number of ORADEs recorded in nursing assessments on hospitalization days 1 through 5, length of stay, and mortality. Multimodal analgesic medications included acetaminophen, gabapentinoids, non-steroidal anti-inflammatory drugs, muscle relaxants, and transdermal lidocaine. Results: The pre- and post-groups included 86 535 patients and 85 194 patients, respectively. The average oral MMEs used on days 1 through 5 were lower in the post-group (P < .0001). Utilization of multimodal analgesia as measured by the percentage of patients with 1 or more scheduled multimodal analgesia agent ordered increased from 33% to 49% at the end of the analysis. Conclusion: Utilization of a multimodal analgesia order set was associated with a decrease in opioid use and an increase in multimodal analgesia use in an entire hospital adult population.

Pharmacist-driven epoetin alfa-epbx dosing for hospitalized patients.

PURPOSE: To determine the effectiveness of pharmacy consultation in managing epoetin alfa-epbx dosing for inpatients on hemodialysis. METHODS: This multisite, retrospective cohort study evaluated the implementation of an initial dose consultation for epoetin alfa-epbx by pharmacists. A pre-post cohort study evaluated patients from August 2020 through January 2021 and August 2021 through January 2022, respectively. Hospitalized patients were included if they were at least 18 years of age, received hemodialysis, and were administered an erythropoiesis-stimulating agent (ESA) for anemia due to chronic kidney disease. Patients were excluded for religious objections to receiving blood products or if patients were discharged or died before their first hemodialysis session. The primary outcome was the average epoetin alfa-epbx acquisition cost per patient. Secondary endpoints were the epoetin alfa-epbx overall pharmacy purchasing cost, the average dose, and the number of administered doses. A subgroup analysis was performed for patients in the post group with an outpatient ESA before admission to determine the epoetin alfa-epbx days saved. RESULTS: A total of 264 patients were included in the pre group, and 272 patients were included in the post group. The average acquisition cost was significantly lower in the post group ($1,681.77 vs $1,041.35, P < 0.0001). The overall pharmacy purchasing cost was also lower in the post group ($148,970.89 vs $127,873.25). The post group had a significantly lower average dose (13,694 vs 10,112 units, P = 0.0004), while the number of administered doses did not differ significantly between the groups (2.09 vs 1.79 doses, P = 0.0668). The subgroup analysis included 83 patients, which yielded 53 epoetin alfa-epbx days saved. CONCLUSION: Pharmacist-driven ESA dosing was associated with significant decreases in ESA average acquisition cost and average total dose per patient.

A Variable Selection Algorithm for Creating Replicable Factor Structures.

Exploratory and confirmatory factor analyses are commonly employed to identify and explore underlying factor structures. Unfortunately, when variable selection is involved, results often fluctuate across studies making it difficult to determine the "best" and most replicable factor structure. This study proposes a new factor analysis variable selection algorithm called the Replicable Factor Analytic Solutions (RFAS) that incorporates sound statistical and psychometric practices when selecting the final factor structure, while simultaneously examining the observed variables and factor structures replicability. This article outlines the algorithm development and rationale for each decision in the algorithm's development. An example using simulated and empirical data is also provided to display the algorithm results and delineate the utility of these results for future analysts.

Características de mujeres en puerperio valoradas por el programa Cuidamujer / Characteristics of postpartum women evaluated by the Cuidamujer program

Introducción: el puerperio es un periodo de alta vulnerabilidad y las complicaciones pueden asociarse con elevada mortalidad materna. El programa Cuidamujer está enfocado en educación durante el puerperio. Objetivo: describir las características sociodemográficas y psicosociales del programa Cuidamujer entre noviembre 2018 y diciembre 2019. Materiales y métodos: estudio descriptivo, transversal y retrospectivo. La información se obtuvo de las historias clínicas para el análisis descriptivo de las variables sociodemográficas y clínicas con el software SPSS IBM® V 20. Resultados: se incluyeron 712 mujeres entre 18 y 35 años con bachillerato completo, 79.2% pertenecían a familia nuclear y 63,5% estaban en el ciclo vital familiar en expansión. 15.7% asistieron a consulta preconcepcional, 62.9% y 9% presentaban alto riesgo obstétrico y psicosocial, la tasa de cesárea fue 74.7% y las actividades educativas y de anticoncepción tuvieron cobertura de 99%, recibiéndolas al egreso hospitalario el 82.72%. Conclusiones: el perfil de las mujeres en puerperio es de adultas jóvenes con educación secundaria y familias nucleares en expansión, pobre adherencia a atención preconcepcional, bajo riesgo psicosocial y alto riesgo obstétrico. Llama la atención las tasas elevadas de cesárea, lo cual merece ser estudiado en esta población.

Introduction: the puerperium period carries high maternal vulnerability and complications which may lead to high maternal mortality. The Cuidamujer program is centered on providing postpartum education. Objective: to describe the sociodemographic and psychosocial characteristics of the Cuidamujer program between November 2018 and December 2019. Materials and methods: a descriptive, retrospective cross-sectional study. Information was obtained from medical records and used for the descriptive analysis of socio-demographic and clinical variables in the SPSS IBM® V 20 software. Results: 712 women aged between 18 and 35 years with completed high school were included, 79.2% belonged to nuclear families and 63.5% were in the expanding family life cycle; 15.7% attended a preconception care program; 62.9% and 9% had high obstetric and psychosocial risk; the cesarean section rate was 74.7% and the educational and contraceptive counseling activities coverage was 99%; 82.72% received the latter at hospital discharge. Conclusions: the profile of postpartum women is that of young adults with secondary education and expanding nuclear families, poor adherence to preconception care, low psychosocial risk and high obstetric risk. The high cesarean section rates are noteworthy and deserve to be studied in this population.

Review of Pharmacist Driven Penicillin Allergy Assessments and Skin Testing: A Multi-Center Case-Series.

Objective: To describe the impact of pharmacy driven penicillin allergy assessments on de-labeling penicillin allergies and antibiotic streamlining opportunities for hospitalized patients. Design: Multi-center, retrospective case-series study. Setting: A health system of 4 non-teaching hospitals. Participants: Patients aged 18 years and older with a physician order for a pharmacist penicillin allergy assessment. Exclusion criteria consisted of patients with anaphylaxis or a type II penicillin allergy, anaphylaxis of any cause within 4 weeks, refusal of penicillin allergy skin test (PAST), antihistamine use within 24 hours, penicillin intolerance, immunosuppression or immunosuppressive medications, or skin conditions that could interfere with PAST. Interventions: The primary endpoint evaluated the number of de-labeled penicillin allergies after pharmacists provided penicillin allergy assessments. Secondary endpoints evaluated the percent of patients with antibiotics deescalated to beta-lactam antibiotics and classification of notable interventions made by pharmacists. Measurements and Main Results: There were 35 patients who met inclusion criteria. Twenty-four patients underwent both penicillin allergy skin testing and oral (PO) amoxicillin challenge. Five patients had allergies de-labeled only after a pharmacist interview. Four patients received only the PO amoxicillin challenge and 2 patients received only PAST. Penicillin allergies were de-labeled from the electronic health record (EHR) in 31 (89%) patients despite all testing negative for a penicillin allergy from PAST or a PO amoxicillin challenge. Four patients had the allergy re-added to the chart on subsequent admissions. No patients experienced a reaction from PAST, PO amoxicillin challenge, or subsequent beta-lactam antibiotics. Twenty-eight (80%) patients had their antibiotic therapy changed as a result of the allergy assessment. Seventeen patients were de-escalated onto beta-lactam antibiotics and aztreonam was stopped in 6 patients. Conclusion: Results from this study suggests that pharmacists expanding their scope of practice with PAST is a safe and effective allergy de-labeling tool. Pharmacist-driven penicillin allergy assessments could provide antibiotic cost savings and avoid aztreonam use. The study supports the need to emphasize education for patients and caretakers regarding allergy testing results to avoid relabeling in future hospital visits.

A framework for addressing health inequities in sexual and gender diverse populations by nurses.

There is a need to increase health equity in sexual and gender diverse (SGD) populations, a medically underserved group with widening health disparities. To better understand and address SGD health disparities, we have developed a multi-level conceptual framework for nurse scientists that incorporates the concepts of stigma, intersectionality, identify affirmation, and life course trajectory. Social determinants of health formed the background of our conceptual framework. Using this framework, we proposed recommendations to promote SGD health equity through nursing research, health care practice, health care education, and public health care policy. These recommendations align with the National Institute of Nursing Research's goals of dismantling structures that perpetuate racism and impede health inequity and the need to implement interventions that address social determinants of health. As a result, nurse scientists are poised to influence health care policy by translating effective interventions to reduce health disparities for the SGD population into practice.

Retrospective identification of infection in the emergency department: A significant challenge in sepsis clinical trials.

BACKGROUND: This study examined three methods for retrospectively identifying infection in emergency department (ED) patients: modified objective definitions of infection (MODI) from the CDC/NHSN, physician adjudication determination of infection, and ED treating physician behavior. METHODS: This study used a subset of data from a prospective sepsis trial. We used Fleiss's Kappa to compare agreement between two physicians retrospectively adjudicating infection based on the patient's medical record, modified infection definition from the CDC/NHSN, and ED treating physician behavior. RESULTS: Overall, there was similar agreement between physician adjudication of infection and MODI criteria (Kappa=0.59) compared to having two physicians independently identify infection through retrospective chart review (Kappa=0.58). ED treating physician behavior was a poorer proxy for infection when compared to the MODI criteria (0.41) and physician adjudication (Kappa = 0.50). CONCLUSIONS: Retrospective identification of infection poses a significant challenge in sepsis clinical trials. Using modified definitions of infection provides a standardized, less time consuming, and equally effective means of identifying infection compared to having multiple physicians adjudicate a patient's chart.

Four weeks of electrical stimulation improves glucose tolerance in a sedentary overweight or obese Hispanic population.

Introduction/purpose: Most US adults (54%) do not meet the minimum exercise recommendations by the American College of Sports Medicine. Neuromuscular electrical stimulation (NMES) is a novel alternate strategy to induce muscle contraction. However, the effectiveness of NMES to improve insulin sensitivity and energy expenditure is unclear. The purpose of this study was to investigate the effects of 4 weeks of NMES on glucose tolerance in a sedentary overweight or obese population. Methods: Participants (n = 10; age: 36.8 ± 3.8 years; BMI = 32 ± 1.3 kg/m2) were randomized into either control or NMES group. All participants received bilateral quadriceps stimulation (12 sessions; 30 min/session; three times/week at 50 Hz and 300 µs pulse width) altering pulse amplitude to either provide low-intensity sensory level (control; tingling sensation) or at high-intensity neuromuscular level (NMES; maximum tolerable levels with visible muscle contraction). Glucose tolerance was assessed by a 3-h oral glucose tolerance test (OGTT), and substrate utilization was measured by indirect calorimetry and body composition via dual X-ray absorptiometry at baseline and after 4 weeks of NMES intervention. Results: Control and NMES groups had comparable fasting blood glucose, glucose tolerance, substrate utilization, and muscle mass at baseline. Four weeks of NMES resulted in a significant improvement in glucose tolerance measured by OGTT, whereas no change was observed in the control group. There was no change in substrate utilization and muscle mass in both control and NMES groups. Conclusion: NMES is a novel and effective strategy to improve glucose tolerance in an at-risk overweight or obese sedentary population.

Impact of a pharmacist-driven transitions of care clinic for a multisite integrated delivery network.

PURPOSE: To assess the impact on readmission rates for CMS core measures (CCM) patients and patients receiving care under the Bundled Payment for Care Improvement (BPCI) Advanced Model resulting from implementing a pharmacist-led transitions of care (TOC) clinic in central Florida. METHODS: These study cohorts consisted of patients in 2 strata (CCM and BPCI), and pre-post comparisons were conducted within each stratum. CCM and BPCI patient stratification was based on diagnoses. Patients referred to the TOC clinic were identified and compared to patients who did not receive TOC clinic services in the prior year. The pharmacist-led TOC clinic services consisted of a postdischarge telephone interview by a pharmacist to identify TOC barriers. Pharmacists in the TOC clinic conducted medication reconciliations, provided education, and completed follow-up telephone visits to mitigate these barriers. The primary outcome was the 30-day readmission rate for CCM patients and 90-day readmission rate for BPCI patients. The secondary outcomes were the numbers and types of interventions performed in the pharmacist-led TOC clinic. RESULTS: A total of 1,203 patients met the inclusion criteria for the CCM stratum. The CCM post-group had an overall reduction in the rate of 30-day readmission relative to the pre-group (6.25% vs 13.29%, P < 0.0327). A total of 1,416 patients met the inclusion criteria for the BPCI strata. Relative to the BPCI pre-group, the BPCI post-group had an overall reduction in occurrence of 90-day readmission (17.27% vs 25.61%, P < 0.0306). Clinical pharmacists performed 456 interventions in the CCM and BPCI post-groups, with an average of 2 interventions per patient. CONCLUSION: A pharmacist-driven TOC clinic was associated with significant reductions in 30-day CCM and 90-day BPCI hospital readmissions.

Evaluation of a Pharmacy-Driven Calcitonin Protocol for Treating Hypercalcemia in Hospitalized Patients: A Multisite Study.

BACKGROUND: The dramatic increase in the acquisition cost of injectable calcitonin led to creating a pharmacy-driven calcitonin protocol to improve the appropriate use of calcitonin and other treatment modalities for hypercalcemia. OBJECTIVE: This study aimed to characterize the use of calcitonin before and after implementation of a pharmacy-driven calcitonin protocol. METHODS: This was a multi-center, retrospective study of the use of injectable calcitonin in adult hospitalized patients with hypercalcemia. The study included patients treated with calcitonin from October 2014 to September 2016 and from October 2017 to September 2019. The primary outcomes were percentage of patients with a complete response, partial response, and non-responders. The secondary outcomes were time to relapse, duration of partial response, number of doses, and associated costs of calcitonin. RESULTS: Of the 131 patients included in this study, 93 were included in a pre-protocol group and 38 were included in a post-protocol group. The primary outcome of complete response by 3 days was met in 28% of patients in the pre-protocol group and 53% of patients in the post-protocol group (P = 0.007). Calcitonin spending in dollars in the pre-protocol group was $818,956 compared to $224,320 in the post-protocol group; a difference of $594,636. CONCLUSION: Implementation of a pharmacy-driven calcitonin protocol effectively improved calcium levels, reduced inappropriate calcitonin use, and reduced calcitonin spending during a period of 2 fiscal years.

Comparison of Clevidipine and Nicardipine for Acute Blood Pressure Reduction in Hemorrhagic Stroke.

BACKGROUND: Intracranial hemorrhage is associated with high mortality and morbidity. Lowering systolic blood pressure (SBP) with an intravenous antihypertensive, such as nicardipine or clevidipine, may reduce the risk of hematoma expansion and rebleeding. Previous studies comparing nicardipine and clevidipine in patients with stroke found no significant difference in blood pressure management. The inclusion of patients with ischemic stroke limited those studies because of convoluted results related to faster door-to-needle times. The purpose of this study was to compare clevidipine with nicardipine in time to goal SBP in hemorrhagic stroke. METHODS: This single-center retrospective observational cohort study evaluated adult hemorrhagic patients with stroke who received clevidipine or nicardipine from January 1, 2015, to December 31, 2020. Patients were excluded if they had trauma-related hemorrhage, received concurrent continuous intravenous antihypertensives, received the study drug for less than 1-h duration, had a less than 24-h washout period between agents, required any dialysis, were pregnant, or were incarcerated. The primary outcome was time to goal SBP. Secondary outcomes included need for additional antihypertensives, percentage of time at goal SBP, all-cause mortality, 30-day readmission, rebleeding, total volume of antihypertensive infusion, hematoma expansion, intensive care unit length of stay (LOS), hospital LOS, and cost of infusion. Safety outcomes included hypotension, severe hypotension, rebound hypertension, bradycardia, tachycardia, onset of atrial fibrillation, and acute kidney injury. RESULTS: Of 89 patients included in this study, 60 received nicardipine and 29 received clevidipine. There was no significant difference between nicardipine and clevidipine in time to goal SBP in the unmatched cohort (30 vs. 45 min; p = 0.73) or the propensity-score-matched cohort (30 vs. 45 min; p = 0.47). Results were not affected by potential confounders in the multiple linear regression. The nicardipine group had a higher total volume from infusion compared with the clevidipine group (1410 vs. 330 mL; p < 0.0001) but significantly lower cost ($99.6 vs. $497.4; p < 0.0001). There were no significant differences in need for additional antihypertensives, percentage of time at goal SBP, all-cause mortality, 30-day readmission, rebleeding, hematoma expansion, intensive care unit LOS, and hospital LOS. Compared with the clevidipine group, the nicardipine group had less rebound hypertension (40% vs. 75.9%; p = 0.0017) and less bradycardia (23.3% vs. 44.8%; p = 0.05). There were no significant differences in hypotension, severe hypotension, tachycardia, and acute kidney injury. CONCLUSIONS: In patients with hemorrhagic stroke, nicardipine appeared to have similar efficacy as clevidipine in SBP reduction, with a more likely reduction of rebound hypertension and drug cost. This retrospective study was underpowered, which may limit these implications. Further prospective studies are warranted to confirm these results.

Changes in Nursing Students' Attitudes and Perceptions After Receipt of Enhanced Substance Use-Related Curricular Content.

BACKGROUND: Negative attitudes toward persons who use alcohol and other drugs contribute to suboptimal care. Nurses are in key roles to address the needs of this population, yet they lack the education needed to identify persons who may be at risk because of substance use and intervene accordingly. The purpose of this study was to evaluate the impact of a substance-use-related curriculum on nursing students' attitudes and therapeutic commitment for working with patients with alcohol- and drug-use-related problems. METHODS: Data were collected for four cohorts of 169 nursing students enrolled in a Master's Entry into Nursing program. Questionnaires included the Person-Centered Alcohol and Alcohol Problems Perception Questionnaire and the Drug and Drug Problems Perception Questionnaire, completed before and after completing the curriculum. Paired samples t test were used to examine pre/post differences for each measure's subscale. RESULTS: Four of the seven Person-Centered Alcohol and Alcohol Problems Perception Questionnaire subscales showing significant increases were role adequacy, role support, role legitimacy, and general perceptions. Four of the five Drug and Drug Problems Perception Questionnaire subscales showing significant increases were role adequacy, role support, job satisfaction, and role legitimacy; there was a significant change in role-related self-esteem, however, in a negative direction. CONCLUSIONS: This study adds to the growing evidence of the positive impact of providing evidence-based information and skill development, which enhance alcohol- and drug-related knowledge and competence for nurses entering professional practice.

Evolución y manejo del síndrome inflamatorio multisistémico pediátrico asociado a infección por SARS CoV-2 en una UCI pediátrica de Lima, Perú / Evolution and management of the pediatric multi-systemic inflammatory syndrome associated with SARS CoV-2 infection in a pediatric ICU in Lima, Peru

Introducción: El Sindrome Inflamatorio Multisistémico Pediátrico (SIMP) asociado a SARS CoV2 afecta gravemente a niños. Objetivo: Describir clínica, tratamiento y evolución del SIMP en pacientes de una Unidad de Cuidados Intensivos Pediátricos (UCIP) de referencia. Hallazgos: Se identificaron 18 niños con edad promedio de 8,76 años, 50% masculino, todos con prueba serológica positiva. Las manifestaciones más frecuentes fueron: Fiebre (100%), dificultad respiratoria (94%), dolor abdominal (89%), Proteina C reactiva elevada (promedio 21,8), plaquetopenia (50%), Radiografía de tórax patológica (89%) y contractilidad miocárdica deprimida (61%). El 72% requirió ventilación mecánica invasiva (promedio 3 días) y catecolaminas; 89% usó corticoides más inmunoglobulinas. La estancia promedio en UCIP fue 5.5 días. Un paciente falleció por hemorragia intracerebral. Conclusiones: El SIMP en UCIP se caracteriza por fiebre, dificultad respiratoria, dolor abdominal, marcadores inflamatorios elevados y depresión miocárdica. Requiriendo corticoides, inmunoglobulina y soporte ventilatorio; presentando estancia intermedia y baja mortalidad.

Background: Pediatric Multisystemic Inflammatory Syndrome(SIMP) associated with SARS CoV2 seriously affects children. To describe the Objective: symptoms, treatment and evolution of SIMP in patients of a reference Pediatric Intensive Care Unit (PICU). Findings: 18 children were identified with a mean age of 8.76 years, 50% male, all with a positive serological test. The most frequent manifestations were: fever (100%), respiratory distress (94%), abdominal pain (89%), elevated C-reactive protein (average 21.8), thrombocytopenia (50%), pathological chest X-ray (89%) and depressed myocardial contractility (61%). 72% required invasive mechanical ventilation (average 3 days) and catecholamines; 89% used corticosteroids plus immunoglobulins. The average stay in the PICU was 5.5 days. One patient died of intracerebral hemorrhage. SIMPin PICU is characterized by fever, Conclusions: respiratory distress, abdominal pain, elevated inflammatory markers, and myocardial depression. Requiring corticosteroids, immunoglobulin and ventilatory support; presenting intermediate stay and low mortality.

Assessment of a Cellular Host Response Test as a Sepsis Diagnostic for Those With Suspected Infection in the Emergency Department.

OBJECTIVES: Sepsis is a common cause of morbidity and mortality. A reliable, rapid, and early indicator can help improve efficiency of care and outcomes. To assess the IntelliSep test, a novel in vitro diagnostic that quantifies the state of immune activation by measuring the biophysical properties of leukocytes, as a rapid diagnostic for sepsis and a measure of severity of illness, as defined by Sequential Organ Failure Assessment and Acute Physiology and Chronic Health Evaluation-II scores and the need for hospitalization. DESIGN SETTING SUBJECTS: Adult patients presenting to two emergency departments in Baton Rouge, LA, with signs of infection (two of four systemic inflammatory response syndrome criteria, with at least one being aberration of temperature or WBC count) or suspicion of infection (a clinician order for culture of a body fluid), were prospectively enrolled. Sepsis status, per Sepsis-3 criteria, was determined through a 3-tiered retrospective and blinded adjudication process consisting of objective review, site-level clinician review, and final determination by independent physician adjudicators. MEASUREMENTS AND MAIN RESULTS: Of 266 patients in the final analysis, those with sepsis had higher IntelliSep Index (median = 6.9; interquartile range, 6.1-7.6) than those adjudicated as not septic (median = 4.7; interquartile range, 3.7-5.9; p < 0.001), with an area under the receiver operating characteristic curve of 0.89 and 0.83 when compared with unanimous and forced adjudication standards, respectively. Patients with higher IntelliSep Index had higher Sequential Organ Failure Assessment (3 [interquartile range, 1-5] vs 1 [interquartile range, 0-2]; p < 0.001) and Acute Physiology and Chronic Health Evaluation-II (7 [interquartile range, 3.5-11.5] vs 5 [interquartile range, 2-9]; p < 0.05) and were more likely to be admitted to the hospital (83.6% vs 48.3%; p < 0.001) compared with those with lower IntelliSep Index. CONCLUSIONS: In patients presenting to the emergency department with signs or suspicion of infection, the IntelliSep Index is a promising tool for the rapid diagnosis and risk stratification for sepsis.

Ionization of many-electron atoms by the action of two plasma models.

The Hartree-Fock equations for many-electron atoms embedded in a plasma medium are solved using two different plasma models: (a) Debye-Hückel screening (DHS) potential and (b) exponential cosine screened Coulomb (ECSC) potential. Roothaan's approach is implemented for these models after solving the inherent difficulties to evaluate integrals where screening appears explicitly. A corresponding computer code was developed using the method of global basis sets (GBS). The reliability of this approach was verified by solving the Hartree-Fock equations through implementation of the finite-differences and finite-element grid methods and applied to two-electron atoms, yielding excellent agreement with the Roothaan-GBS (RGBS) method. The RGBS method was used to study the energy evolution and ionization threshold of several closed- and open-shell many-electron atoms embedded either in weak or strong DHS or ECSC plasma conditions. In all cases, a critical value of the screening length is obtained for which ionization is achieved, being systematically larger for DHS conditions, indicating the effect of a more repulsive ECSC potential. For He-like atoms in the ground state, we report a comprehensive set of accurate total energy data as a function of the screening constant using the Lagrange mesh method, which includes the electron correlation effects. The electron correlation energy is estimated using this data with reference to the RGBS estimates of energy as the Hartree-Fock energy. The variation of correlation energy as a function of screening constant under the different plasma potentials is rationalized in terms of a conjectured comparison theorem. Finally, a discussion on the effect of plasma strength on localization or delocalization of the electronic density derived from the RGBS method is presented in terms of changes in the Shannon entropy, yielding consistent results for delocalization close to the ionization threshold.

Clinical Readiness Program: Refocusing the Military Health System.

INTRODUCTION: The Military Health System serves to globally provide health services and trained medical forces. Military providers possess variable levels of deployment preparedness. The aim of the Clinical Readiness Program is to develop and assess the knowledge, skills, and abilities (KSAs) needed for combat casualty care. METHODS: The Clinical Readiness Program developed a KSA metric for general and orthopedic surgery. The KSA methodology underwent a proof of concept in six medical treatment facilities. RESULTS: The KSA metric feasibly quantifies the combat relevance of surgical practice. Orthopedic surgeons are more likely than general surgeons to meet the threshold. Medical treatment facilities do not provide enough demand for general surgery services to achieve readiness. CONCLUSION: The Clinical Readiness Program identifies imbalances between the health care delivery and readiness missions. To close the readiness gap, the Military Health System needs to recapture high KSA value procedures, expand access to care, and/or partner with civilian institutions.

Psychometric Properties of the Person-Centered Version of the Alcohol and Alcohol Problems Perceptions Questionnaire (PC-AAPPQ).

AIMS: Given the importance of addressing provider attitudes toward individuals with unhealthy alcohol use and the current emphasis on person-centered language to help decrease stigma and mitigate negative attitudes, the aim of this study was to evaluate the psychometric properties of a contemporary version of the Alcohol and Alcohol Problems Perception Questionnaire (AAPPQ) that uses person-centered language and addresses the spectrum of alcohol use. METHODS: The authors created a person-centered version of the AAPPQ (PC-AAPPQ) and conducted a cross-sectional study of its psychometric properties in academic settings in the Northeastern United States. The PC-AAPPQ was administered to 651 nursing students. Reliability analysis of the new instrument was performed using the total sample. Only surveys with complete data (n = 637) were randomly split into two datasets, one used for the exploratory factor analysis (EFA) (n = 310) and the other for confirmatory factor analysis (CFA) (n = 327). RESULTS: Compared to all the models generated from the EFA, neither the original six-factor structure nor the five-factor structure was superior to any of the other models. The results indicate that a seven-factor structure with all 30 items is the best fit for the PC-AAPPQ. CONCLUSIONS: The PC-AAPPQ represents a positive effort to modernize the four-decade-old AAPPQ. This 30-item instrument, which adds one additional subscale, offers a means to assess providers' attitudes using respectful wording that avoids perpetuating negative biases and reinforces efforts to affirm the worth and dignity of the population being treated.

Analysis of the Gas Phase Acidity of Substituted Benzoic Acids Using Density Functional Concepts.

A theoretical study of the effect of the substituent Z on the gas phase acidity of substituted benzoic acids ZC6H4COOH in terms of density functional theory descriptors (chemical potential, softness and Fukui function) is presented. The calculated gas phase ΔacidG° values obtained were close to the experimental ones reported in the literature. The good relationship between the ΔacidG° values and the electronegativity of ZC6H4COOH and its fragments, suggested a better importance of the inductive than polarizability contributions. The balance of inductive and resonance contributions of the substituent in the acidity of substituted benzoic acids showed that the highest inductive and resonance effects were for the -SO2CF3 and -NH2 substituents in the para- and ortho-position, respectively. The Fukui function confirmed that the electron-releasing substituent attached to the phenyl ring of benzoic acid decreased the acidity in the trend ortho > meta > para, and the electron-withdrawing substituent increased the acidity in the trend ortho < meta < para.