Desmopressin Administration and Impact on Hypertonic Saline Effectiveness in Intracranial Hemorrhage.

INTRODUCTION: Desmopressin improves hemostasis through the release of factor VIII, von Willebrand factor, and tissue plasminogen activator, and increases platelet adhesion. Neurocritical Care guidelines recommend consideration of desmopressin in antiplatelet-associated intracranial hemorrhage. Studies supporting its use have not evaluated the potential impact of desmopressin on serum sodium levels in patients receiving hypertonic saline therapy. The purpose of this study was to assess the impact of desmopressin on sodium levels and hypertonic saline effectiveness in intracranial hemorrhage. METHODS: This was a single center retrospective observational chart review. Patients were included in the desmopressin group if they were diagnosed with intracranial hemorrhage, administered desmopressin, and received hypertonic saline infusion. Patients in the hypertonic saline alone group were then matched 1:1 to the patients in the desmopressin group. The primary end point was the effect of desmopressin on reaching a sodium goal of 145-155 mEq/L. The secondary end points included intensive care unit and hospital length of stay, change in sodium, time to reach sodium goal, thrombotic events, mortality, and a composite of increased cerebral edema, hematoma expansion, midline shift, herniation, need for neurosurgical intervention, and neurologic decompensation. RESULTS: Of 112 patients screened, 25 patients met inclusion criteria for the desmopressin group, and 25 patients were matched with patients in the hypertonic saline alone group. The percentage of patients who reached goal sodium in the desmopressin group compared with hypertonic saline alone was similar (80% vs. 88%, respectively). There were no differences in the secondary end points. In the subgroup analysis, patients in the hypertonic saline group met the predefined sodium goal of 150-155 mEq/L within 48 h more often than those in the desmopressin group (82% vs. 60%, respectively, p = 0.042). CONCLUSIONS: The use of desmopressin in intracranial hemorrhage does not appear to negatively impact the ability for patients to reach goal sodium of 145-155 mEq/L. However, in patients with higher sodium goals, desmopressin may decrease hypertonic saline effectiveness.

COVID-19 Medical-Religious Partnerships: Implementation of a Just-In-Time COVID-19 Training in Catholic Schools.

The concept of Just-In-Time Training (JITT) is to provide critical information specific to a public health crisis, allowing individuals to understand and respond to an urgent situation. The design of the JITT curriculum appropriate for school-aged children during the COVID-19 pandemic is vital, as every individual has a role to play in mitigating the spread of SARS-CoV-2. When working with various communities, considering culture and religion is essential, as aligning values and beliefs with the JITT curriculum's objectives may significantly change the community's behavior toward a public health crisis. In this narrative, we describe how a JITT curriculum for the COVID-19 pandemic, created in Maryland, US, and implemented in a Catholic school system, aligned with core Catholic social teachings. This alignment allowed for implementing and delivering the COVID-19 curriculum in Maryland's Archdiocese Catholic school system, culminating in a medical-religious partnership that serves as a model for future public health crises.

Mobility bridges a gap in care: Findings from an early mobilisation quality improvement project in acute care.

AIMS AND OBJECTIVES: To qualitatively evaluate an early mobilisation quality improvement project implemented on a general medicine unit. BACKGROUND: Early mobility quality improvement projects show promising quantitative results yet have failed to collect data from patient and staff experience associated with physical activity during illness and the impact of this change in clinical practice. DESIGN: A mixed methods case study was used to evaluate a mobility quality improvement project. Quantitative results will be published separately. The qualitative evaluation used a phenomenological lens to explore the patient and staff experience. METHODS: Semi-structured interviews with twelve participants (four patients and eight staff) were performed during the project. Data were analysed using open coding, direct interpretation and then categorised into an overarching and four supporting themes. Findings are reported per the Standards for Reporting Qualitative Research. RESULTS: Participants reported that early mobilisation bridged a gap in care. Staff understood the benefits of early mobility. Patients expressed how mobility aligned with personal preferences and their need to prepare for hospital discharge. Greater functional independence and higher mobility levels in patients on the unit reduced staff level of care. When patients were consistently presented with opportunities to be mobile and active, they expected mobility to be a part of their daily care plan. CONCLUSIONS: Findings suggest that early mobility quality improvement projects have the potential to transform clinical practice and improve the quality of care for patients in acute care. RELEVANCE TO CLINICAL PRACTICE: All members of the healthcare team, including the patient, recognise the importance of maintaining mobility and function during hospitalisation yet focus on these needs are often delayed or missed. Early mobility quality improvement projects help to set patient expectations and build a culture that promotes patient mobility and function during acute illness.

International service learning and interprofessional education in Ecuador: Findings from a phenomenology study with students from four professions.

Combined international service learning (ISL) and interprofessional education (IPE) experiences can move health professional student learning beyond the traditional confines of the classroom and outside uniprofessional ethos. The purpose of this transcendental phenomenological study was to describe the shared experience of health professional students participating in an ISL trip to a small community in Ecuador. The study focused on the learning and collaboration that occurred among students from multiple health professions during the trip and the cross-cultural exchange between the students and the patients in Ecuador. Participants included 15 students from 4 health professional programmes (pharmacy, medicine, physical therapy, and nursing). Data included interviews, focus groups, observation, and written documents. The essential meaning that emerged from this study was that the ISL/IPE learning opportunity created a practical opportunity for demystifying other healthcare professions in the context of a resource-limited international patient care setting, while supporting students' personal and professional development. Four structural themes emerged to describe the student experiences. Students had to negotiate the language barrier, limited resources, and unexpected diagnoses, while simultaneously learning about the roles and scope of other professions on the team and how to communicate effectively. Student's perseverance when facing the challenges resulted in their personal growth. The interprofessional component strengthened the students' knowledge of interprofessional collaboration and communication through real-world application.

High Throughput Glycerate Kinase Activity Assay Using Crude Leaf Extract and Recombinant Enzyme to Determine Kinetic Parameters Km and Vmax Using a Microplate Reader.

We describe an assay for measuring the activity of D-glycerate 3-kinase (GLYK) in a 96-well microplate format with the use of a set of coupling enzymes. The assay is appropriate for use with a crude protein extract prepared from leaf tissue and with the recombinant purified enzyme. The 96-well microplate format reduces the needed amounts of reagents and coupling enzymes, making the assay less expensive, high throughput, and suitable for the determination of kinetic parameters Km and Vmax. In addition, we provide a two-step discontinuous assay modified from past work, making it possible to measure the activity of GLYK at temperatures higher than 45 °C.

High Throughput Phosphoglycolate Phosphatase Activity Assay Using Crude Leaf Extract and Recombinant Enzyme to Determine Kinetic Parameters Km and Vmax Using a Microplate Reader.

Determining enzyme activities involved in photorespiration, either in a crude plant tissue extract or in a preparation of a recombinant enzyme, is time-consuming, especially when large number of samples need to be processed. This chapter presents a phosphoglycolate phosphatase (PGLP) activity assay that is adapted for use in a 96-well microplate format. The microplate format for the assay requires fewer enzymes and reagents and allows rapid and less expensive measurement of PGLP enzyme activity. The small volume of reaction mix in a 96-well microplate format enables the determination of PGLP enzyme activity for screening many plant samples, multiple enzyme activities using the same protein extract, and/or identifying kinetic parameters for a recombinant enzyme. To assist in preparing assay reagents, we also present an R Shiny buffer preparation app for PGLP and other photorespiratory enzyme activities and a Km and Vmax calculation app.

The Health Education and Training (HEAT) Corps: A Medical-Community Collaboration Response during the COVID-19 Pandemic.

With the declaration of the COVID-19 pandemic by the World Health Organization in March 2020, many elements of society were faced with attempting to assimilate public health recommendations for infectious control. Vital social organizations had to balance delivering their social services while attempting to stay up to date with COVID-19 information and comply with evolving regulations. In the realm of schools and school systems, guidance on how to best adapt to COVID-19 was often limited. School officials and staff had to assist with multiple public health crises as a consequence of the pandemic, from the pandemic's transmission prevention strategies (e.g., face masks and physical distancing) to the recognition that students would have personal tragedies related to COVID-19. In this review, we highlight the process and feasibility of implementing an international COVID-19 school-based initiative over two years of the pandemic, the Health Education and Training (HEAT) Corps program.

The Effectiveness of a Standardized Ice-Sheet Cooling Method Following Exertional Hyperthermia.

INTRODUCTION: Exertional heat illnesses remain a major threat to military service members in the United States and around the world. Exertional heat stroke (EHS) is the most severe heat illness, characterized by core hyperthermia and central nervous system dysfunction. Per current Army regulations, iced-sheet cooling (ISC) is the recommended immediate treatment for heat casualties in the field, but concerns have been raised regarding the efficacy of this approach. Thus, the purpose of this study was to quantify the cooling rate of ISC following exertional hyperthermia. MATERIALS AND METHODS: We utilized a randomized crossover design with 2 experimental trials. In both trials, exertional hyperthermia was induced by walking (3.5 mph at 5% grade) on a treadmill in an environmental chamber (40 °C, 30% RH) for up to 3 hours or until core body temperature reached 39.2 °C. After the walking portion, individuals either received ISC (experimental trial) or cooling and rested supine in the same environmental conditions for 30 minutes with no ISC (control trial). For ISC, bed sheets soaked in ice water were applied (per Army guidance) at the neck, chest, and groin with another sheet covering the body. Sheets were rotated and resoaked every 3 minutes until core temperature decreased to <38.0 °C. RESULTS: By design, participants finished exercise with increased core temperature (38.8 ± 0.39 °C vs. 38.90 ± 0.34 °C, ISC and control trials, P = 1.00). The ISC trial provided significantly (P = .023) greater cooling rates, 0.068 °C/min 95% confidence interval [CI; 0.053, 0.086], compared to the control trial, 0.047 °C/min 95% CI [0.038, 0.056]. Additionally, the time to decrease to less than 38.0 °C was significantly (P = .018) faster in the ISC trial (median = 9.3 minutes) compared to the control trial (median = 26.6 minutes). CONCLUSION: ISC increases the cooling rate of those recovering from exertional hyperthermia. With the observed cooling rate, we can extrapolate that ISC would reduce core temperature by ∼2 °C within 30 minutes during a case of EHS. We conclude that ISC provides a safe and effective alternative for the field where cold water immersion resources may not be readily available.

Just Us Dialogues: Harnessing the Transformational Power of Discourse to Prevent Violence.

Anchor Institutions (AIs) provide tremendous value and benefit to the communities where they reside through initiatives, partnerships, and investments. As an academic medical center, Johns Hopkins devised to anchor its community by addressing the epidemic of violence and racial injustice through a series of webinars and a symposium entitled the "Just Us Dialogues." An analysis of all comments and policy recommendations made by panelists and attendees was performed and a series of recommendations emerged regarding how an AI should approach addressing community violence and inequities to promote community wellness. The series consisted of 4 panels: "The 4th Amendment: Use, Misuse, and Case for Police Reform"; "Protecting Our Youth: Confronting Society's Role in the Harmonious Development of Adolescents"; "Immigration Matters: Building Humanity Within a Fractured Immigration Landscape"; and "Decriminalizing Mental Illness: Empathetic Approaches to Mental Health Supports." These 4 panels, symposium discussions, and the keynote address yielded 18 recommendations. The recommendations from the panels and the symposium underscore the power and leverage that AIs possess to identify and implement approaches to address community violence.

Whole Person Health: Using Experiential Learning and the ICF Model as a Tool for Introductory Interprofessional Collaborative Practice.

BACKGROUND: The International Classification of Func¬tioning (ICF) model is recommended for interprofessional use to define, measure, and create health and disability policy. Our goal was to expand a uniprofessional student learning experience into an interprofessional experiential clinical learning experience focused on the ICF model. METHODS: An experiential interprofessional education program was developed for Physical Therapy (PT), Physician Assistant (PA), and Pharmacy students. Student teams interviewed a community mentor from a senior living community outside of class to explore their mentor's health journey, assess quality of life, and perform an environmental safety assessment. In this pilot study, students completed an anonymous, unique-identifier electronic survey with open response items pre- and post-experience. Data were coded using inductive thematic analysis. RESULTS: Four themes emerged: learning about other professions (scope of practice), mentor's experiences with health care, treating the whole person, and improving team effectiveness. All four Interprofessional Education Collaborative (IPEC) competencies mapped to the data broadly indicating this learning experience meets interprofessional educational requirements. CONCLUSIONS: Student teams deepened their understanding of their community mentor's health and valued the interprofessional knowledge gained. Using the common lens of the ICF, students' understanding and appreciation of other disciplines emerged and students began to see their mentors from a more holistic perspective.

Impact of cognitive behavioral therapy on depression symptoms after transcatheter aortic valve replacement: A randomized controlled trial.

BACKGROUND: Depression is a significant concern after cardiac surgery and has not been studied in patients undergoing transcatheter aortic valve replacement (TAVR). We sought to examine the prevalence of pre-procedure depression and anxiety symptoms and explore whether brief bedside cognitive behavioral therapy (CBT) could prevent post-TAVR psychological distress. METHODS: We prospectively recruited consecutive TAVR patients and randomized them to receive brief CBT or treatment as usual (TAU) during their hospitalization. Multi-level regression techniques were used to evaluate changes by treatment arm in depression, anxiety, and quality of life from baseline to 1 month post-TAVR adjusted for sex, race, DM, CHF, MMSE, and STS score. RESULTS: One hundred and forty six participants were randomized. The mean age was 82 years, and 43% were female. Self-reported depression and anxiety scores meeting cutoffs for clinical level distress were 24.6% and 23.2% respectively. Both TAU and CBT groups had comparable improvements in depressive symptoms at 1-month (31% reduction for TAU and 35% reduction for CBT, p = .83). Similarly, both TAU and CBT groups had comparable improvements in anxiety symptoms at 1-month (8% reduction for TAU and 11% reduction for CBT, p = .1). Quality of life scores also improved and were not significantly different between the two groups. CONCLUSIONS: Pre-procedure depression and anxiety may be common among patients undergoing TAVR. However, TAVR patients show spontaneous improvement in depression and anxiety scores at 1-month follow up, regardless of brief CBT. Further research is needed to determine whether more tailored CBT interventions may improve psychological and medical outcomes.

Physical Therapists Know Function: An Opinion on Mobility and Level of Activity During Hospitalization for Adult Inpatients.

Negative consequences of immobility during hospitalization are widely known and remain undisputed. Evidence of low mobility for general medicine adult inpatients persists. Patients who experience hospital acquired functional decline due to low mobility require costly post-acute care services. The impact of immobility on post-acute care physical function and quality of life is directly at odds with value-based care. New Medicare payment models emphasize value-based care to promote care improvement and better patient outcomes. Quality improvement projects show promise in changing clinical practice using clinical champions, interprofessional collaboration, and teamwork. Physical therapists have a distinct expertise acutely focused on mobility and physical activity during hospitalization. Patients need acute care team members to develop sustainable clinical practice changes and to accept collective responsibility for a culture of mobility. Partnering with physical therapists and using their expertise to direct mobility, executed by the appropriate support personnel, can achieve the Quadruple Aim.

Timing and Amount of Physical Therapy Treatment are Associated with Length of Stay in the Cardiothoracic ICU.

Significant variability exists in physical therapy early mobilization practice. The frequency of physical therapy or early mobilization of patients in the cardiothoracic intensive care unit and its effect on length of stay has not been investigated. The goal of our research was to examine variables that influence physical therapy evaluation and treatment in the intensive care unit using a retrospective chart review. Patients (n = 2568) were categorized and compared based on the most common diagnoses or surgical procedures. Multivariate semi-logarithmic regression analyses were used to determine correlations. Differences among patient subgroups for all independent variables other than age and for length of stay were found. The regression model determined that time to first physical therapy evaluation, Charlson Comorbidity Index score, mean days of physical therapy treatment and mechanical ventilation were associated with increased hospital length of stay. Time to first physical therapy evaluation in the intensive care unit and the hospital, and mean days of physical therapy treatment associated with hospital length of stay. Further prospective study is required to determine whether shortening time to physical therapy evaluation and treatment in a cardiothoracic intensive care unit could influence length of stay.

Linaclotide: a novel agent for chronic constipation and irritable bowel syndrome.

PURPOSE: The pharmacology, pharmaco-kinetics, and clinical efficacy and safety of linaclotide in the management of chronic constipation (CC) and constipation-predominant irritable bowel syndrome (IBS-C) are reviewed. SUMMARY: Linaclotide (Linzess, Forest Pharmaceuticals) is a 14-amino acid peptide indicated for the treatment of adults with CC and IBS-C. Linaclotide acts on guanylate cyclase-C receptors on the luminal membrane to increase chloride and bicarbonate secretions into the intestine and inhibit the absorption of sodium ions, thus increasing the secretion of water into the lumen and improving defecation; the drug is minimally absorbed into the systemic circulation. Linaclotide is approved by the Food and Drug Administration (FDA) for oral once-daily administration at doses of 145 µg for CC and 290 µg for IBS-C. In placebo-controlled Phase III clinical trials, linaclotide significantly increased weekly spontaneous bowel movements and complete spontaneous bowel movements (CSBMs) while reducing abdominal pain in patients with CC. In patients with IBS-C, linaclotide was demonstrated to be effective in meeting FDA-recommended endpoints such as reductions of at least 30% from baseline in abdominal pain scores and CSBM frequency. The most common adverse effect of linaclotide is diarrhea, which was reported in 16-20% of clinical trial participants. CONCLUSION: Linaclotide is an important advance in the treatment of CC and IBS-C, with a novel mechanism of action resulting in accelerated intestinal transit. In clinical trials, linaclotide demonstrated efficacy relative to placebo for treatment of both CC and IBS-C. Linaclotide's adverse effects are generally mild and confined to the gastrointestinal tract.