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This study examines trends in heat-related mortality rates in the US population from 1999 to 2023.
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INTRODUCTION: Disease and non-battle injury (DNBI) has historically been the leading casualty type among service members in warfare and a leading health problem confronting military personnel, resulting in significant loss of manpower. Studies show a significant increase in disease burden for DNBI when compared to combat-related injuries. Understanding the causes of and trends in DNBI may help guide efforts to develop preventive measures and help increase medical readiness and resiliency. However, despite its significant disease burden within the military population, DNBI remains less studied than battle injury. In this review, we aimed to evaluate the recently published literature on DNBI and to describe the characteristics of these recently published studies. MATERIALS AND METHODS: This systematic review is reported in the Prospective Register of Systematic Reviews database. The systematic search for published articles was conducted through July 21, 2022, in Cumulative Index of Nursing and Allied Health, Cochrane Library, Defense Technical Information Center, Embase, and PubMed. Guided by the Preferred Reporting Items for Systematic Reviews and Meta-analyses, the investigators independently screened the reference lists on the Covidence website (covidence.org). An article was excluded if it met any of the following criteria: (1) Published not in English; (2) published before 2010; (3) data used before 2001; (4) case reports, commentaries, and editorial letters; (5) systematic reviews or narrative reviews; (6) used animal models; (7) mechanical or biomechanical studies; (8) outcome was combat injury or non-specified; (9) sample was veterans, DoD civilians, contractors, local nationals, foreign military, and others; (10) sample was U.S. Military academy; (11) sample was non-deployed; (12) bioterrorism study; (13) qualitative study. The full-text review of 2 independent investigators reached 96% overall agreement (166 of 173 articles; κ = 0.89). Disagreements were resolved by a third reviewer. Study characteristics and outcomes were extracted from each article. Risk of bias was assessed using the Newcastle-Ottawa Scale. Meta-analysis of pooled estimates of incidence rates for disease (D), non-battle injury (NBI), and combined DNBI was created using random-effects models. RESULTS: Of the 3,401 articles, 173 were included for the full review and 29 (16.8%) met all inclusion criteria. Of the 29 studies included, 21 (72.4%) were retrospective designs, 5 (17.2%) were prospective designs, and 3 (10.3%) were surveys. Across all studies, the median number of total cases reported was 1,626 (interquartile range: 619.5-10,203). The results of meta-analyses for 8 studies with reported incidence rates (per 1,000 person-years) for D (n = 3), NBI (n = 7), and DNBI (n = 5) showed pooled incidence rates of 22.18 per 1,000 person-years for D, 19.86 per 1,000 person-years for NBI, and 50.97 per 1,000 person-years for combined DNBI. Among 3 studies with incidence rates for D, NBI, and battle injury, the incidence rates were 20.32 per 1,000 person-years for D, 6.88 per 1,000 person-years for NBI, and 6.83 per 1,000 person-years for battle injury. CONCLUSIONS: DNBI remains the leading cause of morbidity in conflicts involving the U.S. Military over the last 20 years. More research with stronger designs and consistent measurement is needed to improve medical readiness and maintain force lethality. LEVEL OF EVIDENCE: Systematic Review and Meta-Analysis, Level III.
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Militares , Humanos , Militares/estatística & dados numéricos , Ferimentos e Lesões/epidemiologia , Destacamento Militar/estatística & dados numéricosRESUMO
Background: Some clinicians suspect that patients with do-not-resuscitate (DNR) orders receive less aggressive care. Extrapolation from code status to goals of care could cause significant harm. This study asked the question: Do DNR orders in the intensive care unit (ICU) lead to a decrease in invasive interventions? Methods: This was a retrospective cohort study of ICU patients from three teaching hospitals. All ICU patients were assessed for inclusion. Exclusion criteria were medical futility and death, comfort care, or ICU discharge <48 hours after DNR initiation. Five hundred thirty-six patients met inclusion criteria. One hundred forty-five were included in the final analysis. Primary outcomes were occurrence of invasive interventions after DNR initiation-surgical operation, central line, ventilation, dialysis, or other procedure. Secondary outcomes were antibiotic administration, blood transfusion, mortality, and discharge location. Results: Patients with DNR orders underwent fewer surgical operations (14.5% vs. 31.1%, p = 0.002), but more central lines (42.1% vs. 23.0%, p = 0.009), ventilator use (49.0% vs. 18.9%, p < 0.001), and dialysis (20.0% vs. 4.1%, p = 0.002), compared with patients without DNR orders. Transfusions and antibiotic use decreased similarly over admission for both groups (transfusions: ß = 1.25; p = 0.59; and antibiotics: ß = 1.44; p = 0.27). Mortality and hospice discharges were higher for DNR patients (p < 0.001.). Conclusions: DNR status did not decrease the number of nonoperative interventions patients received as compared with full code counterparts. Although differences in populations existed, patients with DNR orders were likely to receive a similar number of invasive interventions. This finding suggests that providers do not wholesale limit these options for patients with code status limitations.
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Diálise Renal , Ordens quanto à Conduta (Ética Médica) , Humanos , Estudos Retrospectivos , Unidades de Terapia Intensiva , AntibacterianosRESUMO
Cell-based therapeutic cancer vaccines use autologous patient-derived tumor cells, allogeneic cancer cell lines or autologous antigen presenting cells to mimic the natural immune process and stimulate an adaptive immune response against tumor antigens. The primary objective of this study is to perform a systematic literature review with an embedded meta-analysis of all published Phase 2 and 3 clinical trials of cell-based cancer vaccines in human subjects. The secondary objective of this study is to review trials demonstrating biological activity of cell-based cancer vaccines that could uncover additional hypotheses, which could be used in the design of future studies. We performed the systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The final review included 36 studies - 16 single-arm studies, and 20 controlled trials. Our systematic review of the existing literature revealed largely negative trials and our meta-analysis did not show evidence of clinical benefit from cell-based cancer-vaccines. However, as we looked beyond the stringent inclusion criteria of our systematic review, we identified significant examples of biological activity of cell-based cancer vaccines that are worth highlighting. In conclusion, the existing literature on cell-based cancer vaccines is highly variable in terms of cancer type, vaccine therapies and the clinical setting with no overall statistically significant clinical benefit, but there are individual successes that represent the promise of this approach. As cell-based vaccine technology continues to evolve, future studies can perhaps fulfill the potential that this exciting field of anti-cancer therapy holds.
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Vacinas Anticâncer , Neoplasias , Humanos , Neoplasias/tratamento farmacológico , Antígenos de Neoplasias , Imunidade AdaptativaRESUMO
STUDY OBJECTIVES: Connecting resident physician work hours and sleep deprivation to adverse outcomes has been difficult. Our study explores clinical reasoning rather than outcomes. Diagnostic errors are a leading cause of medical error and may result from deficits in clinical reasoning. We used simulated cases to explore relationships between sleep duration and diagnostic reasoning. METHODS: Residents were recruited for a 2-month study (inpatient/outpatient). Each participant's sleep was tracked (sleep diary/actigraphy). At the end of each month, residents watched 2 brief simulated clinical encounters and performed "think alouds" of their clinical reasoning. In each session, 1 video was straightforward and the other video contained distracting contextual factors. Sessions were recorded, transcribed, and interpreted. We conducted a thematic analysis using a constant comparative approach. Themes were compared based on sleep duration and contextual factors. RESULTS: Residents (n = 17) slept more during outpatient compared with inpatient months (450.5 ± 7.13 vs 425.6 ± 10.78 hours, P = .02). We found the following diagnostic reasoning themes: uncertainty, disorganized knowledge, error, semantic incompetence, emotional content, and organized knowledge. Themes reflecting suboptimal clinical reasoning (disorganized knowledge, error, semantic incompetence, uncertainty) were observed more in cases with contextual factors (distractors). "Think alouds" from cases with contextual factors following sleep restriction had a greater number of themes concerning for problematic diagnostic reasoning. CONCLUSIONS: Residents obtained significantly more sleep during outpatient compared with inpatient months. Several negative clinical reasoning themes emerged with less sleep combined with cases containing contextual distractors. Our findings reinforce the importance of adequate sleep and supervision in house officers, particularly in cases with distracting elements. CITATION: Collen J, Durning S, Berk J, Mang J, Alcover K, Jung E. Exploring sleep duration and clinical reasoning process in resident physicians: a thematic analysis. J Clin Sleep Med. 2024;20(8):1279-1289.
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Raciocínio Clínico , Internato e Residência , Adulto , Feminino , Humanos , Masculino , Competência Clínica/estatística & dados numéricos , Erros de Diagnóstico/prevenção & controle , Médicos/psicologia , Médicos/estatística & dados numéricos , Privação do Sono/diagnóstico , Privação do Sono/fisiopatologia , Duração do SonoRESUMO
INTRODUCTION: Adolescent drug use can result in clinically significant psychiatric outcomes later in life mitigated by targeted prevention strategies. While mean age of drug initiation has increased over time, there is little research of mean age of drug initiation among adolescents by race/ethnicity. METHODS: The study used the National Survey on Drug Use and Health data (2004-2019). Sample included individuals aged 12 to 21 years. Year-by-year drug use initiation (i.e., first-time use within the past year) trends examined for each drug by race/ethnicity using jointpoint regression. RESULTS: Sample included 95,022 initiates for any of 18 drugs. Year-by-year mean initiation age significantly increased for alcohol (except Non-Hispanic [NH] White, 2004-2012), tobacco cigarettes (except NH American Indian/Alaska Native [AI/AN]), cigars, marijuana (except NH Asian or Pacific Islander, NH Multiracial), cocaine (except NH Black). Significant increase in mean initiation age found for heroin (Hispanic/Latinx only), hallucinogens (NH White, NH Black only), LSD (NH White only), methamphetamines (NH White only), smokeless tobacco (NH White, NH Black only), inhalants (only NH White, NH AI/AN; NH Multiracial, 2004-2011), sedatives (NH White, Hispanic/Latinx only), stimulants (NH White, Hispanic/Latinx only), and ecstasy (NH White, NH Black, Hispanic/Latinx only). Significant decrease in mean initiation age found for alcohol (only NH White, 2013-2019), smokeless tobacco (only Hispanic/Latinx, 2015-2019; NH AI/AN, 2012-2019), and inhalants (only NH Multiracial, 2012-2019). CONCLUSION: Mean initiation age differed widely by race/ethnicity. Mean initiation age in most racial/ethnic groups increased for several drugs including alcohol, marijuana, and tobacco products and decreased for some drugs such as inhalants. These findings could help inform groups to target for future prevention strategies.
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Etnicidade , Transtornos Relacionados ao Uso de Substâncias , Adolescente , Criança , Feminino , Humanos , Masculino , Adulto Jovem , Fatores Etários , Etnicidade/estatística & dados numéricos , Inquéritos Epidemiológicos , Grupos Raciais/estatística & dados numéricos , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/etnologia , Estados Unidos/epidemiologia , Indígena Americano ou Nativo do Alasca , Hispânico ou Latino , Nativo Asiático-Americano do Havaí e das Ilhas do Pacífico , Negro ou Afro-Americano , BrancosRESUMO
Importance: While brain cancer is rare, it has a very poor prognosis and few established risk factors. To date, epidemiologic work examining the potential association of traumatic brain injury (TBI) with the subsequent risk of brain cancer is conflicting. Further data may be useful. Objective: To examine whether a history of TBI exposure is associated with the subsequent development of brain cancer. Design, Setting, and Participants: A retrospective cohort study was conducted from October 1, 2004, to September 20, 2019, and data analysis was performed between January 1 and June 26, 2023. The median follow-up for the cohort was 7.2 (IQR, 4.1-10.1) years. Veterans Affairs (VA) and Department of Defense (DoD) administrative data on 1â¯919â¯740 veterans from the Long-Term Impact of Military-Relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium were included. Exposure: The main exposure of interest was TBI severity (categorized as mild, moderate or severe [moderate/severe], and penetrating). Main Outcomes and Measures: The outcome of interest was the development of brain cancer based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnostic codes in either the DoD/VA medical records or from the National Death Index. Results: After 611â¯107 exclusions (predominately for no encounter during the study period), a cohort including 1â¯919â¯740 veterans was included, most of whom were male (80.25%) and non-Hispanic White (63.11%). Median age at index date was 31 (IQR, 25-42) years. The cohort included 449â¯880 individuals with TBI (mild, 385â¯848; moderate/severe, 46â¯859; and penetrating, 17â¯173). Brain cancer occurred in 318 individuals without TBI (0.02%), 80 with mild TBI (0.02%), 17 with moderate/severe TBI (0.04%), and 10 or fewer with penetrating TBI (≤0.06%). After adjustment, moderate/severe TBI (adjusted hazard ratio [AHR], 1.90; 95% CI, 1.16-3.12) and penetrating TBI (AHR, 3.33; 95% CI, 1.71-6.49), but not mild TBI (AHR, 1.14; 95% CI, 0.88-1.47), were associated with the subsequent development of brain cancer. Conclusions and Relevance: In this cohort study of veterans of the Iraq and Afghanistan wars, moderate/severe TBI and penetrating TBI, but not mild TBI, were associated with the subsequent development of brain cancer.
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Concussão Encefálica , Lesões Encefálicas Traumáticas , Neoplasias Encefálicas , Veteranos , Estados Unidos/epidemiologia , Masculino , Humanos , Adulto , Feminino , Iraque , Afeganistão , Estudos de Coortes , Estudos Retrospectivos , Lesões Encefálicas Traumáticas/epidemiologia , Lesões Encefálicas Traumáticas/etiologia , Neoplasias Encefálicas/epidemiologia , Neoplasias Encefálicas/etiologiaRESUMO
To perform a systematic review and meta-analysis to generate estimates of mortality in patients with COVID-19 that required hospitalization, ICU admission, and organ support. DATA SOURCES: A systematic search of PubMed, Embase, and the Cochrane databases was conducted up to December 31, 2021. STUDY SELECTION: Previously peer-reviewed observational studies that reported ICU, mechanical ventilation (MV), renal replacement therapy (RRT) or extracorporeal membrane oxygenation (ECMO)-related mortality among greater than or equal to 100 individual patients. DATA EXTRACTION: Random-effects meta-analysis was used to generate pooled estimates of case fatality rates (CFRs) for in-hospital, ICU, MV, RRT, and ECMO-related mortality. ICU-related mortality was additionally analyzed by the study country of origin. Sensitivity analyses of CFR were assessed based on completeness of follow-up data, by year, and when only studies judged to be of high quality were included. DATA SYNTHESIS: One hundred fifty-seven studies evaluating 948,309 patients were included. The CFR for in-hospital mortality, ICU mortality, MV, RRT, and ECMO were 25.9% (95% CI: 24.0-27.8%), 37.3% (95% CI: 34.6-40.1%), 51.6% (95% CI: 46.1-57.0%), 66.1% (95% CI: 59.7-72.2%), and 58.0% (95% CI: 46.9-68.9%), respectively. MV (52.7%, 95% CI: 47.5-58.0% vs 31.3%, 95% CI: 16.1-48.9%; p = 0.023) and RRT-related mortality (66.7%, 95% CI: 60.1-73.0% vs 50.3%, 95% CI: 42.4-58.2%; p = 0.003) decreased from 2020 to 2021. CONCLUSIONS: We present updated estimates of CFR for patients hospitalized and requiring intensive care for the management of COVID-19. Although mortality remain high and varies considerably worldwide, we found the CFR in patients supported with MV significantly improved since 2020.
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ABSTRACT: Background: Sepsis is the leading cause of mortality among burn patients that survive acute resuscitation. Clinical criteria have poor diagnostic value for burn-induced sepsis, making it difficult to diagnose. Protein biomarkers (e.g., procalcitonin) have been examined with limited success. We aimed to explore other biomarkers related to mitochondria (mitochondrial DNA [mtDNA]) and mitochondrial function of peripheral blood mononuclear cells (PBMCs) for sepsis diagnosis in burn patients. Methods: We conducted a follow-up analysis of a single center, prospective observational study of subjects (n = 10 healthy volunteers, n = 24 burn patients) to examine the diagnostic value of mtDNA and PBMC respirometry. Patients were enrolled regardless of sepsis status and followed longitudinally. Patient samples were classified as septic or not based on empiric clinical criteria. Isolated PBMCs were loaded into a high-resolution respirometer, and circulating mtDNA was measured with a PCR-based assay. Sequential Organ Failure Assessment (SOFA) criteria were also compared. Results: The SOFA criteria comparing septic versus before/nonseptic patients revealed significantly higher heart rate ( P = 0.012) and lower mean arterial pressure ( P = 0.039) in burn sepsis. MtDNA was significantly elevated in septic burn patients compared with healthy volunteers ( P < 0.0001) and nonseptic patients ( P < 0.0001), with no significant difference between healthy volunteers and nonseptic burn patients ( P = 0.187). The area under the ROC curve (AUC) for mtDNA was 0.685 (95% confidence interval = 0.50-0.86). For PBMC respirometry, burn patients exhibited increased routine and maximal respiration potential compared with healthy volunteers. However, no difference was found between nonseptic and septic patient samples. A subanalysis revealed a significant mortality difference in PBMC respirometry after sepsis diagnosis, wherein survivors had higher routine respiration ( P = 0.003) and maximal respiration ( P = 0.011) compared with nonsurvivors. Conclusion: Our findings reveal that mtDNA may have diagnostic value for burn sepsis, whereas PBMC respirometry is nonspecifically elevated in burns, but may have value in mortality prognosis. A larger, multisite study is warranted for further validity of the diagnostic value of mtDNA and PBMC respirometry as biomarkers for prognosis of sepsis and outcomes in burn patients.
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Queimaduras , Sepse , Humanos , Leucócitos Mononucleares , DNA Mitocondrial , Curva ROC , Biomarcadores , Prognóstico , Queimaduras/complicações , MitocôndriasRESUMO
INTRODUCTION: Over the last two decades, the conflicts in Iraq and Afghanistan have cost the United States significantly in terms of lives lost, disabling injuries, and budgetary expenditures. This manuscript calculates the differences in costs between veterans with combat injuries vs veterans without combat injuries. This work could be used to project future costs in subsequent studies. MATERIALS AND METHODS: In this retrospective cohort study, we randomly selected 7,984 combat-injured veterans between February 1, 2002, and June 14, 2016, from Veterans Affairs Health System administrative data. We matched injured veterans 1:1 to noninjured veterans on year of birth (± 1 year), sex, and first service branch. We observed patients for a maximum of 10 years. This research protocol was reviewed and approved by the David Grant USAF Medical Center institutional review board (IRB), the University of Utah IRB, and the Research Review Committee of the VA Salt Lake City Health Care System in accordance with all applicable Federal regulations. RESULTS: Patients were primarily male (98.1% in both groups) and White (76.4% for injured patients, 72.3% for noninjured patients), with a mean (SD) age of 26.8 (6.6) years for the injured group and 27.7 (7.0) years for noninjured subjects. Average total costs for combat-injured service members were higher for each year studied. The difference was highest in the first year ($16,050 compared to $4,135 for noninjured). These differences remained significant after adjustment. Although this difference was greatest in the first year (marginal effect $12,386, 95% confidence interval $9,736-$15,036; P < 0.001), total costs continued to be elevated in years 2-10, with marginal effects ranging from $1,766 to $2,597 (P < 0.001 for all years). More severe injuries tended to increase costs in all categories. CONCLUSIONS: Combat injured patients have significantly higher long-term health care costs compared to their noninjured counterparts. If this random sample is extrapolated to the 53,251 total of combat wounded service members, it implies a total excess cost of $1.6 billion to date after adjustment for covariates and a median follow-up time of 10 years. These costs are likely to increase as injured veterans age and develop additional chronic conditions.
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BACKGROUND: Accurate accounting of coronavirus disease 2019 (COVID-19) critical care outcomes has important implications for health care delivery. RESEARCH QUESTION: We aimed to determine critical care and organ support outcomes of intensive care unit (ICU) COVID-19 patients and whether they varied depending on the completeness of study follow-up or admission time period. STUDY DESIGN AND METHODS: We conducted a systematic review and meta-analysis of reports describing ICU, mechanical ventilation (MV), renal replacement therapy (RRT), and extracorporeal membrane oxygenation (ECMO) mortality. A search was conducted using PubMed, Embase, and Cochrane databases.We included English language observational studies of COVID-19 patients, reporting ICU admission, MV, and ICU case fatality, published from December 1, 2019 to December 31, 2020. We excluded reports of less than 5 ICU patients and pediatric populations. Study characteristics, patient demographics, and outcomes were extracted from each article. Subgroup meta-analyses were performed based on the admission end date and the completeness of data. RESULTS: Of 6,778 generated articles, 145 were retained for inclusion (n = 60,357 patients). Case fatality rates across all studies were 34.0% (95% CI = 30.7%, 37.5%, P < 0.001) for ICU deaths, 47.9% (95% CI = 41.6%, 54.2%, P < 0.001) for MV deaths, 58.7% (95% CI = 50.0%, 67.2%, P < 0.001) for RRT deaths, and 43.3% (95% CI = 31.4%, 55.4%, P < 0.001) for extracorporeal membrane oxygenation deaths. There was no statistically significant difference in ICU and organ support outcomes between studies with complete follow-up versus studies without complete follow-up. Case fatality rates for ICU, MV, and RRT deaths were significantly higher in studies with patients admitted before April 31st 2020. INTERPRETATION: Coronavirus disease 2019 critical care outcomes have significantly improved since the start of the pandemic. Intensive care unit outcomes should be evaluated contextually (study quality, data completeness, and time) for the most accurate reporting and to effectively guide mortality predictions.
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COVID-19 , Criança , Humanos , COVID-19/epidemiologia , COVID-19/terapia , Cuidados Críticos , Unidades de Terapia Intensiva , Hospitalização , PacientesRESUMO
This study was a secondary data analysis of factors associated with alcohol-related child removal among American Indian/Alaska Native (AI/AN) adults enrolled in a clinical trial of an alcohol intervention. Among 326 parent participants, 40% reported ever having a child removed from their care in part because of the parent's alcohol use, defined here as alcohol-related child removal. Seventy-five percent of parents reported at least one separation during their own childhood (M = 1.3, SD = 1.0). In a multivariable analysis, alcohol-related child removal was associated with parental boarding school attendance. No relationship was found between alcohol-related child removal and alcohol intervention outcomes. Results may provide evidence of multigenerational child removal impacts of boarding schools on AI/AN adults receiving an alcohol use disorder intervention. Assessment of parental history of child removal by practitioners, strategies to prevent alcohol-related separation and to support reunification should be integrated into addiction treatment in AI/AN communities.
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Alcoolismo , Indígena Americano ou Nativo do Alasca , Serviços de Proteção Infantil , Adulto , Criança , Humanos , Alcoolismo/terapia , Etanol , Serviços de Proteção Infantil/métodosRESUMO
INTRODUCTION: Examinations of risk factors for suicide attempt in United States service members at high risk of mental health diagnoses, such as those with combat injuries, are essential to guiding prevention and intervention efforts. METHODS: Retrospective cohort study of 8727 combat-injured patients matched to deployed, non-injured patients utilizing Department of Defense and Veterans Affairs administrative records. RESULTS: Combat injury was positively associated with suicide attempt in the univariate model (HR = 1.75, 95% CI 1.5-2.1), but lost significance after adjustment for mental health diagnoses. Utilizing Latent Transition Analysis in the combat-injured group, we identified five mental/behavioral health profiles: (1) Few mental health diagnoses, (2) PTSD and depressive disorders, (3) Adjustment disorder, (4) Multiple mental health comorbidities, and (5) Multiple mental health comorbidities with alcohol use disorder (AUD). Multiple mental health comorbidities with AUD had the highest suicide attempt rate throughout the study and more than four times that of Multiple mental health comorbidities in the first study year (23.4 vs. 5.1 per 1000 person years, respectively). CONCLUSION: Findings indicate that (1) combat injury's impact on suicide attempt is attenuated by mental health and (2) AUD with multiple mental health comorbidities confers heightened suicide attempt risk in combat-injured service members.
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Transtornos Mentais , Militares , Tentativa de Suicídio , Lesões Relacionadas à Guerra , Humanos , Masculino , Feminino , Adulto Jovem , Adulto , Transtornos Mentais/diagnóstico , Transtornos Mentais/epidemiologia , Transtornos Mentais/psicologia , Militares/psicologia , Tentativa de Suicídio/prevenção & controle , Tentativa de Suicídio/psicologia , Tentativa de Suicídio/estatística & dados numéricos , Lesões Relacionadas à Guerra/epidemiologia , Lesões Relacionadas à Guerra/psicologia , Estudos Retrospectivos , Estados Unidos/epidemiologia , United States Department of Defense , Saúde dos Veteranos , Campanha Afegã de 2001- , Guerra do Iraque 2003-2011 , Análise Multivariada , Análise de Classes LatentesRESUMO
INTRODUCTION: Previous studies have identified combat exposure and combat traumatic experience as problematic drinking risk factors. Increasing evidence suggests that opioid use increases the risk of alcohol use disorder. This study investigated the association between opioid prescription use after injury and (1) alcohol use disorder and (2) severity of alcohol use disorder among deployed military servicemembers. METHODS: Deidentified health records data of 9,029 deployed servicemembers from a retrospective cohort study were analyzed. Data were randomly selected from the Department of Defense Trauma Registry and included servicemembers with combat injuries during deployment in Iraq or Afghanistan (2002-2016). Pharmacy records and International Classification of Diseases, Ninth and Tenth Revision diagnosis codes were used. Three groups were identified (no opioid prescription use, nonpersistent opioid prescription use, and persistent opioid prescription use) and were compared on the basis of alcohol use disorder risk using Cox proportional hazard models. Data analyses were performed in 2021. RESULTS: Of the 9,029 servicemembers with combat injury, 2,262 developed alcohol use disorder (1,322 developed severe alcohol use disorder). Compared with no opioid prescription use, increased alcohol use disorder risk was associated with persistent opioid prescription use, with a hazard ratio of 1.13 (95% CI=1.02, 1.26). After covariate adjustment, increased risk remained statistically significant (hazards ratio=1.24; 95% CI=1.10, 1.39). There was no significant difference in alcohol use disorder risk between no opioid prescription use and nonpersistent opioid prescription use. The risk of severe alcohol use disorder did not vary by opioid use among servicemembers with alcohol use disorder diagnosis. CONCLUSIONS: The findings of the study suggest that the incidence of alcohol use disorder was higher among injured servicemembers with persistent opioid prescription use than among those without opioid use. If replicated in prospective studies, the findings highlight the need for clinicians to consider the current and history of alcohol use of patients in initiating treatment involving opioids.
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Alcoolismo , Militares , Transtornos Relacionados ao Uso de Opioides , Humanos , Analgésicos Opioides/efeitos adversos , Alcoolismo/epidemiologia , Estudos Retrospectivos , Estudos Prospectivos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , PrescriçõesRESUMO
INTRODUCTION: Intravenous immunoglobulin (IVIG) preparations, used for the treatment of antibody deficiencies, provide a glimpse of the general population's antibody profile as each preparation is generated from a pool of thousands of donors. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus responsible for the coronavirus disease 2019 (Covid-19) pandemic, and a vaccine for the prevention of Covid-19 was authorized for emergency use in December 2020. We completed a longitudinal analysis of SARS-CoV-2 antibody levels in commercial IVIG preparations. MATERIALS AND METHODS: We collected IVIG samples from our infusion clinic. IVIG product lot number, product name, and manufacturer information were recorded, with the date of preparation verified from the manufacturer. SARS-CoV-2 antibody titers as well as total immunoglobulin levels were measured using commercially available assays. The study received Institutional Review Board approval. RESULTS: We found no SARS-CoV-2 antibodies in preparations generated on or before January 2020. Overall, SARS-CoV-2 antibody levels in IVIG preparations tended to increase with progressing preparation date. We observed a dramatic and continual rise of SARS-CoV-2 antibody levels in IVIG preparations made in the beginning after January 2021, coinciding with the peak in incidence of confirmed cases and availability of Covid-19 vaccines in the United States. CONCLUSION: SARS-CoV-2 antibody levels in IVIG mirror case prevalence, and vaccination resulted in a far more rapid rate of rise in antibody levels. IVIG preparations or serum repositories can provide an accessible way to model a population's evolving novel pathogen exposure, immunity, and vaccine response.
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The Seraph100 Microbind Affinity Blood Filter (Seraph 100) (ExThera Medical, Martinez, CA) is an extracorporeal therapy that can remove pathogens from blood, including severe acute respiratory syndrome coronavirus 2. The aim of this study was to evaluate safety and efficacy of Seraph 100 treatment for COVID-19. DESIGN: Retrospective cohort study. SETTING: Nine participating ICUs. PATIENTS: COVID-19 patients treated with Seraph 100 (n = 53) and control patients matched by study site (n = 53). INTERVENTION: Treatment with Seraph 100. MEASUREMENTS AND MAIN RESULTS: At baseline, there were no differences between the groups in terms of sex, race/ethnicity, body mass index, and need for mechanical ventilation. However, patients in the Seraph 100 group were younger (median age, 54 yr; interquartile range [IQR], 41-65) compared with controls (median age, 64 yr; IQR, 56-69; p = 0.009). Charlson comorbidity index scores were lower in the Seraph 100 group (2; IQR, 0-3) compared with the control group (3; IQR, 2-4; p = 0.006). Acute Physiology and Chronic Health Evaluation II scores were also lower in Seraph 100 subjects (12; IQR, 9-17) compared with controls (16; IQR, 12-21; p = 0.011). The Seraph 100 group had higher vasopressor-free days with an incidence rate ratio of 1.30 on univariate analysis. This difference was not significant after adjustment. Seraph 100-treated subjects were less likely to die compared with controls (32.1% vs 64.2%; p = 0.001), a difference that remained significant after adjustment. However, no difference in mortality was observed in a post hoc analysis utilizing an external control group. In the full cohort of 86 treated patients, there were 177 total treatments, in which only three serious adverse events were recorded. CONCLUSIONS: Although this study did not demonstrate consistently significant clinical benefit across all endpoints and comparisons, the findings suggest that broad spectrum, pathogen agnostic, blood purification can be safely deployed to meet new pathogen threats while awaiting targeted therapies and vaccines.
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Screening and assessing alcohol use accurately to maximize positive treatment outcomes remain problematic in regions with high rates of alcohol use and HIV and TB infections. In this study, we examined the concordance between self-reported measures of alcohol use and point-of-care (POC) urine ethyl glucuronide (uEtG) test results among persons with HIV (PWH) in Uganda who reported drinking in the prior 3 months. For analyses, we used the screening data of a trial designed to examine the use of incentives to reduce alcohol consumption and increase medication adherence to examine the concordance between POC uEtG (300 ng/mL cutoff) and six measures of self-reported alcohol use. Of the 2136 participants who completed the alcohol screening, 1080 (50.6%) tested positive in the POC uEtG test, and 1756 (82.2%) self-reported using alcohol during the prior 72 h. Seventy-two percent of those who reported drinking during the prior 24 h had a uEtG positive test, with lower proportions testing uEtG positive when drinking occurred 24-48 h (64.7%) or 48-72 h (28.6%) prior to sample collection. In multivariate models, recency of drinking, number of drinks at last alcohol use, and Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) score were associated with uEtG positivity. The highest area under the curve (AUC) for a uEtG positive test was for recency of drinking. Overall, we concluded that several measures of drinking were associated with POC uEtG positivity, with recency of drinking, particularly drinking within the past 24 h, being the strongest predictor of uEtG positivity.
Assuntos
Alcoolismo , Infecções por HIV , Consumo de Bebidas Alcoólicas/epidemiologia , Consumo de Bebidas Alcoólicas/urina , Alcoolismo/complicações , Glucuronatos , Infecções por HIV/complicações , Infecções por HIV/diagnóstico , Infecções por HIV/epidemiologia , Humanos , Sistemas Automatizados de Assistência Junto ao Leito , Autorrelato , Uganda/epidemiologiaRESUMO
OBJECTIVES: To compare the diagnostic value of clinical sepsis criteria to novel protein biomarkers in the burn patient. DESIGN: Prospective observational study. SETTING: American Burn Association verified Burn Center ICU. PATIENTS: Burn patients (n = 24) and healthy volunteers (n = 10). INTERVENTIONS: Enrolled burn patients (n = 24) were stratified based on whether or not they met a clinical definition of sepsis. Four separate clinical criteria for sepsis were analyzed for their diagnostic sensitivity and specificity, which were compared to a panel of protein biomarkers. The most significant protein biomarkers were further analyzed via the area under the receiver operating characteristic curves (AUROCs). MEASUREMENTS AND MAIN RESULTS: Of the clinical criteria, SEPSIS-2 criteria led to the highest AUROC (0.781; p < 0.001), followed by the quick Sequential Organ Failure Assessment score (AUROC = 0.670; p = 0.022). Multiplexing revealed a number of inflammatory proteins (complement C5) and matrix metalloproteinases (MMP1, MMP7) that were significantly elevated in septic samples compared with both healthy controls and nonseptic burn samples. Furthermore, three proteins associated with endothelial dysfunction and glycocalyx shedding revealed diagnostic potential. Specifically, syndecan-1, p-selectin, and galectin-1 were all significantly elevated in sepsis, and all resulted in an AUROC greater than 0.7; analyzing the sum of these three markers led to an AUROC of 0.808. CONCLUSIONS: These data reveal several potential biomarkers that may help with sepsis diagnosis in the burn patient. Furthermore, the role of endotheliopathy as a mechanistic etiology for sepsis after burns warrants further investigation.
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At Michigan State University (MSU), the AGEP learning community features the participation of over 70% of the African-American, Latinx, and Native-American under-represented minorities (URM), also referred to as Black, Indigenous, and People of Color (BIPOC) doctoral students in fields sponsored by the National Science Foundation (NSF). Monthly learning community (LC) meetings allow AGEP participants to create dialogues across disciplines through informal oral presentations about current research. The learning communities also offer opportunities to share key information regarding graduate school success and experience; thus providing a social network that extends beyond the academic setting. At MSU, AGEP also provides an interdisciplinary and multigenerational environment that includes graduate students, faculty members, post-docs and prospective graduate students. Using monthly surveys over a 4-year period, we evaluated the impact of this AGEP initiative focusing on the utility of the program, perceptions of departmental climate, career plans and institutional support. Findings indicate that AGEP participants consider their experiences in the program as vital elements in the development of their professional identity, psychological safety, and career readiness. Experiences that were identified included networking across departments, focus on career placement, involvement in minority recruitment and professional development opportunities. Additionally, AGEP community participants resonated with the "sense of community" that is at the core of the MSU AGEP program legacy. In this article, we proposed a variation of Tomlinson's Graduate Student Capital model to describe the AGEP participants' perceptions and experiences in MSU AGEP. Within this 4-year period, we report over 70% graduation rate (completing with advanced degrees). More than half of Ph.D. students and almost 30% of master's degree students decided to pursue academia as their careers. In addition, we found a high satisfaction rate of AGEP among the participants. Our analysis on graduate student capital helped us identify motivating capital development by years spent at MSU and as an AGEP member. These findings may provide some insight into which capitals may be deemed important for students relative to their experiences at MSU and in AGEP and how their priorities change as they transition toward graduation.
RESUMO
Prevalence of alcohol use disorders (AUD) varies across racial/ethnic groups. It remains unclear whether rapid transition from first-time alcohol use to developing AUD varies by race and ethnicity. In this study, we investigate racial/ethnic differences in AUD onset among first-time alcohol drinkers and identify specific predictors of AUD onset by racial/ethnic group. The study population was non-institutionalized US residents aged 12 and older. Within four nationally representative probability samples (n â¼70,000/year) drawn from the 2015-2018 National Surveys on Drug Use and Health, we identified 9,381 individuals who initiated alcohol use within 1-12 months prior to the survey. The probability of AUD after initiation was estimated for the entire sample, followed by racial/ethnic group stratification. Bivariate and multivariable logistic regression models were used to identify predictors of AUD onset among alcohol initiates. The overall incidence estimate of AUD among alcohol initiates was 3.7% (95% CI = 3.0%, 4.6%). There was no significant variation in the incidence of AUD between racial/ethnic groups. Drug use, drug use disorders, and major depressive episode were significant predictors of AUD onset among all alcohol initiates. However, these predictors were not significant among non-Hispanic/Latinx Black individuals. Drug use and drug use disorders were strong predictors of AUD onset among alcohol initiates, except among non-Hispanic/Latinx Black individuals. These findings strengthen the importance of focusing on the co-use of alcohol and other drugs and the need to further investigate the risk profile differences between racial/ethnic groups.