ChatGPT: Friend or Foe?-Utility in Trauma Triage.

Artificial intelligence (AI) has been growing rapidly in the health and production industry. The most recent AI program that has caught everyone's eye is, Chat Generative Pre-trained Transformer (ChatGPT). It is a program based on Open AI and was released in November 2022 to the public. It is a chatbot that helps with analyzing and learning data from the net, based on human literature and data. How to cite this article: Jacob J. ChatGPT: Friend or Foe?-Utility in Trauma Triage. Indian J Crit Care Med 2023;27(8):563-566.

Reducing the number of catheter-associated urinary tract infections at an inpatient rehabilitation facility: A quality improvement project.

During the coronavirus disease 2019 (COVID-19) pandemic, the incidence of healthcare-associated infections (HAIs), including catheter-associated urinary tract infections (CAUTIs), increased significantly across the country. This report describes a quality improvement project aimed at reducing the incidence of CAUTIs at an inpatient rehabilitation facility.

Frequency of Course Remediation and the Effect on North American Pharmacist Licensure Examination Pass Rates.

Objective. Remediation is a tool that allows students to correct an academic deficiency after earning an unsatisfactory grade. There is a lack of data on remediation processes and their impact on future academic performance. This study aimed to evaluate the impact of remediation frequency on North American Pharmacist Licensure Examination (NAPLEX) performance.Methods. The primary analysis was the relationship between the NAPLEX first-time pass rate and the frequency of course remediations (no remediations, one remediation, and two or more remediations). Additional analyses included the correlation between the NAPLEX scaled score and the number of course remediations and characteristics of the course remediated.Results. A total of 116 students with NAPLEX data were included for analysis. Compared to students who never remediated, NAPLEX first-time pass rates were similar among those who remediated only one course; however, students who remediated two or more courses had significantly lower NAPLEX pass rates. Remediation in courses mapped to Pharmacy Curriculum Outcomes Assessment (PCOA) area 4.0 (clinical sciences), and courses with mixed PCOA content areas were negatively correlated with NAPLEX scaled scores. A significant negative correlation existed between remediation in students' second or third years in pharmacy school and the NAPLEX scaled score, but this correlation was not significant for students in their first year.Conclusion. Multiple course remediations are negatively correlated with NAPLEX scaled scores and a reduced first-time NAPLEX pass rate, but a single course remediation has no effect. Institutions should aim to evaluate their current remediation practices and assess whether additional support should be provided to students with multiple course remediations.

Apolipoprotein A5 gene polymorphism (rs662799) and cardiovascular disease in end-stage kidney disease patients.

BACKGROUND: Plasma triglyceride (TG) levels are a significant risk factor for cardiovascular disease (CVD). The APOA5 gene is one of the crucial factors in plasma TG metabolism regulation. The rs662799 polymorphism in the APOA5 gene has been reported to be associated with cardiovascular disease. The goal of this study was to evaluate the potential association of this variant with CVD in patients with end-stage kidney disease.  METHODS: In this case-control study the polymorphism was analyzed using the PCR-RFLP method in 800 consecutive patients with ESKD and 500 healthy controls. The genotype and allele distribution was compared between subgroups of patients with CVD (552) versus those without CVD (248). RESULTS: The frequency of the minor allele (C) in the healthy individuals was 9% compared to 12% in ESRD group (p = 0.09). The difference between groups was slightly higher for CC homozygote (3.5% versus 1.6%, p = 0.042). The ESKD patient group was analyzed according to the presence or absence of CVD. The significant differences in the polymorphism distribution were revealed in this analysis. The frequency of the C allele in the CVD + subgroup was 14% compared to 6% in CVD- patients (p = 0.001). In the CVD + subgroup the ORs (95% CI) for the C allele and CC genotype were 2.41 (1.61-3.6), p < 0.001 and 3.13 (1.07-9.14), p = 0.036, respectively. This indicates to the association of the variant C allele with cardiovascular disease in ESKD patients. The CC homozygotes have a threefold higher odds of CVD compared to TT homozygotes. The highest frequency of the C allele (18%) was observed in subgroup of patients with diabetic nephropathy, with OR (95% CI) 3.40 (2.13-5.43), p < 0.001.The presence of minor allele (CC and CT genotypes) was significantly associated with increased plasma triglyceride levels (p < 0.001 for both CVD + and CVD- groups). CONCLUSION: The present study demonstrated the effect of rs662799 polymorphism on plasma TG levels and its association with the development of cardiovascular disease in ESKD patients.

"The Toxic Depot": Parenteral Insecticide Injection.

Background: Organophosphorus (OP) pesticides are extensively used both in developed and developing countries. Organophosphorus poisoning primarily occurs through occupational, accidental, and suicidal exposures. Toxicity through parenteral injections is seldom reported and there are only very few case reports till date. Case presentation: We report a case of parenteral injection of 10 mL of OP compound (Dichlorvos 76%) into a swelling over the left leg. The compound was injected by the patient himself as adjuvant therapy for swelling. Initial manifestations included vomiting, abdomen pain, and excessive secretions followed by neuromuscular weakness. The patient was subsequently intubated and treated with atropine and pralidoxime. The patient did not improve with antidotes for OP poisoning, attributed to the depot the OP compound had formed. The swelling was excised and the patient immediately showed response to the treatment. Biopsy of the swelling showed granuloma and fungal hyphae. The patient developed intermediate syndrome during the ICU stay and was discharged after 20 days of hospital stay. How to cite this article: Jacob J, Reddy CHK, James J. "The Toxic Depot": Parenteral Insecticide Injection. Indian J Crit Care Med 2022;26(7):877-878.

Respiratory Microbiome Disruption and Risk for Ventilator-Associated Lower Respiratory Tract Infection.

BACKGROUND: Ventilator-associated lower respiratory tract infection (VA-LRTI) is common among critically ill patients and has been associated with increased morbidity and mortality. In acute critical illness, respiratory microbiome disruption indices (MDIs) have been shown to predict risk for VA-LRTI, but their utility beyond the first days of critical illness is unknown. We sought to characterize how MDIs previously shown to predict VA-LRTI at initiation of mechanical ventilation change with prolonged mechanical ventilation, and if they remain associated with VA-LRTI risk. METHODS: We developed a cohort of 83 subjects admitted to a long-term acute care hospital due to their prolonged dependence on mechanical ventilation; performed dense, longitudinal sampling of the lower respiratory tract, collecting 1066 specimens; and characterized the lower respiratory microbiome by 16S rRNA sequencing as well as total bacterial abundance by 16S rRNA quantitative polymerase chain reaction. RESULTS: Cross-sectional MDIs, including low Shannon diversity and high total bacterial abundance, were associated with risk for VA-LRTI, but associations had wide posterior credible intervals. Persistent lower respiratory microbiome disruption showed a more robust association with VA-LRTI risk, with each day of (base e) Shannon diversity <2.0 associated with a VA-LRTI odds ratio of 1.36 (95% credible interval, 1.10-1.72). The observed association was consistent across multiple clinical definitions of VA-LRTI. CONCLUSIONS: Cross-sectional MDIs have limited ability to discriminate VA-LRTI risk during prolonged mechanical ventilation, but persistent lower respiratory tract microbiome disruption, best characterized by consecutive days with low Shannon diversity, may identify a population at high risk for infection and may help target infection-prevention interventions.

LDLR gene polymorphism (rs688) affects susceptibility to cardiovascular disease in end-stage kidney disease patients.

BACKGROUND: The low-density lipoprotein receptor (LDLR) plays a significant role in maintaining the cellular cholesterol homeostasis. Mutations in the LDLR gene can lead to a significant rise in plasma LDL levels that may result in an increased risk of atherosclerosis and coronary heart disease. The purpose of this study was to assess the potential association of the LDLR rs688 polymorphism with cardiovascular disease (CVD) in patients with end-stage kidney disease (ESKD) undergoing hemodialysis. METHODS: In this case-control study the polymorphism was genotyped by the allele specific PCR method in 800 patients with ESKD and 500 healthy controls. The genotype and allele distribution was compared in subgroups of patients with CVD (552) versus those without CVD (248). RESULTS: A significant difference was observed in genotype distribution among ESKD patients and healthy controls. The frequencies of the T allele and TT genotype in ESKD group were significantly higher, with OR (95% CI) 2.2 (1.87-2.6), p <  0.0001 and 5.84 (3.94-8.65), p <  0.0001, respectively. In the he ESKD cohort the distribution of the rs688 was compared between CVD+ and CVD- subgroups. A strong association of the polymorphism with the CVD risk was observed in this analysis. The frequencies of the T allele and TT genotype were significantly higher in CVD+ subgroup, with OR (95% CI) 3.4 (2.71-4.26), p <  0.0001 and 13.2 (7.87-22.09), p <  0.0001, respectively. A multivariate logistic regression analysis was performed to estimate the association between rs688 T variant and risk of CVD. After adjustment for age, sex, BMI, hypertension and diabetes, both CT and TT genotypes were associated with an increased risk of developing CVD in the dominant, recessive and codominant models of inheritance. No significant differences in serum LDL cholesterol levels were found when compared between genotypes. CONCLUSIONS: The present study is the first to demonstrate the association of the LDLR gene polymorphism with increased susceptibility to cardiovascular disease in ESKD patients. This finding needs further investigation to confirm that LDLR rs688 might be a novel genetic risk factor with some prognostic capacity for CVD in ESKD patients.

Validity of ICD-10-CM diagnoses to identify hospitalizations for serious infections among patients treated with biologic therapies.

PURPOSE: Identifying hospitalizations for serious infections among patients dispensed biologic therapies within healthcare databases is important for post-marketing surveillance of these drugs. We determined the positive predictive value (PPV) of an ICD-10-CM-based diagnostic coding algorithm to identify hospitalization for serious infection among patients dispensed biologic therapy within the FDA's Sentinel Distributed Database. METHODS: We identified health plan members who met the following algorithm criteria: (1) hospital ICD-10-CM discharge diagnosis of serious infection between July 1, 2016 and August 31, 2018; (2) either outpatient/emergency department infection diagnosis or outpatient antimicrobial treatment within 7 days prior to hospitalization; (3) inflammatory bowel disease, psoriasis, or rheumatological diagnosis within 1 year prior to hospitalization, and (4) were dispensed outpatient biologic therapy within 90 days prior to admission. Medical records were reviewed by infectious disease clinicians to adjudicate hospitalizations for serious infection. The PPV (95% confidence interval [CI]) for confirmed events was determined after further weighting by the prevalence of the type of serious infection in the database. RESULTS: Among 223 selected health plan members who met the algorithm, 209 (93.7% [95% CI, 90.1%-96.9%]) were confirmed to have a hospitalization for serious infection. After weighting by the prevalence of the type of serious infection, the PPV of the ICD-10-CM algorithm identifying a hospitalization for serious infection was 80.2% (95% CI, 75.3%-84.7%). CONCLUSIONS: The ICD-10-CM-based algorithm for hospitalization for serious infection among patients dispensed biologic therapies within the Sentinel Distributed Database had 80% PPV for confirmed events and could be considered for use within pharmacoepidemiologic studies.

Association between p22PHOX gene C242T polymorphism and hypertension in end-stage kidney disease patients.

Oxidative stress plays an important role in hypertension associated vascular damage. It is mediated by nicotinamide adenine dinucleotide phosphate (NADPH) oxidase activation. The C242T polymorphism in the p22PHOX gene encoding essential subunit of NADPH oxidase was associated with CVD, hypertension, and endothelial function. The aim of this study was to assess a potential association of C242T polymorphism with hypertension in end-stage kidney disease (ESKD) patients. DNA samples from 495 patients were genotyped by polymerase chain reaction (PCR) with subsequent cleavage with Rsa I restriction endonuclease. There were no significant differences in genotype and allele distribution between ESKD patients and healthy controls. When patients were stratified into male and female subgroups, there were no differences in the frequency of the T allele (0.35 and 0.34, respectively). Genotype and allele frequencies were also comparable between HY+ and HY- subgroups. We analyzed whether there were any differences between genders in the effect of C242T polymorphism on the presence of hypertension by comparing HY+ males with normotensive males and HY+ females with normotensive females. No difference in polymorphism distribution was found in female subgroup. The significant differences were observed in males. In HY+ subgroup, the frequencies of T allele and TT genotype were higher than in HY- males, with OR 1.91 (1.31-2.8), p = 0.0008 and OR 4.2 (1.67-10.6), p = 0.002, respectively. In conclusion, this is the first study to demonstrate significant association of the p22PHOX gene polymorphism with hypertension in male ESKD patients, with T allele as a risk factor for hypertension.

Clostridium difficile in an Urban, University-Affiliated Long-Term Acute-Care Hospital.

OBJECTIVES To describe the characteristics and impact of Clostridium difficile infection (CDI) in a long-term acute-care hospital (LTACH). DESIGN Retrospective matched cohort study. SETTING A 38-bed, urban, university-affiliated LTACH. METHODS The characteristics of LTACH-onset CDI were assessed among patients hospitalized between July 2008 and October 2015. Patients with CDI were matched to concurrently hospitalized patients without a diagnosis of CDI. Severe CDI was defined as CDI with 2 or more of the following criteria: age ≥65 years, serum creatinine ≥2 mg/dL, or peripheral leukocyte count ≥20,000 cells/µL. A conditional Poisson regression model was developed to determine characteristics associated with a composite primary outcome of 30-day readmission to an acute-care hospital, or mortality. RESULTS The overall incidence of CDI was 21.4 cases per 10,000 patient days, with 27% of infections classified as severe. Patients with CDI had a mean age of 70 years (SD, 14 years), a mean Charlson comorbidity index of 3.6 (SD, 2.0), a median length of stay of 33 days (interquartile range [IQR], 24-45 days), and a median time between admission and CDI diagnosis of 16 days (IQR, 9-23 days). The most commonly prescribed antibiotic preceding a CDI diagnosis was a cephalosporin, with median duration of 8 days (IQR, 4-14 days). In multivariate analysis, CDI was not significantly associated with the primary outcome (relative risk, 0.97; 95% CI, 0.59-1.58). CONCLUSIONS Incidence of CDI in an urban, university-affiliated LTACH was high. Future research should focus on infection prevention measures to decrease the burden of CDI in this complex patient population. Infect Control Hosp Epidemiol 2017;38:294-299.

Diseases Transmitted by Man's Best Friend: The Dog.

The relationship between dogs and humans is ancient and mutually beneficial. Dogs have served people well as companions, workmates, guides, and protectors. However, on occasion, dogs may injure humans through biting or may transmit pathogens resulting in a large number of problems ranging from a trivial rash to life-threatening bacteremia. Given that there are more than 80 million pet dogs in the United States, it is worth knowing the potential problems that can result from canine exposure. Annually, almost 5 million people in the United States suffer a dog bite. Dog bite wounds become infected up to 15% of the time. In those who have had a splenectomy, a dog bite may transmit the bacterium Capnocytophaga canimorsus, leading to life-threatening bacteremia. Other illnesses that humans can acquire from dog contact include ringworm, diarrheal disease (salmonellosis, campylobacteriosis, and intestinal parasites), leptospirosis, brucellosis, Q fever, visceral larva migrans, and echinococcosis. Evidence exists that the family dog may serve as a reservoir for uropathogenic Escherichia coli that can lead to urinary tract infections among human household contacts. In this article we discuss dog-related infectious diseases as well as measures to minimize dog-associated illness (e.g., do not disturb sleeping dogs; HIV-infected persons who wish to acquire a puppy should have the dog's stool checked for Cryptosporidium).

Implementing faculty evaluation of written sign-out.

PURPOSE: Recently the Accreditation Council for Graduate Medical Education mandated decreased shift duration for intern physicians to no more than 16 hours. Such work-hour restrictions are likely to increase patient care hand-offs. It is well accepted that sign-out (i.e., hand-off) processes are error prone and lack standardization. Moreover, many residency programs do not evaluate sign-out. We designed and tested whether a sign-out evaluation process could be implemented to improve written sign-out. METHOD: Based on observed sign-out deficiencies at our institution we adapted a simple curriculum incorporating the SIGNOUT mnemonic, which we paired with weekly faculty member evaluation and feedback on sign-out using a structured sign-out evaluation tool. Later in the week, written sign-out was independently scored by 2-blinded senior resident reviewers who compared the inclusion of sign-out content, organization, and readability. RESULTS: Compared to baseline data in 128 written sign-outs, the pairing of a 1-page curriculum with weekly faculty member evaluation of written sign-out improved the inclusion of advanced directives from 38% to 69% (p < .001) and anticipatory guidance from a mean score of 1.8 (SD = 1.2) to 2.3 (SD = 1.5) on a 5-point scale (p = .01) in 177 written sign-outs. Readability and organization were unchanged. CONCLUSIONS: A simple curriculum paired with structured faculty evaluation and feedback can improve some parameters of sign-out. Structured evaluative sign-out tools may be useful to improve and teach sign-out skills.

The tetraspanin protein peripherin-2 forms a complex with melanoregulin, a putative membrane fusion regulator.

Peripherin-2, the product of the rds gene, is a tetraspanin protein. In this study, we show that peripherin-2 forms a complex with melanoregulin (MREG), the product of the Mreg locus. Genetic studies suggest that MREG is involved in organelle biogenesis. In this study, we explore the role of this protein in processes associated with the formation of disk membranes, specialized organelles of photoreceptor rod cells. MREG antibodies were generated and found to be immunoreactive with a 28 kDa protein in retinal extracts, bovine OS, ARPE-19 cells, and rat RPE. MREG colocalized with peripherin-2 in WT (CB6F1/J) and in rds+/- retinas. Western blots of serial tangential sections confirmed the close association of these two proteins within the IS and basal outer segment of rods. Immunoprecipitation (IP) of OS extracts showed formation of a complex between MREG and peripherin-2-ROM-1 hetero-oligomers. This interaction was confirmed with pulldown analyses in which the GST-PerCter protein selectively pulled down His-MREG and His-MREG selectively pulled down PerCter. Biacore analysis using peptide inhibitors and per-2 truncation mutant studies allowed us to map the MREG binding site on per-2 to the last five residues of the C-terminus (Gln341-Gly346), and kinetic data predicted a KD of 80 nM for PerCter-MREG binding. Finally, the effect of MREG on photoreceptor specific membrane fusion was assayed using a disk-plasma membrane cell free assay. Preincubation of target membranes with MREG resulted in a dose-dependent inhibition of fusion with an IC50 in the submicromolar range. Collectively, these results suggest that this newly identified protein regulates peripherin-2 function.