Diagnosis and treatment of coagulopathy using thromboelastography with platelet mapping is associated with decreased risk of pulmonary failure in COVID-19 patients.

INTRODUCTION: Treatment of coronavirus disease 2019 (COVID-19) patients may require antithrombotic and/or anti-inflammatory medications. We hypothesized that individualized anticoagulant (AC) management, based on diagnosis of coagulopathy using thromboelastography with platelet mapping (TEG-PM), would decrease the frequency of pulmonary failure (PF) requiring mechanical ventilation (MV), mitigate thrombotic and hemorrhagic events, and, in-turn, reduce mortality. METHODS: Hospital-admitted COVID-19 patients, age 18 or older, with escalating oxygen requirements were included. Prospective and supplemental retrospective chart reviews were conducted during a 2-month period. Patients were stratified into two groups based on clinician-administered AC treatment: TEG-PM guided vs. non-TEG guided. RESULTS: Highly-elevated inflammatory markers (D-dimer, C-reactive protein, ferritin) were associated with poor prognosis but did not distinguish coagulopathic from noncoagulopathic patients. TEG-guided AC treatment was used in 145 patients vs. 227 treated without TEG-PM guidance. When managed by TEG-PM, patients had decreased frequency of PF requiring MV (45/145 [31%] vs. 152/227 [66.9%], P  < 0.0001), fewer thrombotic events (2[1.4%] vs. 39[17.2%], P  = 0.0019) and fewer hemorrhagic events (6[4.1%] vs. 24[10.7%], P  = 0.0240), and had markedly reduced mortality (43[29.7%] vs. 142[62.6%], P  < 0.0001). Platelet hyperactivity, indicating the need for antiplatelet medications, was identified in 75% of TEG-PM patients. When adjusted for confounders, empiric, indiscriminate AC treatment (not guided by TEG-PM) was shown to be an associated risk factor for PF requiring MV, while TEG-PM guided management was associated with a protective effect (odds ratio = 0.18, 95% confidence interval 0.08-0.4). CONCLUSIONS: Following COVID-19 diagnosis, AC therapies based on diagnosis of coagulopathy using TEG-PM were associated with significantly less respiratory decompensation, fewer thrombotic and hemorrhagic complications, and improved likelihood of survival.

Dimensions of food texture: A conceptual discussion.

Food texture is a collective term for all texture-related features of a food product. A comprehensive description of food texture is therefore practically challenging due to too many parameters that are associated simultaneously with the food. Using every day, non-technical (layman's) language, we attempt in this work to rationalize the different dimensions that contribute to the texture of foods, and we explain the rheological reasons behind the concept. For solid foods, three dimensions are identified being the "hard-soft," "strong-weak," and "brittle-plastic." For liquid foods, three further dimensions are suggested, being "elastic-viscous," "thick-thin," and "shear thinning-shear thickening." As these dimensions are bipolar, for foods where any of the dimensions are not relevant, we conceive that dimension takes on a zero value, aligning at the center of the scale.

Low Threshold for Laparoscopic Exploration in Dementia Patients With Unexplained Abdominal Pain and Risk Factors for Acute Mesenteric Ischemia.

Acute mesenteric ischemia (AMI) is associated with a high mortality and morbidity. There are limited studies on the presentation and management of elderly dementia patients with AMI. The following case of an 88-year-old female with dementia presenting with AMI highlights the challenges in the care of elderly dementia patients with AMI, the importance of identifying risk factors and hallmarks of acute mesenteric ischemia early in the clinical course, and suggests that aggressive workup with diagnostic laparoscopy is crucial to timely diagnosis and effective care.

Comparing Severely Injured Trauma Patients Admitted to Investor-Owned versus Public and Not-For-Profit Hospitals Reveals Opportunities for Improvement in the US.

BACKGROUND: Non-elderly trauma patients represent the largest portion of preventable years of life loss in the US. The purpose of this study was to compare outcomes in patients admitted to investor-owned vs public and not-for-profit hospitals across the US. MATERIAL AND METHODS: The Nationwide Readmissions Database 2018 was queried for trauma patients with an Injury Severity Score greater than 15 and age 18-65 years. The primary outcome was mortality; secondary outcomes were prolonged length of stay (LOS) greater than 30 days, readmission within 30 days, and readmission to a different hospital. Patients admitted to investor-owned hospitals were compared to public and not-for-profit hospitals. Univariable analysis was performed using chi-squared tests. Multivariable logistic regression was performed for each outcome. RESULTS: 157 945 patients were included with 11.0% (n = 17 346) admitted to investor-owned hospitals. The overall mortality rate and prolonged LOS were similar for both groups. The overall readmission rate was 9.2% (n = 13 895), with the rate in investor-owned hospitals at 10.5% (n = 1,739, P < .001). Multivariable logistic regression revealed investor-owned hospitals had an increased risk of readmission (OR 1.2 [1.1-1.3] P < .001) and readmission to a different hospital (OR 1.3 [1.2-1.5] P < .001). DISCUSSION: Severely injured trauma patients have similar rates of mortality and prolonged length of stay in investor-owned vs public and not-for-profit hospitals. However, patients admitted to investor-owned hospitals have an increased risk of readmission and readmission to different hospitals. Efforts to improve outcomes after trauma must consider hospital ownership and readmission to different hospitals.

Comparing Payments to Surgeons From Drug and Medical Device Corporations Reveals Inequalities Between Genders and Specialties.

INTRODUCTION: Maintaining trust in the patient-doctor relationship requires transparency in the details of the financial relationships between physicians and drug and medical device corporations. These details are publicly available through the Open Payments database, and patients are encouraged to ask surgeons to interpret their implications. The purpose of this study was to better equip surgeons in responding to these inquiries and to compare the distribution of these payments by gender and specialty. METHODS: The 2021 Open Payments dataset was searched for all payments to surgeons from the 14 different specialties recognized by the American College of Surgeons. The total payments per surgeon were compared by calculating the mean and median payments. The Gini index, a measure of income inequality, was also calculated for each specialty. RESULTS: There were 96 724 surgeons who received over $755 million in payments from drug and medical device companies. There were 72 245 (74.7%) men and 24 479 (25.3%) women. The total amount of payments to men was $712 million (94.2%) and for women it was $44 million (5.8%). The overall Gini index was .9508. The specialty with the highest Gini index was pediatric surgery (.9844) and the lowest was cardiothoracic surgery (.8656). DISCUSSION: Male surgeons received disproportionately higher payments from drug and device corporations than female surgeons. Surgeons should be aware of their own standing within the Open Payments database in order to respond appropriately to patient inquiries.

Financial Toxicity in Emergency General Surgery: Novel Propensity-Matched Outcome Comparison.

BACKGROUND: Financial toxicity describes the harmful effect of individual treatment costs and fiscal burdens that have a compounding negative impact on outcomes in surgery. While this phenomenon has been widely studied in surgical oncology, the purpose of this study was to perform a novel exploration of the impact of financial toxicity in emergency general surgery (EGS) patients throughout the US. STUDY DESIGN: The Nationwide Readmissions Database for January and February 2018 was queried for all EGS patients aged 18 to 65 years. One-to-one propensity matching was performed with and without risk for financial toxicity. The primary outcome was mortality, and the secondary outcomes were venous thromboembolism (VTE), prolonged length of stay (LOS), and readmission within 30 days. RESULTS: There were 24,154 EGS patients propensity matched. The mortality rate was 0.2% (n = 39), and the rate of VTE was 0.5% (n = 113). With financial toxicity, there was no statistically significant difference for mortality (p = 0.08) or VTE (p = 0.30). The rate of prolonged LOS was 6.2% (n = 824), and the risk was increased with financial toxicity (risk ratio 1.24 [1.12 to 1.37]; p < 0.001). The readmission rate was 7.0% (n = 926), and the risk with financial toxicity was increased (risk ratio 1.21 [1.10 to 1.33]; p < 0.001). The mean count of comorbidities per patient per admission during readmission within 1 year with financial toxicity was 2.1 ± 1.9 versus 1.8 ± 1.7 without (p < 0.001). CONCLUSIONS: Despite little difference in the rate of mortality or VTE, EGS patients at risk for financial toxicity have an increased risk of readmission and longer LOS. Fewer comorbidities were identified at index admission than during readmission in patients at risk for financial toxicity. Future studies aimed at reducing this compounding effect of financial toxicity and identifying missed comorbidities have the potential to improve EGS outcomes.

Pneumothorax in the Setting of Spinal Surgery: A Case Report and Review of the Literature.

The purpose of this paper is to review the occurrence and management of a tension pneumothorax, which was exacerbated status post posterior spinal surgery. A retrospective review of intraoperative reports, imaging, and pertinent medical records was conducted for a patient who underwent posterior spinal surgery with a tiny apical pneumothorax, which subsequently developed into a major pneumothorax. The clinical signs imperative to recognition and prompt treatment are discussed. Our case report demonstrates that the unrecognized disruption of the pleural cavity during posterior spinal surgery caused the exacerbation of the patient's bilateral pneumothoraces. The patient was successfully treated with finger thoracostomy and chest tube insertion. In conclusion, posterior spinal surgery is an invasive procedure with the potential for serious complications such as the exacerbation of a previous non-surgical pneumothorax. A low index of suspicion is imperative due to the potentially lethal nature of pneumothoraces. Vital signs, pulmonary exam findings, portable radiography, and sonography equipment are all invaluable to the accurate diagnosis and early intervention of patients with pneumothoraces.

Hemipelvectomy as a Salvage Procedure in Massive Pelvic Trauma.

"Pedestrian struck by train" represents one of the highest magnitude blunt force traumas. Despite the severity of injuries, these patients can have good outcomes. A 25-year-old male presented after being struck by a train. He had several injuries, including extensive complex pelvic fractures, right external iliac artery and vein laceration, and right femur and tibia fracture. He was taken to the operating room for damage control surgery and attempted revascularization of the right lower extremity. The extremity became ischemic and required above knee amputation followed by hip disarticulation and hemipelvectomy. His pelvic wounds were treated with negative pressure wound therapy and gradually closed. He was eventually discharged to a rehab facility for continued recovery. This case highlights the interventions that allowed a young man who was struck by a train to survive. He improved significantly since undergoing hemipelvectomy, indicating that severe pelvic injuries from high energy trauma may necessitate hemipelvectomy.

Nationwide Analysis of Hospital Admissions Prior to Hartmann's Procedure for Acute Diverticulitis.

INTRODUCTION: Diverticular disease is one of the most common gastrointestinal diseases that require hospital admission. This study aims to identify trends in prior hospital admissions for patients that ultimately require a Hartmann's procedure for complicated diverticulitis. METHODS: The Nationwide Readmissions Database for 2010-2014 was queried for all patients aged 18 years or older admitted with an ICD-9 code for colonic diverticulitis and end colostomy creation. Patients with prior hospital admissions were identified. The primary outcome was mortality after Hartmann's procedure. Secondary outcomes were prior hospital admission and previous percutaneous drain placement. Multivariable logistic regression was performed to control for confounding factors for each outcome and results were weighted for national estimates. RESULTS: There were 90,162 patients admitted with complicated diverticulitis requiring end colostomy creation. Prior hospital admissions were found in 28.1% (n = 25,307) and 14.4% (n = 12,947) had a previous percutaneous drain placed during a prior admission. The overall mortality rate was 5.9% (n = 5314) after Hartman's procedure. The mortality rate for patients with prior hospital admissions was 8.7% (P < .001), and the mortality rate for patients with previous percutaneous drain placement was 4.3% (P < .001). After controlling for confounding factors including comorbidities, patients with prior admission had an increased risk of mortality (OR 1.48 [1.40-1.58], P < .001) and patients with previous percutaneous drain placement had a decreased risk of mortality (OR .66 [.60-.72], P < .001). CONCLUSIONS: Hospitalizations for complications of diverticulitis are a costly burden to our healthcare system. By identifying those patients at high risk for readmission and emergency surgery, perioperative outcomes may be improved.

Jejuno-jejunal intussusception secondary to recurrent/metastatic melanoma.

Intussusception is uncommon in adults, and usually secondary to a neoplasm. Small bowel obstruction (SBO) is prevalent in adults but rarely due to intussusception. A 55-year-old woman with history of melanoma (four years in remission) presented with abdominal pain and melena. Upper and lower endoscopy was normal. She developed bilious emesis and worsening pain, so she presented to the emergency department. CT abdomen/pelvis identified a SBO with transition point at a small bowel intussusception; she was taken to the operating room. A mid-jejunal intussusception was reduced revealing a mass; resection and primary anastomosis was performed. Final pathology demonstrated a 5.5 cm melanoma, likely metastatic. She required no additional therapy and remains in remission eighteen months later. Intussusception due to metastatic melanoma is rare but should be on the differential for patients with SBO and history of melanoma. Knowledge of this history should prompt consideration for oncologic resection to optimize outcome.

Cerebral Fat Embolism via a Patent Foramen Ovale.

Fat embolism syndrome (FES) is a multisystem process predominantly secondary to long bone/pelvic fractures and orthopedic procedures. A 19-year-old man presents after motor vehicle collision with trace right pneumothorax, right grade 3 kidney laceration, left pubic rami, and right femoral shaft fractures. Right femur closed reduction ensued and he underwent intramedullary nailing; his other injuries were managed nonoperatively. Upon awakening in recovery, he was newly aphasic. Despite negative repeat CT brain, he continued to worsen and became tachycardic and hypoxemic. MRI/MRA brain demonstrated innumerable bilateral frontal, parietal, and occipital acute ischemic infarcts in a starfield pattern. Echocardiogram revealed a PFO. With supportive care, he improved and was discharged with planned outpatient PFO closure. One month later, he had complete symptom resolution with return to neurologic baseline. FES is a potentially devastating condition which may include cerebral fat embolism (CFE) with outcomes varying widely from mortality to complete recovery.

Artifacts and errors in the measurement of the stickiness of liquid foods with tack tests.

We encounter stickiness in many areas of our daily life and as humans, we are able to discriminate different levels of stickiness. Yet attempts to measure stickiness with instruments have been challenging. One of the commonest approaches has been the "tack test" in which a probe is brought into contact with the sticky food and then pulled away while measuring the resisting force-various indices, such as the maximum force or the area below the force curve have been used to describe stickiness. This work rationalizes results from tack tests for liquid foods and helps us explain the influence of probe geometry. Photographic evidence of the way that the liquid adheres/detaches from the probe suggests that the terms "cohesive" and "adhesive" failure depend on the speed of the test. Application of a fixed deformation with time shows rapid loss of adhesive force suggesting that liquid samples flow from the probe. We propose that stickiness of liquid foods is entirely due to the liquid's viscosity and surface tension, and that measurements of tack for liquid foods-while highly reproducible-are entirely artifacts of the test method employed and are in effect snapshots in time of non-equilibrium processes.

Left Ventricular Ballooning Patterns in Recurrent Takotsubo Cardiomyopathy: A Systematic Review and Meta-analysis of Reported Cases.

Recurrent takotsubo cardiomyopathy (TTC) and the clinical profiles and outcomes of patients have not been fully evaluated, nor has the effect of left ventricular ballooning pattern. After searching the medical literature for reports of patients with recurrent TTC, we identified 84 articles with 101 case descriptions. We divided the cases into those with only apical left ventricular ballooning patterns at recurrence (typical, n=60), and those with at least one midventricular or basal ballooning pattern (atypical, n=41). We then compared their clinical profiles and outcomes. The groups were similar in terms of baseline demographic characteristics, presence and types of triggers, use of heart failure medications at TTC recurrence, electrocardiographic changes at presentation, initial left ventricular ejection fractions, timespans between recurrent TTC episodes, and recovery times after each event. However, patients in the atypical group had significantly fewer severe adverse events (cardiogenic shock and cardiac arrest) than did those in the typical group, with an estimated 63% lower odds (adjusted odds ratio=0.37; 95% CI, 0.14-0.97; P=0.039). Survival to hospital discharge was statistically similar but lower in the typical group (n=53; 88.3%) than in the atypical group (n=24; 96%). Our results suggest that left ventricular ballooning patterns influence clinical outcomes, and that outcomes are more favorable in patients with recurrent TTC who have atypical left ventricular ballooning patterns.

Muscle activity during oral processing of sticky-cohesive foods.

We investigated muscle activity during oral processing of sticky model foods. Chewing Time extracted from the EMG data distinguished the most sticky and least sticky model foods from the others, but was not a good discriminator between the other models. Mean chew work declined by 25.4%, while the median frequency shift (which is related to muscle fatigue) increased by 54.9% during oral processing for all the model foods, with the effect being greatest for the stickiest foods. We conclude that the degree of stickiness is not a trigger for swallowing and changes in the other bolus properties, such as softness, may influence muscle activity to a level at which we can swallow.

Reformulation of Muffins Using Inulin and Green Banana Flour: Physical, Sensory, Nutritional and Shelf-Life Properties.

This study demonstrates a scenario of industrial reformulation by developing muffins that resemble store-branded ones and testing the possibility of reformulating them using inulin and green banana flour (GBF). Ten different formulations were created through reducing 10% or 30% of sugar and/or fat. Physical characteristics, consumer acceptance and purchase preferences, baking losses, nutritional properties, shelf-life, as well as cost and industrial processability were considered and discussed. Results on physical properties showed that firmness had increased in reformulated muffins while springiness only decreased when both sugar and fat were reduced by 30% (p < 0.05). Texture and sensory properties of reformulated muffins were acceptable, and the purchase intent rate was high. Regarding the nutritional properties, muffins incorporating more than 10% of fibres allowed the addition of nutritional claims. The incremental area under the curve iAUC120min of blood glucose in healthy adults (n = 13) was significantly lower than control after ingesting 30% reduced sugar or fat muffins using inulin (p < 0.01). The microbial profile was not affected by reformulation during storage at 25 °C for 10 days. This study concluded that there is a significant potential to industrially produce reduced sugar or fat muffins using inulin or GBF up to 30% without significantly deteriorating quality attributes.

What is cohesiveness?-A linguistic exploration of the food texture testing literature.

Cohesiveness is a widely used term in the food texture literature. Authors of this literature employ divergent methodologies, and can be divided into those who assess texture through sensory evaluation and those who use instrumental techniques. Within each of these disciplines, there are some specialized uses of the word, creating discipline specific terms such as "cohesiveness of mass." The fact that many researchers attempt to (re)define cohesiveness, does suggest that the term is not universally understood. This blurring arises partly from the abstract nature of what it describes and also from ill matching measurements being used to quantify it. A widely agreed definition is that cohesiveness is "the strength of the internal bonds making up the body of the product," yet a challenge continues to be how we can measure it. Using the Sketch Engine corpus analysis interface to examine a corpus of articles from the food texture literature in the periods 2002-2017, the contexts in which the word stem "cohes*" is used were explored. Collocation analysis suggests that in addition to considerable commonality in the way that "cohesiveness" combines with other terms, differences reflect the foci of the disciplines with the instrumental community predominantly dealing with physical measurement while the sensory community relate "cohesiveness" more to oral processing and texture perception.

Integral Use of Thromboelastography With Platelet Mapping to Guide Appropriate Treatment, Avoid Complications, and Improve Survival of Patients With Coronavirus Disease 2019-Related Coagulopathy.

OBJECTIVES: Coagulopathy of coronavirus disease 2019 is largely described as hypercoagulability, yet both thrombotic and hemorrhagic complications occur. Although therapeutic and prophylactic anticoagulant interventions have been recommended, empiric use of antifactor medications (heparin/enoxaparin) may result in hemorrhagic complications, including death. Furthermore, traditional (antifactor) anticoagulation does not address the impact of overactive platelets in coronavirus disease 2019. The primary aim was to evaluate if algorithm-guided thromboelastography with platelet mapping could better characterize an individual's coronavirus disease 2019-relatedcoagulopathic state and, secondarily, improve outcomes. DESIGN SETTING AND PATIENTS: Coronavirus disease 2019 patients (n = 100), receiving thromboelastography with platelet mapping assay upon admission to an 800-bed tertiary-care hospital, were followed prospectively by a hospital-based thromboelastography team. Treating clinicians were provided with the option of using a pre-established algorithm for anticoagulation, including follow-up thromboelastography with platelet mapping assays. Two groups evolved: 1) patients managed by thromboelastography with platelet mapping algorithm (algorithm-guided-thromboelastography); 2) those treated without thromboelastography with platelet mapping protocols (non-algorithm-guided). Outcomes included thrombotic/hemorrhagic complications, pulmonary failure, need for mechanical ventilation, acute kidney injury, dialysis requirement, and nonsurvival. INTERVENTIONS: Standard-of-care therapy with or without algorithm-guided-thromboelastography support. MEASUREMENTS AND MAIN RESULTS: Although d-dimer, C-reactive protein, and ferritin were elevated significantly in critically ill (nonsurvivors, acute kidney injury, pulmonary failure), they did not distinguish between coagulopathic and noncoagulopathic patients. Platelet hyperactivity (maximum amplitude-arachidonic acid/adenosine diphosphate > 50 min), with or without thrombocytosis, was associated with thrombotic/ischemic complications, whereas severe thrombocytopenia (platelet count < 100,000/µL) was uniformly fatal. Hemorrhagic complications were observed with decreased factor activity (reaction time > 8 min). Non-algorithm-guided patients had increased risk for subsequent mechanical ventilation (relative risk = 10.9; p < 0.0001), acute kidney injury (relative risk = 2.3; p = 0.0017), dialysis (relative risk = 7.8; p < 0.0001), and death (relative risk = 7.7; p < 0.0001), with 17 of 28 non-algorithm-guided patients (60.7%) dying versus four algorithm-guided-thromboelastography patients (5.6%) (p < 0.0001). Thromboelastography with platelet mapping-guided antiplatelet treatment decreased mortality 82% (p = 0.0002), whereas non-algorithm-guided (compared with algorithm-guided-thromboelastography) use of antifactor therapy (heparin/enoxaparin) resulted in 10.3-fold increased mortality risk (p = 0.0001). CONCLUSIONS: Thromboelastography with platelet mapping better characterizes the spectrum of coronavirus disease 2019 coagulation-related abnormalities and may guide more tailored, patient-specific therapies in those infected with coronavirus disease 2019.

Influence of candy particle size on oral behaviour.

Oral processing of hard candy was examined to ascertain the extent of sucking and chewing. The proportion of chewing increased as the particles in the mouth are broken down into smaller ones. While the overall eating time for men and women was not significantly different, when eight-small items were present in the mouth, women chewed more at the start of the oral residence time, while chewing for men progressively increased. Individuals who reported a history of eating difficulties tended to chew less and take longer to eat eight-small items than those who had never experienced eating difficulties.

Application of Multimodal Neuromonitoring in Posterior Inferior Cerebellar Artery Aneurysm Clippings: Review of Two Cases.

Neurophysiological monitoring is advocated for the prevention of neurological sequelae secondary to the clipping of an aneurysm involved in posterior circulation. Unfortunately, there is a paucity in the literature regarding what neurophysiological monitoring techniques are best employed. The authors here present two cases where multimodal neuromonitoring techniques were used during the clippings of two posterior inferior cerebellar artery (PICA) aneurysms. There is increased neurologic morbidity associated with PICA aneurysm clippings, as a number of eloquent structures live in close proximity to the PICA. The application of a multimodal neuromonitoring paradigm may reduce a poor neurological outcome.