Assessing the Association Between Pre-operative Feeding and the Development of Oral Feeding Skills in Infants with Single Ventricle Heart Disease: An Analysis of the NPC-QIC Dataset.

Pre-operative feeding may improve long-term feeding outcomes in single ventricle patients, including weaning from supplemental tube feedings in infancy. This study examines the association between pre-operative enteral feeding and subsequent long-term feeding outcomes while also assessing the counterbalancing risk of necrotizing enterocolitis (NEC). Secondary analysis of the National Pediatric Cardiology Quality Improvement Collaborative database was performed. The association between pre-operative feeding practice and achieving all oral feeds through the first year of life was examined using a multivariable regression model. Similarly, the association between pre-operative oral feeding and NEC was also assessed. Of 944 patients with 1-year feeding outcomes available, 58% were fed preoperatively (41.3% exclusively oral) and 12.3% were not fed per institutional approach. At hospital discharge after Stage 1 palliation, 57% required a feeding tube, while 39% required a feeding tube at their first birthday. In infants who were orally fed, the odds ratio to achieving tube-free feeding at 1 year was not significantly increased (1.3, confidence interval 0.8-2.0). Of 1740 infants with pre-operative feeding and Stage 1 there was no statistically significant difference in NEC among patients who were preoperatively fed versus those that were not fed per institutional approach (p = 0.2). Pre-operative feeding of infants with single ventricle heart disease was not associated with early achievement of tube-free feeding in the first year of life. However, pre-operative oral feeding was also not associated with increased risk of NEC, suggesting that it can be safely offered among appropriate patients.

Verbal and spatial working memory among drug-using HIV-infected men and women.

Working memory (WM) is a critical component of many neurocognitive functions. The literature has demonstrated consistently that WM impairment is more frequent and severe among substance-dependent individuals (SDIs) infected with HIV compared with uninfected SDIs; however, the SDIs who participated in these previous studies were primarily male. There are few published data on WM performance among HIV+ women with or without substance use disorders, and essentially no direct comparisons of WM performance between HIV+ men and women, regardless of substance use. We investigated potential sex and serostatus effects on WM among a sample of 360 SDIs (114 with HIV; 66% female) verified abstinent from alcohol and drugs of abuse at testing and generally comparable on substance use and comorbid characteristics. Participants were tested with the n-back task, a well-established WM measure that is sensitive to HIV-associated cognitive impairment. HIV+ men and women performed spatial and verbal versions of the n-back significantly less accurately compared with HIV- participants. Women showed slower response times compared with men on both versions, regardless of HIV serostatus. Individuals dependent on cocaine showed faster RTs compared with non-dependent users, but this effect was not apparent among opioid- or alcohol-dependent groups. Findings on n-back accuracy are consistent with our previous proposal that WM impairment represents a signature deficit among HIV+ SDIs; however, WM impairment appears less common among HIV+ women without a substance use history. The pattern of sex differences in response speed but serostatus effects on response accuracy is comparable to a recent report by our group of sex differences in learning speed but serostatus effects on delayed recall.

Effects of sex and HIV serostatus on spatial navigational learning and memory among cocaine users.

Spatial learning and memory are critically dependent on the integrity of hippocampal systems. Functional MRI and neuropathological studies show that hippocampal circuitry is prominently affected among HIV-seropositive individuals, but potential spatial learning and memory deficits have not been studied in detail in this population. We investigated the independent and interactive effects of sex and HIV serostatus on performance of a spatial learning and memory task in a sample of 181 individuals with a history of cocaine dependence. We found that men showed faster times to completion on immediate recall trials compared with women and that delayed recall was significantly poorer among HIV-infected compared with HIV-uninfected participants. Additionally, a sex × serostatus effect was found on the total number of completed learning trials. Specifically, HIV-infected men successfully completed more learning trials compared with HIV-infected women. Results are discussed in the context of recent reports of sex and HIV serostatus effects on episodic memory performance.

Predictability of transcutaneous bilirubinometry in late preterm and term infants at risk for pathological hyperbilirubinemia.

BACKGROUND: The aim was to assess the predictability of transcutaneous bilirubinometry in late preterm and term neonates at risk for pathological hyperbilirubinemia, and to identify the neonatal population in which transcutaneous bilirubin most accurately predicts serum bilirubin level (SB, mg/dl). METHODS: The correlations between transcutaneous bilirubin (TCB, mg/dl) and SB in different neonatal population subsets; and between ΔTSB (TCB-SB) and relevant neonatal variables and clinical groups were analyzed. RESULTS: TCB correlated with SB (r = 0.82, p < 0.05) in the cohort (n = 350) and in population subsets (r = 0.81-0.9, p < 0.001). Black infants with gestational age (GA) >35 weeks and chronological age (CA) >3 days recorded strongest correlation (r = 0.9, p < 0.001) followed by Blacks, and non-Black infants with CA >3 days and GA >35 weeks. ΔTSB was positive in Blacks, and in infants with CA <3 days, or with no phototherapy. ΔTSB was negative in non-Blacks, in infants with positive direct Coombs test (DC+) or those receiving phototherapy. Black race [beta (SE) = 1.3(0.33), p < 0.001] had positive, while CA [beta (SE) =-1.74 (0.36), p < 0.001], DC + status [beta (SE) =-0.72 (0.25), p = 0.004] and receipt of phototherapy [beta (SE) =-0.84 (0.21), p < 0.001] each had negative correlation with ΔTSB. ΔTSB for Blacks was >Whites, Hispanics and Asians. CONCLUSION: SB is best predicted by TCB in Black infants with CA over 3 days and GA over 35 weeks. Variability in SB estimation by TCB is race, CA and immune mediated hemolysis specific.

Should COVID-19 patients >75 years be Ventilated? An Outcome Study.

BACKGROUND: Elderly patients with COVID-19 disease are at increased risk for adverse outcomes. Current data regarding disease characteristics and outcomes in this population are limited. AIM: To delineate the adverse factors associated with outcomes of COVID-19 patients ≥75 years of age. DESIGN: Retrospective cohort study. METHODS: Patients were classified into mild/moderate, severe/very severe and critical disease (intubated) based on oxygen requirements. The primary outcome was in-hospital mortality. RESULTS: A total of 355 patients aged ≥75 years hospitalized with COVID-19 between 19 March and 25 April 2020 were included.Mean age was 84.3 years. One-third of the patients developed critical disease. Mean length of stay was 7.10 days. Vasopressors were required in 27%, with the highest frequency in the critical disease group (74.1%). Overall mortality was 57.2%, with a significant difference between severity groups (mild/moderate disease: 17.4%, severe/very severe disease: 71.3%, critical disease: 94.9%, P < 0.001).Increased age, dementia, and severe/very severe and critical disease groups were independently associated with increased odds for mortality while diarrhea was associated with decreased odds for mortality (OR: 0.12, 95% CI: 0.02-0.60, P < 0.05). None of the cardiovascular comorbidities were significantly associated with mortality. CONCLUSION: Age and dementia are associated with increased odds for mortality in patients ≥75 years of age hospitalized with COVID-19. Those who require intubation have the greatest odds for mortality. Diarrhea as a presenting symptom was associated with lower odds for mortality.

Ascribing intentions in clinical decision-making.

BACKGROUND: The intentions of clinicians are widely considered to be relevant to the ethical assessment of their actions. A better understanding of the psychological factors that influence the ascription of intentions in clinical practice is important for improving the self-understanding of clinical decision-making and, ultimately, the ethics of clinical care. Drawing on empirical research on intentionality that has been done in other contexts, this is the first study to test whether the "asymmetric effect" of intention ascription is exhibited by respondents when presented with clinical decision-making scenarios. OBJECTIVE: To assess how individuals attribute intentions to clinical actors in clinical decision-making scenarios. METHODS: A total of 149 first and second year medical students was randomly assigned to two groups (group A, group B). Subjects in each group read two scenarios and submitted anonymous responses to questions regarding each scenario. RESULTS: The asymmetric effect was strongly exhibited by the responses given to scenario 2, but it was not exhibited by the responses given to scenario 1. CONCLUSION: The present study provided evidence for the view that people's ascription of intentions to others is influenced by their previous evaluative judgement of the conduct in question.

Relationship between functional evaluation measures and self-assessment in nonacute low back pain.

STUDY DESIGN: The correlations between objective biomechanical indicators of function and self-assessment scores were examined retrospectively for 91 subjects with nonacute low back pain. OBJECTIVES: To examine the correlation between self-assessment, trunk range of motion (ROM), velocity, and complex mechanical coordination patterns of the spine in nonacute low back pain. SUMMARY OF BACKGROUND DATA: In low back pain, there is often little concordance between pain, physical impairment, and disability. Use of range of motion and velocity to enhance objectivity in impairment evaluations has been ineffectual. In this study, two hypotheses were examined: range of motion and velocity are controllable and inherently correlated with self-assessment; complex spinal coordination patterns such as range of lordosis cannot be controlled and are independent of self-assessment. METHODS: Self-assessment questionnaires were administered, and indexes of spinal motion and coordination were measured through skin marker kinematics. The correlation between self-assessments and biomechanical measures was determined. RESULTS: Self-assessments of function were significantly correlated with parameters prone to regulation: range of motion, velocity, and load lifted. In contrast, little correlation was found with measures of complex spinal coordination less susceptible to conscious or affective regulation, namely, range of lordosis and estimated segmental mobility. This effect was magnified with increased load. Self-assessment scores were significantly poorer among insurance referrals, regardless of functional status. CONCLUSIONS: Simple parameters of the functional examination, such as range of motion and velocity, are strongly correlated with cognitive state, and thus the information they supply is less than ideal. Complex spinal coordination is a better indicator of the degree of spinal dysfunction and enhances the process of differentiating between pain, disability, and functional impairment.

Predictors of hospital length of stay and nursing home placement in an elderly medical population.

OBJECTIVE: To identify predictors of adverse outcomes (nursing home placement and hospital length of stay) in a cohort of older hospitalized patients. DESIGN: Prospective cohort study. SETTING: A suburban medical center in the New York City metropolitan area. PARTICIPANTS: Patients aged 65 years and older admitted from the emergency department to medical services who could be seen within 24 hours. Patients with terminal illness, planned stays < 2 days, and admission to other than medicine were excluded. MEASUREMENTS: Sociodemographic data, mobility, Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), mental status, length of stay (LOS), discharge diagnosis, and disposition (nursing home vs. other). RESULTS: Of 681 patients screened, 322 were eligible and assessed at admission,206 were reassessed at discharge. Using multiple regression, greater dependency in IADL, more household help, and impaired mental status at admission predicted hospital LOS significantly (P = 0.0001). Compared with those discharged home, the nursing home (NH) group had lower scores on mean mobility and mean ADLs and IADLs and was more likely to exhibit a decline in at least one ADL. Stepwise discriminant analysis was performed using admission, discharge, and combined variables. In our final model of the predictors of discharge disposition, the use of admission functional variables, age, and sex correctly classified 100% of the NH group and 91% of the other group, with IADL, ADL, and mobility defining the function that discriminated the groups. CONCLUSIONS: Our data indicate the value of cognitive and physical function at admission as predictors of adverse outcomes and support early assessment of the elderly for discharge planning for long-term care.

Minor depression as a predictor of the first onset of major depressive disorder over a 15-year follow-up.

OBJECTIVE: To study the relationship of minor depression to first onset of major depressive disorder (MDD) among 1634 individuals over a 15-year follow-up using the Baltimore Epidemiologic Catchment Area cohort. METHOD: Logistic regression analyses were conducted with minor depression alone and also adjusting for anxiety, sociodemographic, and medical variables, with MDD as the outcome variable. Also, among those with minor depression, depressive symptom categories were studied with both logistic regression and population attributable risk (PAR) to determine if they predicted MDD. RESULTS: Individuals with a history of minor depression had an odds ratio of more than 5 of having a first lifetime episode of MDD (adjusted OR: 5.37, 95% CI: 2.87, 10.06). Suicidal ideation, appetite/weight issues, and sleep difficulty had the highest PARs. CONCLUSION: Minor depression strongly predicts MDD. Clinical and public health interventions for individuals with minor depression can potentially impact the pathway leading to MDD.

Simultaneous high-performance liquid chromatography assay of acetylsalicylic acid and salicylic acid in film-coated aspirin tablets.

A reversed-phase high-performance liquid chromatography (HPLC) method has been developed for the simultaneous assay of acetylsalicylic acid (I) and salicylic acid (II) in film-coated aspirin tablets. As little as 0.1% II (relative to I) can be quantitatively determined. Using a 5-microns octadecylsilane column with water-acetonitrile-phosphoric acid (76:24:0.5) as the mobile phase enabled the chromatographic separation to be completed in 4 min. Due to the slow rate of decomposition of I to II in the extraction solvent, acetonitrile-methanol-phosphoric acid (92:8:0.5), the analysis of many samples was routinely performed by means of automated HPLC equipment. Other compounds (non-aspirin salicylates, caffeine and acetaminophen) were also separated by the chromatographic system.

Validation of liquid chromatographic method for assay of chlorthalidone in tablet formulations.

A stability-indicating, reverse phase liquid chromatographic (LC) method was developed for assay of chlorthalidone in tablet formulations. The chromatographic system separates the parent compound from its potential hydrolysis product (4'-chloro-3'-sulfamoyl-2-benzophenone carboxylic acid), which can be quantitated at low levels, and another degradation product (2-chloro-5-(1-methoxy-3-oxo-1-isoindolinyl)benzenesulfonamide), which was found during the experimental work. The procedure can also be used for content uniformity determinations. The general utility of the method was demonstrated by the assay of several product brands. The validated procedure was shown to be accurate, precise, reproducible, and specific.

Dorsal myelotomy for relief of spasticity in spinal injury patients.

Seven male patients, five complete quadriplegic and two complete high thoracic paraplegic, were treated by dorsal longitudinal myelotomy to relieve intractable spasticity of the lower extremities. All had intact neurogenic bladders before surgery. All patients had initial relief of spasticity but had recurrence of spasticity in varying degrees at two to three months postoperation. One patient had repeat myelotomy with similar results. One patient had successful relief of spasticity but lost neurogenic bladder function. Three patients required surgical releases of spastic contractures after surgery. Only one patient was satisfied with the procedure but required additional procedures for relief of spasticity. None of the procedures was considered successful. Dorsal longitudinal myelotomy is not successful in the treatment of spasticity in the spinal-injured patient.

Quantitative studies of argyrophilic APUD cells in airways. III. The effects of sensitization and anaphylactic shock.

A morphometric study of argyrophilic APUD cells in airways and intestine of guinea pigs during sensitization with ovalbumin and anaphylactic shock is reported. The APUD cell densities are expressed as APUD cell number/mm of airway or gut perimeter length and as APUD cell/100 epithelial cells. The latter ratio is useful to distinguish specific changes in APUD cells from generalized epithelial changes. Control guinea pigs have greater densities of APUD cells in the larynx (0.075 +/- 0.021 APUD/100 nuclei) than in more distal airways: trachea (0.025 +/- 0.007), bronchi (0.013 +/- 0.003), and bronchioles (0.003 +/- 0.002). In the ileal mucosa APUD cells are present in greatest density: 10.0 +/- 3.0 APUD/100 nuclei. Immunization with ovalbumin followed by sham challenge with saline results in 2- to 10-fold increases in APUD cell densities in all airway sectors as compared to control subjects. These differences are statistically significant in the trachea and bronchioles when ratios of APUD cells/mm are compared to control subjects but only in bronchioles when the ratios of APUD cells/100 nuclei are calculated. Immunization with ovalbumin followed by challenge with this antigen results in similar changes in large airways. However, bronchiolar APUD cells exhibit a 30-fold decrease in density when compared to immunized-sham challenged animals within the limits of our ability to quantitate them. Our findings suggest that argyrophilic APUD cells participate in the complex physiologic events that take place in the lung during sensitization and anaphylaxis.

Outcomes following physical restraint reduction programs in two acute care hospitals.

BACKGROUND: Physical restraint rates can be reduced safely in long term care settings, but the strategies used to prevent wandering, falls, and patient aggression have not been tested for their effectiveness in preventing therapy disruption. A restraint reduction program (RRP) consisting of four core components (administrative, educational, consultative, and feedback) was implemented in 1998-1999 in 14 units at two acute care hospitals in geographically distant cities. METHODS: The RRP was targeted at units with prevalence rates of > or = 4% for non-intensive care units (non-ICUs) and > or = 25% for ICUs, as well as two additional units. The RRP was implemented by an interdisciplinary team consisting of geriatricians and nurse specialists. RESULTS: Of the 16,605 admissions to the RRP units, 2,772 cases received RRP consultations. Only six units (four of seven general units and two of six ICUs) demonstrated a relative reduction of > or = 20% in the physical restraint use rate. No increase in secondary outcomes of patient falls and therapy disruptions (patient-initiated discontinuation or dislodgment of therapeutic devices) occurred, injury rates were low, and no deaths occurred as a direct result of either a fall or therapy disruption event. DISCUSSION: Given the minimal success in the ICU settings, further studies are needed to determine effective nonrestraint strategies for critical care patients. ICU clinicians need to be persuaded of the favorable risk-to-benefit ratio of alternatives to physical restraint before they will change their practice patterns. SUMMARY: Efforts to identify more effective interventions that match patient needs and to identify non-clinician factors that affect physical restraint use are needed.