Characteristics and Outcomes Among Patients With Autoimmune Rheumatic Diseases Requiring a Higher Level of Care.

OBJECTIVE: Patients with autoimmune rheumatic diseases (ARDs) have a higher risk of developing organ failure, and they may require admission to the intensive care unit (ICU). The aim of our study is to determine the reasons for admission to the ICU, identify potential risk factors associated with mortality, and assess the outcomes of patients with ARD diseases admitted to the ICU. METHODS: We conducted a medical records review study of patients with ARD admitted to the ICU from 2012 to 2018. Patient data included demographic and clinical characteristics, ICU admission diagnoses, length of stay, complications, and immunosuppressive regimen. Short-term and long-term outcomes were assessed. RESULTS: A total of 80 ARD patients were identified with the mean age of 48.8, 67% were female, and 56% were Hispanic. The most common disease associated with ICU admission was systemic lupus erythematosus (42%), followed by rheumatoid arthritis (26%), and 12% of patients had systemic vasculitis. Sepsis was the leading cause of ICU admission, accounting for 31%, followed by respiratory failure due to pneumonia (10%) and congestive heart failure (10%). Twenty percent of patients died in the ICU, 5% died 30 days after ICU admission, and 7.5% died within 1 year after the ICU stay, resulting in overall mortality of 33% by the end of 1 year. Nonsurvivors were more likely to need mechanical ventilation (p = 0.001), vasopressor support (p < 0.001), had renal (p = 0.041) or cardiovascular (p < 0.001) involvement on admission, APACHE II score higher than 19 (p = 0.001), and 4 days or longer stay in the ICU (p = 0.001). CONCLUSIONS: Our findings indicated that systemic lupus erythematosus is the most common ARD associated with ICU admission, and sepsis was the most frequent cause. Predictors associated with higher mortality were the requirement for mechanical ventilation, vasopressor support, increase length of ICU stay, and renal and cardiovascular involvement on admission.

Pain After Unilateral Total Knee Arthroplasty: A Prospective Randomized Controlled Trial Examining the Analgesic Effectiveness of a Combined Adductor Canal Peripheral Nerve Block with Periarticular Infiltration Versus Adductor Canal Nerve Block Alone Versus Periarticular Infiltration Alone.

BACKGROUND: Total knee arthroplasty is a painful surgery that requires early mobilization for successful joint function. Multimodal analgesia, including spinal analgesia, nerve blocks, periarticular infiltration (PI), opioids, and coanalgesics, has been shown to effectively manage postoperative pain. Both adductor canal (AC) and PI have been shown to manage pain without significantly impairing motor function. However, it is unclear which technique is most effective. This 3-arm trial examined the effect of AC block with PI (AC + PI) versus AC block only (AC) versus PI only (PI). The primary outcome was pain on walking at postoperative day (POD) 1. METHODS: One hundred fifty-one patients undergoing unilateral total knee arthroplasty were included. Patients received either AC block with 30 mL of 0.5% ropivacaine or sham block. PI was performed intraoperatively with a 110-mL normal saline solution containing 300 mg ropivacaine, 10 mg morphine, and 30 mg ketorolac. Those patients randomly assigned to AC only received normal saline knee infiltration. RESULTS: On POD 1, participants who received AC + PI reported significantly lower pain numeric rating scale scores on walking (3.3) compared with those who received AC (6.2) or PI (4.9) (P < 0.0001). Participants who received AC reported significantly higher pain scores at rest and knee bend compared with those who received AC + PI or PI (P < 0.0001). The difference in pain scores between participants who received AC + PI and those who received AC was 2.83 (95% confidence interval, 1.58-4.09) and the difference between those who received AC + PI and those who received PI was 1.61 (95% confidence interval, 0.37-2.86). On POD 2, participants who received AC + PI reported significantly less pain on walking (4.4) compared with those who received AC (5.6) or PI (5.6) (P = 0.006). On POD 2, there was no difference between the groups for pain at rest or knee bending. Participants who received AC used more IV patient-controlled analgesia on POD 0. There was no difference between the groups regarding distance walked. CONCLUSIONS: Participants who received AC + PI reported significantly less pain on walking on PODs 1 and 2 compared with those who received AC only or PI only.

Physician Follow-up after Hospital Discharge in Alberta and Saskatchewan.

The period immediately after discharge from hospital can potentially be high risk and a vulnerable transition point for patients. This analysis from the Canadian Institute for Health Information assessed adherence to best practices for patient follow-up in the community after hospitalization in Alberta and Saskatchewan. For three selected conditions - acute myocardial infarction, heart failure and chronic obstructive pulmonary disease - the majority of patients (77-92%) saw a physician within a month of their discharge. However, fewer patients saw a physician within the first week (35-56%).

Quality of care: international comparisons of Canadian provinces.

There is increasing interest in comparing Canada's health system internationally to enhance accountability, promote benchmarking and increase mutual learning. The Canadian Institute for Health Information (CIHI) developed an interactive web display using data from the Organization for Economic Co-operation and Development, CIHI and Statistics Canada.

Medication use among Canadian seniors.

As they age, many seniors develop a progressively more complex mix of health conditions. Multiple prescription medications are often required to help manage these conditions and control symptoms, with the goal of maintaining seniors' health for as long as possible. This article explores trends in the number and types of medications used by seniors on public drug programs in Canada. Our findings suggest that a high proportion of Canadian seniors are taking several medications, highlighting the need for medication management systems focusing on this population.

Management of MDA-5 antibody positive clinically amyopathic dermatomyositis associated interstitial lung disease: A systematic review.

INTRODUCTION: Anti-melanoma differentiation-associated gene 5 (MDA5) antibody-positive clinically amyopathic dermatomyositis (CADM) is frequently associated with rapidly progressive interstitial lung disease (RP-ILD) and high mortality rates. There is a lack of data on management of this often fatal condition. The aim of this systematic review was to evaluate current evidence that assesses the available management options and discuss the associated management challenges. MATERIAL AND METHODS: This systematic review was conducted according to PRISMA guidelines.  Online databases were searched from inception to April of 2021 using the search terms: "dermatomyositis" OR "amyopathic dermatomyositis" OR "clinically amyopathic dermatomyositis" AND "MDA-5″ OR "melanoma differentiation-associated gene-5″ OR "CADM-140″ AND "management" OR "treatment" OR "therapy" OR "therapeutics". Articles assessing the use of pharmacologic agents on 10 or more patients with MDA5-antibody positive CADM associated with ILD were included. Narrative or systematic reviews and meta-analyses were not eligible for inclusion. RESULTS: A total of 15 eligible studies and 399 unique patients were selected. We identified only one open-label randomized controlled trial (RCT) that examined the management of anti-MDA5 antibody CADM/DM-ILD. Further, 3 cohort studies with prospective arms matched against historical controls, 10 retrospective cohort studies, and 1 retrospective case series were included. A combined therapeutic regimen of high-dose systemic glucocorticoids and other immunosuppressive agents such as calcineurin inhibitors and/or cyclophosphamide, administered early, appears to give the highest rates of survival in those with RP-ILD, while additional therapies such as plasma exchange can be added for refractory disease. Further, tofacitinib and rituximab might have a place in the therapeutic armamentarium of this challenging to treat condition.   Early detection and treatment are of extreme importance, given the risk for rapid decline and high mortality in this subset of patients. CONCLUSION: There are limited RCTs evaluating the treatment of ILD associated with MDA5-antibody positive CADM. Initiating a combined immunosuppressive therapeutic regimen early in the disease course improves overall morbidity and mortality. RCTs and larger prospective studies are needed to provide high-quality evidence to inform future treatment guidelines.

Characteristics of martial art injuries in a defined Canadian population: a descriptive epidemiological study.

BACKGROUND: The martial arts have emerged as common activities in the Canadian population, yet few studies have investigated the occurrence of associated injuries on a population basis. METHODS: We performed such an investigation and suggest potential opportunities for prevention. The data source was 14 years (1993 to 2006) of records from the Kingston sites of the Canadian Hospital Injury Reporting and Prevention Program (CHIRPP). RESULTS: 920 cases were identified. Incidence rates were initially estimated using census data as denominators. We then imputed annual injury rates per 10000 using a range of published estimates of martial arts participation available from a national survey. Rates of injury in males and females were 2300 and 1033 per 10000 (0.3% participation) and 575 and 258 per 10000 (1.2% participation). Injuries were most frequently reported in karate (33%) and taekwondo (14%). The most common mechanisms of injury were falls, throws and jumps (33%). Fractures (20%) were the most frequently reported type of injury and the lower limb was the most common site of injury (41%). CONCLUSIONS: Results provide a foundation for potential interventions with a focus on falls, the use of weapons, participation in tournaments, as well as head and neck trauma.

Aviation-Modeled Investigation of Significant Obstetric Events.

INTRODUCTION: In this research, the authors attempted to ascertain whether or not the Root Cause Analysis Event Support and Engagement Team (RESET) investigates the use of U.S. Army aviation-based techniques by staff members or organizations in which serious obstetrical events have occurred. Root cause analysis (RCA), originating in the manufacturing and engineering sectors, attempts to elucidate an underlying cause of a problem. Most recently, this process has been applied to the investigation of medical error. RESET was established in order to perform centralized investigation of significant medical error within U.S. Army medical and dental treatment facilities based on request from a hospital commander or general officer. Significant obstetric events are high profile, discussed in multiple safety forums, and an area of close RESET focus. Yet it is unclear if RESET investigates the use of aviation-based techniques by staff and/or organizations involved in serious obstetrical events. Therefore the present survey study was conducted. MATERIALS AND METHODS: A structured, anonymous, voluntary survey was fielded to RESET staff in order to assess whether or not the RESET investigates the use of aviation-based techniques by staff members or organizations in which serious obstetrical events have occurred. RESULTS: Five of six members of this small team completed the survey. Prebriefs, debriefs, and checklist use were consistently investigated. The employment of a sterile cockpit, first-name introductions, annual check ride, and emergency procedure rehearsal were infrequently investigated. CONCLUSION: Obstetric RESET investigations inconsistently ascertain whether or not some of the aviation-based techniques are utilized by staff members or organizations in which serious obstetrical events have occurred. Standardization of investigative procedures and education directed at under-investigated practices may optimize medical investigation using proven tenets of an aviation-based approach.

Selective Serotonin Reuptake Inhibitor Use Among Army Aviators.

INTRODUCTION: Mental health is an important aspect of Army aviation medicine given that it significantly impacts career longevity, readiness, and healthcare usage. One of the most commonly used classes of medications to treat mental health disorders is the selective serotonin reuptake inhibitor (SSRI). Here we present a descriptive epidemiological review of SSRI use in Army aviators over a 10-yr period.METHODS: An archival dataset retrieved from the U.S. Army Aeromedical Electronic Resource Office covering the years 2005 to 2015 was queried for cases of SSRI use. Frequencies were generated by primary diagnoses and aeromedical disposition for the SSRI subset of data.RESULTS: A total of 114 unique cases of SSRI use were identified (122 total aeromedical outcomes). These cases included 41 waiver recommendations, 59 suspension recommendations, and 22 cases of waiver continuations. The top five most common primary diagnoses were depressive disorder (N 32), anxiety state (N 21), posttraumatic stress disorder (N 16), single major depressive episode (N 13), and adjustment disorder with depressed mood (N 12).DISCUSSION: Understanding of the etiology, pathophysiology, and treatment of mental health disorders particularly within the safety-focused and unforgiving aviation environment has continued to evolve. With the application of evidence-based policy, deliberate aeromedical decision-making, and methodical risk mitigation, SSRI use does have a place within aviation. Aviators suffering in silence with deleterious impact to performance and safety or aircrew seeking services on the outside without knowledge or oversight of certification authorities must remain in the past.Kelley AM, Bernhardt K, McPherson M, Persson JL, Gaydos SJ. Selective serotonin reuptake inhibitor use among Army aviators. Aerosp Med Hum Perform. 2020; 91(11):897900.

Transferring Aviation Practices into Clinical Medicine for the Promotion of High Reliability.

BACKGROUND: Aviation is a classic example of a high reliability organization (HRO)-an organization in which catastrophic events are expected to occur without control measures. As health care systems transition toward high reliability, aviation practices are increasingly transferred for clinical implementation. METHODS: A PubMed search using the terms aviation, crew resource management, and patient safety was undertaken. Manuscripts authored by physician pilots and accident investigation regulations were analyzed. Subject matter experts involved in adoption of aviation practices into the medical field were interviewed. RESULTS: A PubMed search yielded 621 results with 22 relevant for inclusion. Improved clinical outcomes were noted in five research trials in which aviation practices were adopted, particularly with regard to checklist usage and crew resource-management training. Effectiveness of interventions was influenced by intensity of application, leadership involvement, and provision of staff training. The usefulness of incorporating mishap investigation techniques has not been established. Whereas aviation accident investigation is highly standardized, the investigation of medical error is characterized by variation. DISCUSSION: The adoption of aviation practices into clinical medicine facilitates an evolution toward high reliability. Evidence for the efficacy of the checklist and crew resource-management training is robust. Transference of aviation accident investigation practices is preliminary. A standardized, independent investigation process could facilitate the development of a safety culture commensurate with that achieved in the aviation industry.Powell-Dunford N, McPherson MK, Pina JS, Gaydos SJ. Transferring aviation practices into clinical medicine for the promotion of high reliability. Aerosp Med Hum Perform. 2017; 88(5):487-491.

Physical activity, sedentary behavior, and melatonin among rotating shift nurses.

OBJECTIVE: To determine the effect of physical activity and sedentary behavior on melatonin levels in a group of rotating shift nurses. METHODS: Physical activity and sedentary behaviors for 118 nurses were recorded during both a day shift and a night shift using activity diaries, and concentrations of urinary 6-sulfatoxymelatonin were analyzed for each shift. RESULTS: During the day shift, energy expended in moderate- and vigorous-intensity physical activity between 3 PM and 7 AM was negatively associated with melatonin levels (P = 0.024). During the night shift, energy expended in sedentary behaviors was negatively associated with melatonin levels (P = 0.008). CONCLUSIONS: Physical activity and energy expended in sedentary behavior are inversely associated with morning urinary melatonin concentrations. Nevertheless, energy expenditure explains a relatively small amount of melatonin variation, perhaps suggesting that peak melatonin is minimally affected by these patterns of physical activity.