Patellar tendinopathy: an overview of prevalence, risk factors, screening, diagnosis, treatment and prevention.

Patellar tendinopathy (PT), or jumper's knee, is an overuse injury that occurs in professional, as well as recreational, athletes. This condition is a noncontact injury, typically characterized by gradually increasing pain in the patellar tendon. It is prevalent in participants of several sports, but it occurs mostly in jumping sports. The diagnosis of PT is primarily clinical; however, imaging techniques can be useful as well. Risk factors differ between sexes, playing conditions, the kind of sport, playing level and personal characteristics. Screening is an essential tool to assess PT. This condition affects athletic performance and often persists for years. The use of preventative methods is imperative because of the persistence of this condition, especially in elite athletes who sometimes end their career after long and failed treatments. There are a wide variety of treatment and rehabilitation options available, the majority of which are non-operative, such as eccentric exercises, cryotherapy, platelet-rich plasma (PRP) injections, and anti-inflammatory strategies. If conservative treatment fails, surgery is the next most preferable step. Even though there are many surgical treatment methods, there is no clear evidence on what is the most effective approach to address PT. Taking this into consideration, as well as the extent of this clinical entity, novel therapeutic techniques, as well as screening and prevention methods, are expected to emerge in the near future.

Therapeutic hypothermia after out-of-hospital cardiac arrest in children.

BACKGROUND: Therapeutic hypothermia is recommended for comatose adults after witnessed out-of-hospital cardiac arrest, but data about this intervention in children are limited. METHODS: We conducted this trial of two targeted temperature interventions at 38 children's hospitals involving children who remained unconscious after out-of-hospital cardiac arrest. Within 6 hours after the return of circulation, comatose patients who were older than 2 days and younger than 18 years of age were randomly assigned to therapeutic hypothermia (target temperature, 33.0°C) or therapeutic normothermia (target temperature, 36.8°C). The primary efficacy outcome, survival at 12 months after cardiac arrest with a Vineland Adaptive Behavior Scales, second edition (VABS-II), score of 70 or higher (on a scale from 20 to 160, with higher scores indicating better function), was evaluated among patients with a VABS-II score of at least 70 before cardiac arrest. RESULTS: A total of 295 patients underwent randomization. Among the 260 patients with data that could be evaluated and who had a VABS-II score of at least 70 before cardiac arrest, there was no significant difference in the primary outcome between the hypothermia group and the normothermia group (20% vs. 12%; relative likelihood, 1.54; 95% confidence interval [CI], 0.86 to 2.76; P=0.14). Among all the patients with data that could be evaluated, the change in the VABS-II score from baseline to 12 months was not significantly different (P=0.13) and 1-year survival was similar (38% in the hypothermia group vs. 29% in the normothermia group; relative likelihood, 1.29; 95% CI, 0.93 to 1.79; P=0.13). The groups had similar incidences of infection and serious arrhythmias, as well as similar use of blood products and 28-day mortality. CONCLUSIONS: In comatose children who survived out-of-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit in survival with a good functional outcome at 1 year. (Funded by the National Heart, Lung, and Blood Institute and others; THAPCA-OH ClinicalTrials.gov number, NCT00878644.).

Antivenom for critically ill children with neurotoxicity from scorpion stings.

BACKGROUND: Clinically significant scorpion envenomation by Centruroides sculpturatus produces a dramatic neuromotor syndrome and respiratory insufficiency that often necessitate intensive supportive care. We hypothesized that a scorpion-specific F(ab')(2) antivenom would promptly resolve clinical symptoms in children with this syndrome. METHODS: In a randomized, double-blind study, the efficacy of scorpion-specific F(ab')(2) antivenom, as compared with placebo, was assessed in 15 children 6 months to 18 years of age who were admitted to a pediatric intensive care unit with clinically significant signs of scorpion envenomation. The primary end point was the resolution of the clinical syndrome within 4 hours after administration of the study drug. Secondary end points included the total dose of concomitant midazolam for sedation and quantitative plasma venom levels, before and after treatment. RESULTS: The clinical syndrome resolved more rapidly among recipients of the antivenom than among recipients of placebo, with a resolution of symptoms in all eight antivenom recipients versus one of seven placebo recipients within 4 hours after treatment (P=0.001). More midazolam was administered in the placebo recipients than in the antivenom recipients (mean cumulative dose, 4.61 vs. 0.07 mg per kilogram of body weight; P=0.01). Plasma venom concentrations were undetectable in all eight antivenom recipients but in only one placebo recipient 1 hour after treatment (P=0.001). CONCLUSIONS: Among critically ill children with neurotoxic effects of scorpion envenomation, intravenous administration of scorpion-specific F(ab')(2) antivenom resolved the clinical syndrome within 4 hours, reduced the need for concomitant sedation with midazolam, and reduced the levels of circulating unbound venom. (ClinicalTrials.gov number, NCT00685230.)

Garbage in, toxic data out: a proposal for ethical artificial intelligence sustainability impact statements.

Data and autonomous systems are taking over our lives, from healthcare to smart homes very few aspects of our day to day are not permeated by them. The technological advances enabled by these technologies are limitless. However, with advantages so too come challenges. As these technologies encompass more and more aspects of our lives, we are forgetting the ethical, legal, safety and moral concerns that arise as an outcome of integrating our lives with technology. In this work, we study the lifecycle of artificial intelligence from data gathering to deployment, providing a structured analytical assessment of the potential ethical, safety and legal concerns. The paper then presents the foundations for the first ethical artificial intelligence sustainability statement to guide future development of AI in a safe and sustainable manner.

Let Me Take Over: Variable Autonomy for Meaningful Human Control.

As Artificial Intelligence (AI) continues to expand its reach, the demand for human control and the development of AI systems that adhere to our legal, ethical, and social values also grows. Many (international and national) institutions have taken steps in this direction and published guidelines for the development and deployment of responsible AI systems. These guidelines, however, rely heavily on high-level statements that provide no clear criteria for system assessment, making the effective control over systems a challenge. "Human oversight" is one of the requirements being put forward as a means to support human autonomy and agency. In this paper, we argue that human presence alone does not meet this requirement and that such a misconception may limit the use of automation where it can otherwise provide so much benefit across industries. We therefore propose the development of systems with variable autonomy-dynamically adjustable levels of autonomy-as a means of ensuring meaningful human control over an artefact by satisfying all three core values commonly advocated in ethical guidelines: accountability, responsibility, and transparency.

IEEE P7001: A Proposed Standard on Transparency.

This paper describes IEEE P7001, a new draft standard on transparency of autonomous systems. In the paper, we outline the development and structure of the draft standard. We present the rationale for transparency as a measurable, testable property. We outline five stakeholder groups: users, the general public and bystanders, safety certification agencies, incident/accident investigators and lawyers/expert witnesses, and explain the thinking behind the normative definitions of "levels" of transparency for each stakeholder group in P7001. The paper illustrates the application of P7001 through worked examples of both specification and assessment of fictional autonomous systems.

A socio-technical framework for digital contact tracing.

In their efforts to tackle the COVID-19 crisis, decision makers are considering the development and use of smartphone applications for contact tracing. Even though these applications differ in technology and methods, there is an increasing concern about their implications for privacy and human rights. Here we propose a framework to evaluate their suitability in terms of impact on the users, employed technology and governance methods. We illustrate its usage with three applications, and with the European Data Protection Board (EDPB) guidelines, highlighting their limitations.

Approach to High Volume Enrollment in Clinical Research: Experiences from an All of Us Research Program Site.

Clinical trials and cohort studies are required to meet target recruitment of study participants within stipulated timelines, especially when the priority is to include populations traditionally unrepresented in biomedical research. By the third quarter of 2019, the University of Arizona-Banner Health Provider Organization (UA-Banner HPO) has enrolled > 30,000 core participants into the All of Us Research Program (AoURP), the research cohort of the Precision Medicine Initiative. The majority of enrolled participants meet the criteria for individuals under-represented in biomedical research. The enrollment goals were calculated based on a target of 20,000 as set by the National Institutes of Health and our health provider organization achieved enrollment numbers between 17% and 86% above the targeted daily enrollment. We evaluated enrollment methods and challenges to enrollments encountered by the UA-Banner Health Provider Organization into the AoURP. Challenges to enrollment centered around the need for high-touch engagement methods, time investment necessary for stakeholder inclusion, and the use of purely digital enrollment methods especially in populations under-represented in biomedical research. These challenges occurred at the level of the individual, provider, institutions, and community, and cumulatively impacted participant enrollment. Successful strategies for engagement and enrollment leveraged provider partners as advocates for the program. For high-volume enrollment in clinical research, it is important to engage leaders in the healthcare setting, patient providers, and tailor engagement and enrollment to potential participant needs. We emphasize the need for precision engagement and enrollment methods tailored to individual needs.

Nationwide Survey in Greece about Knowledge, Risk Perceptions, and Preventive Behaviors for COVID-19 during the General Lockdown in April 2020.

BACKGROUND: The aim of this study was to investigate the knowledge, attitudes, and practices of the Greek general population toward coronavirus disease 2019 (COVID-19) during the lockdown period in April 2020, to examine factors associated with misperceptions and to determine behavioral patterns that may require interventions. METHODS: A cross-sectional study of the general Greek population (N = 1858) was conducted. A geographically stratified cluster sampling was implemented. A questionnaire was composed consisting of 35 questions. Data collection took place from 15 April to 2 May 2020. A random-digit dialing survey was conducted by 29 interviewers. RESULTS: The majority of respondents (62.7%) answered ≥12/17 questions correctly. Participants aged 18-44 years, male gender, specific occupations (freelancer, unemployed, housewife, retiree) and those who sought information about COVID-19 from less than two sources received lower aggregated scores on knowledge questions. Regarding attitudes toward future vaccination, 18.9% declared that were against it, while 81.1% that they may consider or will be vaccinated. About 40% were not using a face mask and only 42% washed their hands appropriately. CONCLUSION: Adjusting information campaigns targeting especially people below 45 years of age can help to sensitize them and realise their role to control the spread. Further targeted surveys are needed to adjust/design prevention campaigns.

Hospitals with more-active participation in conducting standardized in-situ mock codes have improved survival after in-hospital cardiopulmonary arrest.

AIM: The American Heart Association (AHA) and the Institute of Medicine have published a national "call-to-action" to improve survival from in-hospital cardiopulmonary arrest (IHCA). Our aim was to determine if more-active hospital participation in standardized in-situ mock code (ISMC) training is associated with increased IHCA survival. METHODS: We performed an ecological study across a multi-state healthcare system comprising 26 hospitals. Hospital-level ISMC performance was measured during 2016-2017 and IHCA hospital discharge survival rates in 2017. We performed univariate and multivariate analysis of the hospital-level association between more-active ISCM participation and IHCA survival, with adjustment for hospital expected mortality as determined by a commercial severity scoring system. Other potential confounders were analyzed using univariate statistics. RESULTS: Hospitals with more-active ISMC participation conducted a median of 17.6 ISMCs/100 beds/year (vs 3.2/100 beds/year in less-active hospitals, p = 0.001) in 2016-2017. 220,379 patients were admitted and 3289 experienced IHCA in study hospitals in 2017, with an overall survival rate of 37.4%. Hospitals with more-active ISMC participation had a mean IHCA survival rate of 42.8% vs. 31.8% in hospitals with less-active ISMC participation (p < 0.0001), and a significantly reduced odds ratio (OR) of 0.62 for IHCA mortality (95% CI: 0.54-0.72; p < 0.0001) which was unchanged after adjustment for hospital-level expected mortality (adjusted OR: 0.62; 95% CI: 0.54-0.71; p < 0.001). CONCLUSIONS: Hospitals in our healthcare system with more-active ISMC participation have higher IHCA survival. Prospective trials are needed to establish the efficacy of standardized ISMC training programs in improving patient survival after cardiac arrest.

Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit.

OBJECTIVE: To determine the incidence, type, and stage of occurrence of medication errors and potential and actual adverse drug events (ADEs) in a pediatric intensive care unit (ICU) using trained observers. The preventability and severity of ADEs and the system failures leading to medication error occurrence were also investigated. DESIGN: Prospective, direct observation study. SETTING: A 16-bed pediatric medical/surgical ICU at a tertiary care academic medical center. PATIENTS: One enrolled nurse caring for at least one pediatric ICU patient age <18 yrs was randomly chosen during each observation period. INTERVENTIONS: Observers would intervene only in the event that the medication error would cause substantial patient harm or discomfort. MEASUREMENTS AND MAIN RESULTS: Medication errors and potential and actual ADEs were identified throughout the entire medication use process. The 26 12-hr observation periods included 357 reviewed written orders and 263 observed doses. The study observers identified 58 incidents, which were subsequently classified by the evaluators according to clinical importance, severity, and preventability. Fifty-two of these incidents were considered medication errors; six incidents were determined to be nonpreventable ADEs. Of the 52 medication errors, 42 (81%) were considered clinically important. Potential ADEs comprised 35 (83%) of these important medication errors; the other seven (17%) were classified as actual, preventable ADEs. Overall, the actual and potential ADE rate occurred at 3.6 events and 9.8 events per 100 orders, respectively. CONCLUSIONS: Our medication error rate was similar to that of previous pediatric ICU studies that used the direct observation method for reporting but higher than the rates in previous studies using other detection techniques such as voluntary incident reporting. Periodic direct observation and other ongoing data collection methods such as voluntary incident reporting have the potential to be complementary approaches to medication error and ADE detection.

Hyponatremic hypertensive syndrome (HHS) in an 18-month old-child presenting as malignant hypertension: a case report.

BACKGROUND: The combination of hyponatremia and renovascular hypertension is called hyponatremic hypertensive syndrome (HHS). Malignant hypertension as a presentation has been reported in adults with HHS but is rare in children. CASE PRESENTATION: An eighteen month-old male presented with drowsiness, sudden onset status epilepticus and blood pressure of 210/160. The electrolytes on admission revealed sodium of 120 mEq/L and potassium of 2.1 mEq/L. The peripheral renin activity (PRA) was 172 ng/ml/min (normal 3-11 ng/ml/min) and serum aldosterone level was 91 ng/dl (normal 4 to 16 ng/dl). Patient underwent angioplasty with no success, followed by surgical correction. Two years since the diagnosis, the blood pressure is controlled with labetolol and amlodipine (at less than sixth of the pre-operative dosages). The PRA is 2.4 ng/ml/min and aldosterone 15.5 ng/dl. The child not only had three renal arteries on left but all of them were stenosed which to best of our knowledge has not been described. CONCLUSION: As uncommon as HHS with malignant hypertension may be in adults it is under-reported in children and purpose of the case report is to raise its awareness.

Comparison of methods for the detection of medication safety events in the critically ill.

PURPOSE: To categorize and synthesize medication safety event detection methods in the critically ill in order to provide clinicians and administrators with approaches to event detection that are intended to expand and complement traditional voluntary reporting systems. METHODS: A literature search of OvidMEDLINE was performed to identify articles related to medication safety involving critically ill patients in the intensive care unit setting. The inclusion of articles was restricted to comparative studies. The bibliographies of all retrieved articles were reviewed to obtain additional articles of relevance. The various event detection methods were compared by: evidence supporting their use; number, type and severity of events detected; phase of the medication use process in which events were detected; and ease and cost of implementation. Major limitations of each method were also collated. RESULTS: There are a number of methods that can be used to identify medication safety events in the critically ill. These can broadly be categorized as: 1) voluntary reporting, 2) record review, 3) rules/triggers and 4) direct observation and 5) interviews/surveys. Relatively few studies have directly compared these assessment methods in the ICU setting, although the limitations of the traditional voluntary reporting system as the sole method of event detection are well established. Although not truly dichotomous, these methods can be broken down into more proactive and reactive approaches. Rules/triggers and direct observation of the medication use process in the ICU are examples of proactive approaches to event detection, while the traditional unsolicited voluntary reporting is typically reactive. However, each of the event detection methods has advantages and disadvantages, so the methods should not be considered mutually exclusive with respect to obtaining information about medication safety. CONCLUSIONS: Given the limitations of traditional voluntary reporting systems, a multimodal approach used to identify medication safety events is most likely to capture the largest number and type of events. We would advise not trying to implement additional approaches beyond voluntary reporting systems all at once. This would be difficult and costly. Rather, we suggest a systematic implementation of additional event detection approaches that takes into account hospital-specific considerations.

Interdisciplinary patient care in the intensive care unit: focus on the pharmacist.

The field of critical care medicine began to flourish only within the last 40 years, yet it provides some of the best examples of collaborative pharmacy practice models and evidence for the value of pharmacist involvement in interdisciplinary practice. This collaborative approach is fostered by critical care organizations that have elected pharmacists into leadership positions and recognized pharmacists through various honors. There is substantial literature to support the value of the critical care pharmacist as a member of an interdisciplinary intensive care unit (ICU) team, particularly in terms of patient safety. Furthermore, a number of economic investigations have demonstrated cost savings or cost avoidance with pharmacist involvement. As the published evidence supporting pharmacist involvement in patient care activities in the ICU setting has increased, surveys have demonstrated an increase in the percentage of pharmacists performing clinical activities. In addition, substantial support of pharmacists has been provided by other clinicians, safety officers, and administrative personnel who have been involved with the initiation and expansion of critical care pharmacy services in their own institutions. Although there is still room for improvement in the range of pharmacist involvement, particularly with respect to interdisciplinary activities related to education and scholarship, pharmacists have become essential members of interdisciplinary care teams in ICU settings.

Serum levels and urine detection of Centruroides sculpturatus venom in significantly envenomated patients.

INTRODUCTION: Envenomation by Centruroides sculpturatus can cause systemic signs and symptoms requiring treatment. The toxicokinetics of C. sculpturatus venom has not been described. METHODS: Venom components were separated for cross-reactivity testing. Serum and urine collected from three patients envenomated by C. sculpturatus had venom levels determined by sandwich enzyme-linked immunosorbent assay (ELISA). RESULTS: Western blot analysis indicated recognition of C. sculpturatus venom by Alacramyn, an equine F(ab')(2) antivenom developed against Centruroides scorpion venoms, including C. sculpturatus. Serum venom levels in ng/mL with post-envenomation times in minutes (min) were as follows: 85-year-old woman = 8.2 (approximately 150), 2.8 (515), 1.6 (1,200); 14-month-old girl = 29.7 (approximately 50), 5.0 (729); 3-year-old girl = 11.1 (approximately 313), urine venom level of 9.0 (approximately 490). CONCLUSION: There is sufficient venom cross-antigenicity among different Centruroides species to allow this ELISA technique with Alacramyn to determine serum and urine C. sculpturatus venom concentrations in envenomated patients.

Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection.

OBJECTIVE: To determine the incidence and preventability of medication errors and potential/actual adverse drug events. To evaluate system failures leading to error occurrence. DESIGN: Prospective, direct observation study. SETTING: Tertiary care academic medical center. PATIENTS: Patients in a medical/surgical intensive care unit. INTERVENTIONS: Observers would intervene only in the event that the medication error would cause substantial patient harm or discomfort. MEASUREMENTS AND MAIN RESULTS: The observers identified 185 incidents during a pilot period and four phases totaling 16.5 days (33 12-hr shifts). Two independent evaluators concluded that 13 of 35 (37%) actual adverse drug events were nonpreventable (i.e., not medication errors). An additional 40 of the remaining 172 medication errors were judged not to be clinically important. Of the 132 medication errors classified as clinically important, 110 (83%) led to potential adverse drug events and 22 (17%) led to actual, preventable adverse drug events. There was one error (i.e., resulting in a potential or actual, preventable adverse drug event) for every five doses of medication administered. The potential adverse drug events mostly occurred in the administration and dispensing stages of the medication use process (34% in each); all of the actual, preventable adverse drug events occurred in the prescribing (77%) and administration (23%) stages. Errors of omission accounted for the majority of potential and actual, preventable adverse drug events (23%), followed by errors due to wrong dose (20%), wrong drug (16%), wrong administration technique (15%), and drug-drug interaction (10%). CONCLUSIONS: Using a direct observation approach, we found a higher incidence of potential and actual, preventable adverse drug events and an increased ratio of potential to actual, preventable adverse drug events compared with studies that used chart reviews and solicited incident reporting. All of the potential adverse drug events and approximately two thirds of the actual adverse drug events were judged to be preventable. There was one preventable error for every five doses of medication administered; most errors were due to dose omission, wrong dose, wrong drug, wrong technique, or interactions.

Femoral central venous catheter-associated deep venous thrombosis in children with diabetic ketoacidosis.

OBJECTIVE: To describe the incidence of clinical deep venous thrombosis associated with femoral central venous catheters (CVC-DVT) in children with diabetic ketoacidosis (DKA). DESIGN: Retrospective case-matched control series. SETTING: Pediatric intensive care units of two university-affiliated hospitals. PATIENTS: All eight pediatric DKA patients with femoral central venous catheters between 1998 and 2001, and 16 age-matched control patients with femoral central venous catheters and circulatory shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The records of all children with DKA and the control patients were reviewed. CVC-DVT was defined as persistent ipsilateral leg swelling after removal of a femoral central venous catheter. Control patients with coagulopathies, thrombocytopenia, cancer, and hyperglycemia were excluded. Four of eight patients with DKA developed CVC-DVT compared with none of the 16 control patients (p = .007, Fisher's exact test). All four patients with DKA and CVC-DVT were <3 yrs old. Doppler ultrasound examination was performed on three of the four patients with clinical CVC-DVT, confirming the diagnosis in each case. CONCLUSIONS: This study suggests that young children with DKA have an increased incidence of clinical DVT associated with the placement of femoral central venous catheters.