Three cases of black pleural effusion.

Black pleural effusions (BPE) are rare, exudative pleural effusions that produce a black fluid on thoracentesis. While the name and definition of this pathology is undeniably simple, the etiologies, outcomes, and treatments for BPE are incredibly complex. Currently, BPE is not well-demonstrated in the literature. This case series reports three patients with different etiologies, past medical histories, presenting symptoms, treatments, and outcomes. BPE caused by pancreatic-pleural fistula and opportunistic infections are demonstrated in this case series. This report shows that early identification and treatment of the underlying cause of BPE is critical to the recovery of the patients.

Perception versus reality: analysis of time spent on bedside rounds in an academic ICU (Intensive Care Unit).

BACKGROUND: Despite its importance, teaching at the bedside is declining over time. This purported decline has not been quantified. Quantifying bedside teaching is challenging, and we found only one study quantifying bedside teaching on a hospitalist service. OBJECTIVE: We conducted a study to understand the prevalence of bedside teaching in our medical intensive care unit. METHODS: We conducted a single-center single-unit study in the medical intensive care unit of an academic tertiary care institution. We used a survey tool to assess perceived time spent on bedside teaching, quality of teaching, and total rounding time. In parallel, independent observers objectively measured time spent on rounds and on bedside teaching. Residents were asked to complete the survey once a week. Independent observers collected data daily and weekly averages were obtained. RESULTS: 43 responses were collected over a 4-month period. Most respondents (73%) reported a total rounding time of either 90-120 min or greater than 120 min. Median reported bedside teaching time was 16-20 min with 16 respondents (37%) reporting less than 15 min and 27 respondents (63%) reporting 16 min or more. The amount of time spent on bedside teaching was reported as adequate or more than adequate by 77% (33) of respondents with 58% (25) reporting that bedside teaching was very or extremely effective in helping them learn. Mean census reported by the independent observers was 12.75 patients per team. Bedside teaching represented an average of 12% of total rounding time, 16.85 min per day. While total rounding time increased with increasing census, there was no decline in bedside teaching time. CONCLUSION: It is reported that bedside teaching has decreased over time. Our study has demonstrated that bedside teaching occurs in our Medical ICU, and though it represents a minority of the time spent on rounds, residents still reported teaching in the ICU to be adequate.

High incidence of barotrauma in patients admitted with COVID-19 to ICU and associated mortality in rural Appalachia: An observational study.

OBJECTIVES: To assess the incidence of barotrauma and its impact on mortality in COVID-19 patients admitted to ICU. DESIGN: Single-center retrospective study of consecutive COVID-19 patients admitted to a rural tertiary-care ICU. The primary outcomes were incidence of barotrauma in COVID-19 patients and all-cause 30-day mortality. Secondary outcomes were the length of stay (LOS) in the hospital and ICU. Kaplan-Meier method and log-rank test were used in the survival data analysis. SETTING: Medical ICU, West Virginia University Hospital (WVUH), USA. PATIENTS: All adult patients were admitted to the ICU for acute hypoxic respiratory failure due to coronavirus disease 2019 between September 1, 2020, and December 31, 2020. Historical controls were ARDS patients admitted pre-COVID. INTERVENTION: Not applicable. MEASUREMENTS AND MAIN RESULTS: One hundred and sixty-five consecutive patients with COVID-19 were admitted to the ICU during the defined period, compared to 39 historical non-COVID controls. The overall incidence of barotrauma in COVID-19 patients was 37/165 (22.4%) compared to 4/39 (10.3%) in the control group. Patients with COVID-19 and barotrauma had a significantly worse survival (HR = 1.56, p = 0.047) compared to controls. In those requiring invasive mechanical ventilation, the COVID group also had significantly higher rates of barotrauma (OR 3.1, p = 0.03) and worse all-cause mortality (OR 2.21, p = 0.018). COVID-19 with barotrauma had significantly higher LOS in the ICU and the hospital. CONCLUSIONS: Our data on critically ill COVID-19 patients admitted to the ICU shows a high incidence of barotrauma and mortality compared to the controls. Additionally, we report a high incidence of barotrauma even in non-ventilated ICU patients.

Addressing Lung Cancer Health Disparities in West Virginia: An Academic-Industry Collaboration Model.

Lung cancer screening is underused nationwide, particularly in rural areas where incidence and mortality rates are high, suggesting the need for innovative methods to reach underserved populations. Partners from national, state, and community positions can combine the service and science needed to save lives with mobile lung cancer screening.

Exploring Primary Care Non-Attendance: A Study of Low-Income Patients.

INTRODUCTION: While evidence has been established on the impact of medical appointment non-attendance on the healthcare system and patient health, previous research has not focused on how poverty and rurality may influence patient experiences with non-attendance. This paper explores patient perceptions of non-attendance among those experiencing poverty in a rural U.S county to better inform providers to the context in which their patients make attendance-related decisions. METHODS: Using a grounded theory approach, we conducted semi-structured interviews with 32 U.S. low-income adults in the rural Western U.S. who recurrently missed primary care appointments. We also used a questionnaire to assess individual characteristics related to health, resiliency, personal mastery, medical mistrust, life chaos, and adverse childhood experiences. RESULTS: Participants identified 3 barriers to attending appointments: appointment disinterest, competing demands, and insufficient systems. Appointment disinterest stemmed from physical and mental health issues, misalignment between needs and treatment, and comfort with the provider. Competing demands included family responsibilities, employment, and relationships. Finally, participants reported that current scheduling and transportation systems were helpful but insufficient. To provide further context, participants also reported low overall health, moderate levels of medical mistrust, life chaos, and mastery, moderate to low resilience, and very a high number of adverse childhood experiences. CONCLUSIONS: Results point to the need for modified structures that allow low-income patients more control over their personal health and highlight opportunities for clinics to address patients' lack of interest and fear in the medical encounter.

Transition to an In-House Night Float System for Critical Care Fellows: Resident Experience, Morbidity, and Mortality in a Rural Academic Hospital.

Background In-house night call systems for ICUs are frequently implemented to enable hands-on patient care and provide direct supervision of resident physicians at night. Previous studies have highlighted the benefits of an in-house night float (NF) such as minimized time to intervention but failed to consistently demonstrate an improvement in patient outcomes. This study aimed to evaluate the impact of an in-house critical care fellow at night on the resident experience and assess for impact on patient morbidity and mortality. Methods An in-house overnight critical care fellow shift was implemented at West Virginia University Hospital in 2018. Resident physicians rotating overnight in the medical ICU (MICU) for six-month periods before and after the intervention were anonymously surveyed. A retrospective chart review of 300 patients admitted overnight to the MICU was performed. Multiple patient outcomes from the pre (2017) and post (2018) intervention periods were collected and compared using a two-sample t-test. Results In the post-intervention survey, nearly every element of resident experience improved (availability of support, comfort in performing invasive procedures, and input in treatment plans), and far fewer residents felt overwhelmed relative to the pre-intervention survey. The resident experience markedly improved with the addition of an in-house critical care fellow. For the retrospective chart review, both groups had similar severity of illness and there was no change in ICU or hospital length of stay. No difference in mortality was found, though the study was underpowered for this outcome. For secondary measures, there was no difference in mechanical ventilation or use days, though more procedures performed were overnight compared to the former staffing model. Conclusions Implementation of an in-house overnight critical care fellow shift in the MICU positively impacted resident experience without worsening patient outcomes. The intervention did not worsen measures of morbidity or mortality but did lead to an increased number of procedures performed overnight. The model of in-house NF coverage continues to be preferred by clinicians.

An Analysis of Literature on Sport Officiating Research.

Sport officials are crucial members of sport. Researchers have studied their roles numerous times, with results often informing sport procedures (e.g., athlete order in artistic sports). As the research on sport officiating spans five decades and several topics of interest, it is important that researchers periodically synthesize the literature. Purpose: The purpose of this study, therefore, was to conduct an analysis of literature on sport officiating research. Method: Guided by previous researchers, we executed four methodological steps including the article search, article retrieval, sample validity, and article coding. These steps yielded 386 articles for analysis, which ranged from 1971 to 2018. We coded the articles based on four main categories: article information, participant demographics, contextual information, and methodology. Results: Key findings from this analysis include a recent influx in sport officiating research, a vast number of publication journals, few studies dedicated to female-only participants, many studies missing relevant demographic information, an over-representation of interactors, and a reliance on quantitative studies. Conclusions: Though many researchers have conducted studies on sport officiating, several articles had poor methodological rigor (e.g., not reporting key demographic information). In the discussion and conclusion sections, we highlight strengths and weaknesses within the field and provide recommendations to guide future researchers and practitioners, to ensure robust research designs and guide applied practice.

Promoting school lunch fruit and vegetable intake through role modeling: a pilot study.

OBJECTIVES: Child fruit and vegetable consumption is a critical component of adult chronic disease prevention, yet fruit and vegetable intake remains low among elementary school children in the United States. This pilot study tested a role modeling intervention designed to promote fruit and vegetable consumption in a U.S elementary school cafeteria setting. METHODS: This one-year, repeated cross-sectional study used digital photographs to assess fruit and vegetable waste at baseline (n = 566 trays) and follow-up (n = 231 trays) of kindergarten through fifth grade students in one elementary school. Differences in waste were assessed through Mann-Whitney statistical tests. Feedback on intervention acceptability was provided by the intervention team during implementation. RESULTS: The proportion of students consuming all of their selected fruits and vegetables increased by 11.1% and 8.7% respectively (p < 0.01). There was a significant decrease in the proportion of students not consuming any of their selected fruit (16.0%, p < 0.001). Staff and students provided positive reports of intervention acceptance. CONCLUSIONS AND IMPLICATIONS: Findings from this pilot study indicate that role modeling in a school cafeteria setting may be a promising health promotion strategy and provide groundwork for future research in the development of school cafeteria role modeling interventions. Further research is needed to assess intervention efficacy and acceptability at a larger scale.

Derivation and Validation of a Prognostic Model to Predict 6-Month Mortality in an Intensive Care Unit Population.

RATIONALE: Identification of terminally ill patients in the intensive care unit (ICU) would facilitate decision making and timely palliative care. OBJECTIVES: To develop and validate a patient-specific integrated prognostic model to predict 6-month mortality in medical ICU patients. METHODS: A longitudinal prospective cohort study of temporally split samples of 1,049 consecutive medical ICU patients in a tertiary care hospital was performed. For each patient, we collected demographic data, Acute Physiology and Chronic Health Evaluation III score, Charlson comorbidity index, intensivist response to a surprise question (SQ; "Would I be surprised if this patient died in the next 6 months?") on admission, and vital status at 6 months. RESULTS: Between November 2013 and May 2015, derivation and validation cohorts of 500 and 549 consecutive patients were studied to develop a multivariate logistic regression model. In the multivariate logistic regression model, Charlson comorbidity index (P = 0.033), Acute Physiology and Chronic Health Evaluation III score (P < 0.001), and SQ response (P < 0.001) were predictors of vital status at 6 months. The odds of dying within 6 months were significantly higher when the SQ was answered "no" than when it was answered "yes" (odds ratio, 7.29; P < 0.001). The c-statistic for the derivation and validation cohorts were 0.832 (95% confidence interval, 0.795-0.870) and 0.84 (95% confidence interval, 0.806-0.875), respectively. CONCLUSIONS: Our integrated prognostic model, which includes the SQ, has strong discrimination and calibration to predict 6-month mortality in medical ICU patients. This model can aid clinicians in identifying ICU patients who may benefit from the integration of palliative care into their treatment.

Innovations in Practice: Supporting parent and teen communication during outpatient psychotropic medication appointments.

BACKGROUND: Encouragement of youth participation in mental health treatment is relatively new and there have been few specific interventions to improve engagement, particularly as it relates to medication management. This article describes the development of a tool to support engagement during medication appointments by identifying areas of agreement/disagreement between parents and teens. METHOD: Data were analyzed from 240 parent/teen dyads visiting an outpatient community mental health center for medication management. Frequencies and percentages were calculated for all items. Kappa scores were used to assess agreement between parent and teen dyads. RESULTS: The level of agreement between parents and teens was low. Overall, teens expressed preference for discussion of 'positive' aspects of treatment such as what is going well, whereas parents preferred to focus on 'negative' aspects of treatment such as problematic symptoms. The lowest level of agreement was found for the item: 'My teen seems to be having problems with energy levels' (Kappa = .19; 95% CI = .05-.34). The strongest level of agreement was for the question 'How has your teen been using the medication since the last appointment?' (Kappa = .56; 95% CI = .44-.69). CONCLUSIONS: The findings support the utility of the tool for illustrating the variation in needs of teens and parents during medication appointments. Knowledge of these differences can be used by providers to encourage teen participation and may enhance overall communication.