Intermediate or Intensive Care Unit Admission across Race and Ethnicity.

OBJECTIVES: The aim of this study was to assess the association between race and ethnicity and admission to intermediate (IMCUs) or intensive care units (ICUs) among hospitalized patients. METHODS: Using Florida hospital discharge data from the Agency for Healthcare Research and Quality-sponsored State Inpatient Database in 2017, we assessed the relationship between race (White, Black, Other) and Hispanic ethnicity and IMCU or ICU admission. Demographic covariates included age, sex, quartile of household income for patient ZIP code, insurance status, and patient residence. An adjusted model assessed the association between race and ethnicity and IMCU or ICU admission using log binomial regression with generalized estimating equations after controlling for demographic characteristics and the Elixhauser Comorbidity Index. RESULTS: After controlling for demographics and comorbidities, the prevalence of IMCU or ICU admission was higher among non-Hispanic Blacks (adjusted prevalence ratio [aPR] 1.04; 95% confidence interval [CI] 1.02-1.05) and non-Hispanic patients of other races (aPR 1.03; 95% CI 1.01-1.04) compared with non-Hispanic Whites. The prevalence of IMCU or ICU use was lower among Hispanic Whites (aPR 0.98; 95% CI 0.86-1.00) and Hispanics of other races (aPR 0.96; 95% CI 0.95-0.98) compared with non-Hispanic Whites after controlling for other demographic characteristics and comorbidities. CONCLUSIONS: Among hospitalized patients, racial minorities are slightly more likely to use higher levels of care, whereas Hispanic patients are generally slightly less likely than non-Hispanic White patients to use higher levels of care. Further evaluation is needed to identify reasons for disparate IMCU or ICU admission.

Fatal Exacerbations of Systemic Capillary Leak Syndrome Complicating Coronavirus Disease.

We report 2 fatal exacerbations of systemic capillary leak syndrome (SCLS), also known as Clarkson disease, associated with coronavirus disease (COVID-19) in the United States. One patient carried an established diagnosis of SCLS and the other sought treatment for new-onset hypotensive shock, hemoconcentration, and anasarca, classic symptoms indicative of an SCLS flare. Both patients had only mild-to-moderate symptoms of COVID-19. This clinical picture suggests that these patients succumbed to complications of SCLS induced by infection with severe acute respiratory syndrome coronavirus 2. Persons with known or suspected SCLS may be at increased risk for developing a disease flare in the setting of mild-to-moderate COVID-19 infection.

Randomized Controlled Trial of a Novel Communication Device Assessed During Noninvasive Ventilation Therapy.

BACKGROUND: Noninvasive ventilation (NIV), a form of positive airway pressure (PAP) therapy, is the standard of care for various forms of acute respiratory failure (ARF). Communication impairment is a side effect of NIV, impedes patient care, contributes to distress and intolerance, and potentially increases intubation rates. This study aimed to evaluate communication impairment during CPAP therapy and demonstrate communication device improvement with a standardized protocol. RESEARCH QUESTION: How does an oronasal mask affect communication intelligibility? How does use of an NIV communication device change this communication intelligibility? STUDY DESIGN AND METHODS: A single-center randomized controlled trial (36 outpatients with OSA on CPAP therapy) assessed exposure to CPAP 10 cm H2O and PAP communication devices (SPEAX, Ataia Medical). Communication impairment was evaluated by reading selected words and sentences for partners to record and were tabulated as %words correct. Each outpatient-partner pair performed three assessments: (1) baseline (conversing normally), (2) mask baseline (conversing with PAP), and (3) randomized to functioning device (conversing with PAP and device) or sham device. After each stage, both outpatients and partners completed Likert surveys regarding perceived intelligibility and comfort. RESULTS: While conversing with PAP, word and sentence intelligibility decreased relatively by 52% (87% vs 41%) and relatively by 57% (94% vs 40%), respectively, compared with normal conversation. Word and sentence intelligibility in the intervention arm increased relatively by 75% (35% vs 61%; P < .001) and by 126% (33% vs 76%; P < .001) higher than the control arm, respectively. The device improved outpatient-perceived PAP comfort relatively by 233% (15% vs 50%, P = .042) and partner-perceived comfort by relatively 245% (20% vs 69%, P = .0074). INTERPRETATION: Use of this PAP communication device significantly improves both intelligibility and comfort. This is one of the first studies quantifying communication impairment during PAP delivery. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT03795753; URL: www.clinicaltrials.gov.

Paddling Upstream With Point-of-Care Ultrasound to Diagnose Cardiac Ascites.

Ascites has multiple etiologies, including cirrhosis and heart failure, which can be differentiated by point-of-care ultrasound (POCUS). One cause of cardiac ascites that can be difficult to identify is portopulmonary hypertension (PPH), a rare disorder caused by pulmonary artery vasoconstriction due to advanced liver disease. POCUS can readily identify right ventricular dysfunction which can accelerate a PPH diagnosis. This case report describes the use of POCUS to work-up new onset ascites and expedite diagnosis of cardiac ascites due to PPH.

Consequences and Solutions for the Impact of Communication Impairment on Noninvasive Ventilation Therapy for Acute Respiratory Failure: A Focused Review.

OBJECTIVES: With over 2 million cases of acute respiratory failure in the United States per year, noninvasive ventilation has become a leading treatment modality, often supplanting invasive mechanical ventilation as the initial treatment of choice. Most acute respiratory failure patients use a full face (oronasal) mask with noninvasive ventilation, which is known to impair communication, but its popularity and benefit has led many providers to accept the communication impairment. Medical staff periodically remove masks to communicate with patients, but patients are often limited to short utterances and risk lung derecruitment upon removal of positive pressure. These problems can lead to noninvasive ventilation failure, which is often linked to worse outcomes than first initiating invasive mechanical ventilation and can lead to increased hospitalization costs. DATA SOURCES: We searched MEDLINE and Google Scholar for "speech," "communication," "impairment," "failure," "complications," "NIPPV," "NIV," and "noninvasive ventilation." STUDY SELECTION: We included articles with patients in acute respiratory failure. We excluded articles for patients using noninvasive ventilation therapy for obstructive sleep apnea. DATA SYNTHESIS: Communication impairment has been associated with increasing noninvasive ventilation anxiety (odds ratio, 1.25). Of patients using noninvasive ventilation, 48% require early discontinuation, 22% refuse noninvasive ventilation, and 9% are ultimately intubated. Improvements to communication have been shown to reduce fear and anxiety in invasive mechanical ventilation patients. Analogous communication problems exist with effective solutions in other fields, such as fighter pilot masks, that can be easily implemented to enhance noninvasive ventilation patient care, increase adherence to noninvasive ventilation treatment, and improve patient outcomes. CONCLUSIONS: Communication impairment is an underappreciated cause of noninvasive ventilation complications and failure and requires further characterization. Analogous solutions-such as throat microphones and mask-based microphones-that can be easily implemented show potential as cost-effective methods to reduce noninvasive ventilation failure.

Machine Learning Methods to Predict Acute Respiratory Failure and Acute Respiratory Distress Syndrome.

Acute respiratory failure (ARF) is a common problem in medicine that utilizes significant healthcare resources and is associated with high morbidity and mortality. Classification of acute respiratory failure is complicated, and it is often determined by the level of mechanical support that is required, or the discrepancy between oxygen supply and uptake. These phenotypes make acute respiratory failure a continuum of syndromes, rather than one homogenous disease process. Early recognition of the risk factors for new or worsening acute respiratory failure may prevent that process from occurring. Predictive analytical methods using machine learning leverage clinical data to provide an early warning for impending acute respiratory failure or its sequelae. The aims of this review are to summarize the current literature on ARF prediction, to describe accepted procedures and common machine learning tools for predictive tasks through the lens of ARF prediction, and to demonstrate the challenges and potential solutions for ARF prediction that can improve patient outcomes.

Physical Activity Opportunities and Academic Outcomes of Fourth Grade Elementary School Students in Georgia.

BACKGROUND: Physical activity at schools is an important component in combatting childhood obesity. Studies have shown that physical activity at school is positively associated with academic outcomes. The purpose of this study is to examine associations between opportunity of physical activity time at school and academic outcomes. METHODS: This statewide, cross-sectional study utilized 2 data sources from the Georgia Department of Education and Georgia Shape in 860 schools. Multivariable linear regression analysis assessed the impact of the amount of physical activity time at school and standardized test scores, controlling for aerobic capacity, BMI, race, gender, school size, geographic category, and SES. RESULTS: Time of physical activity opportunity at school was not significantly associated with Mathematics or Reading CRCT scores (p = .94, p = .31, respectively). SES had the greatest impact on test scores, where higher SES schools had higher standardized test scores (p < .01 for all tests scores). CONCLUSION: Time of physical activity opportunities at school was not significantly associated with standardized test scores. SES appears to be the most important factor in academic outcomes. Time spent in PA at school does not negatively affect academic outcomes and should be utilized to prevent/reduce childhood overweight and obesity.

Pericardial closure with extracellular matrix scaffold following cardiac surgery associated with a reduction of postoperative complications and 30-day hospital readmissions.

BACKGROUND: A prospective, multi-center study (RECON) was conducted to evaluate the clinical outcomes of pericardial closure using a decellularized extracellular matrix (ECM) graft derived from porcine small intestinal submucosa. METHODS: Patients indicated for open cardiac surgery with pericardial closure using ECM were eligible for the RECON study cohort. Postoperative complications and readmission of the RECON patients were compared to the patient cohort in the Nationwide Readmissions Database (NRD). Inverse probability of treatment weighting was used to control the differences in patient demographics, comorbidities, and risk factors. RESULTS: A total of 1420 patients at 42 centers were enrolled, including 923 coronary artery bypass grafting (CABG) surgeries and 436 valve surgeries. Significantly fewer valve surgery patients in the RECON cohort experienced pleural effusion (3.1% vs. 13.0%; p < 0.05) and pericardial effusion (1.5% vs. 2.6%; p < 0.05) than in the NRD cohort. CABG patients in the RECON cohort were less likely to suffer bleeding (1.2% vs. 2.9%; p < 0.05) and pericardial effusion (0.2% vs. 2.2%, p < 0.05) than those in the NRD cohort. The 30-day all-cause hospital readmission rate was significantly lower among RECON patients than NRD patients following both valve surgery (HR: 0.34; p < 0.05) and CABG surgery (HR: 0.42; p < 0.05). In the RECON study, 14.4% of CABG patients and 27.0% of valve patients had postoperative atrial fibrillation as compared to previously reported risks, which generally ranges from 20 to 30% after CABG and from 35 to 50% after valve surgery. CONCLUSIONS: Pericardial closure with ECM following cardiac surgery is associated with a reduction in the proportion of patients with pleural effusion, pericardial effusion, and 30-day readmission compared to a nationwide database. TRIAL REGISTRATION: NCT02073331 , Registered on February 27, 2014.

Elementary school physical activity opportunities and physical fitness of students: A statewide cross-sectional study of schools.

BACKGROUND: Using a cross-sectional design, we assessed the relationship between the time schools provide for physical activity and the proportion of students achieving a healthy aerobic capacity or body mass index. METHODS: In 2013-2014, physical education and grade-level teachers from 905 of 1,244 Georgia elementary schools provided survey data about the frequency and duration of physical activity opportunities offered before, during, and after school. Log-binomial models related the weekly physical activity minutes provided by schools to the proportion of children in the FitnessGram healthy fitness zone for aerobic capacity or body mass index while adjusting for school characteristics and demographics. RESULTS: During-school physical activity time was not associated with student fitness, but schools with before-school physical activity programs had a moderately higher prevalence of healthy aerobic capacity (prevalence ratio among girls: 1.06; 99% confidence interval: 1.00-1.13; prevalence ratio among boys: 1.03; 99% confidence interval: 0.99-1.08). Each additional 30 minutes of recess per week was associated with no more than a 3%-higher proportion of students with healthy body mass indexes (prevalence ratio among girls: 1.01; 99% confidence interval: 1.00-1.03; prevalence ratio among boys: 1.01; 99% confidence interval: 0.99-1.03). CONCLUSIONS: The amount of physical activity time provided by schools is not strongly associated with school-aggregated student fitness. Future studies should be designed to assess the importance of school-based physical activity time on student fitness, relative to physical activity type and quality.

Impact of an American board of pediatrics maintenance of certification (MOC) on weight-related counseling at well-child check-ups.

OBJECTIVE: The Healthy Weight Counseling Maintenance of Certification (MOC) program integrates pediatrician training and clinic changes to promote use of evidence-based, diet and physical activity (PA) health messages and counseling strategies. This interrupted time series study assessed the impact of this MOC program on provision of weight-related counseling. METHODS: We randomly selected 10-15 well-child visit charts at three time points before and three time points after 102 Georgia pediatricians began the MOC in 2012-2015. Linear binomial regression compared the frequency of behavior-change goal setting and health messaging documentation (fruit/vegetable consumption, sugar-sweetened beverage consumption, out-of-home food consumption, PA, and screen time) before and after MOC participation. RESULTS: At baseline, pediatricians documented behavior-change goals with 44% of patients, with an additional 49% of patients having documented goals after their pediatrician started the MOC (99.5% confidence interval [CI]: 21-77%). Similarly, absolute increases in the proportion of patients with documentation for sugar-sweetened beverage consumption (adjusted prevalence difference [aPD]: 37%; 99.5% CI: 13-62%) and out-of-home eating were observed (aPD: 38%; 99.5% CI: 12-64%). CONCLUSION: The Healthy Weight Counseling MOC is associated with increased and sustained use of evidence-based health messages and counseling strategies. PRACTICE IMPLICATIONS: Continuing education and facilitation of system changes help improve physicians' weight-related counseling.

Socioeconomic and Racial/Ethnic Disparities in Physical Activity Environments in Georgia Elementary Schools.

PURPOSE: This study aimed to characterize physical activity (PA) environments in Georgia public elementary schools and to identify socioeconomic status (SES) and racial/ethnic disparities in PA environments. DESIGN: A school setting PA survey was launched in 2013 to 2014 as a cross-sectional online survey assessing PA environment factors, including facility access and school PA practices, staff PA opportunities, parental involvement in school PA, and out-of-school PA opportunities. SETTING: All 1333 Georgia public elementary schools were recruited. PARTICIPANTS: A total of 1083 schools (81.2%) responded. Survey respondents included school administrators, physical education (PE) teachers, and grade-level chairs. MEASURES: Physical activity environment factors were assessed via an online questionnaire adapted from school PA surveys and articles. ANALYSIS: The chi-square and Fisher exact analyses were conducted to examine the reporting of PA environment factors overall and by school SES, as measured by free/reduced lunch rate, and/or racial/ethnic composition. RESULTS: Overall, many PA environment factors were widely prevalent (ie, gym [99%] or field [79%] access), although some factors such as some PA-related programs (ie, a structured walk/bike program [11%]) were less widely reported. Disparities in school PA environment factors were largely patterned by SES, though they varied for some factors by racial/ethnic composition and across SES within racial/ethnic composition categories. For example, lower SES schools were less likely to report access to blacktops and tracks ( p-value < .0001), and higher SES schools were less likely to report access to playgrounds ( p-value = .0076). Lower SES schools were also less likely to report "always/often" giving access to PE/PA equipment during recess ( p-value < .01). Lower SES and majority nonwhite schools were less likely to report having joint use agreements with community agencies ( p-value < .0001). CONCLUSION: This study highlights SES and racial/ethnic disparities in PA environments in Georgia public elementary schools.

Childhood Obesity Incidence in the United States: A Systematic Review.

BACKGROUND: This systematic review synthesizes the literature on incidence of obesity during childhood. METHODS: We searched PubMed, Excerpta Medica database (EMBASE), and Cumulative Index to Nursing and Allied Health Literature (CINAHL), and used the Web of Science tool in June 2015. Studies were included if they were published in English, presented results from primary or secondary analyses, used data about children in the US, provided obesity incidence data on children 0 to 18 years born after 1970, and did not pertain to clinically defined populations (disease, medication use, etc.). Author(s), study year, study design, location, sample size, age, and obesity incidence estimates were abstracted. RESULTS: Nineteen studies were included, three of which used nationally representative data. The median study-specific annual obesity incidences among studies using U.S. Centers for Disease Control and Prevention (CDC) growth charts were 4.0%, 3.2%, and 1.8% for preschool (2.0-4.9 years), school aged (5.0-12.9 years), and adolescence (13.0-18.0 years), respectively. This pattern of declining obesity incidence with age was consistent between and within studies. CONCLUSIONS: Studies of childhood obesity in the US indicate declining incidence with age. Childhood obesity prevention efforts should be targeted to ages before obesity onset. Longitudinal data and consistent obesity definitions that correlate with long-term morbidity are needed to better characterize the life history of obesity.

The genome of Heliobacterium modesticaldum, a phototrophic representative of the Firmicutes containing the simplest photosynthetic apparatus.

Despite the fact that heliobacteria are the only phototrophic representatives of the bacterial phylum Firmicutes, genomic analyses of these organisms have yet to be reported. Here we describe the complete sequence and analysis of the genome of Heliobacterium modesticaldum, a thermophilic species belonging to this unique group of phototrophs. The genome is a single 3.1-Mb circular chromosome containing 3,138 open reading frames. As suspected from physiological studies of heliobacteria that have failed to show photoautotrophic growth, genes encoding enzymes for known autotrophic pathways in other phototrophic organisms, including ribulose bisphosphate carboxylase (Calvin cycle), citrate lyase (reverse citric acid cycle), and malyl coenzyme A lyase (3-hydroxypropionate pathway), are not present in the H. modesticaldum genome. Thus, heliobacteria appear to be the only known anaerobic anoxygenic phototrophs that are not capable of autotrophy. Although for some cellular activities, such as nitrogen fixation, there is a full complement of genes in H. modesticaldum, other processes, including carbon metabolism and endosporulation, are more genetically streamlined than they are in most other low-G+C gram-positive bacteria. Moreover, several genes encoding photosynthetic functions in phototrophic purple bacteria are not present in the heliobacteria. In contrast to the nutritional flexibility of many anoxygenic phototrophs, the complete genome sequence of H. modesticaldum reveals an organism with a notable degree of metabolic specialization and genomic reduction.

Niche adaptation and genome expansion in the chlorophyll d-producing cyanobacterium Acaryochloris marina.

Acaryochloris marina is a unique cyanobacterium that is able to produce chlorophyll d as its primary photosynthetic pigment and thus efficiently use far-red light for photosynthesis. Acaryochloris species have been isolated from marine environments in association with other oxygenic phototrophs, which may have driven the niche-filling introduction of chlorophyll d. To investigate these unique adaptations, we have sequenced the complete genome of A. marina. The DNA content of A. marina is composed of 8.3 million base pairs, which is among the largest bacterial genomes sequenced thus far. This large array of genomic data is distributed into nine single-copy plasmids that code for >25% of the putative ORFs. Heavy duplication of genes related to DNA repair and recombination (primarily recA) and transposable elements could account for genetic mobility and genome expansion. We discuss points of interest for the biosynthesis of the unusual pigments chlorophyll d and alpha-carotene and genes responsible for previously studied phycobilin aggregates. Our analysis also reveals that A. marina carries a unique complement of genes for these phycobiliproteins in relation to those coding for antenna proteins related to those in Prochlorococcus species. The global replacement of major photosynthetic pigments appears to have incurred only minimal specializations in reaction center proteins to accommodate these alternate pigments. These features clearly show that the genus Acaryochloris is a fitting candidate for understanding genome expansion, gene acquisition, ecological adaptation, and photosystem modification in the cyanobacteria.