Reducing Facial Hospital-Acquired Pressure Injuries Related to Prone Positioning in the Intensive Care Unit.

PURPOSE: The purpose of this quality improvement (QI) initiative was to evaluate the effects of a repositioning intervention bundle on the occurrences and severity of hospital-acquired pressure injuries (HAPIs) of the face in patients with COVID-19-related acute respiratory distress syndrome (ARDS) managed by ventilation and placed in a prone position. PARTICIPANTS AND SETTING: Eighteen critically ill, ventilated patients were placed in a prone position for extended periods (range, 1-13 days). The study setting was critical care units in a 504-bed nonprofit teaching hospital located in the Northeastern United States. APPROACH: Standard of care for the prevention of pressure injury (PI) in ventilated patients placed in a prone position at our facility included use of foam dressings over bony prominences on the face and the application of tape to secure the endotracheal (ET) tube as compared to commercial ET tube securement devices. We also placed a fluidized pillow with pillowcase wrapped with an absorbent pad under the head to absorb secretions. We added 2 interventions to our facility's existing HAPI prevention bundle. The first was a repositioning strategy; ventilated and prone patients were lifted by their shoulders by critical care RNs while their ET tube was stabilized by a respiratory therapist every 6 hours. The RNs then repositioned the patient's head and arms to the opposite side into a swimmer's position (head lying to the side with one cheek in contact with the fluidized pillow). The second intervention was micromovement of the head performed by an RN every 4 hours. OUTCOMES: Prior to implementation of the QI initiative, data collected during the early pandemic demonstrated that multiple patients developed facial PIs secondary to prone positioning; a majority were full-thickness or unstageable PIs, whereas a minority were partial-thickness PIs (stage 2). Following implementation of the QI initiative, data indicated that 5 of 18 (28%) patients placed in a prone position had HAPIs of the face; 4 (22%) of the HAPIs were stage 1 or 2 and 1 was unstageable. Patients were placed in a prone position from 1 to 13 days. All facial HAPIs developed within the first 2 days of placement in a prone position. IMPLICATIONS FOR PRACTICE: The addition of an RN and a respiratory therapist repositioning intervention and micromovements of the head every 4 hours by the RN to an existing pressure prevention bundle during prone positioning led to a clinically relevant reduction in the severity of facial HAPIs. As a result, care for these patients has been changed to incorporate the repositioning interventions implemented during this QI project.

Speech and Language Delay in Children.

Childhood speech and language concerns are commonly encountered in the primary care setting. Family physicians are integral in the identification and initial evaluation of children with speech and language delays. Parental concerns and observations and milestone assessment aid in the identification of speech and language abnormalities. Concerning presentations at 24 months or older include speaking fewer than 50 words, incomprehensible speech, and notable speech and language deficits on age-specific testing. Validated screening tools that rely on parental reporting can serve as practical adjuncts during clinic evaluation. Early referral for additional evaluation can mitigate the development of long-term communication disorders and adverse effects on social and academic development. All children who have concerns for speech and language delays should be referred to speech language pathology and audiology for diagnostic and management purposes. Parents and caretakers may also self-refer to early intervention programs for evaluation and management of speech and language concerns in children younger than three years.

Treatment of Insertional Achilles Tendinopathy Using Adjunct Electroacupuncture Therapy: A Randomized Controlled Trial.

Objective: Achilles tendinopathy is a common musculoskeletal condition associated with decreased functionality. The insertional variant (<2cm from the calcaneus) is less responsive to eccentric-exercise therapy. This study looked at the effect of electroacupuncture (EA) + eccentric exercise for treating insertional Achilles tendinopathy. Materials and Methods: Fifty-two active duty and Department of Defense beneficiaries older than 18 years of age with insertional Achilles tendinopathy were randomized to treatment with either eccentric exercise or eccentric exercise with EA. They were evaluated at 0, 2, 4, 6, and 12 weeks. The treatment group received EA treatment in the first 4 visits. The Victorian Institute of Sports Assessment-Achilles Questionnaire (VISA-A; scored 0-100; higher score = increased function) was used to assess the patients and patient-reported pain (0-10, increasing pain with score) pre- and post-demonstration of the exercises during each visit. Results: Both the treatment group (53.6% reduction; confidence interval [CI]: 2.1, 3.9; P < 0.001) and the control group (37.5% reduction; CI: 0.4, 2.9; P = 0.023) reported decreased pain between the first and last visit. The treatment group had reduced pain (mean difference [MD] = 1.0; P < 0.01) between pre- and post-eccentric-exercise performance at each visit, while the control group did not (MD = -0.3; P = 0.065). VISA-A scores did not show a difference in functional improvement between the groups (P = 0.296). Conclusions: EA as an adjunct to eccentric therapy significantly improves short-term pain control for insertional Achilles tendinopathy.

Isolated Pre-existing HLA-DP Donor-Specific Antibodies are Associated With Poorer Outcomes in Renal Transplantation.

Introduction: The importance of donor-specific antibodies (DSAs) in renal transplantation has long been recognized, but the significance of human leukocyte antigen (HLA)-DP antibodies remains less clear. We performed a retrospective single center study of renal transplants with pre-existing isolated HLA-DP-DSAs to assess clinical outcomes. Methods: Twenty-three patients with isolated HLA-DP-DSAs were compared with 3 control groups as follows: standard immunological risk (calculated reaction frequency [cRF] < 85%, no current or historical DSA, no repeat mismatched antigens with previous transplants, n = 46), highly sensitized (cRF > 85%, n = 27), and patients with HLA-DP antibodies that were not donor-specific (n = 18). Univariate and multivariate analyses were performed comparing antibody-mediated rejection (ABMR)-free and graft survival. Factors in the final multivariable models included patient group, % cRF, B-cell flow crossmatch (BFXM) positivity and regrafts. Results: Over a median follow-up of 1197 days, 65% of HLA-DP-DSA patients had ABMR on indication biopsies, and 30% of HLA-DP-DSA patients lost their graft. Pre-existing HLA-DP DSAs remained the single factor associated with ABMR after multivariable analysis (hazard ratio [HR] = 9.578, P = 0.012). Patients with HLA-DP DSAs had increased microvascular scores (P = 0.0346) and worse transplant glomerulopathy (P = 0.015) on biopsy compared with the standard immunological risk group. Furthermore, flow crossmatch (FXM) positivity did not help inform on the risk of graft failure or ABMR in patients with preformed DP-DSA. Conclusion: Transplants with pre-existing HLA-DP-DSAs should be considered high risk. Routine laboratory tests are unable to further risk stratify these patients. Recipients should be considered for intensified immunosuppression and closely monitored.

Prescribe an SGLT2 inhibitor for heart failure in the absence of diabetes?

An RCT demonstrates that dapagliflozin produces better cardiovascular outcomes than placebo for heart failure patients with and without diabetes.

Gender Issues and Oral and Maxillofacial Surgery Advanced Education Program Accreditation.

The author explores gender issues related to oral and maxillofacial training programs and the role that accreditation should have to ensure gender equity, antidiscrimination, and support of women in the profession of oral and maxillofacial surgery.

SARS-CoV-2 diagnostics: Towards a more comprehensive approach to routine patient testing.

The SARS-CoV-2 pandemic has provided the stimulus for the rapid development of a variety of diagnostic testing methods. Initially these were deployed as screening tools to evidence spread of the virus within populations. The recent availability of vaccines against the virus and the need to better understand the parameters of post-infection protective immunity requires development of methods, suitable for use in the routine diagnostic laboratory, capable of characterising the viral immune response in greater detail. Such methods need to consider both cellular and humoral immunity. Toward this aim we have investigated use of a commercial multiplex assay (COVID Plus Assay, One Lambda), providing assessment of the SARS-CoV-2 response at structural level, and developed an in-house cell stimulation assay using commercially available viral peptides (Miltenyi). This paper reports our experience in use of these methods in extended investigation of a cohort of healthcare workers with prior screening results indicative of viral infection. The antibody response generated is shown to be both qualitatively and quantitatively different in different individuals. Similarly a recall response to SARS-CoV-2 antigen involving the T cell compartment can be readily demonstrated in recovered individuals but is of variable magnitude.

PURL: Ruling out PE in pregnancy.

Can clinical probability and a high-sensitivity D-dimer test reliably and safely rule out pulmonary embolism during pregnancy?

A role for human leucocyte antigens in the susceptibility to SARS-Cov-2 infection observed in transplant patients.

We analysed data from 80 patients who tested positive for SARS-CoV-2 RNA who had previously been HLA typed to support transplantation. Data were combined from two adjacent centres in Manchester and Leeds to achieve a sufficient number for early analysis. HLA frequencies observed were compared against two control populations: first, against published frequencies in a UK deceased donor population (n = 10,000) representing the target population of the virus, and second, using a cohort of individuals from the combined transplant waiting lists of both centres (n = 308), representing a comparator group of unaffected individuals of the same demographic. We report a significant HLA association with HLA- DQB1*06 (53% vs. 36%; p < .012; OR 1.96; 95% CI 1.94-3.22) and infection. A bias towards an increased representation of HLA-A*26, HLA-DRB1*15, HLA-DRB1*10 and DRB1*11 was also noted but these were either only significant using the UK donor controls, or did not remain significant after correction for multiple tests. Likewise, HLA-A*02, HLA-B*44 and HLA-C*05 may exert a protective effect, but these associations did not remain significant after correction for multiple tests. This is relevant information for the clinical management of patients in the setting of the current SARS-CoV-2 pandemic and potentially in risk-assessing staff interactions with infected patients.

Acute rhinosinusitis: When to prescribe an antibiotic.

Yes, the majority of antibiotics prescribed for acute rhinosinusitis are unnecessary, but when should you prescribe one and which one(s) should you use?

The Leeds hand transplant programme: Review of the laboratory management of the first six cases.

The UK hand transplantation programme is hosted by the Department of Plastic and Reconstructive Surgery at Leeds Teaching Hospitals under the leadership of Professor Simon Kay. Since programme launch in 2013, ten procedures in six individuals have been performed involving unilateral or bilateral transplants. The multi-disciplinary team that delivers the programme includes the transplant immunology service. The laboratory experience in programme support is reported here.

How well do we manage the odontogenic keratocyst? A multicenter study.

OBJECTIVE: The aim of this study was to answer the following clinical questions: Among patients treated for odontogenic keratocysts (OKCs), what is the overall 5-year disease-free rate, and what factors are associated with disease recurrence? STUDY DESIGN: We implemented a multicenter retrospective cohort study composed of patients presenting for the evaluation and management of previously untreated OKCs. The predictor variables were grouped into demographic, medical, radiographic, and operative categories. The primary outcome variable was time to lesion recurrence. Data analyses were performed by using bivariate analysis and univariate or multivariate Cox proportional hazards models. RESULTS: The study sample was composed of 231 OKCs. Of these, 57 (24.7%) were treated with decompression with residual cystectomy, 86 (37.2%) with enucleation without adjuvant therapy, and 78 (33.8%) with enucleation with peripheral ostectomy. There were 44 recurrences (19%), with a median time to recurrence of 26.7 months (range 15.8-49.8). CONCLUSIONS: This multicenter study is the largest study analyzing disease recurrence after treatment of OKCs by using appropriate statistical analysis for a time-to-event outcome (disease recurrence). The 5-year disease-free estimate was 29%. Mandibular lesions, multilocular lesions, and lesions treated with decompression and residual cystectomy were associated with recurrence.

PURLs: Tamsulosin for patients with ureteral stones?

A 54-year-old man presents to the emergency department with acute onset left flank pain that radiates to the groin. A computed tomography scan of the abdomen/pelvis without contrast reveals a 7-mm distal ureteral stone. He is deemed appropriate for outpatient management. In addition to pain medications, should you prescribe tamsulosin?

Rare X Chromosome Abnormalities in Systemic Lupus Erythematosus and Sjögren's Syndrome.

OBJECTIVE: Sjögren's syndrome (SS) and systemic lupus erythematosus (SLE) are related by clinical and serologic manifestations as well as genetic risks. Both diseases are more commonly found in women than in men, at a ratio of ~10 to 1. Common X chromosome aneuploidies, 47,XXY and 47,XXX, are enriched among men and women, respectively, in either disease, suggesting a dose effect on the X chromosome. METHODS: We examined cohorts of SS and SLE patients by constructing intensity plots of X chromosome single-nucleotide polymorphism alleles, along with determining the karyotype of selected patients. RESULTS: Among ~2,500 women with SLE, we found 3 patients with a triple mosaic, consisting of 45,X/46,XX/47,XXX. Among ~2,100 women with SS, 1 patient had 45,X/46,XX/47,XXX, with a triplication of the distal p arm of the X chromosome in the 47,XXX cells. Neither the triple mosaic nor the partial triplication was found among the controls. In another SS cohort, we found a mother/daughter pair with partial triplication of this same region of the X chromosome. The triple mosaic occurs in ~1 in 25,000-50,000 live female births, while partial triplications are even rarer. CONCLUSION: Very rare X chromosome abnormalities are present among patients with either SS or SLE and may inform the location of a gene(s) that mediates an X dose effect, as well as critical cell types in which such an effect is operative.