Does Practice Match Protocol? A Comparison of Triage-to-Provider Time Among More vs. Less Acute Emergency Department Patients.

Introduction The Emergency Severity Index (ESI) stratifies emergency department (ED) patients for triage, from "most acute" (level 1) to "least acute" (level 5). Many EDs have a split flow model where less acute (ESI 4 and 5) are seen in a fast track, while more acute (ESI 1, 2, and 3) are seen in the acute care area. A core principle of emergency medicine (EM) is to attend to more acute patients first. Deliberately designating an area for less acute patients to be initially assessed quickly by a first provider might result in them being seen before more acute patients. This study aims to determine the percentage of less acute patients seen by a provider sooner after triage than more acute patients who arrived within 10 minutes of one another. Additionally, this study compares the fast track and acute care areas to see if location affects triage-to-provider time. Methods A random convenience sample of 252 ED patients aged ≥18 was taken. Patients were included if their ESI was available for the provider during sign-up. Patients were excluded if they were directly sent to the ED psychiatric area or attended to by the author. We collected data on the ESI level, time stamps for triage and first provider sign-up, and the location to which the patient was triaged (fast track vs. acute care). Paired patients' ESI levels, locations, and triage and first provider sign-up times were compared. Results  The study included 126 pairs of patients. There was a statistically significant difference in triage-to-provider times for paired ESI 2 vs. 3 patients (60.5 vs. 35.5 minutes, p = 0.0007) and overall paired high- vs. low-acuity patients (55 vs. 39.5 minutes, p = 0.004). However, in 34.8% of paired ESI 2 vs. 3 patients, the ESI 3 patient was seen prior to the paired ESI 2 patient, and in 39.4% of overall paired high vs. low acuity patients, the less acute patient was seen before the more acute patient. Additionally, patients in the acute care area had significantly shorter median triage-to-provider times (~40 minutes) compared to those in the fast track area for ESI 2 (acute care) vs. ESI 3 (fast track) and overall high acuity (acute care) vs. low acuity (fast track). Nonetheless, approximately one-third of ESI 3 patients triaged to fast track were seen before ESI 2 patients triaged to the acute care area. Conclusion The split flow model reduces overall ED length of stay, improving flow volume, revenue, and patient satisfaction. However, it comes at the expense of the fundamental ethos of EM and potentially subverts the intended triage process. Although most more acute patients are seen by a provider sooner after triage than less acute patients, a substantial number are seen later, which could delay urgent medical needs and negatively impact patients' outcomes. Furthermore, patients triaged to acute care are, in general, seen sooner post-triage than identical-ESI-level fast track patients, suggesting fast track might not function as intended (for low-acuity patients to be quickly assessed and initiate diagnostic and treatment plans). We intend to follow this exploratory study with a more comprehensive, multivariate analysis that will consider confounding variables such as initial vital signs, how busy a provider was that day, etc. The future study will also examine patient outcomes to determine the impact on more acute patients of the split flow model and, in particular, on less acute patients being seen sooner by a first provider.

Integrating Pre-test Probability and Point-of-Care Ultrasound (POCUS) in the Emergency Department (ED) Diagnosis of Small Bowel Obstruction (SBO).

Introduction A computed tomography (CT) scan and point-of-care ultrasound (POCUS) are commonly employed for diagnosing small bowel obstructions (SBOs). Prior studies demonstrated that POCUS has 90-95% sensitivity and specificity compared with CT scanning, which is the gold standard. Unlike other imaging modalities (in which the ordering and performing clinician are not the same), POCUS-performing/interpreting sonologists must recognize the risk of confirmation bias in the POCUS application. Per Bayesian analysis, the likelihood of a diagnosis being true following a diagnostic test is based on the ordering clinician's pre-test probability and the test characteristics (sensitivity and specificity, from which positive and negative likelihood ratios can be calculated). Consequently, establishing pre-test probability is important in informing downstream diagnostic or therapeutic interventions, as pre-test probability influences post-test odds. Little research has been done on the role of POCUS sonologist's pre-test probability and actual POCUS results regarding SBO. This study assessed the role of POCUS, integrating pre-test probability and POCUS results to determine post-test odds. Methods One hundred six patients were recruited on a convenience basis and underwent POCUS and CT between April 2017 and December 2022. All sonographers were credentialed in POCUS. POCUS sonologists' pre-test probabilities and POCUS and CT results were captured, which were compared. Sensitivity, specificity, LR+, and LR- were calculated, and correlations were made between pre-test probability and POCUS and CT results.  Results POCUS exhibited a sensitivity of 92% and specificity of 90%, with a corresponding positive likelihood ratio (LR+) of 9.3 and a negative likelihood ratio (LR-) of 0.09 for diagnosing SBO. Among patients with a high pre-test probability of SBO, a negative ultrasound yielded post-test odds of 0.4%, whereas a positive POCUS yielded post-test odds of 39.6%. Among patients with a low pre-test probability, a negative POCUS resulted in post-test odds of 0%, while a positive POCUS led to post-test odds of 2.1%, yielding a number needed to scan (NNS) of ~50 to identify a patient with an SBO on CT. Conclusion This study confirmed POCUS's sensitivity and specificity of ~90-95% and a corresponding LR+ of 9.2 and LR- of 0.9. Pre-test probability substantially affected post-test odds. Patients with a high pre-test probability and a positive POCUS had post-test odds of 39.6 and should have a confirmatory CT, while those with a negative POCUS have very low post-test odds and very likely will not benefit from CT. Patients with low pre-test probability and a positive POCUS have post-test odds of 2.1%, similar to the Wells Score and HEART score; such patients may not benefit from a CT, though clinicians should use their judgment/discretion. Patients with a low pre-test probability and a negative POCUS have post-test odds of 0% and should not have a CT. Among low pre-test probability patients, the NNS was ~50 to identify patients with an SBO on CT.

X-ray imaging of 30 year old wine grape wood reveals cumulative impacts of rootstocks on scion secondary growth and Ravaz index.

Annual rings from 30 year old vines in a California rootstock trial were measured to determine the effects of 15 different rootstocks on Chardonnay and Cabernet Sauvignon scions. Viticultural traits measuring vegetative growth, yield, berry quality, and nutrient uptake were collected at the beginning (1995 to 1999) and end (2017 to 2020) of the lifetime of a vineyard initially planted in 1991 and removed in 2021. X-ray Computed Tomography (CT) was used to measure ring widths in 103 vines. Ring width was modeled as a function of ring number using a negative exponential model. Early and late wood ring widths, cambium width, and scion trunk radius were correlated with 27 traits. Modeling of annual ring width shows that scions alter the width of the first rings but that rootstocks alter the decay of later rings, consistently shortening ring width throughout the lifetime of the vine. Ravaz index, juice pH, photosynthetic assimilation and transpiration rates, and instantaneous water use efficiency are correlated with scion trunk radius. Ultimately, our research indicates that rootstocks modulate secondary growth over years, altering physiology and agronomic traits. Rootstocks act in similar but distinct ways from climate to modulate ring width, which borrowing techniques from dendrochronology, can be used to monitor both genetic and environmental effects in woody perennial crop species.

Grapevine rootstocks affect growth-related scion phenotypes.

Grape growers use rootstocks to provide protection against pests and pathogens and to modulate viticulture performance such as shoot growth. Our study examined two grapevine scion varieties ('Chardonnay' and 'Cabernet Sauvignon') grafted to 15 different rootstocks and determined the effect of rootstocks on eight traits important to viticulture. We assessed the vines across five years and identified both year and variety as contributing strongly to trait variation. The effect of rootstock was relatively consistent across years and varieties, explaining between 8.99% and 9.78% of the variation in growth-related traits including yield, pruning weight, berry weight and Ravaz index (yield to pruning weight ratio). Increases in yield due to rootstock were generally the result of increases in berry weight, likely due to increased water uptake by vines grafted to a particular rootstock. We demonstrated a greater than 50% increase in yield, pruning weight, or Ravaz index by choosing the optimal rootstock, indicating that rootstock choice is crucial for grape growers looking to improve vine performance.

Immune Pharmacodynamic Responses of the Novel Cancer Immunotherapeutic Imprime PGG in Healthy Volunteers.

Imprime PGG (Imprime) is an i.v. administered, yeast ß-1,3/1,6 glucan in clinical development with checkpoint inhibitors. Imprime-mediated innate immune activation requires immune complex formation with naturally occurring IgG anti-ß glucan Abs (ABA). We administered Imprime to healthy human volunteers to assess the necessity of ABA for Imprime-mediated immunopharmacodynamic (IPD) changes. Imprime (4 mg/kg) was administered i.v. in single and multiple infusions. Subsets of subjects were premedicated with antihistamine and corticosteroid. Peripheral blood was measured before, during and after Imprime administration for IPD changes (e.g., ABA, circulating immune complexes, complement activation, complete blood counts, cytokine/chemokine, and gene expression changes). IPD changes were analyzed based on pretreatment serum ABA levels: low-ABA (<20 µg/ml), mid-ABA (≥20-50 µg/ml), and high-ABA (≥50 µg/ml). At the end of infusion, free serum ABA levels decreased, circulating immune complex levels increased, and complement activation was observed. At ∼1-4 h after end of infusion, increased expression of cytokines/chemokines, a 1.5-4-fold increase in neutrophil and monocyte counts and a broad activation of innate immune genes were observed. Low-ABA subjects typically showed minimal IPD changes except when ABA levels rose above 20 µg/ml after repeated Imprime dosing. Mild-to-moderate infusion-related reactions occurred in subjects with ABA ≥20 µg/ml. Premedications alleviated some of the infusion-related reactions, but also inhibited cytokine responses. In conclusion, ABA levels, being critical for Imprime-mediated immune activation may provide a plausible, mechanism-based biomarker to identify patients most likely to respond to Imprime-based anticancer immunotherapy.

Loss of PDCD4 contributes to enhanced chemoresistance in Glioblastoma multiforme through de-repression of Bcl-xL translation.

Glioblastoma multiforme (GBM) is the most common and aggressive form of tumor of the central nervous system. Despite significant efforts to improve treatments, patient survival rarely exceeds 18 months largely due to the highly chemoresistant nature of these tumors. Importantly, misregulation of the apoptotic machinery plays a key role in the development of drug resistance. We previously demonstrated that Bcl-xL, an important anti-apoptotic protein, is regulated at the level of translation by the tumor suppressor programmed cell death 4 (PDCD4). We report here a strong correlation between low expression of PDCD4 and high expression of Bcl-xL in adult de novo GBM, GBM tumor initiating cells, and established GBM cell lines. Importantly, high Bcl-xL expression correlated significantly with poor progression and patient survival. We demonstrate that re-expression of PDCD4 in GBM cells down-regulated Bcl-xL expression and decreased cell viability. Finally, we show that direct inhibition of Bcl-xL by small molecule antagonist ABT-737 sensitizes GBM cells to doxorubicin. Our results identify Bcl-xL as a novel marker of GBM chemoresistance and advocate for the combined use of Bcl-xL antagonists and existing chemotherapeutics as a treatment option for this aggressive tumor.

Tumor suppressor PDCD4 represses internal ribosome entry site-mediated translation of antiapoptotic proteins and is regulated by S6 kinase 2.

Apoptosis can be regulated by extracellular signals that are communicated by peptides such as fibroblast growth factor 2 (FGF-2) that have important roles in tumor cell proliferation. The prosurvival effects of FGF-2 are transduced by the activation of the ribosomal protein S6 kinase 2 (S6K2), which increases the expression of the antiapoptotic proteins X chromosome-linked Inhibitor of Apoptosis (XIAP) and Bcl-x(L). We now show that the FGF-2-S6K2 prosurvival signaling is mediated by the tumor suppressor programmed cell death 4 (PDCD4). We demonstrate that PDCD4 specifically binds to the internal ribosome entry site (IRES) elements of both the XIAP and Bcl-x(L) messenger RNAs and represses their translation by inhibiting the formation of the 48S translation initiation complex. Phosphorylation of PDCD4 by activated S6K2 leads to the degradation of PDCD4 and thus the subsequent derepression of XIAP and Bcl-x(L) translation. Our results identify PDCD4 as a specific repressor of the IRES-dependent translation of cellular mRNAs (such as XIAP and Bcl-x(L)) that mediate FGF-2-S6K2 prosurvival signaling and provide further insight into the role of PDCD4 in tumor suppression.

Distinct 5' UTRs regulate XIAP expression under normal growth conditions and during cellular stress.

X-chromosome linked inhibitor of apoptosis, XIAP, is cellular caspase inhibitor and a key regulator of apoptosis. We and others have previously shown that XIAP expression is regulated primarily at the level of protein synthesis; the 5' untranslated region (UTR) of XIAP mRNA contains an Internal Ribosome Entry Site (IRES) that supports cap-independent expression of XIAP protein during conditions of pathophysiological stress, such as serum deprivation or gamma irradiation. Here, we show that XIAP is encoded by two distinct mRNAs that differ in their 5' UTRs. We further show that the dominant, shorter, 5' UTR promotes a basal level of XIAP expression under normal growth conditions. In contrast, the less abundant longer 5' UTR contains an IRES and supports cap-independent translation during stress. Our data suggest that the combination of alternate regulatory regions and distinct translational initiation modes is critical in maintaining XIAP levels in response to cellular stress and may represent a general mechanism of cellular adaptation.

Infant obesity: are we ready to make this diagnosis?

OBJECTIVES: To assess the prevalence, risk factors, diagnosis and treatment of infant obesity (weight-for-length) in a pediatric practice. STUDY DESIGN: This was a retrospective nested case-control design. The investigators reviewed and abstracted data from the records of the mothers (while pregnant) and their offspring. RESULTS: The prevalence of infant obesity was 16%. Children who were obese at age 24 months were highly likely to have been obese at age 6 months (odds ratio=13.3, 95% CI=4.50-39.53). Mothers of obese infants gained more weight during pregnancy (+6.9 kg, P<.05) than mothers of healthy weight infants. Obese infants were more likely to have been large for gestational age (Odds ratio=2.81, 95% CI=1.27-6.22). However, only 14% and 23% of obese infants aged 6 and 24 months were diagnosed with obesity. CONCLUSION: Infant obesity was common in our practice. Infant obesity strongly predicted obesity at age 24 months. Risk factors included excessive intrapartum weight gain or being born large for gestational age. Clinicians diagnosed obesity in only a minority of children. Primary care providers need to diagnose obesity in infants and work to develop effective interventions.

eIF2alpha phosphorylation tips the balance to apoptosis during osmotic stress.

Regulation of cell volume is of great importance because persistent swelling or shrinkage leads to cell death. Tissues experience hypertonicity in both physiological (kidney medullar cells) and pathological states (hypernatremia). Hypertonicity induces an adaptive gene expression program that leads to cell volume recovery or apoptosis under persistent stress. We show that the commitment to apoptosis is controlled by phosphorylation of the translation initiation factor eIF2alpha, the master regulator of the stress response. Studies with cultured mouse fibroblasts and cortical neurons show that mutants deficient in eIF2alpha phosphorylation are protected from hypertonicity-induced apoptosis. A novel link is revealed between eIF2alpha phosphorylation and the subcellular distribution of the RNA-binding protein heterogeneous nuclear ribonucleoprotein A1 (hnRNP A1). Stress-induced phosphorylation of eIF2alpha promotes apoptosis by inducing the cytoplasmic accumulation of hnRNP A1, which attenuates internal ribosome entry site-mediated translation of anti-apoptotic mRNAs, including Bcl-xL that was studied here. Hypertonic stress induced the eIF2alpha phosphorylation-independent formation of cytoplasmic stress granules (SGs, structures that harbor translationally arrested mRNAs) and the eIF2alpha phosphorylation-dependent accumulation of hnRNP A1 in SGs. The importance of hnRNP A1 was demonstrated by induction of apoptosis in eIF2alpha phosphorylation-deficient cells that express exogenous cytoplasmic hnRNP A1. We propose that eIF2alpha phosphorylation during hypertonic stress promotes apoptosis by sequestration of specific mRNAs in SGs in a process mediated by the cytoplasmic accumulation of hnRNP A1.

Choroid plexus dysfunction: the initial event in the pathogenesis of Wernicke's encephalopathy and ethanol intoxication.

BACKGROUND: In both acute ethanol intoxication and in thiamin deficient glucose metabolism, previous studies have detected blood-brain barrier (BBB) and/or blood-CSF-barrier (BCSFB) impairment but were unable to assess their significance in relation to other changes in the brain. METHODS: Contrast-enhanced, magnetic resonance imaging (MRI) was used to detect and time any impairment of the BBB or BCSFB in rats given an acute ethanol load or in rats made thiamin deficient to the point of mild ataxia and then given an acute glucose load. RESULTS: The BCSFB at the choroid plexus (CP) was impaired within 10 minutes by either (i) a single i.p. dose of glucose in thiamin-deficiency, an effect that was attenuated by prior MK801 and preceded the published onset of exacerbation of motor incoordination and elevation of brain glutamate derivatives; or (ii) a single i.p. dose of ethanol in thiamin-sufficiency, an effect that was proportional to the blood alcohol concentration and preceded the published onset of signs of intoxication. In contrast to the BCSFB, the BBB remained intact throughout the 90 minutes period of these experiments. CONCLUSIONS: In both ethanol intoxication and thiamin-deficient glucose metabolism, BCSFB impairment exposes the CSF and hence the brain extracellular fluid to neuroactive substances from the blood. CP impairment is the earliest detected event in both these animal models; and explains the paraventricular location of WE neuropathology and why WE is associated with, but not dependent on, alcoholism.

Quality of life and diet intervention in individuals at risk for recurrence of colorectal adenomas.

The effect of participation in a diet intervention study on self-reported quality of life (QOL) with subjects at risk of recurrence of colorectal adenomas was explored in 77 men and women, aged 18-80 years, with a history of adenomatous polyps. Participants were randomly assigned to intervention and control groups and followed for 1 year. Dietary goals for the intervention group included reduced intake of fat and increased intakes of fiber, calcium, and vegetables and fruit. Diet counseling was provided by telephone. Anthropometric measurements were obtained and dietary intakes were assessed at baseline and 6 and 12 months. The quality of life factors questionnaire (QF), designed to explore the absolute effects of the diet intervention on participants' perceived QOL, was administered at baseline and study end. Based on repeated 24-h dietary recalls, the intervention group reported significantly higher consumption of vegetables, fruit, low-fat dairy products, fiber, and calcium at 12 months. There were no significant differences in total QF scores for the two groups at study end, and no significant changes within groups between baseline and study end. Findings suggest that even though the intervention participants made significant modifications in their eating behavior, these changes did not impact their perceived QOL negatively.