Pharmacist optimization of lipid therapy in patients with peripheral vascular disease.

DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: American College of Cardiology/American Heart Association guidelines recommend high-intensity statin therapy and consideration for nonstatin therapy for patients with peripheral vascular disease (PVD); however, utilization rates remain suboptimal. The primary objective of this study was to determine whether pharmacist intervention for patients with PVD could improve the percentage of patients discharged on a high-intensity statin. METHODS: The study used a single-center pre/post design and included patients with PVD who underwent peripheral bypass during their admission. Postintervention patients managed with an order set including a preselected consult for a pharmacy lipid protocol were compared to preintervention patients managed using the order set without the consult. The primary outcome was the percentage of patients discharged on a high-intensity statin. Secondary outcomes included intensification of statin therapy, the addition of ezetimibe, and referral to an outpatient lipid clinic. RESULTS: A total of 175 patients were included in the analysis, with 94 patients in the preintervention group and 81 patients in the postintervention group. The primary outcome met statistical significance, with an increase in the percentage of patients discharged on a high-intensity statin in the postintervention group (70.4%) compared to the preintervention group (38.3%) (P < 0.001; 95% confidence interval, 1.37-2.46). Secondary outcomes that met statistical significance included an increase in the percentage of patients with any increase in statin intensity (35.8% vs 20.2%; P = 0.02). CONCLUSION: The addition of a pharmacist consult led to an increase in the percentage of patients discharged on a high-intensity statin and an increase in overall statin intensification.

Pediatric influenza vaccination in the perioperative setting: A quality improvement project.

INTRODUCTION/BACKGROUND: Unmet need for seasonal influenza vaccination administration to pediatric patients exists at national and local levels. Vaccination during the perioperative period remains controversial, though opportunity exists to meet vaccination need through perioperative programs. The initial SMART Aim of this quality improvement initiative was to establish and increase seasonal influenza vaccination rate in eligible patients during in person preoperative clinic visits in a pediatric perioperative surgical home (PSH) to 10%. Informed by each prior season's experience, we increased our SMART Aim target for vaccinations in seasons two and three to 15 and 18%, respectively. METHODS: Following the Model for Improvement methodology, the PSH team developed and implemented a perioperative pediatric influenza vaccination program. Across three influenza seasons, key interventions included updates to organizational perioperative vaccination policy, obtaining material influenza vaccination supplies, development of EHR tools, PSH staff education, and communication with patient-families. Rate of eligible patients receiving influenza vaccination at their PSH clinic appointment was tracked over time. Influenza vaccination rates were reported monthly during Season 1, then weekly during seasons two and three. The balancing measure was same day surgery case cancellations related to influenza vaccination given at PSH clinic appointment. Statistical analysis methods utilized include Shewart's control chart and statistical process control (SPC) standards. Special cause variation was determined by eight or more consecutive data points above or below the centerline. RESULTS: The influenza vaccination rates in each of the three influenza seasons exceeded vaccination rate goals of 10, 15, and 18%, respectively. A total of 695 vaccines have been administered since program inception. No same day surgical case cancellations were observed as balancing measure. CONCLUSIONS: Over three consecutive influenza vaccination seasons, we safely established and met vaccination rate goals of 10, 15, and 18% to eligible patients during preoperative clinic visits within a pediatric PSH system. Through iterative PDSA cycles, we continue to identify opportunities for future improvement. This suggests that the perioperative period presents opportunity for seasonal influenza vaccination with potential program expansion to include routine vaccines of childhood.

Bivalirudin anticoagulation for cardiopulmonary bypass during cardiac surgery.

INTRODUCTION: Heparin is the primary anticoagulant for cardiopulmonary bypass (CPB) support during cardiac surgery. While widely used, ∼2% of cardiac surgery patients develop heparin-induced thrombocytopenia (HIT) and 4-26% develop heparin resistance. Bivalirudin is an alternative anticoagulant mainly used for percutaneous coronary interventions. Given the challenges associated with heparin anticoagulation, we conducted a review to explore the use of bivalirudin for CPB surgery. METHODS: PubMed and Embase scoping review included 2 randomized controlled trials, a retrospective comparison study, 3 pilot studies, and 30 case reports. To provide a contemporary series, we searched for articles published from 2010 to 2023. Our review included studies from both adult and pediatric populations. RESULTS: While data is limited, bivalirudin seems to supply similar effectiveness and safety as heparin for CPB anticoagulation. Across the three comparative studies, the heparin cohorts had a 0-9% mortality rate and 0-27% rate of major bleeding/reoperation compared to a 0-3% mortality and 0-6% major bleeding/reoperation rate for the bivalirudin cohorts. Bivalirudin was successfully used as an anticoagulant in a wide range of CPB surgeries (e.g., heart transplants, ventricular assisted device placements, and valve repairs). Successful patient outcomes were reported with bivalirudin infusion of ∼2 mg/kg/hour, activated clotting time monitoring (target >400 s or 2.5× baseline), use of cardiotomy suctions, minimization of stagnant blood, and post-bypass modified ultrafiltration. CONCLUSION: Bivalirudin is a safe and effective anticoagulant for CPB, especially for patients with HIT or heparin resistance. Further comparative research is called for to optimize bivalirudin utilization for CPB during cardiac surgery.

Characterization of patients receiving surgical versus non-surgical treatment for infective endocarditis in West Virginia.

BACKGROUND: Infective endocarditis (IE) has increased in rural states such as West Virginia (WV) with high injection drug use. IE is medically managed with antimicrobial treatment alone or combined with surgical treatment. This study aimed to characterize the predictors associated with surgical treatment and rates of inpatient mortality and readmission among IE patients in WV's rural centers. METHODS: This retrospective review of electronic health records includes all adults hospitalized for IE at major rural tertiary cardiovascular centers in WV during 2014-2018. Descriptive statistics were presented on demographics, history of injection drug use, clinical characteristics, and hospital utilization by surgery status, and multivariable logistic regression examined the association of surgery with key predictor variables, generating odds ratios (OR). RESULTS: Of the 780 patients with IE, 38% had surgery, with a 26-fold increase in patients undergoing surgery between 2014-2018. Comparing surgery and non-surgery patients revealed significant differences. Surgery patients were significantly younger (median age 35.6 vs. 40.5 years; p<0.001); had higher rates of drug use history (80% vs. 65%; p<0.001), psychiatric disorders (57% vs. 31%; p<0.001), and readmissions (18% vs.12%; p = 0.015). Surgery patients had lower rates of discharge against medical advice (11% vs.17%; p = 0.028) and in-hospital mortality (5% vs.12%; p<0.001). In the multivariable logistic regression, surgery was associated with injection drug use (OR: 1.9; 95% CI:1.09-3. 3), indications for surgery (OR: 1.68; 95% CI:1.48-1.91), left-sided IE (OR: 2.14; 95%CI:1.43-3.19) and later years (OR:3.75; 95%CI:2.5-5.72). CONCLUSION: This study characterizes the predictors associated with surgical treatment and rates of inpatient mortality and readmission among IE patients across rural WV. The decision to perform cardiac surgery on IE patients is complex. Results with increased injection drug use-associated IE emphasize the importance of comprehensive care by a multidisciplinary team for optimal management of patients with IE.

Factor XI Inhibition With Heparin Reduces Clot Formation in Simulated Pediatric Extracorporeal Membrane Oxygenation.

Extracorporeal membrane oxygenation (ECMO) supplies circulatory support and gas exchange to critically ill patients. Despite the use of systemic anticoagulation, blood exposure to ECMO surfaces causes thromboembolism complications. Inhibition of biomaterial surface-mediated activation of coagulation factor XI (FXI) may prevent device-associated thrombosis. Blood was collected from healthy volunteers (n = 13) following the U.S. Army Institute of Surgical Research standard operating procedure for testing in an ex vivo ECMO circuit. A roller-pump circuit circulated either 0.5 U/ml of unfractionated heparin alone or in combination with the anti-FXI immunoglobulin G (IgG) (AB023) for 6 hours or until clot formation caused device failure. Coagulation factor activity, platelet counts, time to thrombin generation, peak thrombin, and endogenous thrombin potential were quantified. AB023 in addition to heparin sustained circuit patency in all tested circuits (5/5) after 6 hours, while 60% of circuits treated with heparin alone occluded (3/8), log-rank p < 0.03. AB023 significantly prolonged the time to clot formation as compared to heparin alone (15.5 vs . 3.3 minutes; p < 0.01) at the 3-hour time point. AB023 plus heparin significantly reduced peak thrombin compared to heparin alone (123 vs . 217 nM; p < 0.01). Inhibition of contact pathway activation of FXI may be an effective adjunct to anticoagulation in extracorporeal life support.

The formation and revision of intuitions.

This paper presents 59 new studies (N = 72,310) which focus primarily on the "bat and ball problem." It documents our attempts to understand the determinants of the erroneous intuition, our exploration of ways to stimulate reflection, and our discovery that the erroneous intuition often survives whatever further reflection can be induced. Our investigation helps inform conceptions of dual process models, as "system 1" processes often appear to override or corrupt "system 2" processes. Many choose to uphold their intuition, even when directly confronted with simple arithmetic that contradicts it - especially if the intuition is approximately correct.

Beyond yellow flags: The Big-Five personality traits and psychologically informed musculoskeletal rehabilitation.

BACKGROUND: Psychosocial variables are known to play an important role in musculoskeletal pain. Recent efforts incorporating psychological theory into rehabilitative medicine, as part of patient-centred care or psychologically informed physical therapy, have gained broader acceptance. The fear-avoidance model is the dominant psychosocial model and has introduced a variety of phenomena which assess psychological distress (i.e., yellow flags). Yellow flags, such as fear, anxiety and catastrophizing, are useful concepts for musculoskeletal providers but reflect a narrow range of psychological responses to pain. OBJECTIVE: Clinicians lack a more comprehensive framework to understand psychological profiles of each patient and provide individualised care. This narrative review presents the case for applying personality psychology and the Big-Five trait model (extraversion, agreeableness, conscientiousness, neuroticism and openness to experience) to musculoskeletal medicine. These traits have strong associations with various health outcomes and provide a robust framework to understand patient emotion, motivation, cognition and behaviour. KEY RESULTS: High conscientiousness is associated with positive health outcomes and health promoting behaviours. High neuroticism with low conscientiousness increases the odds of negative health outcomes. Extraversion, agreeableness and openness have less direct effects but have positive correlations with important health behaviours, including active coping, positive affect, rehabilitation compliance, social connection and education level. CLINICAL APPLICATION: The Big-Five model offers an evidence-based way for MSK providers to better understand the personality of their patients and how it relates to health. These traits offer the potential for additional prognostic factors, tailored treatments and psychological intervention.

A cohort study on blood coagulation in childhood cancer survivors.

Cancer survivors are at an increased risk of thromboembolism compared to the general pediatric population. Anticoagulant therapy decreases the risk of thromboembolism in cancer patients. We hypothesized that pediatric cancer survivors are in a chronically hypercoagulable state compared to healthy controls. Children who survived for more than five years from cancer diagnosis at the UT Health Science Center at San Antonio Cancer Survivorship Clinic were compared to healthy controls. The exclusion criteria were recent NSAID use or a history of coagulopathy. Coagulation analysis included platelet count, thrombin-antithrombin complexes (TAT), plasminogen activator inhibitor (PAI), routine coagulation assays, and thrombin generation with and without thrombomodulin. We enrolled 47 pediatric cancer survivors and 37 healthy controls. Platelet count was significantly lower in cancer survivors at a mean of 254 × 109/L (95%CI: 234-273 × 109/L) compared at 307 × 109/L (283-331 × 109/L) in healthy controls (p < 0.001), although not outside the normal range. Routine coagulation assays showed no differences, except for a significantly lower prothrombin time (PT) in cancer survivors (p < 0.004). Cancer survivors has significantly elevated biomarkers of the procoagulant state, such as TAT and PAI, compared to healthy controls (p < 0.001). A multiple logistic regression model controlling for age, BMI, gender, and race/ethnicity documented that a low platelet count, short prothrombin clot time, and higher procoagulant biomarkers (TAT and PAI) were significantly associated with past cancer therapy. Survivors of childhood cancer have a persistent procoagulant imbalance for more than five years after diagnosis. Further studies are needed to establish whether procoagulant imbalance increases the risk of thromboembolism in childhood cancer survivors.

A Narrative Review of Postoperative Anticoagulation Therapy for Congenital Cardiac Disease.

Congenital heart disease encompasses a range of cardiac birth defects. Some defects require early and complex surgical intervention and post-operative thromboprophylaxis primarily for valve, conduit, and shunt patency. Antiplatelet and anticoagulant management strategies vary considerably and may or may not align with recognized consensus practice guidelines. In addition, newer anticoagulant agents are being increasingly used in children, but these medications are not addressed in most consensus statements. This narrative review evaluated the literature from 2011 through 2021 on the topic of postoperative thromboprophylaxis after congenital heart disease operations. The search was focused on the descriptions and results of pediatric studies for replacement and/or repair of heart valves, shunts, conduits, and other congenital heart disease operations. Wide variability in practice exists and, as was true a decade ago, few randomized controlled trials have been conducted. Aspirin, warfarin, and perioperative heparin remain the most commonly used agents with varying dosing, duration, and monitoring strategies, making comparisons difficult. Only recently have data on direct oral anticoagulants been published in children, suggesting evolving paradigms of care. Our findings highlight the need for more research to strengthen the evidence for standardized thromboprophylaxis strategies.

Regional blood acidification inhibits coagulation during extracorporeal carbon dioxide removal (ECCO2 R).

BACKGROUND: Consumption of platelets and coagulation factors during extracorporeal carbon dioxide removal (ECCO2 R) increases bleeding complications and associated mortality. Regional infusion of lactic acid enhances ECCO2 R by shifting the chemical equilibrium from bicarbonate to carbon dioxide. Our goal was to test if regional blood acidification during ECCO2 R inhibits platelet function and coagulation. METHODS: An ECCO2 R system containing a hemofilter circulated blood at 0.25 L/min in eight healthy ewes (Ovis aries) for 36 h. Three of the sheep received ECCO2 R with no recirculation compared to five sheep that received ECCO2 R plus 12 h of regional blood acidification via the hemofilter, placed upstream from the oxygenator, into which 4.4 M lactic acid was infused. Blood gases, platelet count and function, thromboelastography, coagulation-factor activity, and von Willebrand factor activity (vWF:Ag) were measured at baseline, at start of lactic acid infusion, and after 36 h of extracorporeal circulation. RESULTS: Twelve hours of regional acid infusion significantly inhibited platelet aggregation response to adenosine diphosphate; vWF; and platelet expression of P-selectin compared to control. It also significantly reduced consumption of fibrinogen and of coagulation factors V, VII, IX, compared to control. CONCLUSIONS: Regional acidification reduces platelet activation and vitamin-K-dependent coagulation-factor consumption during ECCO2 R. This is the first report of a simple method that may enhance effective anticoagulation for ECCO2 R.

¿Qué Está Haciendo Papá? Mexican-Heritage Fathers' Physical Activity Networks After a Father-Focused Health Program.

Physical activity (PA) is a public health priority due to holistic health benefits; however, many adults do not meet PA guidelines. Few studies have examined Mexican-heritage fathers' social networks, specifically with whom they are physically active. This study examines changes in Mexican-heritage fathers' PA networks after participation in a father-focused, family-centered health program. Families consisting of child (aged 9-11 years), mother, and father were recruited from colonias on the Texas-Mexico border for participation in a 6-week father-focused, family-centered program concentrated on healthy eating and active living. Fathers reported up to 5 people with whom they were active most in the previous month before and after the program as well as how often they were active with the person and what activities they did most often. Multilevel regression models examined changes in networks. Fathers (n = 42; mean age = 39.07 years, SD = 7.45) were significantly more likely to report more frequent PA with others after the program as compared with before. General active play and conditional support were mentioned most frequently. This study provides context to the social networks and PA behaviors of Mexican-heritage fathers and suggests that a father-focused, family-centered health program can increase the PA frequency with social network connections.

Sport Participation Associations With Child Friend Selection and Physical Activity While at Summer Care Programs.

Child physical activity (PA) declines during summer reducing PA-related health benefits. Summer care programs (e.g., Boys & Girls Clubs) can promote active play while providing opportunities for friendships. Sport participation is a positive influence on PA and social development. Purpose: This article investigates the role of sport participation in PA attainment, perceived skill competency, and social connection at a summer care program. Methods: Children self-reported PA, sport participation, and the names of up to five peers whom they played with most at the program at the start (T1; n = 100; M age = 9.94 years; SD = 1.34; 47% male) and end (T2; n = 77; M age = 9.83 years; SD = 1.46; 51% male) of summer. Network autocorrelation models were used to determine if child sport participation was significantly associated with those they played with at the program. Results:Children who reported sport participation reported significantly more PA than those who did not at T1, but not T2. Child sport participation was significantly related to that of the peers they said they spent time with while at the program for T1 (ß = 0.07, p < .01), but not T2 (ß = 0.06, p = .10). Additionally, PA (ß = 0.08, p < .01; ß = 0.07, p = .01) and skill competency (ß = 0.11, p = .02; ß = 0.15, p < .01) were significantly associated with sport participation at both time points. While sports participation was a key factor in child friendships at the start of summer, the program allowed children, regardless of sport participation, to become friends outside of sports. Conclusions: These results suggest summer care programs promote PA through play and provide opportunities for children to facilitate friendships regardless of sport participation.

¿Qué Pasa Con Papá? Exploring Paternal Responsibilities and Physical Activity in Mexican-Heritage Families.

Mexican-heritage children often achieve less physical activity (PA) than their counterparts and are at greater risk for associated comorbidities. Child PA is greatly influenced by their parents, yet researchers have rarely involved fathers in community health promotion. The purpose of this study is to examine Mexican-heritage fathers' perceptions of responsibilities and self-reported activities. Promotoras recruited fathers (n = 300) from colonies on the Texas-Mexico border and administered Spanish-language surveys including paternal responsibilities, father PA, and PA co-participation. Two researchers coded responses. Open-ended items were coded and cross-tabulations between responsibilities and activities with children were examined. Fathers reported feeling monetary responsibilities most often. Fathers reported engaging in more activities with their sons than daughters; however, fathers engaged in very few activities specifically with their children. Feeling responsible for family expenses was associated with paternal PA co-participation with family and children. This study adds clarity to the role of Mexican-heritage fathers in child PA. Findings highlight potential areas for intervention including supporting fathers to take an active role in their children's PA.

Accuracy of Measuring Knee Flexion after TKA through Wearable IMU Sensors.

Wearable sensors have the potential to facilitate remote monitoring for patients recovering from knee replacement surgery. Using IMU sensors attached to the patients' leg, knee flexion can be monitored while the patients are recovering in their home environment. Ideally, these flexion angle measurements will have an accuracy and repeatability at least on par with current clinical standards. To validate the clinical accuracy of a two-sensor IMU system, knee flexion angles were measured in eight subjects post-TKA and compared with other in-clinic angle measurement techniques. These sensors are aligned to the patients' anatomy by taking a pose resting their operated leg on a box; an initial goniometer measurement defines the patients' knee flexion while taking that pose. The repeatability and accuracy of the system was subsequently evaluated by comparing knee flexion angles against goniometer readings and markerless optical motion capture data. The alignment pose was repeatable with a mean absolute error of 1.6 degrees. The sensor accuracy through the range of motion had a mean absolute error of 2.6 degrees. In conclusion, the presented sensor system facilitates a repeatable and accurate measurement of the knee flexion, holding the potential for effective remote monitoring of patients recovering from knee replacement surgery.

Post-tonsillectomy hemorrhage control with nebulized tranexamic acid: A retrospective cohort study.

OBJECTIVE: Evaluate nebulized tranexamic acid (TXA) as a treatment to reduce the need for an operation to control a post-tonsillectomy hemorrhage (PTH). METHODS: Based on a successful case report of a child treated with nebulized TXA for PTH in 2018, our institution began to treat PTH patients with three doses of nebulized TXA. To evaluate the outcomes of this non-invasive management, we conducted a three-year retrospective cohort study of children presenting with PTH from 2016 to 2019. Demographics, insurance, and laboratory information were collected from all pediatric tonsillectomies with and without adenoidectomy performed during the study period. Tonsillar fossae observations of bleeding and clot were documented before and after receiving TXA. RESULTS: The incidence of pediatric PTH at our institution during the study period was 5.4%. Fourteen out of 58 PTH patients received nebulized TXA. Receiving nebulized TXA had no adverse events and over 60% showed resolution of bleeding on exam. Receiving nebulized TXA compared to routine care decreased the need for an operation to restore hemostasis by 44%, p < 0.005. There was no significant difference in age, gender, body mass index, hemoglobin, platelet count, trainee presence, or Medicaid status between the children that received TXA and those that did not. CONCLUSION: Treatment of PTH with nebulized TXA may be a safe first-line therapy to decrease the need for operative control of bleeding. This data suggests that a large clinical trial is needed to determine the efficacy of nebulized TXA to mitigate this common and potentially fatal post-operative complication. LEVEL OF EVIDENCE: 4.

Shifts in precipitation and agricultural intensity increase phosphorus concentrations and loads in an agricultural watershed.

Fertilizers and manure applied to cropland to increase yields are often lost via surface erosion, soil leaching, and runoff, increasing nutrient loads in surface and sub-surface waters, degrading water quality, and worsening the 'dead zone' in the Gulf of Mexico. We leverage spatial and temporal variation in agricultural practices and precipitation events to examine how these factors affect stream total phosphorus (TP) concentrations and loads in the Sugar River (Wisconsin), recently listed as impaired. To perform our analysis, we first collected water quality data from 1995 to 2017 from 40 sites along the Sugar River and its tributaries. Starting in 2004, three dairy farms expanded to become concentrated animal feeding operations (CAFOs) in this watershed. We then estimated how time of year, stream position, discharge volume, and proximity to the newly expanded CAFOs affected TP concentrations and loads. Total P concentrations, which ranged from 0.02 to 1.4 mg/L and often exceeded the EPA surface water standard of 0.1 mg/L, increased with increases in stream discharge and proximity to dairy operations, peaking in early spring to mid-summer coincident with extreme precipitation events. Our empirical analysis also shows that TP concentrations downstream from the newly permitted CAFOs increased by 19% relative to upstream concentrations. When examining total daily phosphorus loads (concentration × discharge) from this 780 km2 watershed, we found that loads ranged from 5.88 to 4801 kg. Compared to upstream TP loads, those downstream from the CAFOs increased by 91% after the expansions - over four times that of concentration increases - implying that the rate of downstream phosphorus transfer has increased due to CAFO expansion. Our results argue for standards that focus on loads rather than concentrations and monitoring that includes peak events. As agriculture intensifies and extreme rainfall events become more frequent, it becomes increasingly important to limit soil and TP runoff from manure and fertilizer. Siting CAFOs carefully, limiting their size, and improving farming practices in proximity to CAFOs in spring and early summer could considerably reduce nutrient loads.

Thrombosis and Bleeding in Extracorporeal Membrane Oxygenation (ECMO) Without Anticoagulation: A Systematic Review.

Extracorporeal membrane oxygenation (ECMO) causes both thrombosis and bleeding. Major society guidelines recommend continuous, systemic anticoagulation to prevent thrombosis of the ECMO circuit, though this may be undesirable in those with active, or high risk of, bleeding. We aimed to systematically review thrombosis and bleeding outcomes in published cases of adults treated with ECMO without continuous systemic anticoagulation. Ovid MEDLINE, Cochrane CENTRAL and CDSR, and hand search via SCOPUS were queried. Eligible studies were independently reviewed by two blinded authors if they reported adults (≥18 years) treated with either VV- or VA-ECMO without continuous systemic anticoagulation for ≥24 hours. Patient demographics, clinical data, and specifics of ECMO technology and treatment parameters were collected. Primary outcomes of interest included incidence of bleeding, thrombosis of the ECMO circuit requiring equipment exchange, patient venous or arterial thrombosis, ability to wean off of ECMO, and mortality. Of the 443 total publications identified, 34 describing 201 patients met our inclusion criteria. Most patients were treated for either acute respiratory distress syndrome or cardiogenic shock. The median duration of anticoagulant-free ECMO was 4.75 days. ECMO circuity thrombosis and patient thrombosis occurred in 27 (13.4%) and 19 (9.5%) patients, respectively. Any bleeding and major or "severe" bleeding was reported in 66 (32.8%) and 56 (27.9%) patients, respectively. Forty patients (19%) died. While limited by primarily retrospective data and inconsistent reporting of outcomes, our systematic review of anticoagulant-free ECMO reveals an incidence of circuity and patient thrombosis comparable to patients receiving continuous systemic anticoagulation while on ECMO.

Electromagnetic Versus Blind Guidance of a Postpyloric Feeding Tube in Critically Ill Children.

BACKGROUND AND OBJECTIVES: Postpyloric feeding tube placement is a time-consuming procedure associated with multiple attempts and radiation exposure. Our objective with this study is to compare the time, attempts, and radiation exposure using the electromagnetic versus blind method to place a postpyloric feeding tube in critically ill children. Our hypothesis is that using electromagnetic guidance decreases the procedure time, number of x-rays, and number of attempts, compared to the blind method. METHODS: Eleven pediatric nurses participated in a randomized controlled intention-to-treat study at an academic pediatric medical, surgical, and congenital cardiac ICU. University of Texas Health Epidemiology and Biostatistics generated a randomization sequence with sealed envelopes. A standard (2-sided) F-test of association between the electromagnetic and blind method yielded 40 subjects with 86% power. Data were analyzed with Fisher's exact test for categorical variables and the Wilcoxon rank test for continuous variables, with data documented as median (interquartile range [IQR]). RESULTS: We randomly assigned 52 patients to either the electromagnetic (n = 28) or blind method (n = 24). The number of attempts and radiographs was at a median of 2 (IQR: 1-2.25) using the blind method, compared to the electromagnetic method at a median of 1 (IQR: 1.0-1.0; P = .001). Successful guidance was 96.4% with the electromagnetic method, compared to only 66.7% with the blind technique (P = .008). The total time required was 2.5 minutes (IQR: 2.0-7.25) with the electromagnetic method, compared to 19 minutes (IQR: 9.25-27.0) for the blind method (P = .001). CONCLUSIONS: Electromagnetic guidance is a superior, faster, and overall safer method to place a postpyloric feeding tube in critically ill children.

Peripheral neuropathy and depressive symptoms: examining the association in a primary health care setting among persons with and without diabetes mellitus.

PURPOSE: The purpose of this study was to measure the association between peripheral neuropathy symptoms and depressive symptoms among a sample of patients with and without diabetes mellitus (DM). METHODS: Patients were administered the 15-item Michigan Neuropathy Screening Instrument (MNSI) and the patient health questionnaire depression scale (PHQ-8). Patients with an MNSI score ≥ 4 were categorized as having PN and patients with a PHQ-8 score ≥ 10 were considered to have current depression. Log-binomial regression was used to analyze the relationship between PN and depressive symptoms. RESULTS: 406 patients were included in the final analysis. There were no statistically significant differences by diabetes status in PN symptoms (Diabetes = 61.8%; No diabetes = 55.4%; p = .20) or in depression status (Diabetes = 37.6%; No diabetes = 36.6%; p = .83). After adjustment for covariates, PN was associated with depression (aRR = 4.46; 95% CI 2.91,6.85) independent of diabetes status. CONCLUSIONS: PN symptoms may be common among aging persons even in the absence of DM. Past literature and our study demonstrate that PN and depression are closely associated. More work is needed to understand the etiology and potential utility of intervention for depression symptoms among patients with neuropathy.

TEG PlateletMapping assay results may be misleading in the presence of cold stored platelets.

BACKGROUND: Viscoelastic tests (VETs) are used widely to monitor hemostasis in settings such as cardiac surgery. There has also been renewed interest in cold stored platelets (CSPs) to manage bleeding in this setting. CSPs are reported to have altered hemostatic properties compared to room temperature platelets (RTPs), including activation of GPIIb/IIIa. We investigated whether the functional differences between CSP and RTP affected the performance of the PlateletMapping VET on the TEG 5000 and 6s analyzer. METHOD: Platelet concentrates were divided equally into CSP (stored at 4°C ± 2°C) and RTP (stored at 22°C ± 2°C) fractions. Whole blood was treated to induce platelet dysfunction (WBIPD) by incubating with anti-platelet drugs (1.0 µM ticagrelor and 10 µM aspirin) or by simulating cardiopulmonary bypass. WBIPD samples were then mixed with 20% by volume of CSPs or RTPs to model platelet transfusion before analysis using the PlateletMapping VET. RESULTS: Addition of CSPs to WBIPD increased the PlateletMapping MAFIBRIN and MAADP parameters with the TEG 5000 analyzer (both p < 0.0001 compared to addition of buffer alone). This effect was not observed with RTPs. The differential effect of CSPs on the MAFIBRIN corrected after pre-incubation with the GPIIb/IIIa antagonist tirofiban and was quantitatively less with the PlateletMapping test for the TEG 6s analyzer which contains the GPIIb/IIa antagonist abciximab. DISCUSSION: The PlateletMapping MAFIBRIN and MAADP test results may be misleadingly high with CSPs, particularly with the TEG 5000 analyzer, most likely due to constitutive activation of GPIIb/IIIa on CSPs during storage. TEG PlateletMapping results should be interpreted with caution following CSP transfusion.