Late Follow-up for a Randomized Trial of Surgical Treatment of Tricuspid Valve Regurgitation in Patients Undergoing Left Ventricular Assist Device Implantation.

OBJECTIVES: We previously reported that concurrent tricuspid valve surgery (TVS) was not associated with a lower incidence of early RHF among patients undergoing durable LVAD implantation. This is a follow-up analysis to further define the clinical impact of concurrent TVS within 12-months of follow-up. METHODS: Patients with moderate or severe TR on pre-operative echocardiography (n=71) were randomized to either LVAD implantation alone (No TVS, n=34) or with concurrent TVS (TVS, n=37). Randomization was stratified by pre-operative right ventricular dysfunction. Patients were followed for at least 12-months after surgery. The incidence of RHF was determined using INTERMACS criteria by an adjudication committee. Functional studies and repeat echocardiography were performed at 12-months. RESULTS: Demographics were similar between the two arms. At 12-months, the rate of moderate or severe RHF was 50.0% (No TVS) versus 51.4% (TVS). No patients developed RHF between 6- and 12-months following the procedure. Death from RHF was 5.4% (TVS) versus 8.8% (No TVS). At 12-months, there was no significant difference in TR severity between the two arms due to improvement in TR severity in the No TVS arm. On cardiopulmonary exercise testing at 12+ months, there was no significant difference in peak oxygen consumption. CONCLUSIONS: In patients with significant pre-implant TR, the severity of TR improved over time in the LVAD implantation alone arm. By 12-months, there is no significant difference in TR severity between the two arms. This may account for the lack of difference in late clinical or functional parameters.

Feasibility of a Novel Augmented 6-Minute Incremental Step Test: A Simplified Cardiorespiratory Fitness Assessment Tool.

Background: The cardiopulmonary exercise test (CPET) is considered a gold standard in assessing cardiorespiratory fitness (CRF) but has limited accessibility due to competency requirements and cost. Incorporating portable sensor devices into a simple bedside test of CRF could improve diagnostic and prognostic value. Objectives: The authors sought to evaluate the association of an augmented 6-minute incremental step test (6MIST) with standard CPET. Methods: We enrolled patients undergoing clinically indicated supine cycle ergometry CPET with invasive hemodynamics (iCPET) for the same-day 6MIST. CRF-related variables were simultaneously recorded using a signal morphology-based impedance cardiograph (PhysioFlow Enduro) and a portable metabolic analyzer (VO2 Master Pro) during incremental pace stationary stepping. The correlation between CPET and hemodynamic parameters from both tests was assessed using the intraclass correlation coefficient (ICC). Results: Fifteen patients (mean age 60 ± 14 years, 40% female, 27% Black) were included. All patients who agreed to undergo 6MIST completed the study without any test-related adverse events. We observed good to excellent correlation between iCPET- and 6MIST-measured CPET parameters: peak heart rate (ICC = 0.60; 95% CI: 0.15-0.85), absolute peak O2 consumption (VO2) (ICC = 0.77; 95% CI: 0.44-0.92), relative peak VO2 (ICC = 0.64; 95% CI: 0.20-0.86), maximum ventilation (ICC = 0.59; 95% CI: 0.13-0.84), O2 pulse (ICC = 0.71; 95% CI: 0.33-0.89), and cardiorespiratory optimal point (ICC = 0.82; 95% CI: 0.52-0.94). No significant correlation was determined between iCPET and 6MIST in measuring cardiac index at rest (ICC = 0.19; 95% CI: -0.34 to 0.63) or at peak exercise (ICC = 0.36; 95% CI: -0.17 to 0.73). Conclusions: We demonstrate the feasibility of a novel augmented 6MIST with wearable devices for simultaneous CPET and hemodynamic assessment. 6MIST-measured CPET parameters were strongly correlated with the iCPET-derived measurements. Additional studies are needed to confirm the validity of the 6MIST compared to standard upright CPET.

Association of RBC Transfusion Thresholds and Outcomes in Medical Patients With Acute Respiratory Failure Supported With Extracorporeal Membrane Oxygenation: A Single-Center Retrospective Cohort Study.

BACKGROUND: The hemoglobin value to trigger RBC transfusion for patients receiving venovenous extracorporeal membrane oxygenation (ECMO) is controversial. Previous guidelines recommended transfusing to a normal hemoglobin level, but recent studies suggest that more RBC transfusions are associated with increased adverse outcomes. RESEARCH QUESTION: Is implementation of different institutional RBC transfusion thresholds for patients receiving venovenous ECMO associated with changes in RBC use and patient outcomes? STUDY DESIGN AND METHODS: This single-center retrospective study of patients receiving venovenous ECMO used segmented regression to test associations between implementation of institutional transfusion thresholds and trends in RBC use. Associations with secondary outcomes, including in-hospital survival, also were assessed. RESULTS: The study included 229 patients: 91 in the no threshold cohort, 48 in the hemoglobin < 8 g/dL cohort, and 90 in the hemoglobin < 7 g/dL cohort. Despite a decrease in number of RBC units transfused per day of ECMO support after implementation of different thresholds (mean ± SD: 0.6 ± 1.0 in the no threshold cohort, 0.3 ± 0.8 in the hemoglobin < 8 g/dL cohort, and 0.3 ± 1.1 in the hemoglobin < 7 g/dL cohort; P < .001), segmented regression showed no association between implementation of transfusion thresholds and changes in trends in number of RBC units per day of ECMO. We observed an increased hazard of death in the no threshold cohort compared with the hemoglobin < 8 g/dL cohort (adjusted hazard ratio [aHR], 2.08; 95% CI, 1.12-3.88) and in the hemoglobin < 7 g/dL cohort compared with the hemoglobin < 8 g/dL cohort (aHR, 1.93; 95% CI, 1.02-3.62). No difference was found in the hazard of death between the no threshold and hemoglobin < 7 g/dL cohorts (aHR, 1.08; 95% CI, 0.69-1.69). INTERPRETATION: We observed a decrease in number of RBC units per day of ECMO over time, but changes were not associated temporally with implementation of transfusion thresholds. A transfusion threshold of hemoglobin < 8 g/dL was associated with a lower hazard of death, but these findings are limited by study methodology. Further research is needed to investigate optimal RBC transfusion practices for patients supported with venovenous ECMO.

Single-shot interscalene block with liposomal bupivacaine vs. non-liposomal bupivacaine in shoulder arthroplasty.

BACKGROUND: Regional anesthesia is a valuable component of multimodal pain control in total shoulder arthroplasty (TSA), and multiple interscalene block anesthetic options exist, including nonliposomal interscalene bupivacaine (NLIB) and liposomal interscalene bupivacaine (LIB). The purpose of this study was to compare pain control and opioid consumption within 48 hours postoperation in those undergoing TSA with either LIB or NLIB. METHODS: This was a retrospective cohort study at a single academic medical center including consecutive patients undergoing inpatient (>23-hour hospitalization) primary anatomic or reverse TSA from 2016 to 2020 who received either LIB or an NLIB for perioperative pain control. Perioperative patient outcomes were collected including pain levels and opioid usage, as well as 30- and 90-day emergency department (ED) visits or readmissions. The primary outcome was postoperative pain and opioid use. RESULTS: Overall, 489 patients were included in this study (316 LIB and 173 NLIB). Pain scores at 3, 6, 12, and 48 hours postoperatively were not statistically significantly different (P > .05 for all). However, the LIB group had improved pain scores at 24 and 36 hours postoperation (P < .05 all). There was no difference in the incidence of severe postoperative pain, defined as a 9 or 10 numeric rating scale-11 score, between the 2 anesthesia groups after adjusting for preoperative pain and baseline opioid use (odds ratio 1.25, 95% confidence interval 0.57-2.74; P = .57). Overall, 99 of 316 patients receiving LIB (31.3%) did not require any postoperative opioids compared with 38 of 173 receiving NLIB (22.0%); however, this difference was not statistically significant after adjusting for prior opioid use and preoperative pain (P = .33). No statistically significant differences in postoperative total morphine equivalents or mean daily morphine equivalents consumed between the groups were found during their hospital stays (P > .05 for both). Finally, no significant differences were found in 30- and 90-day ED visits or readmission rates (all P > .05). CONCLUSION: LIB and NLIB demonstrated differences in patient-reported pain scores at 24 and 36 hours postoperation, although these did not reach clinical significance. There were no statistically significant differences in opioid consumption during the hospital stay, including opioid use, total morphine equivalents, and daily mean morphine equivalents consumed during the hospital stay. Additionally, no differences were observed in 30- and 90-day ED visits or readmission rates.

Multisite Study of the Management of Musculoskeletal Infection After Trauma: The MMUSKIT Study.

Background: The optimal duration and choice of antibiotic for fracture-related infection (FRI) is not well defined. This study aimed to determine whether antibiotic duration (≤6 vs >6 weeks) is associated with infection- and surgery-free survival. The secondary aim was to ascertain risk factors associated with surgery- and infection-free survival. Methods: We performed a multicenter retrospective study of patients diagnosed with FRI between 2013 and 2022. The association between antibiotic duration and surgery- and infection-free survival was assessed by Cox proportional hazard models. Models were weighted by the inverse of the propensity score, calculated with a priori variables of hardware removal; infection due to Staphylococcus aureus, Staphylococcus lugdunensis, Pseudomonas or Candida species; and flap coverage. Multivariable Cox proportional hazard models were run with additional covariates including initial pathogen, need for flap, and hardware removal. Results: Of 96 patients, 54 (56.3%) received ≤6 weeks of antibiotics and 42 (43.7%) received >6 weeks. There was no association between longer antibiotic duration and surgery-free survival (hazard ratio [HR], 0.95; 95% CI, .65-1.38; P = .78) or infection-free survival (HR, 0.77; 95% CI, .30-1.96; P = .58). Negative culture was associated with increased hazard of reoperation or death (HR, 3.52; 95% CI, 1.99-6.20; P < .001) and reinfection or death (HR, 3.71; 95% CI, 1.24-11.09; P < .001). Need for flap coverage had an increased hazard of reoperation or death (HR, 3.24; 95% CI, 1.61-6.54; P = .001). Conclusions: The ideal duration of antibiotics to treat FRI is unclear. In this multicenter study, there was no association between antibiotic treatment duration and surgery- or infection-free survival.

Leveraging Hematopoietic Cell Transplant Data and Biorepository Resources at the Center for International Blood and Marrow Transplant Research to Improve Patient Outcomes.

Hematopoietic cell transplantation (HCT) has undergone many advances over the decades. Trends in HCT utilization have been impacted by research based on the data and samples collected by the Center for International Blood and Marrow Transplant Research (CIBMTR). Here, we provide a summary report of the CIBMTR Biorepository resource and describe the biospecimen inventory along with collection and request procedures. The diversity captured in this inventory reflects transplant activity, and these samples can be leveraged for secondary analyses to generate more data and insights to advance the field. We describe how our resources have already impacted HCT practice and elaborate on possibilities for further collaboration and utilization to maximize capabilities and research opportunities. Hematopoietic cell transplant data and biorepository resources at the CIBMTR have been and continue to be leveraged to improve patient outcomes.

Racial Disparities Exist in 90-Day Unplanned Return to the Emergency Department Following Orthopaedic Trauma Surgery.

OBJECTIVES: Racial disparities in healthcare outcomes exist, including in orthopaedic trauma care. The aim of this study was to determine the impact of race, social deprivation, and payor status on 90-day emergency department (ED) revisits among orthopaedic trauma surgery patients at a Level 1 trauma academic medical center. DESIGN: Retrospective chart review analysis. SETTING: Level 1 trauma academic center in Durham, NC. PATIENT SELECTION CRITERIA: Adult patients undergoing orthopaedic trauma surgery between 2017 and 2021. OUTCOME MEASURES AND COMPARISONS: The primary outcome of this retrospective cohort study was 90-day return to the ED. Logistic regression analysis was performed for variables of interest [race, social deprivation (measured by the Area Deprivation Index), and payor status] separately and combined, with each model adjusting for distance to the hospital. Results were interpreted as odds ratios (ORs) of 90-day ED revisits comparing levels of the respective variables. Statistical significance was assessed at α = 0.05. RESULTS: A total of 3120 adult patients who underwent orthopaedic trauma surgery between 2017 and 2021 were included in the analysis. Black race (OR = 1.47; 95% confidence interval [CI]: 1.17-1.84, P < 0.001) and Medicaid coverage (OR = 1.63, 95% CI: 1.20-2.21, P = 0.002) were significantly associated with higher odds of return to ED compared with non-Black or non-Medicaid-covered patients. While ethnic minority (Hispanic/Latino or non-White) was statistically significant while adjusting only for distance to the hospital (OR = 1.23, 95% CI: 1.00-1.50, P = 0.047), it was no longer significant after adjusting for the other sociodemographic variables (OR = 1.13, 95% CI: 0.91-1.39, P = 0.27). The weighted Area Deprivation Index was not associated with a difference in odds of return to ED in any adjusted models. CONCLUSIONS: The results highlight the presence of racial and socioeconomic disparities in ED utilization, with Black race and Medicaid coverage significantly associated with higher odds of return to the ED. Future research should delve deeper into comprehending the root causes contributing to these racial and socioeconomic utilization disparities and evaluate the effectiveness of targeted interventions to reduce them. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Tuberculosis Is Associated with Chronic Hypoxemia among Kenyan Adults (CHAKA): A Case-Control Study.

Rationale: Data on risk factors for chronic hypoxemia in low- and middle-income countries are lacking. Objectives: We aimed to quantify the association between potential risk factors and chronic hypoxemia among adults hospitalized in Kenya. Methods: A hospital-based, case-control study was conducted at Moi Teaching and Referral Hospital in Eldoret, Kenya. Adult inpatients were screened on admission and enrolled in a 1:2 case-to-control ratio. Cases were patients with chronic hypoxemia, defined as resting oxygen saturation as measured by pulse oximetry (SpO2) ⩽ 88% on admission and either 1-month postdischarge SpO2 ⩽ 88% or, if they died before follow-up, documented SpO2 ⩽ 88% in the 6 months before enrollment. Control subjects were randomly selected, stratified by sex, among nonhypoxemic inpatients. Data were collected using questionnaires and structured chart review. Regression was used to assess the associations between chronic hypoxemia and age, sex, smoking status, biomass fuel use, elevation, and self-reported history of tuberculosis and human immunodeficiency virus diagnosis. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported. Results: We enrolled 108 chronically hypoxemic cases and 240 nonhypoxemic control subjects into our Chronic Hypoxemia among Kenyan Adults (CHAKA) cohort. In multivariable analysis, compared with control subjects, chronically hypoxemic cases had significantly higher odds of older age (OR, 1.2 per 5-year increase [95% CI, 1.1-1.3]), female sex (OR, 3.6 [95% CI, 1.8-7.2]), current or former tobacco use (OR, 4.7 [95% CI, 2.3-9.6]), and prior tuberculosis (OR, 11.8 [95% CI, 4.7-29.6]) but no increase in the odds of human immunodeficiency virus diagnosis and biomass fuel use. Conclusions: These findings highlight the potential impact of prior tuberculosis on chronic lung disease in Kenya and the need for further studies on posttuberculosis lung disease.

Metformin use associated with lower rate of hospitalization for influenza in individuals with diabetes.

AIM: To investigate if patients with diabetes taking metformin have better outcomes versus those not taking metformin following an emergency room visit for influenza. METHODS: Using electronic medical records, we performed a retrospective chart review of all adult patients with a diagnosis of diabetes seen in any Duke University Medical Center-affiliated emergency department for influenza over a 6-year period. We documented patient characteristics and comorbidities, and compared outcomes for patients taking metformin versus patients not taking metformin using both univariable and multivariable analyses. Our primary outcome was hospital admission rate. Secondary outcomes were in-hospital length of stay and in-hospital death. RESULTS: Our cohort included 1023 adult patients with diabetes, of whom 59.9% were female. The mean age was 62.9 years, 58.4% were African American, 36.1% were White, and 81.9% were obese or overweight. Of these patients, 347 (34%) were taking metformin. Patients with diabetes taking metformin were less likely to be hospitalized following an emergency department visit for influenza than patients with diabetes not taking metformin (56.8% vs. 70.1%; p < 0.001). Of those patients admitted, there was no statistically significant difference in length of stay or death. CONCLUSIONS: In patients with diabetes, metformin use is associated with lower rate of hospitalization following an emergency department visit for influenza.

Sacubitril/valsartan and cardiovascular biomarkers among patients with recent COVID-19 infection: The PARACOR-19 randomized clinical trial.

AIMS: The PARACOR-19 randomized controlled trial (RCT) was designed to examine the effects of sacubitril/valsartan on markers of cardiac injury, inflammation, structure, and function among patients who have recovered from acute coronavirus disease 2019 (COVID-19) infection. METHODS AND RESULTS: PARACOR-19 was a single-centre, double-blind RCT of patients with cardiovascular risk factors and a history of COVID-19 infection 4-16 weeks prior to enrolment. Patients were randomized to sacubitril/valsartan (titrated to the maximum dose of 97/103 mg twice daily) versus matching placebo. Co-primary endpoints were change from baseline to 12 weeks in high-sensitivity cardiac troponin T (hs-cTnT) and soluble ST2 (sST2). Exploratory endpoints included change from baseline to 12 weeks in additional circulating biomarkers. Overall, 42 patients were randomized between August 2021 and March 2023 (n = 20 sacubitril/valsartan, n = 22 placebo). Median (25th-75th) time from COVID-19 diagnosis to enrolment was 67 (48-80) days. Median age was 67 (62-71) years, 48% were female, and 91% were White. Compared with placebo, sacubitril/valsartan did not have a significant effect on the co-primary endpoints of change from baseline in hs-TnT and sST2 (all p ≥ 0.29). In exploratory analyses, sacubitril/valsartan led to a 46% greater reduction in N-terminal pro-B-type natriuretic peptide (NT-proBNP) and 51% greater reduction in C-terminal telopeptide of collagen type I (CITP). Permanent drug discontinuation occurred in four patients in the sacubitril/valsartan group and three patients in the placebo group. There were no deaths and one patient was hospitalized in each group. CONCLUSION: In this pilot RCT of patients who recovered from acute COVID-19, sacubitril/valsartan did not lower hs-cTnT or sST2 compared with placebo. Exploratory analyses suggested potential benefits of sacubitril/valsartan on cardiac wall stress and collagen turnover as measured by NT-proBNP and CITP. Sacubitril/valsartan was well tolerated. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT04883528.

Static Versus Articulating Spacer: Does Infectious Pathogen Type Affect Treatment Success?

BACKGROUND: Treatment with a static or an articulating antibiotic-containing spacer is a common strategy for treating periprosthetic joint infection (PJI), yet many patients have persistent infections after spacer treatment. Although previous studies have compared the efficacy of a static and articulating spacer for treating PJI, few studies have assessed infection control from the time of spacer implantation, or they defined treatment failure as including reinfection, reoperation, or chronic suppressive therapy. Additionally, few studies have examined whether there is an interaction between spacer and pathogen type with respect to treatment success. QUESTIONS/PURPOSES: (1) Is there a difference in failure-free survival (defined as no reoperation, reinfection, or suppressive antibiotic therapy) between static and articulating spacers after spacer implantation for PJI? (2) Did the relationship between spacer type and failure-free survival differ by pathogen type (staphylococcal versus nonstaphylococcal and difficult-to-treat [including methicillin-resistant Staphylococcus aureus, methicillin-susceptible S. aureus , Corynebacterium, Mycobacterium, Enterococcus spp , and other gram-negative bacterium] versus not-difficult-to-treat organisms)? METHODS: Between January 2014 and January 2022, a convenience sample of 277 patients was identified as having knee PJIs treated with an articulating (75% [208 of 277]) or static (25% [69 of 277]) antibiotic spacer and potentially eligible for this study. During that time, providers at our institution generally used spacers for later-presenting or chronic infections. Spacer choice was determined by surgeon preference, with static spacers used more often in instances of higher bone loss and poor soft tissue coverage. Thirty-one patients (8 static and 23 articulating spacers) were considered lost to follow-up or had incomplete datasets and were excluded from the analysis, resulting in a final analysis cohort of 246 patients: 25% (61 of 246) received a static spacer and 75% (185 of 246) received an articulating spacer. The mean ± standard deviation age of patients was 66 ± 9.9 years, BMI was 33.3 ± 6.9 kg/m 2 , and Elixhauser score was 18.1 ± 16.9. Demographic and clinical characteristics were similar between the two groups. Pathogen type was collected and categorized as staphylococcal versus nonstaphylococcal , and difficult-to-treat (including methicillin-resistant Staphylococcus aureus , methicillin-susceptible S. aureus , Corynebacterium, Mycobacterium, Enterococcus spp , and other gram-negative bacterium) versus not-difficult-to-treat, as defined by an infectious disease physician. Other variables we collected included sex, age, American Society of Anesthesiologists classification, BMI, and Elixhauser score. The primary outcome of interest was failure-free survival, which was a composite time-to-event outcome, with failure defined as reoperation, reinfection, death owing to infection, or chronic antibiotic use at a minimum of 1 year after the completion of the patient's Stage 1 postoperative antibiotic course, whichever came first. Reinfection was determined by the treating physicians in accordance with the Musculoskeletal Infection Society guidelines and included an evaluation of infectious laboratory values, cultures, and clinical signs of infection. We compared static and articulating spacers using a Cox proportional hazards model, with spacer type as the primary predictor variable. We compared staphylococcal versus nonstaphylococcal and difficult-to-treat versus not-difficult-to-treat infections by running additional models with interaction terms between spacer type and pathogen type. RESULTS: No difference was observed in the cause-specific hazard ratio for static versus articulating (reference) spacers (HR 1.45 [95% confidence interval 0.94 to 2.22]; p = 0.09), after adjusting for covariates. Additionally, no difference in the association between spacer type and failure-free survival was found between pathogen types or treatment difficulty after evaluating interactions (staphylococcal HR 0.37 [95% CI 0.15 to 0.91], nonstaphylococcal HR 0.79 [95% CI 0.49 to 1.28]; p value for interaction = 0.14; difficult-to-treat HR 0.37 [95% CI 0.14 to 0.99], not-difficult-to-treat HR 0.75 [95% CI 0.47 to 1.20]; p value for interaction = 0.20). CONCLUSION: The lack of a difference in failure-free survival and insufficient evidence of a difference in the association between spacer type and treatment failure by pathogen type suggests that infectious organism may not be an important consideration in the decision about spacer treatment type. Further studies should aim to elucidate which patient factors are the most influential in surgeon decision-making when choosing a spacer type in patients with PJI of the knee.Level of Evidence Level III, therapeutic study.

Incorporation of Drone Technology Into the Chain of Survival for OHCA: Estimation of Time Needed for Bystander Treatment of OHCA and CPR Performance.

BACKGROUND: Drone-delivered automated external defibrillators (AEDs) hold promises in the treatment of out-of-hospital cardiac arrest. Our objective was to estimate the time needed to perform resuscitation with a drone-delivered AED and to measure cardiopulmonary resuscitation (CPR) quality. METHODS: Mock out-of-hospital cardiac arrest simulations that included a 9-1-1 call, CPR, and drone-delivered AED were conducted. Each simulation was timed and video-recorded. CPR performance metrics were recorded by a Laerdal Resusci Anne Quality Feedback System. Multivariable regression modeling examined factors associated with time from 9-1-1 call to AED shock and CPR quality metrics (compression rate, depth, recoil, and chest compression fraction). Comparisons were made among those with recent CPR training (≤2 years) versus no recent (>2 years) or prior CPR training. RESULTS: We recruited 51 research participants between September 2019 and March 2020. The median age was 34 (Q1-Q3, 23-54) years, 56.9% were female, and 41.2% had recent CPR training. The median time from 9-1-1 call to initiation of CPR was 1:19 (Q1-Q3, 1:06-1:26) minutes. A median time of 1:59 (Q1-Q3, 01:50-02:20) minutes was needed to retrieve a drone-delivered AED and deliver a shock. The median CPR compression rate was 115 (Q1-Q3, 109-124) beats per minute, the correct compression depth percentage was 92% (Q1-Q3, 25-98), and the chest compression fraction was 46.7% (Q1-Q3, 39.9%-50.6%). Recent CPR training was not associated with CPR quality or time from 9-1-1 call to AED shock. Younger age (per 10-year increase; ß, 9.97 [95% CI, 4.63-15.31] s; P<0.001) and prior experience with AED (ß, -30.0 [95% CI, -50.1 to -10.0] s; P=0.004) were associated with more rapid time from 9-1-1 call to AED shock. Prior AED use (ß, 6.71 [95% CI, 1.62-11.79]; P=0.011) was associated with improved chest compression fraction percentage. CONCLUSION: Research participants were able to rapidly retrieve an AED from a drone while largely maintaining CPR quality according to American Heart Association guidelines. Chest compression fraction was lower than expected.

Positive Outliers: A Mixed Methods Study of Resiliency to Childhood Obesity in High-Risk Neighborhoods.

OBJECTIVE: Despite the high prevalence of obesity and the clustering of risk by neighborhood, few studies have examined characteristics which promote healthy child weight in neighborhoods with high obesity risk. We aimed to identify protective factors for children living in neighborhoods with high obesity risk. METHODS: We identified neighborhoods with high obesity risk using geolocated electronic health record data with measured body mass index (BMI) from well-child visits (2012-2017). We then recruited caregivers with children aged 5 to 13 years who lived in census tracts with mean child BMI percentile ≥72 (February 2020-August 2021). We used sequential mixed methods (quantitative surveys, qualitative interviews) to compare individual, interpersonal, and perceived neighborhood factors among families with children at a healthy weight (positive outliers [PO]) versus families with ≥1 child with overweight or obesity (controls). Regression models and comparative qualitative analysis were used to identify protective characteristics. RESULTS: Seventy-three caregivers participated in the quantitative phase (41% PO; 34% preferred Spanish) and twenty in the qualitative phase (50% PO; 50% preferred Spanish). The frequency of healthy caregiver behaviors was associated with being a PO (Family Health Behavior Scale Parent Score adjusted ß 3.67; 95% CI 0.52-6.81 and qualitative data). Protective factors also included caregivers' ability to minimize the negative health influences of family members and adhere to family routines. CONCLUSIONS: There were few differences between PO and control families. Support for caregiver healthy habits and adherence to healthy family routines emerged as opportunities for childhood obesity prevention in neighborhoods with high obesity risk.

The burden of severe asthma in sub-Saharan Africa: Findings from the African Severe Asthma Project.

Background: Severe asthma is associated with high morbidity, mortality, and health care utilization, but its burden in Africa is unknown. Objective: We sought to determine the burden (prevalence, mortality, and activity and work impairment) of severe asthma in 3 countries in East Africa: Uganda, Kenya, and Ethiopia. Methods: Using the American Thoracic Society/European Respiratory Society case definition of severe asthma, we analyzed for the prevalence of severe asthma (requiring Global Initiative for Asthma [GINA] steps 4-5 asthma medications for the previous year to achieve control) and severe refractory asthma (remains uncontrolled despite treatment with GINA steps 4-5 asthma medications) in a cohort of 1086 asthma patients who had been in care for 12 months and had received all GINA-recommended medications. Asthma control was assessed by the asthma control questionnaire (ACQ). Results: Overall, the prevalence of severe asthma and severe refractory asthma was 25.6% (95% confidence interval [CI], 23.1-28.3) and 4.6% (95% CI, 3.5-6.0), respectively. Patients with severe asthma were (nonsevere vs severe vs severe refractory) older (39, 42, 45 years, P = .011), had high skin prick test reactivity (67.1%, 76.0%, 76.0%, P = .004), had lower forced expiratory volume in 1 second percentage (81%, 61%, 55.5%, P < .001), had lower quality of life score (129, 127 vs 121, P < .001), and had higher activity impairment (10%, 30%, 50%, P < .001). Factors independently associated with severe asthma were hypertension comorbidity; adjusted odds ratio 2.21 (1.10-4.47), P = .027, high bronchial hyperresponsiveness questionnaire score; adjusted odds ratio 2.16 (1.01-4.61), P = .047 and higher ACQ score at baseline 2.80 (1.55-5.08), P = .001. Conclusion: The prevalence of severe asthma in Africa is high and is associated with high morbidity and poor quality of life.

Supplemental Patch Testing Identifies Allergens Missed by Standard Screening Series.

Background: Supplemental patch testing is an adjunct to standard patch test screening series. Objective: To determine the demographics, characteristics, frequency, relevance, and interpretation of patch test reactions for supplemental patch testing. Methods: Retrospective study of patients tested 2017-2020 with North American Contact Dermatitis Group (NACDG) and supplemental screening series (Supplemental Series A [SSA], Supplemental Series B [SSB]). Demographics, characteristics, reaction strengths, relevance, and final interpretation were recorded. Results: Cohort included 791 patients; 73.5% female, 68.6% age >40 years. 74.1% were White, 15.2% Black, 5.7% Asian, and 1.5% Hispanic. The most common Dermatitis sites were scattered/generalized (27.2%), face (24.0%), and hands (23.5%). For 2017-2018 and 2019-2020, respectively, 82% (318/388) and 78.4% (316/403) had ≥1 "allergic" reaction. In addition, 13.5% (52/385) and 11.7% (47/403) had SSA reactions, and 38.1% (115/302) and 31.5% (101/321) had SSB reactions. In the 87 (2017-2018) and 99 (2019-2020) patients with negative NACDG testing, 17 (19.5%) and 12 (12.1%) had supplemental reactions. Of the 34 supplemental allergens with reaction frequency ≥1%, 58.8% (20/34) are not part of the American Contact Dermatitis Society 90 (2020) or NACDG 2021-2022 screening series. The highest frequency allergens from this group were dodecyl and octyl gallate, cinnamic alcohol, phenyl salicylate, hexahydro-1,3,5-tris-(2-hydroxyethyl) triazine, and abitol. Conclusions: Supplemental patch testing identifies additional relevant allergens in patients with suspected allergic contact Dermatitis.

Outcomes after total ankle arthroplasty with an average follow-up of 10 years: A systematic review and meta-analysis.

BACKGROUND: The literature demonstrating positive outcomes after total ankle arthroplasty (TAA) is mounting. However, the long-term outcomes of TAA (≥ 10 years) remain minimally reported. The purpose of this systematic review and meta-analysis was to evaluate outcome metrics over multiple TAA studies with greater than 10 years of average follow-up. METHODS: TAA studies were searched in Medline, Embase, and Scopus from the date of inception to September 12, 2022. Inclusion criteria included 1) studies of patients that underwent uncemented TAA, and 2) studies with an average follow-up time of at least ten years. Manuscripts in non-English languages and isolated abstracts were excluded. We collected American Orthopaedic Foot and Ankle Score (AOFAS) and Visual Analog Scale (VAS) scores from the included studies for pooled meta-analysis. Due to the varying definition of survivability between studies, this metric was not assessed in our final evaluation. RESULTS: Our data included approximately 3651 patients (3782 ankles). Of the 25 studies with an average follow-up of 10 years included in the systematic review, 5 provided pre- and post-operative AOFAS means and 5 provided pre- and post-operative VAS means with associated measures of variability and were included in our meta-analysis. The weighted mean difference between pre-and post-operative AOFAS and VAS scores was -40.36 (95% CI -47.24 to -33.47) and 4.52 (95% CI: 2.26-6.43), respectively. The risk of bias was low to moderate for the included studies. CONCLUSION: Outcomes following TAA are favorable and indicate patient-reported outcome improvement over long-term follow-up. However, a significant amount of heterogeneity exists between studies. Future, prospective, randomized research should focus on standardizing outcome measures, survivorship, and complication reporting methodologies to allow for pooled meta-analyses of these important outcome metrics.