Outcomes Associated With Intensive Care and Organ Support Among Patients With COVID-19: A Systematic Review and Meta-Analysis.

BACKGROUND: Accurate accounting of coronavirus disease 2019 (COVID-19) critical care outcomes has important implications for health care delivery. RESEARCH QUESTION: We aimed to determine critical care and organ support outcomes of intensive care unit (ICU) COVID-19 patients and whether they varied depending on the completeness of study follow-up or admission time period. STUDY DESIGN AND METHODS: We conducted a systematic review and meta-analysis of reports describing ICU, mechanical ventilation (MV), renal replacement therapy (RRT), and extracorporeal membrane oxygenation (ECMO) mortality. A search was conducted using PubMed, Embase, and Cochrane databases.We included English language observational studies of COVID-19 patients, reporting ICU admission, MV, and ICU case fatality, published from December 1, 2019 to December 31, 2020. We excluded reports of less than 5 ICU patients and pediatric populations. Study characteristics, patient demographics, and outcomes were extracted from each article. Subgroup meta-analyses were performed based on the admission end date and the completeness of data. RESULTS: Of 6,778 generated articles, 145 were retained for inclusion (n = 60,357 patients). Case fatality rates across all studies were 34.0% (95% CI = 30.7%, 37.5%, P < 0.001) for ICU deaths, 47.9% (95% CI = 41.6%, 54.2%, P < 0.001) for MV deaths, 58.7% (95% CI = 50.0%, 67.2%, P < 0.001) for RRT deaths, and 43.3% (95% CI = 31.4%, 55.4%, P < 0.001) for extracorporeal membrane oxygenation deaths. There was no statistically significant difference in ICU and organ support outcomes between studies with complete follow-up versus studies without complete follow-up. Case fatality rates for ICU, MV, and RRT deaths were significantly higher in studies with patients admitted before April 31st 2020. INTERPRETATION: Coronavirus disease 2019 critical care outcomes have significantly improved since the start of the pandemic. Intensive care unit outcomes should be evaluated contextually (study quality, data completeness, and time) for the most accurate reporting and to effectively guide mortality predictions.

Hazards and Management of Wire Bristle ingestions: A Systematic Review.

OBJECTIVE: Inadvertently ingested grill brush bristles can lodge in various locations and lead to a variety of injuries. They can also be difficult to identify and remove. Our primary objective was to perform a systematic review of cases reported in the literature, with analysis of trends in clinical presentation and success of diagnostic modalities and treatment approaches. DATA SOURCES: Cases of reported grill brush bristle ingestion reported in PubMed, PubMed Central, and Google Scholar databases through April 30, 2021. REVIEW METHODS: Databases were searched for the following terms: ("ingestion" OR "injury" OR "barbeque" OR "BBQ" OR "grill" OR "foreign body" OR "brush" AND "wire" OR "bristle"). Data were collected on patient demographics, clinical presentation, and treatment course. Statistical analysis was performed on characteristics with low risk of confounding. RESULTS: An overall 57 studies involving 91 patients were included. Grill brush bristles presented most commonly in the upper aerodigestive tract (48/91), followed by the abdomen (26/91) and deep neck (17/91). Computed tomography was the most accurate imaging modality for initial diagnosis, identifying 92.8% of bristles. Less invasive or adjunctive techniques such as endoscopy, intraoperative imaging, or minimally invasive surgery may be useful particularly for bristles located in the head and neck given the low rate of success of transoral surgery (66.7%). CONCLUSION: Although this review of retained bristle may be biased toward complex cases, retained grill brush bristles represent an underrecognized and difficult-to-manage hazard. When cases are suspected, clinicians should obtain computed tomography imaging based on presentation and tailor management appropriately.

Atraumatic forearm swelling in a patient with poorly controlled asthma.

We present a case of sarcoidosis presenting as unilateral forearm swelling. A 65-year-old male with a long history of asthma presented with unexplained left forearm and hand swelling. Over many years, chest imaging had been devoid of adenopathy or parenchymal findings suspicious for sarcoid, until after the extremity findings emerged. The patient was diagnosed based on subcutaneous, dermal and mediastinal lymph node histopathology. Sarcoid presenting with isolated extremity findings prior to more typical pulmonary manifestations is rare even for cutaneous or soft tissue sarcoid, highlighting the need to maintain a high index of suspicion for sarcoidosis.

Maternal bleeding complications following early versus delayed umbilical cord clamping in multiple pregnancies.

BACKGROUND: In 2015, the American Academy of Pediatrics recommended delayed umbilical cord clamping for at least 30-60 s for all infants. However, there is limited data regarding the maternal safety of delayed cord clamping in multiple pregnancies. We aimed to compare the maternal bleeding complications following early cord clamping (ECC) versus of delayed cord clamping (DCC) in multiple pregnancies. METHODS: A retrospective cohort study of pregnant women with multiples who delivered live-born infants at Sharp Healthcare Hospitals in San Diego, CA, USA during January 1st, 2016 - September 30th, 2017. Bleeding complications of 295 women who underwent ECC (less than 30 s) were compared with 154 women who underwent DCC (more than 30 s). ECC or DCC was performed according to individual obstetrician discretion. RESULTS: Four hundred forty-nine women with multiple pregnancies (N = 910 infants) were included in the study. 252 (85.4%) women underwent cesarean section in ECC group vs. 99 (64.3%) in DCC group. 58 (19.7%) women delivered monochorionic twins in ECC group vs. 32 (20.8%) women in DCC group. There was no increase in maternal estimate blood loss when DCC was performed comparing to ECC. There were no differences in operative time, post-delivery decrease in hematocrits, rates of postpartum hemorrhage, bleeding complications, maternal blood transfusions and therapeutic hysterectomy between the two groups. CONCLUSIONS: No differences in maternal bleeding complications were found with DCC in multiple pregnancies compared to ECC. Delayed cord clamping can be done safely in multiple pregnancies without any increased maternal risk.

The effect of scopolamine on matching behavior and the estimation of relative reward magnitude.

We investigated the behavioral effects of scopolamine on rats that bar pressed for trains of electrically stimulating pulses under concurrent variable interval schedules of reward. For the first half of the session (30 min) a 1:4 ratio in the programmed number of stimulation trains delivered at each option was in effect. At the start of the second half of the session, an unsignaled reversal in the relative train number (4:1) occurred. We tracked the relative magnitude of reward estimated for each contiguous pair of reinforced visits to competing options. Scopolamine hydrobromide led to a reduction in the relative magnitude of reward. A similar result was obtained in a follow-up test in which relative magnitude was manipulated by varying the pulse frequency of stimulation, while equating the train number at each option. The effect of scopolamine hydrobromide could not be attributed to undermatching, side bias, nor to an effect of scopolamine on the reward integration process. When the same rats were treated with scopolamine methylbromide, no effects on matching behavior were observed. Our results suggest a cholinergic basis for the computation of choice variables related to matching behavior. (PsycINFO Database Record

CS-specific modifications of auditory evoked potentials in the behaviorally conditioned rat.

The current report provides a detailed analysis of the changes in the first two components of the auditory evoked potential (AEP) that accompany associative learning. AEPs were recorded from the primary auditory cortex before and after training sessions. Experimental subjects underwent one (n=5) or two (n=7) days of conditioning in which a tone, serving as a conditioned stimulus (CS), was paired with mild foot shock. Control subjects received one (n=5) or two (n=7) days of exposure to the same stimuli delivered randomly. Only animals receiving paired CS-US training developed a conditioned tachycardia response to the tone. Our analyses demonstrated that both early components of the AEP recorded from the granular layer of the cortex undergo CS-specific associative changes: (1) the first, negative component (occurring ∼21ms following tone onset) was significantly augmented after one and two days of training while maintaining its latency, and (2) the second, positive component (occurring ∼50ms following tone onset) was augmented after two days of training, and showed a significant reduction in latency after one and two days of training. We view these changes as evidence of increased cortical synchronization, thereby lending new insight into the temporal dynamics of neural network activity related to auditory learning.

Living up to safety values in health care: the effect of leader behavioral integrity on occupational safety.

While previous research has identified that leaders' safety expectations and safety actions are important in fostering occupational safety, research has yet to demonstrate the importance of leader alignment between safety expectations and actions for improving occupational safety. We build on safety climate literature and theory on behavioral integrity to better understand the relationship between the leader's behavioral integrity regarding safety and work-related injuries. In a time-lagged study of 658 nurses, we find that behavioral integrity for high safety values is positively associated with greater reporting of fewer and less severe occupational injuries. The effects of behavioral integrity regarding safety can be better understood through the mediating mechanisms of safety compliance and psychological safety toward one's supervisor. We discuss the implications of our findings for future research on safety climate.

Relationships of hardiness to physical and mental health status in military men: a test of mediated effects.

Evidence links the personality trait hardiness to both mental (MH) and physical health (PH) status, but few unifying models delineate interrelationships of these variables. The first purpose of this study was to examine the association of hardiness to MH and PH in military men. Second, we tested the hypothesis that MH would mediate the association of hardiness with PH. Identical measures were collected in two separate, demographically-similar samples (n = 65 and n = 55). All subjects completed a background questionnaire, the Dispositional Resilience Scale-15 and the Short Form 36 Medical Outcomes Survey. Associations between hardiness, PH and MH were examined using regression-based mediation analyses followed by the Sobel test of indirect effects. In the total sample, hardiness predicted PH in an initial regression model (ß = 0.37, p < .001). When MH was added to the model, however, PH's influence was substantially attenuated and no longer significant (ß = 0.06, p > .05). A Sobel test of significance confirmed a mediated effect (p < .001). Similar patterns were observed in each individual sample. Hardiness is associated with PH in military men, and this relationship is mediated by MH.

Extension of the simulated drinking game procedure to multiple drinking games.

The present study extended the Simulated Drinking Game Procedure (SDGP) to obtain information about different types of drinking games. Phase I participants (N = 545) completed online screening questionnaires assessing substance use and drinking game participation. Participants who met the selection criteria for Phase II (N = 92) participated in laboratory sessions that consisted of three different periods of drinking game play. Sixty-two percent (N = 57) of the sample was female. Data from these sessions was used to estimate the peak Blood Alcohol Concentration (BAC) a participant would achieve if they consumed alcohol while participating in the SDGP. Total consumption and estimated BAC varied as a function of game type. The total consumption and estimated BAC obtained while playing Beer Pong and Memory varied significantly as a function of group. Total ounces consumed while playing Three Man varied significantly as a function of group; however, the variation in estimated BAC obtained while playing Three Man was not significant. Results indicated that estimated BACs were higher for female participants across game type. Previous experience playing the three drinking games had no impact on total drink consumption or estimated BAC obtained while participating in the SDGP. The present study demonstrated that the SDGP can be used to generate estimates of how much alcohol is consumed and the associated obtained BAC during multiple types of drinking games. In order to fully examine whether previous experience factors in to overall alcohol consumption and BAC, future research should extend the SDGP to incorporate laboratory administration of alcohol during drinking game participation.

Conditioned tone control of brain reward behavior produces highly specific representational gain in the primary auditory cortex.

Primary sensory cortices have been assumed to serve as stimulus analyzers while cognitive functions such as learning and memory have been allocated to "higher" cortical areas. However, the primary auditory cortex (A1) is now known to encode the acquired significance of sound as indicated by associatively-induced specific shifts of tuning to the frequencies of conditioned stimuli (CS) and gains in area of CS representations. Rewarding brain stimulation can be a very powerful motivator and brain reward systems have been implicated in addictive behavior. Therefore, it is possible that a cue for brain reward will gain cortical territory and perhaps thereby increase its control of subsequent behavior. To investigate the effect of brain reward on cortical organization, adult male rats (n=11) were first tested with varying amounts of stimulation of the ventral tegmental area (VTAstm) to generate sigmoidal psychometric functions of nose poke (NP) rates as a function of reward magnitude (duration). Next, we attempted to accomplish tone control of NPs by maintaining intertrial NPs using a low reward duration and presenting a 20s tone (2.0kHz, 70dB) which signaled an increase in reward to a high magnitude 10s after tone onset. Tone control was demonstrated by a significant increase in the rate of NPs during the first 10s of tone presentation, which anticipated the delivery of the high magnitude of reward. Tone control was achieved in seven of 11 subjects. This was accompanied by a highly specific and significant gain in representational area, specifically for the half-octave range centered on the CS frequency. However, this plasticity developed only in tone-controlled (TC) animals. The auditory cortex of non-tone-controlled subjects (n=4) did not differ from that of naïve controls (n=9) although their VTAstm was as rewarding as for the TC group. These findings reveal that auditory instrumental behavior can be controlled by rewarding VTAstm and that such control appears necessary for the highly specific recruitment of cortical cells to increase the representation of a sound that acquires behavioral importance.

Avoidance learning facilitates temporal processing in the primary auditory cortex.

The primary auditory cortex is now known to be involved in learning and memory, as well as auditory perception. For example, spectral tuning often shifts toward or to the frequency of the conditioned stimulus during associative learning. As previous research has focused on tonal frequency, less is known about how learning might alter temporal parameters of response in the auditory cortex. This study addressed the effects of learning on the fidelity of temporal processing. Adult male rats were trained to avoid shock that was signaled by an 8.0 kHz tone. A novel control group received non-contingent tone and shock with shock probability decreasing over days to match the reduced number of shocks received by the avoidance group as they mastered the task. An untrained (nai ve) group served as a baseline. Following training, neuronal responses to white noise and a broad spectrum of tones were determined across the primary auditory cortex in a terminal experiment with subjects under general anesthesia. Avoidance conditioning significantly improved the precision of spike-timing: the coefficient of variation of 1st spike latency was significantly reduced in avoidance animals compared to controls and nai ves, both for tones and for noise. Additionally, avoidance learning was accompanied by a reduction of the latency of peak response, by 2.0-2.5 ms relative to nai ves and approximately 1.0 ms relative to controls. The shock-matched controls also exhibited significantly shorter peak latency of response than nai ves, demonstrating the importance of this non-avoidance control. Plasticity of temporal processing showed no evidence of frequency specificity and developed independently of the non-temporal parameters magnitude of response, frequency tuning and neural threshold, none of which were facilitated. The facilitation of temporal processing suggests that avoidance learning may increase synaptic strength either within the auditory cortex, in the subcortical auditory system, or both.

Representation of time by neurons in the posterior parietal cortex of the macaque.

The neural basis of time perception is unknown. Here we show that neurons in the posterior parietal cortex (area LIP) represent elapsed time relative to a remembered duration. We trained rhesus monkeys to report whether the duration of a test light was longer or shorter than a remembered "standard" (316 or 800 ms) by making an eye movement to one of two choice targets. While timing the test light, the responses of LIP neurons signaled changes in the monkey's perception of elapsed time. The variability of the neural responses explained the monkey's uncertainty about its temporal judgments. Thus, in addition to their role in spatial processing and sensorimotor integration, posterior parietal neurons encode signals related to the perception of time.