Clinical characteristics and outcomes of obstetric patients transferred directly to intensive care units.

BACKGROUND: Medical complications in peripartum patients are uncommon. Often, these patients are transferred to tertiary care centers, but their conditions and outcomes are not well understood. Our study examined peripartum patients transferred to an intensive care unit (ICU) at an academic quaternary center. METHODS: We reviewed charts of adult, non-trauma, interhospital transfer (IHT) peripartum patients sent to an academic quaternary ICU between January 2017 and December 2021. We conducted a descriptive analysis and used multivariable ordinal regression to examine associations of demographic and clinical factors with ICU length of stay (LOS) and hospital length of stay (HLOS). RESULTS: Of 1,794 IHT peripartum patients, 60 (3.2%) were directly transferred to an ICU. The average was 32 years, with a median Sequential Organ Failure Assessment (SOFA) score of 3 (1-4.25) and Acute Physiology and Chronic Health Evaluation (APACHE) II score of 8 (7-12). Respiratory failure was most common (32%), followed by postpartum hemorrhage (15%) and sepsis (14%). Intubation was required for 24 (41%), and 4 (7%) needed extracorporeal membrane oxygenation. Only 1 (1.7%) died, while 45 (76.3%) were discharged. Median ICU LOS and HLOS were 5 days (212) and 8 days (5-17). High SOFA score was linked to longer HLOS, as was APACHE II. CONCLUSIONS: Transfers of critically ill peripartum patients between hospitals were rare but involved severe medical conditions. Despite this, their outcomes were generally positive. Larger studies are needed to confirm our findings.

Self-Measured Blood Pressure Monitoring During the COVID-19 Pandemic: Perspectives From Community Health Center Clinicians.

ABSTRACT: The early period of the COVID-19 pandemic necessitated a rapid increase in out-of-office care. To capture the impact from COVID-19 on care for patients with hypertension, a questionnaire was disseminated to community health center clinicians. The extent, types, and causes of care delays and disruptions were assessed along with adaptations and innovations used to address them. Clinician attitudinal changes and perspectives on future hypertension care were also assessed. Of the 65 respondents, most (90.8%) reported their patients with hypertension experienced care delays or disruptions, including lack of follow-up, lack of blood pressure assessment, and missed medication refills or orders. To address care delays and disruptions for patients with hypertension, respondents indicated that their health center increased the use of telehealth or other technology, made home blood pressure devices available to patients, expanded outreach and care coordination, provided medication refills for longer periods of time, and used new care delivery options. The use of self-measured blood pressure monitoring (58.5%) and telehealth (43.1%) was identified as the top adaptations that should be sustained to increase access to and patient engagement with hypertension care; however, barriers to both remain. Policy and system level changes are needed to support value-based care models that include self-measured blood pressure and telehealth.

Craniofacial tendon development-Characterization of extracellular matrix morphology and spatiotemporal protein distribution.

Craniofacial (CF) tendons are often affected by traumatic injuries and painful disorders that can severely compromise critical jaw functions, such as mastication and talking. Unfortunately, tendons lack the ability to regenerate, and there are no solutions to restore their native properties or function. An understanding of jaw tendon development could inform tendon regeneration strategies to restore jaw function, however CF tendon development has been relatively unexplored. Using the chick embryo, we identified the jaw-closing Tendon of the musculus Adductor Mandibulae Externus (TmAM) and the jaw-opening Tendon of the musculus Depressor Mandibulae (TmDM) that have similar functions to the masticatory tendons in humans. Using histological and immunohistochemical (IHC) analyses, we characterized the TmAM and TmDM on the basis of cell and extracellular matrix (ECM) morphology and spatiotemporal protein distribution from early to late embryonic development. The TmAM and TmDM were detectable as early as embryonic day (d) 9 based on histological staining and tenascin-C (TNC) protein distribution. Collagen content increased and became more organized, cell density decreased, and cell nuclei elongated over time during development in both the TmAM and TmDM. The TmAM and TmDM exhibited similar spatiotemporal patterns for collagen type III (COL3), but differential spatiotemporal patterns for TNC, lysyl oxidase (LOX), and matrix metalloproteinases (MMPs). Our results demonstrate markers that play a role in limb tendon formation are also present in jaw tendons during embryonic development, implicate COL3, TNC, LOX, MMP2, and MMP9 in jaw tendon development, and suggest TmAM and TmDM possess different developmental programs. Taken together, our study suggests the chick embryo may be used as a model with which to study CF tendon extracellular matrix development, the results of which could ultimately inform therapeutic approaches for CF tendon injuries and disorders.

Does Physician Gender and Gender Composition of Clinical Teams Affect Guideline Concordance and Patient Outcomes in Out-of-Hospital Cardiac Arrest?

Objective: Prior literature has shown improved outcomes in morbidity and mortality for admitted patients cared for by female physicians. One theory is that female physicians adhere closely to guideline recommendations. We sought to determine whether patients who have out-of-hospital cardiac arrest (OHCA) experience more guideline-concordant postcardiac arrest care and potentially better outcomes based on the gender of their treating physician and gender distribution of the treatment teams. Methods: This study is a retrospective cohort study from the Colorado Cardiac Arrest Registry, local registry of OHCA patients treated at one academic urban tertiary care hospital. We analyzed adult OHCA patients who survived to hospital admission but were comatose. Patient demographic data and arrest characteristics were abstracted for subjects, and the gender of the provider was abstracted from the medical record. Results: Patients were admitted by a female attending in 28.5% of the cohort. The difference in guideline-concordant care between male and female providers was not significant. No statistical difference was found between all-male or mixed gender teams in adherence to guideline-concordant care. No patient was cared for by an all-female team. Neither gender of the admitting physician nor gender of the physician who led the family meeting to discuss prognosis was associated with a survival difference. Conclusions: Prior literature has described differences in outcome based on gender of the treating physician. Our analysis targeted a similar question in a cohort of OHCA patients with survival to hospital admission. We determined that there was no difference in postcardiac arrest guideline concordance and survival to hospital discharge based on treating physician gender. This finding differs from the prior literature and supports the importance of diverse clinical teams in medicine.

Lessons Learned from OpenNotes Learning Mode and Subsequent Implementation across a Pediatric Health System.

BACKGROUND: The 21st Century Cures Act has accelerated adoption of OpenNotes, providing new opportunities for patient and family engagement in their care. However, these regulations present new challenges, particularly for pediatric health systems aiming to improve information sharing while minimizing risks associated with adolescent confidentiality and safety. OBJECTIVE: Describe lessons learned preparing for OpenNotes across a pediatric health system during a 4-month trial period (referred to as "Learning Mode") in which clinical notes were not shared by default but decision support was present describing the upcoming change and physicians could request feedback on complex cases from a multidisciplinary team. METHODS: During Learning Mode (December 3, 2020-March 9, 2021), implementation included (1) educational text at the top of commonly used note types indicating that notes would soon be shared and providing guidance, (2) a new confidential note type, and (3) a mechanism for physicians to elicit feedback from a multidisciplinary OpenNotes working group for complex cases with questions related to OpenNotes. The working group reviewed lessons learned from this period, as well as implementation of OpenNotes from March 10, 2021 to June 30, 2021. RESULTS: During Learning Mode, 779 confidential notes were written across the system. The working group provided feedback on 14 complex cases and also reviewed 7 randomly selected confidential notes. The proportion of physician notes shared with patients increased from 1.3% to 88.4% after default sharing of notes to the patient portal. Key lessons learned included (1) sensitive information was often present in autopopulated elements, differential diagnoses, and supervising physician note attestations; and (2) incorrect reasons were often selected by clinicians for withholding notes but this accuracy improved with new designs. CONCLUSION: While OpenNotes provides an unprecedented opportunity to engage pediatric patients and their families, targeted education and electronic health record designs are needed to mitigate potential harms of inappropriate disclosures.

Antibiotic Prescribing Patterns for Acute Otitis Media for Children 2 Years and Older.

OBJECTIVE: To determine the frequency that non-first-line antibiotics, safety-net antibiotic prescriptions (SNAPS), and longer than recommended durations of antibiotics were prescribed for children ≥2 years of age with acute otitis media and examine patient and system level factors that contributed to these outcomes. STUDY DESIGN: Children age ≥2 years with acute otitis media seen at Denver Health Medical Center outpatient locations from January to December 2018 were included. The percentages of patients who received first-line antibiotics, SNAPs, and recommended durations of antibiotics were determined. Factors associated with non-first-line and longer than recommended antibiotic durations were evaluated using multivariate logistic regression modeling. RESULTS: Of the 1025 visits evaluated, 98.0% were prescribed an antibiotic; only 4.5% of antibiotics were SNAPs. Non-first-line antibiotics were prescribed to 18.8% of patients. Most antibiotic durations (94.1%) were longer than the institution recommended 5 days and 54.3% were ≥10 days. Private insurance was associated with non-first-line antibiotics (aOR, 1.89; 95% CI, 1; 14-3.14, P = .01). Patients who were younger (2-5 years; aOR 2.01; 95% CI, 1.32-3.05; P < .001) or seen in emergency/urgent care sites (aOR, 1.73; 95% CI, 1.26-2.38; P < .001) were more likely to receive ≥10 days of antibiotic compared with those in pediatric clinics. CONCLUSIONS: Antibiotic stewardship interventions that emphasize the duration of antibiotic therapy as well as the use of SNAPs or observation may be higher yield than those focusing on first-line therapy alone. Numerous system and patient level factors are associated with off-guideline prescribing.

Effects of Recent Concussion and Injury History on Instantaneous Relative Risk of Lower Extremity Injury in Division I Collegiate Athletes.

BACKGROUND: Growing evidence suggests that concussion increases the risk of lower extremity (LE) musculoskeletal injury. However, it is unclear to how the effect of concussion on LE injury risk may be influenced by previous injuries. This study sought to examine the association between concussion, previous LE injuries, and the risk LE injury to the same previously injured limb (ipsilateral) or the opposite limb (contralateral). METHODS: This retrospective study examined medical records from 110 concussed athletes and 110 matched controls for LE injuries in the 365 days before and after the concussion event. The effect of concussion on time to injury was assessed with a Cox proportional hazard model after adjusting for injury history. Fine and Gray subdistribution models assessed the cumulative risk of ipsilateral and contralateral injury by group. RESULTS: Concussion was associated with an increased instantaneous relative risk of LE injury when adjusting for LE injury history [hazard ratio (HR) = 1.67, 95% confidence interval (CI) = 1.11-2.53], agreeing with previous results. Among individuals who had a history of LE injuries before the concussion event, a nonsignificant yet moderate effect of concussion on the instantaneous relative risk of ipsilateral injuries was found after adjusting for the competing risk of contralateral injuries and censored values (HR = 1.85, 95% CI = 0.76-4.46). CONCLUSIONS: This study provides independent confirmation of previous studies, reporting an association between concussion and LE injury risk. Furthermore, this study suggests that future large-scale studies should consider the competing risk of ipsilateral, contralateral, and new injuries in populations with an injury history.

Ectropion Improvement with Topical Tazarotene in Children with Lamellar Ichthyosis.

BACKGROUND/OBJECTIVES: Lamellar ichthyosis (LI) is a well-described phenotypic subtype of autosomal recessive congenital ichthyosis (ARCI). The condition typically presents at birth with collodion membrane and leads to thick, plate-like scaling of the skin throughout the body, alopecia, and prominent ocular manifestations. Ocular complications include bilateral cicatricial ectropion and lagophthalmos. These ocular complications can lead to chronic exposure keratitis and in some cases corneal ulceration and blindness. No cure for ichthyosis exists. Treatment of ocular complications in LI includes surgical correction, systemic retinoids, and a variety of topical therapies such as emollients, keratolytics, and retinoids. METHODS: Five children with LI cared for at our institution were identified and included. Patient age at the start of therapy ranged from 2 weeks to 9 years. Electronic medical records were reviewed and data from pediatric dermatologist and pediatric ophthalmologist visits were obtained. Data were collected before and after treatment of daily or twice-daily 0.05% to 0.1% tazarotene cream applied to the face and eyelids. RESULTS: All patients had improvement in the degree of ectropion, with complete resolution in two of the five patients. The two patients with lagophthalmos at the time of tazarotene initiation experienced complete resolution. No adverse effects were reported. CONCLUSIONS: Tazarotene cream appears to be effective in the management of ectropion and lagophthalmos in the setting of LI in children, even in the neonatal period.

Sex-related dimorphism in dentate gyrus atrophy and behavioral phenotypes in an inducible tTa:APPsi transgenic model of Alzheimer's disease.

Sex differences are a well-known phenomenon in Alzheimer's disease (AD), with women having a higher risk for AD than men. Many AD mouse models display a similar sex-dependent pattern, with females showing earlier cognitive deficits and more severe neuropathology than males. However, whether those differences are relevant to human disease is unclear. Here we show that in AD mouse models that overexpress amyloid precursor protein (APP) under control of the prion protein promoter (PrP), female transgenic mice have higher APP expression than males, complicating interpretations of the role of sex-related factors in such models. By contrast, in a tTa:APPsi model, in which APP expression is driven by the tetracycline transactivator (tTa) from the CaMKIIα promoter, there are no sex-related differences in expression or processing of APP. In addition, the levels of Aß dimers and tetramers, as well as Aß peptide accumulation, are similar between sexes. Behavioral testing demonstrated that both male and female tTa:APPsi mice develop age-dependent deficits in spatial recognition memory and conditional freezing to context. These cognitive deficits were accompanied by habituation-associated hyperlocomotion and startle hyper-reactivity. Significant sex-related dimorphisms were observed, due to females showing earlier onsets of the deficits in conditioned freezing and hyperlocomotion. In addition, tTa:APPsi males but not females demonstrated a lack of novelty-induced activation. Both males and females showed atrophy of the dentate gyrus (DG) of the dorsal hippocampus, associated with widening of the pyramidal layer of the CA1 area in both sexes. Ventral DG was preserved. Sex-related differences were limited to the DG, with females showing more advanced degeneration than males. Collectively, our data show that the tTa:APPsi model is characterized by a lack of sex-related differences in APP expression, making this model useful in deciphering the mechanisms of sex differences in AD pathogenesis. Sex-related dimorphisms observed in this model under conditions of equal APP expression between sexes suggest a higher sensitivity of females to the effects of APP and/or Aß production.

Early pediatric atopic dermatitis shows only a cutaneous lymphocyte antigen (CLA)(+) TH2/TH1 cell imbalance, whereas adults acquire CLA(+) TH22/TC22 cell subsets.

BACKGROUND: Identifying differences and similarities between cutaneous lymphocyte antigen (CLA)(+) polarized T-cell subsets in children versus adults with atopic dermatitis (AD) is critical for directing new treatments toward children. OBJECTIVE: We sought to compare activation markers and frequencies of skin-homing (CLA(+)) versus systemic (CLA(-)) "polar" CD4 and CD8 T-cell subsets in patients with early pediatric AD, adults with AD, and control subjects. METHODS: Flow cytometry was used to measure CD69/inducible costimulator/HLA-DR frequency in memory cell subsets, as well as IFN-γ, IL-13, IL-9, IL-17, and IL-22 cytokines, defining TH1/cytotoxic T (TC) 1, TH2/TC2, TH9/TC9, TH17/TC17, and TH22/TC22 populations in CD4 and CD8 cells, respectively. We compared peripheral blood from 19 children less than 5 years old and 42 adults with well-characterized moderate-to-severe AD, as well as age-matched control subjects (17 children and 25 adults). RESULTS: Selective inducible costimulator activation (P < .001) was seen in children. CLA(+) TH2 T cells were markedly expanded in both children and adults with AD compared with those in control subjects, but decreases in CLA(+) TH1 T-cell numbers were greater in children with AD (17% vs 7.4%, P = .007). Unlike in adults, no imbalances were detected in CLA(-) T cells from pediatric patients with AD nor were there altered frequencies of TH22 T cells within the CLA(+) or CLA(-) compartments. Adults with AD had increased frequencies of IL-22-producing CD4 and CD8 T cells within the skin-homing population, compared with controls (9.5% vs 4.5% and 8.6% vs 2.4%, respectively; P < .001), as well as increased HLA-DR activation (P < .01). CONCLUSIONS: These data suggest that TH2 activation within skin-homing T cells might drive AD in children and that reduced counterregulation by TH1 T cells might contribute to excess TH2 activation. TH22 "spreading" of AD is not seen in young children and might be influenced by immune development, disease chronicity, or recurrent skin infections.

The best of both worlds: emotional cues improve prospective memory execution and reduce repetition errors.

Prospective memory (PM) errors are commonly investigated as failures to execute an intended task (e.g., taking medication), and some studies suggest that emotional PM cues significantly reduce such failures. In Experiment 1, we extended these findings and additionally explored whether improved PM performance with emotional cues comes at the expense of performance on the ongoing task. Our results indicated that both younger and older adults are more likely to respond to emotional than to neutral PM cues, but the emotional cues did not differentially disrupt the performance on the ongoing task for either age group. Because older adults are also prone to mistakenly repeating a completed PM task, in Experiment 2 we further examined whether emotional PM cues increased repetition errors for older adults. Despite equivalent opportunity for repetition errors across cue type, older adults committed significantly fewer repetition errors with emotional than with neutral cues. Thus, these experiments demonstrated that older adults can effectively use emotional cues to help them initiate actions and to minimize repetition errors.

Central obesity and high blood pressure in pediatric patients with atopic dermatitis.

IMPORTANCE: Atopic dermatitis (AD) is associated with multiple potential risk factors for obesity and high blood pressure (BP), including chronic inflammation, sleep disturbance, and mental health comorbidity. Previous studies found associations between general obesity and AD. However, it is unknown whether AD is associated with central obesity and/or high BP. OBJECTIVES: To determine whether central obesity and high BP are increased in pediatric AD. DESIGN, SETTING, AND PARTICIPANTS: This case-control study performed in multicenter pediatric dermatology practices in the United States recruited 132 children (age range, 4-17 years) with active moderate to severe AD and 143 healthy controls from April 1, 2009, through December 31, 2012. EXPOSURES: Diagnosis and severity of AD assessed by a pediatric dermatologist. MAIN OUTCOMES AND MEASURES: Body mass index, waist circumference, waist to height ratio, systolic BP, and diastolic BP. RESULTS: Moderate to severe AD was associated with body mass index for age and sex of 97th percentile or greater (logistic regression; odds ratio [OR], 2.64; 95% CI, 1.15-6.06), International Obesity Task Force obesity cutoffs (OR, 2.38; 95% CI, 1.06-5.34), waist circumference in the 85th percentile or greater (OR, 3.92; 95% CI, 1.50-10.26), and waist to height ratio of 0.5 or greater (OR, 2.22; 95% CI, 1.10-4.50). Atopic dermatitis was associated with higher BP for age, sex, and height percentiles (systolic BP: OR, 2.94; 95% CI, 1.04-8.36; diastolic BP: OR, 3.68; 95% CI, 1.19-11.37), particularly a systolic BP in the 90th percentile or higher (OR, 2.06; 95% CI, 1.09-3.90), in multivariate models that controlled for demographics, body mass index and waist circumference percentiles, and history of using prednisone or cyclosporine. Atopic dermatitis was associated with higher systolic BP in Hispanics/Latinos (general linear model; ß, .23; 95% CI, .04-.43) and Asians (ß, .16; 95% CI, .03-.30). Severe to very severe AD was associated with systolic BP in the 90th percentile or higher (adjusted OR, 3.14; 95% CI, 1.13-8.70). Atopic dermatitis was associated with a family history of hypertension (adjusted OR, 1.88; 95% CI, 1.14-3.10) and type 2 diabetes mellitus (adjusted OR, 1.64; 95% CI, 1.02-2.68) but not obesity or hyperlipidemia. CONCLUSIONS AND RELEVANCE: Moderate to severe pediatric AD may be associated with central obesity and increased systolic BP.

Filaggrin gene mutations in African Americans with both ichthyosis vulgaris and atopic dermatitis.

Atopic dermatitis (AD) and ichthyosis vulgaris (IV) are two common disorders of epidermal homeostasis resulting in dry skin. The profilaggrin gene, located on chromosome 1q22, encodes a keratin filament aggregating protein (filaggrin) that is essential to forming the epidermal barrier and maintaining hydration. Null mutations in filaggrin have been found to underlie IV and are common in patients with AD, but the minority of African Americans with AD or IV show these mutations in filaggrin. We have selectively studied African Americans with both AD and IV to maximize the possibility of finding filaggrin null mutations in this population. DNA was collected using buccal swabs from 18 African American children with both AD and IV and 17 African American controls without either of these diseases. Purified genomic DNA was amplified using polymerase chain reaction from three regions of the filaggrin gene, exon 3, including R501X, 2282del4, E2554X, R2447X, 1249insG, R826X, 2767insT, and E2422X. Of the African American children with both AD and IV, 22.2% were heterozygous for filaggrin null mutations. Out of the control group, one carried a null mutation and was later discovered to have a history of asthma. Null mutations found in this population included R501X (n = 1), 2282del4 (n = 2), and R826X (n = 2, including the control patient). Our data demonstrate a prevalence of filaggrin mutations in the African American population that exceeds previously published data, although the overall prevalence is still lower than in other populations. It is likely that factors other than known FLG mutations are involved in African American patients.

The comparative effectiveness of suction-curettage and onabotulinumtoxin-A injections for the treatment of primary focal axillary hyperhidrosis: a randomized control trial.

BACKGROUND: Botulinum toxin injections and suction-curettage have been separately shown to be effective in treating axillary hyperhidrosis but have not been compared in the same patients. OBJECTIVE: We sought to compare effectiveness of suction-curettage versus neurotoxin for the treatment of axillary hyperhidrosis. METHODS: Each of 20 patients was randomized to receive toxin injections to one axilla and suction-curettage to the contralateral axilla. The primary outcome measure was reduction of sweat rate measured by gravimetry, and the secondary measure was quality of life as measured by a patient-directed questionnaire. RESULTS: At 3 months posttreatment, toxin injections decreased baseline resting sweat production by 72.1% versus 60.4% (P = .29) for suction-curettage, and baseline exercise-induced sweat production by 73.8% versus 58.8% (P = .10). When patients were stratified into the categories of light and heavy sweaters, there was a difference among heavy sweaters, with exercise-induced sweat production lower by 10.48 mg/min or 34.3% (P = .0025) at toxin-treated sites. Compared with suction-curettage, toxin also resulted in greater improvements in quality of life by 0.80 points (P = .0002) and 0.90 points (P = .0017) at 3 and 6 months posttreatment, respectively, as measured by the patient questionnaire. LIMITATIONS: The follow-up period was limited to 6 months. CONCLUSIONS: By objective measures 3 months after treatment, neurotoxin injections are nominally more effective than suction-curettage in all cases, and markedly more effective in heavy sweaters. Patients have a very significant preference for neurotoxin injections at 3 months, and this is maintained at 6 months.

A 3-year-old girl with thin hair.

CME EDUCATIONAL OBJECTIVES: 1.Identify the clinical features of loose anagen syndrome.2.Distinguish between loose anagen syndrome and other types of alopecia in a young child.3.Understand the natural history of loose anagen syndrome. A healthy 3-year-old white girl presented to the pediatric dermatology clinic for evaluation of thin hair. She was born with little hair and slowly grew thin blond hair. Her hair has always remained short, and she has only had one haircut. The patient's mother never noted any scalp abnormalities such as scale or dermatitis. The child does not seem to play with her hair. Her mother notes times when clumps of hair pull out without discomfort. A laboratory work-up prior to presentation revealed normal thyroid studies and an incidental iron deficiency anemia for which she was on oral iron replacement. There was no family history of alopecia, thin hair, or autoimmune disorders.