Crossbow Injuries: Predictors of Mortality.

INTRODUCTION: Crossbow injuries are rare but carry significant morbidity and mortality, and there is limited evidence in the medical literature to guide care. This paper reviews the case reports and case series of crossbow injuries and looks for trends regarding morbidity and mortality based on the type of arrow, anatomic location of injury, and intent of injury. METHODS: Multiple databases were searched for cases of crossbow injuries and data were abstracted into a spreadsheet. Statistics were done in SPSS. RESULTS: 358 manuscripts were returned in the search. After deduplication and removal of nonclinical articles, 101 manuscripts remained. Seventy-one articles describing 90 incidents met the inclusion criteria. The mean age was 36.5 years. There were 10 female and 79 male victims. Fatality was 36% for injuries by field tip arrows and 71% for broadhead arrows, p = .024. Assaults were fatal in 84% of cases, suicides in 29%, and accidental injuries in 17%, p < .001. Mortality was similar for wounds to the head and neck (41%), chest (42%), abdomen (33%), extremities (50%), and multiple regions, p = .618. CONCLUSIONS: Crossbows are potentially lethal weapons sold with fewer restrictions than firearms. Injuries caused by broadhead arrows are more likely to be fatal than injuries from field tip arrows. The anatomic location of injury does not correlate with fatality. More than half of crossbow injuries are due to attempted suicide, with a high case-fatality rate.

Analysis of outcomes of single-unit cord blood transplantation with umbilical cord blood units processed with two different red blood cell sedimentation reagents.

BACKGROUND: Various processing methodologies are routinely used to reduce volume and red blood cell content of umbilical cord blood (UCB) units collected for hematopoietic stem cell transplantation. There is limited information regarding effects of UCB processing techniques on clinical outcomes. STUDY DESIGN AND METHODS: Retrospective data analysis compared laboratory and clinical outcomes following single-unit UCB transplantation performed between 1999 and 2015. All UCB units were from St. Louis Cord Blood Bank and all were manually processed with either Hetastarch processed cord blood units (HCB) (n = 661) or PrepaCyte processed cord blood units (PCB) (n = 84). Additional sensitivity analysis focused on units transplanted from 2010 to 2015 and included 105 HCB and 84 PCB. RESULTS: There were no significant differences in patient characteristics between the two groups. Pre-freeze total nucleated and CD34+ cell counts, cell doses/kg of recipient weight, and total colony-forming units (CFUs) were higher in PCB compared with HCB. Post-thaw, the PCB group had a significantly better total nucleated cell recovery, while there were no significant differences in cell viability, CFU recovery, or CD34+ cell recovery. Primary analysis demonstrated faster neutrophil and platelet engraftment for PCB but no differences in overall survival (OS), whereas sensitivity analysis found no effect of processing method on engraftment, but better OS in the HCB group compared with PCB group. CONCLUSION: The UCB processing method had no significant impact on engraftment. However, we cannot completely exclude the effect of processing method on OS. Additional studies may be warranted to investigate the potential impact of the PCB processing method on clinical outcomes.

Dermatopathologist assessment of "pathologist-to-dermatologist" communication for dermatopathology services.

BACKGROUND: While patients are the ultimate beneficiaries of pathology services, pathologist to clinician communication is an essential component of excellent patient care. OBJECTIVE: To survey dermatologists on how well pathologists communicate with them and to assess which aspects of pathologists' communication skills are deemed most significant to dermatologists, stratified by practice type. METHODS: A survey-based instrument was developed and sent to dermatologists through various email listservs. Of the approximately 400 potential Association of Professors of Dermatology respondents, 64 returned the survey questionnaire (response rate 16%). Of the 79 state and regional dermatologic societies, seven agreed to distribute the survey on their listservs (response rate 9%). RESULTS: Surveyed dermatologists believe that the pathologists with whom they work are meeting expectations in the areas of diagnostic accuracy, communicating pertinent information in a timely fashion, integrating written pathology reports into the electronic medical record, and making a clinically meaningful histopathologic interpretation. Discussion of cost of ancillary testing is an area of improvement. University affiliated dermatologists are more likely to use electronic medical records as their predominant mode of communication compared to community dermatologists with and without academic affiliations. Community dermatologists are more likely to use faxed written pathology reports as their predominant mode of communication. CONCLUSION: Physician-to-physician communication is a key component of effective patient care. When it comes to dermatopathology services, dermatologists appear overall satisfied with the indicators examined, however, potential opportunities for improvement exist.

Prevalence and factors associated with diagnosed depression among hospitalized cancer patients with metastatic disease.

PURPOSE: This study aimed to examine the factors associated with diagnosed depression among patients with a metastatic cancer. METHODS: We conducted a cross-sectional analysis of 39,223 hospital records from 2008 to 2013 National Inpatient Sample for patients with metastatic cancer. Diagnosed depression was defined using ICD-9-CM for major depression. Weighted, multivariable hierarchical regression model was used to examine the association between sociodemographic and clinical factors and depression among patients with a metastatic cancer. RESULTS: The prevalence of clinically diagnosed depression in patients with a metastatic cancer in our study sample was 7.3% (5.9% for males and 8.6% for females). The prevalence rate of diagnosed depression increased from 5.3 to 9.4% between 2008 and 2013. In multivariable analysis, patients were more likely to be diagnosed with depression if they were females (aOR = 1.44; 95% CI 1.25-1.66) compared to males; and had higher number of comorbidities (aOR = 1.11 per 1-unit increase in Elixhauser comorbidity score, 95% CI 1.07-1.15). In contrast, patients were less likely to be diagnosed with depression if they were blacks (aOR = 0.59; 95% CI 0.47-0.74) or other race (aOR = 0.58; 95% CI 0.47-0.72) compared with white patients. CONCLUSIONS: Women and individuals with more comorbidities were diagnosed with depression more frequently, whereas black patients were diagnosed less. Our findings could help providers to identify hospitalized patients with the higher risk of depression and screened patients with signs and symptoms of clinical depression.

Trends in the risk and burden of second primary malignancy among survivors of smoking-related cancers in the United States.

While there are a growing number of cancer survivors, this population is at increased risk of developing second primary malignancies (SPMs). We described the incidence, most common tumor sites, and trends in burden of SPM among survivors of the most commonly diagnosed smoking-related cancers. The current study was a population-based study of patients diagnosed with a primary malignancy from the top 10 smoking-related cancer sites between 2000 and 2014 from Surveillance, Epidemiology, and End Results data. SPM risks were quantified using standardized incidence ratios (SIRs) and excess absolute risks (EARs) per 10,000 person-years at risk (PYR). Trends in the burden of SPM were assessed using Joinpoint regression models. A cohort of 1,608,607 patients was identified, 119,980 (7.5%) of whom developed SPM (76% of the SPMs were smoking-related). The overall SIR of developing second primary malignancies was 1.51 (95% CI, 1.50-1.52) and the EAR was 73.3 cases per 10,000 PYR compared to the general population. Survivors of head and neck cancer had the highest risk of developing a SPM (SIR = 2.06) and urinary bladder cancer had the highest excess burden (EAR = 151.4 per 10,000 PYR). The excess burden of SPM for all smoking-related cancers decreased between 2000 and 2003 (annual percentage change [APC] = -13.7%; p = 0.007) but increased slightly between 2003 and 2014 (APC = 1.6%, p = 0.032). We show that 1-in-12 survivors of smoking-related cancers developed an SPM. With the significant increase in the burden of SPM from smoking-related cancers in the last decade, clinicians should be cognizant of long-term smoking-related cancer risks among these patients as part of their survivorship care plans.

Shear wave elastography correlates with liver fibrosis scores in pediatric patients with liver disease.

BACKGROUND: While liver biopsy remains the gold standard, given the procedure risks and sampling errors, there is a need for reliable noninvasive biomarkers of hepatic fibrosis. OBJECTIVE: Determine the accuracy of two-dimensional shear wave elastography (2-D SWE) in predicting the histological severity of liver fibrosis in pediatric patients with known or suspected liver disease. MATERIALS AND METHODS: Subjects 0-18 years old with known or suspected liver disease and liver biopsy within 30 days (n=70) were included. Comparisons by 2-D SWE were made to a control group (n=79). Two-dimensional SWE was performed using the GE LOGIQ E9 system. Liver biopsy specimens were scored according to METAVIR and Ishak scoring systems using Spearman's Rho correlation. Receiver operator characteristic (ROC) analysis, Kruskal-Wallis and Mann-Whitney U tests were conducted. RESULTS: Control group median 2-D SWE measurements were lower than in subjects with any degree of liver fibrosis (P<0.001). Those with METAVIR F0 and Ishak 0 scores had significantly lower median 2-D SWE measurements (1.35 m/s; 1.36 m/s) than those with more advanced liver disease (F1-F3: 1.49-1.62 m/s; 1-4: 1.45-1.63 m/s) (P<0.05 for all), whereas the 2-D SWE in the higher scores were similar. Results did not differ between METAVIR and Ishak scores for any degree of fibrosis. Fibrosis scores moderately correlated with median 2-D SWE measurements (rs=0.43). The area under the curve for F1 compared to combined control/F0 was 0.89 (95% confidence interval [CI] 0.83-0.95; P<0.001) with sensitivity of 94.6% and specificity of 78.6%. Results for Ishak score 1 were similar. The ideal cutoff value for identifying fibrosis was determined to be 1.29 m/s. CONCLUSION: The liver 2-D SWE measurements correlated with the histological liver fibrosis scores, regardless of the histopathological scoring system, although 2-D SWE was better at identifying patients with early fibrosis, not at distinguishing among the individual fibrosis levels. Two-dimensional SWE using the GE LOGIQ US system is useful for identifying pediatric patients at risk for liver fibrosis.

Diagnostic accuracy of non-contrast magnetic resonance enterography in detecting active bowel inflammation in pediatric patients with diagnosed or suspected inflammatory bowel disease to determine necessity of gadolinium-based contrast agents.

BACKGROUND: Pediatric patients with inflammatory bowel disease (IBD) are at increased risk of gadolinium deposition given the potential need for multiple contrast-enhanced magnetic resonance enterography (MRE) exams over their lifetime. OBJECTIVE: To determine whether gadolinium-based contrast agents are necessary in assessing active bowel inflammation on MRE in pediatric patients with known or suspected IBD. MATERIALS AND METHODS: We conducted a retrospective study of 77 patients (7-18 years; 68.8% male) with known (n=58) or suspected (n=19) IBD and endoscopy with biopsy performed within 30 days of MRE without and with contrast evaluated bowel and non-bowel findings. During three visual analysis sessions, two radiologists reviewed pre-, post-, and pre-/post-contrast MRE images. A third radiologist independently reviewed 27 studies to assess inter-reader reliability. We used Cohen kappa (κ), Fleiss kappa, (κF), McNemar test, and sensitivity and specificity to compare MRE readings to combined endoscopic/histopathological findings (the reference standard). RESULTS: The pre- and pre-/post-contrast-enhanced MRE vs. combined endoscopic/histopathological results had moderate agreement (85.7%; κ 0.713, P<0.001; P-value 0.549). Compared to combined endoscopy/histopathology, pre- vs. pre-/post-contrast sensitivity (67%, confidence interval [CI] 0.53-0.79 vs. 67%, CI 0.53-0.79) and specificity (80%, CI 0.59-0.92 vs. 68%, CI 0.46-0.84) varied little (κ 0.42, P<0.001 and κ 0.32, P=0.003, respectively). The three readers had moderate agreement (85.2%; κ 0.695, P=0.001; P-value 0.625). More penetrating complications were identified following contrast administration (P-value 0.04). CONCLUSION: Use of a contrast agent does not improve the detection of active inflammation in the terminal ileum and colon compared to non-contrast MRE, although use of a contrast agent does aid in the detection of penetrating disease.

The cost of a pediatric neurocritical care program for traumatic brain injury: a retrospective cohort study.

BACKGROUND: Inpatient care for children with severe traumatic brain injury (sTBI) is expensive, with inpatient charges averaging over $70,000 per case (Hospital Inpatient, Children Only, National Statistics. Diagnoses- clinical classification software (CCS) principal diagnosis category 85 coma, stupor, and brain damage, and 233 intracranial injury. Diagnoses by Aggregate charges [ https://hcupnet.ahrq.gov/#setup ]). This ranks sTBI in the top quartile of pediatric conditions with the greatest inpatient costs (Hospital Inpatient, Children Only, National Statistics. Diagnoses- clinical classification software (CCS) principal diagnosis category 85 coma, stupor, and brain damage, and 233 intracranial injury. Diagnoses by Aggregate charges [ https://hcupnet.ahrq.gov/#setup ]). The Brain Trauma Foundation developed sTBI intensive care guidelines in 2003, with revisions in 2012 (Kochanek, Carney, et. al. PCCM 3:S1-S2, 2012). These guidelines have been widely disseminated, and are associated with improved health outcomes (Pineda, Leonard. et. al. LN 12:45-52, 2013), yet research on the cost of associated hospital care is limited. The objective of this study was to assess the costs of providing hospital care to sTBI patients through a guideline-based Pediatric Neurocritical Care Program (PNCP) implemented at St. Louis Children's Hospital, a pediatric academic medical center in the Midwest United States. METHODS: This is a retrospective cohort study. We used multi-level regression to estimate pre-/post-implementation effects of the PNCP program on inflation adjusted total cost of in-hospital sTBI care. The study population included 58 pediatric patient discharges in the pre-PNCP implementation group (July 15, 1999 - September 17, 2005), and 59 post-implementation patient discharges (September 18, 2005 - January 15, 2012). RESULTS: Implementation of the PNCP was associated with a non-significant difference in the cost of care between the pre- and post-implementation periods (eß = 1.028, p = 0.687). CONCLUSIONS: Implementation of the PNCP to support delivery of guideline-based care for children with sTBI did not change the total per-patient cost of in-hospital care. A key strength of this study was its use of hospital cost data rather than charges. Future research should consider the longitudinal post-hospitalization costs of this approach to sTBI care.

Predictors for early readmission in acute pancreatitis (AP) in the United States (US) - A nationwide population based study.

BACKGROUND & AIMS: Population based data on the burden and patterns of acute pancreatitis (AP) early readmissions (≤30-days) are limited. METHODS: 2013 Nationwide Readmission Database (NRD) was queried. AP etiology was determined using associated diagnoses codes. Proportion, reasons for readmission, and associated costs were evaluated. Multivariate logistic regression analysis was performed to identify independent predictors for 30-day readmission. RESULTS: After exclusions, we identified 178,541 patients with primary diagnosis of AP (mean age 53 ± 17 years, 51% male). 13.7% were readmitted ≤30 days [7.1% in acute biliary pancreatitis (ABP) patients with index cholecystectomy (CCY), 16.3% in ABP patients without CCY, and 14.3% in non-biliary AP patients (p < 0.0001)]. Reasons for readmission included AP, chronic pancreatitis, Pseudocyst/walled off necrosis, biliary tract disease, smoldering symptoms and others. On multivariate analysis male gender, comorbidity status (≥3), non-biliary etiology, organ failure, Pseudocyst/walled off necrosis complications, and patients discharged to extended care facilities were associated with increased risk of readmission. ABP patients with index CCY had a significantly lower risk of early unplanned readmission (odds ratio 0.45, p < 0.0001) but ABP patients with index ERCP did not (p = 0.96). CONCLUSIONS: About 1 in 7 AP patients had a 30-day readmission after index hospitalization and about half of these were related to AP. Our data confirms the higher risk of readmission in alcohol and idiopathic AP and a lower risk in ABP. Risk of early unplanned readmission is significantly lower in ABP patients who underwent CCY and not ERCP during index hospitalization. Cholecystectomy should be performed in all ABP patients as per recommended guidelines.

Augmented Th17-type immune responses in preterm neonates exposed to histologic chorioamnionitis.

BACKGROUND: Histologic chorioamnionitis (HCA) is a placental inflammatory disorder that frequently precedes preterm delivery. HCA increases risk for long-standing inflammatory injury and may influence immune programming, particularly in preterm (PT) neonates. We hypothesized that HCA exposure is associated with an increased circulating frequency of proinflammatory, Th17-type responses. METHODS: Placental cord blood was collected from HCA-exposed or control neonates (23-41 wk gestation). Frequencies of Th17 and T regulatory (Treg) cells and assessments of Th17-type features in CD4 and Treg cells were determined by flow cytometric analysis. RESULTS: Cord blood samples from 31 PT and 17 term neonates were analyzed by flow cytometry. A diagnosis of HCA in extremely PT (EPT, GA ≤ 30 wk) gestations was associated with the highest cord blood frequencies of progenitor (pTh17, CD4+CD161+) and mature (mTh17, CD4+CD161+CCR6+) Th17 cells. Preterm neonates exposed to HCA also exhibited elevated cord blood frequencies of IL-17+ Treg cells, as well as T cells with effector memory phenotype (TEM) that coexpressed Th17-type surface antigens. CONCLUSION: Th17-type responses are amplified in preterm neonates exposed to HCA. We speculate that a Th17 bias may potentiate the inflammatory responses and related morbidity observed in preterm neonates whose immune systems have been "primed" by HCA exposure.

The quality of care provided to patients with varices in the department of Veterans Affairs.

OBJECTIVES: Practice guidelines define the criteria and standards of care in patients with cirrhosis and varices. However, the extent to which the patients receive recommended care is largely unknown. We evaluated the quality of varices related care and factors associated with receipt of such care. METHODS: We conducted a retrospective cohort study of 550 patients with cirrhosis who sought care at three VA facilities between 2000 and 2007. Using administrative and clinical data, we assessed quality of varices care as measured by eight explicit Delphi panel-derived quality indicators. We also conducted a structured implicit review of patients' medical records to explore the role of patients' refusal, receipt of care outside the VA, or justifiable exclusions to certain care processes as explanations for non-adherence to the quality indicators. RESULTS: Quality scores (max. 100%) varied across individual indicators, ranging from 24.3% for upper endoscopy for varices screening to 72.4% for secondary prophylaxis for variceal bleeding. Justifiable exclusions to indicated care documented in charts were common for primary prophylaxis in patients with varices; receipt of endoscopy; and endoscopic treatment in patients with active bleeding. In contrast, significant shortfalls remained in the receipt of screening endoscopy, use of beta-blockers (in the absence of varices), and use of somatostatin analogs, antibiotics, and secondary prophylaxis in patients with variceal bleeding. Younger patients (<60 vs. >60 year, odds ratio (OR)=1.29, 95% confidence interval (CI) 1.01-1.68), those who saw a gastroenterologist (OR=1.55, 95% CI=1.09-2.21), or those who were seen in the facility with academic affiliation (OR=1.26, 95% CI=1.01-1.58) received higher quality care. CONCLUSIONS: Health-care quality, measured according to whether patients received recommended varices-related care, was suboptimal in this health-care setting. Care that included gastroenterologists was associated with high quality.

Cost analysis of tonsillectomy in children using medicaid data.

OBJECTIVE: To evaluate the cost-effectiveness of adenotonsillectomy (T&A) for adenotonsillar hypertrophy and recurrent tonsillitis through the use of Missouri Medicaid data. STUDY DESIGN: Children ages 2-16 years who had a diagnosis of adenotonsillar hypertrophy (based on medical claim codes) in 2006 (n = 4276) were included in this population-based study. The main outcome was direct total costs paid by Medicaid. Costs 2 years before and after T&A were compared in children who underwent surgical intervention with those who did not as well as costs comparison pre- and post-T&A. Wilcoxon rank-sum or Wilcoxon Signed-rank test was used for costs comparisons. RESULTS: Children with adenotonsillar hypertrophy who underwent T&A were significantly less likely to be African American. They had more adenotonsillar infections before undergoing T&A and greater total costs (median costs $2313 vs. $1945; P = .009). The median costs were $1228 pre-T&A, compared with $823 post-T&A (P < .0001). This reduction in costs of $405 (33%) compares with a median cost of the procedure of $1088. The reduction in costs was mostly because of less antibiotic use and outpatient visits. CONCLUSIONS: African American children have fewer T&A procedures for adenotonsillar hypertrophy than white children, which represents an unexplained racial disparity. Children with adenotonsillar hypertrophy who underwent T&A compared with those who did not had more adenotonsillar infections and greater health care costs. T&A leads to a reduction in costs that, after 2 years, is 37% of the costs of the procedure. Future studies should examine the effects of demographics, obesity, and disease severity on health care costs in children with adenotonsillar hypertrophy.

Incidence and survival characteristics of pediatric ganglioglioma from 2004 to 2018, with focus on infratentorial sites.

Background: Ganglioglioma (GG) is a slow-growing glioneuronal neoplasm, most frequently seen in the supratentorial location in older children and associated with epilepsy syndromes. GG is rare in the infratentorial location, hence we embarked upon analyzing the National Cancer Institute's (NCI) Survival, Epidemiology, and End Results (SEER) database to better evaluate GG outcomes by location in comparison to the broader pediatric low-grade glioma (pLGG) population. Methods: Pediatric patients diagnosed with GG and pLGG from 2004 to 2018 were included in the study. Their demographic, clinical, and survival characteristics were analyzed using SEER*Stat. Results: This study describes the largest cohort of pediatric GG, including 852 cases from year 2004 to 2018, with focus on infratentorial sites. Patients with brainstem GG or those with subtotally resected disease were identified as having higher risk of death. Conclusions: Our analysis highlights brainstem GG as a high-risk, poor-prognostic subgroup and elaborates on the incidence and survival characteristic of this lesser-known subgroup.

The quality of care provided to patients with cirrhosis and ascites in the Department of Veterans Affairs.

BACKGROUND & AIMS: Ascites are the most common complication of cirrhosis. Evidence-based guidelines define the criteria and standards of care for patients with cirrhosis and ascites. However, little is known about the extent to which patients with ascites meet these standards. METHODS: We evaluated the quality of ascites care, measured by 8 explicit Delphi panel-derived quality indicators, in 774 patients with cirrhosis and ascites, seen at 3 Veterans Affairs Medical Centers between 2000 and 2007. We also conducted a structured implicit review of patients' medical charts to determine whether patient refusal, outside care, or other justifiable exceptions to care processes account for nonadherence to the quality indicators. RESULTS: Quality scores (maximum 100%) varied among individual indicators, ranging from 30% for secondary prophylaxis of spontaneous bacterial peritonitis, to 90% for assays for cell number and type in the paracentesis fluid. In general, care targeted at treatment was more likely to meet standards than preventive care. Only 33.2% (95% confidence interval [CI]: 29.9%-32.9%) of patients received all recommended care. Patients with no comorbidity (Deyo index 0 vs >3; odds ratio = 2.21; 95% CI: 1.43-3.43), who saw a gastroenterologist (odds ratio = 1.33; 95% CI, 1.01-1.74), or were seen in a facility with academic affiliation (odds ratio = 1.73; 95% CI: 1.29-2.35) received higher-quality care. Justifiable exceptions to indicated care, documented in charts, were common for patients with paracentesis after diagnosis with ascites, patients that received antibiotics for gastrointestinal bleeding, and patients that required diuretics. However, most patients did not have an explanation documented for nonadherence to recommended care. CONCLUSIONS: Health care quality, measured by whether patients received recommended services, was suboptimal for patients with cirrhosis-related ascites. Care that included gastroenterologists was associated with high quality. However, for some of the quality indicators, too many denominator exceptions existed to allow for accurate automated measurement.

Plant identification applications do not reliably identify toxic and edible plants in the American Midwest.

INTRODUCTION: Exposure to potentially toxic plants is a global problem, resulting in thousands of calls to poison centers and emergency department visits annually and occasional deaths. Persons with limited botanical knowledge may be tempted to rely on smartphone applications to determine if plants are safe to forage. This study evaluated the reliability of several popular smartphone applications to identify foraged foods and distinguish them from potentially toxic plants in the Midwestern United States. METHODS: Sixteen plant species were selected based on local availability, attractiveness as foraged food, and potential for misidentification. Of the 16 species, five are edible, three are potentially toxic if improperly harvested or prepared, and eight are considered to be toxic. Plant specimens were identified by graduate-level botanists and photographed during multiple stages of their growth cycles. LeafSnap, PictureThis, Pl@ntNet and PlantSnap were used to identify the plants. RESULTS: Overall accuracy of the applications in identifying plant genus was 76% (95% confidence interval: 73-79, range 96% for PictureThis to 53% for PlantSnap). Accuracy for identification of plant species was 58% (95% confidence interval 55-62%, range 94% for PictureThis to 34% for PlantSnap). Five of eleven potentially toxic species were identified as an edible species by at least one application. CONCLUSION: Accuracy of the smartphone applications varies, with PictureThis outperforming other apps. At this time, apps cannot be used to safely identify edible plants. Foragers must have adequate botanical knowledge to ensure safe harvesting of wild plants.

Arrhythmia in chronic hemodialysis as a function of predialysis electrolytes and interdialytic interval.

INTRODUCTION: People with end-stage renal disease on hemodialysis are at increased risk for death due to arrhythmia associated with the prolonged interdialytic interval that typically spans the weekend, with bradycardia being the arrhythmia most closely associated with sudden death. In this prospective observational study we assessed whether predialysis fluid and electrolytes values including hyperkalemia are risk factors for the arrhythmias associated with the prolonged interdialytic interval. METHODS: Sixty patients on hemodialysis with a history of hyperkalemia underwent cardiac monitoring for 1 week. Arrhythmia frequency, average QTc interval, and average root mean square of successive differences (rMSSD) per 4-h period were reported. Predialysis electrolytes and electrocardiograms were collected prior to pre- and post-weekend dialysis sessions. Clinical variables were assessed for correlation with arrhythmias. FINDINGS: Predialysis hyperkalemia occurred in 29 subjects and was more common at the post-weekend dialysis session. Bradycardia occurred in 11 subjects and increased before and during the post-weekend dialysis session, but was not correlated with any electrolyte or clinical parameter. Ventricular ectopy occurred in 50 subjects with diurnal variation unrelated to dialysis. Pre-dialysis prolonged QTc was common and not affected by interdialytic interval. Average QTc increased and rMSSD decreased during dialysis sessions and were not correlated with clinical parameters. DISCUSSION: The results confirm that arrhythmias are prevalent in dialysis subjects with bradycardia particularly associated with the longer interdialytic interval; EKG markers of arrhythmia risk are increased during dialysis independent of interdialytic interval. Larger sample size and/or longer recording may be necessary to identify the clinical parameters responsible.

The Effect of a Merit Point Incentive System on the Willingness to Donate Organs.

PURPOSE: Although over 90% of the population of the United States supports organ donation, only 60% of the population is registered as donors. Currently, there is a need for a nonmonetary incentive that will improve willingness to donate. We assessed the young adult population's perspective on their willingness to donate organs when merit points are granted to their family members to prioritize their potential transplant if needed. METHODS: We administered a Qualtrics survey from March 2022 to September 2022 to the undergraduate students volunteering to participate at Saint Louis University, which comprised 10 questions that addressed the attitudes of participants regarding the effects of various factors, including the type of donation and the presence of merit points (vouchers granted to self or a family member to facilitate a potential transplant if needed), on participant's willingness to donate an organ while alive or after death. The responses were analyzed by using SAS software (SAS Institute). RESULTS: A total of 572 participants completed the survey. Overall, only 6.5% of surveyed students were unwilling to donate after death. The willingness to donate while alive to a family member was significantly higher than donating to a stranger (95.8% vs 71.2%, P < .0001). When merit points were added, the unwillingness to donate significantly decreased from 6.5% to 3.8%. However, this change was observed only when the merit points were given to a family member and not to self. When merit points were granted, unwillingness to provide a living donation to a stranger decreased from 28.8% to 16.4% (P < .0001). CONCLUSIONS: Merit points to first-degree family members improve students' expressed willingness to donate organs after death; however, self-merit points did not decrease the rate of "unwillingness to donate after death." When living donation is assessed, offering merit points appears to decrease the "unwillingness to donate to strangers." The adoption of a merit point system in the United States may increase the rates of organ donation.

An electronic health record alert increases human immunodeficiency virus screening and case identification in a high-risk emergency department population.

Increased screening for HIV is required to reduce mortality and transmission. Patients with risk factors for HIV may lack access to routine care and emergency departments are an important site for screening and linkage to care. We implemented an electronic health record algorithm to identify patients meeting criteria for HIV screening. Compared to unstructured clinical judgement, the EHR alert increased the number of patients screened and case identification.

Absence of Injury Is Not Absence of Pain: Prevalence of Preseason Musculoskeletal Pain and Associated Factors in Collegiate Soccer and Basketball Student Athletes.

Unlike musculoskeletal (MSK) injuries, MSK pain is rarely studied in athletes. In this study, we examined the prevalence of preseason MSK pain in apparently healthy collegiate soccer and basketball players and its relationship with previous injuries (1-year history), among other factors. Ninety-seven eligible student athletes (mean age: 20.1 (SD: 1.6) years; 43% male; 53% soccer players) completed a baseline questionnaire comprising questions related to demographics, medical and 1-year injury history and any current MSK pain and the corresponding body location. The overall prevalence of preseason MSK pain was 26% (95% CI: 17-36%) and it did not differ by sex or sport. The back (6.2%) and knee (5.2%) regions were reported to be the most frequently affected body parts for preseason MSK pain. Athletes with a previous injury and with perception of incomplete healing had 3.5-fold higher odds (OR: 3.50; 95% CI: 1.28-9.36) of baseline MSK pain compared with those without a previous injury. One in four collegiate soccer and basketball players had preseason MSK pain. Collegiate sports medicine professionals should consider conducting routine preseason evaluations of MSK pain in their athletes and initiate appropriate interventions for the prevention of MSK pain and its potential consequences among athletes.