An ICU Expansion of a Novel Chaplain Intervention, "This is My Story," to Support Interdisciplinary Medical Teams Delivering Care to Non-Communicative Patients in an Academic Medical Center.

The intervention "This is My Story" (TIMS) was previously developed and presented as a case study involving chaplains and support to non-communicative patients (Tracey et al in J Religion Health, 60(5):3282-3290, 2021). This further investigation aims to determine feasibility by looking at eight criteria: acceptability, demand, implementation, practicality, adaptation, integration, expansion, and limited-efficacy testing (Bowen et al in Am J Prev Med 36(5):452-457, 2009). Chaplains conducted recorded conversation with a patient's loved one, then it was edited for brevity and succinctness, and uploaded to the patient's medical chart and can be listened to at any time by medical providers. A completed interview, posted to the patient's electronic medical record (EMR), and able to be listened to by the medical team, was found to be contingent upon two factors: proximity to time between referral to call completion and amount of clinical experience of the chaplain.

TIMS: A Mixed Methods Evaluation of the Impact of a Novel Chaplain Facilitated Recorded Interview Placed in the Medical Chart for the Medical Staff in an ICU During the COVID-19 Pandemic.

The purpose of this study is to examine how a novel intervention known as TIMS, "This is My Story," impacted clinicians caring for patients during the COVID-19 pandemic in the medical intensive care unit (MICU) at the Johns Hopkins Hospital. An eight-question survey was administered to MICU staff on their experience with TIMS files for pre- and post-listening reflections. Qualitative interviews were conducted with 17 staff members who prospectively agreed to participate. A total of 97 pre-listening and 88 post-listening questionnaires were completed. Responses indicated that the audio recording was appropriate to discover more about the patient beyond the immediately observable and useful (98%), "considerably" increased staff empathy for the patient (74%), and thought it would "some" or "considerably" improve subsequent interactions with the patient's loved ones (99%). The qualitative analysis revealed that medical staff found the audio format easy to use and helpful in humanizing patients in their clinical practice. The study demonstrates that TIMS audio files are an important addition to the electronic medical record, enabling clinicians to practice with greater awareness of the patient's context and increased empathy for patients and families.

Ultrasound of the Optic Nerve Does Not Appear to Be a Consistently Reliable or Generalizable Method to Monitor Changes in Intracranial Pressure.

OBJECTIVE: Invasive intracranial pressure (ICP) monitoring is the gold standard, but is not always readily accessible or practical. Ultrasound of the optic nerve sheath diameter (ONSD) has been proposed for detecting both elevation and change in the ICP. Our study is a prospective observational trial that seeks to determine if ultrasound can be reliably used to identify changes in ICP with naturally occurring variations in patient care. METHODS: A convenience sample of patients with invasive ICP monitoring were enrolled. Patients were identified prior to interventions that were suspected to cause a change in ICP. Measurement of ICP and ONSD was obtained prior to the intervention, with repeated measurements of both variables obtained immediately following the intervention. RESULTS: 36 total patients were enrolled. There was a positive correlation between the ICP and the right ONSD (r = 0.255, P = 0.0003) and the ICP and the left ONSD (r = 0.274, P < 0.0001). There was no statistically significant relationship between the change in either the ICP and the right ONSD (r -0.2 P = 0.282) or left ONSD (r 0.05 P = 0.805). The location of the lesion in the brain appears to significantly affect discordance between the ONSD and the ICP. CONCLUSIONS: Ultrasound of the ONSD has shown promise as both a marker of elevated ICP and as a method to identify changes in pressure. Although the size of the ONSD and the measurement of ICP were correlated in our study, the ability to follow changes in ICP was not statistically significant. This indicates that use of ultrasound to track changes in ICP cannot be generalized and may be limited to specific circumstances. The location of the intracranial pathology appears to be a significant factor in discordance between the ICP and ONS diameter.

3-Dimensional Printed Alternative to the Standard Synthetic Flocked Nasopharyngeal Swabs Used for Coronavirus Disease 2019 Testing.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19), can be detected in respiratory samples by real-time reverse transcriptase polymerase chain reaction (RT-PCR) or other molecular methods. Accessibility of diagnostic testing for COVID-19 has been limited by intermittent shortages of supplies required for testing, including flocked nasopharyngeal (FLNP) swabs. METHODS: We developed a 3-dimensional printed nasopharyngeal (3DP) swab as a replacement of the FLNP swab. The performance of 3DP and FLNP swabs were compared in a clinical trial of symptomatic patients at 3 clinical sites (n = 291) using 3 SARS-CoV-2 emergency use authorization tests: a modified version of the Centers for Disease Control and Prevention (CDC) RT-PCR Diagnostic Panel and 2 commercial automated formats, Roche Cobas and NeuMoDx. RESULTS: The cycle threshold-C(t)-values from the gene targets and the RNase P gene control in the CDC assay showed no significant differences between swabs for both gene targets (P = .152 and P = .092), with the RNase P target performing significantly better in the 3DP swabs (P < .001). The C(t) values showed no significant differences between swabs for both viral gene targets in the Roche cobas assay (P = .05 and P = .05) as well as the NeuMoDx assay (P = .401 and P = .484). The overall clinical correlation of COVID-19 diagnosis between all methods was 95.88% (Kappa 0.901). CONCLUSIONS: The 3DP swabs were equivalent to standard FLNP in 3 testing platforms for SARS-CoV-2. Given the need for widespread testing, 3DP swabs printed onsite are an alternate to FLNP that can rapidly scale in response to acute needs when supply chain disruptions affect availability of collection kits.

Increased Risk for Ipsilateral Breast Tumor Recurrence in Invasive Lobular Carcinoma after Accelerated Partial Breast Irradiation Brachytherapy.

BACKGROUND: The suitability criteria for accelerated partial breast irradiation (APBI) from the American Brachytherapy Society (ABS), American Society for Radiation Oncology (ASTRO), and The Groupe Européende Curiethérapie European SocieTy for Radiotherapy & Oncology (GEC-ESTRO) have significant differences. MATERIALS AND METHODS: This is a single institution retrospective review of 946 consecutive patients with invasive breast cancer who underwent lumpectomy and APBI intracavitary brachytherapy from 2003 to 2018. Overall survival (OS), breast cancer-specific survival (BCSS), relapse-free survival (RFS), and ipsilateral breast tumor recurrence (IBTR) were estimated with Kaplan-Meier method. RESULTS: Median follow-up time was 60.2 months. Median age was 68 years (46-94 years). The majority of patients had estrogen receptor (ER)-positive disease (94%). There were 821 (87%) cases of invasive ductal carcinoma and 68 cases (7%) of invasive lobular carcinoma (ILC). The 5-year OS, BCSS, RFS, and IBTR were 93%, 99%, 90%, and 1.5%, respectively. Upon univariate analysis, ILC (hazard ratio [HR], 4.6; p = .008) and lack of nodal evaluation (HR, 6.9; p = .01) were risk factors for IBTR. The 10-year IBTR was 2.5% for IDC and 14% for ILC. While the ABS and ASTRO criteria could not predict IBTR, the GEC-ESTRO intermediate risk group was associated with inferior IBTR (p = .04) when compared to both low risk and high risk groups. None of the suitability criteria was able to predict RFS. CONCLUSION: These results show that APBI is an effective treatment for patients with invasive breast cancer. Expansion of the current eligibility criteria should be considered, although prospective validation is needed. Caution is required when considering APBI for patients with ILC. IMPLICATIONS FOR PRACTICE: In a large retrospective review of 946 patients with early breast cancer treated with partial mastectomy and accelerated partial breast irradiation (APBI) intracavitary brachytherapy, this study demonstrates durable local control. Patients deemed unsuitable or high risk by the American Brachytherapy Society, American Society for Radiation Oncology, and European Society for Radiotherapy and Oncology guidelines were not at increased risk for ipsilateral breast tumor recurrence (IBTR), suggesting that expansion of the current criteria should be considered. Importantly, however, these results demonstrate that caution should be taken when considering APBI for patients with invasive lobular carcinoma, as these patients had relatively high risk for IBTR (10-year IBTR, 14%).

Cancer pain management in the emergency department: a multicenter prospective observational trial of the Comprehensive Oncologic Emergencies Research Network (CONCERN).

PURPOSE: Many patients with cancer seek care for pain in the emergency department (ED). Prospective research on cancer pain in this setting has historically been insufficient. We conducted this study to describe the reported pain among cancer patients presenting to the ED, how pain is managed, and how pain may be associated with clinical outcomes. METHODS: We conducted a multicenter cohort study on adult patients with active cancer presenting to 18 EDs in the USA. We reported pain scores, response to medication, and analgesic utilization. We estimated the associations between pain severity, medication utilization, and the following outcomes: 30-day mortality, 30-day hospital readmission, and ED disposition. RESULTS: The study population included 1075 participants. Those who received an opioid in the ED were more likely to be admitted to the hospital and were more likely to be readmitted within 30 days (OR 1.4 (95% CI: 1.11, 1.88) and OR 1.56 (95% CI: 1.17, 2.07)), respectively. Severe pain at ED presentation was associated with increased 30-day mortality (OR 2.30, 95% CI: 1.05, 5.02), though this risk was attenuated when adjusting for clinical factors (most notably functional status). CONCLUSIONS: Patients with severe pain had a higher risk of mortality, which was attenuated when correcting for clinical characteristics. Those patients who required opioid analgesics in the ED were more likely to require admission and were more at risk of 30-day hospital readmission. Future efforts should focus on these at-risk groups, who may benefit from additional services including palliative care, hospice, or home-health services.

Associations of sedentary behavior bouts with community-dwelling older adults' physical function.

The study aim was to explore associations between sedentary behavior (SB) bouts and physical function in 1360 community-dwelling older adults (≥65 years old). SB was measured using an ActiGraph wGT3X + accelerometer for seven consecutive days at the dominant hip and processed accordingly. Various SB bout lengths were assessed including: 1- to 9-minutes; 10- to 29-minutes; 30- to 59-minutes; and ≥60-minutes, as well as maximum time spent in a SB bout. Total SB time was adjusted for within the SB bout variables used (percentage SB time in the SB bout length and number of SB bouts per total SB hour). Physical function was assessed using the 2-minute walk test (2MWT), 5-times sit-to-stand (chair stand) test, and unipedal stance test (UST). Hierarchical linear regression models were utilized. Covariates such as moderate-vigorous physical activity (MVPA), demographic and health characteristics were controlled for. Lower percentage time spent in ≥60-minute SB bouts was significantly (P < .05) associated with longer 2MWT distance while lower numbers of ≥60-minute SB bouts were associated with longer 2MWT distance, shorter chair stand time and longer UST time. There were mixed associations with physical function for 10- to 29-minute SB bouts. In a large cohort of European older adults, prolonged SB bouts lasting ≥60-minutes appear to be associated with reduced physical function after controlling for MVPA and numerous other important covariates. Besides reducing SB levels, these findings suggest there is a need to regularly interrupt prolonged SB to improve physical function in older adults.

Changes in dietary fat intake and associations with mental health in a UK public sample during the COVID-19 pandemic.

BACKGROUND: Consumption of unhealthy foods may have changed during the COVID-19 pandemic. This study explored how dietary fat intake was impacted in a sample of the UK public who were social distancing during the COVID-19 pandemic. METHODS: Data were collected from a UK COVID-19 online survey. Fat intake was measured using the Dietary Instrument for Nutrition Education questionnaire. Anxiety and depressive symptoms were assessed using Becks' Anxiety and Depression Inventories, while the short-form Warwick-Edinburgh Mental Well-being Scale assessed mental well-being. Differences between individuals who increased versus decreased fat intake were explored using chi-square or independent sample t-tests. Association between fat intake and mental health was explored using adjusted linear regression models. RESULTS: Eight hundred and eighty-seven adults were included. Approximately, 34% recorded medium-to-high levels of fat consumption during social distancing. Around 48% reported decreased fat intake during social distancing compared to usual levels, while 41.3% documented increased fat intake. Fat intake was not significantly associated (P > 0.05) with any measures of mental health. CONCLUSIONS: A higher proportion of a sample of UK adults social distancing during the COVID-19 pandemic recorded decreased fat intake when compared to levels prior to social distancing. There appeared to be no associations between fat intake and mental health.

Effect of Antithrombotic Therapy on Clinical Outcomes in Outpatients With Clinically Stable Symptomatic COVID-19: The ACTIV-4B Randomized Clinical Trial.

Importance: Acutely ill inpatients with COVID-19 typically receive antithrombotic therapy, although the risks and benefits of this intervention among outpatients with COVID-19 have not been established. Objective: To assess whether anticoagulant or antiplatelet therapy can safely reduce major adverse cardiopulmonary outcomes among symptomatic but clinically stable outpatients with COVID-19. Design, Setting, and Participants: The ACTIV-4B Outpatient Thrombosis Prevention Trial was designed as a minimal-contact, adaptive, randomized, double-blind, placebo-controlled trial to compare anticoagulant and antiplatelet therapy among 7000 symptomatic but clinically stable outpatients with COVID-19. The trial was conducted at 52 US sites between September 2020 and June 2021; final follow-up was August 5, 2021. Prior to initiating treatment, participants were required to have platelet count greater than 100 000/mm3 and estimated glomerular filtration rate greater than 30 mL/min/1.73 m2. Interventions: Random allocation in a 1:1:1:1 ratio to aspirin (81 mg orally once daily; n = 164), prophylactic-dose apixaban (2.5 mg orally twice daily; n = 165), therapeutic-dose apixaban (5 mg orally twice daily; n = 164), or placebo (n = 164) for 45 days. Main Outcomes and Measures: The primary end point was a composite of all-cause mortality, symptomatic venous or arterial thromboembolism, myocardial infarction, stroke, or hospitalization for cardiovascular or pulmonary cause. The primary analyses for efficacy and bleeding events were limited to participants who took at least 1 dose of trial medication. Results: On June 18, 2021, the trial data and safety monitoring board recommended early termination because of lower than anticipated event rates; at that time, 657 symptomatic outpatients with COVID-19 had been randomized (median age, 54 years [IQR, 46-59]; 59% women). The median times from diagnosis to randomization and from randomization to initiation of study treatment were 7 days and 3 days, respectively. Twenty-two randomized participants (3.3%) were hospitalized for COVID-19 prior to initiating treatment. Among the 558 patients who initiated treatment, the adjudicated primary composite end point occurred in 1 patient (0.7%) in the aspirin group, 1 patient (0.7%) in the 2.5-mg apixaban group, 2 patients (1.4%) in the 5-mg apixaban group, and 1 patient (0.7%) in the placebo group. The risk differences compared with placebo for the primary end point were 0.0% (95% CI not calculable) in the aspirin group, 0.7% (95% CI, -2.1% to 4.1%) in the 2.5-mg apixaban group, and 1.4% (95% CI, -1.5% to 5.0%) in the 5-mg apixaban group. Risk differences compared with placebo for bleeding events were 2.0% (95% CI, -2.7% to 6.8%), 4.5% (95% CI, -0.7% to 10.2%), and 6.9% (95% CI, 1.4% to 12.9%) among participants who initiated therapy in the aspirin, prophylactic apixaban, and therapeutic apixaban groups, respectively, although none were major. Findings inclusive of all randomized patients were similar. Conclusions and Relevance: Among symptomatic clinically stable outpatients with COVID-19, treatment with aspirin or apixaban compared with placebo did not reduce the rate of a composite clinical outcome. However, the study was terminated after enrollment of 9% of participants because of an event rate lower than anticipated. Trial Registration: ClinicalTrials.gov Identifier: NCT04498273.

Is Physical Activity Associated With Loneliness or Social Isolation in Older Adults? Results of a Longitudinal Analysis Using the Irish Longitudinal Study on Ageing.

Social relationships are central to the health and well-being of older adults. Evidence exploring the association of physical activity (PA) with social isolation and loneliness is limited. This study uses a path analysis to investigate the longitudinal association between loneliness and social isolation with PA using the Irish Longitudinal Study on Ageing. Higher levels of social isolation measured using the Berkman-Syme Social Network Index were directly and indirectly associated with lower levels of walking, moderate PA, and vigorous PA over 6 years. Additionally, higher levels of walking were associated with lower levels of loneliness measured using a modified version of the University of California, Los Angeles loneliness scale over a 3-year period. Future interventions should target individuals who are more socially isolated and explore the effects of different types of PA on loneliness over time.

The Mediating Role of Self-Regulation and Self-Efficacy on Physical Activity Change in Community-Dwelling Older Adults (≥65 Years): An Experimental Cross-Lagged Analysis Using Data From SITLESS.

Improving the capacity for physical activity interventions to maintain behavior change is a key public health concern and an important strategy for the health and independence of older adults. Ways of ensuring effective maintenance of physical activity levels in older adults are unclear. This study includes the objective measure of moderate-to-vigorous physical activity (MVPA); self-reported self-efficacy; and self-regulation at four timepoints (baseline, intervention completion at 4 months, 12-, and 18-month follow-up) from the SITLESS study, a clinical trial conducted with a cohort of community-dwelling older adults (≥65 years) from Denmark, Germany, Spain, and the United Kingdom. A cross-lagged analysis found that self-regulation and self-efficacy may be key determinants of MVPA behavior in community-dwelling older adults. More specifically, the use of behavioral support strategies represents an important correlate of MVPA behavior, and its association with MVPA may be mediated by self-regulation and self-efficacy in older adults in the short and long term.

An Introduction to a Novel Intervention, "This is My Story", to Support Interdisciplinary Medical Teams Delivering Care to Non-Communicative Patients.

This set of three case studies portrays a unique intervention undertaken at The Johns Hopkins Hospital in response to the COVID-19 pandemic with a goal to reduce the impact of absentee visitors during patient care on physicians, nurses, and the patient's loved ones. The intervention, known by the acronym TIMS, "This is My Story", involves a chaplain-initiated telephone call to a loved one, someone who has been identified by the patient as part of their care discussions, of hospitalized patients who have difficulty with communicating to the medical team. The call is recorded then edited for conciseness, and attached to the electronic health record for the entire medical care team to hear. The focus of the chaplain lead conversation with a loved one centers around gathering and presenting information about the patient as a person. Medical team members listen to the edited audio file either on rounds or by utilizing a hyperlink in the electronic health record (EHR). The audio file is two minutes or less in length, as this is the optimal size for comprehension without overburdening the care provider. While conducting the interview, there is an opportunity for chaplains to provide spiritual and emotional support to loved ones and medical staff, contributing substantively to patient care, as is illustrated in the case studies.

The effectiveness and complexity of interventions targeting sedentary behaviour across the lifespan: a systematic review and meta-analysis.

BACKGROUND: Evidence suggests that sedentary behaviour (SB) is associated with poor health outcomes. SB at any age may have significant consequences for health and well-being and interventions targeting SB are accumulating. Therefore, the need to review the effects of multicomponent, complex interventions that incorporate effective strategies to reduce SB are essential. METHODS: A systematic review and meta-analysis were conducted investigating the impact of interventions targeting SB across the lifespan. Six databases were searched and two review authors independently screened studies for eligibility, completed data extraction and assessed the risk of bias and complexity of each of the included studies. RESULTS: A total of 77 adult studies (n=62, RCTs) and 84 studies (n=62, RCTs) in children were included. The findings demonstrated that interventions in adults when compared to active controls resulted in non-significant reductions in SB, although when compared to inactive controls significant reductions were found in both the short (MD -56.86; 95%CI -74.10, -39.63; n=4632; I2 83%) and medium-to-long term (MD -20.14; 95%CI -34.13, -6.16; n=4537; I2 65%). The findings demonstrated that interventions in children when compared to active controls may lead to relevant reductions in daily sedentary time in the short-term (MD -59.90; 95%CI -102.16, -17.65; n=267; I2 86%), while interventions in children when compared to inactive controls may lead to relevant reductions in the short-term (MD -25.86; 95%CI -40.77, -10.96; n=9480; I2 98%) and medium-to-long term (MD -14.02; 95%CI -19.49, -8.55; n=41,138; I2 98%). The assessment of complexity suggested that interventions may need to be suitably complex to address the challenges of a complex behaviour such as SB, but demonstrated that a higher complexity score is not necessarily associated with better outcomes in terms of sustained long-term changes. CONCLUSIONS: Interventions targeting reductions in SB have been shown to be successful, especially environmental interventions in both children and adults. More needs to be known about how best to optimise intervention effects. Future intervention studies should apply more rigorous methods to improve research quality, considering larger sample sizes, randomised controlled designs and valid and reliable measures of SB.

Anticoagulant Reversal Strategies in the Emergency Department Setting: Recommendations of a Multidisciplinary Expert Panel.

Bleeding is the most common complication of anticoagulant use. The evaluation and management of the bleeding patient is a core competency of emergency medicine. As the prevalence of patients receiving anticoagulant agents and variety of anticoagulants with different mechanisms of action, pharmacokinetics, indications, and corresponding reversal agents increase, physicians and other clinicians working in the emergency department require a current and nuanced understanding of how best to assess, treat, and reverse anticoagulated patients. In this project, we convened an expert panel to create a consensus decision tree and framework for assessment of the bleeding patient receiving an anticoagulant, as well as use of anticoagulant reversal or coagulation factor replacement, and to address controversies and gaps relevant to this topic. To support decision tree interpretation, the panel also reached agreement on key definitions of life-threatening bleeding, bleeding at a critical site, and emergency surgery or urgent invasive procedure. To reach consensus recommendations, we used a structured literature review and a modified Delphi technique by an expert panel of academic and community physicians with training in emergency medicine, cardiology, hematology, internal medicine/thrombology, pharmacology, toxicology, transfusion medicine and hemostasis, neurology, and surgery, and by other key stakeholder groups.

Sedentary behavior, physical activity, and mental health in older adults: An isotemporal substitution model.

INTRODUCTION: Regular moderate-to-vigorous physical activity (MVPA) is associated with improved mental health, but the evidence for the effect of reducing sedentary behavior (SB) or increasing light PA (LPA) in older adults is lacking. Using isotemporal substitution (IS) models, the aim of this paper was to investigate the effect of substituting SB with LPA or MVPA on associations with mental health in older adults. METHODS: Data from 1360 older adults (mean age 75.18 years) in four countries were utilized. PA and SB was measured using ActiGraph wGT3X-BT + accelerometers worn for 7 days. Self-rated mental health was measured using the Hospital and Anxiety Depression Scale (HADS). IS models estimated cross-sectional associations when 30 minutes of one behavior was substituted with another. Models were adjusted for age, sex, marital status, and educational attainment. RESULTS: Substituting 30 minutes of SB with LPA (ß -.37; 95% CI -0.42, -0.32) or MVPA (ß -.14; 95% CI -0.21, -0.07) and substituting LPA with MVPA (ß -.11; 95% CI -0.18, -0.04) were associated with improvements in anxiety. However, substituting 30 minutes of SB with LPA (ß .55; 95% CI 0.49, 0.62) was associated with increased depression. CONCLUSION: Replacing 30 minutes of SB with LPA or MVPA was associated with improved anxiety symptoms in older adults. Greater benefits were observed when shifting SB and LPA to MVPA.

Impact of leg movement on skin-adductor canal distance: a potential cause for catheter tip displacement?

PURPOSE: Catheter-based adductor canal blocks are an effective pain management strategy for total knee arthroplasty. Nevertheless, catheter-based techniques may fail if the tip migrates because of leg movement. This observational study used ultrasound to measure the distance from the skin to the adductor canal (SAC). We tested the hypothesis that leg movements mimicking those occurring during postoperative physiotherapy change the SAC distance. METHODS: Following total knee arthroplasty under spinal anesthesia, the SAC distance was measured using ultrasound in 40 patients. The leg was passively moved into five standardized positions: neutral, neutral position with manual lateral displacement of the skin, 30° external rotation, straight leg raised to 30°, and knee and hip flexed to 90°. RESULTS: The mean (standard deviation) SAC distance change from the neutral position was +1.0 (0.6) cm with manual displacement, +0.3 (0.4) cm with external rotation, +0.4 (0.4) cm with straight leg raise, and +0.6 (0.5) cm with leg flexion (P < 0.001 for all positions). SAC distance changes did not correlate with height, body mass index, or leg circumference. CONCLUSION: Passive leg movements in five standardized positions increase the SAC distance. We speculate that the altered SAC distance associated with passive leg movement may contribute to catheter tip dislodgement and adductor canal block failure. TRIAL REGISTRATION: www.clinicaltrials.gov , NCT03562559; registered 19 June, 2018.

RéSUMé: OBJECTIF: Les blocs du canal des adducteurs utilisant un cathéter constituent une stratégie efficace du contrôle de la douleur pour l'arthroplastie totale de genou. Néanmoins, les techniques reposant sur des cathéters peuvent échouer si leur extrémité migre du fait d'un mouvement de la jambe. Cette étude observationnelle a utilisé l'échographie pour mesurer la distance séparant la peau du canal des adducteurs (P-CA). Nous avons testé l'hypothèse que des mouvements de la jambe imitant ceux qui surviennent au cours de la physiothérapie postopératoire modifient la distance P-CA. MéTHODES: Après une arthroplastie totale de genou sous rachianesthésie, la distance P-CA a été mesurée par échographie chez 40 patients. La jambe a été mobilisée passivement dans cinq positions standardisées : position neutre, position neutre avec déplacement latéral manuel de la peau, rotation latérale de 30°, jambe tendue soulevée à 30° et, enfin, genou et hanche fléchis à 90°. RéSULTATS: La modification de la distance P-CA moyenne (écart-type) à partir de la position neutre a été +1,0 (0,6) cm avec le déplacement manuel, +0,3 (0,4) cm avec la rotation latérale, +0,4 (0,4) cm avec la jambe tendue soulevée et +0,6 (0,5) cm avec la jambe fléchie (P < 0,001 pour toutes les positions). Les modifications de la distance P-CA n'étaient pas corrélées à la taille, l'indice de masse corporelle ou la circonférence de la jambe du patient. CONCLUSION: Les mouvements passifs de la jambe dans cinq positions standardisées augmentent la distance P-CA. Nous pensons que la modification de la distance P-CA associée à un mouvement passif de la jambe peut contribuer au déplacement de l'extrémité du cathéter et à l'échec du bloc du canal des adducteurs. ENREGISTREMENT DE L'ESSAI CLINIQUE: www.clinicaltrials.gov, NCT 03562559; Enregistré le 19 juin 2018.

Head-to-head competition does not affect pacing or performance in 1 km cycling time trials.

Previous research has shown enhanced performance and altered pacing behaviour in the presence of a virtual opponent during middle-distance cycling time trials with a duration of 2 min and longer. The purpose of this study was to determine whether these effects are also present in cycling time trials of shorter duration. Twelve physically active men completed three 1-km time trials. After a familiarisation trial (FAM), participants performed two experimental conditions: one without opponent (NO) and one with a virtual opponent (OP). Repeated-measures ANOVAs were used to assess differences in pacing and performance using power output and duration (p<0.05). No differences in mean finishing times (FAM: 91.5 ± 7.7 s; NO: 91.6 ± 6.4 s; OP: 90.9 ± 4.9 s; p=0.907) or power output (FAM: 382 ± 111 W; NO: 363 ± 80 W; OP: 367 ± 67; p=0.564) were found between experimental conditions. Furthermore, no differences in pacing profiles between experimental conditions were found (p=0.199). Similarly, rate of perceived exertion did not differ between experimental conditions at any moment (p=0.831). In conclusion, unlike events of a more prolonged duration (>2 min), the presence of an opponent did not affect participants' pacing behaviour in short duration 1-km time trials.

Is Sedentary Behavior or Physical Activity Associated With Loneliness in Older Adults? Results of the European-Wide SITLESS Study.

Research has found that social relationships are central to the health and well-being of an aging population. Evidence exploring the association between physical activity (PA) and sedentary behavior (SB) with social isolation and loneliness is limited. This study uses objectively measured PA and SB (ActiGraph®) and self-reported measures of loneliness (the De Jong Gierveld Loneliness Scale) and social engagement (the Lubben Social Network Scale) from the SITLESS study, a European-wide study of community-dwelling older adults. Social isolation was associated with SB where higher levels of SB were associated with an increase in the level of social isolation, controlling for age, sex, living arrangements, employment status, body mass index, educational background, marital status, and self-reported general health. In contrast, PA was not associated with social isolation, and neither SB nor PA was a statistically significant predictor of loneliness. SB may be linked to social isolation in older adults, but PA and SB are not necessarily linked to loneliness in older community-dwelling adults.

A case series of penetrating spinal trauma: comparisons to blunt trauma, surgical indications, and outcomes.

OBJECTIVEWhile blunt spinal trauma accounts for the majority of spine trauma, penetrating injuries affect a substantial number of patients. The goal of this study was to examine the epidemiology of penetrating spine injuries compared with blunt injuries and review the operative interventions and outcomes in the penetrating spine injury group.METHODSThe prospectively maintained trauma database was queried for spinal fractures from 2012 to 2018. Charts from patients with penetrating spine trauma were reviewed.RESULTSA total of 1130 patients were evaluated for traumatic spinal fractures; 154 injuries (13.6%) were secondary to penetrating injuries. Patients with penetrating injuries were significantly younger (29.2 years vs 44.1 years, p < 0.001), more likely male (87.7% vs 69.2%, p < 0.001), and more commonly African American (80.5% vs 33.3%, p < 0.05). When comparing primary insurers, the penetrating group had a significantly higher percentage of patients covered by Medicaid (60.4% vs 32.6%, p < 0.05) or prison (3.9% vs 0.1%, p < 0.05) or being uninsured (17.5% vs 10.3%, p < 0.05). The penetrating group had a higher Injury Severity Score on admission (20.2 vs 15.6, p < 0.001) and longer hospital length of stay (20.1 days vs 10.3 days, p < 0.001) and were less likely to be discharged home (51.3% vs 65.1%, p < 0.05). Of the penetrating injuries, 142 (92.2%) were due to firearms. Sixty-three patients (40.9%) with penetrating injuries had a concomitant spinal cord or cauda equina injury. Of those, 44 (69.8%) had an American Spinal Injury Association Impairment Scale (AIS) grade of A. Ten patients (15.9%) improved at least 1 AIS grade, while 2 patients (3.2%) declined at least 1 AIS grade. Nine patients with penetrating injuries underwent neurosurgical intervention: 5 for spinal instability, 4 for compressive lesions with declining neurological examination results, and 2 for infectious concerns, with some patients having multiple indications. Patients undergoing neurosurgical intervention did not show a significantly greater change in AIS grade than those who did not. No patient experienced a complication directly related to neurosurgical intervention.CONCLUSIONSPenetrating spinal trauma affects a younger, more publicly funded cohort than blunt spinal trauma. These patients utilize more healthcare resources and are more severely injured. Surgery is undertaken for limiting progression of neurological deficit, stabilization, or infection control.

Acute HIV Infection in a Patient with Repeat HIV Antibody/Antigen Negative Results Presenting at an Urban Emergency Department: A Case Report.

BACKGROUND: It is not uncommon for patients with human immunodeficiency virus (HIV) infections to visit the emergency department (ED) during seroconversion. However, patients with newly acquired HIV may not have a reactive screening result. We report a case of a patient who initially screened reactive on a fourth generation HIV test and subsequently nonreactive twice, but ultimately had positive viral load tests. CASE REPORT: A 41-year-old woman experiencing symptoms of a sore throat, odynophagia, and back and flank pain for 5 days presented to the ED. The patient had a reactive HIV screen but negative confirmatory antibody test. The ED provider ordered a HIV viral load, informed the patient, and discharged with oral antibacterial agent. The patient returned the next day and after review of Visit 1 results, the ED provider ordered a second HIV screen, which had a nonreactive result. Another HIV viral load order was placed. The patient was discharged and returned a third time, 4 days after initial presentation. On this visit she was admitted, and the initial HIV viral load result returned positive. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We report a case of a patient who initially screened reactive on a fourth generation HIV screening and then twice nonreactive on the same screening test, ultimately having positive viral loads. The most probable explanation for her series of atypical HIV results is that the patient presented during the p24 seroconversion window, which is graphically conveyed in Figure 1. If her first screening had been performed during the window, no further test would have been performed to rule out HIV, contributing to misdiagnosis. ED providers need to be aware that, at some time points during seroconversion from "negative" to "positive", patients recently infected with HIV and manifesting prodromal symptoms may nonetheless have a negative screening result.