Management of Pediatric Cavum Cysts: A Scoping Review and a Single Institution Case Series.

INTRODUCTION: Pediatric cavum cysts are a rare yet complicated pathology to manage. The literature is scarce, primarily consisting of case series, and lacking a consensus regarding clear management. In this scoping review, we aimed to compile existing information in the literature regarding the management of pediatric cavum cysts across the last 10 years. We also present our management of 19 patients, the largest case series to date, highlighting knowledge gaps surrounding the management of this salient pathology. METHODS: A literature search using PubMed and SCOPUS was conducted using the following search terms: (pediatric) AND (Cavum septum pellucidum) OR (cavum vergae) OR (cavum velum interpositum) AND (management). Eligibility criteria included peer-reviewed publication published in the last 10 years, pediatric population, cavum cyst, and English language. A retrospective search was conducted for all pediatric cavum cysts between 2013 and 2023 at our institution. Clinical and radiographic characteristics as well as intervention and outcome data were collected for both the scoping review and our cases. RESULTS: 330 total articles were populated using our search. 12 articles met our inclusion criteria. 41.7% (n = 5) of the articles were case series, 33.3% (n = 4) were case reports, 8.3% (n = 1) was a technical article, 8.3% (n = 1) was a systematic review, and 8.3% (n = 1) was a case questionnaire. Resolution of symptoms was noted in all articles of our scoping review, regardless of treatment modality. The average age in our case series was 9.84 years old and average age at diagnosis was 5.53 years old. 6 patients (31.6%) were female and 13 patients (68.4%) were male. 2 out of the 19 patients (10.5%) were surgically treated. CONCLUSION: There is no clear consensus on the management of cavum cysts. A prospective, multicenter study is needed to create standardized pediatric cyst management guidelines. The current thought is that surgical intervention should be saved for those patients with obstructive hydrocephalus and signs of intracranial hypertension.

Clinical characteristics, appropriateness of empiric antibiotic therapy, and outcome of Pseudomonas aeruginosa bacteremia across multiple community hospitals.

There is relatively little contemporary information regarding clinical characteristics of patients with Pseudomonas aeruginosa bacteremia (PAB) in the community hospital setting. This was a retrospective, observational cohort study examining the clinical characteristics of patients with PAB across several community hospitals in the USA with a focus on the appropriateness of initial empirical therapy and impact on patient outcomes. Cases of PAB occurring between 2016 and 2019 were pulled from 8 community medical centers. Patients were classified as having either positive or negative outcome at hospital discharge. Several variables including receipt of active empiric therapy (AET) and the time to receiving AET were collected. Variables with a p value of < 0.05 in univariate analyses were included in a multivariable logistic regression model. Two hundred and eleven episodes of PAB were included in the analysis. AET was given to 81.5% of patients and there was no difference in regard to outcome (p = 0.62). There was no difference in the median time to AET in patients with a positive or negative outcome (p = 0.53). After controlling for other variables, age, Pitt bacteremia score ≥ 4, and septic shock were independently associated with a negative outcome. A high proportion of patients received timely, active antimicrobial therapy for PAB and time to AET did not have a significant impact on patient outcome.

Desmopressin Administration and Impact on Hypertonic Saline Effectiveness in Intracranial Hemorrhage.

INTRODUCTION: Desmopressin improves hemostasis through the release of factor VIII, von Willebrand factor, and tissue plasminogen activator, and increases platelet adhesion. Neurocritical Care guidelines recommend consideration of desmopressin in antiplatelet-associated intracranial hemorrhage. Studies supporting its use have not evaluated the potential impact of desmopressin on serum sodium levels in patients receiving hypertonic saline therapy. The purpose of this study was to assess the impact of desmopressin on sodium levels and hypertonic saline effectiveness in intracranial hemorrhage. METHODS: This was a single center retrospective observational chart review. Patients were included in the desmopressin group if they were diagnosed with intracranial hemorrhage, administered desmopressin, and received hypertonic saline infusion. Patients in the hypertonic saline alone group were then matched 1:1 to the patients in the desmopressin group. The primary end point was the effect of desmopressin on reaching a sodium goal of 145-155 mEq/L. The secondary end points included intensive care unit and hospital length of stay, change in sodium, time to reach sodium goal, thrombotic events, mortality, and a composite of increased cerebral edema, hematoma expansion, midline shift, herniation, need for neurosurgical intervention, and neurologic decompensation. RESULTS: Of 112 patients screened, 25 patients met inclusion criteria for the desmopressin group, and 25 patients were matched with patients in the hypertonic saline alone group. The percentage of patients who reached goal sodium in the desmopressin group compared with hypertonic saline alone was similar (80% vs. 88%, respectively). There were no differences in the secondary end points. In the subgroup analysis, patients in the hypertonic saline group met the predefined sodium goal of 150-155 mEq/L within 48 h more often than those in the desmopressin group (82% vs. 60%, respectively, p = 0.042). CONCLUSIONS: The use of desmopressin in intracranial hemorrhage does not appear to negatively impact the ability for patients to reach goal sodium of 145-155 mEq/L. However, in patients with higher sodium goals, desmopressin may decrease hypertonic saline effectiveness.

Care coordination for complex cancer survivors in an integrated safety-net system: a study protocol.

BACKGROUND: The growing numbers of cancer survivors challenge delivery of high-quality survivorship care by healthcare systems. Innovative ways to improve care coordination for patients with cancer and multiple chronic conditions ("complex cancer survivors") are needed to achieve better care outcomes, improve patient experience of care, and lower cost. Our study, Project CONNECT, will adapt and implement three evidence-based care coordination strategies, shown to be effective for primary care conditions, among complex cancer survivors. Specifically, the purpose of this study is to: 1) Implement a system-level EHR-driven intervention for 500 complex cancer survivors at Parkland; 2) Test effectiveness of the strategies on system- and patient-level outcomes measured before and after implementation; and 3) Elucidate system and patient factors that facilitate or hinder implementation and result in differences in experiences of care coordination between complex patients with and without cancer. METHODS: Project CONNECT is a quasi-experimental implementation study among 500 breast and colorectal cancer survivors with at least one of the following chronic conditions: diabetes, hypertension, chronic lung disease, chronic kidney disease, or heart disease. We will implement three evidence-based care coordination strategies in a large, county integrated safety-net health system: 1) an EHR-driven registry to facilitate patient transitions between primary and oncology care; 2) co-locating a nurse practitioner trained in care coordination within a complex care team; 3) and enhancing teamwork through coaching. Segmented regression analysis will evaluate change in system-level (i.e. composite care quality score) and patient-level outcomes (i.e. self-reported care coordination). To evaluate implementation, we will merge quantitative findings with structured observations and physician and patient interviews. DISCUSSION: This study will result in an evaluation toolkit identifying key model elements, barriers, and facilitators that can be used to guide care coordination interventions in other safety-net settings. Because Parkland is a vanguard of safety-net healthcare nationally, findings will be widely applicable as other safety-nets move toward increased integration, enhanced EHR capability, and experience with growing patient diversity. Our proposal recognizes the complexity of interventions and scaffolds evidence-based strategies together to meet the needs of complex patients, systems of care, and service integration. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02943265 . Registered 24 October 2016.

Can fatigue affect acquisition of new surgical skills? A prospective trial of pre- and post-call general surgery residents using the da Vinci surgical skills simulator.

OBJECTIVE: To study the effects of fatigue on general surgery residents' performance on the da Vinci Skills Simulator (dVSS). METHODS: 15 General Surgery residents from various postgraduate training years (PGY2, PGY3, PGY4, and PGY5) performed 5 simulation tasks on the dVSS as recommended by the Robotic Training Network (RTN). The General Surgery residents had no prior experience with the dVSS. Participants were assigned to either the Pre-call group or Post-call group based on call schedule. As a measure of subjective fatigue, residents were given the Epworth Sleepiness Scale (ESS) prior to their dVSS testing. The dVSS MScore™ software recorded various metrics (Objective Structured Assessment of Technical Skills, OSATS) that were used to evaluate the performance of each resident to compare the robotic simulation proficiency between the Pre-call and Post-call groups. RESULTS: Six general surgery residents were stratified into the Pre-call group and nine into the Post-call group. These residents were also stratified into Fatigued (10) or Nonfatigued (5) groups, as determined by their reported ESS scores. A statistically significant difference was found between the Pre-call and Post-call reported sleep hours (p = 0.036). There was no statistically significant difference between the Pre-call and Post-call groups or between the Fatigued and Nonfatigued groups in time to complete exercise, number of attempts, and high MScore™ score. CONCLUSION: Despite variation in fatigue levels, there was no effect on the acquisition of robotic simulator skills.

Urban primate ranging patterns: GPS-collar deployments for Macaca fascicularis and M. sylvanus.

The global increase in urbanization is leading to heavier interface between humans and wildlife. Within these anthropogenic landscapes, little is known about ranging patterns, particularly with regard to urban primates. Here we present the results of the first long-term deployment of multiple GPS collars on two species of macaques to investigate the impacts of urbanization on urban primate ranging patterns in Singapore and Gibraltar. Collars data acquisition were excellent with respect to the amount, quality, and accuracy of data collected; however, remote connectivity and drop-off functionality was poor across all deployments. Analyses highlighted high variability in ranging patterns between individuals within each species that aligned with access to human food resources and patterns of tourism. Individuals from troops with less access to human food had much larger home, core, and day ranges relative to those with regular provisioning or raiding opportunities. Almost no temporal range overlap was observed between any focal individuals at either site and spatial overlap was low for all but two troops at each site. We found no relationship between anthropogenic schedules and changes in ranging patterns. Significant seasonal variation existed for daily path length and day range size for both the Singapore long-tailed and the Gibraltar Barbary macaques, with long-tailed macaques increasing their range during the equatorial monsoon season and Barbary macaques increasing their range during drier, summer months. This study highlights how the behavioral plasticity found within the genus Macaca is reflected in ranging pattern variability within urban environments.

Lessons Learned Designing and Using an Online Discussion Forum for Care Coordinators in Primary Care.

While an increasing number of researchers are using online discussion forums for qualitative research, few authors have documented their experiences and lessons learned to demonstrate this method's viability and validity in health services research. We comprehensively describe our experiences, from start to finish, of designing and using an asynchronous online discussion forum for collecting and analyzing information elicited from care coordinators in Patient-Centered Medical Homes across the United States. Our lessons learned from each phase, including planning, designing, implementing, using, and ending this private online discussion forum, provide some recommendations for other health services researchers considering this method. An asynchronous online discussion forum is a feasible, efficient, and effective method to conduct a qualitative study, particularly when subjects are health professionals.

A typology of primary care workforce innovations in the United States since 2000.

PURPOSE: Innovative workforce models are being developed and implemented to meet the changing demands of primary care. A literature review was conducted to construct a typology of workforce models used by primary care practices. METHODS: Ovid Medline, CINAHL, and PsycInfo were used to identify published descriptions of the primary care workforce that deviated from what would be expected in the typical practice in the year 2000. Expert consultants identified additional articles that would not show up in a regular computerized search. Full texts of relevant articles were read and matrices for sorting articles were developed. Each article was reviewed and assigned to one of 18 cells in the matrices. Articles within each cell were then read again to identify patterns and develop an understanding of the full spectrum of workforce innovation within each category. RESULTS: This synthesis led to the development of a typology of workforce innovations represented in the literature. Many workforce innovations added personnel to existing practices, whereas others sought to retrain existing personnel or even develop roles outside the traditional practice. Most of these sought to minimize the impact on the existing practice roles and functions, particularly that of physicians. The synthesis also identified recent innovations which attempted to fundamentally transform the existing practice, with transformation being defined as a change in practice members' governing variables or values in regard to their workforce role. CONCLUSIONS: Most conceptualizations of the primary care workforce described in the literature do not reflect the level of innovation needed to meet the needs of the burgeoning numbers of patients with complex health issues, the necessity for roles and identities of physicians to change, and the call for fundamentally redesigned practices. However, we identified 5 key workforce innovation concepts that emerged from the literature: team care, population focus, additional resource support, creating workforce connections, and role change.

Barbary macaques show sex-related differences in body weight based on anthropogenic food exposure despite comparable female-male stable isotope ratios.

As the human-primate interface expands, many nonhuman primate (NHP) populations exploit anthropogenic foods to survive, while some populations opportunistically target them. Though anthropogenic food consumption is sometimes associated with greater reproductive output and survival in these populations, there is a dearth of research on possible health effects. We explore how differential exposure to anthropogenic foods is linked to variation in isotopic compositions (δ13C and δ15N) and body weights in Barbary macaques (Macaca sylvanus) in the Upper Rock Nature Reserve, Gibraltar. We placed monkeys into three categories based on anthropogenic food exposure. We then analyzed individuals for isotopic signatures (N = 147) and body weight measurements (N = 80). Using the lowest exposure category as the comparison, we found body weights and δ15N values, but not δ13C values, significantly differed across key categories. Within categories, we found no significant associations between sex and δ13C or δ15N values, suggesting that individuals within categories consumed similar foods regardless of sex. We found a significant interaction effect between category and sex for predicting body weights. These results suggest that sex plays a role in how anthropogenic foods are accessed and consumed regardless of exposure, which may result in differential health profiles for female and male macaques.

Effects of facilitated team meetings and learning collaboratives on colorectal cancer screening rates in primary care practices: a cluster randomized trial.

PURPOSE: The purpose of this study was to evaluate a primary care practice-based quality improvement (QI) intervention aimed at improving colorectal cancer screening rates. METHODS: The Supporting Colorectal Cancer Outcomes through Participatory Enhancements (SCOPE) study was a cluster randomized trial of New Jersey primary care practices. On-site facilitation and learning collaboratives were used to engage multiple stakeholders throughout the change process to identify and implement strategies to enhance colorectal cancer screening. Practices were analyzed using quantitative (medical records, surveys) and qualitative data (observations, interviews, and audio recordings) at baseline and a 12-month follow-up. RESULTS: Comparing intervention and control arms of the 23 participating practices did not yield statistically significant improvements in patients' colorectal cancer screening rates. Qualitative analyses provide insights into practices' QI implementation, including associations between how well leaders fostered team development and the extent to which team members felt psychologically safe. Successful QI implementation did not always translate into improved screening rates. CONCLUSIONS: Although single-target, incremental QI interventions can be effective, practice transformation requires enhanced organizational learning and change capacities. The SCOPE model of QI may not be an optimal strategy if short-term guideline concordant numerical gains are the goal. Advancing the knowledge base of QI interventions requires future reports to address how and why QI interventions work rather than simply measuring whether they work.

Bumps and Bruises in the Trauma Bay: A Level One Trauma Center's Analysis of Dedicated Skeletal X-Ray Imaging.

The Ottawa Ankle Rule and Canadian C-Spine Rule were created to guide the utility of radiographic studies. There are no guidelines to guide X-rays within trauma. Our objective was to evaluate which findings have the highest yield for determining fractures on skeletal x-ray. A retrospective study was performed on 5050 patients at a level one trauma center from January 2018 through October 2019. 2382 patients received X-Rays. Our analysis focused on five categories: limb deformity/obvious open fracture, abrasions, hematoma/contusion/sprain, laceration, and skin tear. Standard demographic and outcome variables were collected. While the cost burden on an overwhelmed system, time in the trauma bay prior to disposition and radiation exposure has not been fully evaluated, our evidence shows that X-Rays ordered for soft tissue defects are less sensitive at identifying fracture (0.0-6.9% fracture detection rate, P = 0.00) than when ordered for limb deformity or obvious fracture.

A Community-Engaged Approach to Understanding Suicide in a Small Rural County in Georgia: A Two-Phase Content Analysis of Individual and Focus Group Interviews.

Suicide is a significant public health problem, with disproportionate rates in rural areas. Rural communities face substantial structural and cultural barriers to suicide prevention. This study aimed to gain a deeper understanding of the need for suicide prevention and gauge the appropriateness of prevention efforts in the context of a rural Georgia county by leveraging existing community resources and knowledge. Twenty one-on-one, semi-structured interviews and two focus groups were conducted, with participants recruited via purposive snowball sampling. Data analysis included qualitative deductive and inductive content analysis from individual interviews and focus groups with community stakeholders. The findings highlight how rural contexts exacerbate drivers of death by suicide and how the substantial loss of community members to suicide contributes to the ongoing crisis and reduces available support. Access to mental health care often depended on a connection to an established public system such as schools, a military base, or Veterans Administration. There were perceived gaps in crisis and post-crisis services, with participants actively trying to address these gaps and build community support through coalition building. This study contributes knowledge to contextual drivers of suicide in rural areas beyond individual-level risk factors. Community-engaged suicide prevention research in rural areas is promising, but there is a need to develop interventions to best support coalition building and capacity development.

Influenza virus infection in nonhuman primates.

To determine whether nonhuman primates are infected with influenza viruses in nature, we conducted serologic and swab studies among macaques from several parts of the world. Our detection of influenza virus and antibodies to influenza virus raises questions about the role of nonhuman primates in the ecology of influenza.

Are ultrasound-guided ophthalmic blocks injurious to the eye? A comparative rabbit model study of two ultrasound devices evaluating intraorbital thermal and structural changes.

BACKGROUND: Since Atkinson's original description of retrobulbar block in 1936, needle-based anesthetic techniques have become integral to ophthalmic anesthesia. These techniques are unfortunately associated with rare, grave complications such as globe perforation. Ultrasound has gained widespread acceptance for peripheral nerve blockade, but its translation to ocular anesthesia has been hampered because sonic energy, in the guise of thermal or biomechanical insult, is potentially injurious to vulnerable eye tissue. The US Food and Drug Administration (FDA) has defined guidelines for safe use of ultrasound for ophthalmic examination, but most ultrasound devices used by anesthesiologists are not FDA-approved for ocular application because they generate excessive energy. Regulating agencies state that ultrasound examinations can be safely undertaken as long as tissue temperatures do not increase >1.5°C above physiological levels. METHODS: Using a rabbit model, we investigated the thermal and mechanical ocular effects after prolonged ultrasonic exposure to single orbital- and nonorbital-rated devices. In a dual-phase study, aimed at detecting ocular injury, the eyes of 8 rabbits were exposed to continuous 10-minute ultrasound examinations from 2 devices: (1) the Sonosite Micromaxx (nonorbital rated) and (2) the Sonomed VuMax (orbital rated) machines. In phase I, temperatures were continuously monitored via thermocouples implanted within specific eye structures (n = 4). In phase II the eyes were subjected to ultrasonic exposure without surgical intervention (n = 4). All eyes underwent light microscopy examinations, followed at different intervals by histology evaluations conducted by an ophthalmic pathologist. RESULTS: Temperature changes were monitored in the eyes of 4 rabbits. The nonorbital-rated transducer produced increases in ocular tissue temperature that surpassed the safe limit (increases >1.5°C) in the lens of 3 rabbits (at 5.0, 5.5, and 1.5 minutes) and cornea of 2 rabbits (both at 1.5 minutes). A secondary analysis of temporal temperature differences between the orbital-rated and nonorbital transducers revealed statistically significant differences (Bonferroni-adjusted P < 0.05) in the cornea at 3.5 minutes, the lens at 2.5 minutes, and the vitreous at 4.0 minutes. Light microscopy and histology failed to elicit ocular injury in either group. CONCLUSIONS: The nonorbital-rated ultrasound machine (Sonosite Micromaxx) increases the ocular tissue temperature. A larger study is needed to establish safety. Until then, ophthalmic ultrasound-guided blocks should only be performed with ocular-rated devices.

From the mouths of monkeys: detection of Mycobacterium tuberculosis complex DNA from buccal swabs of synanthropic macaques.

Although the Mycobacterium tuberculosis complex (MTBC) infects a third of all humans, little is known regarding the prevalence of mycobacterial infection in nonhuman primates (NHP). For more than a century, tuberculosis has been regarded as a serious infectious threat to NHP species. Advances in the detection of MTBC open new possibilities for investigating the effects of this poorly understood pathogen in diverse populations of NHP. Here, we report results of a cross-sectional study using well-described molecular methods to detect a nucleic acid sequence (IS6110) unique to the MTBC. Sample collection was focused on the oral cavity, the presumed route of transmission of MTBC. Buccal swabs were collected from 263 macaques representing 11 species in four Asian countries and Gibraltar. Contexts of contact with humans included free ranging, pets, performing monkeys, zoos, and monkey temples. Following DNA isolation from buccal swabs, the polymerase chain reaction (PCR) amplified IS6110 from 84 (31.9%) of the macaques. In general, prevalence of MTBC DNA was higher among NHP in countries where the World Health Organization reports higher prevalence of humans infected with MTBC. This is the first demonstration of MTBC DNA in the mouths of macaques. Further research is needed to establish the significance of this finding at both the individual and population levels. PCR of buccal samples holds promise as a method to elucidate the mycobacterial landscape among NHP, particularly macaques that thrive in areas of high human MTBC prevalence.

A Descriptive Analysis of Patients With Attempted Suicide at a Rural Level I Trauma Center.

Objectives: For patients with self-harm, suicide attempt, or suicide completion, the trauma bay is often the single point of contact. Regional differences and patterns exist for suicide that should be studied to enhance preventive strategies. Our goal was to critically evaluate the suicidal population of Southeast Georgia over a 9-year period. Methods: A retrospective review of our trauma database from January 2010 through December 2019 was conducted at a Level I Trauma Center. All ages were included. All patients arriving with attempted suicide or death due to a suicidal complication were included. Patients with deaths highly suspicious for suicide were also included. Exclusion criteria included accidental motor vehicle death, accidental generalized deaths, and accidental drowning. Age, gender, race, ethnicity, mechanism of injury (MOI), death rates, length of stay (LOS), injury severity score (ISS), home zip code, day of the week, transfer vs. from scene, location of injury, alcohol levels, and urine drug screening results were analyzed. Results: From 2010 to 2019, there were 381 total suicides with 260 survivals and 121 completions (mortality: 31.7%) at our Level I Trauma Center. The majority of suicides were performed by middle-aged White men with an average age of 40 years (SD: 17.2). This was true even if the White race was not the majority race in the patient's zip code. The majority of the time, these patients presented directly from the scene and, if the patient's suicide location was known, it usually took place at their home. Other common areas included secluded areas, such as wooded areas, and personal vehicles. Of the suicides, 11.6% were performed within the criminal justice system including jail and solitary confinement. The average LOS following admission was 7.51 days (SD: 22.1). The majority of suicides came from the metro Savannah district, which has higher unemployment and poverty rates than other parts of our study area. Gun violence was the most common MOI for suicide (75%). If suicide was attempted via a penetrating mechanism including glass, knife, or gun, there was an increased rate of death when compared to our general data (38% vs. 31%). When the gun mechanisms were analyzed as a group, there was a 57% rate of death after arrival at the hospital. Acute alcohol intoxication was present in 56.6% of patients and 80 (21%) had drugs in their system. Conclusion: Our data demonstrate epidemiologic and socioeconomic trends in Southeast Georgia. This included increased alcohol intoxication, deaths related to gun use, and in a higher incidence of suicide among White males, including geographic locations where the White race is not the majority. Suicides and suicide attempts were also more common in areas with higher unemployment rates.

Quality of ICU Discharge Summaries Produced by Pediatric Residents: The Memorial Health University Medical Center Experience.

Background: Discharging intensive care unit (ICU) patients directly home is becoming more common. High-quality ICU discharge summaries are crucial in the transition of patient care. Currently, at Memorial Health University Medical Center (MHUMC), there exists no standardized ICU discharge summary template or consistency when discharge documentation is completed. Investigators evaluated the timeliness and completeness of ICU discharge summaries at MHUMC produced by pediatric residents. Methods: A single-center retrospective chart review of pediatric patients discharged directly from a 10-bed Pediatric ICU to home was conducted. Charts were evaluated pre- and post-intervention. The intervention included the implementation of a standardized ICU discharge template, formal resident training in writing discharge summaries, and a new policy mandating documentation completion within 48 hours of patient discharge. Timeliness was based on documentation completion within 48 hours. Completeness was evaluated on the presence of the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) recommendations of specific components that should be included in all discharge summaries. Results were reported as proportions, with differences calculated using Fisher's exact and chi-square tests. Patient descriptive characteristics were recorded. Results: Thirty-nine total patients, 13 pre-intervention and 26 post-intervention were included in the study. In the pre-intervention group, 38.5% (5/13) had discharge summaries completed in less than 48 hours from patient discharge compared to 88.5% (23/26) in the post-intervention group (P=.002). Post-intervention discharge documentation was more likely than pre-intervention to contain the discharge diagnosis (100% vs. 69.2%, P=.009) and to provide follow-up care instructions for the outpatient physician (100% vs. 75%, P=.031). Conclusion: Standardizing discharge summary templates and encouraging stricter institutional policies regarding the timely completion of discharge summaries can improve the ICU discharge process. Formal resident training in medical documentation is important and should be incorporated into graduate medical education curricula.

Isolated Hip Fractures in the Elderly: Best Practice Analysis of Perioperative Medical Optimization Including Effect of Comorbidities, Functional Status, and Demographics.

Isolated hip fractures (IHFs) contribute to functional decline in the elderly. Our purpose was to evaluate IHF at two level 1 trauma centers and the effect of comorbidities on length of stay (LOS), ICU admission, disposition, and mortality. A retrospective study from July 2016 through December 2020 including patients ≥65 with IHFs identified 785 patients. Prior dependent functional status yielded a longer LOS (>6 days vs <6 days, P = .01). Comorbidities were not associated with increased LOS or ICU admission. ICU admission rate was 12.75%. Patients with advanced directive had increased ICU admission (8% vs 3%). The mortality rate was 2%. Increased mortality was seen with advanced directives (17% vs 2%, P < .05) and cirrhosis/substance abuse (12% vs 2%, P < .05). Disposition included home (20%), rehabilitation (43%), and SNF (31%). Comorbidities did not affect ICU admission, LOS, or disposition; however, cirrhosis/substance abuse demonstrated increased mortality.

Utility of the HScore for Predicting COVID-19 Severity.

BACKGROUND: Cytokine release syndrome is a life-threatening condition known to cause fever and multiple organ dysfunction and is suspected to be related to the severity of coronavirus disease 2019 (COVID-19). We sought to examine the utility of the HScore and non-cytokine markers of inflammation for predicting COVID-19 outcomes. We hypothesized that cytokine storm, assessed by a modified HScore, would be linked to more severe COVID-19 symptoms and higher mortality. METHODS:  A retrospective review of records from a large, private hospital system was conducted on patients with hemophagocytic lymphohistiocytosis (HLH) (2014-2019) and compared to a large cohort of COVID-19-positive patients (2020). Patients with a sufficient number of elements in their record for a modified HScore calculation (n=4663), were further subdivided into population 1 (POP1, n=67; HLH, n=493 COVID-19), which had eight HScore elements, and population 2 (POP2) with six available HScore elements (POP2, n=102; HLH, n=4561 COVID-19). RESULTS: Modified HScore predicted COVID-19 severity in POP1 and POP2 as measured by higher odds of being on a ventilator (POP2 OR: 1.46, CI: 1.42-1.5), ICU admission (POP2 OR: 1.38, CI: 1.34-1.42), a longer length of stay (p<0.0001), and higher mortality (POP2 OR: 1.34, CI: 1.31-1.39). C-reactive protein (CRP) and white blood cell (WBC) count were the most consistent non-cytokine predictors of COVID-19 severity. CONCLUSION:  Cytokine storm, evaluated using a modified HScore, appeared to play a role in the severity of COVID-19 infection, and selected non-cytokine markers of inflammation were predictive of disease severity.