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In response to the rapid spread of novel coronavirus disease 2019 (COVID-19), health-care systems should establish procedures for early recognition and management of suspected or confirmed cases. We describe the various steps taken for the development, implementation, and dissemination of the interdisciplinary COVID-19 protocol at Jackson Health System (JHS), a complex tertiary academic health system in Miami, Florida. Recognizing the dynamic nature of COVID-19, the protocol addresses the potential investigational treatment options and considerations for special populations. The protocol also includes infection prevention and control measures and routine care for suspected or proven COVID-19 patients.
Three-dimensional printing (3DP) is becoming a standard manufacturing practice for a variety of biomaterials and biomedical devices. This layer-by-layer methodology provides the ability to fabricate parts from computer-aided design files without the need for part-specific tooling. Three-dimensional printed medical components have transformed the field of medicine through on-demand patient care with specialized treatment such as local, strategically timed drug delivery, and replacement of once-functioning body parts. Not only can 3DP technology provide individualized components, it also allows for advanced medical care, including surgical planning models to aid in training and provide temporary guides during surgical procedures for reinforced clinical success. Despite the advancement in 3DP technology, many challenges remain for forward progress, including sterilization concerns, reliability, and reproducibility. This article offers an overview of biomaterials and biomedical devices derived from metals, ceramics, polymers, and composites that can be three-dimensionally printed, as well as other techniques related to 3DP in medicine, including surgical planning, bioprinting, and drug delivery.
Introduction: Prevalence and incidence of delirium in older patients admitted to acute and long-term care facilities ranges between 9.6% and 89% but little is known in the context of emergency department (ED) incident delirium. Literature regarding the incidence of delirium in the ED and its potential impacts on hospital length of stay (LOS), functional status and unplanned ED readmissions is scant, its consequences have yet to be clearly identified in order to orient modern acute medical care. Methods: This study is part of the multicenter prospective cohort INDEED study. Three Canadian EDs completed the two years prospective study (March-July 2015 and Feb-May 2016). Patients aged 65 years old, initially free of delirium with an ED stay 8hours were followed up to 24h after ward admission. Patients were assessed 2x/day during their entire ED stay and up to 24 hours on hospital ward by research assistants (RA). The primary outcome of this study was incident delirium in the ED or within 24 h of ward admission. Functional and cognitive status were assessed using validated Older Americans’ Resources and Services and the Telephone Interview for Cognitive Status- modified tools. The Confusion Assessment Method (CAM) was used to detect incident delirium. ED and hospital administrative data were collected. Inter-observer agreement was realized among RA. Results: Incident delirium was not different between sites, nor between phases, nor between times from one site to another. All phases confounded, there is between 7 to 11% of ED related incident delirious episodes. Differences were seen in ED LOS between sites in non-delirious patients, but also between some sites for delirious participants (p<0.05). Only one site had a difference in ED LOS between their delirious and non-delirious patients, respectively of 52.1 and 40.1 hours (p<0.05). There is also a difference between sites in the time between arrival to the ED and the incidence of delirium (p=0.003). Kappa statistics were computed to measure inter-rater reliability of the CAM. Based on an alpha of 5%, 138 patients would allow 80% power for an estimated overall incidence proportion of 15 % with 5% precision.. Other predictive delirium variables, such as cognitive status, environmental factors, functional status, comorbidities, physiological status, and ED and hospital length of stay were similar between sites and phases. Conclusion: The fact that incidence of delirium was the same for all sites, despite the differences of ED LOS and different time periods suggest that many other modifiable and non-modifiable factors along LOS influenced the incidence of ED induced delirium. Emergency physician should concentrate on improving senior-friendly environment for the ED.
Introduction: It is documented that physicians and nurses fail to detect delirium in more than half of cases from various clinical settings, which could have serious consequences for seniors and for our health care system. The present study aimed to describe the rate of documented incident delirium in 5 Canadian Emergency departments (ED) by health professionals (HP). Methods: This study is part of the multicenter prospective cohort INDEED study. Patients aged 65 years old, initially free of delirium with an ED stay 8hours were followed up to 24h after ward admission. Delirium status was assessed twice daily using the Confusion Assessment Method (CAM) by trained research assistants (RA). HP reviewed patient charts to assess detection of delirium. HP had no specific routine detection of delirious ED patients. Inter-observer agreement was realized among RA. Comparison of detection between RA and HP was realized with univariate analyses. Results: Among the 652 included patients, 66 developed a delirium as evaluated with the CAM by the RA. Among those 66 patients, only 10 deliriums (15.2%) were documented in the patients medical file by the HP. 54 (81.8%) patients with a CAM positive for delirium by the RA were not recorded by the HP, 2 had incomplete charts. The delirium index was significantly higher in the HP reported group compared to the HP not reported, respectively 7.1 and 4.5 (p<0.05). Other predictive delirium variables, such as cognitive status, functional status, comorbidities, physiological status, and ED and hospital length of stay were similar between groups. Conclusion: It seems that health professionals missed 81.8% of the potential delirious ED patients in comparison to routine structured screening of delirium. HP could identify patients with a greater severity of symptoms. Our study points out the need to better identify elders at risk to develop delirium and the need for fast and reliable tools to improve the screening of this disorder.
Coinfection with human immunodeficiency virus (HIV) and viral hepatitis is associated with high morbidity and mortality in the absence of clinical management, making identification of these cases crucial. We examined characteristics of HIV and viral hepatitis coinfections by using surveillance data from 15 US states and two cities. Each jurisdiction used an automated deterministic matching method to link surveillance data for persons with reported acute and chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infections, to persons reported with HIV infection. Of the 504 398 persons living with diagnosed HIV infection at the end of 2014, 2.0% were coinfected with HBV and 6.7% were coinfected with HCV. Of the 269 884 persons ever reported with HBV, 5.2% were reported with HIV. Of the 1 093 050 persons ever reported with HCV, 4.3% were reported with HIV. A greater proportion of persons coinfected with HIV and HBV were males and blacks/African Americans, compared with those with HIV monoinfection. Persons who inject drugs represented a greater proportion of those coinfected with HIV and HCV, compared with those with HIV monoinfection. Matching HIV and viral hepatitis surveillance data highlights epidemiological characteristics of persons coinfected and can be used to routinely monitor health status and guide state and national public health interventions.
To evaluate the incidence of surgical-site infections (SSIs) in a cohort of liver transplant recipients and to assess risk factors predisposing patients to these infections.
Prospective observational cohort study.
Single transplant center in Canada.
Patients who underwent liver transplantation between February 2011 and August 2014.
Multivariate logistic regression was used to identify independent risk factors for SSIs in liver transplant patients.
We enrolled 250 liver transplant recipients. The recipients’ median age at the time of transplantation was 56 years (range, 19–70 years), and 166 patients (66.4%) were male. Moreover, 47 SSIs were documented in 43 patients (17.2%). Organ-space, superficial, and deep SSIs were noted in 29, 7, and 3 patients, respectively. In addition, 2 patients developed superficial and organ-space SSIs, and another 2 patients were found to have deep as well as organ-space infections. In total, we identified 33 organ-space SSIs (70.2%), 9 superficial SSIs (19.1%), and 5 deep SSIs (10.6%). Factors predictive of SSIs by multivariate analysis were duct-to-duct anastomosis (odds ratio [OR], 3.88; 95% CI, 1.85–8.13; P<.001) and dialysis (OR, 3.57; 95% CI, 1.02–12.50; P=.046). Of the 66 organisms isolated in both deep and organ-space SSIs, 55 (83%) were resistant to cefazolin.
Organ-space SSIs are a common complication after liver transplantation. Duct-to-duct anastomosis and dialysis were independent risk factors associated with SSIs. Appropriate perioperative prophylaxis targeting patients with duct-to-duct anastomosis and dialysis while simultaneously providing optimum coverage for the potential pathogens causing SSIs is warranted.
Persistent pain is common and inadequately treated in cancer patients. Behavioral pain interventions are a recommended part of multimodal pain treatments, but they are underused in clinical care due to barriers such as a lack of the resources needed to deliver them in person and difficulties coordinating their use with clinical care. Pain coping skills training (PCST) is an evidence-based behavioral pain intervention traditionally delivered in person. Delivering this training via the web would increase access to it by addressing barriers that currently limit its use. We conducted a patient pilot study of an 8-week web-based PCST program to determine the acceptability of this approach to patients and the program features needed to meet their needs. Focus groups with healthcare providers identified strategies for coordinating the use of web-based PCST in clinical care.
Participants included 7 adults with bone pain due to multiple myeloma or metastasized breast or prostate cancer and 12 healthcare providers (4 physicians and 8 advanced practice providers) who treat cancer-related bone pain. Patients completed web-based PCST at home and then took part in an in-depth qualitative interview. Providers attended focus groups led by a trained moderator. Qualitative analyses identified themes in the patient and provider data.
Patients reported strongly favorable responses to web-based PCST and described emotional and physical benefits. They offered suggestions for adapting the approach to better fit their needs and to overcome barriers to completion. Focus groups indicated a need to familiarize healthcare providers with PCST and to address concerns about overburdening patients. Providers would recommend the program to patients they felt could benefit. They suggested applying a broad definition of cancer pain and having various types of providers help coordinate program its use with clinical care.
Significance of results:
Web-based PCST was acceptable to patients and providers. Our findings suggest that patients could benefit from this approach, especially if patient and provider barriers are addressed.
Introduction: Influenza and pneumococcal disease are vaccine preventable diseases that account for significant morbidity and mortality in Canada. Influenza vaccination has been shown to reduce mortality and pneumococcal vaccination reduces invasive pneumococcal disease. Previous studies have shown that emergency department (ED) patients are often at high risk for influenza and pneumococcal disease and willing to be vaccinated during their ED stay. Our study set out to determine what proportion of adult patients in the ED qualify for and are willing to be vaccinated against influenza and pneumococcus during their ED visit. Methods: Our study used a convenience sample of patients presenting to the ED at a large Canadian tertiary care centre (Vancouver General Hospital). Inclusion criteria were: adult patients (19 years or greater); consenting to be screened for immunization status; and able to communicate in English. The exclusion criteria were: critically ill patients and patients in severe pain. The primary outcome was the proportion of patients presenting to the ED that could be immunized for influenza and pneumococcus (member of a high risk group, unvaccinated and willing to be vaccinated). Secondary outcomes included additional demographic characteristics and patient attitudes regarding vaccination. Results: We screened 413 patients of which 55 did not meet inclusion/exclusion criteria and 104 declined participation. A total of 254 patients completed the survey for a response rate of 71%. Our primary outcome was present in 20% of patients for influenza (high risk for complications, unvaccinated and willing to be vaccinated in the ED). For pneumococcus, 15% were at high risk, unvaccinated and willing to be vaccinated in the ED. In our population, 83% were at high risk of complications from influenza and 58% were at high risk of complications from pneumococcus. In total, 53% of patients would accept influenza vaccine and 44% would accept pneumococcal vaccine. Conclusion: Our study demonstrates that there is a significant high-risk population that is otherwise unreached and are willing to be vaccinated for influenza and pneumococcus in the ED. Our patient population has a very high prevalence of risk factors for complications of pneumonia and influenza. This data suggests that ED patients are a high-risk population and could be a target group for vaccination campaigns.
Introduction: Early warning scores (EWS) use vital signs to identify patients at risk of critical events as defined by unplanned intensive care unit (ICU) admission, cardiopulmonary resuscitation (CPR), or death. Systems that combine an EWS with a ICU outreach team can improve hospital survival and cardiac arrest rates. Although initially developed for use in ward patients, evidence suggests that EWS are useful in emergency department (ED) patients and may aid in the earlier identification of sepsis. The Hamilton Early Warning Score (HEWS) was recently developed as part of quality improvement process in our health system. The current study examined HEWS at ED triage among a cohort of patients who experienced a critical event during their hospitalization. HEWS were also evaluated as a predictor of sepsis. Methods: Patient were selected from a database of patients admitted to a medical or surgical ward at two tertiary care hospitals over a six-month period. Cases were patients who experienced a critical event during admission and were admitted via the ED. Controls were randomly selected from the database in a two-to-one ratio using an algorithm to match cases based upon burden of comorbid illness. Receiver operator curves (ROC) and likelihood ratios were used to evaluate HEWS at ED triage as a predictor of likelihood of critical deterioration and sepsis. Results: The sample included 845 patients of whom 267 experienced a critical event. The median time to occurrence of critical event from admission was 124 hours. ROC analysis indicated that HEWS at ED triage had poor discriminative ability for predicting likelihood of experiencing a critical event 0.63 [95%CI: 0.58-0.67]. HEWS had fair discriminative ability for predicting likelihood of meeting criteria for sepsis 0.75 [95%CI: 0.71-0.80], and good discriminative ability for predicting likelihood of experiencing a critical event among patients meeting criteria for sepsis 0.80 [95%CI: 0.74-0.86]. Conclusion: This retrospective study indicates that HEWS at ED triage has limited utility for identifying patients at risk of experiencing a critical event. This may be because deterioration commonly occurred days after admission. However, HEWS may have utility as tool for aiding earlier identification of critically ill septic patients. Prospective studies are needed to further delineate the utility of the HEWS in the ED.
Information about viral acute respiratory infections (ARIs) is essential for prevention, diagnosis and treatment, but it is limited in tropical developing countries. This study described the clinical and epidemiological characteristics of ARIs in children hospitalized in Vietnam. Nasopharyngeal samples were collected from children with ARIs at Ho Chi Minh City Children's Hospital 2 between April 2010 and May 2011 in order to detect respiratory viruses by polymerase chain reaction. Viruses were found in 64% of 1082 patients, with 12% being co-infections. The leading detected viruses were human rhinovirus (HRV; 30%), respiratory syncytial virus (RSV; 23·8%), and human bocavirus (HBoV; 7·2%). HRV was detected all year round, while RSV epidemics occurred mainly in the rainy season. Influenza A (FluA) was found in both seasons. The other viruses were predominant in the dry season. HRV was identified in children of all age groups. RSV, parainfluenza virus (PIV) 1, PIV3 and HBoV, and FluA were detected predominantly in children aged <6 months, 6–12 months, 12–24 months, and >24 months, respectively. Significant associations were found between PIV1 with croup (P < 0·005) and RSV with bronchiolitis (P < 0·005). HBoV and HRV were associated with hypoxia (P < 0·05) and RSV with retraction (P < 0·05). HRV, RSV, and HBoV were detected most frequently and they may increase the severity of ARIs in children.
An algorithm of operational modal analysis in time domain is presented for the
discrimination between structural modes, harmonic excitations and spurious modes. A
classification factor is developed and based on the construction of the damped signal- to-
noise ratio which separates the physical modes from the numerical ones. The harmonic
excitations are then recognized at very high power indexes and zero damping. Furthermore,
after the modal discrimination, the harmonic spectrum and the estimated frequency response
function can be derived. The method can be updated in the time domain either by a short
time sliding window or a recursive technique to provide the modal monitoring in both
stationary and non-stationary process. An industrial application on a hydro-electrical
generator is discussed to identify the machine frequencies under operational working
This study presents a finite element (FE) model of the human hand-arm system to derive
natural frequencies and mode shapes. The FE model is calibrated by considering modal
parameters obtained from experimental vibration analyzed by using operational modal
analysis (OMA) and transmissibility. Modal and harmonic analyses of the FE model are
performed for two boundary conditions. The first one considers fixed shoulder condition
while the second one introduces the trunk in order to permit motion of the shoulder. The
results show that the natural frequencies of the second model that permits shoulder motion
are comparable with those determined from measurements. Especially, the natural frequency
about 12 Hz, which is corresponding to the frequency of maximum weight in ISO-5349-1
(2001), is not present in the model with fixed shoulder condition, while it appears in the
second model. The results of the present study suggest that improved finite element models
of the human hand-arm system may reveal hand-arm injury mechanism, the understanding of
which may assist in deriving appropriate frequency weightings for the assessment of
different components of the hand-arm vibration syndrome.
The sensor team at the Los Alamos National Laboratory is an integrated multidisciplinary group that develops both core technologies as well as accessory tools for efficient biodetection. We have developed a waveguide-based optical biosensor for the efficient and ultra-sensitive, rapid detection of biological agents. We have previously demonstrated the use of this technology for the detection of biomarkers associated with many diseases. Herein, we present the preliminary data demonstrating the extension of this technology to the discovery and detection of Traumatic Brain Injury (TBI). TBI afflicts a significant percentage of US troops deployed in Iraq and Afghanistan, but is difficult to diagnose efficiently. Currently, only neuropsychological questionnaires are being used for the diagnosis of this condition, which can range from mild concussion to severe brain damage. The ultimate goal of this project is to develop a rapid biomarker-based diagnostic for TBI in blood. However, this cannot be accomplished until a comprehensive repertoire of biomarkers secreted during brain injury is established. This requires an integrated biomarker discovery and detection approach that is sampled directly from human serum and cerebrospinal fluid.
The results reported here are preliminary steps in that direction wherein we aim to develop two different methods for the discovery of novel biomarkers of TBI in blood and cerebrospinal fluid, as well as develop assays for two biomarkers on an ultra-sensitive waveguide-based platform that was developed at LANL. We were able to evaluate two different methods for biomarker discovery: Matrix-assisted laser desorption/ionization mass spectrometry (MALDI-MS) and two dimensional gel electrophoresis (2-DE) in serum samples. In addition to development of depletion protocols to remove abundant proteins in serum, we were also able to detect spiked TBI biomarkers using both methods. However, the results clearly show that for protein biomarkers, MALDI MS is much more sensitive than 2-DE. We also developed a sandwich immunoassay on a waveguide-based platform for a TBI biomarker, procalcitonin, using commercially available antibodies. We show with our methods that we were able to directly detect procalcitonin from human serum. While our discovery and detection methods show promising results, these methods need to be further optimized before we can apply it to clinically relevant samples.
Stable, aqueous, red-to-near infrared emission is critical for the use of silicon nanoparticles (Si NPs) in biological fluorescence assays, but such Si NPs have been difficult to attain. We report a synthesis and surface modification strategy that protects Si NPs and preserves red photoluminescence (PL) in water for more than 6 mo. The Si NPs were synthesized via high temperature reaction, liberated from an oxide matrix, and functionalized via hydrosilylation to yield hydrophobic particles. The hydrophobic Si NPs were phase transferred to water using the surfactant cetyltrimethylammonium bromide (CTAB) with retention of red PL. CTAB apparently serves a double role in providing stable, aqueous, red-emitting Si NPs by (i) forming a hydrophobic barrier between the Si NPs and water and (ii) providing aqueous colloidal stability via the polar head group. We demonstrate preservation of the aqueous red emission of these Si NPs in biological media and examine the effects of pH on emission color.
Hyperemesis gravidarum (HG), severe nausea and vomiting of pregnancy, is characterized by prolonged maternal stress, undernutrition and dehydration. Maternal stress and malnutrition of pregnancy are linked to poor neonatal outcome and associated with poor adult health, and we recently showed that in utero exposure to HG may lead to increased risks of psychological and behavioral disorders in the offspring. In addition, we have shown familial aggregation of HG, which is strong evidence for a genetic component to the disease. In this study, we compare the rates of psychological and behavioral disorders in 172 adults with and 101 adults without a sibling with HG. The rate of emotional/behavioral disorders is identical (15%) in both groups. The results suggest that the etiology of HG is not likely to include genetic factors associated with emotional and behavioral disorders. In addition, this study provides evidence that the increased incidence of psychological/behavioral disorders among offspring of women with HG is attributable to the HG pregnancy itself, rather than to confounding genetic factors linked to HG.