Citations

Background: Benefits of hospice care, such as improvement in quality of life and reduced costs, depend on duration of enrollment in hospice services, making timely hospice referral essential. Patient-, provider-, and system-level factors associated with hospice referral timing and length of stay (LOS) are unclear. 1 – 6 Objective: To review existing hospice referral patterns to identify patient- and system-level factors associated with hospice LOS. Methods: We performed a retrospective review of all adult patients referred from our institution (located in Rochester, Minnesota, USA) to a nonprofit hospice agency between 2013 and 2017. The primary dependent variable was hospice LOS. Patient-level variables included demographic characteristics, place of residence, and hospice diagnosis. System-level variables included referral setting and provider-specific variables, such as title and gender. Statistical analyses were performed using multivariate logistic regression. Results: A total of 2072 patients were referred to hospice during the study period. Patient-level factors associated with LOS included hospice diagnosis and place of residence. Patients referred for cancer had a higher odds of a long LOS, while patients from long-term care facilities had a higher odds of a short LOS. System-level factors associated with LOS included provider gender and title. Referral by a female provider or by a physician, rather than an advanced practice provider, was associated with a lower odds of a short LOS. Conclusion: Based on a review of hospice referral patterns, the integration of hospice care into subspecialty practices, long-term care facilities, and advanced practice education could be an effective strategy to improve hospice LOS.

SUMMARY Lymph nodes with tuberculous lesions identified by federal meat inspectors were collected from 36 swine carcasses at an abattoir in southeastern Minnesota. Nonchromogenic mycobacteria were isolated by culture from 25. By animal pathogenicity and serologic tests, 24 of the 25 were identified as Mycobacterium avium and 1 was a Battey type. Corynebacterium equi was isolated from 4 lesions with M. avium and from 2 without other bacteria. Lesions with C. equi could not be distinguished from others either grossly or microscopically.

Abstract Postpartum pain management practices have significant variation and are known to be influenced by nonclinical factors. We aimed to examine factors that contribute to clinicians' assessment and management of postpartum pain, including the role of opioids. We conducted a qualitative study of obstetric clinicians providing postpartum care at a single, large, tertiary care center (November 2021–June 2022). Attending and trainee OB/GYN physicians and advanced practice providers (APPs) completed in-depth interviews using a semistructured interview guide. Purposive sampling was employed to ensure a representative sample of each clinician type was included. Participants were asked about factors that influence postpartum pain management. Data were analyzed using the constant comparative method. Of 46 participants, 48% were attending physicians, 32% trainee physicians, and 20% APPs. The analysis demonstrated three key themes related to postpartum assessment and management: influencing factors (knowledge or experiences that influence practice), objective findings, and the role of counseling. While clinicians reported guidelines and patient satisfaction as major influencing factors, several also shared the inherent conflict that may arise between them. Objective findings, specifically the impact of pain on patients achieving functional goals, also influenced clinician decision-making. Conversely, many participants reported the limited utility of the numeric pain scale as an objective metric. Additionally, the role of counseling in shared decision-making and providing anticipatory guidance was emphasized. Finally, clinicians had a range of opinions on the role of opioids in pain management, but many spoke to the value of opioids as second-line treatment and the impact of the opioid epidemic on prescribing practices. The factors that influence clinicians' assessment and management of postpartum pain are occasionally in conflict. Furthermore, objective measures, such as the numeric pain scale, have significant limitations.

SUMMARY Normative values were established for results of tests of blood coagulation and platelet function in swine. In swine that have von Willebrand's disease, bleeding time was prolonged, platelet retention was decreased glass bead column), and factor VIII concentration was low.

SUMMARY Factor VIII concentrations in plasma, platelet retention, and ear bleeding times were determined on 35 normal pigs, 40 obligate carriers of porcine von Willebrand's disease, and 25 bleeders. The bleeders could be distinguished from the normal pigs by each of the 3 tests. At most, only one-third of the carriers could be distinguished from the normal pigs by any one test. A hemostatic score, derived from the results of the 3 tests, increased the discrimination to slightly more than half. The degrees of abnormality on the 3 diagnostic tests seemed to vary from family to family and might have been related to the sire of the bleeder.

ABSTRACT Presented is a 76-year-old man with metastatic melanoma that was successfully treated with pembrolizumab, an immune checkpoint inhibitor (ICI). He underwent 20 months of ICI treatment without dose limiting side effects. Nearly 18 months after ICI discontinuation, the patient developed intermittent epigastric pain and diarrhea. Owing to mild symptoms, he was not immediately evaluated. Three years after ICI cessation, he was diagnosed with stricturing, jejunal Crohn's disease. He was treated with vedolizumab and displayed clinical and radiographic response to treatment. This case serves as an example of potential gastrointestinal-related, long-term autoimmune implications of ICI therapy, even in patients without acute side effects.

Purpose To evaluate the effectiveness of adding lateral extra‐articular tenodesis (LET) to primary anterior cruciate ligament reconstruction (ACLR) in competitive female soccer athletes with greater preoperative generalized ligamentous laxity. Methods A retrospective review of female high school and collegiate soccer players who underwent primary ACLR from 2013 to 2021, with a minimum of 2 years of follow‐up, was conducted. Participants were divided into 2 groups: those who received ACLR alone and those who received ACLR with LET. Generalized ligamentous laxity was defined as a Beighton score ≥4 and was not considered an indication for LET. Anterior cruciate ligament (ACL) autografts included the quadriceps, bone−patellar tendon−bone, and hamstrings in both groups. Patient demographics and physical examination findings, including pivot shift results, were collected. Positive pivot‐shift refers to a grade ≥2. Patient outcomes included graft failure (defined as ACL retear), International Knee Documentation Committee score, Lysholm score, return to sport, and complications. Independent t tests, χ 2 tests, and Mann‐Whitney U tests were conducted to compare outcomes between the 2 groups. Minimally clinical important difference was calculated from preoperative to final follow‐up. Results A total of 133 female soccer players who underwent ACLR met inclusion criteria, including 43 patients that received an ACLR + LET and 90 patients who underwent isolated ACLR. Average follow‐up was 39.0 and 36.1 months in the LET group and the control group, respectively. Patients who underwent LET had a greater generalized ligamentous laxity rate (48.8% vs 18.9%; P < .001) and greater median Beighton score (3.0 vs 1.0; P < .001) than those without LET. There was a similar rate of graft failure in patients who underwent LET compared with the control group (4.7% vs 3.0%; P = .658). On the basis of minimally clinical important difference thresholds, there were no clinically relevant differences in International Knee Documentation Committee or Lysholm scores noted between the 2 groups. Return‐to‐sport rates also were comparable between the LET and control cohorts (90.7% vs 85.6%; P = .807). Conclusions The addition of LET during ACLR in female soccer players with preoperative generalized ligamentous laxity yields graft retear and return‐to‐sport rates comparable with those of athletes without ligamentous laxity. Level of Evidence Level III, retrospective comparative study.

ABSTRACTEndobronchial valves have a variety of potential applications, from lung volume reduction in patients with severe emphysema to closing cavities in those with drug‐resistant tuberculosis. This report presents two cases in which endobronchial valves were effectively used to treat pneumomediastinum.

Abstract The expanding use of continuous‐flow left ventricular assist devices (CF‐LVADs) for end‐stage heart failure warrants familiarity with the physiologic interaction of the device with the native circulation. Contemporary devices utilize predominantly centrifugal flow and, to a lesser extent, axial flow rotors that vary with respect to their intrinsic flow characteristics. Flow can be manipulated with adjustments to preload and afterload as in the native heart, and ascertainment of the predicted effects is provided by differential pressure‐flow ( H ‐ Q ) curves or loops. Valvular heart disease, especially aortic regurgitation, may significantly affect adequacy of mechanical support. In contrast, atrioventricular and ventriculoventricular timing is of less certain significance. Although beneficial effects of device therapy are typically seen due to enhanced distal perfusion, unloading of the left ventricle and atrium, and amelioration of secondary pulmonary hypertension, negative effects of CF‐LVAD therapy on right ventricular filling and function, through right‐sided loading and septal interaction, can make optimization challenging. Additionally, a lack of pulsatile energy provided by CF‐LVAD therapy has physiologic consequences for end‐organ function and may be responsible for a series of adverse effects. Rheological effects of intravascular pumps, especially shear stress exposure, result in platelet activation and hemolysis, which may result in both thrombotic and hemorrhagic consequences. Development of novel solutions for untoward device‐circulatory interactions will facilitate hemodynamic support while mitigating adverse events. © 2021 American Physiological Society. Compr Physiol 12:1‐37, 2021.

Abstract Cardiovascular disease (CVD) continues to be the leading cause of death in adults, highlighting the need to develop novel strategies to mitigate cardiovascular risk. The advancing obesity epidemic is now threatening the gains in CVD risk reduction brought about by contemporary pharmaceutical and surgical interventions. There are sex differences in the development and outcomes of CVD; premenopausal women have significantly lower CVD risk than men of the same age, but women lose this advantage as they transition to menopause, an observation suggesting potential role of sex hormones in determining CVD risk. Clear differences in obesity and regional fat distribution among men and women also exist. While men have relatively high fat in the abdominal area, women tend to distribute a larger proportion of their fat in the lower body. Considering that regional body fat distribution is an important CVD risk factor, differences in how men and women store their body fat may partly contribute to sex‐based alterations in CVD risk as well. This article presents findings related to the role of obesity and sex hormones in determining CVD risk. Evidence for the role of sex hormones in determining body composition in men and women is also presented. Lastly, the clinical potential for using sex hormones to alter body composition and reduce CVD risk is outlined. © 2022 American Physiological Society. Compr Physiol 12:1‐45, 2022.