Citations

Introduction The literature has consistently demonstrated utilization disparities in joint replacement procedures, though no studies have evaluated disparities in total shoulder arthroplasty with regard to operative volume. Methods We queried the New York (NY) Statewide Planning and Research Cooperative System (SPARCS) database for 32 410 total shoulder arthroplasties performed between 2009 and 2017. Patients were identified using Clinical Classifications Software code 154 for Non-Hip/Knee Arthroplasty and All Patient Refined-Diagnosis Related Group code 322 for Shoulder. Racial groups included Hispanic, non-Hispanic white, non-Hispanic black, and Other. High-volume centers were facilities that performed 2 standard deviations above the mean annual procedures. Utilization rates were calculated by dividing total shoulder arthroplasties per group by the 2010 NY Census population of that group. The Fisher exact test was used to determine significance. Results Total shoulder arthroplasty utilization increased from 43/100 000 to 73/100 000, two-thirds of which was driven by an increase in white resident utilization. More White residents per 100 000 underwent shoulder arthroplasty than Black, Hispanic, and Other residents per 100 000 residents of their respective race. White residents were 90% more likely than Hispanic residents to undergo total shoulder arthroplasty at high-volume centers ( P = .04). There were no differences in utilization rate regarding operative volume comparing Black or Other residents to White residents. More females underwent total shoulder arthroplasty than males, though there was no difference in utilization rate regarding operative volume. Conclusion Though total shoulder arthroplasty utilization nearly doubled, disparities persisted across gender and minority groups particularly in Hispanic utilization as White residents were 90% more likely than Hispanic residents to undergo shoulder arthroplasty at high-volume centers.

Abstract Background The current global pandemic has created unprecedented challenges in the blood supply network. Given the recent shortages, there must be a civilian plan for massively bleeding patients when there are no blood products on the shelf. Recognizing that the time to death in bleeding patients is less than 2 h, timely resupply from unaffected locations is not possible. One solution is to transfuse emergency untested whole blood (EUWB), similar to the extensive military experience fine‐tuned over the last 19 years. While this concept is anathema in current civilian transfusion practice, it seems prudent to have a vetted plan in place. Methods and Materials During the early stages of the 2020 global pandemic, a multidisciplinary and international group of clinicians with broad experience in transfusion medicine communicated routinely. The result is a planning document that provides both background information and a high‐level guide on how to emergently deliver EUWB for patients who would otherwise die of hemorrhage. Results and Conclusions Similar plans have been utilized in remote locations, both on the battlefield and in civilian practice. The proposed recommendations are designed to provide high‐level guidance for experienced blood bankers, transfusion experts, clinicians, and health authorities. Like with all emergency preparedness, it is always better to have a well‐thought‐out and trained plan in place, rather than trying to develop a hasty plan in the midst of a disaster. We need to prevent the potential for empty shelves and bleeding patients dying for lack of blood.

Abstract There are few data on the quality of cancer treatment information available on social media. Here, we quantify the accuracy of cancer treatment information on social media and its potential for harm. Two cancer experts reviewed 50 of the most popular social media articles on each of the 4 most common cancers. The proportion of misinformation and potential for harm were reported for all 200 articles and their association with the number of social media engagements using a 2-sample Wilcoxon rank-sum test. All statistical tests were 2-sided. Of 200 total articles, 32.5% (n = 65) contained misinformation and 30.5% (n = 61) contained harmful information. Among articles containing misinformation, 76.9% (50 of 65) contained harmful information. The median number of engagements for articles with misinformation was greater than factual articles (median [interquartile range] = 2300 [1200-4700] vs 1600 [819-4700], P = .05). The median number of engagements for articles with harmful information was statistically significantly greater than safe articles (median [interquartile range] = 2300 [1400-4700] vs 1500 [810-4700], P = .007).

Substantial evidence indicates the importance of elevated cAMP in polycystic kidney disease (PKD). Preclinical and clinical trials have shown the feasibility of therapies (vasopressin V2 receptor antagonists and somatostatin analogs) acting on G protein coupled receptors to inhibit adenylyl cyclase activity and production of cAMP. An additional or alternative approach could be to increase phosphodiesterase (PDE) mediated hydrolysis of cAMP. Of the large PDE superfamily, PDE1 is the only family activated by calcium, which is reduced in PKD cells. To assess the contribution of PDE1A to renal cyst formation, we depleted PDE1A levels using antisense morpholinos in zebrafish. We identified two splice isoforms with alternative starts corresponding to human PDE1A1 and PDE1A5. Two splice‐blocking morpholinos targeting the common hydrolase domain of both isoforms induced renal cysts. Two additional morpholinos, targeting each start, also induced renal cysts with dose dependence and additive effects. Co‐injection of the start 1 morpholino with pkd2 morpholino increased the severity of hydrocephalus, renal cysts, and body curvature, demonstrating functional interaction of PDE1A and PC2. Overall, data implicate PDE1A in PKD pathogenesis and validate further investigation of PDE1A as a therapeutic target in PKD.

Introduction Visceral obesity is associated with GERD and, traditionally, it has been assumed that visceral fat predisposes to GERD primarily by increasing intra‐abdominal pressure. However, transmission electron microscopy (TEM) of esophageal biopsies from obese individuals without GERD exhibit dilated intercellular spaces (DIS) and, in earlier studies, we found that substances secreted by mature adipocytes in visceral fat from obese patients impair esophageal epithelial barrier function, induce DIS and reduce transepithelial resistance (TER). There is a fat pad at the gastroesophageal junction (GEJ) that is in intimate contact with the distal esophagus. We now explore whether whole GEJ fat tissue of obese individuals secretes substances that impair esophageal barrier function. Methods We obtained GEJ fat from 3 obese (BMI 46, 60, 74) and 3 non‐obese (BMI 24, 26, 27) patients having foregut surgery. Human esophageal squamous cells were seeded into transwells and grown to confluence for 3 days. On day 4, cells were raised to an air‐liquid interface (ALI) to allow for differentiation, stratification, and esophageal barrier formation. ALI cultures were exposed to conditioned media (CM) from GEJ fat or to control medium beginning at day 4. TER was measured on days 4, 6, and 8 using the EVOM2 Epithelial Volt/Ohm Meter. On day 8, ALI cultures were stained with H&E and Ki‐67 and imaged; barrier permeability was assessed by a biotinylation reagent applied to the ALI surface. TEM of ALIs and of esophageal biopsies from 2 non‐obese and 2 obese patients without GERD were assessed. Results CM from all 3 obese patients significantly reduced TER on days 6 and 8; CM from 2 non‐obese patients did not reduce TER whereas CM from 1 non‐obese patient induced a slight reduction in TER at day 8 (Table 1). Marked DIS were found only in ALI cultures grown with CM from obese patients. In ALIs grown with CM from non‐obese patients, the biotinylation reagent stopped at the superficial layers of esophageal cells. In contrast, the biotinylation reagent diffused through all cell layers in ALIs grown with obese patient CM. Increases in basaloid cells and in Ki‐67 were found in ALIs grown with obese patient CM. TEMs of ALIs grown with non‐obese patient CM demonstrated well‐oriented cell‐cell junctions similar to TEMs of non‐obese patient esophageal biopsies. In contrast, ALIs grown with obese patient CM demonstrated cell‐cell junctional structures that were disorganized, aggregated, and floating within the DIS, similar in appearance to TEMs of the obese patients’ esophageal biopsies. Conclusion Substances produced by GEJ fat of obese patients impair esophageal epithelial barrier integrity, cause basal cell hyperplasia and DIS, and disrupt intercellular connections. These findings in ALI cultures recapitulate abnormalities seen by TEM in esophageal biopsies of obese patients.

Hospital medicine ward rounds are often conducted away from patients’ bedsides, but it is unknown if more time-at-bedside is associated with improved patient outcomes. Our objective is to measure the association between “time-at-bedside,” patient experience, and patient–clinician care agreement during ward rounds. Research assistants directly observed medicine services to quantify the amount of time spent discussing each patient’s care inside versus outside the patient’s room. “Time-at-bedside” was defined as the proportion of time spent discussing a patient’s care in his or her room. Patient experience and patient–clinician care agreement both were measured immediately after ward rounds. Results demonstrated that the majority of patient and physicians completely agreement on planned tests (66.3%), planned procedures (79.7%), medication changes (50.6%), and discharge location (66.9%), but had no agreement on the patient’s main concern (74.4%) and discharge date (50.6%). Time-at-bedside was not correlated with care agreement or patient experience ( P > .05 for all comparisons). This study demonstrates that spending more time at the bedside during ward rounds, alone, is insufficient to improve patient experience.

Objectives: Little is known about the experiences of caregivers who provide care to persons with terminal delirium (TD) in home settings. This scarcity of information is suggestive that further research is needed about care for hospice patients with delirium in the home and community. Aim: To elicit views, feelings, and end-of-life care experiences of primary caregivers assisting dying persons with TD in hospice at home. Design: Qualitative, exploratory, cross-sectional study design was chosen. In-depth semistructured interviews explored caregiver experiences in caring for persons with TD. Qualitative thematic framework analysis was used. Participants: Fifteen bereaved adult primary caregivers who received services from a hospice care program affiliated with a large nonprofit health system in the US Midwest. Results: Caregiver experiences were broad and reflected 4 major themes: symptomology, coping, effective and noneffective interventions, and support. The most distressing factors for caregivers were behaviors and symptomology of TD. They did not know what to say, how to respond, and how best to behave with someone who had delirium. Many caregivers had the impression that medication does not lessen delirium symptoms and that nonpharmacologic interventions are effective and beneficial only when they were important and meaningful to patients before delirium onset. Conclusions: This study added new knowledge from direct and personal perspectives of caregivers providing end-of-life care to patients at home. Understanding developed about provision of care to someone with TD in home hospice. Improved comprehension of caregiver experiences can help professional hospice and palliative care staff better prepare caregivers for when patients have TD.

AbstractBackgroundChecklists have been shown to reduce morbidity and mortality in medicine by improving documentation and reducing errors. In the modern era of care, where patients are the centre of decision‐making, this study examines patient perception of care and error prevention with the use of ward round checklist.MethodsWe conducted a prospective stepped‐wedge cluster randomized controlled checklist intervention study using a standardized questionnaire to investigate patients' perception of ward rounds before and after implementation of a ward round checklist.ResultsA total of 124 patients completed the questionnaire. The overall percentage of items endorsed increased significantly by 5.1% from 64.8% to 70.0% (P = 0.014). Statistically significant improvements were seen in patients knowing their diagnosis (P = 0.027), the day's plan (P = 0.038), observing a medication chart (P < 0.001) and observation chart review (P = 0.008).ConclusionOur study indicates that the use of a ward round checklist leads to patient‐perceived improvements in aspects of quality of care.

Abstract Background The etiology of febrile neutropenia in patients with hematological malignancy is identified in only 20–30% of cases. Sinus computed tomography (CT) is often used, regardless of symptoms, to rule out rhinocerebral source of infection. There are no clear guidelines on when to perform sinus CT in this population. In this study, we evaluated the role of sinus CT in febrile neutropenic patients. Methods We retrospectively reviewed medical records of all adults (age ≥18 years) with febrile neutropenia (T≥ 38.3ºC, ANC &lt; 0.5 x 109/L) and hematological malignancies who underwent sinus CT from January 2014 to May 2020. We present the preliminary analysis of the impact of sinus CT findings on the management of febrile neutropenia. Results 47 patients with a total of 56 episodes of febrile neutropenia met the inclusion criteria. The median age at presentation was 57 years (IQR: 42 - 68 years). The most common underlying malignancy was acute myeloid leukemia (51%), followed by myelodysplastic syndrome (19%). At presentation, 47% had refractory disease, 21% were newly diagnosed, 15% had relapsed, 15% were in complete remission, and 2% were in partial remission. Of the total 56 episodes, 29 (52%) had symptoms of rhinorrhea (20%), facial pain (14%), and sinus congestion (14%). The remaining 27 of 56 episodes (48%) had no sinus symptoms. Sinus CT was abnormal in 48 of 56 episodes (86%); the most common finding was mucosal thickening (47/48; 98%), followed by air-fluid levels (7/48; 14.5%), partial opacification (6/48; 12.5%), complete opacification (2/48; 4%), and bony invasion (2/48; 4%). The source of febrile neutropenia was attributed to the CT sinus findings in 9 cases (9/48; 29%), leading to a change in therapeutic management. All 9 patients were symptomatic, with evidence of necrosis in 22% (2/9) and purulence in 22% (2/9) on nasal endoscopy. Table 1 Conclusion Mucosal thickening is a frequent and non-specific imaging finding, particularly in patients without sinus symptoms. Sinus CT findings in patients with febrile neutropenia without sinus symptoms had no impact on clinical management. Consequently, sinus CT may be reserved for patients presenting with sinus symptoms. Disclosures M. Rizwan Sohail, MD, Aziyo Biologics (Consultant)Medtronic Inc (Consultant, Research Grant or Support)