Citations

Background/Purpose: Research about mobilization of patients who receive IV-tPA is scarce. Patients are routinely kept on bed rest for 24-48 hours after tPA for monitoring despite a lack of evidence justifying this lengthy immobilization. Several stroke rehabilitation studies report mobilizing patients within 24 hours of stroke. However, none of these studies included patients who received tPA and there are no published recommendations for safe timeframes for initiating mobilization of these patients. We completed a preliminary study to assess the hypothesis that adverse safety outcomes of early mobilization of this patient population are minor. Methods: We conducted a study between June 2011 and July 2012 involving early mobilization (i.e. PT/OT between 13 and 24 hours) of patients administered tPA. A safety screen was performed before mobilization occurred to verify hemodynamic stability of patients. Mobilization may have included sitting, standing, transferring to a chair, and ambulation. Results: Nearly 97% (30/31) of patients provided consent (12 female, 18 male; mean age: 66.8, range: 32-89; mean admission NIHSS 5.37, range 0 - 27). All consented patients were screened and 23/30 were mobilized without adverse response. Eighty-six percent (70/81) of activity events had no adverse response. The adverse events that were observed were transient and minor: 2 subjects reported “dizziness” (without a corresponding drop in BP), 3 subjects had an increase in DBP to > 105 (with resting DBPs as follows: 93, 104, and 62 mmHg), 1 subject had a HR > 100 bpm (resting HR was 96 bpm), and 1 had new-onset of neurological signs (transient L hemiparesis that resolved within an hour). Analysis is currently being performed Biostatistician. Conclusion: Early mobilization of patients post ischemic stroke 13-24 hours after IV-tPA infusion appears safe for 76.7% of patients and during 86.4% of activity events. In conclusion, adverse responses were largely minor with no sustained worsening of neurologic deficits. Study investigators recommend larger-powered studies for validation of safety findings to develop evidenced-based guidelines for early mobilization of this patient population.

Introduction: Elevations of troponin after subarachnoid hemorrhage (SAH) frequently occur and are associated with cardiopulmonary complications. The time to peak elevation remains poorly described in terms of the natural history after SAH. Our two objectives were to define the temporal profile of troponin T elevation after SAH and correlate levels of troponin T with baseline neurological status. We hypothesized that troponin T would peak early after initial presentation. Methods: We reviewed the medical records of all aneurysmal and non-traumatic SAH patients from March 2011-December 2012. Troponin T from patients with ≥ 2 values was recorded with respect to SAH symptom onset. Patients with ≥ 1 Troponin T value were stratified according to admission Glasgow Coma Scale (GCS). GCS was dichotomized to > 8 or ≤ 8. Fisher’s exact test was performed comparing elevated peak troponin T (≥0.01 ng/ml) versus normal against GCS status cutoffs > 8 or 8 or less. Results: We identified 124 patients who had both troponin T and GCS reported, and 30 patients had ≥2 troponin T measurements within the first 40 hours of hospitalization. The median time to peak troponin T in these patients was 11.2 hours with a standard deviation of 6.2 hours (Range: 4.9-35.0 hours). Elevated troponin T was seen in 52 of 124. GCS of ≤ 8 was present in 43 of 124. Patients with elevated levels of troponin T had a greater chance of lower GCS [Odds ratio = 4.8 (95% CI: 2.2 to 10.7)] (P= <0.0001). Conclusions: The median time to peak troponin T after SAH injury was 11 hours. There was a statistically significant association between troponin T elevation and worse neurologic status at presentation (GCS ≤ 8). Although our small sample size found large variation in time to peak troponin, it supports the hypothesis that troponin peaks early after the initial presentation. Future studies using troponin elevation as a biomarker should focus on sample acquisition at the time of admission and in the first 1-2 days.

Background. Apical hypertrophic cardiomyopathy (AHCM) has been considered a ``benign” form of HCM in Asian and non-Asian patients (pt). However, data on long-term outcome of pt with AHCM are limited. The purpose of this study was to determine the natural history of pt with AHCM followed at a tertiary referral center in North America. Methods. Between July 1976 and September 2006, 193 pt with the diagnosis of AHCM were seen at the Hypertrophic Cardiomyopathy Clinic. The last echocardiographic exam was reviewed in all pt. Follow-up data were obtained where possible (clinic visit). Results. Mean age at diagnosis 56±17 years, mean age at first presentation at our center was 58±17 years. Symptoms included chest pain in 69 pt (36 %), and exertional dyspnea ≥NYHA II in 97 pt (50 %). A family history of either HCM and/or sudden cardiac death was reported by 36 pt (19 %). Coronary artery disease was proven in 40 pt (21 %). Median follow up was 50 months (1–318) and obtained in 124 pt (64 %). The following events were reported at the last clinic visit: heart failure in =5 pt, syncope in =0 pt, ventricular tachycardia in =7 pt, ICD implantation in 22 pt, and stroke in 22 pt. Death from all causes occurred in 51 of 193 pt (26 %) at a mean age of 72 years (14–78). Kaplan-Meier survival analysis was used to examine survival from all causes of death since first presentation. Observed survival in patients with AHCM was significantly less than expected in an age- and gender matched Minnesota white population (p=0.009). The observed survival at 5, 10 and 15 years was 87 %, 82 %, and 57 % respectively, while the expected survival for these time points was 91 %, 81 %, and 72 %. Conclusions. AHCM in this predominantly North American patient population is associated with an increased mortality. Patients with AHCM have a high incidence of significant cardiovascular symptoms and ventricular arrhythmias. As the disease is less benign than previously suspected, careful longitudinal care by a cardiologist is warranted.

COVID-19 is a devastating respiratory and inflammatory illness caused by a new coronavirus that is rapidly spreading throughout the human population. Over the past 12 months, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for COVID-19, has already infected over 160 million (>20% located in United States) and killed more than 3.3 million people around the world (>20% deaths in USA). As we face one of the most challenging times in our recent history, there is an urgent need to identify drug candidates that can attack SARS-CoV-2 on multiple fronts. We have therefore initiated a computational dynamics drug pipeline using molecular modeling, structure simulation, docking and machine learning models to predict the inhibitory activity of several million compounds against two essential SARS-CoV-2 viral proteins and their host protein interactors—S/Ace2, Tmprss2, Cathepsins L and K, and Mpro—to prevent binding, membrane fusion and replication of the virus, respectively. All together, we generated an ensemble of structural conformations that increase high-quality docking outcomes to screen over >6 million compounds including all FDA-approved drugs, drugs under clinical trial (>3000) and an additional >30 million selected chemotypes from fragment libraries. Our results yielded an initial set of 350 high-value compounds from both new and FDA-approved compounds that can now be tested experimentally in appropriate biological model systems. We anticipate that our results will initiate screening campaigns and accelerate the discovery of COVID-19 treatments.

ABSTRACT The coronavirus disease 2019 (COVID-19) pandemic has required swift implementation of innovative practices in health care across the globe. We describe a nurse practitioner (NP) and physician assistant (PA)–led initiative to implement telemonitoring (TM) of noncritical patients with COVID-19 by critical care NPs and PAs (C19TM) for early detection of decompensation and early transfer to the intensive care unit (ICU). Every hospitalized patient with suspected or confirmed COVID-19 received an initial telemedicine consult with a critical care NP or PA. Patients were subsequently monitored via electronic health record once every 12-hour shift for the following indicators: oxygen modality and flow, increase in oxygen requirements, sustained tachypnea, and hemodynamic instability. If signs of decompensation were noted, the NP/PA would remotely reassess the patient, provide recommendations to the hospital internal medicine team, and transfer the patient to the ICU. The primary goal was to avoid cardiopulmonary deterioration requiring aerosol-generating procedures outside of the ICU. Over 65 days, 113 patients (86 suspected and 27 confirmed) were enrolled in C19TM. As a result, there were 13 transfers to the ICU, none of which required an aerosol-generating procedure outside of the ICU.

AbstractTraumatic brain injury (TBI) is a major cause of morbidity, mortality, and economic burden. Despite this, there are no proven medical therapies in the pharmacologic management of TBI. A better understanding of disease pathophysiology might lead to novel approaches. In one area of increasing interest, bioactive lipids known to attenuate inflammation might serve as an important biomarker and mediator of disease after TBI. In this review, we describe the pathophysiology of inflammation following TBI, the actions of endogenous bioactive lipids in attenuating neuroinflammation, and their possible therapeutic role in the management of TBI. In particular, specialized pro‐resolving lipid mediators (SPMs) of inflammation represent endogenous compounds that might serve as important biomarkers of disease and potential therapeutic targets. We aim to discuss the current literature from animal models of TBI and limited human experiences that suggest that bioactive lipids and SPMs are mechanistically important to TBI recovery, and by doing so, aim to highlight the need for further clinical and translational research. Early investigations of dietary and parenteral supplementation of pro‐resolving bioactive lipids have been promising. Given the high morbidity and mortality that occurs with TBI, novel approaches are needed.

Abstract IntroductionRacially and ethnically diverse minorities often experience the disease burden of sexually transmitted infections or diseases (STD) more often than their White counterparts. Yet, little is known about the connection of STD systematic discrimination, racism, and social and behavioral determinants. Plus, little to no details exists related to how this information is recorded in their Electronic Health Records (EHRs). The objective of this study is to assess the completeness of social and behavioral determinants of health (SDOH) data in the EHRs of a minority cohort with STD.Materials and Methods2,993 minority patients diagnosed with a STD at the Mayo Clinic were identified for this study. A natural language processing (NLP) algorithm was applied on the Patient-Provided Information (PPI) in their EHRs to extract SDOH information in six domains that are associated with STD, namely alcohol use, substance use, sexual activity, sexual orientation, housing status, and employment status. The completeness of SDOH was assessed in terms of documentation, breadth, and density.ResultsOur study indicates that nearly half of 2,993 patients did not have SDOH-related PPI records in their EHRs whereas the patients who had SDOH-related PPI records had well-documented records for five out of six SDOH domains, including alcohol use, substance use, sexual activity, housing status, and employment status, except for sexual orientation. A total of 1,504 patients had PPI in their EHRs for at least one of six SDOH domains, which is about 50.3% of the study cohort. Most SDOH domains have a short time span of 1 year, with up to 18 years of record data. Our analysis also indicated that education and age have a significant impact on the recording of SDOH-related PPI records. Patients that are female, older, and higher educated tend to have more SDOH information available in their records.Discussion and ConclusionWe assessed the completeness of SDOH information recorded in the PPI from patients’ EHRs. Due to large amounts of missing SDOH information in the PPI, future research is needed to integrate accurate and robust SDOH related data for downstream research and the impact of systematic discrimination on how this information is collected and interpreted in the EHRs.