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COPD is a common respiratory disorder that poses a major health-care burden with societal and financial ramifications. Although effective inhaled therapies are available, nonadherence is common among patients with COPD and potentially contributes to the burden of this disease. Electronic inhaler monitoring (EIM) is a novel modality that enables real-time assessment of adherence to inhaled therapy and informs the assessment of treatment effectiveness. EIM can be combined with physician feedback, automated audiovisual reminders, and text messaging to bolster adherence. Clinical studies have suggested that EIM can diagnose nonadherence, improve adherence, and predict exacerbations. Using an EIM-guided protocol has the potential to avoid treatment escalation in the nonadherent. Coupling EIM to behavioral intervention is an area of ongoing research with mixed results, with some studies showing benefit and others showing minimal or no significant change in clinical outcomes. Further investigation is necessary to understand the incremental benefits of EIM features, delineate optimal program implementation, and target patient populations that would benefit the most from monitoring.

BackgroundBody composition measures, specifically low weight or reduced muscle mass, are associated with mortality in COPD, but the effect of longitudinal body composition changes is undefined.Research questionIs the longitudinal loss of fat-free mass (FFM) associated with increased mortality, including in those with initially normal or elevated body composition metrics?Study design and methodsParticipants with complete data for at least one visit in the COPDGene study (n= 9,268) and the ECLIPSE study (n= 1,760) were included and monitored for 12 and 8 years, respectively. Pectoralis muscle area (PMA) was derived from thoracic CT scans and used as a proxy for FFM. A longitudinal mixed submodel for PMA and a Cox proportional hazards submodel for survival were fitted on a joint distribution, using a shared random intercept parameter and Markov chain Monte Carlo parameter estimation.ResultsBoth cohorts demonstrated a left-shifted distribution of baseline FFM, not reflected in BMI, and an increase in all-cause mortality risk associated with longitudinal loss of PMA. For each 1-cm2 PMA loss, mortality increased 3.1%(95%CI, 2.4%-3.7%; P< .001) in COPDGene, and 2.4%(95%CI, 0.9%-4.0%; P< .001) in ECLIPSE. Increased mortality risk was independent of enrollment values for BMI and disease severity [BODE (body mass, airflow obstruction, dyspnea, and exercise capacity) index quartiles] and was significant even in participants with initially greater than average PMA.InterpretationLongitudinal loss of PMA is associated with increased all-cause mortality, regardless of BMI or initial muscle mass. Consideration of novel screening tests and further research into mechanisms contributing to muscle decline may improve risk stratification and identify novel therapeutic targets in ever smokers.

Background Practice guidelines (PGs) attempt to standardize practice to optimize care. For uncommon lung diseases like alpha-1 antitrypsin deficiency (AATD), a paucity of definitive studies and geographic variation in prevalence may hamper guideline generation. The current study assembled and assesses the degree of concordance among available PGs regarding AATD. Methods To assess concordance, 15 eligible guidelines focused on AATD were evaluated regarding recommendations surrounding 24 key clinical issues. A Delphi process achieved consensus on ratings for each statement among 3 reviewers. Agreement was quantified as the proportion of guideline comparisons with a matching rating. Results The overall level of agreement was 47% (1190/2520 comparisons). The overall "affirmative agreement percentage" (ie, when guidelines agreed in endorsing a practice), was 42% (501/1190 comparisons). The agreement for individual clinical statements ranged from 26% to 75%. A broad consensus was seen in the recommendation to test all patients with a history of fixed obstruction on pulmonary function testing (either from asthma or COPD). Given that AATD is an under-recognized disease and that diagnosis often occurs at a late stage, the authors are encouraged by this consensus. Where overall the guidelines were less explicit was when to refer to a specialist or AATD center. Deciding on a treatment strategy requires a thorough understanding of the alpha 1 serum level, genotype, pulmonary function testing, and imaging, and therefore the authors feel that all patients would benefit from a specialty referral if the diagnosis of AATD is being considered. Conclusion Available guidelines regarding AATD frequently disagreed in management recommendations. Possible explanations for discordance include differences in regional prevalence, availability of augmentation therapy, and insurance environments. Attempts to harmonize the various guidelines by empaneling a broadly representative international group of disease experts should be considered for AATD. Similar comparisons among guidelines for other diseases are recommended.

IntroductionThe effect of electronic inhaler monitoring (EIM) on healthcare utilization in chronic obstructive pulmonary disease (COPD) has not been studied. We hypothesized that the use of EIM in conjunction with a disease management program reduces healthcare utilization in patients with COPD.MethodsThis is a retrospective pre- and post-analysis of a quality improvement project. Patients with COPD and high healthcare utilization (≥one hospitalization or emergency room visit during the year prior to enrolment) were provided with electronic monitoring devices for monitoring controller and rescue inhaler utilization for one year. Patients were contacted when alerts were triggered, indicating suboptimal adherence to controller inhaler or increased use of rescue inhalers, potentially signalling an impending exacerbation. Healthcare utilization was assessed pre- and post-monitoring, with each subject serving as his/her own control.ResultsPatients with COPD and high healthcare utilization ( n = 39) were recruited. Mean EIM duration was 280.5 (±120.6) days. The mean age was 68.6 (±9.9) years, FEV1 (mean forced expiratory volume in one second) was 1.1 (±0.4) L, and mean Charlson Comorbidity index was 5.6 (±2.7). Average adherence was 44.4% (28.4%). Compared with the year prior to enrolment, EIM was associated with a reduction in COPD-related healthcare utilization per year (2.2 (±2.3) versus 3.4 (±3.2), p = 0.01). Although there was a reduction in all-cause healthcare utilization, this was not statistically significant (3.4 (±2.6) versus 4.7 (±4.1), p = 0.06).DiscussionEIM in conjunction with a disease management program may play a role in reducing healthcare utilization in COPD patients with a history of high healthcare utilization.

Patients with advanced COPD develop skeletal muscle loss (sarcopenia) that is associated with adverse clinical outcomes including mortality. We evaluated if thoracic muscle area is associated with clinical outcomes in patients with severe COPD. We analyzed consecutive patients with severe COPD undergoing evaluation for lung volume reduction from 2015 to 2019 (n=117) compared to current and former smoking controls undergoing lung cancer screening with normal lung function (n=41). Quantitative assessments of pectoralis muscle (PM) and erector spinae muscle (ESM) cross sectional area (CSA) were related to clinical outcomes including composite endpoints. Our results showed a reduction in PM CSA but not ESM CSA was associated with the severity of GOLD stage of COPD. Current smokers demonstrated reduced PM CSA which was similar to that in COPD patients who were GOLD stages 3 and 4. PM CSA was associated positively with FEV1, FEV1% predicted, FVC, DLCO, and FEV1/FVC ratio, and was associated negatively with the degree of radiologic emphysema. ESM correlated positively with DLCO, RV/TLC (a marker of hyperinflation), and correlated negatively with radiologic severity of emphysema. Kaplan-Meier analysis showed that reductions in PM but not ESM CSA was associated with the composite end point of mortality, need for lung volume reduction, or lung transplant. In conclusion, in well-characterized patients with severe COPD referred for lung volume reduction, PM CSA correlated with severity of lung disease, mortality and need for advanced therapies. In addition to predicting clinical outcomes, targeting sarcopenia is a potential therapeutic approach in patients with severe COPD.

OBJECTIVES: Skeletal muscle loss or sarcopenia is a frequent complication in heart failure (HF) and contributes to adverse clinical outcomes. We evaluated if age (primary) and chronic disease (secondary) related sarcopenia, that we refer to as compound sarcopenia, impacts clinical outcomes in hospitalized patients with HF. DESIGN: Cross sectional study using hospitalized patient data. SETTING: Data from the Agency for Healthcare Research and Quality through the Healthcare Cost and Utilization Project (HCUP). PARTICIPANTS. Hospitalized adult patients with a primary or secondary diagnosis of HF (n=64,476) and a concurrent random 2% sample of general medical population (GMP; n=322,217) stratified by age (65y) from the Nationwide Inpatient Sample (NIS) database (years 2010–2014). MEASUREMENTS. In-hospital mortality, length of stay (LoS), cost of hospitalization per admission (CoH), comorbidities and discharge disposition, with and without muscle loss phenotype, were analyzed. Muscle loss phenotype was defined using a comprehensive code set from international classification of diseases-9 (ICD-9). RESULTS: Muscle loss phenotype was observed in 8,673(13.5%) patients with HF compared to 5,213(1.6%) GMP across all age strata. In patients with HF, muscle loss phenotype was associated with higher mortality, LoS, and CoH. Patients with HF (>65y) and muscle loss phenotype had higher mortality (adjusted OR: 1.81; 95% CI 1.56–2.10), CoH (adjusted OR 1.48; 95% CI 1.44–1.1.52) and LoS (adjusted OR 1.40; 95% CI 1.37–1.43) compared to >65y GMP with muscle loss phenotype. CONCLUSION: Muscle loss phenotype is more commonly associated with increasing age in hospitalized patients with HF. Clinical outcomes were significantly worse in patients with HF age >65y compared to younger patients with HF and all age strata in GMP with and without a muscle loss phenotype.

Severe covid-19 pneumonia has posed critical challenges for the research and medical communities. Older age, male sex, and comorbidities increase the risk for severe disease. For people hospitalized with covid-19, 15-30% will go on to develop covid-19 associated acute respiratory distress syndrome (CARDS). Autopsy studies of patients who died of severe SARS CoV-2 infection reveal presence of diffuse alveolar damage consistent with ARDS but with a higher thrombus burden in pulmonary capillaries. When used appropriately, high flow nasal cannula (HFNC) may allow CARDS patients to avoid intubation, and does not increase risk for disease transmission. During invasive mechanical ventilation, low tidal volume ventilation and positive end expiratory pressure (PEEP) titration to optimize oxygenation are recommended. Dexamethasone treatment improves mortality for the treatment of severe and critical covid-19, while remdesivir may have modest benefit in time to recovery in patients with severe disease but shows no statistically significant benefit in mortality or other clinical outcomes. Covid-19 survivors, especially patients with ARDS, are at high risk for long term physical and mental impairments, and an interdisciplinary approach is essential for critical illness recovery.

Rationale Patients with COPD who are afflicted with COVID-19 have an increased risk for adverse outcomes. Inhaled Corticosteroids (ICS) are commonly prescribed to patients with severe COPD and recurrent exacerbations. Given the concern for increased viral shedding related to oral corticosteroids seen with the related coronaviruses MERS-CoV and SARS-CoV-1, our study analyzed the impact of ICS on COPD patients with COVID-19. Methods This study examined 27,810 patients with COPD from the Cleveland Clinic COVID-19 registry between March 8th and September 16th, 2020. We used electronic health records (EHR) to gather patient data on the diagnosis of COPD, ICS use and clinical outcomes. Patients with a concurrent diagnosis of asthma and less than a 10 pack year smoking history, and those aged 35 and younger, were excluded to minimize bias and uncertainty about the diagnosis of COPD. Multivariate logistic regression was used to adjust for demographics, month of COVID-19 testing, and comorbidities known to be associated with increased COVID-19 risk for infection and severe disease. Results Amongst the COPD patients who were tested for COVID-19, 44.1% of those taking an ICS-containing inhaler tested positive versus 47.2% who tested negative (p=0.033). Of those who tested positive for COVID-19 (n=1288), 371 (28.8%) required hospitalization. Comparing the groups of individuals with COPD treated with, and without ICS, there was no significant difference in terms of age (66.9+14.0 vs 67.1+15.0, p=0.92) or gender (38.3% [77/201] vs 46.7% [79/170] males, p=0.13) respectively. In-hospital outcomes were not significantly different when comparing ICS versus no ICS in terms of sepsis (28.4% [57/201] vs 26.5% [45/170], p=0.77), shock (15.9% [32/201] vs 12.4% [21/170], p=0.41), ICU admission (36.8% [74/201] vs 31.2% [53/170], p=0.30), endotracheal intubation (21.9% [44/201] vs 16.5% [28/170], p=0.24), or mortality (18.4% [37/201] vs 20.0% [34/170], p=0.80). Multivariate logistic regression demonstrated that ICS therapy in patients with COPD was associated with less COVID-19 infection (adj OR 0.85, CI: 0.76-0.96);however, there were no significant differences in hospitalization (adj OR 1.12, CI: 0.90-1.38), ICU admission (adj OR: 1.31, CI: 0.82-2.10), need for mechanical ventilation (adj OR 1.65, CI: 0.69-4l02), or mortality (OR: 0.80, CI: 0.43-1.49). Conclusions The lack of adverse outcomes from ICS therapy among individuals with COPD infected with COVID-19 infection as demonstrated in this study, and the known advantages of ICS therapy in lowering the risk of COPD exacerbations, support continuing ICS in individuals with COPD who meet the recommended criteria.

Background Although toxicologists, medical professionals, and service providers have determined that the risk of overdose from fentanyl exposure is extremely low for law enforcement and other first responders, hundreds of media and social media accounts contradict these facts, making these civil servants unnecessarily concerned about such occupational hazards. Methods We conducted a qualitative study to explore knowledge and fear of fentanyl exposure by interviewing 23 law enforcement leaders and officers in five diverse law enforcement agencies in the United States. Results Nearly all leaders and officers interviewed wrongly believed that dermal exposure to fentanyl was deadly and expressed fear about such exposure on scene. Officers had a lack of education about fentanyl exposure and faulty or dubious sources of information about it. Conclusion There is a substantial, pressing need for dissemination of research about the lack of overdose risk associated with dermal fentanyl exposure through channels that law enforcement trust, including through basic academy, in-service training, and law enforcement bulletins and newsletters.

Background We sought to determine whether COPD conferred a higher risk for healthcare utilization in terms of hospitalization and clinical outcomes due to COVID-19. Methods A cohort study with covariate adjustment using multivariate logistic regression was conducted at the Cleveland Clinic Health System in Ohio and Florida. Symptomatic patients aged 35 years and older who were tested for SARS-CoV-2 between March 8 and May 13, 2020 were included. Findings 15,586 individuals tested for COVID-19 at the Cleveland Clinic between March 8, 2020 and May 13, 2020 met our inclusion criteria. 12.4% of COPD patients (164/1319) tested positive for COVID-19 compared to 16.6% (2363/14,267) of the non-COPD population. 48.2% (79/164) of COVID-19 positive COPD patients required hospitalization and 45.6% (36/79) required ICU admission. After adjustment for covariates, rates of COVID-19 infection were not significantly different than the non-COPD population (adj OR 0.97; CI: 0.89–1.05), but COPD patients had increased healthcare utilization as demonstrated by risk for hospitalization (adj OR 1.36; CI: 1.15–1.60), ICU admission (OR 1.20; CI: 1.02–1.40), and need for invasive mechanical ventilation (adj OR 1.49; CI: 1.28–1.73). Unadjusted risk for in-hospital mortality was higher in the COPD population (OR 1.51; CI: 1.14–1.96). After adjusting for covariates however, the risk for in-hospital mortality was not significantly different than the non-COPD population (adj OR 1.08: CI: 0.81–1.42). Interpretation Our analysis demonstrated that COPD patients with COVID-19 had a higher risk for healthcare utilization, although adjusted in-hospital mortality risk was not different than the non-COPD patients with COVID-19.

Patients with COPD have an increased risk for severe COVID-19. Symptoms such as high-grade fever, anorexia, and myalgia may distinguish COVID-19 from dyspnea due to a COPD-related exacerbation. Management of COVID-19 in the patient with COPD may still warrant standard-of-care exacerbation treatment with antimicrobial agents and corticosteroids. Modalities to treat acute respiratory failure can be used with some caveats. Patients with COPD and COVID-19 infection who treat their illness at home should self-isolate, use nebulizers with precautions to avoid viral aerosolization, and frequently disinfect room surfaces.

BACKGROUND AND OBJECTIVE COPD is the third most common cause of death worldwide and fourth most common in the United States. In hospitalized patients with COPD, mortality, morbidity and healthcare resource utilization are high. Skeletal muscle loss is frequent in patients with COPD. However, the impact of muscle loss on adverse outcomes has not been systematically evaluated. We tested the hypothesis that patients hospitalized for COPD exacerbation with, compared to those without, a secondary diagnosis of muscle loss phenotype (all ICD-9 codes associated with muscle loss including cachexia) will have higher mortality and cost of care. METHODS The NIS database of hospitalized patients in 2011 (1 January-31 December) in the United States was used. The impact of a muscle loss phenotype on in-hospital mortality, LOS and cost of care for each of the 174 808 hospitalizations for COPD exacerbations was analysed. RESULTS Of the subjects admitted for a COPD exacerbation, 12 977 (7.4%) had a secondary diagnosis of muscle loss phenotype. A diagnosis of muscle loss phenotype was associated with significantly higher in-hospital mortality (14.6% vs 5.7%, P

BACKGROUND AND AIMS. There is very limited data on the healthcare burden of muscle loss, the most frequent complication in hospitalized cirrhotics. We determined the healthcare impact of a muscle loss phenotype in hospitalized cirrhotics. METHODS. The Nationwide Inpatient Sample (NIS) database (years 2010–2014) was analyzed. Search terms included cirrhosis and its complications, and an expanded definition of a muscle loss phenotype that included all conditions associated with muscle loss. In-hospital mortality, length of stay (LOS), post-discharge disposition, co-morbidities and cost during admission were analyzed. Univariate and multivariate analyses were performed to identify associations between a muscle loss phenotype and outcomes. Impact of muscle loss in cirrhotics was compared to that in a random sample (2%) of general medical inpatients. RESULTS. A total of 162,694 hospitalizations for cirrhosis were reported, of which 18,261(11.2%) included secondary diagnosis codes for a muscle loss phenotype. A diagnosis of muscle loss was associated with a significantly (p

Purpose The purpose of this research is to investigate the relationship among jurors’ attribution of responsibility of the error, patient styles and juror decisions (e.g. acquittal of the physician). Specifically, this research examines the influence of an individual’s approach to their healthcare (active vs. passive), and decisions to acquit in malpractice cases. Design/methodology/approach In total, 459 individuals were surveyed using a commercial call center for participation in a corresponding mail survey. Surveys were also distributed to undergraduate business students at a Midwestern university. Findings Cluster analysis revealed two categories of patient styles: “active patients” (39.4 per cent) and “passive patients” (60.6 per cent). Regardless of patient style, this research found all respondents viewed medical error disclosure as important. However, respondents in the passive group were more likely to acquit the physician and the hospital nursing staff as compared with those classified as active. Practical implications The safety of patients in the healthcare system and prevention of errors is a critical issue. However, when errors occur, medical providers should disclose information to the patient and take responsibility to attenuate their negative impact. Further, this research reveals that patients who rely more on their physicians, trust their recommendations and question physicians less are more likely to acquit. Medical providers can use this information as motivation to continue to build this type of trust with their patients. Originality/value Medical errors are costly for all parties involved. This research provides insight for not only members of the legal profession involved in medical malpractice cases, but also risk managers and hospital administrators and healthcare providers regarding the decision-making process used by individuals serving on a jury.

Background Sites of entry for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are highly expressed in nasal epithelial cells; however, little is known about the impact of intranasal corticosteroids (INCS) on coronavirus disease 2019 (COVID-19)-related outcomes. Objective To determine the association between baseline INCS use and COVID-19-related outcomes. Methods Using the Cleveland Clinic COVID-19 Research Registry, we performed a propensity score matching for treatment with INCS before SARS-CoV-2 infection (April 1, 2020, to March 31, 2021). Of the 82,096 individuals who tested positive, 72,147 met inclusion criteria. Our endpoints included the need for hospitalization, admission to the intensive care unit (ICU), or in-hospital mortality. Results Of the 12,608 (17.5%) who were hospitalized, 2935 (4.1%) required ICU admission and 1880 (2.6%) died during hospitalization. A significant proportion (n = 10,187; 14.1%) were using INCS before SARS-CoV-2 infection. Compared with nonusers, INCS users demonstrated lower risk for hospitalization (adjusted odds ratio [OR] [95% confidence interval (CI)]: 0.78 [0.72; 0.85]), ICU admission (adjusted OR [95% CI]: 0.77 [0.65; 0.92]), and in-hospital mortality (adjusted OR [95% CI]: 0.76 [0.61; 0.94]). These findings were replicated in sensitivity analyses where patients on inhaled corticosteroids and those with allergic rhinitis were excluded. The beneficial effect of INCS was significant after adjustment for baseline blood eosinophil count (measured before SARS-CoV-2 testing) in a subset of 30,289 individuals. Conclusion INCS therapy is associated with a lower risk for COVID-19-related hospitalization, ICU admission, or death. Future randomized control trials are needed to determine if INCS reduces the risk for severe outcomes related to COVID-19.

Background Pediatric appendicitis is a common, potentially serious condition. Determining perforation status is crucial to planning effective management. Purpose Determine the efficacy of serum total bilirubin concentration [STBC] in distinguishing perforation status in children with appendicitis. Methods Retrospective review of 257 cases of appendicitis who received abdominal CT scan and measurement of STBC. Results There were 109 with perforation vs 148 without perforation. Although elevated STBC was significantly more common in those with [36%] vs without perforation [22%], the mean difference in elevated values between groups [0.1mg/dL] was clinically insignificant. Higher degrees of hyperbilirubinemia [>2mg/dL] were rarely encountered [5%]. Predictive values for elevated STBC in distinguishing perforation outcome were imprecise [sensitivity 38.5%, specificity 78.4%, PPV 56.8%, NPV 63.4%]. ROC curve analysis of multiple clinical and other laboratory factors for predicting perforation status was unenhanced by adding the STBC variable. Specific analysis of those with perforated appendicitis and percutaneously-drained intra-abdominal abscess which was culture-positive for Escherichia coli showed an identical rate of STBC elevation compared to all with perforation. Conclusions The routine measurement of STBC does not accurately distinguish perforation status in children with appendicitis, nor discern infecting organism in those with perforation and intra-abdominal abscess.

Summary: As evidence linking Zika virus with serious health complications strengthens, public health officials and clinicians worldwide need to know which locations are likely to be at risk for autochthonous Zika infections. We created risk maps for epidemic and endemic Aedes-borne Zika virus infections globally using a predictive analysis method that draws on temperature, precipitation, elevation, land cover, and population density variables to identify locations suitable for mosquito activity seasonally or year-round. Aedes mosquitoes capable of transmitting Zika and other viruses are likely to live year-round across many tropical areas in the Americas, Africa, and Asia. Our map provides an enhanced global projection of where vector control initiatives may be most valuable for reducing the risk of Zika virus and other Aedes-borne infections. Keywords: Geographic information systems, Geographic information science, Risk mapping, Zika, Aedes modeling

Microbial burden associated with near-patient touch surfaces results in a greater risk of health care-associated infections (HAIs). Acute care beds may be a critical fomite, as traditional plastic surfaces harbor the highest concentrations of bacteria associated with high-touch surfaces in a hospital room’s patient zone. Five high-touch intensive care unit (ICU) bed surfaces encountered by patients, health care workers, and visitors were monitored by routine culture to assess the effect U.S. Environmental Protection Agency (U.S. EPA)-registered antimicrobial copper materials have on the microbial burden. Despite both daily and discharge cleaning and disinfection, each control bed’s plastic surfaces exceeded bacterial concentrations recommended subsequent to terminal cleaning and disinfection (TC&D) of 2.5 aerobic CFU/cm(2). Beds with self-disinfecting (copper) surfaces harbored significantly fewer bacteria throughout the patient stay than control beds, at levels below those considered to increase the likelihood of HAIs. With adherence to routine daily and terminal cleaning regimes throughout the study, the copper alloy surfaces neither tarnished nor required additional cleaning or special maintenance. Beds encapsulated with U.S. EPA-registered antimicrobial copper materials were found to sustain the microbial burden below the TC&D risk threshold levels throughout the patient stay, suggesting that outfitting acute care beds with such materials may be an important supplement to controlling the concentration of infectious agents and thereby potentially reducing the overall HAI risk. IMPORTANCE Despite cleaning efforts of environmental service teams and substantial compliance with hand hygiene best practices, the microbial burden in patient care settings often exceeds concentrations at which transfer to patients represents a substantial acquisition risk for health care-associated infections (HAIs). Approaches to limit HAI risk have relied on designing health care equipment and furnishings that are easier to clean and/or the use of no-touch disinfection interventions such as germicidal UV irradiation or vapor deposition of hydrogen peroxide. In a clinical trial evaluating the largest fomite in the patient care setting, the bed, a bed was encapsulated with continuously disinfecting antimicrobial copper surfaces, which reduced the bacteria on surfaces by 94% and sustained the microbial burden below the terminal cleaning and disinfection risk threshold throughout the patient’s stay. Such an intervention, which continuously limits microbes on high-touch surfaces, should be studied in a broader range of health care settings to determine its potential long-range efficacy for reducing HAI.

Background Asthma is a prevalent disease with a high economic cost. More than 50% of its direct cost relates to asthma hospitalizations. Diabetes mellitus (DM) is a significant comorbidity in asthmatic patients, yet its impact on asthma-related hospitalizations is unknown. Objective To compare the outcome of asthma-related hospitalizations in patients with and without DM. Methods Using Healthcare Cost and Utilization Project Nationwide Readmissions Database, we analyzed data of all adults with index admission for asthma and with no other chronic pulmonary conditions, and compared outcomes between patients with and without DM. Weighted regression analysis was used to determine the impact of DM on hospitalization outcomes. All multivariate regression models were adjusted for patient demographics, socioeconomic status, and chronic medical comorbidities. Results A total of 717,200 asthmatic patients were included, with 202,489 (28.3%) having DM. Diabetic patients were older and had more comorbidities. When hospitalized for asthma, diabetic patients had increased hospital length of stay, cost, and risk for 30-day all-cause and asthma-related readmission. They also had a higher risk for developing nonrespiratory complications during their hospital stay compared with nondiabetic patients. The risk of mortality was similar between the 2 groups. Conclusions Patients hospitalized for asthma with coexisting DM had increased hospital length of stay, cost, and risk for readmission. Interventions are urgently needed to reduce the risk for hospital admission and readmission in patients with coexisting DM and asthma. These interventions would have profound economic and societal impact.

Introduction/Objective The pre-transplant clinical evaluation of patients with liver disease are critical components determining prognoses, eligibility and placement on the transplant waiting (eg. hepatocellular carcinoma (HCC) may decrease time on list), and surgical planning for the type of biliary anastomosis performed. For example, patients with Primary Sclerosing Cholangitis (PSC) are given direct liver to small bowel anastomosis, a type prone to ascending cholangitis, compared to duct to duct types in all other etiologies, and a clinical diagnoses of alcohol-induced cirrhosis impacts the patient’s and family’s psycho-social well-being. The goal of our study was to determine the frequency and types of differences in the clinical versus liver explant pathology diagnoses. Methods A search for “liver explant” for all in-house cases between 7/15/2019 to 7/15/2018 and 1/1/2010 to 12/31/2010 identified 105 and 108 cases, respectively. For each case, pre-operative clinical diagnoses determined by the electronic medical record was compared to pathologic diagnosis. Cases with non-concordance were divided into two groups: 1. Concordant etiology but incidental malignancy identified in explant 2. Non-concordant etiology. Results In the 2018–2019 group, of the 105 liver explants, 6 had concordant etiology but previously unknown HCC and 9 cases had non-concordant diagnoses. Similarly, the 2010 group, of the 108 liver explants, 6 had consistent etiology but previously unknown HCC and 8 cases non-concordant diagnoses. Of the total 17 non-concordant cases, 4 carried a pre-transplant diagnosis of PSC and were reversed to autoimmune hepatitis (2), chronic rejection, and primary biliary cholangitis on explant pathology and 3 carried a diagnosis of alcohol-induced cirrhosis and were reversed to portal tract venopathy, viral hepatitis, and alpha-1 antitrypsin. Conclusion There are clinically significant discordances between pre-transplant and explant diagnoses with 6% incidental malignancies and 8% etiology changes. Of particular importance for anastomoses complications and psycho-social issues are patients with a pre-operative diagnoses of PSC or alcohol whose diagnosis was changed by pathology explant assessment, respectfully. Strategies to refine and improve pre-operative liver disease diagnoses particularly with regard to biliary and alcohol diagnoses will be explored.

Background Stethoscopes may serve as vehicles for transmission of bacteria among patients. The aim of this study was to assess the efficacy of antimicrobial copper surfaces to reduce the bacterial concentration associated with stethoscope surfaces. Methods A structured prospective trial involving 21 health care providers was conducted at a pediatric emergency division (ED) (n = 14) and an adult medical intensive care unit located in tertiary care facilities (n = 7). Four surfaces common to a stethoscope and a facsimile instrument fabricated from U.S. Environmental Protection Agency–registered antimicrobial copper alloys (AMCus) were assessed for total aerobic colony counts (ACCs), methicillin-resistant Staphylococcus aureus , gram-negative bacteria, and vancomycin-resistant enterococci for 90 days. Results The mean ACCs collectively recovered from all stethoscope surfaces fabricated from the AMCus were found to carry significantly lower concentrations of bacteria (pediatric ED, 11.7 vs 127.1 colony forming units [CFU]/cm 2 , P P 2 ) by at least 25×, supporting that the stethoscope warrants consideration in plans mitigating microbial cross-transmission during patient care. Conclusions Stethoscope surfaces fabricated with AMCus were consistently found to harbor fewer bacteria.

Steatotic livers are sensitive to ischemic events and associated ATP depletion. Hepatocellular necrosis following these events may result from mitochondrial uncoupling protein-2 (UCP2) expression. To test this hypothesis, we developed a model of in vitro steatosis using primary hepatocytes from wild-type (WT) and UCP2 knockout (KO) mice and subjected them to hypoxia/reoxygenation (H/R). Using cultured hepatocytes treated with emulsified fatty acids for 24 h, generating a steatotic phenotype (i.e., microvesicular and broad-spectrum fatty acid accumulation), we found that the phenotype of the WT and UCP2 KO were the same; however, cellular viability was increased in the steatotic KO hepatocytes following 4 h of hypoxia and 24 h of reoxygenation; Hepatocellular ATP levels decreased during hypoxia and recovered after reoxygenation in the control and UCP2 KO steatotic hepatocytes but not in the WT steatotic hepatocytes; mitochondrial membrane potential in WT and UCP2 KO steatotic groups was less than control groups but higher than UCP2 KO hepatocytes. Following reoxygenation, lipid peroxidation, as measured by thiobarbituric acid reactive substances, increased in all groups but to a greater extent in the steatotic hepatocytes, regardless of UCP2 expression. These results demonstrate that UCP2 sensitizes steatotic hepatocytes to H/R through mitochondrial depolarization and ATP depletion but not lipid peroxidation.

Background Risk maps identifying suitable locations for infection transmission are important for public health planning. Data on dengue infection rates are not readily available in most places where the disease is known to occur. Methods A newly available add-in to Esri’s ArcGIS software package, the ArcGIS Predictive Analysis Toolset (PA Tools), was used to identify locations within Africa with environmental characteristics likely to be suitable for transmission of dengue virus. Results A more accurate, robust, and localized (1 km × 1 km) dengue risk map for Africa was created based on bioclimatic layers, elevation data, high-resolution population data, and other environmental factors that a search of the peer-reviewed literature showed to be associated with dengue risk. Variables related to temperature, precipitation, elevation, and population density were identified as good predictors of dengue suitability. Areas of high dengue suitability occur primarily within West Africa and parts of Central Africa and East Africa, but even in these regions the suitability is not homogenous. Conclusion This risk mapping technique for an infection transmitted by Aedes mosquitoes draws on entomological, epidemiological, and geographic data. The method could be applied to other infectious diseases (such as Zika) in order to provide new insights for public health officials and others making decisions about where to increase disease surveillance activities and implement infection prevention and control efforts. The ability to map threats to human and animal health is important for tracking vectorborne and other emerging infectious diseases and modeling the likely impacts of climate change.

Dialysis patients are known to tolerate high potassium due to the chronic hyperkalemia that is inherent in their disease. Despite this, most reports of extremely high potassium (>9 mmol/L) are in the setting of cardiac arrest. We describe the case of a 57-year-old Caucasian male with past medical history significant for end stage renal disease known to be non-adherent to a low potassium diet as well as missed dialysis appointments. Stat potassium off of a basic metabolic panel was 10.2 mmol/L, which was non-hemolyzed and confirmed on repeat testing. A stat EKG was performed which revealed peaked T waves, mildly increased PR interval (200 ms), and mild QRS widening (142 ms). There was no evidence of bradycardia or sinusoidal wave form. The patient received emergent dialysis and his EKG normalized.

A 72-year-old smoker with a history of ankylosing spondylitis, who was not receiving immunosuppressants, was hospitalized for severe influenza pneumonia in January. He was treated with oseltamivir and antibiotics and enrolled in a clinical trial that evaluated steroids for the treatment of community-acquired pneumonia. It is unknown whether he was in the placebo or treatment group; however, treatment involved an initial methylprednisolone 40mgbolus, followed by 40mg/d for 5 days, and then a rapid taper over 1week. He then presented in March with worsening dyspnea, productive cough, weight loss, lethargy, and an overall decline in clinical status. Imaging during this admission revealed bilateral upper lobe cavitary lesions with fungus balls and associated infiltrates. Multiple sputum cultures were positive for Aspergillus fumigatus, and Aspergillus antibodies were detected by immunodiffusion and complement fixation (1:64). He was diagnosed presumptively with subacute invasive pulmonary aspergillosis and began treatment with voriconazole. Patients with ankylosing spondylitis can develop pulmonary manifestations of their disease, including apical fibrobullous disease (1). They are more likely to develop apical superinfections with mycobacterial or fungal infections as well, the most common of which is Aspergillus (2, 3). Influenza is associated with increased risk for invasive aspergillosis; this is believed to be because of the disruption of the bronchial mucosa, which leads to an impaired immune response (4). This, possibly coupled with the use of steroids, could have promoted further immune dysregulation and facilitated an environment for Aspergillus to grow. n

Background The human dicer1 gene has been predicted to produce several mRNA variants that encode truncated Dicer1 proteins of varying lengths. One of these Dicer1 variants, Dicer1e, was recently found to be differentially expressed in breast cancer cells. Because the expression and function of the Dicer1e protein variant has not been well characterized and the underlying molecular mechanisms for the development of oral squamous cell carcinomas (OSCCs) are poorly understood, the present study sought to characterize the biological role of Dicer1e and determine its relationship, if any, to OSCC pathogenesis. Methods Western blot analyses were used to examine Dicer1e expression levels in a panel of oral cancer cells/tissues and during epithelial-mesenchymal transition (EMT), followed by 5′/3′-RACE analyses to obtain the full-length Dicer1e transcript. Biochemical fractionation and indirect immunofluorescent studies were performed to determine the cellular localization of Dicer1e and the effects of Dicer1e silencing on cancer cell proliferation, clonogenicity, and drug sensitivity were also assessed. Results Dicer1e protein levels were found to be overexpressed in OSCC cell lines of epithelial phenotype and in OSCC tissues with its levels downregulated during EMT. Moreover, the Dicer1e protein was observed to predominantly localize in the nucleus. 5′/3′-RACE analyses confirmed the presence of the Dicer1e transcript and silencing of Dicer1e impaired both cancer cell proliferation and clonogenicity by inducing either apoptosis and/or G2/M cell cycle arrest. Lastly, Dicer1e knockdown enhanced the chemosensitivity of oral cancer cells to cisplatin. Conclusion The expression levels of Dicer1e influence the pathogenesis of oral cancer cells and alter their response to chemosensitivity, thus supporting the importance of Dicer1e as a therapeutic target for OSCCs. Electronic supplementary material The online version of this article (doi:10.1186/1476-4598-13-190) contains supplementary material, which is available to authorized users.

Introduction: Endotracheal intubations are a vital cornerstone of care for critically ill patients. The decision to intubate a critically ill patient is often complicated secondary to long term prognosis of underlying illness and extent of aggressive treatment a patient would desire. This study was done to identify association of cardiovascular disorder requiring endotracheal intubation to in-hospital mortality and discharge status of the patients. Methods: Nationwide Inpatient Sample data (which represents 20% of all the hospitals data in US) was used for the study and data related to all the intubations for the year 2011 was extracted. Patients with complete data on endotracheal intubations associated with primary cardiovascular diagnosis of acute myocardial infarction (MI), cardiac arrest and ventricular fibrillation (CA/VFib), congestive heart failure (CHF), acute cerebrovascular accident (CVA) and cardiac dysrhythmia were included in the study. Statistical analysis was done using SPSS. Results: A total of 17,128 intubations associated with primary cardiovascular diagnosis were identified. In-hospital mortality for endotracheal intubations secondary to cardiovascular etiology was significantly higher than intubations secondary to non-cardiovascular etiology (58.5 % vs 29.43%, p value Conclusions: Our study reports that patients who are intubated secondary to cardiovascular etiology have higher in-hospital mortality. Among these patients, patients having cardiac arrest/ventricular fibrillation have high in-hospital mortality and patients with CHF have higher routine discharges. This data can help clinicians to have well informed discussion with the family and weigh the risk and benefits of aggressively treating certain populations of critically ill cardiac patients with endotracheal intubation.

INTRODUCTION: Dengue fever, a mosquito-borne viral infection, is a growing threat to human health in tropical and subtropical areas worldwide. There is a demand from public officials for maps that capture the current distribution of dengue and maps that analyze risk factors to predict the future burden of disease. METHODS: To identify relevant articles, we searched Google Scholar, PubMed, BioMed Central, and WHOLIS (World Health Organization Library Database) for published articles with a specific set of dengue criteria between January 2002 and July 2013. RESULTS: After evaluating the currently available dengue models, we identified four key barriers to the creation of high-quality dengue maps: (1) data limitations related to the expense of diagnosing and reporting dengue cases in places where health information systems are underdeveloped; (2) issues related to the use of socioeconomic proxies in places with limited dengue incidence data; (3) mosquito ranges which may be changing as a result of climate changes; and (4) the challenges of mapping dengue events at a variety of scales. CONCLUSION: An ideal dengue map will present endemic and epidemic dengue information from both rural and urban areas. Overcoming the current barriers requires expanded collaboration and data sharing by geographers, epidemiologists, and entomologists. Enhanced mapping techniques would allow for improved visualizations of dengue rates and risks.

Rats with sham, unilateral, or bilateral aspiration lesions of the posterior parietal cortex (PPC) were trained in a water T-maze to use flashing lights located along the starting alley (two each) and inner walls of the goal alleys (two each) to find a hidden escape platform. Thereafter, the performance of the spatial response was tested under several conditions. Rats with bilateral PPC lesions were significantly inferior to unilateral- and sham-injured rats in learning the “turn-signal” cued spatial task. Also, left-PPC-injured rats committed significantly more errors than did the control animals. After mastering the task, cue saliency was reduced and the amount of spatial discontiguity between the stimuli and escape site was increased in two stages. That is, the flashing light closest to the escape platform was turned off for one testing session. On the following day, animals were required to rely on information located within the starting alley to make the correct spatial response at the choice point. Animals with bilateral or left PPC lesions were significantly impaired on the task with cues located only in the starting alley. The animals were then tested with competing constant illumination of the lights on the side of the apparatus opposite the flashing-light cues. The performance of all animals dropped to chance and failed to improve with training. Finally, three of the sham-operated controls were retrained to criterion on the original discrimination and prepared with bilateral PPC injuries. Substantial savings was observed. The results reveal a greater role of the left PPC than the right in the use of local sensory cues for spatial navigation, and they show that the PPC is not the repository of the “engram” for this learned visuospatial behavior.

Cleaning is an effective way to lower the bacterial burden (BB) on surfaces and minimize the infection risk to patients. However, BB can quickly return. Copper, when used to surface hospital bed rails, was found to consistently limit surface BB before and after cleaning through its continuous antimicrobial activity.

Objective.Healthcare-acquired infections (HAIs) cause substantial patient morbidity and mortality. Items in the environment harbor microorganisms that may contribute to HAIs. Reduction in surface bioburden may be an effective strategy to reduce HAIs. The inherent biocidal properties of copper surfaces offer a theoretical advantage to conventional cleaning, as the effect is continuous rather than episodic. We sought to determine whether placement of copper alloy-surfaced objects in an intensive care unit (ICU) reduced the risk of HAI.Design.Intention-to-treat randomized control trial between July 12, 2010, and June 14, 2011.Setting.The ICUs of 3 hospitals.Patients.Patients presenting for admission to the ICU.Methods.Patients were randomly placed in available rooms with or without copper alloy surfaces, and the rates of incident HAI and/or colonization with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) in each type of room were compared.Results.The rate of HAI and/or MRSA or VRE colonization in ICU rooms with copper alloy surfaces was significantly lower than that in standard ICU rooms (0.071 vs 0.123; P = .020). For HAI only, the rate was reduced from 0.081 to 0.034 (P = .013).Conclusions.Patients cared for in ICU rooms with copper alloy surfaces had a significantly lower rate of incident HAI and/or colonization with MRSA or VRE than did patients treated in standard rooms. Additional studies are needed to determine the clinical effect of copper alloy surfaces in additional patient populations and settings.

While the most common presentation of actinomycosis is cervicofacial disease, or “lumpy jaw syndrome,” Actinomyces meyeri has a predilection for pulmonary disease as well as dissemination to distant organs. We describe a 61-year-old Caucasian male with a relapsing-remitting mandibular sinus tract who would go on to develop weight loss, dyspnea, and a cough productive of malodorous sputum. Imaging revealed a right lower lobe pneumonia and a large left sided empyema. He underwent thoracotomy and decortication on the left side, and 1 L of foul-smelling purulent fluid was drained. Culture grew Actinomyces meyeri. He completed an extended antibiotic course and had his teeth extracted with good clinical outcome.

The contribution of environmental surface contamination with pathogenic organisms to the development of health care-associated infections (HAI) has not been well defined. The microbial burden (MB) associated with commonly touched surfaces in intensive care units (ICUs) was determined by sampling six objects in 16 rooms in ICUs in three hospitals over 43 months. At month 23, copper-alloy surfaces, with inherent antimicrobial properties, were installed onto six monitored objects in 8 of 16 rooms, and the effect that this application had on the intrinsic MB present on the six objects was assessed. Census continued in rooms with and without copper for an additional 21 months. In concert with routine infection control practices, the average MB found for the six objects assessed in the clinical environment during the preintervention phase was 28 times higher (6,985 CFU/100 cm 2 ; n = 3,977 objects sampled) than levels proposed as benign immediately after terminal cleaning (2 ). During the intervention phase, the MB was found to be significantly lower for both the control and copper-surfaced objects. Copper was found to cause a significant (83%) reduction in the average MB found on the objects (465 CFU/100 cm 2 ; n = 2714 objects) compared to the controls (2,674 CFU/100 cm 2 ; n = 2,831 objects [ P < 0.0001]). The introduction of copper surfaces to objects formerly covered with plastic, wood, stainless steel, and other materials found in the patient care environment significantly reduced the overall MB on a continuous basis, thereby providing a potentially safer environment for hospital patients, health care workers (HCWs), and visitors.

Background Commonly touched items are likely reservoirs from which patients, health care workers, and visitors may encounter and transfer microbes. A quantitative assessment was conducted of the risk represented by the intrinsic bacterial burden associated with bed rails in a medical intensive care unit (MICU), and how disinfection might mitigate this risk. Methods Bacteria present on the rails from 36 patient beds in the MICU were sampled immediately before cleaning and at 0.5, 2.5, 4.5, and 6.5 hours after cleaning. Beds were sanitized with either a bottled disinfectant (BD; CaviCide) or an automated bulk-diluted disinfectant (ABDD; Virex II 256). Results The majority of bacteria recovered from the bed rails in the MICU were staphylococci, but not methicillin-resistant Staphylococcus aureus. Vancomycin-resistant enterococci were recovered from 3 beds. Bottled disinfectant reduced the average bacterial burden on the rails by 99%. However, the burden rebounded to 30% of that found before disinfection by 6.5 hours after disinfection. ABDD reduced the burden by an average of 45%, but levels rebounded within 2.5 hours. The effectiveness of both disinfectants was reflected in median reductions to burden of 98% for BD and 95% for ABDD. Conclusions Cleaning with hospital-approved disinfectants reduced the intrinsic bacterial burden on bed rail surfaces by up to 99%, although the population, principally staphylococci, rebounded quickly to predisinfection levels.

Disease Practice Author(s): Seema Rai, Bruce E. Hirsch, Hubert H. Attaway, Richard Nadan, S. Fairey, J. Hardy, G. Miller, Donna Armellino, Wilton R. Moran, Peter Sharpe, Adam Estelle, J. H. Michel, Harold T. Michels, Michael G. Schmidt Reviewed work(s): Source: Infection Control and Hospital Epidemiology, Vol. 33, No. 2 (February 2012), pp. 200201 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/663701 . Accessed: 12/01/2012 12:27