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Pollution and Cardiovascular Health, a Developmental Stages Approach from Death Metal to Laws
No full textCME available for 1 year after presentation
CME Text Code: 97033
In order to claim CME credit, please complete an evaluation in CloudCME for each presentation.https://knowledgeconnection.mainehealth.org/pediatrics_gr/1079/thumbnail.jp
Impact of Physiological Stress and Reserve on the Cost of Care: Operative Stress Score and Frailty
No full textBACKGROUND: Physiological stress and reserve negatively impact surgical patients. METHODS: Patients undergoing elective surgery were included. Operative stress was defined by operative stress score (OSS) and frailty by RAI. RESULTS: 6,182 patients were included. When OSS score of 5, patients were older (67 vs. 65.4), more likely male (70.2 vs 53.9), had longer length of stay (9.7 days vs 3.3 days), and higher mortality (30 days- 3.9 vs. 0.7, 90 days- 6.27 vs. 1.37, and 120 days- 8.24 vs.1.8). Frail patients were older (76 versus 65.4 years), more likely male (68.9 versus 53.9), had higher mortality (30 days- 1.6 versus 0.7, 90 days- 4.4 versus 1.73, and 120 days- 4.7 versus 1.8,), and longer length of stay (4.8 versus 3.3 days). Costs increased with OSS. Net income differed between OSS categories; the highest was OSS of 4 (5,213, p \u3c 0.001). Total charges and costs increased with increasing frailty (p \u3c 0.0001). There is a decrease in net income with frailty. Overall, for frail patients, there was a net negative income (5231, p \u3c 0.0001). Trends were similar with each OSS category (1/2, 3, 4, and 5). Net income was negative for almost all OSS categories in frail (1/2 -4,440, 4 -9,932). Net income was positive for commercially insured but negative for most with Medicare. CONCLUSIONS: Increasing OSS was associated with increased costs and profit, and frailty was associated with increased costs and decreased profit. Most with Medicare are cared for at a loss
Lipidomic and proteomic insights from extracellular vesicles in the postmortem dorsolateral prefrontal cortex reveal substance use disorder-induced brain changes
No full textSubstance use disorder (SUD) significantly increases the risk of neurotoxicity, inflammation, oxidative stress, and impaired neuroplasticity. The activation of inflammatory pathways by substances may lead to reactive astrogliosis and chronic neuroinflammation, potentially mediated by the release of extracellular particles (EPs), such as extracellular condensates (ECs) and extracellular vesicles (EVs). These particles, which reflect the physiological, pathophysiological, and metabolic states of their cells of origin, might carry molecular signatures indicative of SUD. In particular, our study investigated neuroinflammatory signatures in SUD patients by isolating EVs from the dorsolateral prefrontal cortex (dlPFC) Brodmann\u27s area 9 (BA9) from postmortem subjects. We isolated BA9-derived EVs from postmortem brain tissues of eight individuals (controls: n = 4, SUD: n = 4). The physical properties (concentration, size, zeta potential, morphology) of the EVs were analyzed, and the EVs were subjected to integrative multiomics analysis to profile the lipidomic and proteomic characteristics. We assessed the interactions and bioactivity of EVs by evaluating their uptake by glial cells. We further assessed the effects of EVs on complement mRNA expression in glial cells and on microglial migration. No significant differences in EV concentration, size, zeta potential, or surface markers were observed between the SUD group and the control group. However, lipidomic analysis revealed significant enrichment of glycerophosphoinositol bisphosphate (PIP2) in SUD-derived EVs. Proteomic analysis revealed the downregulation of SERPINB12, ACYP2, CAMK1D, DSC1, and FLNB and the upregulation of C4A, C3, and ALB in SUD-derived EVs. Gene Ontology (GO) and protein‒protein interactome analyses revealed functions associated with the identified proteins, such as cell motility, focal adhesion, and acute phase response signaling. Both control and SUD-derived EVs increased C3 and C4 mRNA expression in microglia, but only SUD-derived EVs upregulated these genes in astrocytes. SUD-EVs also significantly enhanced microglial migration in a wound healing assay. This study successfully isolated EVs from postmortem brains and used a multiomics approach to identify EV-associated lipids and proteins in SUD. Elevated C3 and C4 in SUD-derived EVs and the distinct effects of EVs on glial cells suggest a crucial role for these cells in acute phase response signaling and neuroinflammation
Postvaccine early-onset (PoVEO) forms of Graves\u27 disease after anti-SARS-CoV-2 vaccination are characterized by favourable long-term disease outcomes.
No full textINTRODUCTION: In a previous cohort of patients with new-onset of Graves\u27 Disease (GD) during 2021, a postvaccine early-onset (PoVEO) after anti-COVID-19 vaccination emerged as a new and frequent nosological entity occurring in approximately one third of patients. Similar cohorts have also been reported with GD after anti-COVID vaccines, but to date there are no available data on long-term clinical outcomes.
METHODS: This is a single-center retrospective study evaluating the 24-month clinical course of patients with early-onset (\u3c 4 weeks) GD after anti-COVID vaccination (PoVEO) compared to non-PoVEO patients. Biochemical tests, therapies used and follow-up visits were scheduled according to current guidelines, clinicians\u27 experience and patients\u27 needs.
RESULTS: As previously described, 64 patients were observed in 2021 and 20 (31.2%) had PoVEO. Individuals with PoVEO were characterized by distinctive features such as older age, a higher prevalence of male sex, and a better initial biochemical response. Eleven individuals were followed at other Centers (2 with PoVEO and 9 without) and were lost to follow-up. During the two-year follow-up, of the 53 individuals, 7 (13%) underwent definitive surgical or radioactive-iodine therapy (3 PoVEO and 4 non-PoVEO p = 0.67), and 30 (57%) presented disease remission with medical therapy alone. Excluding those who underwent definitive treatments, remission with medical therapy alone was observed in 13/15 (87%) individuals with PoVEO form and 17/31 (55%) non-PoVEO (p = 0.048).
CONCLUSION: In this retrospective study of a cohort of individuals with the PoVEO form of GD, we found a more favourable clinical course, likely linked to transience of the triggering events. Despite these findings, individuals presenting with GD after SARS-CoV-2 vaccination should undergo an active surveillance program with repeat thyroid function testing
Food Insecurity and Rural Child and Family Functioning.
No full textIMPORTANCE: In the US, children in food-insecure households are at risk for adverse psychological outcomes despite being shielded from hunger and malnutrition by their caregivers and school- and community-based programs. Parenting stress may be an important mechanism through which food insecurity is associated with negative outcomes for child mental health.
OBJECTIVE: To investigate associations of household food insecurity with child mental health, parenting stress, and family functioning.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used a daily-diary design in a community-based sample to examine associations between daily fluctuations in food insecurity and child and family functioning. The study was conducted remotely during the COVID-19 pandemic in the rural (defined by the Health Resource Services Administration) Northeastern US. Caregivers of school-aged children were enrolled during the 2021 school year and completed a baseline visit followed by mobile surveys for 30 days. Participants were adult, legal caregivers of children ages 6 to 12 years who experienced food insecurity within the past month. Participants were required to have English proficiency and access to a device with internet and texting capabilities. Prospective participants completed an online questionnaire to determine eligibility. A total of 553 respondents were screened, of which 327 respondents (59.1%) met all inclusion criteria. The most common reason for ineligibility was not having a child in the study age range. Data analyses were performed between May 2022 and April 2023.
EXPOSURE: Household food insecurity.
MAIN OUTCOMES AND MEASURES: The primary outcomes were caregiver hunger, negative affect, executive functioning, and parent-child interactions (measured via a daily self-report survey) and child mental health problems (measured via the Child Behavior Checklist [CBCL]).
RESULTS: Among 61 caregivers (mean [SD] age, 36.1 [5.9] years; 51 women [83.6%]; 2 American Indian or Alaska Native [3.3%], 1 Black [1.6%], and 55 non-Hispanic White [90.2%]), greater day-to-day fluctuations in household and child food insecurity were associated with more severe child internalizing problems (CBCL Internalizing Problems scale: β = 0.40; P = .003 for household and β = 0.49; P \u3c .001 for child food insecurity) and total mental health problems (CBCL Total Problems scale: β = 0.34; P = .01 for household and β = 0.35; P = .01 for child food insecurity). Additionally, the daily association between food insecurity and parent-child conflict was fully mediated via 2 sequential pathways of caregiver hunger and negative affect (b = .02; P = .001) and caregiver hunger and attention and impulse control (b = 0.01; P = .04). This model explained 17% of variability in daily parent-child conflict (R2 = 0.17).
CONCLUSIONS AND RELEVANCE: This study\u27s findings suggest that caregiver stress and household instability may be key mechanisms by which food insecurity is negatively associated with child mental health
Outcomes of ruptured abdominal aortic aneurysms in older adults and who should be offered surgery.
No full textAs life expectancy increases, the prevalence of ruptured abdominal aortic aneurysms (rAAA) poses a significant challenge for our healthcare system. Aging induces biochemical changes, including degradation of the extracellular matrix and loss of vascular smooth muscle cells, which increase the propensity for the development of aneurysms and subsequent rupture due to compromised integrity of the aortic wall. The mortality rate for elderly patients presenting with rAAA is high, ranging from 80 to 90%. Both open and endovascular repair come with substantial risk for elderly patients. While EVAR has been shown to have lower perioperative mortality in this population, elderly patients face significant post-operative recovery challenges related to age and frailty. In determining who should be offered surgery for rAAA, patient selection is crucial. Frailty and existing comorbidities should be factored into whether or not patients are offered surgery. A tailored approach that is individualized to patient specific goals and accounts for pre-existing comorbidities and functional status is essential to improving outcomes for elderly patients presenting with rAAA
Integration of Health Care, Public Health, and Communities: A New Model for Rural Public Health.
No full textRural public health has been hit with a triple set of challenges: overstretched health care, poor health status, and limited public health capacities. MaineHealth, a nonprofit integrated 10-hospital health system, serves a mostly rural area with no local public health departments in its rural communities. By integrating primary care with public health and partnering with communities, MaineHealth has developed an infrastructure to successfully address these challenges. We believe this approach is worthy of consideration in other rural areas.
Patient, Hospital, and Outcome Factors Associated With Attaining Substantial Clinical Benefit Following Primary Total Hip Arthroplasty.
No full textBACKGROUND: Centers for Medicare and Medicaid Services (CMS) began mandating at least 50% institutional compliance of patient-reported outcome-based performance measures for Medicare fee-for-service patients undergoing inpatient, elective total hip arthroplasty (THA). The patient-reported outcome-based performance measure is calculated to represent the proportion of patients meeting or exceeding the substantial clinical benefit (SCB) threshold between preoperative and postoperative patient-reported outcome measures (PROMs). The purpose of this study was to evaluate demographics, operative variables, hospital outcomes, and PROMs among two groups of patients following primary THA: those achieving SCB and those who did not reach this threshold.
METHODS: A retrospective review was performed of patients undergoing primary THA at a single large academic center between January 2015 and November 2024. Demographic, operative, and outcome variables were compared between patients meeting and not meeting SCB. Multivariable analysis was performed to identify risk factors for failure to achieve SCB.
RESULTS: A total of 1,257 patients were included; 54% were women, and 88% met SCB. Few differences between groups in demographics and complications were observed. Patients not meeting SCB more often had a contralateral hip arthroplasty (P \u3c 0.001), government insurance (P = 0.011), and a higher preoperative Hip Disability and Osteoarthritis Outcome Score, Joint Replacement interval score (q \u3c 0.001); these associations remained significant on multivariable analysis. At postoperative time points, functional PROMs were lower and pain scores were higher among patients not achieving SCB.
CONCLUSIONS: The institution of this new Centers for Medicare and Medicaid Services mandate puts renewed attention on the SCB metric. Our results indicate the difficulty in collecting PROMs in accordance with this mandate. Patients not meeting SCB following THA demonstrated few differences in demographics or hospital course, yet exhibited a significant difference in PROMs profile. Future studies are needed to elucidate the underlying causes of observed differences and are essential for equitable arthroplasty care
Well Controlled GDM vs Poorly Controlled GDM Effects on Infant Blood Glucose Levels at Birth
No full textIn pregnant women with gestational diabetes, how does well-controlled maternal blood glucose during pregnancy, compared to poorly controlled glucose levels, affect the incidence of abnormal newborn blood glucose levels at birth?https://knowledgeconnection.mainehealth.org/nurseresidency/1133/thumbnail.jp
Hospitalized Adult Patients with Hypokalemia (cont.)
No full textIn hospitalized adult patients with hypokalemia, how does intravenous potassium supplementation compare to oral (PO) potassium supplementation in affecting the time to normalization of serum potassium levels within a 72-hour inpatient stay?https://knowledgeconnection.mainehealth.org/nurseresidency/1141/thumbnail.jp