DigitalCommons@The Texas Medical Center
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Critical Care Cadets: A Serious Game for Managing Mechanical Ventilation
No full textBackground: Pediatric critical care medicine (PCCM) fellows require proficiency in mechanical respiratory support and ventilator management strategies. Traditional training methods have limitations, and there is a need to expedite the learning process. Serious games have emerged as effective supplements to traditional teaching methods, promoting knowledge acquisition through immersive and engaging experiences. However, there is a void in the context of complex decision making in mechanical ventilation management.
Objective: To develop a serious game to enhance the knowledge and practical strategies of PCCM fellows in mechanical ventilation management.
Methods: The game was designed on the basis of theory-informed design principles and employed an iterative development process. A mixed methods approach, grounded in the Model for the Evaluation of Educational Games, was used for evaluation of usability, player experience, satisfaction, and learning outcomes. Game play and evaluation occurred in July 2022.
Results: Our game proved highly engaging, enjoyable, and facilitated learning among the PCCM fellows. The evaluation data indicated high ratings in all Model for the Evaluation of Educational Games domains. The fellows reported achieving the learning objectives and demonstrated knowledge gained in post-game play modified essay questions, and the game received positive feedback.
Conclusion: The developed serious game fills an educational gap in complex decision making in mechanical ventilation management. By using theory-informed design principles and an iterative development process, the game effectively enhanced the knowledge and practical skills of PCCM fellows. The positive outcomes and feedback from the evaluation support the use of serious games as innovative educational tools in medical education
Should All Pediatric Patients With Type 1 Autoimmune Hepatitis Be Screened for Inflammatory Bowel Disease?
No full textElastic Cytomatrix Dynamics Influences Metabolic Rate and Tumor Microenvironment Formation
No full textIn healthy cells, the cytomatrix mechanics utilize mitochondrial respiration to control cytosolic motion and fine-tune the chemical processes. In cancer, the cytosolic motion is energized by glycolytic fermentation (the Warburg effect), which provides additional energy to supply the needs of the cytomatrix. Here, we describe the physical and chemical processes of the integrated and cooperative cytomatrix cytoarchitecture, in which structure and function are inseparable. The extracellular matrix is interconnected with the intracellular cytomatrix and functions as two integrated elastic solid phases. This finding led us to propose mechanisms of tumor microenvironment formation resulting from the mutational burden, in which altered proteins with corresponding post-translational modifications translocate to the cell surface, where they attract immunocompetent cells and activated fibroblasts, producing a tumor-insulating niche. This insulation disrupts cell-to-cell recognition and other signaling pathways that affect the intracellular cytomatrix, particularly actin dynamics, which influence both cell size and shape, recognized as the dedifferentiated state of cancer cells. We also discuss the perspectives of AI in cytomatrix modeling and neural network modeling, focusing on the effects of intracellular and extracellular matrices on the development of the tumor microenvironment
The Use of Biased Language in the Care of Seriously Ill Children: A Pilot Study.
No full textBackground Implicit bias pervades health care, decreases quality of care, and disproportionately affects health outcomes for persons of color. Little is known about the use of biased language in the care of seriously ill children as documented in the electronic health record (EHR). Objective To describe the use of biased language in the EHR of critically ill pediatric patients and to assess if there is a difference based on patient demographics and clinical characteristics. Setting/Participants A retrospective review of EHRs was conducted on patients admitted to a Pediatric Intensive Care Unit (PICU) with a palliative care consult at a large, urban academic center in the United States in 2019. Measurements Demographics and clinical characteristics were compared between patients with and without biased language in their EHR in univariate and multivariate analyses. Frequencies of descriptor usage and health care team members using the descriptor were recorded. Exemplar quotes using biased language were recorded. Results In 63 patients, no differences were found in demographic or clinical characteristics between patients with and without positively and negatively biased language. In adjusted analysis, there was no effect of demographics or clinical characteristics on the odds of having at least 1 instance of negatively biased language. Physicians and social workers used more biased language than other health care team members. Conclusion Despite no statistically significant difference noted in this pilot study, linguistic biases exist in the EHR of seriously ill children, which may lead to testimonial injustice. Efforts to combat bias and racism in pediatric health care documentation may focus on revising note templates and educating across disciplines
Extracorporeal Membrane Oxygenation for Systemic Lupus Erythematosus: An ELSO Registry Analysis
No full textThe success of extracorporeal membrane oxygenation (ECMO) in treating Systemic Lupus Erythematosus (SLE) and the risk factors associated with mortality remain uncertain. Methods: We describe the survival outcomes at discharge of the largest SLE cohort on ECMO support. We performed a retrospective cohort study of the Extracorporeal Life Support Organization registry database from 2012 to 2022. Pediatric and adult survivor groups were analyzed using descriptive statistics for the primary study outcome of survival to hospital discharge. Risk predictors for survival were determined by logistic regression.Results: We included 48 children and 368 adults with SLE. Overall, 198 patients (54%) survived to hospital discharge, with a survival of 52% and 47% of pediatric and adult patients, respectively.Conclusion: We conclude that ECMO can be considered a life supporting strategy in pediatric and adult SLE patients
Characteristics Associated With EuroLupus Versus Modified National Institutes of Health Cyclophosphamide Regimen Use in Children and Young Adults With Lupus Nephritis
No full textObjective: To determine the demographic and clinical characteristics associated with use of the EuroLupus or modified National Institutes of Health (NIH) cyclophosphamide (CYC) regimen for treatment of lupus nephritis (LN) at North American pediatric centers.
Methods: A retrospective cohort study was conducted at 11 North American centers. Patients \u3c 22 years of age with active LN treated with CYC using the EuroLupus or NIH regimen between July 2014 and June 2021 were included. Data were extracted via electronic medical record review. Demographic and clinical characteristics were compared at CYC initiation. A multivariable generalized estimating equation with logit link was fit to model EuroLupus use. An exchangeable correlation structure was used to account for correlation within centers. Independent variables were chosen using elastic net regression.
Results: The cohort consisted of 191 patients (85 EuroLupus, 106 NIH) with a median age of 15.3 years at CYC initiation. In multivariable analysis, characteristics significantly associated with EuroLupus regimen use (vs NIH regimen use) included more recent year of CYC initiation, longer disease duration, Hispanic ethnicity and Asian race (as compared to Black), previous CYC treatment, renal impairment (dialysis or mild kidney impairment), and absence of neuropsychiatric involvement.
Conclusion: For children and young adults with LN requiring CYC, use of the EuroLupus regimen increased over time and is associated with demographic and clinical factors such as race or Hispanic ethnicity, renal impairment, and absence of neuropsychiatric involvement. The differences in regimen use with severe renal impairment and neuropsychiatric lupus highlight areas for future study in CYC dosing
New Onset Refractory Status Epilepticus: Long-Term Outcomes Beyond Seizures
No full textWe propose and prioritize important outcome domains that should be considered for future research investigating long-term outcomes (LTO) after new onset refractory status epilepticus (NORSE). The study was led by the international NORSE Institute LTO Working Group. First, literature describing the LTO of NORSE survivors was identified using a PubMed search and summarized to identify knowledge gaps. Subsequently, a consensus-building process was performed to prioritize and rank important LTO domains for further research. The prioritization of LTO domains was qualitative, enabling the expert panel to generate ideas, share opinions, and provide reasons for the rankings. A second round took place to allow expansion and agreement regarding specific details for each domain. Outcomes were classified into eight main domains: (1) Function: Neuropsychological, Neurological (other than seizures), and Psychiatric (mood and behavior); (2) Quality of Life; (3) Epilepsy; (4) Nonneurological (medical); (5) Social; (6) Caregiver Burden; (7) Long-Term Mortality; and (8) Health Care System Impact. In addition, the working group suggested obtaining outcome measures for each domain at 6 months and 1 year after discharge and annually thereafter until stability has been reached. There are no currently established time frames set for when LTO in NORSE begin or plateau, and previously there existed no consensus regarding which LTO should be considered. This consensus process identifies and recommends NORSE LTO domains that should be considered in future research studies to provide more consistent results that can be compared between studies. Survivors of NORSE should be evaluated serially and at fixed points over time to maximize our understanding of the recovery trajectory for all LTO domains. Establishing reliable and standardized data describing LTO (beyond seizures) after NORSE will support discussions with families during the acute stages, prognostication, the development of targeted management strategies for survivors, and future comparative research globally helping to identify biomarkers that may predict LTO
Response to: Correspondence on “Hyperleukocytosis in a Neuroblastoma Patient After Treatment With Natural Killer T Cells Expressing a GD2-Specific Chimeric Antigen Receptor and Il-15” by Ataca Atilla and Atilla
No full textSex Differences in Beneficial and Pathogenic Bacteria in People With HIV (PWH) With a History of Heavy Alcohol Drinking
No full textBACKGROUND: HIV-1 infection and hazardous levels of alcohol consumption have been independently linked to gut dysbiosis affecting beneficial butyrate-producing bacteria. However, sex-based differences in the composition and function of gut microbiome of People With HIV (PWH) with a history of heavy alcohol drinking remain undetermined, which is the focus of this study.
METHODS: Cross-sectional study examining structural and functional features of the gut microbiome in PWH between men and women with a history of hazardous alcohol drinking recruited at St. Petersburg, Russia. 16S rDNA sequencing information was used for metataxonomic, Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt2) and Linear Discriminant Analysis Effect Size (LEfSe) analyses. Group-wise comparisons were done using Mann-Whitney
RESULTS: Metataxonomic analysis demonstrated that women depicted significantly higher microbial diversity (Operational Taxonomic Units, OTUs and Shannon Index), higher percent relative abundance (%RA) of
CONCLUSION: Overall, we observed significant sex-based differences in the relative abundances of beneficial bacterial communities such as butyrate producers and potential pathogenic Prevotella community in the gut microbiome of PWH with a history of heavy alcohol consumption. The observed sex-based differences are clinically relevant and could inform therapeutic strategies with evidence-based probiotics
Oral Inflammation and Microbiome Dysbiosis Exacerbate Chronic Graft-Versus-Host Disease
No full textThe oral microbiota, second in abundance to the gut, is implicated in chronic systemic diseases, but its specific role in graft-versus-host disease (GVHD) pathogenesis has been unclear. Our study finds that mucositis-induced oral dysbiosis in patients after hematopoietic cell transplantation (HCT) associated with increased chronic GVHD (cGVHD), even in patients receiving posttransplant cyclophosphamide. In murine HCT models, oral dysbiosis caused by bilateral molar ligatures exacerbated cGVHD and increased bacterial load in the oral cavity and gut, with Enterococcaceae significantly increasing in both organs. In this model, the migration of Enterococcaceae to cervical lymph nodes both before and after transplantation activated antigen-presenting cells, thereby promoting the expansion of donor-derived inflammatory T cells. Based on these results, we hypothesize that pathogenic bacteria increase in the oral cavity might not only exacerbate local inflammation but also enhance systemic inflammation throughout the HCT course. Additionally, these bacteria translocated to the gut and formed ectopic colonies, further amplifying systemic inflammation. Furthermore, interventions targeting the oral microbiome mitigated murine cGVHD. Collectively, our findings highlight the importance of oral dysbiosis in cGVHD and suggest that modulation of the oral microbiome during transplantation may be an effective approach for preventing or treating cGVHD