Jacobs Institute of Women's Health
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Performance of individual criteria of the Pediatric Emergency Care Applied Research Network (PECARN) intraabdominal injury prediction rule
No full textOBJECTIVE: The Pediatric Emergency Care Applied Research Network (PECARN) derived and externally validated a clinical prediction rule to identify children with blunt torso trauma at low risk for intraabdominal injuries undergoing acute intervention (IAI). Little is known about the risk for IAI when only one or two prediction rule variables are positive. We sought to determine the risk for IAI when either one or two PECARN intraabdominal injury rule variables are positive. METHODS: We performed a planned secondary analysis of a prospective, multicenter study that included 7542 children (\u3c18 years old) with blunt torso trauma evaluated in six emergency departments from December 2016 to August 2021. Patients with only one or two PECARN rule variables positive were included. The outcome was IAI (IAI undergoing therapeutic laparotomy, angiographic embolization, blood transfusion, or two or more nights of intravenous fluids). RESULTS: Among the 7542 children enrolled, 2986 (39.6%, 95% confidence interval [CI] 38.5%-40.7%) had one or two PECARN variables positive and were included. Of this subpopulation, 227 (7.6%, 95% CI 6.7%-8.6%) had intraabdominal injuries. In the 1639 patients with only one rule variable positive, 21 (1.3%, 95% CI 0.8%-2.0%) had IAI. In the 1347 patients with two rule variables positive, 27 (2.0%, 95% CI 1.3%-2.9%) had IAI. Risk for IAI for each variable was highest for Glasgow Coma Scale (GCS) score \u3c14 (16/291, 5.5%, 95% CI 3.2%-8.8%) and abdominal wall trauma (three of 321, 0.9%, 95% CI 0.2%-2.7%). Risk for IAI when two variables were present was highest when decreased breath sounds (three of 44, 6.8%, 95% CI 1.4%-18.7%) and GCS \u3c14 (10/207, 4.8%, 95% CI 2.3%-8.7%) were present with one other variable. CONCLUSIONS: Few children with blunt torso trauma and one or two PECARN predictor variables present have IAI. Those with GCS score \u3c14, however, are at highest risk for IAI
Retooling the Massive Transfusion Protocol at a Veterans Affairs Medical Center
No full textINTRODUCTION: Massive transfusion protocols (MTPs) ensure the timely and life-saving delivery of blood products to patients who are rapidly exsanguinating. Although essential, MTPs are also highly resource-intensive. Effective MTP implementation must balance the resources of the hospital with the needs of the patient population that they serve, as well as avoid instances of unjustified activations. Toward this goal, we implemented a set of policy improvements to our institution\u27s MTP aimed at ensuring appropriate clinical activation. MATERIALS AND METHODS: Following interdisciplinary discussions with clinical teams, we revamped our institution\u27s MTP in the spring of 2019, focusing on the improved training of junior clinicians by requiring final approval of all MTP activations by attendings and fellows, and providing opportunities to review MTP execution during quarterly meetings. Other changes included implementing blood warmers and streamlining the MTP ordering process. We then performed a retrospective study to evaluate the effects of our refurbished MTP on the frequency, characteristics, and outcomes of massive transfusions activated at the Washington DC Veterans Affairs Medical Center between March 2018 to February 2019 and March 2019 to February 2020 (before and after the policy change, respectively). Descriptive statistics were used to summarize the data. Fisher exact test, Wilcoxon test, and Poisson test were used to compare differences in categorical variables, continuous variables, and the rate of MTP activation, before and after policy changes were implemented, respectively. This study is exempt from the Institutional Review Board\u27s review. RESULTS: We did not detect statistically significant changes in patient and MTP-related parameters, nor survival outcomes following policy improvement. However, we observed a decreasing trend in MTP activations, and concomitantly, a significant increase in the number of days between MTP activations, from 12.5 days (median) in the first year to 41 days (median) in the second year (P = 0.0274). CONCLUSIONS: In summary, we developed an MTP tailored to the needs of our Veterans Affairs Medical Center, providing a reliable system for blood product administration to patients with real massive transfusion requirements while reducing unjustified MTP activations. We credit the reduction in MTP activations mainly to improved education and training of clinicians, which, in turn, changed their ordering behaviors. Fewer unjustified MTP activations decrease the potential for wastage of resources such as blood and blood components and preserves work hours of staff for patients with true transfusion needs. We believe our strategy may have a widespread and compounding effect on improving blood stewardship nationwide, given our trainees\u27 propensity to work at medical centers across the country and educate future trainees of their own
Expert Rater Agreement for Symptoms and Diagnosis of Bipolar Disorder in Youth
No full textThe diagnosis of bipolar disorder (BD) in young children has been a topic of debate, in part owing to varied interpretation of manic-like symptoms. We examined how expert academic clinicians participating in the pediatric bipolar biobank varied in their interpretation and application of Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria and diagnoses. Study co-investigators reviewed 12 standardized narratives and for each marked a visual analog scale with their confidence in the presence of manic episodes and criteria. We analyzed raters\u27 confidence and inter-rater agreement using interclass correlation (ICC). Symptoms with good ICC ranging from 0.60 to 0.74 included inflated self-esteem/grandiosity and decreased need for sleep. Diagnoses and episodes with poor ICCs (\u3c 0.4) included Hypomania and Bipolar Not Elsewhere Classified/Not Otherwise Specified. Despite efforts made to refine BD criteria with DSM-5, there was substantive variation in diagnostic interpretation among investigators working with children presenting with manic-like symptoms
Chronic viral mimicry induction following p53 loss promotes immune evasion
No full textEpigenetic therapies facilitate transcription of immunogenic repetitive elements that cull cancer cells through \u27viral mimicry\u27 responses. Paradoxically, cancer-initiating events also facilitate transcription of repetitive elements. Contributions of repetitive element transcription towards cancer initiation, and the mechanisms by which cancer cells evade lethal viral mimicry responses during tumor initiation remain poorly understood. In this report, we characterize premalignant lesions of the fallopian tube along with syngeneic epithelial ovarian cancer models to explore the earliest events of tumorigenesis following loss of the p53 tumor suppressor protein. We report that p53 loss permits transcription of immunogenic repetitive elements and chronic viral mimicry activation that increases cellular tolerance of cytosolic nucleic acids and diminishes cellular immunogenicity. This selection process can be partially attenuated pharmacologically. Altogether, these results reveal that viral mimicry conditioning following p53 loss promotes immune evasion and may represent a pharmacological target for early cancer interception
Ultrasound modulation of melatonin release from pineal glands in vitro
No full textOBJECTIVES: In this study, we aim to investigate whether therapeutic ultrasound can modulate the release of melatonin from the pineal gland-either increasing or decreasing its levels-and to assess the safety of this technique. This research could address a significant clinical need by providing a noninvasive method to potentially regulate sleep and circadian rhythms through the targeted modulation of melatonin. METHODS: Rat pineal glands were placed in a well with a Krebs Ringer Buffer solution. Ultrasound was applied to the glands using unfocused transducers set at an average intensity of 1 W/cm and three different frequencies (400, 600, and 800 kHz) with continuous exposure for 5 min. Fluid samples were collected from the well before (t = 0 min), immediately after (t = 5 min), and 30 min post-ultrasound treatment (t = 30 min). Melatonin release was subsequently measured using an ELISA kit and analyzed statistically. In addition, histological analysis was completed to determine any structural abnormalities due to ultrasound application. RESULTS: In the 600 kHz group there was a statistically significant decrease from t = 0 min to t = 5 min. No other statistically significant differences were observed. In addition, no histological changes were observed in the pineal glands due to ultrasound application. CONCLUSIONS: This study indicated that ultrasound may be able to modulate melatonin release, however follow-up studies are necessary to determine optimal ultrasound parameters for this application
Effect of information awareness on attitudes toward human papillomavirus vaccination intentions in Japan
No full textBACKGROUND: The Human Papillomavirus (HPV) vaccination rate among Japanese high school girls remains critically low, reflecting ongoing public apprehension and misinformation. This study explores the relationship between information presentation and attitudes toward HPV vaccination in Japan. METHODS: We conducted a web-based survey of female high school students aged 15 to 16 and mothers of daughters of similar age across Japan. The first screening questionnaire investigated the vaccine uptake among eligible students. The detailed questions assessing awareness of HPV vaccination information, including vaccine eligibility and its cost, effectiveness, lifetime prevalence of HPV infection, and vaccine safety, were asked to the respondents. After presenting each piece of information, we investigated how the information influenced the vaccination attitudes of unvaccinated students and mothers of unvaccinated girls. RESULTS: Data collection occurred from August 20 to August 24, 2021. Of 473 students, 68 (14.4 %) had already been vaccinated before the study. Over half of the 245 participating students were aware of vaccine eligibility and cost (68.7 %) and effectiveness (63.6 %), but fewer understood lifetime prevalence (28.7 %) and safety (45.3 %). In contrast, awareness of the same questions in 245 mothers was higher than that in the students: 90.2 %, 92.5 %, 55.4 %, and 61.1 %, respectively. Among unvaccinated students and mothers of unvaccinated girls, the intention to get vaccinated increased the most after being informed about the lifetime risks of HPV infection; 50.5 % of students and 38.8 % of mothers showed a positive attitude toward the HPV vaccination. CONCLUSIONS: Bridging the awareness gap between students and mothers is crucial for improving HPV vaccination rates. The findings underscore the potential of specific, targeted information to influence vaccination intentions, particularly regarding the HPV infection rate
An Analysis of School-Based Mental Health Models and Policies
No full textThe youth mental health crisis in the United States was exacerbated by the COVID-19 pandemic, as well as in part by widespread, frequent use of the internet and social media. Schools provide an opportune setting for delivering prompt preventative interventions to actively mitigate this crisis. The purpose of this project was to identify policy recommendations for improving school-based mental health services and reducing inequities in care, as well as to produce guidelines on how to advocate for better policies for school mental health services. School policies were analyzed in 3 states at 3 different levels: the state level, district level, and school level. To augment the policy reviews, unstructured interviews were conducted with 5 school nurses from the 3 states. Recommendations for just and sustainable policies for school-based mental health care and strategies on how to advocate for such policies are outlined. This project exemplifies the need for strong policies to support school mental health, with a focus on the role of the school nurse
