Massachusetts General Hospital

Study objective: In a perioperative emergency, anesthesiologists must acknowledge the unfolding crisis promptly, call for timely assistance, and avert patient harm. We aimed to identify vital signs and qualitative factors prompting crisis acknowledgment and to compare responses between observers and participants in simulation. Design: Prospective, simulation-based, observational study. Setting: An anesthesia crisis resource management course at a freestanding simulation center. Subjects: Sixty attending anesthesiologists from a variety of practice settings. Interventions: In each case, a primary anesthesiologist in charge (PAIC) managed a simulated patient undergoing a uniformly scripted sequence of perioperative anaphylaxis and called for help from another anesthesiologist when a crisis began. Anesthesiologist observers (AOs) viewed the case separately and recorded times of crisis onset. Measurements: Simulation footage was reviewed by investigators for patient vital signs and participant behaviors at times of crisis acknowledgment, with the call for help as an explicit proxy for PAIC crisis acknowledgment. These factors were categorized, and group-level data were compared. Results: Nineteen PAICs and 41 AOs were included. Clinicians acknowledged crises around a mean arterial pressure (MAP) of 65 mmHg and oxygen saturation of 94% as anaphylactic shock progressed. PAICs acknowledged crises at a higher respiratory rate than AOs (20 vs. 18 breaths/min, p = 0.038). Other vitals and timing of crisis acknowledgment did not differ between PAICs and AOs. Nearly half of all participants (45%) identified crises at MAP <65 mmHg. Timing of crisis acknowledgment varied widely (range: 421 s). Conclusions: Despite overall heterogeneity in clinical performance, anesthesiologists acknowledged crises per standard definitions of hypotension. Thresholds for crisis acknowledgment did not significantly differ between PAICs and AOs, suggesting minimal effect from active care responsibility. Many indicated crises at MAP <65 mmHg or after significant deterioration, risking failure-to-rescue events. We suggest that crisis management instruction should address triggers for requesting help.

Purpose of Review While the benefits of palliative care for patients with cancer are well established, palliative care in neuro-oncology is still in its early stages. However, in recent years, there has been increasing attention drawn to the need for better palliative care for patients with brain tumors. Recent Findings There is a growing body of literature demonstrating the high symptom burden and significant supportive care and information needs of these patients and their caregivers. In the area of caregiver needs, the last 3 years has seen a more rapid growth in recognizing and characterizing these needs. However, there remains a knowledge gap regarding the optimal means of addressing these needs. Summary In this article, we outline important recent advances in the literature on palliative care for patients with brain tumors and highlight areas in need of greater attention and investigation.

Percutaneous drains have provided a minimally invasive way to treat a wide range of disorders from abscess drainage to enteral feeding solutions to treating hydronephrosis. These drains suffer from a high rate of dislodgement of up to 30% resulting in emergency room visits, repeat hospitalizations, and catheter repositioning/replacement procedures, which incur significant morbidity and mortality. Using ex vivo and in vivo models, a force body diagram was utilized to determine the forces experienced by a drainage catheter during dislodgement events, and the individual components which contribute to drainage catheter securement were empirically collected. Prototypes of a skin level catheter securement and valved quick release system were then developed. The system was inspired by capstans used in boating for increasing friction of a line around a central spool and quick release mechanisms used in electronics such as the Apple MagSafe computer charger. The device was tested in a porcine suprapubic model, which demonstrated the effectiveness of the device to prevent drain dislodgement. The prototype demonstrated that the miniaturized versions of technologies used in boating and electronics industries were able to meet the needs of preventing dislodgement of patient drainage catheters.

The 2023 International Olympic Committee (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs) notes that exposure to low energy availability (LEA) exists on a continuum between adaptable and problematic LEA, with a range of potential effects on both health and performance. However, there is variability in the outcomes of LEA exposure between and among individuals as well as the specific manifestations of REDs. We outline a framework for a ‘systems biology’ examination of the effect of LEA on individual body systems, with the eventual goal of creating an integrated map of body system interactions. We provide a template that systematically identifies characteristics of LEA exposure (eg, magnitude, duration, origin) and a variety of moderating factors (eg, medical history, diet and training characteristics) that could exacerbate or attenuate the type and severity of impairments to health and performance faced by an individual athlete. The REDs Physiological Model may assist the diagnosis of underlying causes of problems associated with LEA, with a personalised and nuanced treatment plan promoting compliance and treatment efficacy. It could also be used in the strategic prevention of REDs by drawing attention to scenarios of LEA in which impairments of health and performance are most likely, based on knowledge of the characteristics of the LEA exposure or moderating factors that may increase the risk of harmful outcomes. We challenge researchers and practitioners to create a unifying and dynamic physiological model for each body system that can be continuously updated and mapped as knowledge is gained.

Background We sought to identify potentially modifiable in‐hospital factors associated with global cognition, post‐traumatic stress disorder (PTSD) symptoms, and depression symptoms at 12 months. Methods This was a multi‐center prospective cohort study in adult hospitalized patients with acute COVID‐19. The following in‐hospital factors were assessed: delirium; frequency of in‐person and virtual visits by friends and family; and hydroxychloroquine, corticosteroid, and remdesivir administration. Twelve‐month global cognition was characterized by the MOCA‐Blind. Twelve‐month PTSD and depression were characterized using the PTSD Checklist for the DSM‐V and Hospital Anxiety Depression Scale, respectively. Findings Two hundred three patients completed the 12‐month follow‐up assessments. Remdesivir use was associated with significantly higher cognition at 12 months based on the MOCA‐Blind (adjusted odds ratio [aOR] = 1.98, 95% CI: 1.06, 3.70). Delirium was associated with worsening 12‐month PTSD (aOR = 3.44, 95% CI: 1.89, 6.28) and depression (aOR = 2.18, 95% CI: 1.23, 3.84) symptoms. Multiple virtual visits per day during hospitalization was associated with lower 12‐month depression symptoms compared to those with less than daily virtual visits (aOR = 0.40, 95% CI: 0.19, 0.85). Conclusion Potentially modifiable factors associated with better long‐term outcomes included remdesivir use (associated with better cognitive function), avoidance of delirium (associated with less PTSD and depression symptoms), and increased virtual interactions with friends and family (associated with less depression symptoms).

In the past decade, the study of relationships among nutrition, exercise and the effects on health and athletic performance, has substantially increased. The 2014 introduction of Relative Energy Deficiency in Sport (REDs) prompted sports scientists and clinicians to investigate these relationships in more populations and with more outcomes than had been previously pursued in mostly white, adolescent or young adult, female athletes. Much of the existing physiology and concepts, however, are either based on or extrapolated from limited studies, and the comparison of studies is hindered by the lack of standardised protocols. In this review, we have evaluated and outlined current best practice methodologies to study REDs in an attempt to guide future research. This includes an agreement on the definition of key terms, a summary of study designs with appropriate applications, descriptions of best practices for blood collection and assessment and a description of methods used to assess specific REDs sequelae, stratified as either Preferred , Used and Recommended or Potential . Researchers can use the compiled information herein when planning studies to more consistently select the proper tools to investigate their domain of interest. Thus, the goal of this review is to standardise REDs research methods to strengthen future studies and improve REDs prevention, diagnosis and care.

Background The purpose of the present study was to examine the effects of arthroscopic labral repair with capsular augmentation on blood flow in vivo with use of laser Doppler flowmetry (LDF) to measure microvascular perfusion of the labrum and autograft tissue. Methods The present prospective case series included patients ≥18 years old who underwent arthroscopic acetabular labral repair with capsular augmentation; all procedures were performed by a single surgeon between 2018 and 2022. The LDF probe measured microvascular blood flow flux within 1 mm ³ of the surrounding labral and capsular tissue of interest. Mean baseline measurements of flux were compared with readings immediately following capsular elevation and after completing labral augmentation. Blood flux changes were expressed as the percent change from the baseline measurements. Results The present study included 41 patients (24 men [58.5%] and 17 women [41.5%]) with a mean age (and standard deviation) of 31.3 ± 8.4 years, a mean BMI of 24.6 ± 3.4 kg/m ² , a mean lateral center-edge of angle 35.3° ± 4.9°, a mean Tönnis angle of 5.8° ± 5.8°, and a mean arterial pressure of 93.7 ± 10.9 mm Hg. Following capsular elevation, the mean percent change in capsular blood flow flux was significantly different from baseline (−9.24% [95% confidence interval (CI), −18.1% to −0.04%]; p < 0.001). Following labral augmentation, the mean percent change in labral blood flow flux was significantly different from baseline both medially (−22.3% [95% CI, −32.7% to −11.9%]; p < 0.001) and laterally (−32.5% [95% CI, −41.5% to −23.6%]; p = 0.041). There was no significant difference between the changes in medial and lateral perfusion following repair (p = 0.136). Conclusions Labral repair with capsular augmentation sustains a reduced blood flow to the native labrum and capsular tissue at the time of fixation. The biological importance of this reduction is unknown, but these findings may serve as a benchmark for other labral preservation techniques and support future correlations with clinical outcomes. Level of Evidence Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Depression impacts many individuals with autism spectrum disorder (ASD), carrying increased risk of functional impairment, hospitalization, and suicide. Prescribing medication to target depression in patients with ASD occurs despite limited available systematic data describing medication management of depression in this population. The purpose of this study is to discover prescribing patterns for individuals with MDD and ASD during this time period (2004–2012) to inform current and future prescribing practices with historical data. Drawing from a large clinical database describing the prescribing practices in patients with ASD, we identified 166 individuals with ASD (mean age 14.5 ± 8.3 years old) who received medication targeting symptoms of depression. We report prescribing rates for specific drugs, drug treatment duration, and reasons for drug discontinuation when applicable. Sertraline, mirtazapine, and fluoxetine were the three most commonly prescribed medications to treat comorbid depression for this patient population. Among 241 drug starts, 123 (49%) drug treatments were continued at the final reviewed follow-up visit (average treatment duration of ± 0.72 years). The most common reason for discontinuation across all medications prescribed was loss of or lack of effectiveness. This study raises concern that standard of care pharmacological treatments for depression in individuals with ASD may be less effective than in neurotypical populations. There remains a need to develop effective interventions for depression specifically tailored to the needs of individuals with ASD.

Objective To elucidate particular placental pathology findings that are associated with hypoxic ischemic encephalopathy (HIE) and determine which patterns are associated with adverse fetal/neonatal outcomes. Study Design Multi-institutional retrospective case-control study of newborns with HIE (2002–2022) and controls. Four perinatal pathologists performed gross and histologic evaluation of placentas of cases and controls. Results A total of 265 placentas of neonates with HIE and 122 controls were examined. Infants with HIE were more likely to have anatomic umbilical cord abnormalities (19.7% vs 7.4%, P = .003), fetal inflammatory response in the setting of amniotic fluid infection (27.7% vs 13.9%, P = .004), and fetal vascular malperfusion (30.6% vs 9.0%, P = <.001) versus controls. Fetal vascular malperfusion with maternal vascular malperfusion was more common in those who died of disease ( P = .01). Conclusion Placental pathology examination of neonates with HIE may improve our understanding of this disorder and its adverse outcomes.

In this Viewpoint, the authors urge the USPSTF to undertake a comprehensive effort to ensure its recommendations systematically consider the effects of ableism and structural ableism on individuals with disability.

Objective Gastrointestinal symptoms, particularly postprandial fullness, are frequently reported in eating disorders. Limited data exist evaluating how these symptoms change in response to outpatient psychological treatment. The current study sought to describe the course of postprandial fullness and early satiation across psychological treatment for adults with bulimia nervosa and related other specified feeding or eating disorders and to test if anxiety moderates treatment response. Methods Secondary data analysis was conducted on questionnaire data provided by 30 individuals (80% white, M (SD) age = 31.43(13.44) years; 90% female) throughout treatment and six‐month follow‐up in a pilot trial comparing mindfulness and acceptance‐based treatment with cognitive‐behavioral therapy for bulimia nervosa. Participants completed items from the Rome IV Diagnostic Questionnaire for Adult Functional Gastrointestinal Disorders and the State Trait Anxiety Inventory. Results Postprandial fullness and early satiation both significantly decreased over time (ds = 1.23–1.54; p 's < .001). Baseline trait anxiety moderated this outcome, such that greater decreases were observed for those with higher baseline anxiety ( p = .02). Discussion Results extend prior work in inpatient samples by providing preliminary data that postprandial fullness and early satiation decrease with outpatient psychological treatment for bulimia nervosa. Baseline anxiety moderated this effect for postprandial fullness. Future work should replicate findings in a larger sample and test anxiety as a mechanism underlying postprandial fullness in eating disorders. Public Significance The current study found that common gastrointestinal symptoms (postprandial fullness and early satiation) decrease over the course of outpatient psychotherapy for adults with full and subthreshold bulimia nervosa. Postprandial fullness decreased more across time for those high in anxiety.

The risks of malignancy for cytologic categories in renal biopsy specimens differ from the risks in most other sites. There are obvious areas in which cytopathologists can do better at classifying these cases, and the routine use of immunohistochemistry and core‐needle biopsy may improve the accuracy of the classification of these specimens.

Familial Alzheimer’s disease (fAD) mutations in the amyloid-β protein precursor (AβPP) enhance brain AβPP C-Terminal Fragment (CTF) levels to inhibit lysosomal v-ATPase. Consequent disrupted acidification of the endolysosomal pathway may trigger brain iron deficiencies and mitochondrial dysfunction. The iron responsive element (IRE) in the 5’Untranslated-region of AβPP mRNA should be factored into this cycle where reduced bioavailable Fe-II would decrease IRE-dependent AβPP translation and levels APP-CTFβ in a cycle to adaptively restore iron homeostasis while increases of transferrin-receptors is evident. In healthy younger individuals, Fe-dependent translational modulation of AβPP is part of the neuroprotective function of sAβPPα with its role in iron transport.

Background Both nonoperative and operative treatments for spinal metastasis are expensive interventions. Patients' expected 3‐month survival is believed to be a key factor to determine the most suitable treatment. However, to the best of our knowledge, no previous study lends support to the hypothesis. We sought to determine the cost‐effectiveness of operative and nonoperative interventions, stratified by patients' predicted probability of 3‐month survival. Methods A Markov model with four defined health states was used to estimate the quality‐adjusted life years (QALYs) and costs for operative intervention with postoperative radiotherapy and radiotherapy alone (palliative low‐dose external beam radiotherapy) of spine metastases. Transition probabilities for the model, including the risks of mortality and functional deterioration, were obtained from secondary and our institutional data. Willingness to pay thresholds were prespecified at $100,000 and $150,000. The analyses were censored after 5‐year simulation from a health system perspective and discounted outcomes at 3% per year. Sensitivity analyses were conducted to test the robustness of the study design. Results The incremental cost‐effectiveness ratios were $140,907 per QALY for patients with a 3‐month survival probability >50%, $3,178,510 per QALY for patients with a 3‐month survival probability <50%, and $168,385 per QALY for patients with independent ambulatory and 3‐month survival probability >50%. Conclusions This study emphasizes the need to choose patients carefully and estimate preoperative survival for those with spinal metastases. In addition to reaffirming previous research regarding the influence of ambulatory status on cost‐effectiveness, our study goes a step further by highlighting that operative intervention with postoperative radiotherapy could be more cost‐effective than radiotherapy alone for patients with a better survival outlook. Accurate survival prediction tools and larger future studies could offer more detailed insights for clinical decisions.

We used the information component (IC), a disproportionate Bayesian analysis comparing the number of observed versus expected adverse drug reactions, to determine the potential association between anti‐neoplastic agents and thrombotic microangiopathy (TMA). The IC025 indicates the lower end of 95% of IC, in which a value >0 suggests a disproportionality signal between the drug of interest and the adverse drug reaction. Carfilzomib had the highest IC025 for TMA among all studied chemotherapies followed by gemcitabine, mitomycin, bevacizumab, and bortezomib. image