George Washington University Hospital

Covid-19 is officially a pandemic. It is a novel infection with serious clinical manifestations, including death, and it has reached at least 124 countries and territories. Although the ultimate course and impact of Covid-19 are uncertain, it is not merely possible but likely that the disease will produce enough severe illness to overwhelm health care infrastructure. Emerging viral pandemics “can place extraordinary and sustained demands on public health and health systems and on providers of essential community services.” Such demands will create the need to ration medical equipment and interventions. Rationing is already here. In the United States, perhaps the earliest example was the near-immediate recognition that there were not enough high-filtration N-95 masks for health care workers, prompting contingency guidance on how to reuse masks designed for single use. Physicians in Italy have proposed directing crucial resources such as intensive care beds and ventilators to patients who can benefit most from treatment. Daegu, South Korea — home to most of that country’s Covid-19 cases — faced a hospital bed shortage, with some patients dying at home while awaiting admission. In the United Kingdom, protective gear requirements for health workers have been downgraded, causing condemnation among providers. The rapidly growing imbalance between supply and demand for medical resources in many countries presents an inherently normative question: How can medical resources be allocated fairly during a Covid-19 pandemic?

The purposes of this study were to identify the incidence of postural abnormalities of the thoracic, cervical, and shoulder regions in two age groups of healthy subjects and to explore whether these abnormalities were associated with pain. Eighty-eight healthy subjects, aged 20 to 50 years, were asked to answer a pain questionnaire and to stand by a plumb line for postural assessment of forward head, rounded shoulders, and kyphosis. Subjects were divided into two age groups: a 20- to 35-year-old group (mean = 25, SD = 63) and a 36- to 50-year-old group (mean = 47, SD = 2.6). Interrater and intrarater reliability (Cohen's Kappa coefficients) for postural assessment were established at .611 and .825, respectively. Frequency counts revealed postural abnormalities were prevalent (forward head = 66%, kyphosis = 38%, right rounded shoulder = 73%, left rounded shoulder = 66%). No relationship was found between the severity of postural abnormality and the severity and frequency of pain. Subjects with more severe postural abnormalities, however, had a significantly increased incidence of pain, as determined by chi-square analysis (critical chi 2 = 6, df = 2, P less than .05). Subjects with kyphosis and rounded shoulders had an increased incidence of interscapular pain, and those with a forward-head posture had an increased incidence of cervical, interscapular, and headache pain.

CONTEXT: During the last 50 years, the incidence and mortality of gastric cancer has declined in many countries. This decline has primarily included the intestinal type (Lauren classification). However, there is an impression among pathologists that the diffuse type, especially the signet ring cell subtype, has become more prevalent. OBJECTIVES: Using data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute, we analyzed the trends of the 2 primary types (intestinal and diffuse) of gastric carcinomas from 1973 through 2000. DESIGN: Trends in age-adjusted rates were determined for gastric carcinomas through the SEER statistical program (SEER*Stat), which is available on the Internet to the public. RESULTS: During the period studied, the intestinal type continued to decline in males, females, African Americans, and whites. The intestinal type was more common in males than in females and more common in African Americans than in whites. In contrast, a consistent increase in the rate of the diffuse type of gastric carcinoma was seen during this period. The rate increased from 0.3 cases per 100 000 persons in 1973 to 1.8 cases per 100 000 persons in 2000. This increase was seen in males, females, African Americans, and whites. The predominant increase occurred in the signet ring type. CONCLUSIONS: The results indicate a progressive decrease in the incidence of the intestinal type of gastric cancer and an increase in the diffuse type of gastric carcinoma, especially the signet ring cell type. The clinical implications of the increase are considered.

Section Editor Pain Clinical Nurse Specialist The George Washington University Hospital Washington, D.C.

Background: Publication of the 2015 American Thyroid Association (ATA) management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer was met with disagreement by the extended nuclear medicine community with regard to some of the recommendations related to the diagnostic and therapeutic use of radioiodine ( 131 I). Because of these concerns, the European Association of Nuclear Medicine and the Society of Nuclear Medicine and Molecular Imaging declined to endorse the ATA guidelines. As a result of these differences in opinion, patients and clinicians risk receiving conflicting advice with regard to several key thyroid cancer management issues. Summary: To address some of the differences in opinion and controversies associated with the therapeutic uses of 131 I in differentiated thyroid cancer constructively, the ATA, the European Association of Nuclear Medicine, the Society of Nuclear Medicine and Molecular Imaging, and the European Thyroid Association each sent senior leadership and subject-matter experts to a two-day interactive meeting. The goals of this first meeting were to (i) formalize the dialogue and activities between the four societies; (ii) discuss indications for 131 I adjuvant treatment; (iii) define the optimal prescribed activity of 131 I for adjuvant treatment; and (iv) clarify the definition and classification of 131 I-refractory thyroid cancer. Conclusion: By fostering an open, productive, and evidence-based discussion, the Martinique meeting restored trust, confidence, and a sense of collegiality between individuals and organizations that are committed to optimal thyroid disease management. The result of this first meeting is a set of nine principles (The Martinique Principles) that (i) describe a commitment to proactive, purposeful, and inclusive interdisciplinary cooperation; (ii) define the goals of 131 I therapy as remnant ablation, adjuvant treatment, or treatment of known disease; (iii) describe the importance of evaluating postoperative disease status and multiple other factors beyond clinicopathologic staging in 131 I therapy decision making; (iv) recognize that the optimal administered activity of 131 I adjuvant treatment cannot be definitely determined from the published literature; and (v) acknowledge that current definitions of 131 I-refractory disease are suboptimal and do not represent definitive criteria to mandate whether 131 I therapy should be recommended.

OBJECTIVES: Excessive fluid therapy in patients with sepsis may be associated with risks that outweigh any benefit. We investigated the possible influence of early fluid balance on outcome in a large international database of ICU patients with sepsis. DESIGN: Observational cohort study. SETTING: Seven hundred and thirty ICUs in 84 countries. PATIENTS: All adult patients admitted between May 8 and May 18, 2012, except admissions for routine postoperative surveillance. For this analysis, we included only the 1,808 patients with an admission diagnosis of sepsis. Patients were stratified according to quartiles of cumulative fluid balance 24 hours and 3 days after ICU admission. MEASUREMENTS AND MAIN RESULTS: ICU and hospital mortality rates were 27.6% and 37.3%, respectively. The cumulative fluid balance increased from 1,217 mL (-90 to 2,783 mL) in the first 24 hours after ICU admission to 1,794 mL (-951 to 5,108 mL) on day 3 and decreased thereafter. The cumulative fluid intake was similar in survivors and nonsurvivors, but fluid balance was less positive in survivors because of higher fluid output in these patients. Fluid balances became negative after the third ICU day in survivors but remained positive in nonsurvivors. After adjustment for possible confounders in multivariable analysis, the 24-hour cumulative fluid balance was not associated with an increased hazard of 28-day in-hospital death. However, there was a stepwise increase in the hazard of death with higher quartiles of 3-day cumulative fluid balance in the whole population and after stratification according to the presence of septic shock. CONCLUSIONS: In this large cohort of patients with sepsis, higher cumulative fluid balance at day 3 but not in the first 24 hours after ICU admission was independently associated with an increase in the hazard of death.

Recurrent anterior unidirectional instability of the shoulder is not always associated with a classic Bankart lesion, which is an avulsion of the anterior labroligamentous structures from the anterior glenoid rim. Because the anterior scapular periosteum ruptures, the labrum and the attached ligaments are found to float out anterior to the glenoid rim when viewed arthroscopically. The anterior labroligamentous periosteal sleeve avulsion (ALPSA) of the supporting anterior inferior ligamentous and labral structures of the shoulder joint was found in four of eight acute primary anterior shoulder dislocations. This lesion differs from the Bankart lesion because the anterior scapular periosteum does not rupture, thereby allowing the labroligamentous structures to displace medially and rotate inferiorly on the scapular neck. These lesions eventually heal, and lead to recurrent anterior dislocations because of the subsequent incompetence of the anterior inferior glenohumeral ligament. An arthroscopic technique that converts the ALPSA lesion to a Bankart lesion and subsequently reconstructs the supporting anterior inferior structures of the shoulder has been successful in 26 cases (4 acute and 22 chronic) which were followed for > or = 2 years. Only one dislocation occurred, and it was the result of severe trauma.

Immune cells that infiltrate a tumor may be a prognostic factor for patients who have had surgically resected hepatocellular carcinoma (HCC). The density of intratumoral total (CD3(+)) and cytotoxic (CD8(+)) T lymphocytes was measured in the tumor interior and in the invasive margin of 65 stage I to IV HCC tissue specimens from a single cohort. Immune cell density in the interior and margin was converted to a binary score (0, low; 1, high), which was correlated with tumor recurrence and relapse-free survival (RFS). In addition, the expression of programmed death 1 (PD-1) and programmed death ligand 1 (PD-L1) was correlated with the density of CD3(+) and CD8(+) cells and clinical outcome. High densities of both CD3(+) and CD8(+) T cells in both the interior and margin, along with corresponding Immunoscores, were significantly associated with a low rate of recurrence (P = 0.007) and a prolonged RFS (P = 0.002). In multivariate logistic regression models adjusted for vascular invasion and cellular differentiation, both CD3(+) and CD8(+) cell densities predicted recurrence, with odds ratios of 5.8 [95% confidence interval (CI), 1.6-21.8] for CD3(+) and 3.9 (95% CI, 1.1-14.1) for CD8(+) Positive PD-L1 staining was correlated with high CD3 and CD8 density (P = 0.024 and 0.005, respectively) and predicted a lower rate of recurrence (P = 0.034), as well as prolonged RFS (P = 0.029). Immunoscore and PD-L1 expression, therefore, are useful prognostic markers in patients with HCC who have undergone primary tumor resection. Cancer Immunol Res; 4(5); 419-30. ©2016 AACR.

Addition of fentanyl to bupivacaine administered for spinal anesthesia for cesarean delivery was evaluated in 56 ASA physical status 1 term parturients. Preservative-free saline was added to 0, 2.5, 5, 6.25, 12.5, 25, 37.5, or 50 micrograms fentanyl to make a 1 ml total volume, which was injected intrathecally prior to bupivacaine in a double-blind, randomized fashion. Vital signs, sensory level, motor block, pain score, and side effects were recorded every 2 min for the first 12 min and then at 15, 30, 45, and 60 min and at 30-min intervals until the patient complained of pain. At delivery maternal vein, umbilical artery, and umbilical vein blood gases were obtained. Apgar scores at 1 and 5 min were recorded. Early Neonatal Neurobehavioral Scales (ENNS) were performed on days 1 and 2. Side effects and opioid requirements were recorded for the first 24 h. All of the patients in the control group reported a pain score greater than 0 during surgery and 67% required intraoperative opioids. None of the patients who received greater than or equal to 6.25 micrograms fentanyl required intraoperative opioids. Complete analgesia (time from injection to first report of pain) lasted 33.7 +/- 30.8 min (mean +/- SD) in the control group and increased to 130 +/- 30 min (P less than 0.05) with addition of 6.25 micrograms fentanyl. Duration of effective analgesia (time from injection to first parenteral opioid) was 71.8 +/- 43.2 min in the control group and increased (P less than 0.05) to 192 +/- 74.9 min with addition of 6.25 micrograms fentanyl.(ABSTRACT TRUNCATED AT 250 WORDS)

PTC is a clinical entity of uncertain etiology characterized by intracranial hypertension. The syndrome classically manifests with headaches and visual changes in women with obesity. Traditionally, imaging ruled out secondary causes of elevated CSF pressure but now may reveal findings frequently seen in patients with PTC, including the following: flattening of the globe, an empty sella, an enlarged ONS, protrusion and enhancement of the optic nerve head, and increased tortuosity of the optic nerve. Novel imaging methods, including MR venography, have additionally identified sinovenous stenosis as a potential indicator of PTC.

The incidence of the acquired immune deficiency syndrome (AIDS) among persons infected with human T-lymphotropic virus type III (HTLV-III) was evaluated prospectively among 725 persons who were at high risk of AIDS and had enrolled before October 1982 in cohort studies of homosexual men, parenteral drug users, and hemophiliacs. A total of 276 (38.1 percent) of the subjects were either HTLV-III seropositive at enrollment or developed HTLV-III antibodies subsequently. AIDS had developed in 28 (10.1 percent) of the seropositive subjects before August 1985. By actuarial survival calculations, the 3-year incidence of AIDS among all HTLV-III seropositive subjects was 34.2 percent in the cohort of homosexual men in Manhattan, New York, and 14.9 percent (range 8.0 to 17.2 percent) in the four other cohorts. Out of 117 subjects followed for a mean of 31 months after documented seroconversion, five (all hemophiliacs) developed AIDS 28 to 62 months after the estimated date of seroconversion, supporting the hypothesis that there is a long latency between acquisition of viral infection and the development of clinical AIDS. This long latency could account for the significantly higher AIDS incidence in the New York cohort compared with other cohorts if the virus entered the New York homosexual population before it entered the populations from which the other cohorts were drawn. However, risk of AIDS development in different populations may also depend on the presence of as yet unidentified cofactors.

Central pontine and extrapontine myelinolysis was experimentally produced in dogs by the rapid correction of severe, sustained, vasopressin-induced hyponatremia. Hyponatremia alone or slowly corrected hyponatremia did not produce the disease. Affected dogs showed rigid quadriparesis. The central pons, lateral aspects of the thalamus and adjacent internal capsules, deep layers of cerebral cortex and subjacent white matter, cerebellum, and other regions were symmetrically involved. Myelin and oligodendroglia were affected out of proportion to axons and neurons. Thus, the clinical features, the distribution of the lesions, and their histological features closely resemble the human disease. These experiments document an electrolyte manipulation that can cause permanent neuropathological lesions. Taken with the available clinical data on human patients, the experimental results indicate that human myelinolysis may be due to a rapid increase in serum sodium from previously low levels, and that rapid normalization of severe, sustained hyponatremia should therefore be avoided.

Variant angina of Prinzmetal has been generally presumed to be caused by a significant focal obstruction in a single major coronary artery which should be an ideal lesion for aortocoronary saphenous vein bypass graft. Recognition of this clinical syndrome would then be of particular diagnostic and therapeutic importance if such a consistent association can be demonstrated. Of five patients with variant angina studied in our cardiac catheterization laboratories, four had normal coronary arteriograms. Two important conclusions may be derived from this study. First, identical ECG changes may be observed both in the presence and absence of pain and thus the incidence and severity of the variant angina could be underestimated. Second, until a larger series of patients with variant angina is studied by coronary arteriography, one must exercise reservation in assuming that all patients with the clinical syndrome are operative candidates for saphenous vein bypass surgery.

BACKGROUND AND OBJECTIVES: The impact of the coronavirus disease 2019 (COVID-19) pandemic on pediatric emergency department (ED) visits is not well characterized. We aimed to describe the epidemiology of pediatric ED visits and resource use during the pandemic. METHODS: We conducted a cross-sectional study using the Pediatric Health Information System for ED visits to 27 US children’s hospitals during the COVID-19 pandemic period (March 15, 2020, to August 31, 2020) and a 3-year comparator period (March 15 to August 31, 2017–2019). ED visit rates, patient and visit characteristics, resource use, and ED charges were compared between the time periods. We specifically evaluated changes in low–resource-intensity visits, defined as ED visits that did not result in hospitalization or medication administration and for which no laboratory tests, diagnostic imaging, or procedures were performed. RESULTS: ED visit rates decreased by 45.7% (average 911 026 ED visits over 2017–2019 vs 495 052 visits in 2020) during the pandemic. The largest decrease occurred among visits for respiratory disorders (70.0%). The pandemic was associated with a relative increase in the proportion of visits for children with a chronic condition from 23.7% to 27.8% (P < .001). The proportion of low–resource-intensity visits decreased by 7.0 percentage points, and total charges decreased by 20.0% during the pandemic period. CONCLUSIONS: The COVID-19 pandemic was associated with a marked decrease in pediatric ED visits across a broad range of conditions; however, the proportional decline of poisoning and mental health visits was less pronounced. The impact of decreased visits on patient outcomes warrants further research.

The frequency of DSM-III, Axis II personality disorders and their relationship to selected demographic and clinical characteristics were investigated in a sample of 249 outpatients with major depressive disorder. Thirty-five percent of the sample had at least one personality disorder using stringent criteria; an additional 40% had a probable personality disorder. The most frequent disorders were in the “anxious' cluster of Axis II, including avoidant, dependent, and obsessive-compulsive. Paranoid, histrionic, and borderline were the next most common disorders. Personality disorder patients had more prior episodes of depression and were more likely to be diagnosed as recurrent MDD. They also had a longer duration of current episode, were more likely to have a diagnosis of endogenous depression, and had higher ratings of distress on multiple dimensions of general symptomatology. In addition, patients in the Axis II “odd” and “dramatic” clusters were less likely to be married, and dramatic patients were younger at age of first episode and had a history of more suicide attempts.

Zinc is necessary to maintain normal concentrations of vitamin A in plasma. By using animals deficient in both zinc and vitamin A, it was demonstrated that zinc is necessary for normal mobilization of vitamin A from the liver. These results suggest that cases of depressed vitamin A in plasma, unresponsive to vitamin A therapy, may respond to zinc supplementation.

The distal femur is a common site for primary and metastatic bone tumors and therefore, it is a frequent site in which limb-sparing surgery is done. Between 1980 and 1998, the authors treated 110 consecutive patients who had distal femur resection and endoprosthetic reconstruction. There were 61 males and 49 females who ranged in age from 10 to 80 years. Diagnoses included 99 malignant tumors of bone, nine benign-aggressive lesions, and two nonneoplastic conditions that had caused massive bone loss and articular surface destruction. Reconstruction was done with 73 modular prostheses, 27 custom-made prostheses, and 10 expandable prostheses. Twenty-six gastrocnemius flaps were used for soft tissue reconstruction. All patients were followed up for a minimum of 2 years. Function was estimated to be good or excellent in 94 patients (85.4%), moderate in nine patients (8.2%), and poor in seven patients (6.4%). Complications included six deep wound infections (5.4%), six aseptic loosenings (5.4%), six prosthetic polyethylene component failures (5.4%), and local recurrence in five of 93 patients (5.4%) who had a primary bone sarcoma. The limb salvage rate was 96%. Distal femur endoprosthetic reconstruction is a safe and reliable technique of functional limb sparing that provides good function and local tumor control in most patients.

INTRODUCTION: The projected growth of Alzheimer's disease (AD) and AD-related dementia (ADRD) cases by midcentury has expanded the research field and impelled new lines of inquiry into structural and social determinants of health (S/SDOH) as fundamental drivers of disparities in AD/ADRD. METHODS: In this review, we employ Bronfenbrenner's ecological systems theory as a framework to posit how S/SDOH impact AD/ADRD risk and outcomes. RESULTS: Bronfenbrenner defined the "macrosystem" as the realm of power (structural) systems that drive S/SDOH and that are the root cause of health disparities. These root causes have been discussed little to date in relation to AD/ADRD, and thus, macrosystem influences, such as racism, classism, sexism, and homophobia, are the emphasis in this paper. DISCUSSION: Under Bronfenbrenner's macrosystem framework, we highlight key quantitative and qualitative studies linking S/SDOH with AD/ADRD, identify scientific gaps in the literature, and propose guidance for future research. HIGHLIGHTS: Ecological systems theory links structural/social determinants to AD/ADRD. Structural/social determinants accrue and interact over the life course to impact AD/ADRD. Macrosystem is made up of societal norms, beliefs, values, and practices (e.g., laws). Most macro-level determinants have been understudied in the AD/ADRD literature.

As use of imaging in the evaluation of pregnant and lactating patients continues to increase, misperceptions of radiation and safety risks have proliferated, which has led to often unwarranted concerns among patients and clinicians. When radiologic examinations are appropriately used, the benefits derived from the information gained usually outweigh the risks. This review describes appropriateness and safety issues, estimated doses for imaging examinations that use iodizing radiation (ie, radiography, computed tomography, nuclear scintigraphy, and fluoroscopically guided interventional radiology), radiation risks to the mother and conceptus during various stages of pregnancy, and use of iodinated or gadolinium-based contrast agents and radiotracers in pregnant and lactating women. Maternal radiation risk must be weighed with the potential consequences of missing a life-threatening diagnosis such as pulmonary embolus. Fetal risks (ie, spontaneous abortion, teratogenesis, or carcinogenesis) vary with gestational age and imaging modality and should be considered in the context of the potential benefit of medically necessary diagnostic imaging. When feasible and medically indicated, modalities that do not use ionizing radiation (eg, magnetic resonance imaging) are preferred in pregnant and lactating patients. Radiologists should strive to minimize risks of radiation to the mother and fetus, counsel patients effectively, and promote a realistic understanding of risks related to imaging during pregnancy and lactation.

Twenty infants with intractable diarrhea, whose onset was before 3 months of age, were analyzed. Twelve had identifiable pathological entities sufficient to explain their protracted diarrhea. A systematic diagnostic scheme for such babies is presented. Eight of the 20 infants had no identifiable cause for diarrhea of such severity and refractoriness, and these babies were termed non-specific enterocolitis. Six of these latter eight babies died and at autopsy had widespread enterocolitis with destruction of the mucosa and inflammatory infiltration. The authors believe that in these latter cases, regardless of the initial cause of the diarrhea, certain vicious cycles came into play which perpetuated the diarrhea. Preliminary evidence suggests that colostomy and, perhaps adrenal corticosteroids, may be useful in the therapy of refractory enterocolitis, particularly if applied before the terminal stages of the disease.