John F. Kennedy Medical Center

Pulmonary embolism (PE) is a life-threatening condition and a leading cause of morbidity and mortality. There have been many advances in the field of PE in the last few years, requiring a careful assessment of their impact on patient care. However, variations in recommendations by different clinical guidelines, as well as lack of robust clinical trials, make clinical decisions challenging. The Pulmonary Embolism Response Team Consortium is an international association created to advance the diagnosis, treatment, and outcomes of patients with PE. In this consensus practice document, we provide a comprehensive review of the diagnosis, treatment, and follow-up of acute PE, including both clinical data and consensus opinion to provide guidance for clinicians caring for these patients.

BACKGROUND: The Study to Assess the Safety of Intramuscular Injection of Hepatocyte Growth Factor Plasmid to Improve Limb Perfusion in Patients With Critical Limb Ischemia (HGF-STAT trial) determined the effect of hepatocyte growth factor (HGF) plasmid on safety and limb tissue perfusion as measured by transcutaneous oxygen tension (TcPo(2)) in patients with critical limb ischemia (CLI). METHODS AND RESULTS: Randomized patients with rest pain or ischemic ulcers and TcPo(2) <40 mm Hg and/or toe pressure <50 mm Hg received placebo or HGF-plasmid intramuscular injection as follows: 0.4 mg at days 0, 14, and 28 (low dose); 4.0 mg at days 0 and 28 (middle dose); or 4.0 mg at days 0, 14, and 28 (high dose). Patients were evaluated for safety, changes in TcPo(2) and ankle and toe pressure, amputation, and wound healing. Ninety-three of 104 treated patients were evaluated for safety (mean age 70 years, 63% male, 53% diabetic, 64% with tissue loss, mean ankle-brachial index 0.41, and mean toe pressure 26 mm Hg). Adverse events occurred in 86% of the patients, most of which were related to CLI or comorbid conditions and were not different between groups. TcPo(2) (mean+/-SE) increased at 6 months in the high-dose group (24.0+/-4.2 mm Hg, 95% CI 15.5 to 32.4 mm Hg) compared with the placebo (9.4+/-4.2 mm Hg, 95% CI 0.9 to 17.8), low-dose (11.1+/-3.7 mm Hg, CI 3.7 to 18.7 mm Hg), and middle-dose (7.3+/-4.8 mm Hg, CI -2.2 to 17.0 mm Hg) groups (ANCOVA P=0.0015). There was no difference between groups in secondary end points, including ankle-brachial index, toe-brachial index, pain relief, wound healing, or major amputation. CONCLUSIONS: Intramuscular injection of HGF plasmid was safe and well tolerated. Larger studies to determine whether HGF plasmid can improve wound healing and limb salvage in patients with CLI are warranted.

This case report provides a description of the first case of fatal inhalational anthrax in the United States in 25 years. This 63-year-old newspaper photo editor had a rapidly progressive febrile illness, and lumbar puncture showed cloudy cerebrospinal fluid with numerous polymorphonuclear leukocytes and many large gram-positive bacilli, singly and in chains. A diagnosis of inhalational anthrax was made, and despite aggressive treatment the patient died soon thereafter. The infection appeared to have been transmitted through mail contaminated with anthrax spores as a result of biologic terrorism.

This study analyzes the muscle moment arms of three different reverse shoulder design philosophies using a previously published method. Digital bone models of the shoulder were imported into a 3D modeling software and markers placed for the origin and insertion of relevant muscles. The anatomic model was used as a baseline for moment arm calculations. Subsequently, three different reverse shoulder designs were virtually implanted and moment arms were analyzed in abduction and external rotation. The results indicate that the lateral offset between the joint center and the axis of the humerus specific to one reverse shoulder design increased the external rotation moment arms of the posterior deltoid relative to the other reverse shoulder designs. The other muscles analyzed demonstrated differences in the moment arms, but none of the differences reached statistical significance. This study demonstrated how the combination of variables making up different reverse shoulder designs can affect the moment arms of the muscles in different and statistically significant ways. The role of humeral offset in reverse shoulder design has not been previously reported and could have an impact on external rotation and stability achieved post-operatively.

AIMS: This article is a report of a study to determine the effect of an educational programme and to follow up weekly meetings on nurses and medical resident's attitudes towards positive communication and collaboration. BACKGROUND: Clear and appropriate communication and interdisciplinary collaboration is critical to the delivery of quality care. Collaborative practice among all healthcare professionals creates a positive work environment, decreases costs, improves job satisfaction among nurses and improves patient care, as well as decreasing patient morbidity and mortality. Poor communication and lack of teamwork or collaboration have been cited as persistent problems in healthcare. METHOD: The study was conducted in 2008 - 2009 at a hospital where a new medical residency programme was beginning and nurses had no prior experience working with medical residents. A quasi-experimental pre test, post-test design was used. The Jefferson Scale of Attitudes towards Physician-Nurse Collaboration and the Communication, Collaboration and Critical Thinking for Quality Patient Outcomes Survey tool measured the attitudes of 68 nurses and 47 medical residents in the areas of positive communication and collaboration. RESULTS/FINDINGS: The study demonstrates that a formal educational programme and follow-up discussions improved the attitudes of both nurses and medical residents on the Jefferson scale (medical residents t = 4·68, P = 0·001, nurses t = 4·37, P = 0·001) and on the communication scale (medical residents t = 4·23, P = 0·001, nurses t = 4·13, P = 0·001). CONCLUSION: Continuing education for nurses, medical residents and other healthcare providers may assist in developing positive communication styles and promote collegiality and team work.

An experimental study was performed to compare computed tomography (CT), magnetic resonance imaging (MRI), and real-time, high resolution ultrasonography (US) for the detection of wooden foreign bodies in muscle tissue. Wooden splinters were prepared, measured for size, soaked in saline, and placed in porcine muscle distant from and adjacent to bone. The specimens were then examined using roentgenography, CT and MRI in planes parallel and perpendicular to the splinters, and US. The largest wooden foreign bodies (minimum smallest width = 10 mm) were easily detected by CT, MRI, and US. Almost all splinters of various sizes, small and large, soaked in saline for 5 months were easily detected by MRI. Smaller splinters (minimum smallest width = 1-4 mm) soaked for only 3 days and placed distant from bone were most easily detected by US; those soaked for 5 months were most easily detected by either US or MRI. The smaller splinters soaked for only 3 days and placed near bone were not reliably detected by any of the imaging methods; CT and MRI were both more sensitive than US in this situation. MRI scanning was more sensitive perpendicular than parallel to the long axis of the splinters. Therefore, either US or MRI may be the best initial imaging modality for evaluation of a suspected wooden foreign body, depending on availability of imaging method, chronicity of symptoms, and proximity to bone.

BACKGROUND AND PURPOSE: The appropriate choice of treatment for traumatic extracranial carotid artery injury is still debated. The purpose of this study was to evaluate outcomes of endovascular carotid repair with regard to vessel patency and retreatment rates. METHODS AND METHODS: We retrospectively reviewed records of patients who underwent endovascular treatment for acute traumatic internal carotid artery dissection with or without pseudoaneurysm formation. The Biffl classification of blunt carotid arterial injuries with an additional modification to stratify grade 2 and 3 injuries into no-flow-limiting (2a/3a) and flow-limiting (2b/3b) was used to classify injuries. RESULTS: Forty-seven patients underwent 50 endovascular interventions. Forty-four were treated with stents alone, 4 required both stent and coil treatments, and 2 were treated with coils alone. Initial treatment resulted in complete restoration of the normal vessel lumen diameter in 25 (50%) treated vessels and good-to-acceptable restoration in 25 (50%) vessels. A single patient had complete stent occlusion. Three patients required stent and/or coil retreatment. There was no mortality or permanent morbidity relating to endovascular carotid artery repair. Twenty-one patients initially treated with medical management ultimately required endovascular treatment. Eighteen (87.5%) of these injuries were initially classified as grade 3a and 3 (14.3%) were initially grade 2a. Injury progression necessitating treatment was identified, on average, within 5 weeks of the initial injury. CONCLUSIONS: In our series, endovascular therapy was a safe and effective option for restoring luminal caliber and eliminating flow within pseudoaneurysms related to traumatic injuries. Imaging follow-up of all cervicocerebral vascular injuries is especially important within the first 45 days, a critical interval during which most lesions demonstrate healing or progression.

BACKGROUND AND PURPOSE: MR imaging is the method of choice for evaluating the trigeminal nerve. Detection of abnormalities such as perineural tumor spread requires detailed knowledge of the normal MR appearance of the trigeminal nerve and surrounding structures. The purpose of this study was to clarify the normal MR appearance and variations of the trigeminal ganglion, maxillary nerve (V2), and mandibular nerve (V3) with their corresponding perineural vascular plexus. METHOD: S: MR images obtained in 32 patients without symptoms referable to the trigeminal nerve were retrospectively reviewed. The trigeminal ganglion in Meckel's cave, V2 within the foramen rotundum, and V3 at the level of foramen ovale were assessed for visualization and enhancement. The configuration of the perineural vascular plexus was recorded. Correlation to cadaver specimens was made. RESULTS: The trigeminal ganglion and V3 were observed to enhance in 3-4% of patients unilaterally. V2 and V3 were well visualized 93% of the time. The perineural vascular plexus of V2 was observed 91% of the time, and that of V3 in 97% of instances. CONCLUSION: This study characterizes the normal MR appearance of the trigeminal ganglion and its proximal branches. The trigeminal ganglion, V2, and, V3 are almost always reliably seen on thin-section MR studies of the skull base. Enhancement of the perivascular plexus is routinely seen; however, enhancement of the trigeminal ganglion, V2, or V3 alone is seen only on occasion as supported by the avascular appearance of these anatomic structures in cadaver specimens.

BACKGROUND: QDOT MICRO (QDM) is a novel contact force-sensing catheter optimized for temperature-controlled radiofrequency (RF) ablation. The very high-power short-duration (vHPSD) algorithm modulates power, maintaining target temperature during 90 W ablations for ≤4 seconds. OBJECTIVES: This study aims to evaluate safety and 12-month effectiveness of the QDM catheter in paroxysmal atrial fibrillation (AF) ablation using the vHPSD mode combined with conventional-power temperature-controlled (CPTC) mode. METHODS: In this prospective, multicenter, nonrandomized study, patients with drug-refractory, symptomatic paroxysmal AF underwent pulmonary vein (PV) isolation with QDM catheter with vHPSD as primary ablation mode, with optional use of the CPTC mode (25 to 50 W) for PV touch-up or non-PV ablation. The primary safety endpoint was incidence of primary adverse events within ≤7 days of ablation. The primary effectiveness endpoint was freedom from documented atrial tachyarrhythmia recurrence and acute procedural, repeat ablation, and antiarrhythmic drug failure. RESULTS: Of 191 enrolled participants, 166 had the catheter inserted, received RF ablation, and met eligibility criteria. Median procedural, RF application for ablating PVs, and fluoroscopy times were 132.0, 8.0, and 9.1 minutes, respectively. The primary adverse event rate was 3.6%. Imaging conducted in a subset of participants (n = 40) at 3 months did not show moderate or severe PV stenosis. The Kaplan-Meier estimated 12-month rate for primary effectiveness success was 76.7%; freedom from atrial tachyarrhythmia recurrence was 82.1%; clinical success (freedom from symptomatic recurrence) was 86.0%; and freedom from repeat ablation was 92.1%. CONCLUSIONS: Temperature-controlled paroxysmal AF ablation with the novel QDM catheter in vHPSD mode (90 W, ≤4 seconds), alone or with CPTC mode (25 to 50 W), is highly efficient and effective without compromising safety. (Evaluation of QDOT MICRO Catheter for Pulmonary Vein Isolation in Subjects With Paroxysmal Atrial Fibrillation [Q-FFICIENCY]; NCT03775512).

Since the spring of 1988, Carnegie Mellon University and the Naval Air Development Center have been working together to implement several large signal processing systems on the Warp parallel computer. In the course of this work, we have developed a prototype of a software tool that can automatically and efficiently map signal processing systems to distributed-memory parallel machines, such as Warp. We have used this tool to produce Warp implementations of small test systems. The automatically generated programs compare favorably with hand-crafted code. We believe this tool will be a significant aid in the creation of high speed signal processing systems. We assume that signal processing systems have the following characteristics: &bull;They can be described by directed graphs of computational tasks; these graphs may contain thousands of task vertices. &bull; Some tasks can be parallelized in a systolic or data-partitioned manner, while others cannot be parallelized at all. &bull; The side effects of each task, if any, are limited to changes in local variables. &bull; Each task has a data-independent execution time bound, which may be expressed as a function of the way it is parallelized, and the number of processors it is mapped to. In this paper we describe techniques to automatically map such systems to Warp-like parallel machines. We identify and address key issues in gracefully combining different parallel programming styles, in allocating processor, memory and communication bandwidth, and in generating and scheduling efficient parallel code. When iWarp, the VLSI version of the Warp machine, becomes available in 1990, we will extend this tool to generate efficient code for very large applications, which may require as many as 3000 iWarp processors, with an aggregate peak performance of 60 gigaflops.

Abstract Background and study aims Early studies have shown that artificial intelligence (AI) has the potential to augment the performance of gastroenterologists during endoscopy. Our aim was to determine how gastroenterologists view the potential role of AI in gastrointestinal endoscopy. Methods In this cross-sectional study, an online survey was sent to US gastroenterologists. The survey included questions about physician level of training, experience, and practice characteristics and physician perception of AI. Descriptive statistics were used to summarize sentiment about AI. Univariate and multivariate analyses were used to assess whether background information about physicians correlated to their sentiment. Results Surveys were emailed to 330 gastroenterologists nationwide. Between December 2018 and January 2019, 124 physicians (38 %) completed the survey. Eighty-six percent of physicians reported interest in AI-assisted colonoscopy; 84.7 % agreed that computer-assisted polyp detection (CADe) would improve their endoscopic performance. Of the respondents, 57.2 % felt comfortable using computer-aided diagnosis (CADx) to support a “diagnose and leave” strategy for hyperplastic polyps. Multivariate analysis showed that post-fellowship experience of fewer than 15 years was the most important factor in determining whether physicians were likely to believe that CADe would lead to more removed polyps (odds ratio = 5.09; P = .01). The most common concerns about implementation of AI were cost (75.2 %), operator dependence (62.8 %), and increased procedural time (60.3 %). Conclusions Gastroenterologists have strong interest in the application of AI to colonoscopy, particularly with regard to CADe for polyp detection. The primary concerns were its cost, potential to increase procedural time, and potential to develop operator dependence. Future developments in AI should prioritize mitigation of these concerns.

OBJECTIVE: The aim of the present study was to determine whether an increased supply of energy, protein, essential fatty acids, and vitamin A reduces postnatal growth failure in very-low-birth-weight infants. METHODS: Fifty infants with birth weight <1500 g were randomized to an intervention (n = 24) or a control (n = 26) feeding protocol within 24 hours after birth. Forty-four infants were included in the final analysis. This study was discontinued because of an increased occurrence of septicemia in the intervention group. RESULTS: The intervention group had a lower mean birth weight (P = 0.03) and a higher proportion of infants small-for-gestational age (P = 0.04) than the control group. Other baseline characteristics were similar. The median (interquartile range) energy and protein supplies during the first 4 weeks of life were higher in the intervention group: 139 (128-145) versus 126 (121-128) kcal · kg · day (P < 0.001) and 4.0 (3.9-4.2) versus 3.2 (3.1-3.3) g · kg · day (P < 0.001). The infants in the intervention group regained birth weight faster (P = 0.001) and maintained their z scores for weight and head circumference from birth to 36 weeks' postmenstrual age (both P < 0.001). The median (interquartile range) growth velocity was 17.4 (16.3-18.6) g · kg · day in the intervention group and 13.8 (13.2-15.5) g · kg · day in the control group (P < 0.001). In line with the improved growth in the intervention group, the proportion of growth-restricted infants was 11 of 23 both at birth and at 36 weeks' postmenstrual age, whereas this proportion increased among the controls from 4 of 21 to 13 of 21 (P = 0.04). CONCLUSIONS: Enhanced supply of energy, protein, essential fatty acids, and vitamin A caused postnatal growth along the birth percentiles for both weight and head circumference.

BACKGROUND: The number of fatalities due to coronavirus disease 2019 (COVID-19) is escalating with more than 800,000 deaths globally. The scientific community remains in urgent need of prognostic tools to determine the probability of survival in patients with COVID-19 and to determine the need for hospitalization. METHODS: This is a retrospective cohort study of patients with a diagnosis of COVID-19 admitted to a tertiary center between March 2020 and July 2020. Patients age 18 years and older were stratified into two groups based on their troponin-I level in the first 24 h of admission (groups: elevated vs. normal). The aim of the study is to explore the utility of cardiac troponin-I level for early prognostication of patients with COVID-19. RESULTS: This cohort of 257 patients included 122/257 (47%) women with a mean age of 63 ± 17 years. Patients with an elevated troponin-I level were more likely to be older (77 ± 13 vs. 58 ± 16 years, P < 0.0001), have a history of hypertension (P < 0.0001), diabetes mellitus (P = 0.0019), atrial fibrillation or flutter (P = 0.0009), coronary artery disease (P < 0.0001), and chronic heart failure (P = 0.0011). Patients with an elevated troponin-I level in the first 24 h of admission were more likely to have higher in-hospital mortality (52% vs. 10%, P < 0.0001). Troponin-I level in the first 24 h of admission had a negative predictive value of 89.7% and a positive predictive value of 51.9% for all-cause in-hospital mortality. CONCLUSIONS: Troponin-I elevation is commonly seen in patients with COVID-19 and is significantly associated with fatal outcomes. However, a normal troponin-I level in the first 24 h of admission had a high negative predictive value for all-cause in-hospital mortality, thereby predicting favorable survival at the time of discharge.

BACKGROUND: Multiple studies have attempted to identify the association between multivitamin/mineral (MVM) supplementation and cardiovascular disease (CVD) outcomes, but the benefits remain controversial. We performed a systematic review and meta-analysis of the associations between MVM supplementation and various CVD outcomes, including coronary heart disease (CHD) and stroke. METHODS AND RESULTS: We conducted a comprehensive search of Medline, Embase, and the Cochrane Library for studies published between January 1970 and August 2016. We included clinical trials and prospective cohort studies in the general population evaluating associations between MVM supplementation and CVD outcomes. Data extraction and quality assessment were independently conducted by 2 authors, and a third author resolved discrepancies. Eighteen studies with 2 019 862 participants and 18 363 326 person-years of follow-up were included in the analysis. Five studies specified the dose/type of MVM supplement and the rest did not. Overall, there was no association between MVM supplementation and CVD mortality (relative risk [RR], 1.00; 95% confidence interval [CI], 0.97-1.04), CHD mortality (RR, 1.02; 95% CI, 0.92-1.13), stroke mortality (RR, 0.95; 95% CI, 0.82-1.09), or stroke incidence (RR, 0.98; 95% CI, 0.91-1.05). There was no association between MVM supplements and CVD or CHD mortality in prespecified subgroups categorized by mean follow-up period, mean age, period of MVM use, sex, type of population, exclusion of patients with history of CHD, and adjustment for diet, adjustment for smoking, adjustment for physical activity, and study site. In contrast, MVM use did seem to be associated with a lower risk of CHD incidence (RR, 0.88; 95% CI, 0.79-0.97). However, this association did not remain significant in the pooled subgroup analysis of randomized controlled trials (RR, 0.97; 95% CI, 0.80-1.19). CONCLUSIONS: Our meta-analysis of clinical trials and prospective cohort studies demonstrates that MVM supplementation does not improve cardiovascular outcomes in the general population.

This study provides recommendations on the position of the implant in reverse shoulder replacement in order to minimise scapular notching and osteophyte formation. Radiographs from 151 patients who underwent primary reverse shoulder replacement with a single prosthesis were analysed at a mean follow-up of 28.3 months (24 to 44) for notching, osteophytes, the position of the glenoid baseplate, the overhang of the glenosphere, and the prosthesis scapular neck angle (PSNA). A total of 20 patients (13.2%) had a notch (16 Grade 1 and four Grade 2) and 47 (31.1%) had an osteophyte. In patients without either notching or an osteophyte the baseplate was found to be positioned lower on the glenoid, with greater overhang of the glenosphere and a lower PSNA than those with notching and an osteophyte. Female patients had a higher rate of notching than males (13.3% vs 13.0%) but a lower rate of osteophyte formation (22.9% vs 50.0%), even though the baseplate was positioned significantly lower on the glenoid in females (p = 0.009) and each had a similar mean overhang of the glenosphere. Based on these findings we make recommendations on the placement of the implant in both male and female patients to avoid notching and osteophyte formation.

Laparoscopic herniorrhaphy is compared with conventional herniorrhaphy in 20 patients, who underwent laparoscopic herniorrhaphy utilizing a Mersilene plug and patch graft, and high ligation of the neck of the sac with an Endo-GIA. Patients were pain-free and returned to normal activity the first postoperative day. There was one recurrent direct inguinal hernia in an indirect repair. Laparoscopic herniorrhaphy appears to be a safe, effective way to repair indirect inguinal hernias and certain direct inguinal hernias. There is a marked reduction of pain and rapid return to normal activity. The disadvantage of this procedure is the lack of long-term follow-up.

BACKGROUND: The intersection of artificial intelligence (AI) with cancer research is increasing, and many of the advances have focused on the analysis of cancer images. OBJECTIVES: To describe and synthesize the literature on the diagnostic accuracy of AI in early imaging diagnosis of cervical cancer following Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). SEARCH STRATEGY: Arksey and O'Malley methodology was used and PubMed, Scopus, and Google Scholar databases were searched using a combination of English and Spanish keywords. SELECTION CRITERIA: Identified titles and abstracts were screened to select original reports and cross-checked for overlap of cases. DATA COLLECTION AND ANALYSIS: A descriptive summary was organized by the AI algorithm used, total of images analyzed, data source, clinical comparison criteria, and diagnosis performance. MAIN RESULTS: We identified 32 studies published between 2009 and 2022. The primary sources of images were digital colposcopy, cervicography, and mobile devices. The machine learning/deep learning (DL) algorithms applied in the articles included support vector machine (SVM), random forest classifier, k-nearest neighbors, multilayer perceptron, C4.5, Naïve Bayes, AdaBoost, XGboots, conditional random fields, Bayes classifier, convolutional neural network (CNN; and variations), ResNet (several versions), YOLO+EfficientNetB0, and visual geometry group (VGG; several versions). SVM and DL methods (CNN, ResNet, VGG) showed the best diagnostic performances, with an accuracy of over 97%. CONCLUSION: We concluded that the use of AI for cervical cancer screening has increased over the years, and some results (mainly from DL) are very promising. However, further research is necessary to validate these findings.

Laparoscopic-assisted colonic resection was attempted in 18 patients: 12 patients had surgery for ascending colon lesions, three underwent attempted left-sided colectomies, and three patients had low anterior resection. Three early patients required conversion to open laparotomy when the pathologic lesion could not be identified under laparoscopic guidance. In patients undergoing laparoscopic surgery, postoperative pain was markedly reduced. Oral intake was begun between the first and third postoperative days, and average hospital stay was 4 days. No operative morbidity or mortality occurred in this small group of patients.

There have been multiple different approaches to laparoscopic herniorrhaphy with a tendency toward exposure of the preperitoneal space with placement of a prosthesis into this area. The transabdominal preperitoneal (TAPP) approach is a reasonably simple, safe repair, resulting in a less than 1% recurrence rate with minimal complications. This relatively pain-free herniorrhaphy allows rapid return to normal activity.

Today's health care environments are calling for new models of care delivery grounded in essential values. This article describes the results of a 2-year funded research project that intentionally grounded an acute care unit in the perspective of nursing as caring. Outcomes of care for patients, families, staff and the organization are described.