Lincoln Medical Center

OBJECTIVE: The Childhood Trauma Interview, a new instrument for brief and comprehensive retrospective assessment of childhood interpersonal trauma, is presented with initial evidence of its reliability and validity. METHOD: Drug- or alcohol-dependent patients (N = 220) were given the Childhood Trauma Interview and a questionnaire measure of child abuse, the Childhood Trauma Questionnaire. Convergent and discriminant validity for the Childhood Trauma Interview were tested by comparing correlations between analogous and nonanalogous trauma scales to those of the Childhood Trauma Questionnaire. RESULTS: Interrater reliability for the majority of trauma dimensions measured by the Childhood Trauma Interview was very high (63% had intraclass correlations above 0.90). Principal-components analysis yielded six rotated factors that accounted for 74% of the variance among scores: separations and losses, physical neglect, emotional abuse or assault, physical abuse or assault, witnessing violence, and sexual abuse or assault. Since these six factors exactly represented the areas that the interview was designed to assess, the construct validity of the Childhood Trauma Interview was supported. Without exception, convergent correlations were significantly higher than discriminant correlations, and convergence was improved when multidimensional variables from the Childhood Trauma Interview and their interactions were regressed onto Childhood Trauma Questionnaire scores. CONCLUSIONS: These initial findings suggest that the Childhood Trauma Interview is a reliable and valid method for brief assessment of multiple dimensions of six types of childhood interpersonal trauma.

Health care in the United States has seen many great innovations and successes in the past decades. However, to this day, the color of a person’s skin determines—to a considerable degree—his/her prospects of wellness; risk of disease, and death; and the quality of care received. Disparities in cardiovascular disease (CVD)—the leading cause of morbidity and mortality globally—are one of the starkest reminders of social injustices, and racial inequities, which continue to plague our society. People of color—including Black, Hispanic, American Indian, Asian, and others—experience varying degrees of social disadvantage that puts these groups at increased risk of CVD and poor disease outcomes, including mortality. Racial/ethnic disparities in CVD, while documented extensively, have not been examined from a broad, upstream, social determinants of health lens. In this review, we apply a comprehensive social determinants of health framework to better understand how structural racism increases individual and cumulative social determinants of health burden for historically underserved racial and ethnic groups, and increases their risk of CVD. We analyze the link between race, racism, and CVD, including major pathways and structural barriers to cardiovascular health, using 5 distinct social determinants of health domains: economic stability ; neighborhood and physical environment ; education ; community and social context ; and healthcare system . We conclude with a set of research and policy recommendations to inform future work in the field, and move a step closer to health equity.

Abstract Objective Prolonged and unaddressed hypoxia can lead to poor patient outcomes. Proning has become a standard treatment in the management of patients with ARDS who have difficulty achieving adequate oxygen saturation. The purpose of this study was to describe the use of early proning of awake, non‐intubated patients in the emergency department (ED) during the COVID‐19 pandemic. Methods This pilot study was carried out in a single urban ED in New York City. We included patients suspected of having COVID‐19 with hypoxia on arrival. A standard pulse oximeter was used to measure SpO 2 . SpO 2 measurements were recorded at triage and after 5 minutes of proning. Supplemental oxygenation methods included non‐rebreather mask (NRB) and nasal cannula. We also characterized post‐proning failure rates of intubation within the first 24 hours of arrival to the ED. Results Fifty patients were included. Overall, the median SpO 2 at triage was 80% (IQR 69 to 85). After application of supplemental oxygen was given to patients on room air it was 84% (IQR 75 to 90). After 5 minutes of proning was added SpO 2 improved to 94% (IQR 90 to 95). Comparison of the pre‐ to post‐median by the Wilcoxon Rank‐sum test yielded P = 0.001. Thirteen patients (24%) failed to improve or maintain their oxygen saturations and required endotracheal intubation within 24 hours of arrival to the ED. Conclusion Awake early self‐proning in the emergency department demonstrated improved oxygen saturation in our COVID‐19 positive patients. Further studies are needed to support causality and determine the effect of proning on disease severity and mortality.

The purpose of this study was to investigate the association between cognitive processes and medication adherence among community-dwelling older adults. Ninety-five participants (M = 78 years) completed a battery of cognitive assessments including measures of executive function, working memory, cued recall, and recognition memory. Medication adherence was examined over 8 weeks for one prescribed medicine by use of an electronic medication-monitoring cap. In a simultaneous regression, the composite of executive function and working memory tasks was the only significant predictor (beta =.44, p <.01). Findings suggest that assessments of executive function and working memory can be used to identify community-dwelling older adults who may be at risk for failure to take medicines as prescribed.

OBJECTIVES: This study examined predictors of entry into shelter and subsequent housing stability for a cohort of families receiving public assistance in New York City. METHODS: Interviews were conducted with 266 families as they requested shelter and with a comparison sample of 298 families selected at random from the welfare caseload. Respondents were reinterviewed 5 years later. Families with prior history of shelter use were excluded from the follow-up study. RESULTS: Demographic characteristics and housing conditions were the most important risk factors for shelter entry; enduring poverty and disruptive social experiences also contributed. Five years later, four fifths of sheltered families had their own apartment. Receipt of subsidized housing was the primary predictor of housing stability among formerly homeless families (odds ratio [OR] = 20.6, 95% confidence interval [CI] = 9.9, 42.9). CONCLUSIONS: Housing subsidies are critical to ending homelessness among families.

OBJECTIVE: To define the incidence, prophylaxis, and treatment of intra-abdominal hypertension (IAH) and its relevance to gut mucosal pH (pHi), multiorgan dysfunction syndrome, and the abdominal compartment syndrome (ACS). METHODS: Seventy patients in the SICU at a Level I trauma center (1992-1996) with life threatening penetrating abdominal trauma had intra-abdominal pressure estimated by bladder pressure. pHi was measured by gastric tonometry every 4 to 6 hours. IAH (intra-abdominal pressure> 25 cm of H2O) was treated by bedside or operating room laparotomy. RESULTS: Injury severity was comparable between patients who had mesh closure as prophylaxis for IAH (n = 45) and those who had fascial suture (n = 25). IAH was seen in 10 (22.2%) in the mesh group versus 13 (52%) in the fascial suture group (p = 0.012) for an overall incidence of 32.9%. Forty-two patients had pHi monitoring, and 11 of them had IAH. Of the 11 patients, eight patients (72.7%) had acidotic pHi (7.10 +/- 0.2) with IAH without exhibiting the classic signs of ACS. The pHi improved after abdominal decompression in six and none developed ACS. Only two patients with IAH and low pHi went on to develop ACS, despite abdominal decompression. Multiorgan dysfunction syndrome points and death were less in patients without IAH than those with IAH and in patients who had mesh closure. CONCLUSIONS: IAH is frequent after major abdominal trauma. It may cause gut mucosal acidosis at lower bladder pressures, long before the onset of clinical ACS. Uncorrected, it may lead to splanchnic hypoperfusion, ACS, distant organ failure, and death. Prophylactic mesh closure of the abdomen may facilitate the prevention and bedside treatment of IAH and reduce these complications.

BACKGROUND: Earlier work from our laboratory highlighted the therapeutic potential of curcumin (turmeric), used as a dietary ingredient and as a natural anti-inflammatory agent in India and other Southeast Asian countries. This agent was shown to decrease the proliferative potential and induce the apoptosis potential of both androgen-dependent and androgen-independent prostate cancer cells in vitro, largely by modulating the apoptosis suppressor proteins and by interfering with the growth factor receptor signaling pathways as exemplified by the EGF-receptor. To extend these observations made in vitro and to study the efficacy of this potential anti-cancer agent in vivo, the growth of LNCaP cells as heterotopically implanted tumors in nude mice was followed. METHODS: The androgen-dependent LNCaP prostate cancer cells were grown, mixed with Matrigel and injected subcutaneously into nude mice. Experimental group received a synthetic diet containing 2% curcumin for up to 6 weeks. At the end point, sections taken from the excised tumors were evaluated for pathology, cell proliferation, apoptosis, and vascularity. RESULTS: Curcumin causes a marked decrease in the extent of cell proliferation as measured by the BrdU incorporation assay and a significant increase in the extent of apoptosis as measured by an in situ cell death assay. Moreover, a significant decrease in the microvessel density as measured by the CD31 antigen staining was also seen. CONCLUSIONS: Curcumin could be a potentially therapeutic anti-cancer agent, as it significantly inhibits prostate cancer growth, as exemplified by LNCaP in vivo, and has the potential to prevent the progression of this cancer to its hormone refractory state.

One hundred hemodynamically stable patients with penetrating abdominal trauma (65, stab wounds, 35, gunshot wounds) were evaluated with laparoscopy. Sixty percent of the patients had wounds in the thoracoabdominal area or the upper abdominal quadrants and 25% had injuries located in the lower abdomen and flanks. Fifteen percent had epigastric wounds. Twenty-two stabs and 21 gunshots had not penetrated the peritoneum (negative laparoscopic results). Fifty-seven patients had peritoneal penetration and were noted to have hemoperitoneum only (n = 14), hemoperitoneum and solid organ injuries (n = 23), diaphragmatic lacerations (n = 17), and hollow viscus injuries (n = 2) on laparoscopic examination. Three of the 57 patients, one with omental herniation only and two with low grade nonbleeding lacerations of the liver, were managed uneventfully without laparotomy. The remaining 54 patients underwent laparotomy with confirmation of the laparoscopic findings. Seven patients (three with stab wounds and four with gunshots) had additional GI tract injuries seen at laparotomy. The diagnostic accuracy of laparoscopy was excellent for hemoperitoneum, solid organ injuries, diaphragmatic lacerations, and retroperitoneal hematomas. For GI injuries, laparoscopy was found to have a 100% specificity but only a 18% sensitivity. The majority of these discordant findings occurred in epigastric SWs and flank and lower quadrant GSWs, all in patients with undetected hollow viscus injuries. The major role of laparoscopy in penetrating abdominal trauma is in avoiding unnecessary laparotomy in tangential SWs and GSWs. It is excellent for evaluating the diaphragm in thoracoabdominal wounds. Caution is urged in excluding hollow viscus injuries based on laparoscopy.

NIH Conferences17 June 2008National Institutes of Health Consensus Development Conference Statement: Hydroxyurea Treatment for Sickle Cell DiseaseFREEOtis W. Brawley, MD, Llewellyn J. Cornelius, PhD, LCSW, Linda R. Edwards, MD, Vanessa Northington Gamble, MD, PhD, Bettye L. Green, RN, Charles Inturrisi, PhD, Andra H. James, MD, MPH, Danielle Laraque, MD, Magda Mendez, MD, Carolyn J. Montoya, RN, MSN, CPNP, Brad H. Pollock, MPH, PhD, Lawrence Robinson, MD, MPH, Aaron P. Scholnik, MD, and Melissa Schori, MD, MBA*Otis W. Brawley, MDFrom Emory University and the American Cancer Society, Atlanta, Georgia; University of Maryland School of Social Work, Baltimore, Maryland; College of Medicine, University of Florida, Jacksonville, Jacksonville, Florida; The George Washington University, Washington, DC; Saint Joseph Regional Medical Center and African-American Women in Touch, South Bend, Indiana; Weill Medical College of Cornell University and Mount Sinai School of Medicine, New York, and Lincoln Medical and Mental Health Center, Bronx, New York; Women's Hemostasis and Thrombosis Clinic and Duke University Medical Center, Durham, North Carolina; National Association of Pediatric Nurse Practitioners and College of Nursing, University of New Mexico, Albuquerque, New Mexico; School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Philadelphia Department of Public Health, Philadelphia, Pennsylvania; Upper Peninsula Hematology/Oncology Associates and Cancer Research Office, Marquette General Health System, Marquette, Michigan; and Princeton Healthcare System, Princeton, New Jersey.Search for more papers by this author, Llewellyn J. Cornelius, PhD, LCSWFrom Emory University and the American Cancer Society, Atlanta, Georgia; University of Maryland School of Social Work, Baltimore, Maryland; College of Medicine, University of Florida, Jacksonville, Jacksonville, Florida; The George Washington University, Washington, DC; Saint Joseph Regional Medical Center and African-American Women in Touch, South Bend, Indiana; Weill Medical College of Cornell University and Mount Sinai School of Medicine, New York, and Lincoln Medical and Mental Health Center, Bronx, New York; Women's Hemostasis and Thrombosis Clinic and Duke University Medical Center, Durham, North Carolina; National Association of Pediatric Nurse Practitioners and College of Nursing, University of New Mexico, Albuquerque, New Mexico; School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Philadelphia Department of Public Health, Philadelphia, Pennsylvania; Upper Peninsula Hematology/Oncology Associates and Cancer Research Office, Marquette General Health System, Marquette, Michigan; and Princeton Healthcare System, Princeton, New Jersey.Search for more papers by this author, Linda R. Edwards, MDFrom Emory University and the American Cancer Society, Atlanta, Georgia; University of Maryland School of Social Work, Baltimore, Maryland; College of Medicine, University of Florida, Jacksonville, Jacksonville, Florida; The George Washington University, Washington, DC; Saint Joseph Regional Medical Center and African-American Women in Touch, South Bend, Indiana; Weill Medical College of Cornell University and Mount Sinai School of Medicine, New York, and Lincoln Medical and Mental Health Center, Bronx, New York; Women's Hemostasis and Thrombosis Clinic and Duke University Medical Center, Durham, North Carolina; National Association of Pediatric Nurse Practitioners and College of Nursing, University of New Mexico, Albuquerque, New Mexico; School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Philadelphia Department of Public Health, Philadelphia, Pennsylvania; Upper Peninsula Hematology/Oncology Associates and Cancer Research Office, Marquette General Health System, Marquette, Michigan; and Princeton Healthcare System, Princeton, New Jersey.Search for more papers by this author, Vanessa Northington Gamble, MD, PhDFrom Emory University and the American Cancer Society, Atlanta, Georgia; University of Maryland School of Social Work, Baltimore, Maryland; College of Medicine, University of Florida, Jacksonville, Jacksonville, Florida; The George Washington University, Washington, DC; Saint Joseph Regional Medical Center and African-American Women in Touch, South Bend, Indiana; Weill Medical College of Cornell University and Mount Sinai School of Medicine, New York, and Lincoln Medical and Mental Health Center, Bronx, New York; Women's Hemostasis and Thrombosis Clinic and Duke University Medical Center, Durham, North Carolina; National Association of Pediatric Nurse Practitioners and College of Nursing, University of New Mexico, Albuquerque, New Mexico; School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Philadelphia Department of Public Health, Philadelphia, Pennsylvania; Upper Peninsula Hematology/Oncology Associates and Cancer Research Office, Marquette General Health System, Marquette, Michigan; and Princeton Healthcare System, Princeton, New Jersey.Search for more papers by this author, Bettye L. Green, RNFrom Emory University and the American Cancer Society, Atlanta, Georgia; University of Maryland School of Social Work, Baltimore, Maryland; College of Medicine, University of Florida, Jacksonville, Jacksonville, Florida; The George Washington University, Washington, DC; Saint Joseph Regional Medical Center and African-American Women in Touch, South Bend, Indiana; Weill Medical College of Cornell University and Mount Sinai School of Medicine, New York, and Lincoln Medical and Mental Health Center, Bronx, New York; Women's Hemostasis and Thrombosis Clinic and Duke University Medical Center, Durham, North Carolina; National Association of Pediatric Nurse Practitioners and College of Nursing, University of New Mexico, Albuquerque, New Mexico; School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Philadelphia Department of Public Health, Philadelphia, Pennsylvania; Upper Peninsula Hematology/Oncology Associates and Cancer Research Office, Marquette General Health System, Marquette, Michigan; and Princeton Healthcare System, Princeton, New Jersey.Search for more papers by this author, Charles Inturrisi, PhDFrom Emory University and the American Cancer Society, Atlanta, Georgia; University of Maryland School of Social Work, Baltimore, Maryland; College of Medicine, University of Florida, Jacksonville, Jacksonville, Florida; The George Washington University, Washington, DC; Saint Joseph Regional Medical Center and African-American Women in Touch, South Bend, Indiana; Weill Medical College of Cornell University and Mount Sinai School of Medicine, New York, and Lincoln Medical and Mental Health Center, Bronx, New York; Women's Hemostasis and Thrombosis Clinic and Duke University Medical Center, Durham, North Carolina; National Association of Pediatric Nurse Practitioners and College of Nursing, University of New Mexico, Albuquerque, New Mexico; School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Philadelphia Department of Public Health, Philadelphia, Pennsylvania; Upper Peninsula Hematology/Oncology Associates and Cancer Research Office, Marquette General Health System, Marquette, Michigan; and Princeton Healthcare System, Princeton, New Jersey.Search for more papers by this author, Andra H. James, MD, MPHFrom Emory University and the American Cancer Society, Atlanta, Georgia; University of Maryland School of Social Work, Baltimore, Maryland; College of Medicine, University of Florida, Jacksonville, Jacksonville, Florida; The George Washington University, Washington, DC; Saint Joseph Regional Medical Center and African-American Women in Touch, South Bend, Indiana; Weill Medical College of Cornell University and Mount Sinai School of Medicine, New York, and Lincoln Medical and Mental Health Center, Bronx, New York; Women's Hemostasis and Thrombosis Clinic and Duke University Medical Center, Durham, North Carolina; National Association of Pediatric Nurse Practitioners and College of Nursing, University of New Mexico, Albuquerque, New Mexico; School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Philadelphia Department of Public Health, Philadelphia, Pennsylvania; Upper Peninsula Hematology/Oncology Associates and Cancer Research Office, Marquette General Health System, Marquette, Michigan; and Princeton Healthcare System, Princeton, New Jersey.Search for more papers by this author, Danielle Laraque, MDFrom Emory University and the American Cancer Society, Atlanta, Georgia; University of Maryland School of Social Work, Baltimore, Maryland; College of Medicine, University of Florida, Jacksonville, Jacksonville, Florida; The George Washington University, Washington, DC; Saint Joseph Regional Medical Center and African-American Women in Touch, South Bend, Indiana; Weill Medical College of Cornell University and Mount Sinai School of Medicine, New York, and Lincoln Medical and Mental Health Center, Bronx, New York; Women's Hemostasis and Thrombosis Clinic and Duke University Medical Center, Durham, North Carolina; National Association of Pediatric Nurse Practitioners and College of Nursing, University of New Mexico, Albuquerque, New Mexico; School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Philadelphia Department of Public Health, Philadelphia, Pennsylvania; Upper Peninsula Hematology/Oncology Associates and Cancer Research Office, Marquette General Health System, Marquette, Michigan; and Princeton Healthcare System, Princeton, New Jersey.Search for more papers by this author, Magda Mendez, MDFrom Emory University and the American Cancer Society, Atlanta, Georgia; University of Maryland School of Social Work, Baltimore, Maryland; College of Medicine, University of Florida, Jacksonville, Jacksonville, Florida; The George Washington University, Washington, DC; Saint Joseph Regional Medical Center and African-American Women in Touch, South Bend, Indiana; Weill Medical College of Cornell University and Mount Sinai School of Medicine, New York, and Lincoln Medical and Mental Health Center, Bronx, New York; Women's Hemostasis and Thrombosis Clinic and Duke University Medical Center, Durham, North Carolina; National Association of Pediatric Nurse Practitioners and College of Nursing, University of New Mexico, Albuquerque, New Mexico; School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Philadelphia Department of Public Health, Philadelphia, Pennsylvania; Upper Peninsula Hematology/Oncology Associates and Cancer Research Office, Marquette General Health System, Marquette, Michigan; and Princeton Healthcare System, Princeton, New Jersey.Search for more papers by this author, Carolyn J. Montoya, RN, MSN, CPNPFrom Emory University and the American Cancer Society, Atlanta, Georgia; University of Maryland School of Social Work, Baltimore, Maryland; College of Medicine, University of Florida, Jacksonville, Jacksonville, Florida; The George Washington University, Washington, DC; Saint Joseph Regional Medical Center and African-American Women in Touch, South Bend, Indiana; Weill Medical College of Cornell University and Mount Sinai School of Medicine, New York, and Lincoln Medical and Mental Health Center, Bronx, New York; Women's Hemostasis and Thrombosis Clinic and Duke University Medical Center, Durham, North Carolina; National Association of Pediatric Nurse Practitioners and College of Nursing, University of New Mexico, Albuquerque, New Mexico; School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Philadelphia Department of Public Health, Philadelphia, Pennsylvania; Upper Peninsula Hematology/Oncology Associates and Cancer Research Office, Marquette General Health System, Marquette, Michigan; and Princeton Healthcare System, Princeton, New Jersey.Search for more papers by this author, Brad H. Pollock, MPH, PhDFrom Emory University and the American Cancer Society, Atlanta, Georgia; University of Maryland School of Social Work, Baltimore, Maryland; College of Medicine, University of Florida, Jacksonville, Jacksonville, Florida; The George Washington University, Washington, DC; Saint Joseph Regional Medical Center and African-American Women in Touch, South Bend, Indiana; Weill Medical College of Cornell University and Mount Sinai School of Medicine, New York, and Lincoln Medical and Mental Health Center, Bronx, New York; Women's Hemostasis and Thrombosis Clinic and Duke University Medical Center, Durham, North Carolina; National Association of Pediatric Nurse Practitioners and College of Nursing, University of New Mexico, Albuquerque, New Mexico; School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Philadelphia Department of Public Health, Philadelphia, Pennsylvania; Upper Peninsula Hematology/Oncology Associates and Cancer Research Office, Marquette General Health System, Marquette, Michigan; and Princeton Healthcare System, Princeton, New Jersey.Search for more papers by this author, Lawrence Robinson, MD, MPHFrom Emory University and the American Cancer Society, Atlanta, Georgia; University of Maryland School of Social Work, Baltimore, Maryland; College of Medicine, University of Florida, Jacksonville, Jacksonville, Florida; The George Washington University, Washington, DC; Saint Joseph Regional Medical Center and African-American Women in Touch, South Bend, Indiana; Weill Medical College of Cornell University and Mount Sinai School of Medicine, New York, and Lincoln Medical and Mental Health Center, Bronx, New York; Women's Hemostasis and Thrombosis Clinic and Duke University Medical Center, Durham, North Carolina; National Association of Pediatric Nurse Practitioners and College of Nursing, University of New Mexico, Albuquerque, New Mexico; School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Philadelphia Department of Public Health, Philadelphia, Pennsylvania; Upper Peninsula Hematology/Oncology Associates and Cancer Research Office, Marquette General Health System, Marquette, Michigan; and Princeton Healthcare System, Princeton, New Jersey.Search for more papers by this author, Aaron P. Scholnik, MDFrom Emory University and the American Cancer Society, Atlanta, Georgia; University of Maryland School of Social Work, Baltimore, Maryland; College of Medicine, University of Florida, Jacksonville, Jacksonville, Florida; The George Washington University, Washington, DC; Saint Joseph Regional Medical Center and African-American Women in Touch, South Bend, Indiana; Weill Medical College of Cornell University and Mount Sinai School of Medicine, New York, and Lincoln Medical and Mental Health Center, Bronx, New York; Women's Hemostasis and Thrombosis Clinic and Duke University Medical Center, Durham, North Carolina; National Association of Pediatric Nurse Practitioners and College of Nursing, University of New Mexico, Albuquerque, New Mexico; School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Philadelphia Department of Public Health, Philadelphia, Pennsylvania; Upper Peninsula Hematology/Oncology Associates and Cancer Research Office, Marquette General Health System, Marquette, Michigan; and Princeton Healthcare System, Princeton, New Jersey.Search for more papers by this author, and Melissa Schori, MD, MBA*From Emory University and the American Cancer Society, Atlanta, Georgia; University of Maryland School of Social Work, Baltimore, Maryland; College of Medicine, University of Florida, Jacksonville, Jacksonville, Florida; The George Washington University, Washington, DC; Saint Joseph Regional Medical Center and African-American Women in Touch, South Bend, Indiana; Weill Medical College of Cornell University and Mount Sinai School of Medicine, New York, and Lincoln Medical and Mental Health Center, Bronx, New York; Women's Hemostasis and Thrombosis Clinic and Duke University Medical Center, Durham, North Carolina; National Association of Pediatric Nurse Practitioners and College of Nursing, University of New Mexico, Albuquerque, New Mexico; School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Philadelphia Department of Public Health, Philadelphia, Pennsylvania; Upper Peninsula Hematology/Oncology Associates and Cancer Research Office, Marquette General Health System, Marquette, Michigan; and Princeton Healthcare System, Princeton, New Jersey.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-148-12-200806170-00220 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail National Institutes of Health consensus and state-of-the- science statements are prepared by independent panels of health professionals and public representatives on the basis of 1) the results of a systematic literature review prepared under contract with the Agency for Healthcare Research and Quality (AHRQ), 2) presentations by investigators working in areas relevant to the conference questions during a 2-day public session, 3) questions and statements from conference attendees during open discussion periods that are part of the public session, and 4) closed deliberations by the panel during the remainder of the second day and morning of the third. This statement is an independent report of the panel and is not a policy statement of the National Institutes of Health or the U.S. government. The statement reflects the panel's assessment of medical knowledge available at the time the statement was written. Thus, it provides a “snapshot in time” of the state of knowledge on the conference topic. When reading the statement, keep in mind that new knowledge is inevitably accumulating through medical research.Sickle cell disease is an inherited blood disorder that affects 50 000 to 100 000 people in the United States. It is estimated that 2000 babies are born with sickle cell disease in the United States each year. Sickle cell disease was the first disease for which a specific molecular defect in a gene was identified, and it is the most common genetic disease identified as part of the Newborn Screening Program in the United States. The condition is chronic and lifelong, and it is associated with a decreased lifespan. Sickle cell disease is most common in people whose families come from Africa, South or Central America, Caribbean islands, Mediterranean countries (such as Turkey, Greece, and Italy), India, and Saudi Arabia.Sickle cell disease occurs when an infant inherits the gene for sickle hemoglobin from both parents (Hb SS, or sickle cell anemia) or the gene for sickle hemoglobin from 1 parent and another abnormal hemoglobin gene from the other parent. In addition, approximately 2 million Americans have the sickle cell trait (in which an infant inherits the gene for sickle hemoglobin from 1 parent and a normal hemoglobin gene from the other parent). Several additional sickle syndromes result from genotypes that include, but are not limited to, SCD-Sβ0, SCD-SC, SCD-SD, SCD-Sβ+, and SCD-SOarab.Erythrocytes (red blood cells) in people with sickle cell disease become deoxygenated (depleted of oxygen), dehydrated, and crescent-shaped or “sickled.” The cells aggregate, or clump together, and stick to blood vessel walls. Aggregation blocks blood flow within limbs and organs. This can cause painful episodes and permanent damage to the eyes, brain, heart, lungs, kidneys, liver, bones, and spleen. Infections and lung disease are the leading causes of death in people with sickle cell disease.Patients with sickle cell disease are frequently seen in emergency departments and hospitalized for pain crises. Standard treatments for acute pain crises include painkilling medications, hydration, and oxygen.Hydroxyurea was initially synthesized in Germany in 1869. Nearly 50 years ago, it was developed as an anticancer drug and has been used to treat myeloproliferative syndromes, some types of leukemia, melanoma, and ovarian cancer. It has also been used to treat psoriasis. Hydroxyurea was first tested in sickle cell disease in 1984. Initial studies show that it acts to increase the production of fetal hemoglobin–containing erythrocytes and dilute the number of sickled cells in circulation.In the mid-1990s, investigators of a major study randomly assigned nearly 300 adults with sickle cell disease who had more than 3 severe painful crises or episodes per year to hydroxyurea or placebo. (In the past, the term pain crises has been used; currently, the term severe pain episodes is preferred.) This study was stopped early because it clearly showed that hydroxyurea reduced the number and severity of pain episodes in patients with sickle cell disease compared with placebo. Follow-up with the trial participants, including patients who were originally given placebo and were later prescribed hydroxyurea after the drug was determined to be beneficial, has shown that hydroxyurea reduces the damaging effects of sickle cell disease and improves some aspects of quality of life. The drug also may extend survival. In 1998, the U.S. Food and Drug Administration approved hydroxyurea for prevention of pain crises in adults with sickle cell anemia. Although the efficacy of hydroxyurea has been established in adults, the evidence of its efficacy in children is not as strong; however, the emerging data are supportive.Although hydroxyurea is beneficial to some patients with sickle cell disease, several issues about use of the drug are unresolved. These include patient and health practitioner concerns about the overall safety and effectiveness of hydroxyurea, as well as a lack of providers expert in the treatment of patients with sickle cell disease.To more closely examine this important topic, the National Heart, Lung, and Blood Institute and the Office of Medical Applications of Research of the National Institutes of Health convened a Consensus Development Conference from 25 to 27 February 2008 to assess the available scientific evidence related to the following questions: 1) What is the efficacy (results from clinical studies) of hydroxyurea treatment for patients who have sickle cell disease in 3 groups: infants, preadolescents, and adolescents and adults? 2) What is the effectiveness (in everyday practice) of hydroxyurea treatment for patients who have sickle cell disease? 3) What are the short- and long-term harms of hydroxyurea treatment? 4) What are the barriers to hydroxyurea treatment for patients who have sickle cell disease, and what are the potential solutions? 5) What are the future research needs?At the conference, invited speakers presented information pertinent to these questions, and a systematic literature review prepared under contract with the AHRQ (www.ahrq.gov/clinic/tp/hydscdtp.htm) was summarized. Conference attendees provided both oral and written statements in response to the key questions. The panel members weighed all of this evidence as they addressed the conference questions.This consensus statement is intended to provide researchers, health care providers, patients, and other interested members of the general public with an objective assessment of what is known about hydroxyurea as a treatment for sickle cell disease, and what questions remain.1. What Is the Efficacy (Results from Clinical Studies) of Hydroxyurea Treatment for Patients Who Have Sickle Cell Disease in 3 Groups: Infants, Preadolescents, and Adolescents and Adults?Efficacy is the therapeutic effect of an intervention in a controlled setting, in contrast to effectiveness, which is the therapeutic effect of an intervention in real-world situations. The spectrum of sickle cell disease includes the SCD-SS, SCD-Sβ0, SCD-SC, SCD-SD, SCD-Sβ+, and SCD-SOarab genotypes. Efficacy studies have varied in their inclusion of specific genotypes, but almost all include SCD-SS. In addition, the geographic origin of sickle cell disease is associated with different haplotypes and varying degrees of clinical severity. The 3 most common and phenotypically distinct haplotypes are Senegalese, Benin, and Bantu. Other geographic areas of origin associated with sickle cell disease include Saudi Arabia and the Indian subcontinent. The Benin and Bantu haplotypes are more common among people residing in the Western Hemisphere and are associated with worse clinical outcomes. Response to hydroxyurea therapy may vary by haplotype or genotype. However, few studies of efficacy have appropriately accounted for the heterogeneity of study populations that differed by genotype and phenotype as well as by demographic factors (such as sex and age).Although clinical experience on the use of hydroxyurea for treating sickle cell disease has been amassed over nearly 25 years, the strength of evidence supporting the efficacious use of hydroxyurea is not equivalent across age groups. Hydroxyurea is currently U.S. Food and Drug Administration–approved for use in adults and is the only treatment for sickle cell disease that modifies the disease process. Evidence is strong in adults but more limited in children because the sole randomized clinical trial in the latter population had a weak study design, small sample, and short follow-up. Nonetheless, the evidence in children does not contradict the findings in adults that hydroxyurea improves hematologic variables and decreases hospitalization rates. Published evidence based on weaker, observational study designs, such as cohort studies, before-and-after studies, case series, and case reports, suggests that hydroxyurea is efficacious. Adding to the difficulty in reaching a consensus on the use of hydroxyurea is that published efficacy studies are difficult to interpret because diverse outcome measures have been used, including hematologic end points; reduced incidence of severe pain episodes, the acute chest syndrome, hospitalizations, strokes, and kidney and spleen damage; and need for transfusion therapy. Studies currently under way should provide more information regarding the benefit of hydroxyurea in preventing organ damage and additional sickle cell disease outcomes. Elucidating the mechanism of action of hydroxyurea should prove useful in developing new agents.Adolescents and AdultsStrong evidence supports the efficacy of hydroxyurea use in adults. The published clinical trials included adolescents; however, they were not analyzed or reported as a separate group. Outcomes were diverse and included blood markers as measures of treatment effect (for example, hemoglobin level, hemoglobin F cell count, percentage of hemoglobin F, mean corpuscular volume, leukocyte count, and platelet count). Studies used a variety of clinical outcome measures (severe pain episodes, hospitalizations, the acute chest syndrome, blood transfusion therapy, mortality, priapism [unwanted, prolonged, painful erection], strokes, and leg ulcers) and examined the effects of hydroxyurea on the spleen, kidneys, and blood flow to the brain (Table 1).Table 1. Study Outcomes for Adults Receiving Hydroxyurea for Sickle Cell DiseaseAlthough a reduction in mortality with hydroxyurea therapy has been reported, the published trial was not specifically designed to assess this end point. It is therefore difficult to draw definitive conclusions about the effect of hydroxyurea on mortality.PreadolescentsThe evidence varies on whether the use of hydroxyurea improves short-term end points, especially hematologic measures, in preadolescent populations beyond infancy (Table 2).Table 2. Study Outcomes for Preadolescent Children beyond Infancy Receiving Hydroxyurea for Sickle Cell DiseaseEvidence is strong for an improvement in blood markers and reduced hospitalizations and moderate for a reduction in the incidence of pain crises. Ongoing investigations in this age group will determine the efficacy of hydroxyurea treatment for children with SCD-SS, a history of stroke, and too much iron (iron overload).InfantsNo published, well-designed clinical trials have evaluated the efficacy of hydroxyurea treatment for infants. Ongoing prospective trials and observational studies are attempting to address this gap. The end points of these studies include prevention of damage to the kidney and spleen and improvements in blood markers that predict long-term clinical outcomes.In summary, the efficacy of hydroxyurea treatment for adults with SCD-SS is established. Although the evidence for efficacy of hydroxyurea treatment for children is not as strong, the emerging data are supportive. Future directions include evaluation of efficacy in preadolescent children and infants and further development of other therapeutic techniques, including stem-cell transplantation and gene therapy. Stem-cell transplantation can cure sickle cell anemia.2. What Is the Effectiveness (in Everyday Practice) of Hydroxyurea Treatment for Patients Who Have Sickle Cell Disease?Effectiveness is the therapeutic effect of an intervention as demonstrated or observed in patients in their usual care setting. The efficacy of hydroxyurea in treating adults with sickle ce

Clinical and laboratory characteristics of 224 patients with thyroidal infection reported since 1900 are reviewed. Much of the prior literature on this subject has assumed that most instances of thyroiditis are infectious and that all lymphomatous thyroiditis is tuberculous. Similarly, thyroiditis occurring with syphilis was often equated with treponemal invasion of the gland. Acute bacterial thyroiditis is rapid in onset and more likely than tuberculous infection to produce fever, pain, and tenderness. Suppurative and mycobacterial infections are most common among women with preexisting thyroid disorders. Mortality due to infectious thyroiditis is lower in cases covered by this review than has been previously reported. Gummatous and fungal infections of the thyroid are generally diagnosed only at biopsy or necropsy. Frequent thyroidal involvement in disseminated aspergillosis warrants careful investigation of the gland in patients with this infection. Echinococcosis of the thyroid is a chronic process that is generally diagnosed only following excision.

Maintenance intravenous fluids (IVFs) are used to provide critical supportive care for children who are acutely ill. IVFs are required if sufficient fluids cannot be provided by using enteral administration for reasons such as gastrointestinal illness, respiratory compromise, neurologic impairment, a perioperative state, or being moribund from an acute or chronic illness. Despite the common use of maintenance IVFs, there is high variability in fluid prescribing practices and a lack of guidelines for fluid composition administration and electrolyte monitoring. The administration of hypotonic IVFs has been the standard in pediatrics. Concerns have been raised that this approach results in a high incidence of hyponatremia and that isotonic IVFs could prevent the development of hyponatremia. Our goal in this guideline is to provide an evidence-based approach for choosing the tonicity of maintenance IVFs in most patients from 28 days to 18 years of age who require maintenance IVFs. This guideline applies to children in surgical (postoperative) and medical acute-care settings, including critical care and the general inpatient ward. Patients with neurosurgical disorders, congenital or acquired cardiac disease, hepatic disease, cancer, renal dysfunction, diabetes insipidus, voluminous watery diarrhea, or severe burns; neonates who are younger than 28 days old or in the NICU; and adolescents older than 18 years old are excluded. We specifically address the tonicity of maintenance IVFs in children. The Key Action Statement of the subcommittee is as follows: 1A: The American Academy of Pediatrics recommends that patients 28 days to 18 years of age requiring maintenance IVFs should receive isotonic solutions with appropriate potassium chloride and dextrose because they significantly decrease the risk of developing hyponatremia (evidence quality: A; recommendation strength: strong)

BACKGROUND: Gastric tonometry, as a method of organ-specific monitoring of the status of the splanchnic circulation, has demonstrated prognostic and therapeutic implications in critically ill patients. The experience with this method in patients with trauma has been limited. STUDY DESIGN: Fifty-seven patients were prospectively randomized into two groups: group 1, n = 30, normalization and maintenance of gastric mucosal pH (pHi) at or above 7.3 and group 2, n = 27, maintenance of oxygen delivery index of 600 or an oxygen consumption index of greater than 150. The groups had statistically similar injury severity scores, lactate levels, and base deficits. RESULTS: Of the 44 patients with pHi greater than 7.3 at 24 hours, three (6.8 percent) died of multiple organ dysfunction syndrome as compared with seven (53.9 percent) of 13 in whom pHi was not optimized, p = 0.006. Optimization times for oxygen delivery index, oxygen consumption index, lactate levels, and base excess were similar between survivors and nonsurvivors. The time for pHi optimization was significantly longer in nonsurvivors. Multiple organ dysfunction syndrome points were significantly higher in patients who did not have pHi optimized within 24 hours (6.08 compared with 2.5, p = 0.03). Optimization time for pHi was predictive of mortality on multiple regression. Persistently low pHi was frequently associated with systemic or intra-abdominal complications. It was the first finding in all the nonsurvivors at least 48 to 72 hours before death. CONCLUSIONS: Gastric mucosal pH may be an important marker to assess the adequacy of resuscitation. Monitoring of pHi may provide early warning for systemic complications in the postresuscitation period.

B cell maturation antigen (BCMA) is a novel treatment target for multiple myeloma (MM) due to its highly selective expression in malignant plasma cells (PCs). Multiple BCMA-targeted therapeutics, including antibody-drug conjugates (ADC), chimeric antigen receptor (CAR)-T cells, and bispecific T cell engagers (BiTE), have achieved remarkable clinical response in patients with relapsed and refractory MM. Belantamab mafodotin-blmf (GSK2857916), a BCMA-targeted ADC, has just been approved for highly refractory MM. In this article, we summarized the molecular and physiological properties of BCMA as well as BCMA-targeted immunotherapeutic agents in different stages of clinical development.

OBJECTIVES: To establish Department of Veterans Affairs' intensive care unit (ICU) costs from a database and to use this information to validate the Russell equation, the most commonly used method of calculating ICU costs. To compare and trend Department of Veterans Affairs' and nationwide (USA) ICU and healthcare costs. DESIGN: Comparison study. SETTING: Database analysis of Department of Veterans Affairs' and nationwide ICUs over a 6-yr period (1986-1992), with biennial evaluations. MAIN MEASURES: Costs and bed occupancies of Department of Veterans Affairs' and nationwide hospitals and ICUs, as well as United States national health expenditures and gross domestic product. RESULTS: Fifty percent to Department of Veterans Affairs' ICU funds were used for nurse and physician salaries. Department of Veterans Affairs' ICU direct and indirect cost ratios have remained constant (2:1). The Russell equation is valid, providing that the "inpatient only" cost variable is used. ICU costs were consistently lower in the Department of Veterans Affairs' than nationwide, as compared by the Russell equation. A smaller fraction of the hospital budget was allocated to the ICU in the Department of Veterans Affairs than in nationwide institutions. Despite an increasing nationwide ICU patient workload, the percentage of ICU fund allocations has not increased. Health care in the United States increases at a rate greater than the increase in gross domestic product. Healthcare delivery costs are increasing at a greater rate nationwide than in the Department of Veterans Affairs. The percentage increase in ICU cost per day, both in the Department of Veterans Affairs and nationwide, was less than the increase in healthcare costs. The percent of the gross domestic product, national health expenditure, and hospital cost used by the ICU has increased minimally during the course of this study. CONCLUSIONS: The Department of Veterans Affairs has the only national ICU line item cost database available. For the Russell equation calculation to be accurate, inpatient only costs should be used. Until customized Health Care Financing Administration analyses become available, nationwide ICU costs are best determined by the Russell equation. Department of Veterans Affairs' ICUs have a consistent cost advantage over nationwide ICUs. Increases in United States healthcare delivery costs continue to exceed the increase in gross domestic product. Cost containment is already occurring in critical care.

Abstract In order to examine the association between the experience of violent events, trauma, and post‐traumatic stress disorder among women drug users, 105 women in treatment for addictive disorders were interviewed. One hundred four of the study participants reported trauma in 1 or more of 14 categories of traumatic events, 59% of whom reported symptoms consistent with a diagnosis of posttraumatic stress disorder. Among those with PTSD, 97% reported one or more violent traumas as compared with 73% of those without PTSD. The likelihood of PTSD was strongly associated with the number of violent traumas reported by a woman. Women in recovery from drug addiction are likely to have a history of violent trauma and are at high risk for post‐traumatic stress disorder. Screening for PTSD among women with an addictive disorder should become part of the diagnostic and treatment routine.

INTRODUCTION: Alcohol use disorders (AUD) place a significant burden on individuals and society. The emergency department (ED) offers a unique opportunity to address AUD with brief screening tools and early intervention. We undertook a systematic review of the effectiveness of ED brief interventions for patients identified through screening who are at risk for AUD, and the effectiveness of these interventions at reducing alcohol intake and preventing alcohol-related injuries. METHODS: We conducted systematic electronic database searches to include randomized controlled trials of AUD screening, brief intervention, referral, and treatment (SBIRT), from January 1966 to April 2016. Two authors graded and abstracted data from each included paper. RESULTS: We found 35 articles that had direct relevance to the ED with enrolled patients ranging from 12 to 70 years of age. Multiple alcohol screening tools were used to identify patients at risk for AUD. Brief intervention (BI) and brief motivational intervention (BMI) strategies were compared to a control intervention or usual care. Thirteen studies enrolling a total of 5,261 participants reported significant differences between control and intervention groups in their main alcohol-outcome criteria of number of drink days and number of units per drink day. Sixteen studies showed a reduction of alcohol consumption in both the control and intervention groups; of those, seven studies did not identify a significant intervention effect for the main outcome criteria, but nine observed some significant differences between BI and control conditions for specific subgroups (i.e., adolescents and adolescents with prior history of drinking and driving; women 22 years old or younger; low or moderate drinkers); or secondary outcome criteria (e.g. reduction in driving while intoxicated). CONCLUSION: Moderate-quality evidence of targeted use of BI/BMI in the ED showed a small reduction in alcohol use in low or moderate drinkers, a reduction in the negative consequences of use (such as injury), and a decline in ED repeat visits for adults and children 12 years of age and older. BI delivered in the ED appears to have a short-term effect in reducing at-risk drinking.

Background: Coronavirus disease 2019 (COVID-19) can lead to acute respiratory distress syndrome (ARDS) but it is unknown whether prone positioning improves outcomes in mechanically ventilated patients with moderate to severe ARDS due to COVID-19. Methods: A cohort study at a New York City hospital at the peak of the early pandemic in the United States, under crisis conditions. The aim was to determine the benefit of prone positioning in mechanically ventilated patients with ARDS due to COVID-19. The primary outcome was in-hospital death. Secondary outcomes included changes in physiologic parameters. Fine-Gray competing risks models with stabilized inverse probability treatment weighting (sIPTW) were used to determine the effect of prone positioning on outcomes. In addition, linear mixed effects models (LMM) were used to assess changes in physiology with prone positioning. Results: Out of 335 participants who were intubated and mechanically ventilated, 62 underwent prone positioning, 199 met prone positioning criteria and served as controls and 74 were excluded. The intervention and control groups were similar at baseline. In multivariate-adjusted competing risks models with sIPTW, prone positioning was significantly associated with reduced mortality (SHR 0.61, 95% CI 0.46-0.80, P &lt; 0.005). Using LMM to evaluate the impact of positioning maneuvers on physiological parameters, the oxygenation-saturation index was significantly improved during days 1-3 ( P &lt; 0.01) whereas oxygenation-saturation index (OSI), oxygenation-index (OI) and arterial oxygen partial pressure to fractional inspired oxygen (P a O 2 : FiO 2 ) were significantly improved during days 4-7 (P &lt; 0.05 for all). Conclusions: Prone positioning in patients with moderate to severe ARDS due to COVID-19 is associated with reduced mortality and improved physiologic parameters. One in-hospital death could be averted for every 8 patients treated. Replicating results and scaling the intervention are important, but prone positioning may represent an additional therapeutic option in patients with ARDS due to COVID-19.

Intussusception is the most common cause of intestinal obstruction in children between 3 months and 6 years. Intussusception occurs when a more proximal portion of bowel invaginates into more distal bowel. These patients often present with a wide range of non-specific symptoms, with less than one quarter presenting with the classic triad of vomiting, abdominal pain, and bloody stools. Thus, the diagnosis continues to rely on clinical suspicion. This review article discusses the clinical presentation of intussusception and the state-of-the art diagnostic and treatment options, as well as a review of the pertinent literature.

In this country schizophrenia has been consistently overdiagnosed and affective disorders underdiagnosed, particularly among blacks and lower socioeconomic groups. The general causes of such misdiagnoses include overreliance on the classic thought disorder symptoms as pathognomonic of schizophrenia and, for affective disorders, lack of clearly defined boundaries between normal and abnormal mood and failure to realize that patients with affective illness can manifest cognitive symptoms. In addition to the above factors, misdiagnosis among blacks results from such factors as cultural differences in language and mannerisms, difficulties in relating between black patients and white therapists, and the myth that blacks rarely suffer from affective disorders. Clinicians and researchers must pay more attention to the effects of cultural differences on diagnosis, and baseline behaviors and symptomatology for blacks must be established.

An emerging viral infection is a global public health challenge. The development of modern, fast, and extensive transportation makes the outbreak hard to contain. Everyone is at risk, and the outbreak can rapidly turn into a pandemic crisis, like what we are currently facing for the 2019 novel coronavirus disease (COVID-19). Prompt diagnosis of the case is required to improve patients' prognosis and control of the outbreak. The common manifestations of COVID-19 include fever, cough, dyspnea, and malaise. However, patients may present with atypical symptoms that pose a diagnostic challenge. We report the first case of an elderly male who presented with rhabdomyolysis and later was diagnosed with COVID-19. Clinicians should be aware that rhabdomyolysis can be an initial presentation of COVID-19 or can occur at any time during the disease course. Patients with rhabdomyolysis should receive aggressive fluid administration to prevent acute kidney injury (AKI). However, COVID-19 patients are at risk of worsening oxygenation and acute hypoxemic respiratory failure from fluid overload. Therefore, cautious fluid administration is needed in COVID-19 patients with rhabdomyolysis.