In trauma patients, the recognition of fibrinolysis phenotypes has led to a re‐evaluation of the ... more In trauma patients, the recognition of fibrinolysis phenotypes has led to a re‐evaluation of the risks and benefits of antifibrinolytic therapy (AF). Many cardiac patients also receive AF, but the distribution of fibrinolytic phenotypes in that population is unknown. The purpose of this hypothesis‐generating study was to fill that gap.
IMPORTANCE Significant concern has been raised that crisis standards of care policies aimed at gu... more IMPORTANCE Significant concern has been raised that crisis standards of care policies aimed at guiding resource allocation may be biased against people based on race/ethnicity. OBJECTIVE To evaluate whether unanticipated disparities by race or ethnicity arise from a single institution's resource allocation policy. DESIGN, SETTING, AND PARTICIPANTS This cohort study included adults (aged Ն18 years) who were cared for on a coronavirus disease 2019 (COVID-19) ward or in a monitored unit requiring invasive or noninvasive ventilation or high-flow nasal cannula between May 26 and July 14, 2020, at 2 academic hospitals in Miami, Florida. EXPOSURES Race (ie, White, Black, Asian, multiracial) and ethnicity (ie, non-Hispanic, Hispanic). MAIN OUTCOMES AND MEASURES The primary outcome was based on a resource allocation priority score (range, 1-8, with 1 indicating highest and 8 indicating lowest priority) that was assigned daily based on both estimated short-term (using Sequential Organ Failure Assessment score) and longer-term (using comorbidities) mortality. There were 2 coprimary outcomes: maximum and minimum score for each patient over all eligible patient-days. Standard summary statistics were used to describe the cohort, and multivariable Poisson regression was used to identify associations of race and ethnicity with each outcome. RESULTS The cohort consisted of 5613 patient-days of data from 1127 patients (median [interquartile range {IQR}] age, 62.7 [51.7-73.7]; 607 [53.9%] men). Of these, 711 (63.1%) were White patients, 323 (28.7%) were Black patients, 8 (0.7%) were Asian patients, and 31 (2.8%) were multiracial patients; 480 (42.6%) were non-Hispanic patients, and 611 (54.2%) were Hispanic patients. The median (IQR) maximum priority score for the cohort was 3 (1-4); the median (IQR) minimum score was 2 (1-3). After adjustment, there was no association of race with maximum priority score using White patients as the reference group (Black patients: incidence rate ratio [IRR], 1.00; 95% CI, 0.89-1.12; Asian patients: IRR, 0.95; 95% CI. 0.62-1.45; multiracial patients: IRR, 0.93; 95% CI, 0.72-1.19) or of ethnicity using non-Hispanic patients as the reference group (Hispanic patients: IRR, 0.98; 95% CI, 0.88-1.10); similarly, no association was found with minimum score for race, again with White patients as the reference group (Black patients: IRR, 1.01; 95% CI, 0.90-1.14; Asian patients: IRR, 0.96; 95% CI, 0.62-1.49; multiracial patients: IRR, 0.81; 95% CI, 0.61-1.07) or ethnicity, again with non-Hispanic patients as the reference group (Hispanic patients: IRR, 1.00; 95% CI, 0.89-1.13). CONCLUSIONS AND RELEVANCE In this cohort study of adult patients admitted to a COVID-19 unit at 2 US hospitals, there was no association of race or ethnicity with the priority score underpinning (continued) Key Points Question Is there an association of race and/or ethnicity with priority scores based on both short-term and longerterm estimated mortality used for resource allocation under crisis standards of care? Findings In this retrospective cohort study of 1127 patients with 5613 patientdays in 2 US hospitals, there was no significant association of race or ethnicity with priority score. Meaning In this study, the use of a crisis standards of care resource allocation policy based on both short-term and longer-term estimated mortality did not appear to discriminate against hospitalized patients based on selfidentified race or ethnicity.
Recently, the gut microbiome has gained considerable interest as one of the major contributors to... more Recently, the gut microbiome has gained considerable interest as one of the major contributors to the pathogenesis of multi-system inflammatory disorders. Several studies have suggested that the gut microbiota plays a role in modulating complex signaling pathways, predominantly via the bidirectional gut-brain-axis (GBA). Subsequent in vivo studies have demonstrated the direct role of altered gut microbes and metabolites in the progression of neurodevelopmental diseases. This review will discuss the most recent advancements in our understanding of the gut microbiome’s clinical significance in regulating blood-brain barrier (BBB) integrity, immunological function, and neurobiological development. In particular, we address the potentially causal role of GBA dysregulation in the pathophysiology of autism spectrum disorder (ASD) through compromising the BBB and immunological abnormalities. A thorough understanding of the complex signaling interactions between gut microbes, metabolites, n...
Failure to Not up to Failure to Failure of sur-Failure of fol-Characteristics screen at approdate... more Failure to Not up to Failure to Failure of sur-Failure of fol-Characteristics screen at approdate, overall screen veillance low-up priate interval Age (years) 0.84 0.91 0.90 0.68 0.37 50-64 (0.67,1.07) (0.61,1.35) (0.81,1.00) (0.09,5.36) (0.14,0.99)
Background Increasing the number of organ donors may enhance organ transplantation, and past heal... more Background Increasing the number of organ donors may enhance organ transplantation, and past health interventions have shown the potential to generate both large-scale and sustainable changes, particularly among minorities. Objective This study aimed to propose a conceptual data-driven framework that tracks digital markers of public organ donation awareness using Twitter and delivers an optimized social network intervention (SNI) to targeted audiences using Facebook. Methods We monitored digital markers of organ donation awareness across the United States over a 1-year period using Twitter and examined their association with organ donation registration. We delivered this SNI on Facebook with and without optimized awareness content (ie, educational content with a weblink to an online donor registration website) to low-income Hispanics in Los Angeles over a 1-month period and measured the daily number of impressions (ie, exposure to information) and clicks (ie, engagement) among the t...
BackgroundPrevious studies have used using Indirect Calorimetry (IC) with solitary or sparse meas... more BackgroundPrevious studies have used using Indirect Calorimetry (IC) with solitary or sparse measurements of resting energy expenditure (REE). This “snapshot” may not capture the dynamic nature of metabolic requirements. Using continuous IC, we describe the variation of REE during the first days in the intensive care unit.MethodsInjured adults (≥18 years) requiring mechanical ventilation from March 2018 to September 2018 were enrolled. IC was initiated within 4 days of admission and continuous REE recorded until 14 days, extubation, or death. Multiple 10‐minute periods collected during steady state were used to calculate daily REE maximum, minimum, average, and variability [(REEmax − REEmin/2)/average REE].ResultsWe included 55 patients. Median age was 38 [27–58] years, 38 (69%) were male, body mass index was 28 [25–33] kg/m2, and Acute Physiology and Chronic Health Evaluation II was 17 [14–24]. Mechanism of injury was: blunt (n = 38, 69%), penetrating (n = 9, 16%), and burn (n = 8,...
BackgroundOverfeeding and underfeeding are associated with poor clinical outcomes. In the absence... more BackgroundOverfeeding and underfeeding are associated with poor clinical outcomes. In the absence of indirect calorimetry (IC), the Society of Critical Care Medicine/ASPEN recommend prescribing 25–30 kcal/kg. The Harris‐Benedict equation (HBE) multiplied by a stress factor is commonly applied in critically ill patients. We describe the difference between estimated and actual energy needs in critically injured patients.MethodsFrom March to November 2018, we collected demographics and energy needs determined by continuous IC (started within 4 days) in intubated adults. Ideal or adjusted body weight was used for 25–30 kcal/kg, and HBE was multiplied by a 1.3 stress factor (1.3HBE). Daily requirements up to 14 days, extubation, or death were calculated using all 3 methods and compared with IC.ResultsFifty‐five subjects were included. Median age was 38 [27–58] years, 38 (69%) were male, body mass index was 28 [25–33] kg/m2, and Acute Physiology and Chronic Health Evaluation II score was ...
Electrocutions during tree trimming or fruit harvesting are occasionally reported in the public m... more Electrocutions during tree trimming or fruit harvesting are occasionally reported in the public media, but the actual incidence is unknown. Some fruit trees (eg, mango and avocado) can exceed 30 feet, with dense foliage concealing the fruit and overlying power lines so burns associated with harvesting these fruits are often exacerbated with falls. However, there are limited data on this subject. To fill this gap, we provide some of the first information on this unique injury pattern. All electrocutions from 2013 to 2018 were retrospectively reviewed at an ABA-verified burn center. Demographics, injury patterns, and complications were analyzed. Of 97 electrocutions, 22 (23%) were associated with fruit procurement. This population was aged 43 ± 14 years, 95% (n = 21) male, injury severity score of 15 ± 13, and total body surface area burned 4% [1%-9%]. Third-degree burns were present in 36% (n = 8). ICU admission was required in 59% (n = 13) and 39% of the survivors required operative interventions for the burn. Compartment syndrome occurred in 18% (n = 4) and 14% (n = 3) patients required amputations. Falls complicated the care in 50% (n = 11), with associated head, chest, and/or extremity trauma. Mortality was 32% (n = 7), with three patients presenting dead on arrival. All but 3 injuries occurred between June and December, coinciding with mango and avocado season. Electrocution during fruit picking is a seasonal injury often exacerbated by falls. Management is challenging, and favorable outcome depends on recognition of the complexity of the polytrauma.
In trauma patients, the recognition of fibrinolysis phenotypes has led to a re‐evaluation of the ... more In trauma patients, the recognition of fibrinolysis phenotypes has led to a re‐evaluation of the risks and benefits of antifibrinolytic therapy (AF). Many cardiac patients also receive AF, but the distribution of fibrinolytic phenotypes in that population is unknown. The purpose of this hypothesis‐generating study was to fill that gap.
IMPORTANCE Significant concern has been raised that crisis standards of care policies aimed at gu... more IMPORTANCE Significant concern has been raised that crisis standards of care policies aimed at guiding resource allocation may be biased against people based on race/ethnicity. OBJECTIVE To evaluate whether unanticipated disparities by race or ethnicity arise from a single institution's resource allocation policy. DESIGN, SETTING, AND PARTICIPANTS This cohort study included adults (aged Ն18 years) who were cared for on a coronavirus disease 2019 (COVID-19) ward or in a monitored unit requiring invasive or noninvasive ventilation or high-flow nasal cannula between May 26 and July 14, 2020, at 2 academic hospitals in Miami, Florida. EXPOSURES Race (ie, White, Black, Asian, multiracial) and ethnicity (ie, non-Hispanic, Hispanic). MAIN OUTCOMES AND MEASURES The primary outcome was based on a resource allocation priority score (range, 1-8, with 1 indicating highest and 8 indicating lowest priority) that was assigned daily based on both estimated short-term (using Sequential Organ Failure Assessment score) and longer-term (using comorbidities) mortality. There were 2 coprimary outcomes: maximum and minimum score for each patient over all eligible patient-days. Standard summary statistics were used to describe the cohort, and multivariable Poisson regression was used to identify associations of race and ethnicity with each outcome. RESULTS The cohort consisted of 5613 patient-days of data from 1127 patients (median [interquartile range {IQR}] age, 62.7 [51.7-73.7]; 607 [53.9%] men). Of these, 711 (63.1%) were White patients, 323 (28.7%) were Black patients, 8 (0.7%) were Asian patients, and 31 (2.8%) were multiracial patients; 480 (42.6%) were non-Hispanic patients, and 611 (54.2%) were Hispanic patients. The median (IQR) maximum priority score for the cohort was 3 (1-4); the median (IQR) minimum score was 2 (1-3). After adjustment, there was no association of race with maximum priority score using White patients as the reference group (Black patients: incidence rate ratio [IRR], 1.00; 95% CI, 0.89-1.12; Asian patients: IRR, 0.95; 95% CI. 0.62-1.45; multiracial patients: IRR, 0.93; 95% CI, 0.72-1.19) or of ethnicity using non-Hispanic patients as the reference group (Hispanic patients: IRR, 0.98; 95% CI, 0.88-1.10); similarly, no association was found with minimum score for race, again with White patients as the reference group (Black patients: IRR, 1.01; 95% CI, 0.90-1.14; Asian patients: IRR, 0.96; 95% CI, 0.62-1.49; multiracial patients: IRR, 0.81; 95% CI, 0.61-1.07) or ethnicity, again with non-Hispanic patients as the reference group (Hispanic patients: IRR, 1.00; 95% CI, 0.89-1.13). CONCLUSIONS AND RELEVANCE In this cohort study of adult patients admitted to a COVID-19 unit at 2 US hospitals, there was no association of race or ethnicity with the priority score underpinning (continued) Key Points Question Is there an association of race and/or ethnicity with priority scores based on both short-term and longerterm estimated mortality used for resource allocation under crisis standards of care? Findings In this retrospective cohort study of 1127 patients with 5613 patientdays in 2 US hospitals, there was no significant association of race or ethnicity with priority score. Meaning In this study, the use of a crisis standards of care resource allocation policy based on both short-term and longer-term estimated mortality did not appear to discriminate against hospitalized patients based on selfidentified race or ethnicity.
Recently, the gut microbiome has gained considerable interest as one of the major contributors to... more Recently, the gut microbiome has gained considerable interest as one of the major contributors to the pathogenesis of multi-system inflammatory disorders. Several studies have suggested that the gut microbiota plays a role in modulating complex signaling pathways, predominantly via the bidirectional gut-brain-axis (GBA). Subsequent in vivo studies have demonstrated the direct role of altered gut microbes and metabolites in the progression of neurodevelopmental diseases. This review will discuss the most recent advancements in our understanding of the gut microbiome’s clinical significance in regulating blood-brain barrier (BBB) integrity, immunological function, and neurobiological development. In particular, we address the potentially causal role of GBA dysregulation in the pathophysiology of autism spectrum disorder (ASD) through compromising the BBB and immunological abnormalities. A thorough understanding of the complex signaling interactions between gut microbes, metabolites, n...
Failure to Not up to Failure to Failure of sur-Failure of fol-Characteristics screen at approdate... more Failure to Not up to Failure to Failure of sur-Failure of fol-Characteristics screen at approdate, overall screen veillance low-up priate interval Age (years) 0.84 0.91 0.90 0.68 0.37 50-64 (0.67,1.07) (0.61,1.35) (0.81,1.00) (0.09,5.36) (0.14,0.99)
Background Increasing the number of organ donors may enhance organ transplantation, and past heal... more Background Increasing the number of organ donors may enhance organ transplantation, and past health interventions have shown the potential to generate both large-scale and sustainable changes, particularly among minorities. Objective This study aimed to propose a conceptual data-driven framework that tracks digital markers of public organ donation awareness using Twitter and delivers an optimized social network intervention (SNI) to targeted audiences using Facebook. Methods We monitored digital markers of organ donation awareness across the United States over a 1-year period using Twitter and examined their association with organ donation registration. We delivered this SNI on Facebook with and without optimized awareness content (ie, educational content with a weblink to an online donor registration website) to low-income Hispanics in Los Angeles over a 1-month period and measured the daily number of impressions (ie, exposure to information) and clicks (ie, engagement) among the t...
BackgroundPrevious studies have used using Indirect Calorimetry (IC) with solitary or sparse meas... more BackgroundPrevious studies have used using Indirect Calorimetry (IC) with solitary or sparse measurements of resting energy expenditure (REE). This “snapshot” may not capture the dynamic nature of metabolic requirements. Using continuous IC, we describe the variation of REE during the first days in the intensive care unit.MethodsInjured adults (≥18 years) requiring mechanical ventilation from March 2018 to September 2018 were enrolled. IC was initiated within 4 days of admission and continuous REE recorded until 14 days, extubation, or death. Multiple 10‐minute periods collected during steady state were used to calculate daily REE maximum, minimum, average, and variability [(REEmax − REEmin/2)/average REE].ResultsWe included 55 patients. Median age was 38 [27–58] years, 38 (69%) were male, body mass index was 28 [25–33] kg/m2, and Acute Physiology and Chronic Health Evaluation II was 17 [14–24]. Mechanism of injury was: blunt (n = 38, 69%), penetrating (n = 9, 16%), and burn (n = 8,...
BackgroundOverfeeding and underfeeding are associated with poor clinical outcomes. In the absence... more BackgroundOverfeeding and underfeeding are associated with poor clinical outcomes. In the absence of indirect calorimetry (IC), the Society of Critical Care Medicine/ASPEN recommend prescribing 25–30 kcal/kg. The Harris‐Benedict equation (HBE) multiplied by a stress factor is commonly applied in critically ill patients. We describe the difference between estimated and actual energy needs in critically injured patients.MethodsFrom March to November 2018, we collected demographics and energy needs determined by continuous IC (started within 4 days) in intubated adults. Ideal or adjusted body weight was used for 25–30 kcal/kg, and HBE was multiplied by a 1.3 stress factor (1.3HBE). Daily requirements up to 14 days, extubation, or death were calculated using all 3 methods and compared with IC.ResultsFifty‐five subjects were included. Median age was 38 [27–58] years, 38 (69%) were male, body mass index was 28 [25–33] kg/m2, and Acute Physiology and Chronic Health Evaluation II score was ...
Electrocutions during tree trimming or fruit harvesting are occasionally reported in the public m... more Electrocutions during tree trimming or fruit harvesting are occasionally reported in the public media, but the actual incidence is unknown. Some fruit trees (eg, mango and avocado) can exceed 30 feet, with dense foliage concealing the fruit and overlying power lines so burns associated with harvesting these fruits are often exacerbated with falls. However, there are limited data on this subject. To fill this gap, we provide some of the first information on this unique injury pattern. All electrocutions from 2013 to 2018 were retrospectively reviewed at an ABA-verified burn center. Demographics, injury patterns, and complications were analyzed. Of 97 electrocutions, 22 (23%) were associated with fruit procurement. This population was aged 43 ± 14 years, 95% (n = 21) male, injury severity score of 15 ± 13, and total body surface area burned 4% [1%-9%]. Third-degree burns were present in 36% (n = 8). ICU admission was required in 59% (n = 13) and 39% of the survivors required operative interventions for the burn. Compartment syndrome occurred in 18% (n = 4) and 14% (n = 3) patients required amputations. Falls complicated the care in 50% (n = 11), with associated head, chest, and/or extremity trauma. Mortality was 32% (n = 7), with three patients presenting dead on arrival. All but 3 injuries occurred between June and December, coinciding with mango and avocado season. Electrocution during fruit picking is a seasonal injury often exacerbated by falls. Management is challenging, and favorable outcome depends on recognition of the complexity of the polytrauma.
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