Research Spotlight

Posted May 15th 2020

Traumatic Pneumoperitoneum After Vaginal Intercourse.

Clifford J. Buckley M.D.

Clifford J. Buckley M.D.

Thomas, J. W. and C. J. Buckley, 2nd (2020). “Traumatic Pneumoperitoneum After Vaginal Intercourse.” Pediatr Emerg Care 36(5): e301-e303.

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OBJECTIVES: Pneumoperitoneum with peritonitis, although uncommon, is a serious injury encountered in the pediatric emergency department. Although the patients may often appear ill or toxic, they can have normal vital signs at initial presentation. Patients with such injury can present with a variety of complaints because of the nature of referred pain. As a result, some patients may be more or less straightforward, thus illustrating the importance of obtaining a detailed history and performing a thorough physical examination. METHODS: We discuss an uncommon case report of pneumoperitoneum with peritonitis in an adolescent patient presenting with vaginal bleeding and abdominal pain hours after vigorous coitus. RESULTS: Examination under anesthesia, flexible sigmoidoscopy, and exploratory laparoscopy revealed a vaginal laceration and a 2- to 3-cm perforated area at the left edge of the vaginal laceration that involved the rectovaginal septum entering the peritoneal cavity. CONCLUSIONS: Pneumoperitoneum resulting from vaginal intercourse in an otherwise healthy adolescent female is a rare cause of peritonitis. Although it has been described in the adult literature, this case illustrates the importance of considering sexual history as a contributory factor in pediatric patients presenting with an acute abdomen.


Posted May 15th 2020

Influenza vaccine effectiveness in inpatient and outpatient settings in the United States, 2015 – 2018.

Kempapura Murthy M.P.H.

Kempapura Murthy M.P.H.

Tenforde, M. W., J. Chung, E. R. Smith, H. K. Talbot, C. H. Trabue, R. K. Zimmerman, F. P. Silveira, M. Gaglani, K. Murthy, A. S. Monto, E. T. Martin, H. Q. McLean, E. A. Belongia, L. A. Jackson, M. L. Jackson, J. M. Ferdinands, B. Flannery and M. M. Patel (2020). “Influenza vaccine effectiveness in inpatient and outpatient settings in the United States, 2015 – 2018.” Clin Infect Dis Apr 9. pii: ciaa407. [Epub ahead of print].

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BACKGROUND: Demonstration of influenza vaccine effectiveness (VE) against hospitalization for severe illness in addition to milder outpatient illness may strengthen vaccination messaging and improve suboptimal uptake in the U.S. Our objective was to compare patient characteristics and VE between U.S. inpatient and outpatient VE networks. METHODS: We tested adults >/=18-years with acute respiratory illness (ARI) for influenza within two VE networks, one outpatient- and the other hospital-based, from 2015-2018. We compared age, sex, and chronic high-risk conditions between populations. The test-negative design was used to compare vaccination odds in influenza-positive cases versus influenza-negative controls. We estimated VE using logistic regression adjusting for site, age, sex, race/ethnicity, peak influenza activity, time-to-testing from symptom-onset, season (overall VE) and underlying conditions. VE differences (DeltaVE) were assessed with 95% confidence intervals (CI) determined through bootstrapping with significance defined as excluding the null. RESULTS: The VE networks enrolled 14,573 (4144 influenza-positive) outpatients and 6769 (1452 influenza-positive) inpatients. Inpatients were older (median 62-years vs. 49-years) and had more high-risk conditions (median 4 vs. 1). Overall influenza VE across seasons was 31% (95%CI:26%-37%) among outpatients and 36% (27%-44%) among inpatients. Strain-specific VE among outpatients versus inpatients was 37% (25%-47%) vs. 53% (37%-64%) against H1N1pdm09, 19% (9%-27%) vs. 23% (8%-35%) against H3N2, and 46% (38%-53%) vs. 46% (31%-58%) against B-viruses. DeltaVE was not significant for any comparison across all sites. CONCLUSIONS: Inpatients and outpatients with ARI represent distinct populations. Despite comparatively poor health status among inpatients, influenza vaccination was effective in preventing hospitalizations associated with influenza.


Posted May 15th 2020

Low-Value Levels: Ammonia Testing Does Not Improve the Outcomes of Overt Hepatic Encephalopathy.

RESEARCHER'S NAME AS LISTED IN THE ALT TEXT BOX GOES HERE

Robert S. Rahimi M.D.

Tapper, E. B. and R. S. Rahimi (2020). “Low-Value Levels: Ammonia Testing Does Not Improve the Outcomes of Overt Hepatic Encephalopathy.” Am J Gastroenterol 115(5): 685-686.

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Hepatic encephalopathy is a clinical diagnosis. However, many clinicians measure ammonia levels in hospitalized patients presenting with hepatic encephalopathy. In this editorial, we review the results of an important study by Haj and Rockey. The authors examined the management decisions effected affected by and outcomes associated with (i) ordering an ammonia level and (ii) knowing the ammonia level. They found that ammonia level determination did not impact affect clinical decision-making or patient outcomes. These persuasive data demonstrate the limited clinical utility of ammonia levels and highlight the need for testing stewardship to dissuade unnecessary use through educational efforts and decision supports.


Posted May 15th 2020

The COVID-19 pandemic will have a long-lasting impact on the quality of cirrhosis care.

Sumeet K. Asrani M.D.

Sumeet K. Asrani M.D.

Tapper, E. B. and S. K. Asrani (2020). “The COVID-19 pandemic will have a long-lasting impact on the quality of cirrhosis care.” J Hepatol Apr 13. pii: S0168-8278(20)30217-8. [Epub ahead of print].

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The coronavirus disease 2019 (COVID-19) pandemic has shattered the meticulously developed processes by which we delivered quality care for patients with cirrhosis. Care has been transformed by the crisis, but enduring lessons have been learned. In this article, we review how COVID-19 will impact cirrhosis care. We describe how this impact unfolds over 3 waves; i) an intense period with prioritized high-acuity care with delayed elective procedures and routine care during physical distancing, ii) a challenging ‘return to normal’ following the end of physical distancing, with increased emergent decompensations, morbidity, and systems of care overwhelmed by the backlog of deferred care, and iii) a protracted period of suboptimal outcomes characterized by missed diagnoses, progressive disease and loss to follow-up. We outline the concrete steps required to preserve the quality of care provided to patients with cirrhosis. This includes an intensification of the preventative care provided to patients with compensated cirrhosis, proactive chronic disease management, robust telehealth programs, and a reorganization of care delivery to provide a full service of care with flexible clinical staffing. Managing the pandemic of a serious chronic disease in the midst of a global infectious pandemic is challenging. It is incumbent upon the entire healthcare establishment to be strong enough to weather the storm. Change is needed.


Posted May 15th 2020

The utilization of an overground robotic exoskeleton for gait training during inpatient rehabilitation-single-center retrospective findings.

Chad Swank Ph.D.

Chad Swank Ph.D.

Swank, C., M. Trammell, M. Bennett, C. Ochoa, L. Callender, S. Sikka and S. Driver (2020). “The utilization of an overground robotic exoskeleton for gait training during inpatient rehabilitation-single-center retrospective findings.” Int J Rehabil Res Apr 8. [Epub ahead of print].

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Overground robotic exoskeleton gait training is increasingly utilized during inpatient rehabilitation yet without clear guidelines. We describe clinical characteristics associated with robotic exoskeleton gait training and examine outcomes of people with spinal cord injury and stroke who completed usual rehabilitation care with or without robotic exoskeleton gait training. Retrospective review of medical records over a 36 months period. Inpatients with spinal cord injury or stroke and >/=1 robotic exoskeleton gait training session were included. After obtaining a complete list of robotic exoskeleton gait training participants, medical records were reviewed for comparable matches as determined by gait functional independence measure score <4, age 18-100 years, meeting exoskeleton manufacturer eligibility criteria, and participating in usual care only. Functional independence measure was collected on all patients. For spinal cord injury, we collected the walking index for spinal cord injury II. For stroke, we collected the Stroke Rehabilitation Assessment of Movement Measure. Fifty-nine people with spinal cord injury (n = 31 robotic exoskeleton gait training; n = 28 usual care) and 96 people post-stroke (n = 44 robotic exoskeleton gait training; n = 52 usual care) comprised the medical record review. Fifty-eight percent of patients with spinal cord injury and 56% of patients post-stroke completed 5+ robotic exoskeleton gait training sessions and were included in analyses. Robotic exoskeleton gait training dosage varied between our patients with spinal cord injury and patients post-stroke. Robotic exoskeleton gait training utilization during inpatient rehabilitation required consideration of unique patient characteristics impacting functional outcomes. Application of robotic exoskeleton gait training across diagnoses may require different approaches during inpatient rehabilitation.