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OBJECTIVE: To compare rates of anxiety and depression among LGBTQ college students before and during the COVID-19 pandemic and examine pandemic-related stressors and protective factors. PARTICIPANTS: Two cohorts of LGBTQ college students, aged 18-25, sampled before (N = 3,484) and during (N = 1,647) the pandemic. METHODS: The Healthy Minds Study (HMS) is an annual mental health survey administered to college students in the United States, which included additional items related to the COVID-19 pandemic. RESULTS: Mean anxiety symptoms were significantly lower mid-pandemic compared to pre-pandemic, but no differences in mean depressive symptoms were detected. Results varied by sexual and gender minority status. Financial stress, pandemic-related concerns, and witnessing discrimination were risk factors while academic persistence, positive mental health, and formal support were protective factors. CONCLUSIONS: Mental health and instrumental support from institutions will be critical for college students during the pandemic. Affirming and empowering spaces for LGBTQ college students may leverage protective factors.
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Longitudinal changes in aortic diameters of young patients with thoracic aortic aneurysm (TAA) have not been completely described, particularly over long periods of follow-up. This retrospective study sought to characterize the rates of proximal aortic dilation in young patients, identify risk factors for TAA progression, and evaluate the predictive utility of early echocardiographic follow-up. Inclusion criteria were: (1) TAA or TAA-predisposing genetic diagnosis, (2) age < 25 years at first echocardiogram, and (3) minimum of 5 years of echocardiographic follow-up. Proximal aortic diameters were measured by echocardiography and Z-scores calculated to index for body surface area. TAA severity was classified as no TAA (Z-score < 2), mild (Z-score 2 to 4), or at least moderate (Z-score > 4). Among 141 included patients, mean age at first echocardiogram was 7.3 ± 3.5 years. Mean follow-up duration was 9.8 ± 3.5 years. Fifty five patients had a genetic syndrome, and 38 of the non-syndromic patients had bicuspid aortic valve (BAV). The rate of aortic dilation was significantly higher at the ascending aorta than other aortic segments. BAV and age > 10 years at first echocardiogram were associated with increased rate of ascending aorta dilation. At the ascending aorta, over 25% of patients had categorical increase in TAA severity between first and last echocardiograms, and such patients demonstrated higher rate of dilation within their first 2 years of follow-up. These longitudinal findings highlight progressive ascending aorta dilation in young patients, which may worsen around adolescence. This may help determine timing of follow-up and target ages for clinical trials.
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Aorta/patología , Aneurisma de la Aorta Torácica/etiología , Enfermedad de la Válvula Aórtica/patología , Dilatación Patológica/patología , Adolescente , Aorta/diagnóstico por imagen , Enfermedad de la Válvula Aórtica/complicaciones , Enfermedad de la Válvula Aórtica/diagnóstico por imagen , Niño , Preescolar , Dilatación Patológica/complicaciones , Progresión de la Enfermedad , Ecocardiografía , Femenino , Humanos , Masculino , Estudios Retrospectivos , Factores de RiesgoRESUMEN
People experiencing homelessness have worse health outcomes than the general population and limited access to primary/preventative healthcare. This leads to high hospital readmission rates. Effective discharge planning can improve recovery rates and reduce hospital costs. However, most hospital discharge policies and best practice guidelines are not tailored to patients with no fixed address, contributing to inappropriate discharges and health inequities for people experiencing homelessness. We discuss the lack of discharge policies, identifiable processes or plans specifically tailored to this population as a healthcare and policy gap, and we identify key areas for better understanding and addressing this issue.
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Manejo de Caso , Servicios Médicos de Urgencia , Política de Salud , Accesibilidad a los Servicios de Salud , Hospitales , Personas con Mala Vivienda , Alta del Paciente , Planificación en Salud , Necesidades y Demandas de Servicios de Salud , Disparidades en Atención de Salud , Vivienda , Humanos , Problemas SocialesRESUMEN
BACKGROUND: Endoscopic vein harvest for lower extremity arterial bypass grafting has been questioned due to concern for endothelial damage during procurement. We sought to compare nitric oxide (NO)-mediated endothelial-dependent relaxation (EDR) in vein segments harvested using open surgical techniques (OH) versus endoscopic vein harvest (EH) techniques. METHODS: Saphenous vein segments were harvested for lower extremity bypass, and a single, minimally handled section of saphenous vein, free of branches, was taken from the end of the graft. Four 4-mm venous ring segments were then cut and mounted on force transducers. Segments were mounted in 37° oxygenated Krebs-Henseleit solution and maximally contracted using KCl. Individual ring segments that did not react to KCl were excluded from the study. Norepinephrine (NE) was used to achieve submaximal contraction. EDR was determined using increasing concentrations of bradykinin (BDK). Endothelial-independent relaxation (EIR) was confirmed using sodium nitroprusside. Two-way analysis of variance (ANOVA) was used to analyze differences between harvest techniques across BDK concentration and a Student's t-test was used to analyze single comparisons. RESULTS: Vein segments harvested from patients (n = 13) led to 28 viable rings that exhibited a positive reaction to KCl (11 rings; 5 patients EH vs. 17 rings; 8 patients OH). Both vein groups achieved moderate relaxation to maximal BDK concentration, [10-6 M]; (49.5% EH vs. 40.55% OH, P = 0.270). Analysis by 2-way ANOVA for mean % relaxation for BDK concentration [10-11-10-6 M] showed improved EDR in EH samples compared with OH (P = 0.029). Mean nitrite/nitrate (NO(x)) tissue bath concentration measurements post-BDK were 139.8 nM (EH) vs. 97.2 nM (OH; P = 0.264). Histology and positive factor VIII immunohistochemistry staining provided evidence for the presence of intact endothelium in our sample segments. EIR was preserved and was similar in the two groups. CONCLUSIONS: Endothelial function is preserved when utilizing endoscopic harvesting techniques. The advantages of minimally invasive vein procurement for lower extremity bypass can be obtained without concern for damaging venous endothelium.
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Endoscopía , Endotelio Vascular/trasplante , Vena Safena/trasplante , Recolección de Tejidos y Órganos/métodos , Injerto Vascular/métodos , Procedimientos Quirúrgicos Vasculares , Vasodilatación , Anciano , Anciano de 80 o más Años , Relación Dosis-Respuesta a Droga , Endoscopía/efectos adversos , Endotelio Vascular/efectos de los fármacos , Endotelio Vascular/metabolismo , Endotelio Vascular/fisiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Óxido Nítrico/metabolismo , Donantes de Óxido Nítrico/metabolismo , Donantes de Óxido Nítrico/farmacología , Nitroprusiato/metabolismo , Nitroprusiato/farmacología , Estudios Prospectivos , Vena Safena/efectos de los fármacos , Vena Safena/metabolismo , Vena Safena/fisiología , Recolección de Tejidos y Órganos/efectos adversos , Injerto Vascular/efectos adversos , Procedimientos Quirúrgicos Vasculares/efectos adversos , Vasodilatación/efectos de los fármacos , Vasodilatadores/farmacologíaRESUMEN
OBJECTIVES: We initiated the SHOPPING Trial (Show How Options in Price for Procedures can be InflueNced Greatly) to see if percutaneous coronary intervention (PCI) procedures can be performed at a lower cost in a single institution. BACKGROUND: Procedural practice variability is associated with inefficiency and increased cost. We hypothesized that announcing costs for all supplies during a catheterization procedure and reporting individual operator cost relative to peers would spur cost reduction without affecting clinical outcomes. METHODS: Baseline costs of 10 consecutive PCI procedures performed by 9 interventional cardiologists were documented during a 90-day interval. Costs were reassessed after instituting cost announcing and peer reporting the next quarter. The intervention involved labeling of all endovascular supplies, equipment, devices, and disposables in the catheterization laboratory and announcement of the unit price for each piece when requested. For each interventionalist, procedure time and costs were measured and analyzed prior to and after the intervention. RESULTS: We found that total PCI procedural cost was significantly reduced by an average of $234.77 (P = 0.01), equating to a total savings of $21,129.30 over the course of 90 PCI procedures. Major Adverse Cardiac and Cerebrovascular Event (MACCE) rates were similar during both periods (2.3% vs. 3.5%, P = NS). CONCLUSIONS: Announcing costs in the catheterization laboratory during single vessel PCI and peer reporting leads to cost reduction without affecting clinical outcomes. This intervention may have a role in more complex coronary and peripheral interventional procedures, and in other procedural areas where multiple equipment and device alternatives with variable costs are available. © 2016 Wiley Periodicals, Inc.
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Actitud del Personal de Salud , Cardiólogos/economía , Costos de Hospital , Intervención Coronaria Percutánea/economía , Pautas de la Práctica en Medicina/economía , Anciano , Concienciación , Cardiólogos/psicología , Ahorro de Costo , Análisis Costo-Beneficio , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , Masculino , Persona de Mediana Edad , Ohio , Revisión por Pares , Intervención Coronaria Percutánea/instrumentación , Evaluación de Programas y Proyectos de Salud , Estudios Prospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
We present a case of an ex-30 week premature male infant diagnosed postnatally with Tetralogy of Fallot, hemitruncus, and discontinuous pulmonary arteries (PAs) at 6 days of life. The patient was diagnosed by echocardiography, and the diagnosis was confirmed on subsequent dual-energy chest CT angiogram. In our patient, the left PA arose directly from the aorta, whereas the right PA originated normally from the right ventricular outflow tract. At 9 days of life, he underwent successful surgical palliation with placement of a modified Blalock-Taussig (aortopulmonary) shunt from the base of the left subclavian artery to the anomalously connected left PA along with anastomosis together of the right and left branch PAs to establish continuity with the main PA. Such cases have been described and are rare. The specific aim of this case report is to illustrate the added benefit of dual-energy electrocardiographically-triggered computed tomographic angiography (CTA) along with standard echocardiography. In addition, high quality images useful in preoperative planning were obtained noninvasively using an ultra low radiation dose without the need for sedation. The information obtained proved essential for confirmation of the diagnosis, preoperative planning, and post-surgical monitoring of branch PA development.
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K(ATP) channels are metabolic sensors and targets of potassium channel openers (KCO; e.g., diazoxide and pinacidil). They comprise four sulfonylurea receptors (SUR) and four potassium channel subunits (Kir6) and are critical in regulating insulin secretion. Different SUR subtypes (SUR1, SUR2A, SUR2B) largely determine the metabolic sensitivities and the pharmacological profiles of K(ATP) channels. SUR1- but not SUR2-containing channels are highly sensitive to metabolic inhibition and diazoxide, whereas SUR2 channels are sensitive to pinacidil. It is generally believed that SUR1 and SUR2 are incompatible in channel coassembly. We used triple tandems, T1 and T2, each containing one SUR (SUR1 or SUR2A) and two Kir6.2Delta26 (last 26 residues are deleted) to examine the coassembly of different SUR. When T1 or T2 was expressed in Xenopus laevis oocytes, small whole-cell currents were activated by metabolic inhibition (induced by azide) plus a KCO (diazoxide for T1, pinacidil for T2). When coexpressed with any SUR subtype, the activated-currents were increased by 2- to 13-fold, indicating that different SUR can coassemble. Consistent with this, heteromeric SUR1+SUR2A channels were sensitive to azide, diazoxide, and pinacidil, and their single-channel burst duration was 2-fold longer than that of the T1 channels. Furthermore, SUR2A was coprecipitated with SUR1. Using whole-cell recording and immunostaining, heteromeric channels could also be detected when T1 and SUR2A were coexpressed in mammalian cells. Finally, the response of the SUR1+SUR2A channels to azide was found to be intermediate to those of the homomeric channels. Therefore, different SUR subtypes can coassemble into K(ATP) channels with distinct metabolic sensitivities and pharmacological profiles.
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Transportadoras de Casetes de Unión a ATP/metabolismo , Canales de Potasio de Rectificación Interna/metabolismo , Receptores de Droga/metabolismo , Animales , Western Blotting , Línea Celular , Chlorocebus aethiops , Humanos , Inmunohistoquímica , Inmunoprecipitación , Técnicas de Placa-Clamp , Canales de Potasio de Rectificación Interna/clasificación , Receptores de Sulfonilureas , Xenopus laevisRESUMEN
A 56-year-old man, treated with an angiotensin II receptor antagonist for hypertension, presented for placement of a cochlear implant during general anesthesia. Intraoperatively, there was profound hypotension that was resistant to decreasing the anesthetic depth, fluid administration, as well as bolus doses of phenylephrine, ephedrine, and epinephrine. Hypotension was eventually successfully treated with a vasopressin infusion (0.06 U/min). Vasopressin may be a useful agent in such scenarios because its effect is not dependent on either adrenergic or angiotensin receptors, both of which may be affected by angiotensin II receptor antagonists.
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Hipotensión/tratamiento farmacológico , Complicaciones Intraoperatorias/tratamiento farmacológico , Vasoconstrictores/administración & dosificación , Vasopresinas/administración & dosificación , Humanos , Hipotensión/fisiopatología , Infusiones Intravenosas , Complicaciones Intraoperatorias/fisiopatología , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
Mechanical circulatory support can be used to manage acute and chronic cardiac failure in both adult and pediatric patients. Traditionally, extracorporeal membrane oxygenation (ECMO) has been the most common form of mechanical circulatory support in children. However, more recently, in cases of pure ventricular dysfunction, ventricular assist devices (VADs) have offered specific advantages over ECMO, including better ventricular recovery, reduced anticoagulation requirements, decreased use of blood products and decreased cost. We present the use of a VAD in an adolescent with single-ventricle physiology, who could not be weaned from cardiopulmonary bypass (CPB) after undergoing a revision of a modified Fontan operation. Gas exchange was provided by the patient's lungs while the centrifugal VAD was used successfully to support the circulation as a bridge, first to a totally implantable pulsatile VAD and subsequently to heart transplantation.
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Puente Cardíaco Derecho , Trasplante de Corazón , Ventrículos Cardíacos/anomalías , Ventrículos Cardíacos/cirugía , Corazón Auxiliar , Adolescente , Procedimiento de Fontan , Humanos , Masculino , Complicaciones Posoperatorias/terapiaRESUMEN
ATP-sensitive potassium (K(ATP)) channels play important roles in regulating insulin secretion, controlling vascular tone, and protecting cells against metabolic stresses. K(ATP) channels are heterooctamers of four pore-forming inwardly rectifying (Kir6.2) subunits and four sulfonylurea receptor (SUR) subunits. K(ATP) channels containing SUR1 (e.g. pancreatic) and SUR2A (e.g. cardiac) display distinct metabolic sensitivities and pharmacological profiles. The reported expression of both SUR1 and SUR2 together with Kir6.2 in some cells raises the possibility that heteromeric channels containing both SUR subtypes might exist. To test whether SUR1 can coassemble with SUR2A to form functional K(ATP) channels, we made tandem constructs by fusing SUR to either a wild-type (WT) or a mutant N160D Kir6.2 subunit. The latter mutation greatly increases the sensitivity of K(ATP) channels to block by intracellular spermine. We expressed, individually and in combinations, tandem constructs SUR1-Kir6.2 (S1-WT), SUR1-Kir6.2[N160D] (S1-ND), and SUR2A-Kir6.2[N160D] (S2-ND) in Xenopus oocytes, and studied the voltage dependence of spermine block in inside-out macropatches over a range of spermine concentrations and RNA mixing ratios. Each tandem construct expressed alone supported macroscopic K(+) currents with pharmacological properties indistinguishable from those of the respective native channel types. Spermine sensitivity was low for S1-WT but high for S1-ND and S2-ND. Coexpression of S1-WT and S1-ND generated current components with intermediate spermine sensitivities indicating the presence of channel populations containing both types of Kir subunits at all possible stoichiometries. The relative abundances of these populations, determined by global fitting over a range of conditions, followed binomial statistics, suggesting that WT and N160D Kir6.2 subunits coassemble indiscriminately. Coexpression of S1-WT with S2-ND also yielded current components with intermediate spermine sensitivities, suggesting that SUR1 and SUR2A randomly coassemble into functional K(ATP) channels. Further pharmacological characterization confirmed coassembly of not only S1-WT and S2-ND, but also of coexpressed free SUR1, SUR2A, and Kir6.2 into functional heteromeric channels.
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Transportadoras de Casetes de Unión a ATP/metabolismo , Canales KATP/metabolismo , Canales de Potasio de Rectificación Interna/metabolismo , Canales de Potasio/metabolismo , Receptores de Droga/metabolismo , Adenosina Trifosfato/farmacología , Animales , Membrana Celular/fisiología , Electrofisiología , Femenino , Hipoglucemiantes/farmacología , Canales KATP/efectos de los fármacos , Modelos Biológicos , Oocitos/citología , Oocitos/fisiología , Técnicas de Placa-Clamp , Espermina/farmacología , Receptores de Sulfonilureas , Tolbutamida/farmacología , Xenopus laevisRESUMEN
Although the accumulation of gas is the most common cause of an expanding interpleural space, the presence of other structures or substances (hydrothorax, gastrothorax, hemothorax, urohemothorax, pyothorax, and chylothorax) under pressure may be sufficient to cause hemodynamic and respiratory compromise. We present two pediatric patients that developed hemodynamic and respiratory effects secondary to a chylothorax. The first patient presented in respiratory distress and cardiovascular collapse 4 weeks after a Fontan procedure. Placement of a chest tube resulted in the release of chyle under pressure and prompt resolution of hemodynamic and respiratory symptoms. The second patient was a 2100 g neonate who developed a chylothorax during an episode of sepsis following gastroschisis repair. On two separate occasions, the development of the chylothorax was associated with tachycardia, oliguria, and increased requirements during mechanical ventilation. Chest tube placement resulted in the release of chyle under pressure and resolution of the symptoms. These two cases demonstrate that chylothorax like pneumothorax can have deleterious effects on hemodynamic and respiratory function.
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Quilotórax/diagnóstico , Quilotórax/terapia , Presión Sanguínea , Tubos Torácicos , Preescolar , Quilotórax/complicaciones , Drenaje/métodos , Femenino , Frecuencia Cardíaca , Humanos , Recién Nacido , Derrame Pleural/etiología , Derrame Pleural/terapia , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/terapia , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/terapia , Sepsis/complicacionesRESUMEN
OBJECTIVES: To report the occurrence of bradycardia associated with the use of methadone administered to prevent withdrawal in an infant with physical tolerance following long-term opioid therapy in the pediatric intensive care unit setting. DESIGN: Retrospective case report. PATIENTS AND RESULTS: Methadone (0.1 mg/kg) was administered to a 6-month-old infant following prolonged use of intravenous fentanyl for sedation during respiratory failure requiring mechanical ventilation. Approximately 30-60 mins after the first dosing of methadone, the infant's heart rate decreased from his baseline of 130-140 beats/min to 80-90 beats/min for 30 seconds. After the third dose of methadone, the heart rate decreased to a sinus bradycardia of 60-70 beats/min for 4 mins. The episodes resolved with tactile stimulation. Over the next 18 hrs, there were repeated episodes of bradycardia. None of these episodes were associated with hypotension, apnea, change in oxygen saturation, decreased peripheral perfusion, or other signs of hemodynamic instability. The methadone was withdrawn and the intravenous fentanyl infusion was restarted. Eight to 10 hrs after administration of the last dose of methadone, the episodes of bradycardia resolved and the patient remained in a normal sinus rhythm with a heart rate of 120-140 beats/min. CONCLUSION: Methadone's three-dimensional structure shares similarities with calcium channel antagonists. Although it has been reported in the adult literature, there are no previous reports of bradycardia occurring with methadone therapy in infants. Although there were no deleterious physiologic effects related to the bradycardia in our patient, methadone should be used cautiously in patients who may not tolerate alterations in heart rate.
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Analgésicos Opioides/efectos adversos , Bradicardia/inducido químicamente , Metadona/efectos adversos , Síndrome de Abstinencia a Sustancias/prevención & control , Desconexión del Ventilador , Analgésicos Opioides/uso terapéutico , Anestésicos Intravenosos/efectos adversos , Anestésicos Intravenosos/uso terapéutico , Fentanilo/efectos adversos , Fentanilo/uso terapéutico , Humanos , Lactante , Masculino , Metadona/uso terapéutico , Síndrome de Abstinencia a Sustancias/etiologíaRESUMEN
Nesiritide is a recombinant formulation of B-type natriuretic peptide used most commonly in the treatment of adults with decompensated congestive heart failure. The physiologic effects of BNP include natriuresis, diuresis, and smooth muscle relaxation. These physiologic effects result in its beneficial therapeutic effects, including a decrease in afterload, resulting in increased cardiac output with improved peripheral perfusion. The authors report on a 17-year-old with acute myelogenous leukemia who was admitted to the Pediatric ICU for treatment of septic shock, respiratory failure, myocardial dysfunction, and renal insufficiency. After the initial stabilization of his hemodynamic status, nesiritide was started and resulted in a stable balance of fluid intake versus output without the use of diuretics, improvement in myocardial function, and recovery of renal function manifested by a decrease of blood urea nitrogen and creatinine back to baseline values. The end-organ effects of nesiritide, previous reports regarding its use in the pediatric population, and its potential applications in the ICU setting are discussed.
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Cardiomiopatías/tratamiento farmacológico , Leucemia Mieloide Aguda/complicaciones , Péptido Natriurético Encefálico/uso terapéutico , Insuficiencia Renal/tratamiento farmacológico , Choque Séptico/complicaciones , Adolescente , Cardiomiopatías/etiología , Humanos , Leucemia Mieloide Aguda/tratamiento farmacológico , Insuficiencia Renal/etiología , Insuficiencia Respiratoria/etiología , Choque Séptico/tratamiento farmacológico , Resultado del Tratamiento , Equilibrio Hidroelectrolítico/efectos de los fármacosRESUMEN
Liver glutathione peroxidase-1 (GPX1) mRNA is highly regulated by Se status relative to other parameters, but is of limited use for determining Se requirements in humans. To examine the efficacy of using blood for Se status assessment using molecular biology markers, we used a ribonuclease protection assay (RPA) to study mRNA levels in whole blood relative to 16 other rat tissues. Significant amounts of total RNA (>50 microg) were obtained from 1 mL of whole blood. Total RNA from 28-d postweaning Se-adequate (0.2 microg Se/g diet) male rats was analyzed for GPX1, GPX4, GPX3, thioredoxin reductase-1 (TRR1), and selenoprotein-P (SelP). RPA detected significant mRNA expression for at least 1 selenoprotein in all tissues except pancreas. GPX1 mRNA expression using this mix of RPA probes yielded the highest signal for GPX1 relative to the other selenoprotein signals in all tissues except testis; GPX1 expression was 4th highest in blood and similar to the major organs (liver, 1st; heart, 5th; kidney, 6th). Kidney was highest for GPX3, and testes was highest for GPX4, TRR1, and SelP. This study is the first to report the gene expression pattern for a number of selenoproteins and across a comprehensive set of tissues. The mRNA levels for all selenoproteins in blood were comparable to levels in the major organs, and decreases in blood and liver GPX1 mRNA levels in Se deficiency were similar, supporting potential use of whole blood for assessing Se status using molecular biology markers.