Island Hospital

Acoustic telemetry is a common methodology in the study of animal movement, behaviour, and physiology in aquatic environments. In the marine environment, receiver performance is limited by environmental conditions and habitat (which modulate receiver detection range) and the number of tagged animals in the system (with signal collisions reducing the receiver’s ability to decode unique transmitter IDs). The Innovasea NexTrak receiver was developed to address the key challenges of detection range, number of transmissions successfully decoded, and quality of detection data. To assess how NexTrak receivers perform relative to the commonly used VR2AR receiver, we co-deployed NexTrak and VR2AR receivers on six moorings within a larger acoustic array deployed to study white shark movement ecology in Mahone Bay, Nova Scotia, Canada. We compared receiver performance in terms of (i) number of animals detected, (ii) number of transmissions received, (iii) structure and duration of detection events, and (iv) the effects of environmental noise on detection rates. Results showed 27.7 ± 14.4% more white sharks and 86.0 ± 20.9% more detections for NexTrak relative to VR2AR. At the detection-event level, NexTrak recorded more detections (3.9 ± 3.6, range: 0–19) than VR2AR (2.2 ± 3.0, range: 0–11). Detection events were also longer for NexTrak (471 ± 321 s, range: 0–1549 s) than for VR2AR (324 ± 241 s, range: 0–893 s), equating to a 45% higher detection-event duration as a proxy for increased detection range. While noise was a significant predictor of hourly detections, with each mV increase associated with a ~ 0.4% reduction in detections, there was no discernable difference between NexTrak and VR2AR in their performance relative to noise in our relatively quiet study system. Overall, it is evident that the NexTrak receiver has the potential to improve acoustic telemetry capabilities though enhanced detection efficiency and data quality relative to VR2AR. Improvements in detection range and decoding efficiency have implications for research costs, array design decisions, and the accuracy and precision of continuous movement tracks in fine-scale positioning arrays.

Background:Meniscus tears occur in tandem with other degenerative changes at the knee joint, making interpretation of imaging findings challenging. Meniscus tears, commonly treated by general physicians and musculoskeletal specialists, have significant treatment variability.Purpose/Hypothesis:The purpose of this study was to investigate whether big data analytical tools and natural language processing (NLP) of magnetic resonance imaging reports could identify factors that are predictive of treatment decisions in a large cohort of patients. It was hypothesized that surgical treatment would be associated with specific meniscus tear patterns.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Deidentified electronic health records from approximately 5 million patients, available at Information Commons, were analyzed to identify patients with meniscus tears on knee MRI reports. NLP was used to extract descriptive features from MRI reports. Demographics and clinical and treatment data were recorded. Univariate and multivariate analyses were performed.Results:For 4013 patients with meniscus tears on MRI, physical therapy was the most common treatment (62.4% of patients). Opioid medications were prescribed to 25.6% of patients diagnosed with a meniscus tear. Surgery was performed for 19.6% of patients. A bucket-handle tear was the strongest predictor for receiving surgery. Meniscus tear patterns, the presence of degenerative changes, and demographic factors were independent predictors of treatment received.Conclusion:Meniscus tear types and other findings at the knee joint, along with demographic variables, are associated with treatment for meniscus tears. Bucket-handle and root tears were most likely to undergo surgical treatment, while patients on Medicare and those with arthrosis were more likely to be treated with nonoperative modalities. NLP of big data, including radiology findings, may have a role in providing clinical decision support for interpreting findings on knee MRIs. Prescription of opioid medications in meniscal tears was observed at a higher-than-expected rate.

Introduction: Methocarbamol is a skeletal muscle relaxant commonly used in multimodal analgesia and has been shown to reduce postoperative opioid use. Due to the presence of polyethylene glycol, its intravenous (IV) formulation is contraindicated in patients with renal impairment per prescribing information. However, clinical evidence supporting this caution is limited. This study aimed to evaluate safety of the short-term use of IV methocarbamol in hospitalized patients with impaired renal function. Methods: We conducted a multicenter, retrospective cohort study comparing patients with baseline renal impairment (study group) to those with normal renal function (control group). Adults hospitalized for 48 hours or longer who received at least 3 doses of IV methocarbamol were included. Exclusion criteria included dialysis at admission, uncontrolled sepsis, diabetic ketoacidosis, or drug overdose. Primary outcomes were a composite of mortality, new renal replacement therapy, and persistent renal dysfunction, as well as the incidence of acute kidney injury (AKI). Secondary outcomes included in-hospital mortality, length of stay, and metabolic acidosis. Safety outcomes included central nervous system (CNS) effects, hypotension, bradycardia, and drug discontinuation. Results: Of 250 patients, 96 were in the study group and 154 in the control group. The study group was older (75.2 vs. 53.9 years, p < 0.001), had lower creatinine clearance (47.6 vs. 89.2 mL/min, p < 0.001), and more chronic kidney disease (33.3 percent vs. 1.3 percent, p < 0.001). The control group received higher cumulative methocarbamol doses (5000 vs. 3875 mg, p < 0.001) and opioids (167.5 vs. 126.3 morphine equivalents, p = 0.011). The incidence of AKI was similar (6.3 percent vs. 3.9 percent, p = 0.397); no patients required new dialysis or had persistent renal dysfunction. Acid-base parameters and metabolic acidosis rates did not differ significantly. CNS effects, hypotension, bradycardia, and adverse events leading to discontinuation were rare and comparable. Conclusions: IV methocarbamol was well tolerated in patients with renal impairment and was not associated with increased renal or systemic toxicity. These findings support its short-term safety in this population when used appropriately.

Induction of labor (IOL) and hospitalist coverage are becoming more common. While hospitalist coverage has been associated with improved maternal outcomes and lower cesarean delivery rates, its impact on IOL remains unclear. The objective of this study was to compare the induction time to vaginal delivery across three obstetric coverage models: hospitalists, faculty generalists, and private practice generalists.This single-site retrospective cohort study analyzed singleton, term (≥39 weeks), vertex patients undergoing IOL at NYU Langone Hospital-Long Island from January 1, 2022, to September 30, 2022. Hospitalists at this institution managed high-risk obstetric patients, including those under maternal-fetal medicine care, resident clinic, and unregistered patients who presented to labor and delivery, along with serving as labor and delivery safety officer on the labor floor. Faculty and private practice generalists managed their respective groups. Outcomes included induction time to vaginal delivery, mode of delivery, induction methods, and maternal and neonatal complications. Statistical analyses included chi-square, ANOVA, and multivariable linear regression. A p-value of < 0.05 was statistically significant.Among 403 patients, 92 (22.8%) were managed by hospitalists, 115 (28.5%) by faculty, and 196 (48.6%) by private generalists. Median (IQR) induction-to-delivery times were similar across groups: hospitalists 20.5 (15.3-27.5) hours, faculty 23.4 (16.5-31.1) hours, and private 19.7 (14.1-25.6) hours (p = 0.004). However, when limited to vaginal deliveries, no significant difference was observed in induction-to-vaginal-delivery time (p = 0.17). Private generalists had the shortest induction-to-cesarean time and time to membrane rupture leading to cesarean. There were no differences in intrapartum or postpartum complications. Hospitalists had more NICU admissions after vaginal delivery, mostly unrelated to labor.Induction-to-vaginal delivery times and complication rates were similar across coverage models, but differences in NICU admissions and cesarean delivery times highlight care variations. Collaboration and evidence-based standardized induction protocols may optimize outcomes across coverage models. · Induction to vaginal delivery time can be similar across obstetric groups.. · Labor and delivery units with high induction rates may benefit from hospitalists.. · An evidence-based induction protocol may optimize maternal and fetal outcomes..

Medical record audits of primary care practices in the United States, Canada, and the United Kingdom suggest widespread suboptimal implementation of asthma guideline recommendations. Reasons are numerous, but there may be a perceived lack of benefit for patients. In the United Kingdom, more than 95% of scheduled asthma care is provided by primary care. The objective of this study was to determine the implementation of specific guideline-recommended clinical practices (GCPAs) and determine which children were less likely to receive these and their effectiveness at reducing exacerbations.A total of 126 483 five- to sixteen-year-old children with at least 3 asthma codes within 3 years. The study population was drawn from a longitudinal health care database of UK primary care medical records. This database covers approximately 20% of the United Kingdom. Records were individually linked to hospital admissions and emergency department (ED) data.Self-controlled case series methodology was used; each child acts as their own control and outcome events are compared prior to and following the exposure to the GCPA. These measures included asthma review (included an assessment of asthma control), inhaler technique check, and asthma management plan. Other variables included body mass index, socioeconomic status, smoking status, other atopic disease, asthma medications, and asthma exacerbations, defined as a short course of oral corticosteroids, ED visit, or hospitalization. The control period was considered the 12 months prior to guideline-recommended care, and the risk period was considered the 12 months after.In the first year following the asthma diagnosis, 56% received an annual asthma review, falling to 45% in subsequent years. Asthma management plans were provided to 42% in the first year, dropping to 30% thereafter. Inhaler technique checks were conducted in 59% in the first year and 40% in subsequent years. Children who received the GCPA were more likely to be male and older and have more severe asthma. Atopy and previous exacerbations did not distinguish those who received the GCPA. Children less likely to receive the GCPA included those with lower socioeconomic status, those with obesity, those not receiving inhaler prescriptions, and those of a younger age. Standalone annual asthma reviews were associated with a 6% reduction in exacerbations only during the first 6 months; standalone inhaler technique checks were not associated with a decrease in exacerbations, but standalone provision of an asthma management plan was associated with a 15% decrease in exacerbations that persisted. Provision of all 3 GCPAs during the same visit was associated with a 30% decrease in exacerbations that also persisted.Provision of GCPAs is underutilized in the United Kingdom, especially for all 3 given at the same visit. The most vulnerable at-risk children were the least likely to receive the GCPAs. Annual asthma reviews alone, and inhaler technique review alone, have no lasting effect on exacerbations, but asthma management plans alone do reduce exacerbations, and all 3 GCPAs at the same visit are most effective.Annual asthma visits were not noted to be effective, but the only stipulation for those are an assessment of asthma control, which could be minimal. This study adds to the evidence that guideline-recommended care is suboptimal in primary care, and most importantly, a comprehensive asthma visit with provision of all 3 GCPAs can have a significant impact on exacerbations.

The kidneys contribute to glucose homeostasis by gluconeogenesis and glucose reabsorption. Herein, we identified previously unknown fasting-induced, glucagon-mediated inhibitory effect of the circadian clock gene basic helix-loop-helix ARNT like 1 (Bmal1) on the expression of the main proximal tubule glucose transporter solute carrier family 5 member 2 (Sglt2) in mice. During fasting, glucagon induces Bmal1, which increases expression of nuclear receptor subfamily 1, group D, member 1 (Rev-erbα). Rev-erbα represses nuclear respiratory factor 1, a transcriptional activator of Sglt2, and diminishes Sglt2 expression and thereby kidney glucose reabsorption capacity. During refeeding (lower glucagon) this process is attenuated, thereby inducing glucose reabsorption. The physiological role of this mechanism appears to ensure optimal temporal retrieval of filtered glucose during fasting/refeeding. Thus, this study demonstrates that during fasting and refeeding, glucagon regulates renal glucose reabsorption by utilizing the local cellular circadian machinery.

Case Description: BRASH syndrome is characterized by the following: bradycardia, renal failure, atrioventricular blockade, shock, and hyperkalemia. Due to its overlapping features, it is often under-reported and misdiagnosed as isolated hyperkalemia. This case involves a 53-year-old male who presented with palpitations following a hemodialysis session. Upon arrival, the patient was tachycardic and found to be in atrial flutter (Figure 1). Initial treatment with diltiazem effectively controlled his heart rate. However, the following day, the patient received additional beta-blockers and developed hypotension (72/50 mmHg), bradycardia (39 bpm) (Figure 2), and hyperkalemia (K 7.3). Upon being upgraded to the cardiac care unit (CCU), his management included atropine, epinephrine, glucagon, and calcium gluconate. Ultimately, the patient was stabilized with urgent dialysis. Discussion: BRASH syndrome is a cyclical condition that includes the amalgamation of the following: bradycardia, renal failure, atrioventricular (AV) nodal blockade, shock, and hyperkalemia. Carries an in-hospital mortality of 5.7%. It is often underreported and mistaken for isolated hyperkalemia or AV blocker toxicity. One reason for this underreporting is the subtlety of its presentation, which can easily be confused with hyperkalemia alone, especially when patients present primarily with bradycardia and renal dysfunction. Unlike typical hyperkalemia, which generally needs to be severe to induce bradycardia, BRASH syndrome can cause significant bradycardia even with moderate potassium elevations due to the synergistic effect of AV nodal blockers and renal failure. This case of BRASH syndrome, triggered by both beta-blockers and calcium channel blockers, is rare. The combined use of both agents compounds the effects on AV node conduction and can severely depress heart rate, especially when renal impairment leads to reduced drug clearance. Management of BRASH syndrome requires addressing all components of the syndrome. Initial treatment often includes correction of hyperkalemia with calcium gluconate and insulin. Bradycardia may be managed with atropine, epinephrine, or pacing. Additionally, medications contributing to AV node blockade should be held, and hemodynamic support with vasopressors may be necessary if hypotension persists. In some cases, such as ours, dialysis may be required to manage hyperkalemia and improve renal clearance of medications.

Traumatic musculoskeletal injuries may result in chronic pain and mobility limitations, decreasing quality of life, and increasing predisposition to comorbid disorders. Osteopathic manipulative treatment (OMT) utilizes palpatory assessment and application of manual forces as an adjunct intervention for musculoskeletal disease. Multiple studies have demonstrated OMT's potential benefits for a range of disease states, but data on osteopathic OMT are limited. The objective of our study was to understand the potential benefits of a novel OMT for trauma outpatient program for the care of injured patients suffering chronic pain and mobility limitations. In 2021, the New York University (NYU) Langone Hospital-Long Island Level 1 Trauma Center established a novel outpatient OMT for Trauma Program (OTP). We performed a retrospective analysis of OTP patients seen from January 1, 2021 to December 31, 2022 with the chief complaint of refractory chronic (persistent≥3 months since inciting injury) postinjury pain and mobility limitations (inclusion criterion). We excluded patients missing follow-up, then extracted and analyzed patient demographic, injury-specific, and OMT data. Data are presented as frequencies (percentages) or medians (interquartile range [IQR]). Forty-three patients (75.4 % of patients treated at the outpatient OTP) reported a mechanism of injury (MOI). Of these, 30 (69.8 %) met the inclusion criteria, and seven met the exclusion criterion, yielding 23 total patients for the analysis (40.3 % of the total OTP population). 73.9 % were female aged 46 (39-59) years old. Patients presented 3.00 (0.58-20) years since etiologic injury. MOIs included 56.5 % motor vehicle collisions (MVC), 21.7 % falls, 8.7 % penetrating, and 13.0 % sports-related or lifting injuries. Patients reported 3 (2-4) treatment modalities tried and 2 (1-3) medications attempted prior to the OTP. After the first OMT session, 95.7 % of patients reported subjective improvement in pain with a decrease in pain score 3 (3-7) out of 10. After OMT, patients also self-reported ease of activities of daily living (ADLs, 82.6 %), improved sleep hygiene (26.1 %), improved anxiety/mood (65.2 %), and decreased use of analgesic medication (13.0 %). Four (17.4 %) reported post-OMT complication of 2-3 days of self-limited, mild musculoskeletal pain. Univariate logistic regression models demonstrate that OMT benefited patients regardless of time since inciting injury. OMT may benefit refractory chronic traumatic pain and mobility limitations regardless of the time since inciting the injury. This is the first major publication from the OTP and bolsters proof-of-concept for an organized OMT program at a level 1 trauma center. Further study, including comparative analysis with more formalized pain assessments utilizing validated tools as well as standardized OMT session surveys, is warranted.

One of the most common complications of breast implant surgery is the occurrence of capsular contracture. The formation of capsular contracture appears to be due to a prolonged inflammatory state within the breast capsule. Despite treating capsular contracture with surgical capsulectomy, the risk of recurrence can be rather high. Recurrence rates have been reported in the range of 18% to 40%. Chemical capsulectomy can also be considered. The use of 90% trichloroacetic acid (TCA) for chemical capsulectomy was described by Blugerman et al for a variety of indications related to implant capsules. Trichloroacetic acid increases adherence of the flaps which reduces seroma and hematoma formation, thus reducing the risk of recurrence of capsular contracture. The premise of the technique we are presenting is the combination of surgical capsulectomy along with chemical capsulectomy in an effort to minimize surgical risk, reduce postoperative morbidity and further reduce the risk of recurrent capsular contracture. After the planned anterior capsulectomy surgery has been performed, the surgical site is prepared for the use of TCA. The TCA is then applied carefully with a cotton tip applicator to the posterior wall and any remaining capsule. A total of 13 patients have been treated at CAMEO Surgery Center since 2018 with this technique. There is no known recurrence from this cohort to date. Capsular contracture is a known complication of breast augmentation surgery that is associated with a high recurrence rate. Adopting both surgical and chemical capsulectomy approaches combined with other documented measures may reduce recurrence rates of capsular contracture while increasing the margin of safety of the procedure.

Labetalol and nifedipine are first-line antihypertensives for hypertensive disorders of pregnancy. However, there is limited research comparing their effectiveness based on hemodynamic profiles seen in preeclampsia, such as high cardiac output (CO) and high systemic vascular resistance (SVR). This study assesses whether concordance of antihypertensive treatment with the hemodynamic status on echocardiogram reduces time to achieve target postpartum blood pressure (BP) before discharge. This retrospective cohort study included patients with preeclampsia with severe features who received a postpartum echocardiography, excluding patients with cardiac etiology. Antihypertensive choices were provider-dependent. The CO and SVR were calculated retrospectively from the echocardiogram in collaboration with cardiology. Concordance was defined as patients with high CO (>6 L/min) started on labetalol and high SVR (>1,200 dynes·sec·cm5) started on nifedipine; opposite pairings were discordant. The primary outcome was time to achieve target BP, defined as the period from the start of antihypertensive therapy to when no titration was needed to sustain BPs of less than 140/90 mm Hg. Chi-square and Fisher's tests were used for categorical variables, and Mann-Whitney U test for continuous variables. Of 298 patients, 155 (52%) received concordant therapy and 143 (48%) discordant. Of the cohort, 229 (76.8%) had high SVR and 69 (23.2%) had high CO. Median time to target BP was not significantly different (concordant: 32 hours [interquartile range, IQR: 0-61], discordant: 41 hours [IQR: 4-75], p = 0.13). The concordant group needed fewer titrations to achieve target BP (1 [IQR: 0-2] vs. 2 [IQR: 1-3]; p = 0.008) and were less likely to be discharged home on multiple antihypertensive medications compared with the discordant group (28.9 vs. 42.7%, p = 0.014). Maternal demographics were similar between groups. While time to target BP did not differ, concordance of antihypertensive therapy to postpartum hemodynamics in patients with severe preeclampsia reduced medication adjustments and increased the likelihood of discharge on a single-agent regimen. · Echocardiography can be used to assess maternal hemodynamics.. · Aligning BP meds to hemodynamics cuts the need for a second agent.. · Aligning BP meds to hemodynamics reduces dose adjustments..