Lewis Gale Medical Center

Background: Despite advances in extracorporeal membrane oxygenation (ECMO) for cardiogenic shock (CS), little is known about gender-based differences in its utilization and clinical outcomes. We aimed to assess whether gender influences ECMO use and outcomes in CS using Nationwide Inpatient Sample (NIS) Database. Methods: We conducted a retrospective cohort study using the Nationwide Inpatient Sample (NIS, 2016–2020), identifying adults (≥18 years) hospitalized with cardiogenic shock. ECMO use was identified using ICD-10-PCS codes. Survey-weighted logistic and linear regression models were used to assess gender differences in ECMO utilization, in-hospital mortality, length of stay (LOS), hospitalization costs, and major complications. Models adjusted for demographics, comorbidities (Elixhauser index), and hospital characteristics. Results: Among 13,005 patients receiving ECMO for CS, only 33.9% were female. Female patients were significantly less likely to receive ECMO (adjusted OR 0.89; 95% CI 0.82–0.97; p = 0.011). Female ECMO recipients were younger than males (mean age 47.7 vs. 52.8 years; p < 0.001). There was no significant difference in in-hospital mortality by gender (aOR 1.12; 95% CI 0.92–1.35; p = 0.258). Length of stay was similar between genders (23.6 days), with a non-significant trend toward shorter LOS in females (β = –2.25; p = 0.071). Adjusted total hospital charges were significantly lower in females (β = –$95,269; p = 0.017) (Figure 1). Notably, complication rates varied by gender. Females had significantly lower adjusted odds of requiring dialysis (aOR 0.77; 95% CI 0.63–0.95; p = 0.013), developing acute kidney injury (aOR 0.71; 95% CI 0.57–0.88; p = 0.002), arrhythmias (aOR 0.67; 95% CI 0.56–0.80; p < 0.001), and acute myocardial infarction (aOR 0.75; 95% CI 0.61–0.92; p = 0.007). However, female patients had higher adjusted odds of developing pericardial complications (aOR 1.35; 95% CI 1.04–1.74; p = 0.022) and pulmonary embolism (aOR 1.68; 95% CI 1.25–2.26; p = 0.001) (Figure 2). Conclusions: Women were less likely to receive ECMO for cardiogenic shock and tended to be younger at the time of receiving it. While in-hospital mortality and length of stay did not differ by gender, females had significantly lower hospital charges and distinct complication patterns. These findings highlight potential gender-based disparities in ECMO utilization and underscore the need for further investigation to ensure equitable access and outcomes.

Anxiety disorders are among the most common psychological disorders. Although Cognitive Behavioral Therapy (CBT) is the recommended evidence-based treatment, approximately 50% of patients undergoing CBT do not benefit. Therefore, it is important to identify predictors that, at the start of treatment, can provide an indication of who will benefit from CBT for anxiety disorders. Such information can help clinicians offer patients a more effective treatment trajectory. However, to date, no consistent predictors of treatment outcome have been identified. This dissertation proposes a novel approach, employing an experimental psychopathology framework to investigate “speed of return to baseline” as a dynamic predictor of treatment outcome in anxiety. Specifically, it is proposed to intentionally introduce a perturbation that temporarily induces a positive shift in an anxiety-related process. Repeated assessments following this experimental perturbation can then be used to measure the speed of return to baseline. It was hypothesized that individuals with an anxiety disorder who show a slower return to baseline, thus those who maintain a positive change for a longer time following the perturbation, would benefit more from treatment compared to individuals who return to baseline more quickly. Across two separate studies, we found that indeed, benefitting longer from a reduction in negative interpretations and negative beliefs about worry predicted better treatment outcomes. However, this effect was not observed in a study in which the likelihood of a feared outcome was experimentally manipulated. Currently, no firm conclusions can be drawn regarding the utility of a dynamic predictor of treatment outcome in anxiety, given the limited number of studies that have tested this predictor. Nevertheless, the findings presented in this dissertation demonstrate the potential of a dynamic predictor, and future research is needed to examine the conditions under which speed of return to baseline following an (experimental) perturbation may predict treatment outcomes in anxiety.

Recognizing and addressing acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) in critically ill patients is crucial for improving both short- and long-term recovery outcomes. Patients in the ICU often experience significant psychological stress due to the severity of their illness, medical interventions, and unfamiliar, high-stress surroundings, all of which contribute to the development of these disorders. This article explores the epidemiology, risk factors, and patho-physiology of ASD and PTSD in the ICU setting. It reviews the differential diagnosis and complex interplay of medical and mental health comorbidities. The psychological impact of critical care including post-intensive care syndrome (PICS) and the importance of ongoing evaluation is discussed. Nonpharmaco-logical interventions such as cognitive behavioral therapy (CBT) and ICU diaries, as well as pharmacological strategies, are reviewed. The influence of social determinants of health (SDOH), the impact on families, and their involvement in care are also considered.

In recent years, the development of hand-held devices have intrigued POCUS enthusiasts due to improved affordability, portability, and ease of use.They also provide extra functionality for image storage and transmission for remote provider-to-provider communication and review.Due to these capabilities, portable ultrasound has found its use expanded to prehospital, wilderness, and austere settings, where cartbased machines and other imaging modalities are not an option [1].As resident educators, it is exciting to see the enthusiasm our trainees have for POCUS, prehospital, and wilderness medicine.But how do we train the next generation of POCUS wielders for best use in remote environments?

Complex regional pain syndrome (CRPS) is a rare disorder that presents as a highly variable combination of intense regional pain, autonomic and vasomotor disturbances that are uncharacteristic of the inciting trauma or event. We report a 36-year-old male construction worker who presented to the orthopedic department status post crush injury to his hand, with acutely increasing right-hand pain, swelling, skin/hair changes, and dysfunction. Presentation changed over a course of 2-8 weeks, with CRPS becoming the eventual working diagnosis. Initial diagnoses were not made by occupational med, nor the urgent care, and definitive diagnosis was achieved in the orthopedic hand office via a thorough history and physical exam as well as imaging modalities including X-ray, CT, and MRI. A multidisciplinary approach involving aggressive hand therapy, anti-inflammatory agents, high-dose prednisone, Gabapentin, and over-the-counter vitamins and supplements was used in the treatment of this patient. This patient had a unique progression of his condition with respect to his carpus, demonstrating acute reduction of bone density on plain film. Stiffness ensued. This patient’s condition was almost “missed” by the masking of the ulnar ossicle variant (os triangulare), and anatomical snuffbox pain on exam, in the face of initially “normal” X-rays. It is important for providers to recognize the clinical signs of complex regional pain syndrome, especially in the acute phase of crush injury, swelling, skin and hair changes, and stiffness, and to treat patients' symptoms with a variety of treatment options due to the marked variability of this condition. The patient has made a favorable recovery with some residual functional deficits, however, the patient stated that his quality of life has been restored despite his current stiffness.

Foix-Chavany-Marie syndrome (FCMS) is characterized by bilateral facio-glosso-pharyngo-masticatory paralysis of voluntary muscles due to bilateral infarction in the anterior opercular region of the brain. Here, we report a case of a 52-year-old female who presented with FCMS due to an acute left anterior opercular stroke in the setting of a chronic asymptomatic right opercular infarct and asymptomatic bilateral cerebellar infarcts. She also had a concurrent acute-on-chronic episode of congestive heart failure exacerbation. She made a significant recovery by the time of hospital discharge.