Michigan Primary Care Association

An 84-year-old patient, treated in the ICU for acute kidney injury complicating coronary artery bypass surgery, experienced an unusual event during dialysis catheter placement. First, venous blood was drawn while the catheter was inserted into the left internal jugular vein. Ultrasound confirmed the proper guidewire placement, and the dilator and catheter were inserted without difficulty. However, the blood returned from the catheter was unexpectedly bright, raising concerns for arterial placement. Transduced pressures were pulsatile, but levels were inconsistent with arterial positioning. A subsequent chest x-ray revealed the catheter extending into the left mediastinum, and CT imaging confirmed the catheter was inadvertently placed in an anomalous left pulmonary vein. Misplacement of central venous catheters (CVCs) into partial anomalous pulmonary venous return (PAPVR) has been sporadically reported. As imaging modalities, such as CT and MRI, become more prevalent in intensive care practice, incidental detection of PAPVR is expected to increase. Management typically involves removal and repositioning of the catheter, though the decision to treat the PAPVR itself remains nuanced and is based on factors such as pulmonary hypertension risk and shunt volume.

Ischemic colitis constitutes about half of mesenteric vasculopathies, and it shares a similar pathophysiologic process with acute and chronic mesenteric ischemia. These, in turn, can be divided intoocclusive and nonocclusive mesenteric ischemia (NOMI). We present this case of a patient presenting withabdominal pain secondary to right-sided colitis, initially presumed to be infectious, but later attributed tolocalized NOMI. The correlation between localized NOMI, specifically right-sided colitis, andright ventricular (RV) failure has not been well described in the literature. NOMI, in general, is suspected to be secondary tosplanchnic vasoconstriction, which results from sympathetic stimulation and renin-angiotensin-aldosterone system (RAAS) activation. Additionally,patients with RV failure have been shown to develop intestinal congestion due to elevated right atrial pressure (RAP), leading to bowel wall thickening and impaired mesenteric venous drainage, which may further contribute to ischemia. This mechanismsuggests that botharterial hypoperfusion and venous congestionmay play a role in the pathogenesis of right-sided ischemic colitis in RV failure. The predominance of ischemia in the right colon, rather than in classical watershed areas, may be attributed to preferential vasoconstriction of the superior mesenteric artery (SMA), which supplies the right colon, as well as localized venous congestion impairing mesenteric drainage in this region. Individual variability in vascular anatomy and autoregulatory responses could also contribute to this atypical presentation. This case highlights apotentially underrecognized associationbetweenRV dysfunction and right-sided ischemic colitis, emphasizing the interplay oflow cardiac output, mesenteric hypoperfusion, and venous congestion. Given theabsence of direct studies on this relationship, further research is needed to better understand its clinical significance.

Epidemiology provides fundamental opportunities to protect student-athlete health. The goal of this study was to describe the epidemiology of sport-related concussion (SRC) across 8 years (2015/2016-2022/2023) and compare boys' and girls' sports for SRC incidence and SRC mechanisms. This was a retrospective cohort study performed using a statewide high school head injury surveillance system of high school student-athletes (n = 2,182,128; boys, n = 1,267,389; girls, n = 914,739). Exposures of interest included study year and boys and girls in comparable sports. Clinical incidence was calculated by dividing SRC counts in each sport by the number of participants per 100 player-seasons and presented with 95% CIs. The 2019/2020 and 2020/2021 data were included in the analysis, however caution is warranted due to the COVID-19 pandemic. Clinical incidence ratios (CIRs) were estimated for sex-comparable sports, and significance was determined if 95% CIs excluded 1.00. The authors compared mechanism of injury in boys' and girls' comparable sports with chi-square analyses (p < 0.05). Among 25,482 total SRCs, the overall clinical incidence of SRC for all boys and girls was 1.17 (95% CI 1.15-1.18) per 100 player-seasons across all years. Across all years, the overall clinical incidence in boys' sports was 1.34 (95% CI 1.32-1.36) per 100 player-seasons, and 0.93 (95% CI 0.91-0.95) per 100 player-seasons in girls' sports. Boys' sports with the highest clinical incidence included football, ice hockey, and wrestling. Girls' sports with the highest clinical incidence included basketball, soccer, lacrosse, competitive cheer, and gymnastics. Girls consistently had higher SRC rates relative to boys for baseball/softball, basketball, and soccer (CIR range 1.65 [95% CI 1.41-1.93] to 3.32 [95% CI 2.67-4.16]). Girls had lower SRC in lacrosse in 2015/2016 (CIR 0.63, 95% CI 0.40-0.97); no difference in 2016/2017-2020/2021, but had higher clinical incidence in 2021/2022 (CIR 1.69, 95% CI 1.18-2.44) relative to boys. In boys the most common mechanism of SRC occurred from person-to-person contact (n = 8752, 62.8%), whereas girls commonly sustained SRC from person-to-object contact (n = 2369, 33.4%) and from person-to-person contact (n = 2368, 33.4%). There were significant associations between boys' versus girls' sports and mechanism of injury within baseball/softball (χ2 = 12.71, p = 0.005); basketball (χ2 = 36.47, p < 0.001); lacrosse (χ2 = 185.15, p < 0.001); and soccer (χ2 = 122.70, p < 0.001). These findings can help understand the potential impact of interventions aimed at preventing or reducing SRC. Including girls' sports within this study extends research for a largely underrepresented group.

Marshall, Katherine DNP, PMHCNS-BC, NP, CNE; Hale, Deborah MSN, RN, ACNS-BC Author Information

Hale, Deborah MSN, RN, ACNS-BC; Marshall, Katherine DNP, NP, PMHCNS-BC, CNE Author Information

Hale, Deborah MSN, RN, ACNS-BC; Marshall, Katherine DNP, NP, PMHCNS-BC, CNE Author Information

Abstract Despite decades of research demonstrating links between many agricultural practices and water quality, the ability to predict water quality on the basis of changes in soil health remains severely limited. By better understanding how soil health affects downstream water quality, researchers and policymakers could prioritize different conservation practices while exploring more innovative soil health management strategies. Focusing on the Great Lakes region, we describe the value and challenges of different approaches to linking soil health and water quality, specifically applying nitrogen and phosphorus mass balances and adapting simulation models to better incorporate changing soil health conditions. We identify critical research needs, including paying greater attention to a broad suite of conservation practices and to biological indicators of soil health. We also discuss key barriers to farmer adoption of conservation practices from field to national scales, highlighting that improved scientific understanding alone is insufficient to drive widespread change.