Natividad Medical Center

The cut flower industry is growing in the United States and farmers are looking to expand production and enter larger markets. However, farmers growing lisianthus ( Eustoma grandiflorum ) in the field often see reduced stem length and flower quality. Limited work has been conducted to optimize flower quality of field-grown lisianthus, especially in the southeastern United States, which is crucial for growers to maximize profits. In this study, lisianthus (group I and II ‘Arena’ white) was grown under field conditions with three shade treatments (0%, 30%, and 50%) to determine the effect on flower development, flower quality, marketability, and yield. Results showed a delay in the number of stems harvested with the addition of shade. Group I was more impacted by heavy shade treatments in terms of overall flower quality and delayed the timing of flower development by 10 to 15 d. Although group II was less affected by the addition of shade, both groups show trends of maintained quality marketability, and increased stem length with the 30% shade treatments by increasing stem length on average of 6.3 and 9.0 cm for group I and group II, respectively. These results indicate that inexpensive shadecloth may improve stem length and marketability while highlighting the need for further studies to examine lower shade intensities for cut flower production under field conditions for southern growers.

Background Multisystem Inflammatory Syndrome in Children (MIS-C) is a severe systemic hyperinflammatory condition leading to multiorgan dysfunction in a small number of children with COVID-19. Immunomodulatory therapy, including Intravenous Immunoglob

Abstract Purpose: To determine the rate at which focal neurologic deficits respond to pre-operative corticosteroids in patients with brain metastases and whether such an improvement is predictive of long-term improvement in neurologic function following surgery. Methods: Patients with pathology-proven brain metastases who underwent open surgical resection between 2010 and 2019 were identified. Charts were reviewed to identify patients with deficits in language, visual field, or motor domains who received corticosteroids prior to surgery. Descriptive analysis compared characteristics between steroid responders and non-responders. Dosage and duration were binned into deciles and plotted against their corresponding response rates. Results: 96 patients demonstrated a visual field (13 patients), language (19), or motor (64) deficit and received dexamethasone in the week prior to surgery (average cumulative dose 42.66 mg; average duration 64.5 hours). 38.5% of patients’ deficits improved on neurologic exam prior to surgery. 82.3% of patients improved by follow-up. Motor deficits were most likely to improve (46.9%; p = 0.024). All 37 responders demonstrated durable improvement at follow-up whereas 42 of 59 (71%) of non-responders ultimately improved (p < 0.001). Average dosage and duration prior to response were 17.33 mg and 23.94 hours, respectively. All other clinical characteristics were similar between responders and non-responders. Conclusions: A response to steroids prior to surgery predicts long-term improvement for focal neurologic deficits related to brain metastases. Lack of such a response portends a somewhat less favorable prognosis. There is no obvious association between duration or intensity of therapy and response.

Dear Editor, In the United States, an average of 100,000 emergency room visits per year result from horse-related injuries.[1] While riding a horse, the head sits at approximately 3-m height, and the rider can travel at speeds nearing 25–30 mph.[23] Horses can weigh over half a ton, and estimates place the force of their kick at nearly one ton.[4] The Institutional Review Board approval was granted by Touro University for this retrospective review of the Natividad Medical Center's trauma database. Thirty-two patients were identified who had been treated between July 1, 2014, and August 1, 2017, with 27 patients meeting the inclusion criteria for horse-related trauma. Of those patients, 52% were female; the average age was 51 ± 17 years; racial composition was Caucasian (63%) and Hispanic (37%); 67% required admission to the intensive care unit (ICU), intermediate care unit, or medical-surgical floors; and 41% required ICU admission [Tables 1 and 2].[5]Table 1: Demographic dataTable 2: Admission dataThe average Injury Severity Score (ISS) was 7 ± 8 in all patients, with patients whose ISS score of ≥10 having a longer length of stay (average 9 ± 7). Of patients that were admitted, the average age was significantly higher; however, the average ISS score of patients ≥60 was not higher on average than those with ISS score <60 [Tables 3 and 4].Table 3: Injury severity by ageTable 4: Average Injury Severity Score by length of stayHorse-related trauma has the potential to cause significant morbidity and mortality and is especially prevalent in rural or agricultural areas where there is access to horses. In a trauma center such as Natividad Medical Center that treats patients from the entirety of Monterey County, it is important to understand the danger posed by equine activities. In our retrospective review of 27 cases of horse trauma, we found that, although surprisingly, no fatalities occurred, there were many cases of significant injuries sustained by horses. These injuries most often occurred after falling from a horse (70%) and most often involved the chest (44%) or head (41%). Moreover, of the injuries severe enough to present to the emergency room, 67% were severe enough to be admitted for. Almost 41% of these admissions included time in the ICU, but only 26% required surgical intervention [Tables 5 and 6].Table 5: Injury by body regionTable 6: Injury by mechanismDemographic data demonstrated that our population had similar gender composition to the Monterey County census reports, but was mostly Caucasian (67%) and 31% were over the age of 65, in comparison to a census of 12.7% in patients aged over 65 years. Of patients >60 years, there was no significant difference in ISS in relation to those >60. However, patients aged >60 years who were admitted had a significant increase in length of hospital stay than those admitted patients aged <60. This may reflect that, although on an average, the elderly did not sustain worse injuries, doctors may have been more cautious with their monitoring, as is common with this population. Horses pose a significant risk for morbidity and mortality when they are involved in traumatic accidents. The results presented here demonstrate the potential for serious morbidity related to horses in our patient population, especially in those over 60 years old. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Preliminary evidence supports the safety and efficacy of subanesthetic ketamine as an experimental antidepressant, although its effects are often not sustained beyond one week. Studies are lacking that have examined the sustained effects of escalating ketamine doses as augmentation in outpatients with treatment-resistant depression. Therefore, the aims of this study were twofold: (1) to assess the safety and antidepressant efficacy of two-step, repeated-dose ketamine augmentation and (2) to assess the duration of ketamine's antidepressant efficacy as augmentation to ongoing antidepressant pharmacotherapy for 3 months after the final infusion. Fourteen patients with treatment-resistant depression were eligible to receive augmentation with six open-label intravenous ketamine infusions over 3 weeks. For the first three infusions, ketamine was administered at a dose of 0.5 mg/kg over 45 minutes; the dose was increased to 0.75 mg/kg over 45 minutes for the subsequent three infusions. The primary outcome measure was response (as measured on Hamilton Depression Rating Scale-28 items). After the completion of three ketamine infusions, 7.1% (1/14) responded; after all six ketamine infusions, 41.7% (5/12) completers responded and 16.7% (2/12) remitted. Intent-to-treat response and remission rates at the end of the final infusion were 35.7% (5/14) and 14.3% (2/14), respectively. However, all but one responder relapsed within 2 weeks after the final infusion. Repeated, escalating doses of intravenous ketamine augmentation were preliminarily found to be feasible, efficacious and well tolerated. Interaction with concomitant medications and elevated level of treatment resistance are possible factors for non-response.

The Internet may be the first source of information used by parents during a suspected poisoning of their children. Our primary aim was to assess the reliability of the Internet as a resource for information for parents to initially manage a suspected poisoning involving their child without outside consultation. We distributed a self-administered survey to English-speaking parents to evaluate their Internet access behaviors so we could emulate their search strategies for a poisoning. A panel of clinical toxicologists performed an evaluation of Websites to determine the proportion that provided accurate and adequate information on common substances involved in poisonings. Of 21 parents surveyed, 15 (71%) used the Internet daily, with Google and Yahoo being the most commonly used search engines. Seven parents (39%) were somewhat to very likely to utilize the Internet during a poisoning scenario with prescription medications involving their child. Overall, only 27 (38%) of the Websites reviewed advised the user to call the poison center with the proper 800 telephone number, whereas no Website provided adequate information to manage the poisoning without outside consultation. Few Websites provided information on the toxic dose (13%), how to determine whether to manage the poisoning at home or in a hospital (22%), or first aid (28%). The information provided on the Internet for substances involved in poisonings is variable and often incomplete. Reliance on the Internet for poisonings could create needless delays and inappropriate assessments and actions to manage a pediatric poisoning incident.

Founded upon the primacy of the principle of respect for autonomy, three methods of surrogate decision making traditionally have been promoted to help the family and friends of incapacitated patients. Unfortunately, the standards of advance directives, substituted judgment, and best interests are often inadequate in practice. Studies report that few patients have formal, written advance directives; that patients often change their minds about treatment over time; that many patients are simply not ready or willing to plan ahead--in part, because some patients and families simply don't believe in autonomy; that those patients who do plan ahead often do not communicate their plans; and that while some patients want their directives followed strictly, many prefer that their surrogates use judgment in making decisions. After reviewing articles describing a variety of alternative approaches, a new clinical standard of surrogate empowerment is proposed to reconcile and integrate these observations and concepts. The "procedure" for this clinical standard is presented.

To discover where patients with advance directives (ADs) obtain them and to learn what patients' understanding is of how ADs function. Adult patients with ADs admitted to the four acute-care hospitals in Monterey County, California, were asked to participate in a survey during the study period 1 July to 8 September 2009. Of 5,811 total admissions, 455 patients (7 percent) had an AD. Of these 455 patients, 204 (45 percent) completed our survey. Participants included 146 patients with a power of attorney for healthcare (72 percent), and 21 patients who were unable to identify the type of AD they had (10 percent). Attorneys provided ADs to 99 participants (49 percent) and personal physicians provided ADs to 12 participants (6 percent). Most participants (181, or 89 percent) had spoken to their family about their AD; fewer (131, or 65 percent) to their physician. Of the 146 participants with a power of attorney, only 73 (50 percent) said they had spoken specifically to their agent. Family members (38 percent) and attorneys (35 percent) were seen as helpful in completing ADs; physicians (1 percent) were not. Few study participants had advance directives, and attorneys provided and discussed ADs with study participants more than physicians did. Because many patients with ADs seem not to fully understand them, new approaches to advance planning education must be developed.