Publications by authors named "Edward Castillo"

170 Publications

Dynamic lung compliance imaging from 4DCT-derived volume change estimation.

Phys Med Biol 2021 Sep 24. Epub 2021 Sep 24.

Department of Radiation Oncology, Beaumont Health Research Institute, 3601 W. Thirteen Mile Road, Royal Oak, Michigan, 48073, UNITED STATES.

Background: Lung compliance is the ability of the lung to expand with changes in pressure and is one of the earliest physiological measurements to be altered in patients with parenchymal lung disease. Therefore, compliance monitoring could potentially identify patients at risk for disease progression. However, in clinical practice, compliance measurements are prohibitively invasive for use as a routine monitoring tool.

Purpose: We propose a novel method for computing dynamic lung compliance imaging (LCI) from non-contrast computed tomography (CT) scans. LCI applies image processing methods to free-breathing 4DCT images, acquired under two different continuous positive airway pressures (CPAP) applied using a full-face mask, in order to compute the lung volume change induced by the pressure change. LCI provides a quantitative volumetric map of lung stiffness.

Methods: We compared mean LCI values computed for 10 patients with idiopathic pulmonary fibrosis (IPF) and 7 non-IPF patients who were screened for lung nodules. 4DCTs were acquired for each patient at 5cm and 10 cm H20 CPAP, as the patients were free breathing at functional residual capacity. LCI was computed from the two 4DCTs. Mean LCI intensities, which represent relative voxel volume change induced by the change in CPAP pressure, were computed.

Results: The mean LCI values for patients with IPF ranged between [0.0309, 0.1165], whereas the values ranged between [0.0704, 0.2185] for the lung nodule cohort. Two-sided Wilcoxon rank sum test indicated that the difference in medians is statistically significant (p value = 0.009) and that LCI -measured compliance is overall lower in the IPF patient cohort.

Conclusion: There is considerable difference in lung compliance scores between patients with IPF compared to controls. Future longitudinal studies should look for LC alterations in areas of lung prior to radiographic detection of fibrosis to further characterize LCI's potential utility as an image marker for disease progression.
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http://dx.doi.org/10.1088/1361-6560/ac29ceDOI Listing
September 2021

Cancer-related Emergency Department Visits: Comparing Characteristics and Outcomes.

West J Emerg Med 2021 Aug 21;22(5):1117-1123. Epub 2021 Aug 21.

University of California, San Diego, Department of Emergency Medicine, San Diego, California.

Introduction: There is increasing appreciation of the challenges of providing safe and appropriate care to cancer patients in the emergency department (ED). Our goal here was to assess which patient characteristics are associated with more frequent ED revisits.

Methods: This was a retrospective cohort study of all ED visits in California during the 2016 calendar year using data from the California Office of Statewide Health Planning and Development. We defined revisits as a return visit to an ED within seven days of the index visit. For both index and return visits, we assessed various patient characteristics, including age, cancer type, medical comorbidities, and ED disposition.

Results: Among 12.9 million ED visits, we identified 73,465 adult cancer patients comprising 103,523 visits that met our inclusion criteria. Cancer patients had a 7-day revisit rate of 17.9% vs 13.2% for non-cancer patients. Cancer patients had a higher rate of admission upon 7-day revisit (36.7% vs 15.6%). Patients with cancers of the small intestine, stomach, and pancreas had the highest rate of 7-day revisits (22-24%). Cancer patients younger than 65 had a higher 7-day revisit rate than the elderly (20.0% vs 16.2%).

Conclusion: In a review of all cancer-related ED visits in the state of California, we found a variety of characteristics associated with a higher rate of 7-day ED revisits. Our goal in this study was to inform future research to identify interventions on the index visit that may improve patient outcomes.
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http://dx.doi.org/10.5811/westjem.2021.5.51118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8463053PMC
August 2021

Evaluation of the ventilatory effects on human subjects in prolonged hip-flexed/head-down restraint position.

Am J Emerg Med 2021 Jul 2;50:1-4. Epub 2021 Jul 2.

Department of Emergency Medicine, University of California, San Diego, San Diego, CA, United States of America.

Background: The restraint chair is a tool used by law enforcement and correction personnel to control aggressive, agitated individuals. When initiating its use, subjects are often placed in a hip-flexed/head-down (HFHD) position to remove handcuffs. Usually, this period of time is less than two minutes but can become more prolonged in particularly agitated patients. Some have proposed this positioning limits ventilation and can result in asphyxia. The aim of this study is to evaluate if a prolonged HFHD restraint position causes significant ventilatory compromise.

Methods: Subjects exercised on a stationary bicycle until they reached 85% of their predicted maximal heart rate. They were then handcuffed with their hands behind their back and placed into a HFHD seated position for five minutes. The primary outcome measurement was maximal voluntary ventilation (MVV). This was measured at baseline, after initial placement into the HFHD position, and after five minutes of being in the position while still maintaining the HFHD position. Baseline measurements were compared with final measurements for statistically significant differences.

Results: We analyzed data for 15 subjects. Subjects had a mean MVV of 165.3 L/min at baseline, 157.8 L/min after initially being placed into the HFHD position, and a mean of 138.7 L/min after 5 min in the position. The mean baseline % predicted MVV was 115%; after 5 min in the HFHD position the mean was 96%. This 19% absolute difference was statistically significant (p = 0.001).

Conclusions: In healthy seated male subjects with recent exertion, up to five minutes in a HFHD position results in a small decrease in MVV compared with baseline MVV levels. Even with this decrease, mean MVV levels were still 96% of predicted after five minutes. Though a measurable decrease was found, there was no clinically significant change that would support that this positioning would lead to asphyxia over a five-minute time period.
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http://dx.doi.org/10.1016/j.ajem.2021.06.068DOI Listing
July 2021

Active Cancer Patients Presenting to the Emergency Department with Acute Venous Thromboembolism: A Retrospective Cohort Study on Risks and Outcomes.

J Emerg Med 2021 Jun 29. Epub 2021 Jun 29.

Department of Emergency Medicine, UC San Diego Health, San Diego, California.

Background: There is no prior study that has documented emergency department (ED) outcomes or stratified mortality risks of cancer patients presenting with an acute venous thromboembolism (VTE).

Objective: To evaluate ED treatment of these patients, to document their outcomes, and to identify risk factors associated with death.

Methods: A retrospective cohort study was performed on active cancer patients presenting with deep venous thrombosis or pulmonary embolism to two academic EDs between July 2012 and June 2016. Key outcomes included mortality, ED revisit, and admission within 30 days. The patient cohort was characterized; crosstabs and regression analysis were performed to assess relative risks (RRs) and mitigating factors associated with 30-day mortality.

Results: Of 355 patients, 9% died and 38% had one or more ED revisits or admissions. Recent immobility (RR 2.341, 95% CI 1.227-4.465), poor functional status (RR 2.090, 95% CI 1.028-4.248), recent admission (RR 2.441, 95% CI 1.276-4.669), and metastatic cancer (RR 4.669, 95% CI 1.456-14.979) were major risk factors for mortality. ED-provided anticoagulation reduced the overall mortality risk (RR 0.274, 95% CI 0.146-0.515) and mitigated the risk from recent immobility (RR 1.250, 95% CI 0.462-3.381), especially among patients with good or fair functional status.

Conclusion: Immobility and cancer morbidity are key risk factors for mortality after an acute VTE, but ED-provided anticoagulation mitigates the risk of immobility among healthier patients. Eastern Cooperative Oncology Group performance status can help clinicians risk stratify these patients at presentation.
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http://dx.doi.org/10.1016/j.jemermed.2021.05.014DOI Listing
June 2021

Ethnic Disparities in COVID-19 Among Older Adults Presenting to the Geriatric Emergency Department.

J Emerg Med 2021 May 9. Epub 2021 May 9.

Department of Emergency Medicine, University of California, San Diego, La Jolla, California.

Background: There is a dearth of epidemiological data on ethnic disparities among older patients with COVID-19. The objective of this study was to characterize ethnic differences in clinical presentation and outcomes from COVID-19 among older U.S. adults.

Methods: This was a retrospective cohort study within two geriatric emergency departments (GEDs) at a large academic health system. One hundred patients 65 years or older who visited a GED between March 10, 2020 and August 9, 2020 and tested positive for COVID-19 were examined. Electronic medical records were used to determine presenting COVID-19-related symptoms, comorbidities, and clinical outcomes. Descriptive statistics are reported with associated 95% confidence intervals (CIs).

Results: In the overall sample, mean age was 75.9 years; 18% were 85 years or older; 50% were male; and 46.0% were Hispanic. Relative to non-Hispanic patients with COVID-19, Hispanic patients with COVID-19 had a higher percentage of shortness of breath (78.3% vs. 51.9%; difference: 26.4%; 95% CI 7.6-42.5%), pneumonia (82.6% vs. 50.0%; difference: 32.6%; 95% CI 14.1-47.9%), acute respiratory distress syndrome (13.0% vs. 1.9%; difference: 11.1%; 95% CI 0.7-23.9%), and acute kidney failure (41.3% vs. 22.2%; difference: 19.1%; 95% CI 0.9-36.0%). Rates of other poor outcomes, including hospitalization, intensive care unit (ICU) admission, return visits to the GED within 30 days of discharge, or death, did not significantly differ between Hispanic and non-Hispanic patients with COVID-19.

Conclusions: These preliminary data show that older Hispanic patients relative to non-Hispanic patients with COVID-19 presenting to a GED did not experience worse outcomes, including hospitalization, ICU admission, 30-day return visits to the GED, or death.
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http://dx.doi.org/10.1016/j.jemermed.2021.04.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8106891PMC
May 2021

Functional avoidance-based intensity modulated proton therapy with 4DCT derived ventilation imaging for lung cancer.

J Appl Clin Med Phys 2021 Jul 22;22(7):276-285. Epub 2021 Jun 22.

Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA.

The primary objective is to evaluate the potential dosimetric gains of performing functional avoidance-based proton treatment planning using 4DCT derived ventilation imaging. 4DCT data of 31 patients from a prospective functional avoidance clinical trial were evaluated with intensity modulated proton therapy (IMPT) plans and compared with clinical volumetric modulated arc therapy (VMAT) plans. Dosimetric parameters were compared between standard and functional plans with IMPT and VMAT with one-way analysis of variance and post hoc paired student t-test. Normal Tissue Complication Probability (NTCP) models were employed to estimate the risk of two toxicity endpoints for healthy lung tissues. Dose degradation due to proton motion interplay effect was evaluated. Functional IMPT plans led to significant dose reduction to functional lung structures when compared with functional VMAT without significant dose increase to Organ at Risk (OAR) structures. When interplay effect is considered, no significant dose degradation was observed for the OARs or the clinical target volume (CTV) volumes for functional IMPT. Using fV20 as the dose metric and Grade 2+ pneumonitis as toxicity endpoint, there is a mean 5.7% reduction in Grade 2+ RP with the functional IMPT and as high as 26% in reduction for individual patient when compared to the standard IMPT planning. Functional IMPT was able to spare healthy lung tissue to avoid excess dose to normal structures while maintaining satisfying target coverage. NTCP calculation also shows that the risk of pulmonary complications can be further reduced with functional based IMPT.
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http://dx.doi.org/10.1002/acm2.13323DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8292710PMC
July 2021

Extubation Failure in Critically Ill COVID-19 Patients: Risk Factors and Impact on In-Hospital Mortality.

J Intensive Care Med 2021 Sep 2;36(9):1018-1024. Epub 2021 Jun 2.

Division of Pulmonary and Critical Care Medicine, 21818Beaumont Health System, OUWB School of Medicine, Royal Oak, MI, USA.

Purpose: We sought to identify clinical factors that predict extubation failure (reintubation) and its prognostic implications in critically ill COVID-19 patients.

Materials And Methods: Retrospective, multi-center cohort study of hospitalized COVID-19 patients. Multivariate competing risk models were employed to explore the rate of reintubation and its determining factors.

Results: Two hundred eighty-one extubated patients were included (mean age, 61.0 years [±13.9]; 54.8% male). Reintubation occurred in 93 (33.1%). In multivariate analysis accounting for death, reintubation risk increased with age (hazard ratio [HR] 1.04 per 1-year increase, 95% confidence interval [CI] 1.02 -1.06), vasopressors (HR 1.84, 95% CI 1.04-3.60), renal replacement (HR 2.01, 95% CI 1.22-3.29), maximum PEEP (HR 1.07 per 1-unit increase, 95% CI 1.02 -1.12), paralytics (HR 1.48, 95% CI 1.08-2.25) and requiring more than nasal cannula immediately post-extubation (HR 2.19, 95% CI 1.37-3.50). Reintubation was associated with higher mortality (36.6% vs 2.1%; < 0.0001) and risk of inpatient death after adjusting for multiple factors (HR 23.2, 95% CI 6.45-83.33). Prone ventilation, corticosteroids, anticoagulation, remdesivir and tocilizumab did not impact the risk of reintubation or death.

Conclusions: Up to 1 in 3 critically ill COVID-19 patients required reintubation. Older age, paralytics, high PEEP, need for greater respiratory support following extubation and non-pulmonary organ failure predicted reintubation. Extubation failure strongly predicted adverse outcomes.
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http://dx.doi.org/10.1177/08850666211020281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8173445PMC
September 2021

Developing and Implementing a Geriatric Emergency Department (GED): Overview and Characteristics of GED Visits.

J Emerg Med 2021 08 15;61(2):131-139. Epub 2021 May 15.

Department of Emergency Medicine, University of California, San Diego, La Jolla, California.

Background: The traditional model of emergency care may not be sufficient to address the complex care needs of older adults, who present to the emergency department with multiple comorbidities, geriatric syndromes, and social determinants of health, complicating diagnosis and management. Geriatric emergency departments (GEDs) have emerged throughout the last decade to address these concerns and improve the emergency care of older adults.

Objective: Our aim was to describe the policies, procedures, and workflow of our GEDs, and to provide data on patient outcomes and discuss challenges and recommendations in the development and implementation of a GED.

Discussion: Our GED includes interdisciplinary staff trained in geriatric emergency medicine, evidence-based protocols for geriatric care, physical modifications to accommodate older adults' functional limitations, administration of geriatric assessments, care coordination with case managers and social workers, and referrals to care. Assessments screen for geriatric syndromes and social determinants of health. Quality improvement is a critical component and includes a robust medication safety plan to reduce use of potentially inappropriate medications. Hospital administrators considering developing a GED should create a care planning team, conduct an institutional needs assessment, and identify the GED model that will most efficiently help them achieve an age-friendly health system.

Conclusions: The GED will play an important role in addressing the diverse health care needs of older adults in the coming decades. Future research studies of health outcomes among older adults receiving care at GEDs compared with traditional EDs will be critical in informing future improvements and innovations in geriatric emergency care.
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http://dx.doi.org/10.1016/j.jemermed.2021.02.036DOI Listing
August 2021

Moving the needle on fall prevention: A Geriatric Emergency Care Applied Research (GEAR) Network scoping review and consensus statement.

Acad Emerg Med 2021 May 11. Epub 2021 May 11.

Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA.

Background: Although falls are common, costly, and often preventable, emergency department (ED)-initiated fall screening and prevention efforts are rare. The Geriatric Emergency Medicine Applied Research Falls core (GEAR-Falls) was created to identify existing research gaps and to prioritize future fall research foci.

Methods: GEAR's 49 transdisciplinary stakeholders included patients, geriatricians, ED physicians, epidemiologists, health services researchers, and nursing scientists. We derived relevant clinical fall ED questions and summarized the applicable research evidence, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews. The highest-priority research foci were identified at the GEAR Consensus Conference.

Results: We identified two clinical questions for our review (1) fall prevention interventions (32 studies) and (2) risk stratification and falls care plan (19 studies). For (1) 21 of 32 (66%) of interventions were a falls risk screening assessment and 15 of 21 (71%) of these were combined with an exercise program or physical therapy. For (2) 11 fall screening tools were identified, but none were feasible and sufficiently accurate for ED patients. For both questions, the most frequently reported study outcome was recurrent falls, but various process and patient/clinician-centered outcomes were used. Outcome ascertainment relied on self-reported falls in 18 of 32 (56%) studies for (1) and nine of 19 (47%) studies for (2).

Conclusion: Harmonizing definitions, research methods, and outcomes is needed for direct comparison of studies. The need to identify ED-appropriate fall risk assessment tools and role of emergency medical services (EMS) personnel persists. Multifactorial interventions, especially involving exercise, are more efficacious in reducing recurrent falls, but more studies are needed to compare appropriate bundle combinations. GEAR prioritizes five research priorities: (1) EMS role in improving fall-related outcomes, (2) identifying optimal ED fall assessment tools, (3) clarifying patient-prioritized fall interventions and outcomes, (4) standardizing uniform fall ascertainment and measured outcomes, and (5) exploring ideal intervention components.
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http://dx.doi.org/10.1111/acem.14279DOI Listing
May 2021

Characterizing spatial differences between SPECT-ventilation and SPECT-perfusion in patients with lung cancer undergoing radiotherapy.

Radiother Oncol 2021 07 6;160:120-124. Epub 2021 May 6.

Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, United States, United States(1); Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, United States(2).

This study investigates agreement between ventilation and perfusion for lung cancer patients undergoing radiotherapy. Ventilation-perfusion scans of nineteen patients with stage III lung cancer from a prospective protocol were compared using voxel-wise Spearman correlation-coefficients. The presented results show in about 25% of patients, ventilation and perfusion exhibit lower agreement.
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http://dx.doi.org/10.1016/j.radonc.2021.04.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8489737PMC
July 2021

A prospective study to validate pulmonary blood mass changes on non-contrast 4DCT in pulmonary embolism patients.

Clin Imaging 2021 Oct 5;78:179-183. Epub 2021 Mar 5.

Department of Radiation Oncology, Beaumont Health System, OUWB School of Medicine, United States of America; Department of Computational and Applied Mathematics, Rice University, United States of America. Electronic address:

Purpose: Limited diagnostic options exist for patients with suspected pulmonary embolism (PE) who cannot undergo CT-angiogram (CTA). CT-ventilation methods recover respiratory motion-induced lung volume changes as a surrogate for ventilation. We recently demonstrated that pulmonary blood mass change, induced by tidal respiratory motion, is a potential surrogate for pulmonary perfusion. In this study, we examine blood mass and volume change in patients with PE and parenchymal lung abnormalities (PLA).

Methods: A cross-sectional analysis was conducted on a prospective, cohort-study with 129 consecutive PE suspected patients. Patients received 4DCT within 48 h of CTA and were classified as having PLA and/or PE. Global volume change (VC) and percent global pulmonary blood mass change (PBM) were calculated for each patient. Associations with disease type were evaluated using quantile regression.

Results: 68 of 129 patients were PE positive on CTA. Median change in PBM for PE-positive patients (0.056; 95% CI: 0.045, 0.068; IQR: 0.051) was smaller than that of PE-negative patients (0.077; 95% CI: 0.064, 0.089; IQR: 0.056), with an estimated difference of 0.021 (95% CI: 0.003, 0.038; p = 0.0190). PLA was detected in 57 (44.2%) patients. Median VC for PLA-positive patients (1.26; 95% CI: 1.22, 1.30; IQR: 0.15) showed no significant difference from PLA-negative VC (1.25; 95% CI: 1.21, 1.28; IQR: 0.15).

Conclusions: We demonstrate that pulmonary blood mass change is significantly lower in PE-positive patients compared to PE-negative patients, indicating that PBM derived from dynamic non-contrast CT is a potentially useful surrogate for pulmonary perfusion.
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http://dx.doi.org/10.1016/j.clinimag.2021.02.023DOI Listing
October 2021

COVID-19 screening, testing and vaccination: Perceptions from emergency medicine residents and medical students.

Am J Emerg Med 2021 Mar 21. Epub 2021 Mar 21.

Department of Emergency Medicine, University of California, San Diego, San Diego, CA, United States; Department of Computer Science and Engineering, University of California, San Francisco, San Francisco, CA, United States; Department of Biomedical Informatics, University of California, San Diego, San Diego, CA, United States.

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http://dx.doi.org/10.1016/j.ajem.2021.03.048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7981269PMC
March 2021

Pulmonary Blood Mass and Quantitative Lung Function Imaging in Idiopathic Pulmonary Fibrosis.

Radiol Cardiothorac Imaging 2020 Jun 25;2(3):e200003. Epub 2020 Jun 25.

Division of Pulmonary and Critical Care (G.B.N.), Department of Radiology and Molecular Imaging (S.A.K.), and Department of Radiation Oncology (E.C.), Beaumont Health System, Oakland University William Beaumont School of Medicine, 3535 W 13 Mile Rd, Suite 502, Royal Oak, MI 48073.

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http://dx.doi.org/10.1148/ryct.2020200003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7977694PMC
June 2020

Clinical prediction rule for SARS-CoV-2 infection from 116 U.S. emergency departments 2-22-2021.

PLoS One 2021 10;16(3):e0248438. Epub 2021 Mar 10.

Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America.

Objectives: Accurate and reliable criteria to rapidly estimate the probability of infection with the novel coronavirus-2 that causes the severe acute respiratory syndrome (SARS-CoV-2) and associated disease (COVID-19) remain an urgent unmet need, especially in emergency care. The objective was to derive and validate a clinical prediction score for SARS-CoV-2 infection that uses simple criteria widely available at the point of care.

Methods: Data came from the registry data from the national REgistry of suspected COVID-19 in EmeRgency care (RECOVER network) comprising 116 hospitals from 25 states in the US. Clinical variables and 30-day outcomes were abstracted from medical records of 19,850 emergency department (ED) patients tested for SARS-CoV-2. The criterion standard for diagnosis of SARS-CoV-2 required a positive molecular test from a swabbed sample or positive antibody testing within 30 days. The prediction score was derived from a 50% random sample (n = 9,925) using unadjusted analysis of 107 candidate variables as a screening step, followed by stepwise forward logistic regression on 72 variables.

Results: Multivariable regression yielded a 13-variable score, which was simplified to a 13-point score: +1 point each for age>50 years, measured temperature>37.5°C, oxygen saturation<95%, Black race, Hispanic or Latino ethnicity, household contact with known or suspected COVID-19, patient reported history of dry cough, anosmia/dysgeusia, myalgias or fever; and -1 point each for White race, no direct contact with infected person, or smoking. In the validation sample (n = 9,975), the probability from logistic regression score produced an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.79-0.81), and this level of accuracy was retained across patients enrolled from the early spring to summer of 2020. In the simplified score, a score of zero produced a sensitivity of 95.6% (94.8-96.3%), specificity of 20.0% (19.0-21.0%), negative likelihood ratio of 0.22 (0.19-0.26). Increasing points on the simplified score predicted higher probability of infection (e.g., >75% probability with +5 or more points).

Conclusion: Criteria that are available at the point of care can accurately predict the probability of SARS-CoV-2 infection. These criteria could assist with decisions about isolation and testing at high throughput checkpoints.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0248438PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7946184PMC
April 2021

Quantifying pulmonary perfusion from noncontrast computed tomography.

Med Phys 2021 Apr 11;48(4):1804-1814. Epub 2021 Mar 11.

Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, USA.

Purpose: Computed tomography (CT)-derived ventilation methods compute respiratory induced volume changes as a surrogate for pulmonary ventilation. Currently, there are no known methods to derive perfusion information from noncontrast CT. We introduce a novel CT-Perfusion (CT-P) method for computing the magnitude mass changes apparent on dynamic noncontrast CT as a surrogate for pulmonary perfusion.

Methods: CT-Perfusion is based on a mass conservation model which describes the unknown mass change as a linear combination of spatially corresponding inhale and exhale HU estimated voxel densities. CT-P requires a deformable image registration (DIR) between the inhale/exhale lung CT pair, a preprocessing lung volume segmentation, and an estimate for the Jacobian of the DIR transformation. Given this information, the CT-P image, which provides the magnitude mass change for each voxel within the lung volume, is formulated as the solution to a constrained linear least squares problem defined by a series of subregional mean magnitude mass change measurements. Similar to previous robust CT-ventilation methods, the amount of uncertainty in a subregional sample mean measurement is related to measurement resolution and can be characterized with respect to a tolerance parameter . Spatial Spearman correlation between single photon emission CT perfusion (SPECT-P) and the proposed CT-P method was assessed in two patient cohorts via a parameter sweep of . The first cohort was comprised of 15 patients diagnosed with pulmonary embolism (PE) who had SPECT-P and 4DCT imaging acquired within 24 h of PE diagnosis. The second cohort was comprised of 15 nonsmall cell lung cancer patients who had SPECT-P and 4DCT images acquired prior to radiotherapy. For each test case, CT-P images were computed for 30 different uncertainty parameter values, uniformly sampled from the range [0.01, 0.125], and the Spearman correlation between the SPECT-P and the resulting CT-P images were computed.

Results: The median correlations between CT-P and SPECT-P taken over all 30 test cases ranged between 0.49 and 0.57 across the parameter sweep. For the optimal tolerance τ = 0.0385, the CT-P and SPECT-P correlations across all 30 test cases ranged between 0.02 and 0.82. A one-sample sign test was applied separately to the PE and lung cancer cohorts. A low Spearmen correlation of 15% was set as the null median value and two-sided alternative was tested. The PE patients showed a median correlation of 0.57 (IQR = 0.305). One-sample sign test was statistically significant with 96.5 % confidence interval: 0.20-0.63, P < 0.00001. Lung cancer patients had a median correlation of 0.57(IQR = 0.230). Again, a one-sample sign test for median was statistically significant with 96.5 percent confidence interval: 0.45-0.71, P < 0.00001.

Conclusion: CT-Perfusion is the first mechanistic model designed to quantify magnitude blood mass changes on noncontrast dynamic CT as a surrogate for pulmonary perfusion. While the reported correlations with SPECT-P are promising, further investigation is required to determine the optimal CT acquisition protocol and numerical method implementation for CT-P imaging.
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http://dx.doi.org/10.1002/mp.14792DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8252085PMC
April 2021

Age-related incidence and outcomes of sepsis in California, 2008-2015.

J Crit Care 2021 04 23;62:212-217. Epub 2020 Dec 23.

Department of Anesthesiology, University of California San Diego, San Diego, United States of America.

Purpose: Sepsis remains amongst the most common causes of death worldwide. It has been described as a disease of the elderly, but contemporary data on risk factors and mortality is lacking.

Materials And Methods: Multi-center longitudinal cohort study using non-public, state of California data from January 1, 2008 to September 31, 2015. Patients with sepsis, severe sepsis, and septic shock were identified using ICD-9-CM diagnosis and procedure codes with age subgroups of 18-44, 45-64, 65-74, 75-84, and >85 years old. Descriptive statistics and a single direct logistic regression model were used to present data on incidence and mortality and to identify independent factors associated with mortality.

Results: Of 30,282,159 total inpatient encounters, 20,358,569 met inclusion criteria and 1,566,306 met sepsis criteria. Conditions associated with mortality included metastatic cancer, age, liver disease, residing in a care facility, and a gastrointestinal source of infection as well as fungal infection. Mortality in the >85-year-old subgroup with septic shock was 45.7%, lower than previously reported.

Conclusion: Age remains an important sepsis risk factor, but other conditions correlated more closely with sepsis-associated death. Patients over 85 years of age suffering from septic shock may have a better chance of survival than previously thought.
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http://dx.doi.org/10.1016/j.jcrc.2020.12.015DOI Listing
April 2021

An assessment of the correlation between robust CT-derived ventilation and pulmonary function test in a cohort with no respiratory symptoms.

Br J Radiol 2021 Feb 15;94(1118):20201218. Epub 2020 Dec 15.

Department of Radiation Oncology, Beaumont Health, OUWB School of Medicine, Auburn Hills, MI, USA.

Objective: To evaluate CT-ventilation imaging (CTVI) within a well-characterized, healthy cohort with no respiratory symptoms and examine the correlation between CTVI and concurrent pulmonary function test (PFT).

Methods: CT scans and PFTs from 77 Caucasian participants in the NORM dataset (clinicaltrials.gov NCT00848406) were analyzed. CTVI was generated using the robust Integrated Jacobian Formulation (IJF) method. IJF estimated total lung capacity (TLC) was computed from CTVI. Bias-adjusted Pearson's correlation between PFT and IJF-based TLC was computed.

Results: IJF- and PFT-measured TLC showed a good correlation for both males and females [males: 0.657, 95% CI (0.438-0.797); females: 0.667, 95% CI (0.416-0.817)]. When adjusting for age, height, smoking, and abnormal CT scan, correlation moderated [males: 0.432, 95% CI (0.129-0.655); females: 0.540, 95% CI (0.207-0.753)]. Visual inspection of CTVI revealed participants who had functional defects, despite the fact that all participant had normal high-resolution CT scan.

Conclusion: In this study, we demonstrate that IJF computed CTVI has good correlation with concurrent PFT in a well-validated patient cohort with no respiratory symptoms.

Advances In Knowledge: IJF-computed CTVI's overall numerical robustness and consistency with PFT support its potential as a method for providing spatiotemporal assessment of high and low function areas on volumetric non-contrast CT scan.
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http://dx.doi.org/10.1259/bjr.20201218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7934322PMC
February 2021

Clinical Features of Patients with COVID-19: is Temperature Screening Useful?

J Emerg Med 2020 12 21;59(6):952-956. Epub 2020 Sep 21.

Department of Emergency Medicine, University of California San Diego, San Diego, California.

Background: As many businesses reopen after government-induced restrictions, many public agencies and private companies, such as banks, golf courses, and stores, are using temperature screening to assess for possible coronavirus disease 2019 (COVID-19) infection both for patrons and for employees.

Objective: We assessed the frequency of a fever ≥100.4°F and other symptoms associated with COVID-19 among patients in the emergency department (ED) who were tested in the ED for the illness.

Methods: This is a retrospective review of data from patients who were tested for acute COVID-19 infection from March 10, 2020 through June 30, 2020 at two EDs within the same health care system. Data collected included temperature, the presence or recent history of COVID-19-related symptoms, and COVID-19 test results. Descriptive statistics are reported for presenting fever and other COVID-19-related symptoms alone and in combination with presenting fever.

Results: A total of 6894 patients were tested for COVID-19. Among these, 330 (4.8%) tested positive for active infection. Of these patients, 64 (19.4%) presented with a fever ≥100.4°F (≥38.0°C). Increasing the number of COVID-19-related symptoms in combination with a presenting fever ≥100.4°F increased the number of people who could be identified as having a COVID-19 infection.

Conclusions: About a quarter of patients who were tested positive for COVID-19 in our ED did not have a fever at presentation ≥100.4°F. Using only temperature to screen for COVID-19 in the community setting will likely miss the majority of patients with active disease.
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http://dx.doi.org/10.1016/j.jemermed.2020.09.048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7505592PMC
December 2020

Severity of radiation pneumonitis, from clinical, dosimetric and biological features: a pilot study.

Radiat Oncol 2020 Oct 27;15(1):246. Epub 2020 Oct 27.

Department of Respiratory Medicine, Bellvitge University Hospital; L'Hospitalet de Llobregat, Feixa Llarga S/N, 16th Floor, 08907, Barcelona, Spain.

Background And Objective: Radiation pneumonitis (RP) could be a lethal complication of lung cancer treatment. No reliable predictors of RP severity have been recognized. This prospective pilot study was performed to identify early predictors of high grade lung toxicity and to evaluate clinical, biological or dosimetric features associated with different grades of toxicity.

Method: Sixteen patients with non-small cell lung cancer with indication of concurrent chemoradiotherapy using 60 Gy/2 Gy/fraction starting at cycle one of platinum based chemotherapy were included. Bronchoalveolar lavage (BAL), pulmonary function testing (PFT), and F-2-fluoro-2-deoxy-D-glucose positron-emission tomography was performed before radiotherapy (RT), after three weeks of treatment, and two months post-RT. For analysis, patients were grouped by grade (low [G1-G2] vs. high [G3-G5]). The two groups were compared to identify predictors of RP. Protein expression BAL and lung tissue metabolism was evaluated in two patients (RP-G1 vs. RP-G3). Categorical variables such as comorbidities, stages and locations were summarized as percentages. Radiation doses, pulmonary function values and time to RP were summarized by medians with ranges or as means with standard deviation. Longitudinal analysis PFT was performed by a T-test.

Results: All 16 patients developed RP, as follows: G1 (5 pts; 31.3%); G2 (5 pts; 31.3%); G3 (5 pts; 31.3%); and G5 (1 pts; 6.1%). Patients with high grade RP presented significant decrease (p = 0.02) in diffusing lung capacity for carbon monoxide (DLCO) after three weeks of RT. No correlation between dosimetric values and RP grades was observed. BAL analysis of the selected patients showed that CXCL-1, CD154, IL-1ra, IL-23, MIF, PAI-1 and IFN-γ were overexpressed in the lungs of the RP-G3 patient, even before treatment. The pre-RT SUVmax value in the RP-G3 patient was non-significantly higher than in the patient with RP-G1.

Conclusions: RT induces some degree of RP. Our data suggest that decrease in DLCO% is the most sensitive parameter for the early detection of RP. Moreover, we detect biological differences between the two grades of pneumonitis, highlighting the potential value of some cytokines as a prognostic marker for developing high grade lung toxicity. Further multicenter studies with larger sample size are essential to validate these findings.
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http://dx.doi.org/10.1186/s13014-020-01694-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7590478PMC
October 2020

Association of anticoagulation dose and survival in hospitalized COVID-19 patients: A retrospective propensity score-weighted analysis.

Eur J Haematol 2021 Feb 4;106(2):165-174. Epub 2020 Nov 4.

Division of Pulmonary and Critical Care Medicine, Beaumont Health System, OUWB School of Medicine, Royal Oak, MI, USA.

Background: Hypercoagulability may contribute to COVID-19 pathogenicity. The role of anticoagulation (AC) at therapeutic (tAC) or prophylactic doses (pAC) is unclear.

Objectives: We evaluated the impact on survival of different AC doses in COVID-19 patients.

Methods: Retrospective, multi-center cohort study of consecutive COVID-19 patients hospitalized between March 13 and May 5, 2020.

Results: A total of 3480 patients were included (mean age, 64.5 years [17.0]; 51.5% female; 52.1% black and 40.6% white). 18.5% (n = 642) required intensive care unit (ICU) stay. 60.9% received pAC (n = 2121), 28.7% received ≥3 days of tAC (n = 998), and 10.4% (n = 361) received no AC. Propensity score (PS) weighted Kaplan-Meier plot demonstrated different 25-day survival probability in the tAC and pAC groups (57.5% vs 50.7%). In a PS-weighted multivariate proportional hazards model, AC was associated with reduced risk of death at prophylactic (hazard ratio [HR] 0.35 [95% confidence interval {CI} 0.22-0.54]) and therapeutic doses (HR 0.14 [95% CI 0.05-0.23]) compared to no AC. Major bleeding occurred more frequently in tAC patients (81 [8.1%]) compared to no AC (20 [5.5%]) or pAC (46 [2.2%]) subjects.

Conclusions: Higher doses of AC were associated with lower mortality in hospitalized COVID-19 patients. Prospective evaluation of efficacy and risk of AC in COVID-19 is warranted.
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http://dx.doi.org/10.1111/ejh.13533DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675265PMC
February 2021

Technical Note: On the spatial correlation between robust CT-ventilation methods and SPECT ventilation.

Med Phys 2020 Nov 17;47(11):5731-5738. Epub 2020 Oct 17.

Department of Radiation Oncology, Beaumont Health Systems, Royal Oak, MI, USA.

Purpose: The computed tomography (CT)-derived ventilation imaging methodology employs deformable image registration (DIR) to recover respiratory motion-induced volume changes from an inhale/exhale CT image pair, as a surrogate for ventilation. The Integrated Jacobian Formulation (IJF) and Mass Conserving Volume Change (MCVC) numerical methods for volume change estimation represent two classes of ventilation methods, namely transformation based and intensity (Hounsfield Unit) based, respectively. Both the IJF and MCVC methods utilize subregional volume change measurements that satisfy a specified uncertainty tolerance. In previous publications, the ventilation images resulting from this numerical strategy demonstrated robustness to DIR variations. However, the reduced measurement uncertainty comes at the expense of measurement resolution. The purpose of this study was to examine the spatial correlation between robust CT-ventilation images and single photon emission CT-ventilation (SPECT-V).

Methods: Previously described implementations of IJF and MCVC require the solution of a large scale, constrained linear least squares problem defined by a series of robust subregional volume change measurements. We introduce a simpler parameterized implementation that reduces the number of unknowns while increasing the number of data points in the resulting least squares problem. A parameter sweep of the measurement uncertainty tolerance, , was conducted using the 4DCT and SPECT-V images acquired for 15 non-small cell lung cancer patients prior to radiotherapy. For each test case, MCVC and IJF CT-ventilation images were created for 30 different uncertainty parameter values, uniformly sampled from the range . Voxel-wise Spearman correlation between the SPECT-V and the resulting CT-ventilation images was computed.

Results: The median correlations between MCVC and SPECT-V ranged from 0.20 to 0.48 across the parameter sweep, while the median correlations for IJF and SPECT-V ranged between 0.79 and 0.82. For the optimal IJF tolerance , the IJF and SPECT-V correlations across all 15 test cases ranged between 0.12 and 0.90. For the optimal MCVC tolerance , the MCVC and SPECT-V correlations across all 15 test cases ranged between -0.06 and 0.84.

Conclusion: The reported correlations indicate that robust methods generate ventilation images that are spatially consistent with SPECT-V, with the transformation-based IJF method yielding higher correlations than those previously reported in the literature. For both methods, overall correlations were found to marginally vary for , indicating that the clinical utility of both methods is robust to both uncertainty tolerance and DIR solution.
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http://dx.doi.org/10.1002/mp.14511DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7727923PMC
November 2020

Therapeutic Anticoagulation Delays Death in COVID-19 Patients: Cross-Sectional Analysis of a Prospective Cohort.

TH Open 2020 Jul 26;4(3):e263-e270. Epub 2020 Sep 26.

Division of Pulmonary and Critical Care Medicine, Beaumont Health System, Royal Oak, Oakland University William Beaumont School of Medicine, Michigan, United States.

A hypercoagulable state has been described in coronavirus disease 2019 (COVID-19) patients. Others have reported a survival advantage with prophylactic anticoagulation (pAC) and therapeutic anticoagulation (tAC), but these retrospective analyses have important limitations such as confounding by indication. We studied the impact of tAC and pAC compared with no anticoagulation (AC) on time to death in COVID-19. We performed a cross-sectional analysis of 127 deceased COVID-19 patients and compared time to death in those who received tAC (  = 67), pAC (  = 47), and no AC (  = 13). Median time to death was longer with higher doses of AC (11 days for tAC, 8 days for pAC, and 4 days for no AC,  < 0.001). In multivariate analysis, AC was associated with longer time to death, both at prophylactic (hazard ratio [HR] = 0.29; 95% confidence interval [CI]: 0.15 to 0.58;  < 0.001) and therapeutic doses (HR = 0.15; 95% CI: 0.07 to 0.32;  < 0.001) compared with no AC. Bleeding rates were similar among tAC and remaining patients (19 vs. 18%;  = 0.877). In deceased COVID-19 patients, AC was associated with a delay in death in a dose-dependent manner. Randomized trials are required to prospectively investigate the benefit and safety of higher doses of AC in this population.
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http://dx.doi.org/10.1055/s-0040-1716721DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7519875PMC
July 2020

Leveraging Remote Research Associates During a Pandemic.

West J Emerg Med 2020 Jul 21;21(5):1114-1117. Epub 2020 Jul 21.

University of California San Diego, Department of Emergency Medicine, San Diego, California.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has seriously impacted clinical research operations in academic medical centers due to social distancing measures and stay-at-home orders. The purpose of this paper is to describe the implementation of a program to continue clinical research based out of an emergency department (ED) using remote research associates (RA).

Methods: Remote RAs were trained and granted remote access to the electronic health record (EHR) by the health system's core information technology team. Upon gaining access, remote RAs used a dual-authentication process to gain access to a host-based, firewall-protected virtual network where the EHR could be accessed to continue screening and enrollment for ongoing studies. Study training for screening and enrollment was also provided to ensure study continuity.

Results: With constant support and guidance available to establish this EHR access pathway, the remote RAs were able to gain access relatively independently and without major technical troubleshooting. Each remote RA was granted access and trained on studies within one week and self-reported a high degree of program satisfaction, EHR access ease, and study protocol comfort through informal evaluation surveys.

Conclusions: In response to the COVID-19 pandemic, we virtualized a clinical research program to continue important ED-based studies.
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http://dx.doi.org/10.5811/westjem.2020.6.48043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7514379PMC
July 2020

Rates of coinfection with other respiratory pathogens in patients positive for coronavirus disease 2019 (COVID-19).

J Am Coll Emerg Physicians Open 2020 Jul 2. Epub 2020 Jul 2.

Department of Emergency Medicine University of California San Diego California USA.

Objectives: The purpose of this study was to assess coinfection rates of coronavirus disease 2019 (COVID-19) with other respiratory infections on presentation.

Methods: This is a retrospective analysis of data from a 2 hospital academic medical centers and 2 urgent care centers during the initial 2 weeks of testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) , March 10, 2020 to March 23, 2020. Testing was targeted toward high-risk patients following US Centers for Disease Control and Prevention guidelines. Demographics include age group and sex. Laboratory test results included SARS-CoV-2, rapid influenza A/B, and upper respiratory pathogen nucleic acid detection. Patient demographics and coinfections are presented overall and by test results with descriptive statistics.

Results: Complete laboratory results from the first 2 weeks of testing were available for 471 emergency department patients and 117 urgent care center patients who were tested for SARS-CoV. A total of 51 (8.7%) patients tested positive for COVID-19 with only 1 of these patients also testing positive for another respiratory infection. One of the patients positive for COVID-19 also tested positive for influenza A. Among the 537 patients who were screened and tested negative for COVID-19, there were 33 (6.1%) patients who tested positive in the upper respiratory pathogen nucleic acid detection test.

Conclusion: In our study investigating coinfections among 51 patients testing positive for COVID-19, 1 patient also tested positive for influenza A. Although we found limited coinfections in our emergency department and urgent care center patient populations, further research is needed to assess potential coinfection in patients with COVID-19.
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http://dx.doi.org/10.1002/emp2.12172DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7361860PMC
July 2020

Frequent Emergency Department Visitors Associated With a Pain-Discharge Diagnosis.

J Emerg Med 2020 Sep 30;59(3):357-363. Epub 2020 Jul 30.

Department of Emergency Medicine, University of California San Diego, San Diego, California.

Background: Emergency departments (EDs) have experienced an increase in annual patient visits and length of stay over the past decade. Management of frequent-user patients with pain-related diagnoses are challenging in a time-limited setting.

Objective: The purpose of this study was to describe characteristics of frequent ED users with pain-related diagnoses.

Methods: This was a retrospective longitudinal cohort study of hospital ED visits from two EDs in using encounters from September 2016 to August 2018. Frequent users were characterized as having four or more visits in a 1-year period and were further classified into three categories based on the number of pain-related visits in the study period. Descriptive statistics and regression analysis results are reported for all demographic and clinical characteristics for index encounters, patient level data, and pain subgroups.

Results: Of all patients, 11.3% (n = 5174) were identified as frequent users, accounting for 38.9% (n = 91,114) of all ED visits. Overall, frequent pain users were more likely to be of middle age (odds ratio [OR] 1.70, 95% confidence interval [CI] 0.80-1.72), female (OR 2.43, 95% CI 1.79-3.29), have commercial insurance (OR 1.91, 95% CI 1.37-2.66), and have 10 or more ED encounters (super user status) in a 12-month period (OR 23.66, 95% CI 17.12-32.71).

Conclusion: Understanding characteristics of ED frequent users with pain-related diagnoses may inform community-based interventions designed to reduce episodic care and thereby improve care coordination and management.
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http://dx.doi.org/10.1016/j.jemermed.2020.06.058DOI Listing
September 2020

Assessment of stress markers in restrained individuals following physical stress with and without sham CED activation.

J Forensic Leg Med 2020 Aug 26;74:101982. Epub 2020 Jun 26.

Department of Emergency Medicine, University of California, San Diego, CA, USA.

Introduction: Law enforcement and pre-hospital care personnel often confront individuals who must be physically restrained. Many are under the influence of illicit substances, and law enforcement officers may need to use a controlled electrical device (CED) to gain control of the individual and they are often placed into the prone maximum restraint (PMR) position. These techniques have previously been evaluated for their physiologic effects. The purpose of this study was to investigate the psychological effects of anticipating and experiencing a sham CED activation in healthy human subjects who were exercised and restrained compared with no sham activation by assessing the differences in a panel of several known biomarkers of stress.

Methods: We performed a randomized, crossover controlled human subject trial to study the stress associated with exercise, physical exhaustion, and restraint with and without an added psychological stress simulating the field use of a CED. Twenty five total subjects; each subject performed two different trials each consisting of a brief period of intense exercise on a treadmill to exhaustion followed by placement in the PMR with and without induced psychological stress. Blood samples were collected for analysis pre and post exercise, as well as 10 min after completion of the exercise. A panel of hormones and stress markers were measured.

Results: We found no significant differences in any of the stress biomarkers measured between the two study groups. A trend towards higher levels of copeptin was measured in the sham CED activation arm.

Conclusion: During a brief period of intense exercise followed by the psychological stress of anticipated CED application, there did not appear to be statistically significant changes in the stress panel of biomarkers measured, only a trend towards significance for higher copeptin levels in the patients exposed to the psychological stress.
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http://dx.doi.org/10.1016/j.jflm.2020.101982DOI Listing
August 2020

Deep convolutional neural networks for automatic segmentation of thoracic organs-at-risk in radiation oncology - use of non-domain transfer learning.

J Appl Clin Med Phys 2020 Jun;21(6):108-113

Beaumont Artificial Intelligence Research Laboratory, Beaumont Health System, Royal Oak, MI, USA.

Purpose: Segmentation of organs-at-risk (OARs) is an essential component of the radiation oncology workflow. Commonly segmented thoracic OARs include the heart, esophagus, spinal cord, and lungs. This study evaluated a convolutional neural network (CNN) for automatic segmentation of these OARs.

Methods: The dataset was created retrospectively from consecutive radiotherapy plans containing all five OARs of interest, including 22,411 CT slices from 168 patients. Patients were divided into training, validation, and test datasets according to a 66%/17%/17% split. We trained a modified U-Net, applying transfer learning from a VGG16 image classification model trained on ImageNet. The Dice coefficient and 95% Hausdorff distance on the test set for each organ was compared to a commercial atlas-based segmentation model using the Wilcoxon signed-rank test.

Results: On the test dataset, the median Dice coefficients for the CNN model vs. the multi-atlas model were 71% vs. 67% for the spinal cord, 96% vs. 94% for the right lung, 96%vs. 94% for the left lung, 91% vs. 85% for the heart, and 63% vs. 37% for the esophagus. The median 95% Hausdorff distances were 9.5  mm vs. 25.3 mm, 5.1  mm vs. 8.1 mm, 4.0  mm vs. 8.0 mm, 9.8  mm vs. 15.8 mm, and 9.2 mm vs. 20.0 mm for the respective organs. The results all favored the CNN model (P < 0.05).

Conclusions: A 2D CNN can achieve superior results to commercial atlas-based software for OAR segmentation utilizing non-domain transfer learning, which has potential utility for quality assurance and expediting patient care.
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http://dx.doi.org/10.1002/acm2.12871DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7324695PMC
June 2020

Electric scooter craniofacial trauma.

Laryngoscope Investig Otolaryngol 2020 Jun 7;5(3):390-395. Epub 2020 Apr 7.

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery University of California San Diego California USA.

Objective: The use of standing electronic scooters associated with micromobility applications (e-scooters) has risen nationally. The aim of this study was to obtain a detailed view of soft tissue and bony craniofacial injury associated with e-scooter-related trauma.

Methods: Single-institution retrospective case series of patients presenting to a level 1 trauma center emergency department or trauma unit with documented e-scooter-related craniofacial injury.

Results: Of 203 included patients, 188 (92.6%) patients sustained craniofacial injury. One hundred thirty-one (64.5%) had exclusively soft tissue injury, 3 (1.5%) exclusively bony injury, 51 (25.1%) both soft and bony injuries, and twenty-five (12.3%) patients sustained dental injury. Aesthetic units most frequently sustaining acute soft tissue injury were the forehead (n = 106, 34.6%), scalp (n = 36, 11.8%), chin (n = 34, 11.1%), upper lip (n = 32, 10.5%), and cheek (n = 31, 10.1%). Aesthetic subunits most often sustaining acute soft tissue injury included the brow (42, 13.7%), central forehead (39, 12.7%), lateral forehead (n = 25, 8.2%), and upper lip vermillion (n = 23, 7.5%). Craniofacial osseous fracture most often occurred in the orbit (n = 42, 24.6%) and maxilla (n = 40, 23.4%). Individual osseous segments most frequently sustaining acute fracture included the anterior maxillary sinus wall (n = 22, 12.9%), nasal bone (n = 20, 11.7%), lateral orbital wall (n = 16, 9.4%), orbital floor (n = 15, 8.8%), and zygomatic bone (13, 7.6%).

Conclusions: Our analysis demonstrates that most patients presenting to our center with craniofacial trauma sustained acute bony fracture, most often to the midface. Our data of common injuries associated with e-scooter trauma could inform implementation in the form of facial safety equipment or safety skills training for e-scooter riders.

Level Of Evidence: 4.
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http://dx.doi.org/10.1002/lio2.380DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7314474PMC
June 2020

Further study on the physiological effects of an alternative spit mask.

J Forensic Leg Med 2020 May 31;72:101945. Epub 2020 Mar 31.

Department of Emergency Medicine, University of California, San Diego Medical Center, USA.

Objectives: Spit masks are used by law enforcement officers and healthcare providers to protect themselves from the spread of communicable disease by subjects who pose a potential risk of biological exposure by spitting. Little research is available regarding the safety of these masks. However, concerns surround the ability of subjects to properly ventilate while wearing these masks as there are several anecdotal incidents of asphyxiation. A recent pilot study performed by our group showed no significant changes in ventilatory or circulatory parameters in healthy adults wearing a standard spit mask. In this study we aim to further this baseline research by testing physiological parameters in subjects wearing an alternative design of spit mask.

Methods: This prospective study evaluated the changes in respiratory and circulatory parameters in healthy adult subjects wearing a Safariland Tranzport Hood spit mask (SKU: 8320-0-2C) at rest. Baseline measurements of pulse, blood pressure, respiratory rate, oxygen saturation, and end-tidal CO2 were taken while sitting at rest. The spit mask was then placed over the subject's head and repeat measurements were taken at 5, 10, and 15 min. Measurements at 5, 10, and 15 min were compared to baseline using paired t tests with 95% confidence intervals using SPSS.

Results: A total of 15 subjects participated in the study. There was no significant difference between baseline and at 5, 10, and 15 min after spit mask application in heart rate (p = 0.246, p = 0.785, p = 0.502, respectively), oxygen saturation (p = 0.751, p = 0.334, p = 1.00, respectively), respiratory rate (p = 0.866, p = 0.270, p = 0.106, respectively), systolic blood pressure (p = 0.385, p = 0.481, p = 0.182, respectively), and diastolic blood pressure (p = 0.832, p = 0.516, p = 0.597, respectively). For end-tidal CO2, there was no significant difference between baseline and at 10 and 15 min (p = 0.586, p = 0.416, respectively). End-tidal CO2 was significantly increased from baseline at 5 min (p = 0.042).

Conclusions: In healthy adult subjects, there were no clinically significant differences in respiratory or circulatory parameters while wearing the Safariland Tranzport Hood spit mask.
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http://dx.doi.org/10.1016/j.jflm.2020.101945DOI Listing
May 2020

Preliminary Results of Initial Testing for Coronavirus (COVID-19) in the Emergency Department.

West J Emerg Med 2020 03 27;21(3):503-506. Epub 2020 Mar 27.

University of California, San Diego, Department of Emergency Medicine, San Diego, California.

Introduction: On March 10, 2020, the World Health Organization declared a global pandemic due to widespread infection of the novel coronavirus 2019 (COVID-19). We report the preliminary results of a targeted program of COVID-19 infection testing in the ED in the first 10 days of its initiation at our institution.

Methods: We conducted a review of prospectively collected data on all ED patients who had targeted testing for acute COVID-19 infection at two EDs during the initial 10 days of testing (March 10-19, 2020). During this initial period with limited resources, testing was targeted toward high-risk patients per Centers for Disease Control and Prevention guidelines. Data collected from patients who were tested included demographics, clinical characteristics, and test qualifying criteria. We present the data overall and by test results with descriptive statistics.

Results: During the 10-day study period, the combined census of the study EDs was 2157 patient encounters. A total of 283 tests were ordered in the ED. The majority of patients were 18-64 years of age, male, non-Hispanic white, had an Emergency Severity Index score of three, did not have a fever, and were discharged from the ED. A total of 29 (10.2%) tested positive. Symptoms-based criteria most associated with COVID-19 were the most common criteria identified for testing (90.6%). All other criteria were reported in 5.51-43.0% of persons being tested. Having contact with a person under investigation was significantly more common in those who tested positive compared to those who tested negative (63% vs 24.5%, respectively). The majority of patients in both results groups had at least two qualifying criteria for testing (75.2%).

Conclusion: In this review of prospectively collected data on all ED patients who had targeted testing for acute COVID-19 infection at two EDs in the first 10 days of testing, we found that 10.2% of those tested were identified as positive. The continued monitoring of testing and results will help providers understand how COVID-19 is progressing in the community.
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http://dx.doi.org/10.5811/westjem.2020.3.47348DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7234708PMC
March 2020
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