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BackgroundOne in three patients hospitalised due to acute exacerbation of COPD (AECOPD) is readmitted within 90 days. No tool has been developed specifically in this population to predict readmission or death. Clinicians are unable to identify patients at particular risk, yet resources to prevent readmission are allocated based on clinical judgement.MethodsIn participating hospitals, consecutive admissions of patients with AECOPD were identified by screening wards and reviewing coding records. A tool to predict 90-day readmission or death without readmission was developed in two hospitals (the derivation cohort) and validated in: (a) the same hospitals at a later timeframe (internal validation cohort) and (b) four further UK hospitals (external validation cohort). Performance was compared with ADO, BODEX, CODEX, DOSE and LACE scores.ResultsOf 2417 patients, 936 were readmitted or died within 90 days of discharge. The five independent variables in the final model were: Previous admissions, eMRCD score, Age, Right-sided heart failure and Left-sided heart failure (PEARL). The PEARL score was consistently discriminative and accurate with a c-statistic of 0.73, 0.68 and 0.70 in the derivation, internal validation and external validation cohorts. Higher PEARL scores were associated with a shorter time to readmission.ConclusionsThe PEARL score is a simple tool that can effectively stratify patients' risk of 90-day readmission or death, which could help guide readmission avoidance strategies within the clinical and research setting. It is superior to other scores that have been used in this population.Trial registration numberUKCRN ID 14214.

BackgroundHospitalisation due to acute exacerbations of COPD (AECOPD) is common, and subsequent mortality high. The DECAF score was derived for accurate prediction of mortality and risk stratification to inform patient care. We aimed to validate the DECAF score, internally and externally, and to compare its performance to other predictive tools.MethodsThe study took place in the two hospitals within the derivation study (internal validation) and in four additional hospitals (external validation) between January 2012 and May 2014. Consecutive admissions were identified by screening admissions and searching coding records. Admission clinical data, including DECAF indices, and mortality were recorded. The prognostic value of DECAF and other scores were assessed by the area under the receiver operator characteristic (AUROC) curve.ResultsIn the internal and external validation cohorts, 880 and 845 patients were recruited. Mean age was 73.1 (SD 10.3) years, 54.3% were female, and mean (SD) FEV1 45.5 (18.3) per cent predicted. Overall mortality was 7.7%. The DECAF AUROC curve for inhospital mortality was 0.83 (95% CI 0.78 to 0.87) in the internal cohort and 0.82 (95% CI 0.77 to 0.87) in the external cohort, and was superior to other prognostic scores for inhospital or 30-day mortality.ConclusionsDECAF is a robust predictor of mortality, using indices routinely available on admission. Its generalisability is supported by consistent strong performance; it can identify low-risk patients (DECAF 0–1) potentially suitable for Hospital at Home or early supported discharge services, and high-risk patients (DECAF 3–6) for escalation planning or appropriate early palliation.Trial registration numberUKCRN ID 14214.

Pluronic PE9400/water binary systems at different concentrations were characterized by means of rheological and microstructural techniques. Temperature ramps revealed a structural transition defined by three zones, which determine time-dependent behaviors. Thus, non-time-dependent, antithixotropic, and thixotropic behaviors were observed depending on Pluronic’s concentration and temperature. These phenomena were analyzed resorting to rheological tools, namely hysteresis loops and transient tests, and supported by Cryo-SEM. The results obtained demonstrated the shear-sensitive character of these systems. All properties presented by these systems make them adequate and interesting for many applications such as injectable systems for tissue repair.

After 9/11/2001, some Fire Department of New York (FDNY) workers had excessive lung function decline. We hypothesized that early serum matrix metalloproteinases (MMP) expression predicts World Trade Center-Lung Injury (WTC-LI) years later. This is a nested case-control analysis of never-smoking male firefighters with normal pre-exposure Forced Expiratory Volume in one second (FEV1) who had serum drawn up to 155 days post 9/11/2001. Serum MMP-1, 2,3,7,8, 9, 12 and 13 were measured. Cases of WTC-LI (N = 70) were defined as having an FEV1 one standard deviation below the mean (FEV1 ≤ 77%) at subspecialty pulmonary evaluation (SPE) which was performed 32 months (IQR 21-53) post-9/11. Controls (N = 123) were randomly selected. We modeled MMP's ability as a predictor of cases status with logistic regression adjusted for time to blood draw, exposure intensity, weight gain and pre-9/11 FEV1. Each log-increase in MMP-3 and MMP-12 showed reduced odds of developing WTC-LI by 73% and 54% respectively. MMP-3 and MMP-12 consistently clustered together in cases, controls, and the cohort. Increasing time to blood draw significantly and independently increased the risk of WTC-LI. Elevated serum levels of MMP-3 and MMP-12 reduce the risk of developing WTC-LI. At any level of MMP-3 or 12, increased time to blood draw is associated with a diminished protective effect.

Introduction In an observational cohort of patients admitted with AECOPD, thrombocytosis was associated with inpatient and 1-year mortality.1 We aimed to validate, and explore mechanisms for, this association within our original DECAF cohort (n = 920).2 Methods Admission platelet counts were categorised as low (<150), normal (150–400), or high (>400) x109 cells/mm3 and odds ratios assessed for inpatient and, among those surviving to discharge, 1-year mortality (normal platelet count=reference). For inpatient mortality, platelet category and DECAF indices were included in multivariate logistic regression. The areas under the ROC curves for DECAF and DECAF+Platelets were compared by the method of DeLong. Associations with thrombocytosis were analysed using Mann-Whitney or Fisher’s exact test. Causes of death at 1-year due to respiratory, cardiac or malignant disease were recorded. Results Thrombocytosis was associated with inpatient (OR 1.83, 95% CI 1.12–3.00, p = 0.016) and 1-year mortality (OR 1.62 95% CI 1.09–2.30, p = 0.017). Thrombocytopenia was associated with inpatient (OR 3.5, 95% CI 1.51–8.12, p = 0.004), but not 1-year mortality (OR 1.81, 95% CI 0.76–4.312.08, p = 0.181). On multivariate analysis, thrombocytosis (OR 1.85, 95% CI 1.03–3.33 p = 0.039) and thrombocytopenia (OR 3.00 95% CI 1.09–8.24 p = 0.033) independently predicted inpatient mortality, but did not improve predictive power of DECAF (AUROC: DECAF=0.86, DECAF+Platelets=0.86; p = 0.93). Thrombocytosis was associated with a higher white cell count (p<0.001) and eMRCD score (i.e. more breathless when stable; p = 0.001), lower: albumin (p = 0.004), BMI (p = 0.002), FEV1 (p = 0.010), haemoglobin (p<0.001), and a lower proportion of women (p = 0.004), and patients with eosinopenia (<0.05 x 109/l) (p = 0.008), cardiac death (p = 0.044), current smoking (p = 0.046), AF (p = 0.029) and diabetes (p = 0.006). Thrombocytosis was not related to cardiovascular disease, prior exacerbation and readmission rates or LTOT use, admission PaO2, pH or NIV, or length of stay. Discussion Thrombocytosis was an independent predictor of both inpatient mortality and, amongst survivors to discharge, 1-year mortality. Thrombocytosis was not associated with cardiovascular disease and the higher 1-year mortality was not due excess cardiovascular or cancer deaths, suggesting that other mechanisms are responsible. Whilst thrombocytosis was not associated with LTOT use or PaO2, it was associated with other indices of disease severity, including breathlessness and lower FEV1, BMI and albumin level. References Harrison Thorax 2014 Steer Thorax 2012 Abstract S29 Table 1 Platelet category and cause of death Platelet count (x109 cells/mm3) Total patients Inpatient deaths, n(% of total) Deaths at 1 year, n(% of total) Respiratory deaths, n(% of all deaths at 1 year) Cardiovascular deaths, n(% of all deaths at 1 year) Cancer deaths, n(% of all deaths at 1 year) <150 32 825.0 1650.0 1381.3 212.5 16.3 150–400 713 628.7 20328.5 15375.4 2411.8 157.4 >400 175 2614.9 7241.1 6184.7 34.2 56.9

Background: Percutaneous peripheral nerve stimulation (PNS) is a form of neuromodulation that involves the transmission of electrical energy via metal contacts known as leads or electrodes. PNS has gained popularity in orthopedic surgery as several studies have supported its use as a pain control device for patients suffering from pain due to orthopedic pathologies involving the knee, shoulder, and foot. The purpose of this systematic review is to summarize the literature involving peripheral nerve stimulation in orthopedic surgery. The existing body of literature provides support for further research regarding the use of PNS in the management of knee pain, hip pain, shoulder pain, foot pain, and orthopedic trauma. Notably, the evidence for its efficacy in addressing knee and shoulder pain is present. Methods: This study was conducted following PRISMA guidelines. Seven hundred and forty-five unique entries were identified. Two blinded reviewers assessed each article by title and abstract to determine its relevance and categorized them as “include”, “exclude”, and “maybe”. After a preliminary review was completed, reviewers were unblinded and a third reviewer retrieved articles labeled as “maybe” and those with conflicting labels to determine their relevance. Twenty-eight articles were included, and seven hundred and seventeen articles were excluded. Articles discussing the use of PNS in the field of orthopedic surgery in patients > 18 years of age after 2010 were included. Exclusion criteria included neuropathic pain, phantom limb pain, amputation, non-musculoskeletal related pathology, non-orthopedic surgery related pathology, spinal cord stimulator, no reported outcomes, review articles, abstracts only, non-human subjects. Results: A total of 16 studies analyzing 69 patients were included. All studies were either case series or case reports. Most articles involved the application of PNS in the knee (8) and shoulder (6) joint. Few articles discussed its application in the foot and orthopedic trauma. All studies demonstrated that PNS was effective in reducing pain. Discussion: Peripheral nerve stimulation can be effective in managing postoperative or chronic pain in patients suffering from orthopedic pathology. This systematic review is limited by the scarcity of robust studies with substantial sample sizes and extended follow up periods in the existing literature.

The use of cocaine is associated with serious complications including coronary vasospasm and myocardial, renal, intestinal, and neurological ischemia. Among these feared complications lies limb ischemia which is a rare potential side effect of chronic cocaine use. We present the case of a 50-year-old female with an extensive history of cocaine use who developed ischemia in all four limbs. Imaging studies revealed pulmonary emboli, multisystem thromboses, and microhemorrhages in the brain. Laboratory studies were significant for leukocytosis, thrombocytopenia, schistocytes on blood smear, and normal rheumatologic and hematologic studies. The patient was diagnosed with cocaine-induced thrombotic microangiopathy and she was treated symptomatically and with continuous heparin infusion. However, she ultimately requested to be discharged home and was lost to follow-up. Cocaine-induced thrombotic microangiopathy has been reported in only a few other patients to date and although there are some theories describing the possible pathophysiology, a clearly defined explanation has not yet been widely accepted.

ObjectiveBoth psychosocial stress and gestational weight gain are independently associated with adverse maternal and fetal outcomes. Studies of the association between psychosocial stress and gestational weight gain (GWG) have yielded mixed results. The objective of this study was to evaluate the association between psychosocial stress and GWG in a large population-based cohort.MethodsData from the nationally representative Pregnancy Risk Assessment Monitoring System (PRAMS) Phase 7 questionnaire 2012–2015 was utilized. Maternal psychosocial stress was assessed through response to questions designed to examine four domains of psychosocial stress (i.e., traumatic, financial, emotional, partner-related) three months prior to or during pregnancy. GWG was categorized using pre-pregnancy BMI and total GWG into inadequate, adequate, or excessive according to the Institute of Medicine’s GWG guidelines. Multinomial logistic regression was used to evaluate the association between psychosocial stressors and adequacy of GWG. Analyses took into account complex survey design.ResultsAll respondents who delivered ≥ 37 weeks gestation with GWG information available were included in the analysis (n = 119,183). After adjusting for confounders, patients who reported financial stress were more likely to experience excessive versus adequate GWG (RRR 1.09 [95%CI: 1.02–1.17]). Exposure to any of the stressor groups did not significantly increase the risk of inadequate GWG.ConclusionsThis large, population-based study revealed that among pregnant people in the US, exposure to financial stress is associated with higher risk of excessive GWG. Understanding the role stress plays in GWG will help to inform initiatives targeting this important aspect of prenatal care.SignificanceWhat is already known on this subject?Excessive gestational weight gain (GWG) has been linked to postpartum weight retention and long-term adverse maternal and child health outcomes. Multiple studies have shown an association between psychosocial stress and adverse fetal outcomes. Risks of inadequate weight gain include low birthweight and failure to initiate breast-feeding whereas the risks of excessive weight gain include cesarean deliveries and postpartum weight retention for the mother and large-for-gestational-age infants, macrosomia, and childhood overweight or obesity for the offspring.What this study adds?The 2012–2015 Pregnancy Risk Assessment Monitoring System (PRAMS) provides unique nationally representative data in which birth outcomes and maternal weight are linked to psychosocial stressors. Our study is the largest of its kind examining the link between stress and GWG and reveals that exposure to financial stress is associated with higher risk of excessive GWG in the US.

Correspondence to Dr Gilbert J Grant, Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, USA; gilbert.grant@nyumc.org We appreciate Dr Elakkumanan’s interest in the epidural gravity flow technique,1 and we appreciate his concern for its safety. In our study, we administered 15–20 mL of a very dilute solution (bupivacaine 0.04%, epinephrine 1.66 μg/mL, and sufentanil 0.4 μg/mL) to provide labor analgesia.3 Dr Elakkumanan correctly noted that the entire volume was given as a bolus, but we would emphasize that we administered it passively by gravity flow. If practitioners are uncomfortable administering large volume boluses directly through the needle into the epidural space, they have the option of introducing an epidural catheter and then fractionating doses as they prefer. [...]by using saline to perform the gravity flow technique, the need to administer any analgesic or anesthetic through the needle can be obviated.

If pressure variation in sync with the maternal pulse was not present, the needle was resited and the gravity flow technique was repeated. In essence, the gravity flow technique transforms a blind procedure into a procedure that provides objective visual feedback.3 Electronically transduced epidural pressure waveforms serve as a confirmatory adjunct to the loss of resistance technique, reducing the thoracic primary epidural failure rate from 24% to 2% (p<0.002),4 but we are skeptical that electronic transduction will gain acceptance for childbirth, due to impracticalities inherent in a labor and delivery setting. Contributors All authors have met the following four criteria: (1) substantial contributions to the conception or design of the work, or the acquisition, analysis or interpretation of data.