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Item Lessons Learned and Opportunities for CBEMS Growth Following the COVID-19 Pandemic(The Journal of Collegiate Emergency Medical Services, 2022-11-30) Balaji, Adhitya; Robishaw-Denton, JacobItem Complications and Outcomes Associated with Two-Stage Treatment of Periprosthetic Total Knee Infection(2024-04-19) Thomas, Jacob; Ziemba-Davis, Mary; Buller, Leonard T.; Meneghini, R. MichaelBackground: Chronic periprosthetic joint infection (PJI) has been traditionally treated with two-stage revision. However, single-stage treatment is gaining popularity based on claims of decreased morbidity and mortality. This study sought to evaluate whether two-stage treatment for chronic knee PJI is associated with high morbidity and complication rates compared to existing literature. Methods: Prospectively collected data on all two-stage knee revisions were retrospectively reviewed (n=97). Modern perioperative optimization protocols were implemented during the interstage and post-reimplantation periods. Surgical complications were quantified for interstage and post-reimplantation periods. Chi-squared tests compared current findings to published data. Results: Patient sex and age were equivalent, with more current smokers in the present study (P=.001) and more renal failure (P=.002) in the comparison study. Infection complexity in the current study is indicated by 84% late chronic infections in compromised (McPherson) hosts (70%) with 14% polymicrobial infections (unknown for comparison). One percent of cases in the current study did not undergo component reimplantation compared to 8.2% in the comparison study (P=.015). There were no differences in interstage and post-reimplantation septic surgeries (P=.566). Within a year of reimplantation, 9% versus 29% underwent septic reoperation (P=.0002). Using a proposed system from the comparison study penalizing additional operations required to eradicate infection, treatment success rates at minimum one-year follow-up were 56% (current study) and 51% (comparison study) (P=.412). Without these penalties, treatment success in the current study was 64% (unknown for comparison). All-cause mortality rates were the same in both samples (13.4%); however, 9/13 deaths in the current study were unrelated to PJI (unknown for comparison). No patients in the current sample died within the first postoperative year compared to 6.7% in the comparison (P=.024). Conclusion: Study data suggest morbidity attributed to two-stage treatment for PJI reflects the inherent complexity of this patient group, and not the two-stage treatment itself.Item Acute Heart Failure in the Setting of Post-Covid MIS-C: A Case Report(2023-03-24) Luster, Taylor; Sloat, Brittany; Mederos, Alexa; Karam, Marie; Pavlik, Lauren; Duncan, FrancescaIntroduction: Multi-inflammatory Syndrome in Children (MIS-C) has emerged as a rare, but severe complication of SARS-CoV-2 infection. Patients present with persistent fever, abdominal pain, diarrhea, vomiting, rash, mucocutaneous lesions, and in severe cases, shock. The diagnostic criteria are age < 21, fever, laboratory evidence of inflammation, multi-organ involvement, and a positive COVID-19 test or known exposure 4 weeks prior to symptoms onset. Case Description: A 17-year-old female with a history of prior COVID-19 infection presented complaining of chest pain, shortness of breath, headache, and fevers with a Tmax of 105F for 4 days. The patient was hypotensive, tachycardic, tachypneic, and hypoxic. Pertinent labs included: Na 126, BUN 48, Creatinine 2.1, ALT 62, AST 86, WBC 27.4, Hg 10.5, Troponin 0.96, Lactate 3.3, CRP 60, ESR 85, Procalcitonin 75, D-dimer 2.02, Fibrinogen >1000, COVID PCR negative, and COVID Ig-G reactive. CT chest was notable for bibasilar pulmonary opacites, cardiomegaly, and bilateral pleural effusions. Echocardiogram showed left ventricular ejection fraction of 21% and global hypokinesis. She was ultimately intubated due to respiratory failure and started on milrinone and vasopressors. She was treated with IVIG, aspirin, and methylprednisolone for MIS-C. She clinically improved and repeat echo showed an improved EF of 57% and was discharged after 10 days with a prolonged prednisone taper. Clinical Significance: The incidence of MIS-C is 316 per 1 million pediatric SARS-CoV-2 infections. This case demonstrates need for increased awareness of potential acute cardiac failure in adolescents with a recent history of COVID-19 infection, elevated inflammatory markers, and signs of multi-organ failure so that IVIG, aspirin and corticosteroids can be started immediately to avoid progression of MIS-C into acute cardiac failure. Conclusion: Pediatric presentation of SARS-CoV-2 infection can be mild, but there is a subset of patients that have been reported to develop MIS-C, a more severe post viral syndrome.Item Complications and Outcomes Associated with Two-Stage Treatment of Periprosthetic Total Knee Infection(2022-07-22) Thomas, Jacob; Ziemba-Davis, Mary; Meneghini, R. MichaelBackground and Hypothesis: Periprosthetic joint infection (PJI) is treated with implant resection, debridement, and component reimplantation after infection eradication. Treatment consists of either a single surgery or two-stage surgery with intravenous antibiotic therapy between stages. We replicated a recent study which concluded two-stage treatment is associated with high morbidity, hypothesizing that complication rates would be similar, but that morbidity is not always conclusively a consequence of two-stage treatment for PJI Project Methods: Prospectively documented data on all primary and revision knees undergoing two-stage treatment for PJI by a single surgeon were retrospectively reviewed. Surgical complications were quantified for the interstage and post-reimplantation periods. Chi-squared tests were used to compare current findings to published findings. Results: Patient demographics and comorbidities were equivalent in the two studies (p ≥ .137). More complex infections characterized the current study as evidenced by significantly more polymicrobial infections (p < .001) and greater use of static spacers due to bone loss (p = .002). Nonetheless, only 1.5% of cases in the current study did not undergo component reimplantation compared to 7.8% in the comparison study (p = .129). There were no differences in the number of additional interstage and post-reimplantation septic surgeries (p ≥ .492). Using a proposed system which penalizes additional operations required to eradicate infection, treatment success rates at minimum one year follow-up were 64% and 71%, respectively (p = .473). Without these penalties, treatment success in the current study was 95.6% (equivalent proportion not available for comparison study). All-cause mortality was statistically equivalent in the two studies (15.6 versus 7.6%, p = .144) but no deaths from PJI were observed in the current study (unknown for comparison study). Potential Impact: Study findings suggest that morbidity attributed to two-stage treatment reflect the inherent complexity of this patient group, and not the two-stage treatment itself.Item In the Weeds: Identifying the Underlying Etiology in a Patient with Suspected Hypertrophic Obstructive Cardiomyopathy(2024-03-22) Wojciechowska, Klaudia; Denning, Ellen; Bice, Caroline; Nadeem, Manahil; Robles, MariaBACKGROUND Many cases of Hypertrophic Obstructive Cardiomyopathy (HOCM) go undetected or are underdiagnosed. Patients are typically young athletes who experience decreased cardiac output, syncope with exercise, or sudden death. The disease is diagnosed with echo but cannot be certain unless a gene mutation is identified. This creates challenges for those who do not fit the classic profile nor have an identified gene mutation. METHODS A 57 y.o. black female presented with a heart murmur. A referral was made to cardiology where imaging results pointed to HOCM, but due to a history of hypertension (HTN) and missing medical records, an underlying etiology of hypertrophy secondary to HTN could not be ruled out. Genetic testing for HOCM was negative despite the patient’s extensive family history of cardiac disease. Due to these conflicting findings, a cardiac MRI was performed. While HTN could not be ruled out as a contributing factor, HOCM was placed as the leading differential. RESULTS The fragmentation of the patient’s medical records meant that the duration of the murmur and HTN is unknown. In addition, each cardiology provider had different interpretations of the radiologic imaging. The led to difficulties obtaining a diagnosis of HOCM vs HCM due to HTN. Given that the patient did not fit the classic demographic presentation of HOCM, it is possible that the diagnosis was not initially considered. By the time a full work-up had been conducted, her HTN had been poorly controlled for years and therefore delineating the root cause of HOCM was difficult. Lastly, the patient tested negative for the 24 gene mutations linked to HOCM, despite an extensive family history of cardiac disease. This highlights that there are likely more unknown mutations and there is a need for improved diagnostic criteria independent of genetic tests. CONCLUSION This case demonstrates the importance of keeping an expanded differential diagnosis, maintaining coherent and comprehensive medical records, and pursuing prompt diagnoses.Item Anxiety or Arrhythmia: When Delayed Diagnosis Leads to Poor Outcomes(2024-03-22) Morris, Ashlyn; Hornberger, Sydney; O'Farrell, Erin; Jaradat, ZiadItem Decision Making in Fertility Preservation Prior to Pursuing Curative Treatments for Sickle Cell Disease(2023-03-24) Collins, Angela; Noel, Josey; Abraham, Olivia; Hornberger, Sydney; Rahim, Mahvish; Jacob, Seethal; Saraf, AmandaItem Relationship between Pantry Characteristics and Clientele Transportation when Accessing Food Resources in St. Joseph County and Surrounding Areas(2023-11-09) Stone, Jackson; Bales, John; Harris, Jonathan; Lassen, DavidFood insecurity affects approximately 13% of the total population in St. Joseph County. To address this need, various food pantries and soup kitchens have been established by local community organizations. The advent of COVID-19, among other economic instabilities, exacerbated many health disparities within our community and further strained many already overstretched local nonprofits. In a survey of 10 local organizations from June to July 2023, we attempt to characterize the experiences and obstacles faced by pantry clients and directors (474 clients and 65 directors surveyed). An unexpected trend appeared as transportation means of clients was gathered: 84% of surveyed clients utilized pantries by car. Furthermore, some pantries were accessed almost exclusively by automobile, while others saw greater traffic from those walking, biking, and bussing. Clearly, means of transportation played a significant role in determining where individuals sought food aid. To explain these observed differences, we evaluate the relationships between transportation and pantry schedule, pantry location relative to bus lines, client choice in food selection, and provision of on-site meals. Our results indicate that the number of adjacent bus lines and distance to the nearest bus stop affect means of transportation to pantries (p<0.001). Furthermore, the presence of on-site meals, operation hours, and service use limits are tied to clients’ transportation method (p<0.001). To ensure equitable access and efficient food distribution, a continued focus on infrastructure and its alignment with pantry accessibility remains a critical aspect to address in the future.Item Weekend Gun Violence January 1-March 29, 2023 Indianapolis, Indiana.(2023-03-30) Spivey, Erin; Crawford, Jara; Kaur, Amarpreet; Magee, Lauren; Grommon, EricBACKGROUND Gun violence in Indianapolis has been more prevalent on weekends than on weekdays thus far in 2023. OBJECTIVE Examine commonalities and trending of shooting incidents reported by the media occurring on Saturdays and Sundays in comparison to weekdays in Indianapolis. KEY FINDINGS Nearly 50% of all shootings reported by the media in 2023 thus far have occurred on Saturdays or Sundays while weekend days make up just 29% of the week. More non-fatal shootings have occurred on weekends than through the week. The rate of shootings on Saturdays and Sundays (r=33) in 2023 is more than double the rate of shootings occurring on weekdays (r=16.2). The occurrence of weekend shootings in 2023 is 25% higher than the average from 2020 through 2022. More shooting victims have walked into hospitals with gunshot wounds on the weekends than through the week and more shootings that took place during a crime in progress also occurred on weekends.Item Media Reported Fatal and Non-Fatal Shootings Monthly Summary June 2023 Indianapolis, Indiana.(2023-07-08) Spivey, Erin; Crawford, Jara; Kaur, Amarpreet; Magee, Lauren; Grommon, EricBACKGROUND As firearm violence continues to be a focus within media and public safety entities, the monthly trends noted will continue to direct discussions and preventative actions. OBJECTIVE Examine trending in type, time, location, and demographics of media reported fatal and non-fatal shooting incidents and victims in Indianapolis during June 2023. KEY FINDINGS Media reported shootings in June 2023 increased 25% over June 2022 and a 22% increase in the total number of victims. From May to June, a 31% increase in incidents and 36% increase in victims was noted. Non-fatal shootings made up 75% of media reported incidents in June while fatal shootings made up 25%. This is the lowest monthly percentage of fatalities reported in 2023. Based upon media reports, June 11, 2023 surpassed May 6th as the single day with the most shootings and shooting victims, with 11 victims involved in 8 incidents. Noted trends: A reported arrest was made or person of interest detained in 18% of shootings. Multiple victims were involved in 17% of shootings and 14% of victims arrived at the hospital on their own. A non-domestic dispute spurred 11% of shootings in June. The victim was targeted in 8% of incidents and the victim was attending a party in 7% of incidents.