Category: Nevin Manimala

BMC Pediatr. 2022 Nov 26;22(1):682. doi: 10.1186/s12887-022-03742-z.

ABSTRACT

Studies have reported significant effect of geographically shared variables on new-born baby weight. Although there is growing use of community-based child health interventions in public health research, such as through provinces, schools, or health facilities, there has been less interest by researchers to study outlying communities to child birth weight outcomes. We apply multinomial logistic regression model diagnostics to identify outlier communities to child birth weight in Malawi. We use a random sample of 850 clusters, each with at least 7 households based on 2015-16 Malawi demographic and health survey data. There were a total of 11,680 children with measured birth weight, that was categorised as either low ([Formula: see text] grams), normal ([Formula: see text] grams) or high ([Formula: see text] grams). The analyses were done in STATA version 15 and R version 3.6.3. Based on a multinomial logit model with various socio-demographic factors associated with child birth weight, the results showed that two clusters from rural parts of Southern region of Malawi had overly influence on estimated effects of the factors on birth weight. Both clusters had normal to high birth weight babies, with no child having low birth weight. There could be some desired motherhood practices applied by mothers in the two rural clusters worth learning from by policy makers in the child healthcare sector.

PMID:36435771 | DOI:10.1186/s12887-022-03742-z

Cardiovasc Diabetol. 2022 Nov 26;21(1):258. doi: 10.1186/s12933-022-01699-y.

ABSTRACT

BACKGROUND: Diabetes and prediabetes are known risk factors for cardiovascular disease and associated with increased mortality risk. Whether patients with a random elevated blood glucose level but no history of diabetes are at a higher mortality and cardiovascular risk is not entirely known.

METHODS: A retrospective cohort study where patients (18-80 years) with no history of diabetes between 2006 and 2016 attending the emergency department (ED) in Sweden were included. Based on the first (index) blood glucose level patients were categorized into four groups: hypoglycemia (< 3.9 mmol/L), normal glucose tolerance (NGT) (3.9-7.8 mmol/L), dysglycemia (7.8-11.1 mmol/L), and hyperglycemia (> 11.1 mmol/L). Data was collected from four nationwide registers (National Patient Register, National Cause of Death Register, Prescribed Drug Register and Statistics Sweden). Cox regression was used to calculate adjusted hazard ratios (HR) with 95% confidence intervals (CI) for all-cause mortality and cardiovascular outcomes using NGT as reference.

RESULTS: 618,694 patients were included during a mean follow-up time of 3.9 years. According to the index blood glucose level: 1871 (0.3%) had hypoglycemia, 525,636 (85%) had NGT, 77,442 (13%) had dysglycemia, and 13,745 (2%) patients had hyperglycemia, respectively. During follow-up 44,532 (7.2%) deaths occurred. After multiple adjustments, mortality risk was highest in patients with hypoglycemia HR 2.58 (2.26-2.96) followed by patients with hyperglycemia HR 1.69 (1.63-1.76) and dysglycemia HR 1.16 (1.13-1.19). Risk for cardiovascular events: i.e., myocardial infarction, stroke and heart failure, were highest among patients with hyperglycemia HR 2.28 (2.13-2.44), HR 1.62 (1.51-1.74) and HR 1.60 (1.46-1.75), respectively.

CONCLUSION: Patients with disturbed blood glucose level at ED admission have a higher mortality risk than patients with NGT. Patients with hyperglycemia have almost a two folded increased long-term mortality risk and more than a doubled risk for cardiovascular events compared to patients with NGT.

PMID:36435766 | DOI:10.1186/s12933-022-01699-y

BMC Musculoskelet Disord. 2022 Nov 26;23(1):1017. doi: 10.1186/s12891-022-05872-y.

ABSTRACT

BACKGROUND: This study assessed surgical accuracy and functional outcomes using hand-held accelerometer-based navigation following total knee arthroplasty (TKA).

QUESTION: (1) Does hand-held navigation (the iAssist system) improve surgical accuracy (assessed with five parameters commonly used to evaluate surgical alignment: the hip-knee-ankle angle (HKA), femoral coronal angle (FCA), tibial coronal angle (TCA), femoral sagittal angle (FSA), and tibial slope angle (TSA)) compared to conventional instruments in TKA? (2) Which surgical alignment parameters among HKA, FCA, TCA, FSA, and TSA can obtain the most advantage from the iAssist system? (3) Does the iAssist system lead to better functional outcomes at two years of follow-up after TKA?

METHODS: This parallel-group double-blinded randomized controlled trial recruited 60 patients (30 patients each in the iAssist and conventional group) with osteoarthritis who underwent primary TKA by a single surgeon at Siriraj Hospital. There was no loss to follow-up in the study. All procedures in both groups were performed using similar surgical exposure, prosthesis implant, perioperative and postoperative protocols. Participants in the iAssist group received the iAssist system as an assistive technique, while those in the conventional group only had conventional instruments. Surgical alignments (HKA, FCA, TCA, FSA, and TSA) were recorded using CT scan at six weeks post-operation. Functional outcomes were assessed with knee ROM, KSS, and EQ-5D at 6 months, 1 year and 2 years post-operation. Baseline characteristics including age, sex, the affected knee side, and body mass index were comparable between the two groups, similar to preoperative ROM, KSS, and EQ-5D.

RESULTS: The mean operative time was relatively longer in the iAssist than the conventional group, although not statistically significant (88.1 ± 13.7 versus 83.4 ± 21.3; p = 0.314). Among the surgical alignment parameters evaluated, FCA was the only radiographic parameter with a statistically significant difference between the two groups and was closer to 90º in the iAssist group (89.4 ± 2.2 in the iAssist versus 87.2 ± 2.1 in the conventional group; p = 0.003). Also, there was a higher proportion of outliers in the conventional than the iAssist group (23.3% versus 10%; p = 0.086). Nonetheless, HKA and TCA did not differ between the two groups (p = 0.25 and 0.096, respectively), although the percentages of outliers were higher in the conventional than the iAssist group (HKA: 26.7% vs. 13.3%; p = 0.101 and TCA: 6.7% versus 0%; p = 0.078). Likewise, we observed other radiographic parameters had no significant group differences, including FSA and TSA. Furthermore, at two years post-operation, we found no differences between the iAssist and the conventional group in knee ROM (106.7 ± 14.6 versus 108.2 ± 12.7; p = 0.324), KSS (82.5 ± 6.4 versus 83.8 ± 3.4; p = 0.324), and EQ-5D (0.9 ± 0.2 versus 1.0 ± 0.1; p = 0.217). All functional outcomes were also comparable at 6 months and 12 months of follow-up postoperatively.

CONCLUSION: The iAssist technology increase surgical precision by allowing for a more precise FCA with fewer outliers than conventional equipment. iAssist had longer operative time. Functional outcomes and quality of life were not different.

LEVEL OF EVIDENCE: I.

PMID:36435760 | DOI:10.1186/s12891-022-05872-y

BMC Anesthesiol. 2022 Nov 26;22(1):362. doi: 10.1186/s12871-022-01905-0.

ABSTRACT

BACKGROUND: Intensivists play an essential role in improving the outcomes of critically ill patients in intensive care units (ICUs). The transition of ICU physician staffing from low-intensity ICUs (elective intensivist or no intensivist consultation) to high-intensity ICUs (mandatory intensivist consultation or a closed ICU) improves clinical outcomes. However, whether a transition from high-intensity to low-intensity ICU staffing affects ICU outcomes and quality of care remains unknown.

METHODS: A retrospective observational study was conducted to examine the impact of high- versus low-intensity staffing models on all-cause mortality in a suburban secondary community hospital with 400 general beds and 8 ICU beds. The ICU was switched from a high-intensity staffing model (high-former period) to low-intensity staffing in July 2019 (low-mid period) and then back to high-intensity staffing in March 2020 (high-latter period). Patients admitted from the emergency department, general ward, or operating room after emergency surgery were enrolled in these three periods and compared, balancing the predicted mortality and covariates of the patients. The primary outcome was all-cause mortality analyzed using hazard ratios (HRs) from Cox proportional hazards regression. An interrupted time-series analysis (ITSA) was also conducted to evaluate the effects of events (level change) and time.

RESULTS: There were 962 eligible admissions, of which 251, 213, and 498 occurred in the high-former, low-mid, and high-latter periods, respectively. In the matched group (n = 600), the all-cause mortality rate comparing the high-former period with the low-mid period showed an HR of 0.88 [95% confidence interval (CI), 0.56, 1.39; p = 0.58] and that comparing the high-latter period with the low-mid period showed an HR of 0.84 [95% CI, 0.54, 1.30; p = 0.43]. The result for comparison between the three periods was p = 0.80. ITSA showed level changes of 4.05% [95% CI, -13.1, 21.2; p = 0.63] when ICU staffing changed from the high-former to the low-mid period and 1.35% [95% CI, -13.8, 16.5; p = 0.86] when ICU staffing changed from the low-mid to the high-latter period.

CONCLUSION: There was no statistically significant difference in all-cause mortality among the three ICU staffing periods. This study suggests that low-intensity ICU staffing might not worsen clinical outcomes in the ICU in a medium-sized community hospital. Multiple factors, including the presence of an intensivist, other medical staff, and practical guidelines, influence the prognosis of critically ill patients.

PMID:36435755 | DOI:10.1186/s12871-022-01905-0

BMC Pregnancy Childbirth. 2022 Nov 26;22(1):877. doi: 10.1186/s12884-022-05203-y.

ABSTRACT

BACKGROUND: Pregnant women expecting twins are more likely to experience stress, which can lead to anxiety and depression. Our aim was to investigate the prevalence of prenatal anxiety and depressive symptoms in women with twin pregnancies and the associated factors.

METHODS: In a cross-sectional survey, 210 women with twin pregnancies who satisfied the inclusion and exclusion criteria in two tertiary centers in Southwestern China were asked to complete a basic information form, the Self-Rating Anxiety Scale (SAS) and the Self-Rating Depression Scale (SDS). To compare statistics with normal distribution in distinct characteristic groups, a paired t-test, and one-way ANOVA were utilized. Binary logistic step regression was used to analyze the associated factors of antenatal anxiety and depressive symptoms.

RESULTS: The 210 women with twin pregnancies (age = 30.8 ± 4.2 years) were between 7 and 37 gestational weeks (29.2 ± 1.2 weeks), were typically well-educated (72.4% had a post-high-school degree), and reasonably affluent (88.1% were above the low-income cutoff). Among them, 34.8% had symptoms associated with clinical levels of anxiety, and 37.1% had symptoms indicating possible depression. The prevalence of co-morbid anxiety and depressive symptoms was 24.3%. Binary stepwise logistic regression analysis showed that previous health status and sleep disturbance during pregnancy were the associated factors of anxiety symptoms in women with twin pregnancies (P < 0.05), whereas age, previous health status, negative life events, and physical activity during pregnancy were the associated factors of depressive symptoms in women with twin pregnancies (P < 0.05).

CONCLUSION: About one-third of women with twin pregnancies had symptoms of anxiety or depression; these were most strongly predicted by some modifiable factors, suggesting that early preventive mind-body interventions may be a promising strategy to protect against mental health issues for women with twin pregnancies.

PMID:36435754 | DOI:10.1186/s12884-022-05203-y

Eur Urol Oncol. 2022 Nov 23:S2588-9311(22)00178-X. doi: 10.1016/j.euo.2022.10.008. Online ahead of print.

ABSTRACT

BACKGROUND: Optimising therapeutic strategies of intermediate-risk non-muscle-invasive bladder cancer (IR-NMIBC) is needed.

OBJECTIVE: To compare recurrence-free survival (RFS) with adjuvant intravesical mitomycin C (MMC) at normothermia or hyperthermia using the COMBAT bladder recirculation system at 43 °C for 30 and 60 min.

DESIGN, SETTING, AND PARTICIPANTS: A prospective open-label, phase 3 randomised controlled trial (HIVEC-1) accrued across 13 centres between 2014 and 2020 in Spain. After complete transurethral resection of the bladder and immediate postoperative MMC instillation, patients with IR-NMIBC were randomised (1:1:1) to four weekly followed by three monthly 40-mg MMC instillations at normothermia (control; n = 106), 43 °C for 30 min (n = 107), or 43 °C for 60 min (n = 106) were investigated. Therapeutic compliance was defined as four or more instillations.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was RFS at 24 mo in the intention-to-treat (ITT) and per-protocol (PP) populations. The secondary outcomes included progression-free survival at 24 mo, safety outcome measures, and changes in health-related quality of life. Log-rank, Fisher, χ², and analysis of variance tests were used.

RESULTS AND LIMITATIONS: The ITT 24-mo RFS was 77% for control, 82% for 43 °C-30 min, and 80% for 43 °C-60 min (p = 0.6). The PP 24-mo RFS was 77% for control, 83% for 43 °C-30 min, and 80% for 43 °C-60 min (p = 0.59). Six patients progressed to muscle-invasive disease in the ITT population (four in the control, 43 °C-30 min, and 43 °C-60 min groups each) and four in the PP population (all controls). Serious adverse events occurred in 26 patients (8.1%), and we were unable to demonstrate a difference between groups (p = 0.5). Adverse events, mainly dysuria and spasms, occurred in 124 patients (33% in control, 35% in 43 °C-30 min, and 48% in 43 °C-60 min; p = 0.05). The total International Prostate Symptom Score worsened by 1.2 ± 7.3 points, similarly across groups (p = 0.29). The Functional Assessment of Cancer Therapy-Bladder domains and indexes showed no significant change.

CONCLUSIONS: Four-month adjuvant hyperthermic MMC using the COMBAT system for 30 and 60 min in IR-NMIBC is well tolerated, but we did not find it to be superior to normothermic MMC at 24 mo.

PATIENT SUMMARY: We were unable to demonstrate the effectiveness of hyperthermia using the COMBAT system in intermediate-risk non-muscle-invasive bladder cancer. Further evaluation of long-term recurrence and progression, and maintenance regimens appears mandatory.

PMID:36435738 | DOI:10.1016/j.euo.2022.10.008

J Surg Educ. 2022 Nov 23:S1931-7204(22)00295-1. doi: 10.1016/j.jsurg.2022.10.011. Online ahead of print.

ABSTRACT

OBJECTIVE: In March 2020, COVID-19 was declared a pandemic by the World Health Organization. This led to the outright cancellation of away rotations and in person residency interviews for the class of 2021. This study aims to identify the geographic relationships in the orthopedic match and further explore COVID-19’s effect on these geographic relationships. Furthermore, we aim to compare the home program match rates before and after COVID-19.

SETTING: Southern Illinois University School of Medicine, Department of Orthopedic Surgery (tertiary, university-based).

DESIGN AND PARTICIPANTS: Residency websites and social media sites were used to record basic residency information as well as each resident’s year, matriculated medical school, and matriculated medical school geographic data. This information was used to evaluate the proportion of orthopedic residents from “home program” medical schools and evaluate the geographic relationship of matched orthopedic residents. 202 Orthopedic residencies were initially identified and 134 allopathic and nonmilitary residency programs met the inclusion criteria. In all, 3253 of the 3931 (82.7%) current U.S orthopedic residents were included in the analysis.

RESULTS: In the 4 orthopedic surgery residency classes before the pandemic (2017-2020), 21.8% of residency slots were filled by home program students. During the pandemic match cycle (2021), this number jumped to 28.2% (p < 0.0006). The increase was observed consistently across residency subgroup analysis: class size, doximity rank, and doximity research rank. Correspondingly, there was a statistically significant increase from 34.7% (2017-2020) to 39.3% (2021) (p = 0.0318) in residencies matching with same state medical students. Regional trends stayed consistent. Our study showed that residency programs matched applicants who went to same region medical schools during the 2020 to 2021 cycle at nearly the exact same rate as they did pre-pandemic (63.6%, up from 63.3%).

CONCLUSIONS: Our study demonstrates that despite widespread virtual away rotations and virtual open houses, residency programs showed an increased preference for their home program students. This trend was significant and widespread, highlighting the generalized nationwide hesitation of both residency programs and students on the virtual interview process.

PMID:36435733 | DOI:10.1016/j.jsurg.2022.10.011

Urol Oncol. 2022 Nov 23:S1078-1439(22)00427-6. doi: 10.1016/j.urolonc.2022.10.026. Online ahead of print.

ABSTRACT

OBJECTIVES: To evaluate whether a restaging transurethral resection of bladder tumor (TURBT) is necessary in high-risk nonmuscle invasive bladder cancer (NMIBC) if the initial TURBT was performed using blue light (BL) technology.

METHODS AND MATERIALS: Using the multi-institutional Cysview registry between 2014 and 2021, all consecutive adult patients with known NMIBC (Ta and T1 disease) who underwent TURBT followed by a restaging TURBT within 8 weeks were reviewed. Patients were stratified according to their initial TURBT, BL vs. white light (WL), and compared to determine rates of residual disease and upstaging. Univariate analysis was performed using Mann-Whitney U and chi-square tests, with P < 0.05 considered significant.

RESULTS: Overall, 115 patients had TURBT for NMIBC followed by a restaging TURBT within 8 weeks and were included in the analysis. Patients who underwent BL compared to WL for their initial TURBT had higher rates of benign pathology on restaging TURBT, although this was not statistically significant (47% vs. 30%; P = 0.08). Of patients with residual tumors on restaging TURBT, there were no differences in rates of Ta (22% vs. 26.5%; P = 0.62), T1 (22% vs. 26.5%; P = 0.62), or CIS (5.5% vs. 13%; P = 0.49) when the initial TURBT was done using BL compared to WL. Rates of upstaging to muscle invasive disease were also not different when initial TURBT was performed using BL compared to WL (3% vs. 4%; P = 0.78).

CONCLUSIONS: TURBT using BL does not reduce rates of residual disease or risk of upstaging on restaging TURBT in Ta or T1 disease. Thus, a restaging TURBT is still necessary even if initial TURBT was performed using BL.

PMID:36435710 | DOI:10.1016/j.urolonc.2022.10.026

Br J Anaesth. 2022 Nov 23:S0007-0912(22)00593-1. doi: 10.1016/j.bja.2022.10.022. Online ahead of print.

NO ABSTRACT

PMID:36435666 | DOI:10.1016/j.bja.2022.10.022

J Am Geriatr Soc. 2022 Nov 26. doi: 10.1111/jgs.18134. Online ahead of print.

ABSTRACT

BACKGROUND: CT head is commonly performed in the setting of delirium and altered mental status (AMS), with variable yield. We aimed to evaluate the yield of CT head in hospitalized patients with delirium and/or AMS across a variety of clinical settings and identify factors associated with abnormal imaging.

METHODS: We included studies in adult hospitalized patients, admitted to the emergency department (ED) and inpatient medical unit (grouped together) or the intensive care unit (ICU). Patients had a diagnosis of delirium/AMS and underwent a CT head that was classified as abnormal or not. We searched Medline, Embase and other databases (informed by PRISMA guidelines) from inception until November 11, 2021. Studies that were exclusively performed in patients with trauma or a fall were excluded. A meta-analysis of proportions was performed; the pooled proportion of abnormal CTs was estimated using a random effects model. Heterogeneity was determined via the I² statistic. Factors associated with an abnormal CT head were summarized qualitatively.

RESULTS: Forty-six studies were included for analysis. The overall yield of CT head in the inpatient/ED was 13% (95% CI: 10.2%-15.9%) and in ICU was 17.4% (95% CI: 10%-26.3%), with considerable heterogeneity (I² 96% and 98% respectively). Heterogeneity was partly explained after accounting for study region, publication year, and representativeness of the target population. Yield of CT head diminished after year 2000 (19.8% vs. 11.1%) and varied widely depending on geographical region (8.4%-25.9%). The presence of focal neurological deficits was a consistent factor that increased yield.

CONCLUSION: Use of CT head to diagnose the etiology of delirium and AMS varied widely and yield has declined. Guidelines and clinical decision support tools could increase the appropriate use of CT head in the diagnostic etiology of delirium/AMS.

PMID:36434820 | DOI:10.1111/jgs.18134