Category: Nevin Manimala

J Pediatr Orthop B. 2021 Sep 21. doi: 10.1097/BPB.0000000000000917. Online ahead of print.

ABSTRACT

OBJECTIVE: We aimed to investigate the progression of patella alta (PA) in patients with cerebral palsy (CP) using the Koshino-Sugimoto (KS) index and assess associated risk factors.

METHOD: Participants in our retrospective study met the following inclusion criteria: patients with CP who visited our institute from May 2003 to December 2019, were ≤18 years of age, were followed up for >2 years and had at least two lateral knee radiographs. KS indices of both knee radiographs were measured for each patient. A linear mixed model was implemented.

RESULTS: Our participants included 222 CP patients. KS index values were measured via 652 knee radiographs. Reference values of the KS index for those between 4 and 18 years of age were determined according to Gross Motor Function Classification System (GMFCS) levels. In all GMFCS levels, the KS index decreased with patients’ ages (P < 0.0001). In groups where the KS index increased, GMFCS levels IV (P = 0.0045) and V (P = 0.0040) were statistically significant.

CONCLUSIONS: Change in the KS index values indicates that PA improves as patients age within all GMFCS levels. However, in patients with GMFCS levels of IV and V, progressive PA is expected.

PMID:34561382 | DOI:10.1097/BPB.0000000000000917

J Trauma Acute Care Surg. 2021 Sep 24. doi: 10.1097/TA.0000000000003418. Online ahead of print.

ABSTRACT

OBJECTIVES: Trauma is a major risk factor for the development of a venous thromboembolism (VTE). After observing higher than expected VTE rates within our center’s Trauma Quality Improvement Program (TQIP) data, we instituted a change in our VTE prophylaxis protocol, moving to enoxaparin dosing titrated by anti-Xa levels. We hypothesized that this intervention would lower our symptomatic VTE rates.

METHODS: Adult trauma patients at a single institution meeting National Trauma Data Standard criteria from April 2015 to September 2019 were examined with regards to VTE chemoprophylaxis regimen and VTE incidence. Two groups of patients were identified based on VTE protocol – those who received enoxaparin 30 mg twice daily without routine anti-Xa levels (“pre”) versus those who received enoxaparin 40 mg twice daily with dose titrated by serial anti-Xa levels (“post”). Univariate and multivariate analyses were performed to define statistically significant differences in VTE incidence between the two cohorts.

RESULTS: There were 1698 patients within the “pre” group and 1406 patients within the “post” group. The two groups were essentially the same in terms of demographics and risk factors for bleeding or thrombosis. There was a statistically significant reduction in VTE rate (p=0.01) and DVT rate (p=0.01) but no significant reduction in PE rate (p = 0.21) after implementation of the anti-Xa titration protocol. Risk-adjusted TQIP data showed an improvement in rate of symptomatic pulmonary embolism from 5th decile to 1st decile.

CONCLUSIONS: A protocol titrating prophylactic enoxaparin dose based on anti-Xa levels reduced VTE rates. Implementation of this type of protocol requires diligence from the physician and pharmacist team. Further research will investigate the impact of protocol compliance and time to appropriate anti-Xa level on incidence of VTE.

LEVEL OF EVIDENCE: IV, therapeutic/care management.

PMID:34561398 | DOI:10.1097/TA.0000000000003418

BMJ Open. 2021 Sep 24;11(9):e048189. doi: 10.1136/bmjopen-2020-048189.

ABSTRACT

OBJECTIVE: This study examines the effects of household shocks on access to healthcare services in Kenya. Shocks are adverse events that lead to loss of household income and/or assets.

DESIGN AND SETTING: The study used data from the Kenya Integrated Household Budget Survey 2015/2016, a nationally representative cross-sectional survey. A propensity score matching approach was applied for the analysis.

PARTICIPANTS: The study sample included 16 297 individuals from households that had experienced shocks (intervention) and those that had not experienced shocks (control) within the last 12 months preceding the survey.

OUTCOME MEASURES: The outcome of interest was access to healthcare services based on an individual’s perceived need for health intervention.

RESULTS: The results indicate that shocks reduce access to healthcare services when household members are confronted with an illness. We observed that multiple shocks in a household exacerbate the risk of not accessing healthcare services. Asset shocks had a significant negative effect on access to healthcare services, whereas the effect of income shocks was not statistically significant. This is presumably due to the smoothing out of income shocks through the sale of assets or borrowing. However, considering the time when the shock occurred, we observed mixed results that varied according to the type of shock.

CONCLUSIONS: The findings suggest that shocks can limit the capacity of households to invest in healthcare services, emphasising their vulnerability to risks and inability to cope with the consequences. These results provoke a debate on the causal pathway of household economic shocks and health-seeking behaviour. The results suggest a need for social protection programmes to integrate mechanisms that enable households to build resilience to shocks. A more viable approach would be to expedite universal health insurance to cushion households from forgoing needed healthcare when confronted with unanticipated risks.

PMID:34561259 | DOI:10.1136/bmjopen-2020-048189

J Investig Med. 2021 Sep 24:jim-2021-002001. doi: 10.1136/jim-2021-002001. Online ahead of print.

ABSTRACT

Tocilizumab is an interleukin receptor inhibitor that has been used in patients with COVID-19 pneumonia. There are recent randomized controlled trials (RCTs) that evaluated the efficacy and safety of tocilizumab in hospitalized patients with COVID-19 pneumonia. We performed a systematic review and meta-analysis of RCTs that evaluated the effectiveness of tocilizumab in hospitalized patients with COVID-19 not requiring mechanical ventilation. RCTs comparing tocilizumab with the standard of care treatment in hospitalized patients with COVID-19 pneumonia not requiring mechanical ventilation at the time of administration were included for analysis. The primary outcome was a composite of mechanical ventilation or 28-day mortality and the secondary outcomes were 28-day mortality and major adverse events. A total of 6 RCTs were included for the analysis. Tocilizumab was associated with a statistically significant reduction in the primary composite outcome of mechanical ventilation or 28-day mortality (risk ratio (RR): 0.83 (95% CI: 0.74 to 0.92, I²=0, tau²=0). Treatment with tocilizumab did not show a statistically significant reduction in 28-day mortality (RR: 0.90 (95% CI: 0.76 to 1.07), I²=0, tau²=0) and rate of serious adverse events (RR: 0.82 (95% CI: 0.62 to 1.10), I²=0, tau²=0). Tocilizumab was associated with a decrease in the incidence of primary outcome, that is, mechanical ventilation or death at 28 days in hospitalized patients with COVID-19 pneumonia.

PMID:34561232 | DOI:10.1136/jim-2021-002001

BMJ Open. 2021 Sep 24;11(9):e046432. doi: 10.1136/bmjopen-2020-046432.

ABSTRACT

OBJECTIVE: To measure knowledge, attitude and practice of antibiotics and antibiotic resistance (ABR) and their determinants in the Eritrean urban population.

DESIGN: A population-based, nation-wide, cross-sectional study.

SETTING: Urban settings of Eritrea.

PARTICIPANTS: Members of the general public aged ≥18 years and living in 13 urban places of Eritrea. Three-stage stratified cluster sampling was used to select the study participants.

DATA COLLECTION AND ANALYSIS: Date were collected from July 2019 to September 2019 in a face-to-face interview using a structured questionnaire. The collected data were double entered and analysed using Census and Survey Processing system (V.7.0) and SPSS (V.23), respectively. Descriptive statistics, χ² test, t-tests, analysis of variance, factorial analysis and multivariable logistic regression were performed. All analyses were weighted and p<0.05 was considered significant.

PRIMARY AND SECONDARY OUTCOME MEASURES: Main outcome variables were knowledge, attitude and practice of antibiotics and ABR. Secondary outcome measure was the determinants of knowledge, attitude and practice.

RESULTS: A total of 2477 adults were interviewed. The mean score of knowledge and attitude of antibiotics and ABR was 10.36/20 (SD=3.51, minimum=0 and maximum=20) and 22.34/30 (SD=3.59, minimum=6 and maximum=30), respectively. Of those who used antibiotics, the proportion of at least one inappropriate practice (use of antibiotics without prescription and/or discontinuation of prescribed antibiotics before completing the full course) was 23.8%. Young age <24 years (adjusted odds ratio (AOR)=1.61, 95% CI: 1.08 to 2.41), male sex (AOR=1.48, 95% CI: 1.14 to 1.91), higher level of education (AOR=1.76, 95% CI: 1.08 to 2.88), and negative attitude towards appropriate use of antibiotics (AOR=0.95, 95% CI: 0.92 to 0.97) were found to be the significant determinants of inappropriate practice of antibiotics.

CONCLUSION: The gap in knowledge and inappropriate practice of antibiotics in the Eritrean urban population was widespread; requiring immediate attention from policy-makers and healthcare professionals.

PMID:34561253 | DOI:10.1136/bmjopen-2020-046432

Eur Urol Focus. 2021 Sep 21:S2405-4569(21)00241-8. doi: 10.1016/j.euf.2021.09.012. Online ahead of print.

ABSTRACT

BACKGROUND: Robot-assisted partial nephrectomy (RAPN) is increasingly adopted for the treatment of localized renal tumors; however, rates and predictors of significant renal function (RF) loss after RAPN are still poorly investigated, especially at a long-term evaluation.

OBJECTIVE: To analyze the predictive factors and develop a clinical nomogram for predicting the likelihood of ultimate RF loss after RAPN.

DESIGN, SETTING, AND PARTICIPANTS: We prospectively evaluated all patients treated with RAPN in a multicenter series (RECORd2 project).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Significant RF loss was defined as >25% reduction in estimated glomerular filtration rate (eGFR) from preoperative assessment at 48th month follow-up after surgery. Uni- and multivariable logistic regression analyses for RF loss were performed. The area under the receiving operator characteristic curve (AUC) was used to quantify predictive discrimination. A nomogram was created from the multivariable model.

RESULTS AND LIMITATIONS: A total of 981 patients were included. The median age at surgery was 64.2 (interquartile range [IQR] 54.3-71.4) yr, and 62.4% of patients were male. The median Charlson Comorbidity Index (CCI) was 1 (IQR 0-2), 12.9% of patients suffered from diabetes mellitus, and 18.6% of patients showed peripheral vascular disease (PVD). The median Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score was 7 (IQR 7-9). Imperative indications to partial nephrectomy were present in 3.6% of patients. Significant RF loss at 48th month postoperative evaluation was registered in 108 (11%) patients. At multivariable analysis, age (p = 0.04), female gender (p < 0.0001), CCI (p < 0.0001), CCI (p < 0.0001), diabetes (p < 0.0001), PVD (p < 0.0001), eGFR (p = 0.02), imperative (p = 0.001) surgical indication, and PADUA score (p < 0.0001) were found to be predictors of RF loss. The developed nomogram including these variables showed an AUC of 0.816.

CONCLUSIONS: We developed a clinical nomogram for the prediction of late RF loss after RAPN using preoperative and surgical variables from a large multicenter dataset.

PATIENT SUMMARY: We developed a nomogram that could represent a clinical tool for early detection of patients at the highest risk of significant renal function impairment after robotic conservative surgery for renal tumors.

PMID:34561199 | DOI:10.1016/j.euf.2021.09.012

Ann Fam Med. 2021 Sep 24:2731. doi: 10.1370/afm.2731. Online ahead of print.

ABSTRACT

We assessed the impact of the COVID-19 pandemic in Spain on new cases of diseases and conditions commonly seen in primary care. In 2020, there were significant reductions from 2017-2019 in the annual incidences of hypertension (40% reduction), hypercholesterolemia (36%), type 2 diabetes (39%), chronic kidney disease (43%), ischemic heart disease (48%), benign prostatic hypertrophy (38%), osteoporosis (40%), hypothyroidism (46%), chronic obstructive pulmonary disease (50%), alcohol use disorder (46%), benign colon polyps and tumors (42%), and melanomas (45%). Prioritization of COVID-19 care changed the physician-patient relationship to the detriment of face-to-face scheduled visits for chronic disease detection and monitoring, which fell by almost 41%. To return to prepandemic levels of diagnosis and management of chronic diseases, primary health care services should reorganize and carry out specific actions for groups at higher risk.

PMID:34561213 | DOI:10.1370/afm.2731

Prim Care Diabetes. 2021 Sep 21:S1751-9918(21)00179-0. doi: 10.1016/j.pcd.2021.09.007. Online ahead of print.

ABSTRACT

BACKGROUND: Gestational diabetes mellitus (GDM) is a high glucose level detected during pregnancy and usually it disappears after 42 days of post partum. The aim of this research was to assess the maternal and newborn effects of GDM in resource limited settings.

METHODS: A prospective cohort was implemented in the five referral hospitals of Amhara region. Data were collected using both primary data collection tool and reviewing the patients’ charts. Descriptive statistics were used to describe the effects of GDM on the pregnancy outcomes, fractional regression was used to estimate the proportion of weight gain in the first 3 months, Poisson regression was used to identify the effects of GDM on the episodes of childhood infectious diseases, independent sample t-test was used to estimate the effects of GDM on the newborn serum zinc and vitamin D levels.

RESULTS: A total of 3459 women were included with a response rate of 85.56%. Cesarean section rate among GDM mother was 40.3% and among GDM free mothers was 7.1%. In the first 3 months, the weight gains of infant born from GDM mothers were 53% higher than infant born from GDM free mothers. GDM increases the risk of infectious disease episodes by 4 folds. GDM decreases the neonatal serum zinc and vitamin D levels.

CONCLUSION: GDM increases the maternal complications of pregnancy; GDM significantly depletes the newborn micronutrient levels and increase the episodes of infectious diseases during the infancy periods.

PMID:34561156 | DOI:10.1016/j.pcd.2021.09.007

Acad Radiol. 2021 Sep 21:S1076-6332(21)00356-1. doi: 10.1016/j.acra.2021.08.003. Online ahead of print.

ABSTRACT

RATIONALE AND OBJECTIVES: Preoperative systemic therapy (PST) followed by mastectomy and radiation improves survival for patients with inflammatory breast cancer (IBC). Residual disease within the skin post-PST adversely impacts surgical outcome and risk of local-regional recurrence (LRR). We aimed to assess magnetic resonance imaging (MRI) breast skin changes post-PST with pathologic response and its impact on surgical resectability.

MATERIALS AND METHODS: We retrospectively reviewed 152 baseline and post-PST breast MRIs of 76 patients with IBC. Using the ACR-BIRADS MRI lexicon, we correlated skin thickness, qualitative enhancement, and kinetic analysis with pathologic response in the skin at mastectomy.

RESULTS: Baseline MRI showed skin thickening in all 76 patients, 75/76 (99%) showed skin enhancement, 54/75 (72%) had medium/fast initial kinetics, usually with persistent delayed kinetics in 49/54 (91%). Following PST, 66/76 (87%) had residual skin thickening with 64/76 (84%) showing a decrease; 33/76 (43%) had persistent enhancement. The median thickness post-PST was 4.7 mm with residual tumor in the skin, and 3.0 mm without residual tumor (p = 0.008). Regardless of pathologic response, the majority of patients had persistent skin thickening on MRI following PST (100% [14/14] with residual tumor and 84% [52/62] without residual tumor). There was no association between post-PST skin thickness on breast MRI and rate of LRR.

CONCLUSION: Patients with IBC have skin thickening and enhancement on baseline breast MRI, with a statistically significant reduction in skin thickness following successful PST. Despite persistent skin changes on MRI, patients achieving a partial or complete parenchymal response to PST may proceed to mastectomy with low LRR rates.

PMID:34561164 | DOI:10.1016/j.acra.2021.08.003

Vaccine. 2021 Sep 21:S0264-410X(21)01226-3. doi: 10.1016/j.vaccine.2021.09.035. Online ahead of print.

ABSTRACT

IMPORTANCE: Passive surveillance systems are susceptible to the under-reporting of adverse events (AE) and a lack of information pertaining to vaccinated populations. Conventional active surveillance focuses on predefined AEs. Advanced data mining tools could be used to identify unusual clusters of potential AEs after vaccination.

OBJECTIVE: To assess the feasibility of a novel tree-based statistical approach to the identification of AE clustering following the implementation of a varicella vaccination program among one-year-olds.

SETTING AND PARTICIPANTS: This nationwide safety surveillance was based on data from the Taiwan National Health Insurance database and National Immunization Information System for the period 2004 through 2014. The study population was children aged 12-35 months who received the varicella vaccine.

EXPOSURE: First-dose varicella vaccine.

OUTCOMES AND MEASURES: All incident ICD-9-CM diagnoses (emergency or inpatient departments) occurring 1-56 days after the varicella vaccination were classified within a hierarchical system of diagnosis categories using Multi-Level Clinical Classifications Software. A self-controlled tree-temporal data mining tool was then used to explore the incidence of AE clustering with a variety of potential risk intervals. The comparison interval consisted of days in the 56-day follow-up period that fell outside the risk interval.

RESULTS: Among 1,194,189 varicella vaccinees with no other same-day vaccinations, nine diagnoses with clustering features were categorized into four safety signals: fever on days 1-6 (attributable risk [AR] 38.5 per 100,000, p < 0.001), gastritis and duodenitis on days 1-2 (AR 5.9 per 100,000, p < 0.001), acute upper respiratory infection on days 1-5 (AR 11.0 per 100,000, p = 0.006), and varicella infection on days 1-9 (AR 2.7 per 100,000, p < 0.001). These safety profiles and their corresponding risk intervals have been identified in previous safety surveillance studies.

CONCLUSIONS: Unexpected clusters of AEs were not detected after the mass administration of childhood varicella vaccines in Taiwan. The tree-temporal statistical method is a feasible approach to the safety surveillance of vaccines in populations of young children.

PMID:34561139 | DOI:10.1016/j.vaccine.2021.09.035