Category: Nevin Manimala

J Trauma Acute Care Surg. 2021 Jun 1;90(6):996-1002. doi: 10.1097/TA.0000000000003128.

ABSTRACT

BACKGROUND: Emergency general surgery (EGS) is a high-volume and high-risk surgical service. Interhospital variation in EGS outcomes exists, but there is disagreement in the literature as to whether hospital admission volume affects in-hospital mortality. Scotland collects high-quality data on all admitted patients, whether managed operatively or nonoperatively. Our aim was to determine the relationship between hospital admission volume and in-hospital mortality of EGS patients in Scotland. Second, to investigate whether surgeon admission volume affects mortality.

METHODS: This national population-level cohort study included EGS patients aged 16 years and older, who were admitted to a Scottish hospital between 2014 and 2018 (inclusive). A logistic regression model was created, with in-hospital mortality as the dependent variable, and admission volume of hospital per year as a continuous covariate of interest, adjusted for age, sex, comorbidity, deprivation, surgeon admission volume, surgeon operative rate, transfer status, diagnosis, and operation category.

RESULTS: There were 376,076 admissions to 25 hospitals, which met our inclusion criteria. The EGS hospital admission rate per year had no effect on in-hospital mortality (odds ratio [OR], 1.000; 95% confidence interval [CI], 1.000-1.000). Higher average surgeon monthly admission volume increased the odds of in-hospital mortality (>35 admissions: OR, 1.139; 95% CI, 1.038-1.250; 25-35 admissions: OR, 1.091; 95% CI, 1.004-1.185; <25 admissions was the referent).

CONCLUSION: In Scotland, in contrast to other settings, EGS hospital admission volume did not influence in-hospital mortality. The finding of an association between individual surgeons’ case volume and in-hospital mortality warrants further investigation.

LEVEL OF EVIDENCE: Care management, Level IV.

PMID:34016923 | DOI:10.1097/TA.0000000000003128

J Trauma Acute Care Surg. 2021 Jun 1;90(6):1032-1039. doi: 10.1097/TA.0000000000003162.

ABSTRACT

INTRODUCTION: Previously, in a murine model of blunt thoracic trauma, we provided evidence of primary pulmonary thrombosis associated with increased expression of the cell adhesion molecule, P-selectin. In this study, mice are treated with P-selectin blocking antibody after injury to investigate the clinical viability of this antibody for the prevention of pulmonary thrombosis. In addition, viscoelastic testing is performed to investigate if P-selectin inhibition has a detrimental impact on normal hemostasis.

METHODS: A murine model of thoracic trauma was used. Mice were divided into sham control and experimental injury groups. Thirty minutes after trauma, mice were treated with the following: P-selectin blocking antibody, isotype control antibody, low-dose heparin, high-dose heparin, or normal saline. At 90 minutes, whole blood was collected for characterization of coagulation by viscoelastic coagulation monitor (VCM Vet; Entegrion, Durham, NC). Mean clotting time, clot formation time, clot kinetics (α angle), and maximum clot firmness were compared between each treatment group.

RESULTS: Mice that received P-selectin antibody 30 minutes after blunt thoracic trauma had four- to fivefold less (p < 0.001) arterial fibrin accumulation than those that received the isotype control. In both sham and trauma groups, compared with vehicle (normal saline) alone, no statistical difference was noted in any coagulation parameters after injection with P-selectin antibody, isotype control, or low-dose heparin. In addition, blinded histopathological evaluation yielded no difference in hemorrhage scores between injured mice treated with P-selectin blocking antibody and those treated with isotype antibody control.

CONCLUSION: This study supports the clinical use of P-selectin blocking antibody for the prevention of pulmonary thrombosis by confirming its efficacy when given after a blunt thoracic trauma. In addition, we demonstrated that the administration of P-selectin antibody does not adversely affect systemic coagulation as measured by viscoelastic testing, suggesting that P-selectin antibody can be safely given during the acute posttraumatic period.

PMID:34016926 | DOI:10.1097/TA.0000000000003162

Prosthet Orthot Int. 2021 May 18. doi: 10.1097/PXR.0000000000000017. Online ahead of print.

ABSTRACT

BACKGROUND: The Scottish Specialist Prosthetics Service has provided microprocessor knees (MPKs) through the National Health Service since 2014, predominantly to high-activity transfemoral amputations (TFAs). Benefits of MPKs to the lower-activity TFA are less established in the literature.

OBJECTIVES: This study aimed to compare patient-reported and functional measures in low-activity TFAs transitioning from a mechanical knee to a MPK.

STUDY DESIGN: This is a retrospective cohort analysis of low-activity individuals with a unilateral TFA provided with an MPK.

METHODS: Patient-reported measures were recorded in routine clinical care before and 6 months after MPK provision. These included HR-QoL (EQ-5D-5L Health Index), Activities Balance Confidence score, Prosthetic Limb User Survey of Mobility, falls frequency, use of walking aids, and Socket Comfort Score. Functional measures included the two-minute walk test (2MWT), L-test, and Amputee Mobility Predictor score, and three-dimensional gait analysis was used to generate a Gait Profile Score (GPS). The primary outcomes were HR-QoL and GPS.

RESULTS: Forty-five participants fulfilled the inclusion criteria. Thirty-one had pre-MPK and post-MPK measures, of which 15 had three-dimensional gait analysis. The mean age (n = 31) was 60 years (SD 11), and 68% were male. HR-QoL and GPS did not significantly improve with MPK provision (p = 0.014 and p = 0.019); Amputee Mobility Predictor score, L-Test, 2MWT, falls, and Activities Balance Confidence score showed a significant improvement with MPK provision (p < 0.001).

CONCLUSIONS: Although no statistically significant change in the primary outcomes was measured, there were sufficient data to support MPK provision in low-activity prosthetic users with participants demonstrating improvements in balance, 2MWT, falls frequency, and confidence.

PMID:34016872 | DOI:10.1097/PXR.0000000000000017

J Pediatr Gastroenterol Nutr. 2021 May 13. doi: 10.1097/MPG.0000000000003153. Online ahead of print.

ABSTRACT

OBJECTIVES: To advance our understanding of monogenic forms of intrahepatic cholestasis.

METHODS: Analyses included participants with pathogenic biallelic mutations in ABCB11 (bile salt export pump; BSEP) or ATP8B1 (familial intrahepatic cholestasis; FIC1), or those with monoallelic or biallelic mutations in ABCB4 (multidrug resistance; MDR3), prospectively enrolled in the Longitudinal Study of Genetic Causes of Intrahepatic Cholestasis (LOGIC; NCT00571272) between 11/2007-12/2013. Summary statistics were calculated to describe baseline demographics, history, anthropometrics, laboratory values, and mutation data.

RESULTS: Ninety-eight participants with FIC1 (n = 26), BSEP (n = 53, including 8 with biallelic truncating mutations [severe] and 10 with p.E297G or p.D482G [mild]), or MDR3 (n = 19, including 4 monoallelic) deficiency were analyzed. Thirty-five had surgical interruption of the enterohepatic circulation (sEHC), including 10 who underwent liver transplant (LT) after sEHC. Onset of symptoms occurred by age 2 years in most with FIC1 and BSEP deficiency, but was later and more variable for MDR3. Pruritus was nearly universal in FIC1 and BSEP deficiency. In participants with native liver, failure to thrive was common in FIC1 deficiency, high ALT was common in BSEP deficiency, and thrombocytopenia was common in MDR3 deficiency. sEHC was successful after more than 1 year in 7 of 19 participants with FIC1 and BSEP deficiency. History of LT was most common in BSEP deficiency. Of 102 mutations identified, 43 were not previously reported.

CONCLUSIONS: In this cohort, BSEP deficiency appears to be correlated with a more severe disease course. Genotype-phenotype correlations in these diseases are not straightforward and will require study of larger cohorts.

An infographic is available for this article at: http://links.lww.com/MPG/C343.

PMID:34016879 | DOI:10.1097/MPG.0000000000003153

J Pediatr Gastroenterol Nutr. 2021 May 11. doi: 10.1097/MPG.0000000000003167. Online ahead of print.

ABSTRACT

OBJECTIVES: While the use of telemedicine has accelerated significantly with the recent pandemic, it has also magnified disparities in access to telemedicine. This study aims to look at telemedicine utilization patterns within a large pediatric gastroenterology practice.

METHODS: A retrospective study of ambulatory care visits within Yale-New Haven Hospital’s pediatric gastroenterology practice during the peak expansion of the telemedicine program was conducted. Zip code level socioeconomic data was obtained using the Distressed Community Index (DCI). A multivariate logistic regression to evaluate disparities between the use of video versus telephone visits was computed, and unadjusted and adjusted odds ratios (OR) with 95% confidence intervals were obtained.

RESULTS: 1273 clinic visits were included in analysis. The majority of patients listed English as their preferred language, had private insurance, and identified as non-Hispanic White. When adjusting for co-variates, having public insurance/Medicaid was associated with decreased odds of having video over telephone visits (aOR 0.60; 95% CI 0.44 – 0.80). Those whose primary language was not English continued to have a statistically significant decreased odds of using video visits (Spanish aOR 0.24; 95% CI 0.13 – 0.44; Other aOR 0.29; 95% CI 0.12 – 0.72). However, within the adjusted multivariate logistic regression, race/ethnicity and SES were no longer found to have a statistically significant decreased odds of video visits.

CONCLUSIONS: The accelerated implementation of telemedicine within pediatric gastroenterology has given rise to disparities in its use. Further studies are needed to understand these disparities and develop interventions to lessen this gap in usage.

An infographic is available for this article at:http://links.lww.com/MPG/C356.

PMID:34016884 | DOI:10.1097/MPG.0000000000003167

Prosthet Orthot Int. 2021 May 18. doi: 10.1097/PXR.0000000000000016. Online ahead of print.

ABSTRACT

BACKGROUND: Microprocessor controlled knees (MPKs) have been shown to improve gait outcomes for individuals with unilateral transfemoral amputation (TFA); however, previous studies have limitations, which may affect their applicability.

OBJECTIVES: To compare gait outcomes between non-MPK and MPK conditions within a large and diverse cohort of established TFAs in the pragmatic context of an operational clinical service and to identify any demographic variables that correlate with changes in gait outcomes.

STUDY DESIGN: This is a retrospective cohort study.

METHODS: Full-body three-dimensional motion capture and a portable breath gas analyser were used to evaluate gait-specific outcomes both pre-MPK and 6 months post-MPK provisions in TFAs (n = 32). The primary outcome measure was gait profile score, along with the following secondary outcome measures: walking velocity, step length, step length symmetry ratio, step time symmetry ratio, vertical ground reaction force symmetry index, base of support, center of mass deviation, and oxygen cost of walking.

RESULTS: Data showed statistically significant improvement in gait profile score from 11.2° ± 2.2° to 10.1° ± 2.1° (p < 0.01) between non-MPK and MPK conditions. Other outcomes which showed significant improvement were walking velocity (p < 0.01), step length (p < 0.01), vertical ground reaction force symmetry index (p < 0.01), and center of mass deviation (p < 0.05).

CONCLUSIONS: MPK provision offered significant gait improvements to this cohort of TFAs in an operational clinical setting. There still remains a large gap in gait outcomes between this cohort and those of healthy unimpaired adults. Improvements in socket design, prosthetic foot design, and physiotherapy intervention could further reduce this gap.

PMID:34016870 | DOI:10.1097/PXR.0000000000000016

J Dev Behav Pediatr. 2021 May 19. doi: 10.1097/DBP.0000000000000964. Online ahead of print.

ABSTRACT

OBJECTIVE: To estimate the prevalence of screen time (ST) and its associated effects, including emotional and behavioral changes, sleep disturbances, and physical activity levels, in children aged 2 to 5 years.

METHODS: We conducted a cross-sectional study among 400 randomly selected children aged 2 to 5 years in Chandigarh, North India. We used a validated, pretested, semistructured digital-screen exposure and physical activity questionnaire; an abbreviated standard Child Sleep Habit Questionnaire; and a standard Preschool Child Behavior Checklist. We considered ST as excessive if it was more than 1 hour per day as per the American Academy of Pediatrics 2016 guidelines. IBM SPSS Statistics for Macintosh, version 25.0, was used to perform linear regression model analysis and stepwise binary multivariate logistic regression.

RESULTS: Approximately 59.5% of children (mean age 3.5 ± 0.9 years) had excessive ST. ST was higher on weekdays (58.5%) compared with the weekends (56.8%). Higher ST correlated positively with the mother’s level of education (r = +0.219) and higher per capita family income (r = +0.227). Screen time was also positively correlated with attending daycare centers (adjusted odd’s ratio [aOR] = 1.82, confidence interval [CI] = 1.18-2.81), caregivers ST of more than 2 hours (aOR = 1.68, CI = 1.12-2.56), and the absence of digital-media rules at home (aOR = 3.3, CI = 0.92-11.65). It was negatively correlated (i.e., protective) with lower mother’s education (i.e., up to middle school) (aOR = 0.62, CI = 0.41-0.96) and watching educational digital-media content (aOR = 0.53, CI = 0.33-0.87).

CONCLUSION: We observed a high prevalence of excessive ST among children aged 2 to 5 years. Screen time was significantly associated with being in daycare centers, higher caregivers’ ST, lower mothers’ educational status, and educational digital content.

PMID:34016828 | DOI:10.1097/DBP.0000000000000964

J Cardiovasc Nurs. 2021 May 19. doi: 10.1097/JCN.0000000000000821. Online ahead of print.

ABSTRACT

OBJECTIVES: Frailty is a syndrome characterized by increased vulnerability and reduced ability to maintain homeostasis after stressful events that results in an increased risk for poor outcomes. Frailty screening could potentially be valuable in cardiac surgery risk assessment. The purpose of this review is to evaluate the current literature linking multicomponent frailty assessment and invasive cardiac surgery outcomes.

METHODS: We searched PubMed, EMBASE, and CINAHL; 1887 articles met the search criteria, and each was independently reviewed by 2 reviewers.

RESULTS: The 19 eligible studies assessed 52 291 subjects using 17 different frailty measurements. The most commonly used instruments were the Fried Frailty Phenotype and the Clinical Frailty Scale. Between 9% and 61% of participants were found to be frail in each study. All 19 studies included mortality as an outcome, 12 included surgical complications, 12 included hospital length of stay, 3 included quality of life, and 2 included functional status. Nine found statistically significant differences in survival between frail and nonfrail patients, 6 of 12 found that frail patients had a longer length of stay, 4 of 12 found that frail patients were more likely to experience major complications, and 2 of 2 found that frail patients were more likely to have a decrease in functional status.

CONCLUSION: Although some studies lacked power, the majority confirmed that frail patients are more likely to experience poor outcomes. Further research is needed to determine which frailty measure provides the best predictive validity and to identify interventions to mitigate the risks that major cardiac surgery poses to frail patients.

PMID:34016838 | DOI:10.1097/JCN.0000000000000821

J Dr Nurs Pract. 2021 May 20:JDNP-D-20-00036. doi: 10.1891/JDNP-D-20-00036. Online ahead of print.

ABSTRACT

BACKGROUND: Quality improvement (QI) projects comprise the majority of University of Maryland School of Nursing (UMSON) Doctor of Nursing Practice (DNP) projects.

METHODS: An online survey was completed by 51% (n = 38) of faculty, who teach or mentor DNP students, and was analyzed using quantitative and descriptive methods.

RESULTS: Faculty were somewhat or not familiar with developing a QI charter 68.4%, human error theory and error proofing 63.2%, driver diagrams 60.5%, characteristics of high-reliability organizations 60.5%, and Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines 55.3%. The faculty were most interested in learning more about (n = 97 responses) were human error theory and error proofing (28.9%), SQUIRE guidelines (26.3%), statistical process control (21.1%), and implementation strategies and tactics (21.1%). The most commonly identified challenges included identifying QI projects (24%), project time constraints (16%), keeping up-to-date on QI concepts, methods, and tools (12%), and balancing professional workload (10%).

CONCLUSIONS: Gaps in self-reported QI knowledge indicate there is a need for further development of DNP and PhD prepared faculty at the UMSON.

PMID:34016785 | DOI:10.1891/JDNP-D-20-00036

Indian Pediatr. 2021 May 20:S097475591600330. Online ahead of print.

ABSTRACT

OBJECTIVE: To study the serum vitamin D levels in neonatal seizures and vitamin D status of the mothers whose babies had vitamin D deficiency.

METHODS: For this case-control study, vitamin D levels were studied in term and late preterm neonates admitted to NICU with seizures in a tertiary care center in South India. Controls were term and late preterm healthy neonates admitted in the postnatal ward with the mothers in the same center.

RESULT: 30 cases and 30 controls were enrolled. The mean (SD) serum vitamin D was 19.33 (7.76) ng/mL among cases and 16.83 (6.74) ng/mL among controls (P=0.18). We tested maternal vitamin D levels in babies with seizures and low vitamin D levels. The mean (SD) serum vitamin D level among these mothers (n=11) was 13.25 (6.17) ng/mL.

CONCLUSION: There was no statistically significant association between serum vitamin D levels and seizures among neonates in our study. However, we found low vitamin D levels in lactating mothers and newborn population of this region.

PMID:34016803