Category: Statistics

Emerg Med J. 2021 Aug 17:emermed-2020-210363. doi: 10.1136/emermed-2020-210363. Online ahead of print.

ABSTRACT

INTRODUCTION: The standard method of chest compression for adults is a two-handed procedure. One-handed external chest compression (ECC) is used in some situations such as during transport of patients who had an out-of-hospital cardiac arrest, but the quality of one-handed ECC is still not well known. The distribution of force is related to the quality of chest compression and may affect the risk of injury. This study aimed to determine the differences in the quality and potential safety concern between one-handed ECC and two- handed ECC.

METHODS: In this randomised crossover study, participants recruited from National Cheng Kung University Hospital and the ambulance team from the fire bureau were asked to perform one-handed and two-handed ECC on the Resusci Anne manikin according to standard 2015 ECC guidelines. The MatScan Pressure Measurement system was used to investigate the compression pressure and force distribution.

RESULTS: Two-handed ECC had better results than one-handed ECC in terms of the median (IQR) depth (51.00 (41.50-54.75) mm vs 42.00 (27.00-49.00) mm, p=0.018), the proportion of depth accuracy (82.05% (13.95%-99.86%) vs 11.17% (0.00%-42.13%), p=0.028) and the proportion of incomplete recoil (0.23% (0.01%-0.44%) vs 2.42% (0.60%-4.21%), p=0.002). The maximum force (45.72 (36.10-80.84) kgf vs 35.64 (24.13-74.34) kgf, p<0.001) and ulnar-radial force difference (7.13 (-16.58 to 21.07) kgf vs 23.93 (11.19-38.74) kgf, p<0.001) showed statistically significant differences. The perceived fatigue of two-handed ECC versus one-handed ECC was 5.00 (3.00-6.00) vs 6.00 (5.00-8.00), p<0.001.

CONCLUSION: The quality of one-handed ECC, based on depth and recoil, is worse than that of standard two-handed ECC. The pressure and force distribution of one-handed ECC result in greater ulnar pronation of the hand than that of two-handed ECC. One-handed ECC more easily causes operator fatigue. Acknowledging these findings and adjusting training for one-handed ECC would potentially improve the quality of cardiopulmonary resuscitation during transport.

PMID:34404678 | DOI:10.1136/emermed-2020-210363

J Adolesc Health. 2021 Aug 14:S1054-139X(21)00376-1. doi: 10.1016/j.jadohealth.2021.07.019. Online ahead of print.

ABSTRACT

PURPOSE: The aim of this study is to test the effects of an electronic screening and feedback tool and training for primary care clinicians on care and adolescent health behaviors.

METHODS: We conducted a stepped-wedge cluster randomized trial with six clinics randomly assigned to sequential crossover from control to intervention periods with clinician training between periods. Adolescents (ages 13-18) with a well visit during the control periods (n = 135) received usual care, while adolescents during the intervention periods (n = 167) received the electronic screening and feedback tool prior to their well visit, with results sent to their clinicians. Adolescents completed surveys at baseline, 1 day, 3 months, 6 months, and 12 months. Linear mixed effects models were used to examine associations between outcomes and treatment, controlling for time as a fixed effect and clinic as a random effect. All analyses employed intent-to-treat analyses and utilized multiple imputations for missing data.

RESULTS: Adolescents who received the intervention had a higher rate of counseling for their endorsed risk behaviors during the well visit (45% vs. 33%, Wald’s T = 2.29, p = .02). There were no significant intervention effects on adolescent satisfaction with the clinician or perception of patient centeredness. The intervention was associated with a small but statistically significant reduction in overall risk score relative to control at 3 months (-.63, 95% confidence interval [-1.07, -.19], Cohen’s d = .21), but not at 6 or 12 months.

CONCLUSIONS: The results suggest that electronic screening and feedback may be associated with small reductions in risk behaviors at 3 months but that changes do not persist at longer term follow-up.

PMID:34404610 | DOI:10.1016/j.jadohealth.2021.07.019

Transfus Apher Sci. 2021 Aug 13:103240. doi: 10.1016/j.transci.2021.103240. Online ahead of print.

ABSTRACT

BACKGROUND AND OBJECTIVES: Stem cell transplantation is a growing treatment strategy for most malignant and non- malignant hematological diseases. Plerixafor and granulocyte colony stimulating factor (G-CSF) are usually used in mobilization regimens to increase the CD34⁺ cell count in the harvest. Heparin is a sulphated glycosaminoglycated polymer with 12-15 kDa mass. Heparin inhibits the CXCR4/SDF1 axis, as does plerixafor. In this study, our aim was to investigate the effect of using heparin on stem cell mobilization and harvesting.

MATERIALS AND METHODS: We administered 5000 units of unfractioned heparin intravenously in 150 mL (mL) of isotonic sodium chloride solution, 15 min before the stem cell harvesting procedure to 141 patients who underwent bone marrow transplantation between the years of 2018 and 2019 at our Stem Cell Transplantation Unit. Thirty patients were included as a control group, and they were not given heparin. The study population included patients with multiple myeloma and lymphoma equally in each group.

RESULTS: In all patients hematopoeitic stem cells were successfully harvested in a single cycle of apheresis. In multiple myeloma patients who received heparin, the mean collected CD34⁺ cell number was 8 × 10⁶/kg, and the mean CD34⁺ cell number yield was 12,555/μl. In the control group, the mean collected CD34⁺ cell number was 4,2 × 10⁶/kg, and mean CD34⁺ cell number in yield was 492/μl. In lymphoma patients who received heparin, the mean collected CD34⁺ cell number was 6,8 × 10⁶/kg, and the mean CD34⁺ cell number was 1421/μl. In the control group the mean collected CD34⁺ cell number was 4,3 × 10⁶/kg, and the mean CD34⁺ cell number was 358/μl. The effect of heparin on the collected stem cell number in both myeloma and lymphoma patients was statistically significant (p < 0.01).

CONCLUSIONS: Our results have shown that heparin increases harvested stem cell numbers significantly. Heparin may be a promising agent for stem cell harvesting.

PMID:34404617 | DOI:10.1016/j.transci.2021.103240

Disabil Health J. 2021 Aug 10:101180. doi: 10.1016/j.dhjo.2021.101180. Online ahead of print.

ABSTRACT

BACKGROUND: People with disabilities have higher health care needs, service utilization, and expenditures. They are also more likely to lack insurance and experience unmet need for medical care. There has been limited research on the effects of the Affordable Care Act Medicaid expansion on people with disabilities.

OBJECTIVE: To examine the effects of the Medicaid expansion on health insurance coverage, access, and service use for working-age adults with disabilities.

METHODS: A retrospective study using 11 years (2007-2017) of data from the Medical Expenditure Panel Survey – Household Components, linked to Area Health Resource Files and Local Area Unemployment Statistics (N = 40,995). Difference-in-differences multinomial logistic and linear probability models with state and year fixed-effects were used to estimate the effects.

RESULTS: We found strong evidence of increased Medicaid coverage in expansion states (3.2 to 5.0 percentage points), reasonably strong evidence of reduced private insurance coverage (-2.2 to -2.5 percentage points), and some evidence of reduced uninsured rate (from no effect to -3.7 percentage points). Results suggest that the increase in Medicaid coverage was due at least in part to the “crowd-out” of private insurance in expansion states. No statistically significant effects were detected for access and use outcomes.

CONCLUSIONS: Findings suggest that state Medicaid expansions led to an increase in Medicaid coverage and a decrease in private insurance coverage as well as the uninsured. However, no evidence was found for health care access and use outcomes. Further research into access and use is needed when more data become available for the post-expansion period.

PMID:34404627 | DOI:10.1016/j.dhjo.2021.101180

J Cardiothorac Vasc Anesth. 2021 Jul 9:S1053-0770(21)00573-5. doi: 10.1053/j.jvca.2021.07.001. Online ahead of print.

ABSTRACT

OBJECTIVES: Neutrophil-lymphocyte ratio (NLR) is an inflammatory biomarker that has been evaluated across a variety of surgical disciplines and is widely predictive of poor postoperative outcome, but its value in cardiac surgery is unclear. The authors did this systematic review and meta-analysis to determine the impact of elevated perioperative NLR on survival after cardiac surgery.

DESIGN: Systematic review and meta-analysis of study-level data.

SETTING: Multiple hospitals involved in an international pool of studies.

PARTICIPANTS: Adults undergoing cardiac surgery.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: The authors searched multiple databases from inception until November 2020. They generated summary hazard ratios (HR) and odds ratios (OR) for the association of elevated preoperative NLR with long-term and short-term mortality following cardiac surgery. They separately reported on elevated postoperative NLR. Between-study heterogeneity was explored using metaregression. The authors included 12 studies involving 13,262 patients undergoing cardiac surgery. Elevated preoperative NLR was associated with worse long-term (>30 days) (hazard ratio [HR] 1.56; 95% CI [confidence interval], 1.18-2.06; 8 studies) and short-term (<30 days) mortality (OR 3.18; 95% CI, 1.90-5.30; 7 studies). One study reported the association of elevated postoperative NLR with long-term mortality (HR 8.58; 95% CI, 2.55-28.85). There was considerable between-study heterogeneity for the analysis of long-term mortality (I² statistic 94.39%), which mostly was explained by study-level variables, such as the number of variables adjusted for by included studies and how many of these significantly increased the risk of long-term mortality, high risk of bias, and number of study centers, as well as participant level factors, such as average participant age and hypertension prevalence.

CONCLUSIONS: Perioperative NLR is an independent predictor of short-term and long-term postoperative mortality following cardiac surgery. Further research is required to determine which patient-level factors modify the prognostic value of NLR and to evaluate its role in routine clinical practice.

PMID:34404595 | DOI:10.1053/j.jvca.2021.07.001

Pancreatology. 2021 Aug 12:S1424-3903(21)00525-1. doi: 10.1016/j.pan.2021.08.002. Online ahead of print.

ABSTRACT

BACKGROUND/OBJECTIVES: Irreversible electroporation (IRE) is an emerging treatment for locally advanced pancreatic cancer (LAPC) which in some cohorts has been associated with severe complications. Additionally, re-resection of isolated local recurrence (ILR) after pancreatic ductal adenocarcinoma (PDAC) can improve survival. We investigated safety, feasibility and oncologic outcomes in the first report on open IRE for unresectable ILR of PDAC in a staged surgical approach.

METHODS: Records of the prospectively documented institutional database were screened for patients undergoing laparotomy in IRE-standby due to questionable resectability. Endpoints were morbidity, mortality and overall (OS) and progression free survival (PFS). Data of LAPC and ILR were compared statistically for safety and feasibility analysis.

RESULTS: Intraoperative IRE was performed in 11 ILR and 14 LAPC. Six (54.5%) ILR and 10 (71.4%) LAPC patients had postoperative complications, type and frequency did not differ significantly. Major complications occurred in one ILR and two LAPC patients. Median OS was 20.0 months (95% CI: 2.7-37.3) after IRE for ILR and 28 (17.4-38.6) for LAPC. Median PFS after IRE was seven months for both ILR (4.1-9.9; n = 9) and LAPC (2.3-11.7; n = 13).

CONCLUSION: Open IRE for unresectable ILR was associated with acceptable perioperative risk. In this small, highly selected subset of patients with limited therapeutic options ancillary treatment with IRE might improve survival. Randomized treatment studies are required to establish the definitive role of IRE as compared to palliative standards of care in unresectable recurrence of PDAC and inconvertible LAPC.

PMID:34404600 | DOI:10.1016/j.pan.2021.08.002

Eur J Surg Oncol. 2021 Aug 11:S0748-7983(21)00686-7. doi: 10.1016/j.ejso.2021.08.016. Online ahead of print.

ABSTRACT

BACKGROUND: The effects of cytotoxic chemotherapy on the expression of programmed cell death 1 (PD-1) and its ligand (PD-L1) in cancer cells and peritumoral cells are unclear. The aim of this study was to investigate the impact of neoadjuvant chemotherapy on PD-1 and PD-L1 expression in adenocarcinomas of the gastroesophageal junction.

METHODS: PD-1 and PD-L1 expression in cancer cells and tumor-infiltrating lymphocytes in paired diagnostic biopsies and surgical specimens from patients with pretreated and curatively resected adenocarcinomas of the gastroesophageal junction were evaluated by immunohistochemistry.

RESULTS: Paired tumor samples were available from 40 patients. PD-1 expression in cancer cells (p < 0.001; Exact Symmetry Test) and tumor-infiltrating lymphocytes (p < 0.001; Exact Symmetry Test) increased significantly after neoadjuvant therapy. Furthermore, we observed a significant decrease in PD-L1 expression in cancer cells (p = 0.003) after neoadjuvant therapy was observed.

CONCLUSION: In this study we could show that tumor-cell expression of PD-1 and PD-L1 was significantly altered in patients with adenocarcinomas of the gastroesophageal junction after receiving neoadjuvant chemotherapy. Based on these observations, patients might profit from the combined use of cytotoxic chemotherapy and the blockade of the PD-1 axis.

PMID:34404561 | DOI:10.1016/j.ejso.2021.08.016

J Foot Ankle Surg. 2021 Jul 20:S1067-2516(21)00263-5. doi: 10.1053/j.jfas.2021.07.009. Online ahead of print.

ABSTRACT

Twenty percent of ankle fractures present with concomitant syndesmosis injury which results in poor clinical outcomes. Surgical stabilization of the syndesmosis can be achieved with either trans-syndesmotic screws or a suture button device. The aim of this study is to investigate the clinical efficacy of suture button fixation and trans-syndesmotic screw fixation in the treatment of ankle fracture combined with distal tibiofibular syndesmosis injury. A retrospective analysis was conducted by enrolling 76 patients with ankle fractures combined with distal tibiofibular syndesmosis injury who were admitted in our trauma center from January 2018 to January 2019, including 34 cases of suture button group and 42 cases of the syndesmotic screw group with a mean follow-up period of 16 ± 7 (range 12-21) months. The demographic data included gender, age, injury mechanism, AO classification and the operation duration were recorded, the radiographic and clinical outcomes were determined by tibiofibular clear space, tibiofibular overlap distance, complications, and the Olerud-Molander Ankle Score at the last follow-up. All the indexes were compared between the 2 groups to discover the related statistical differences. With the numbers available, no significant difference could be detected in the surgical duration, tibiofibular clear space, tibiofibular overlap distance, total complication rate, and middle-term Olerud-Molander Ankle scores between the 2 groups. However, the suture button fixation group showed higher early stage Olerud-Molander Ankle scores (p = .027) and shorter full weightbearing time (p = .018) than that of syndesmotic screw fixation group. Considering the outcomes, we conclude that the suture button fixation not only shows equivalent efficacy to the traditional syndesmotic screw, but also has advantages of allowing early weightbearing, low requirements for routine removal.

PMID:34404589 | DOI:10.1053/j.jfas.2021.07.009

J Reconstr Microsurg. 2021 Aug 17. doi: 10.1055/s-0041-1733922. Online ahead of print.

ABSTRACT

BACKGROUND: Microsurgical free flaps have largely supplanted pedicled flaps as the gold standard for head and neck cancer reconstruction. However, incidence of postoperative complications after accounting for patient comorbidities based on choice of reconstruction has not been well-defined in the literature in recent years.

METHODS: Patients undergoing head and neck reconstruction were identified in the 2011-2016 ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database and stratified into groups by free flap, myocutaneous pedicled flap, and other reconstruction. Demographics were analyzed and covariates balanced using overlap propensity score-based weighting. Logistic regression was used for binary outcomes and Gamma generalized linear model was used for length of stay.

RESULTS: A total of 4,712 patients met inclusion criteria out of which 1,297 patients (28%) underwent free flap, 208 patients (4%) pedicled flap, and 3,207 patients (68%) had other, or no reconstruction performed. After adjusting for patient and disease-specific factors, pedicled flap reconstruction was associated with a higher risk of deep vein thrombosis (odds ratio [OR] = 2.64, confidence interval [CI] 1.02-6.85, p = 0.045), sepsis (OR = 2.95, CI 1.52-5.71, p = 0.001), and infection (OR = 2.03, CI 1.39-2.96, p <0.001) compared with free flap reconstruction. Free flaps had the longest mean operative time compared with the other two groups (unadjusted 578 vs. 440 vs. 326, p <0.001). Pedicled flaps had a lower incidence of bleeding requiring transfusion (adjusted OR = 0.65, CI 0.50-0.85, p = 0.002), and lower incidence of prolonged mechanical ventilation (adjusted OR = 0.33, CI 0.12-0.92, p = 0.034) compared with free flaps. There was no difference in rates of reoperation, hospital readmission, or hospital length-of-stay between pedicled and free flaps.

CONCLUSION: Myocutaneous pedicled flaps are associated with higher overall short-term postoperative complications compared with free flaps in head and neck reconstruction, which demonstrate a more favorable morbidity profile without significantly impacting hospital readmission, reoperation, or length-of-stay.

PMID:34404103 | DOI:10.1055/s-0041-1733922

J Reconstr Microsurg. 2021 Aug 17. doi: 10.1055/s-0041-1732431. Online ahead of print.

ABSTRACT

BACKGROUND: Ethnicity has been shown to play a role in disparate coagulative responses between East Asian and Caucasian patients undergoing nonmicrovascular surgery. In this study, we sought to further investigate this hematologic phenomenon between the two ethnic groups within the field of microsurgical breast reconstruction.

METHODS: A systematic review examining the reported incidence of microvascular thrombosis and all-site bleeding among breast free flaps in East Asians and Westerners was performed. Statistical analysis was performed using the chi-square test.

RESULTS: Ten East Asian studies with 581 flaps and 99 Western studies with 30,767 flaps were included. A statistically significant higher rate of thrombotic complications was found in Westerners compared with East Asians (4.2 vs. 2.2%, p = 0.02). Conversely, bleeding events were more common in East Asians compared with Westerners (2.6 vs. 1.2%, p = 0.002).

CONCLUSION: There appears to be an ethnicity-based propensity for thrombosis in Westerners and, conversely, for bleeding in East Asians, as evident by the current systematic review of microvascular breast reconstruction data. It is therefore advisable to consider ethnicity in the comprehensive evaluation of patients undergoing microsurgical procedures.

PMID:34404099 | DOI:10.1055/s-0041-1732431