Nevin Manimala

Orthop Clin North Am. 2024 Jul;55(3):323-332. doi: 10.1016/j.ocl.2024.02.002. Epub 2024 Mar 23.

ABSTRACT

This study was a retrospective cohort analysis of 20 patients who underwent 23 revision total knee arthroplasty procedures in a single geographic region of the United States from January 2015 to February 2023. We analyzed their 25-OH vitamin D levels preoperatively and postoperatively at 1 month, 3 months, 6 months, 1 year, and 2 years. We categorized their supplementation regimens by dose: none, low dose (1000 IU and below), medium dose (1001-5000 IU), and high dose (>5000 IU). We found that there was a high incidence of vitamin D deficiency in this patient population.

PMID:38782504 | DOI:10.1016/j.ocl.2024.02.002

Stroke Vasc Neurol. 2024 May 23:svn-2023-003024. doi: 10.1136/svn-2023-003024. Online ahead of print.

ABSTRACT

BACKGROUND: We investigated differences in intracranial embolus distribution through communicating arteries in relation to supra-aortic vessel (SAV) patency.

METHODS: For this experimental analysis, we created a silicone model of the extracranial and intracranial circulations using a blood-mimicking fluid under physiological pulsatile flow. We examined the sequence of embolus lodgment on injecting 104 frangible clot analogues (406 emboli) through the right internal carotid artery (CA) as SAV patency changed: (a) all SAV patent (baseline), (b) emboli from a CA occlusion, (c) emboli contralateral to a CA occlusion and (d) occlusion of the posterior circulation. The statistical analysis included a descriptive analysis of thrombi location after occlusion (absolute and relative frequencies). Sequences of occlusions were displayed in Sankey flow charts for the four SAV conditions. Associations between SAV conditions and occlusion location were tested by Fisher’s exact test. Two-sided p values were compared with a significance level of 0.05.

RESULTS: The total number of emboli was 406 (median fragments/clot: 4 (IQR: 3-5)). Embolus lodgment was dependent on SAV patency (p<0.0001). In all scenarios, embolism lodging in the anterior cerebral artery (ACA) occurred after a previous middle cerebral artery (MCA) embolism (MCA first lodge: 96%, 100/104). The rate of ipsilateral ACA embolism was 28.9% (28/97) at baseline, decreasing significantly when emboli originated from an occluded CA (16%, 14/88). There were more bihemispheric embolisations in cases of contralateral CA occlusion (37%, 45/122), with bilateral ACA embolisms preceding contralateral MCA embolism in 56% of cases (14/25 opposite MCA and ACA embolism).

CONCLUSIONS: All emboli in the ACA occurred after a previous ipsilateral MCA embolism. Bihemispheric embolisms were rare, except when there was a coexisting occlusion in either CA, particularly in cases of a contralateral CA occlusion.

PMID:38782495 | DOI:10.1136/svn-2023-003024

BMJ Open Qual. 2024 May 23;13(2):e002706. doi: 10.1136/bmjoq-2023-002706.

ABSTRACT

INTRODUCTION: In healthcare teams, psychological safety is associated with improved performance, communication, collaboration and patient safety. Extracorporeal membrane oxygenation (ECMO) retrieval teams are multidisciplinary teams that initiate ECMO therapy for patients with severe acute respiratory failure in referring hospitals and transfer patients to regional specialised centres for ongoing care. The present study aimed to explore an ECMO team’s experience of psychological safety and generate recommendations to strengthen psychological safety.

METHODS: The study was conducted in the Royal Brompton Hospital (RBH), part of Guy’s and St Thomas’ NHS Foundation Trust in London. RBH is one of six centres commissioned to provide ECMO therapy in the UK. 10 participants were recruited: 2 consultants, 5 nurses and 3 perfusionists. Semistructured interviews were used to explore the team members’ views on teamwork, their perceived ability to discuss concerns within the team and the interaction between speaking up, teamwork and hierarchy. A Reflexive Thematic Analysis approach was used to explore the interview data.

RESULTS: The analysis of the interview dataset identified structural and team factors shaping psychological safety in the specific context of the ECMO team. The high-risk environment in which the team operates, the clearly defined process and functions and the structured opportunities that provide legitimate moments to reflect together influence how psychological safety is experienced. Furthermore, speaking up is shaped by the familiarity among team members, the interdependent work, which requires boundary spanning across different roles, and leadership behaviour. A hierarchy of expertise is privileged over traditional institutional ranking.

CONCLUSION: This study surfaced the structural and team factors that influence speaking up in the specific context of an ECMO retrieval team. Such information is used to suggest interventions to improve and strengthen psychological safety.

PMID:38782489 | DOI:10.1136/bmjoq-2023-002706

BMJ Open Qual. 2024 May 23;13(2):e002737. doi: 10.1136/bmjoq-2023-002737.

ABSTRACT

Hospital length of stay (LOS) in the USA has been increasing since the start of the COVID-19 pandemic, with numerous negative outcomes, including decreased quality of care, worsened patient satisfaction and negative financial impacts on hospitals. While many proposed factors contributing to prolonged LOS are challenging to modify, poor coordination of care and communication among clinical teams can be improved.Geographical cohorting of provider teams, patients and other clinical staff is proposed as a solution to prolonged LOS and readmissions. However, many studies on geographical cohorting alone have shown no significant impact on LOS or readmissions. Other potential benefits of geographical cohorting include improved quality of care, learning experience, communication, teamwork and efficiency.This paper presents a retrospective study at Duke University Hospital (DUH) on the General Medicine service, deploying a bundled intervention of geographical cohorting of patients and their care teams, twice daily multidisciplinary rounds and incremental case management support. The quality improvement study found that patients in the intervention arm had 16%-17% shorter LOS than those in the control arms, and there was a reduction in 30-day hospital readmissions compared with the concurrent control arm. Moreover, there was some evidence of improved accuracy of estimated discharge dates in the intervention arm.Based on these findings, the health system at DUH recognised the value of geographical cohorting and implemented additional geographically based medicine units with multidisciplinary rounds. Future studies will confirm the sustained impact of these care transformations on hospital throughput and patient outcomes, aiming to reduce LOS and enhance the quality of care provided to patients.

PMID:38782488 | DOI:10.1136/bmjoq-2023-002737

BMJ Open Qual. 2024 May 23;13(2):e002637. doi: 10.1136/bmjoq-2023-002637.

NO ABSTRACT

PMID:38782487 | DOI:10.1136/bmjoq-2023-002637

BMJ Open Qual. 2024 May 23;13(2):e002704. doi: 10.1136/bmjoq-2023-002704.

ABSTRACT

This manuscript presents the pioneering use of a post-event staff debriefing tool, TALK, in Acute Child and Adolescent Mental Health Units (CAMHU). While unsuccessful in reducing the rate and severity of patient behavioural events, our centre observed promising psychological benefits for CAMHU staff as a result of debriefing, with the tool promoting emotional resiliency and providing a platform for open conversations. Debriefing also served as a venue for patient concerns with care to be raised by staff, addressed and reflected in updated care plans. This initiative demonstrates the utility of debriefing to foster a culture of learning, improve staff wellness and enhance patient safety in CAMHU settings.

PMID:38782486 | DOI:10.1136/bmjoq-2023-002704

BMJ Open Qual. 2024 May 23;13(2):e002734. doi: 10.1136/bmjoq-2023-002734.

ABSTRACT

BACKGROUND: The Serious Illness Care Programme was developed to promote more, better and earlier serious illness conversations. Conversations about goals and values are associated with improved experiences and outcomes for seriously ill patients. Clinicians’ attitudes and beliefs are thought to influence the uptake and performance of serious illness conversations, yet little is known about how clinicians perceive the impact of these conversations on patients. This study aimed to explore physicians’ perceptions regarding the impact of serious illness conversations for patients.

METHODS: The Serious Illness Care Programme was implemented as a quality improvement project in two hospitals in Southern Sweden. Focus group evaluation discussions were conducted with 14 physicians and inductive thematic analysis was undertaken.

RESULTS: The results revealed that physicians considered potential perils and optimised potential payoffs for patients when engaging in serious illness conversations. Potential perils encompassed inappropriate timing, damaging emotions and shattering hopes. Potential payoffs included reflection time, secure space, and united understandings.

CONCLUSIONS: Physicians depicted a balance in evaluating the perils and payoffs of serious illness conversations for patients and recognised the interrelation of these possibilities through continual assessment and adjustment.

PMID:38782485 | DOI:10.1136/bmjoq-2023-002734

BMJ Paediatr Open. 2024 May 23;8(1):e002572. doi: 10.1136/bmjpo-2024-002572.

ABSTRACT

The aim of this study was to characterise paediatric emergency department presentations during the 2023 thunderstorm asthma (TA) epidemic, characterised by a sudden surge in wheeze presentations, with analysis of environmental factors.Wheeze presentations totalled 50 (28%) on 12 June and 18 (19%) 13 June. There was no prior asthma in 39 (57%) and no atopic disorders in 30 (44%). There was neither asthma nor atopic disorders in 8 (12%). 44 (65%) were severe or life-threatening. There were no endotracheal intubations and no deaths. High pollen and air pollution warnings were issued.TA poses a significant, sudden health threat, often in children without asthma. A surge strategy is required.

PMID:38782482 | DOI:10.1136/bmjpo-2024-002572

Acta Ortop Mex. 2024 Mar-Apr;38(2):105-108.

ABSTRACT

INTRODUCTION: anterior cruciate ligament injuries (ACL) continue increasing in frecuency in the general population and sportmen who practice soccer and american football where we can locate 53% of the total of cases, the annual incidence is 70 per 100,000 persons. The incidence of this injuries has being increasing in women probably of the increase of the participation in such sports.

OBJECTIVE: to document the causes of anterior cruciate ligament (ACL) plasty failure, as well as the diagnosis, surgical technique, and postoperative care of a revision ACL plasty surgery.

MATERIAL AND METHODS: a search for relevant information, original research articles, clinical trials, and reviews in indexed journals was performed.

RESULTS: anterior cruciate ligament injuries continue to increase among the general population and athletes who play soccer and American soccer mainly, in this population group we found 53% of the total cases. The gold standard for treatment is arthroscopic reconstruction of the ligament. ACL reconstruction surgery has good results, with an estimated 75-90% success rate. Long-term failures of anterior cruciate ligament repair represent 5-25%. Among the factors associated with this failure are technical errors, traumatic antecedents, biological factors, among others.

CONCLUSIONS: in ACL revision surgery good results can be achieved with respect to graft stability, return to play and functional stability of the knee, but the results are generally inferior to those of primary ACL reconstruction.

PMID:38782476

Acta Ortop Mex. 2024 Mar-Apr;38(2):101-104.

ABSTRACT

INTRODUCTION: it is estimated that 302 million people worldwide are affected by osteoarthritis, corresponding to 60% osteoarthritis (OA) of the knee, which responsible 80% of disability in older adults, hence the importance of the association of the sign with the early inflammatory process in OA.

OBJECTIVE: to determine the association of digital pressure sign in patients with and without osteoarthritis of the knee.

MATERIAL AND METHODS: this was an observational, comparative cross-sectional study, carried out in patients with and without a diagnosis of knee OA, to whom the digital pressure sign was determined. The sample was calculated with the formula for two proportions, obtaining a total of 40 participants per group, obtained by non-probabilistic sampling for convenience. The statistical analysis included frequencies, percentages, 2 and OR. The bioethics regulations in force were respected.

RESULTS: the study included 80 participants, with a median age of 48.9 years (RQI 46-53.7), 73.1% were predominantly female sex (38), and a statistically significant association was found between patients with OA and the presence of digital pressure sign, 2 4.62 and p value = 0.41, OR of 2.65.

CONCLUSIONS: the presence of digital pressure sign increases the probability of having OA 2.65 times more.

PMID:38782475