Nevin Manimala

Resuscitation. 2023 Sep 1:109956. doi: 10.1016/j.resuscitation.2023.109956. Online ahead of print.

ABSTRACT

AIM: Frequency and timing of Withdrawal of Life-Sustaining Treatment (WLST) after Out-of-Hospital Cardiac Arrest (OHCA) vary across Intensive Care Units (ICUs) in the United Kingdom (UK) and may be a marker of lower healthcare quality if instituted too frequently or too early. We aimed to describe WLST practice, quantify its variability across UK ICUs, and assess the effect of institutional deviation from average practice on patients’ risk-adjusted hospital mortality.

METHODS: We conducted a retrospective multi-centre cohort study including all adult patients admitted after OHCA to UK ICUs between 2010-2017. We identified patient and ICU characteristics associated with early (within 72h) and late (>72h) WLST and quantified the between-ICU variation. We used the ICU-level observed-to-expected (O/E) ratios of early and late-WLST frequency as separate metrics of institutional deviation from average practice and calculated their association with patients’ hospital mortality.

RESULTS: We included 28438 patients across 204 ICUs. 10775 (37.9%) had WLST and 6397 (59.4%) of them had early-WLST. Both WLST types were strongly associated with patient-level demographics and pre-existing conditions but weakly with ICU-level characteristics. After adjustment, we found unexplained between-ICU variation for both early-WLST (Median Odds Ratio 1.59, 95%CrI 1.49-1.71) and late-WLST (MOR 1.39, 95%CrI 1.31-1.50). Importantly, patients’ hospital mortality was higher in ICUs with higher O/E ratio of early-WLST (OR 1.29, 95%CI 1.21-1.38, p<0.001) or late-WLST (OR 1.39, 95%CI 1.31-1.48, p<0.001).

CONCLUSIONS: Significant variability exists between UK ICUs in WLST frequency and timing. This matters because unexplained higher-than-expected WLST frequency is associated with higher hospital mortality independently of timing, potentially signalling prognostic pessimism and lower healthcare quality.

PMID:37661013 | DOI:10.1016/j.resuscitation.2023.109956

Biol Psychiatry. 2023 Sep 1:S0006-3223(23)01530-5. doi: 10.1016/j.biopsych.2023.08.018. Online ahead of print.

ABSTRACT

BACKGROUND: The 1q21.1 distal and 15q11.2 BP1-BP2 CNVs exhibit regional and global brain differences compared to non-carriers. However, interpreting regional differences is challenging if a global difference drives the regional brain differences. Intra-individual variability measures can be used to test for regional differences beyond global differences in brain structure.

METHODS: Magnetic resonance imaging data were used to obtain regional brain values for 1q21.1 distal deletion (n=30) and duplication (n=27), and 15q11.2 BP1-BP2 deletion (n=170) and duplication (n=243) carriers and matched non-carriers (n=2,350). Regional intra-deviation (RID) scores i.e., the standardized difference between an individual’s regional difference and global difference, were used to test for regional differences that diverge from the global difference.

RESULTS: For the 1q21.1 distal deletion carriers, cortical surface area for regions in the medial visual cortex, posterior cingulate and temporal pole differed less, and regions in the prefrontal and superior temporal cortex differed more than the global difference in cortical surface area. For the 15q11.2 BP1-BP2 deletion carriers, cortical thickness in regions in the medial visual cortex, auditory cortex and temporal pole differed less, and the prefrontal and somatosensory cortex differed more than the global difference in cortical thickness.

CONCLUSION: We find evidence for regional effects beyond differences in global brain measures in 1q21.1 distal and 15q11.2 BP1-BP2 CNVs. The results provide new insight into brain profiling of the 1q21.1 distal and 15q11.2 BP1-BP2 CNVs, with the potential to increase our understanding of mechanisms involved in altered neurodevelopment.

PMID:37661008 | DOI:10.1016/j.biopsych.2023.08.018

J Biomed Inform. 2023 Sep 1:104485. doi: 10.1016/j.jbi.2023.104485. Online ahead of print.

ABSTRACT

OBJECTIVE: We propose FedScore, a privacy-preserving federated learning framework for scoring system generation across multiple sites to facilitate cross-institutional collaborations.

MATERIALS AND METHODS: The FedScore framework includes five modules: federated variable ranking, federated variable transformation, federated score derivation, federated model selection and federated model evaluation. To illustrate usage and assess FedScore’s performance, we built a hypothetical global scoring system for mortality prediction within 30 days after a visit to an emergency department using 10 simulated sites divided from a tertiary hospital in Singapore. We employed a pre-existing score generator to construct 10 local scoring systems independently at each site and we also developed a scoring system using centralized data for comparison.

RESULTS: We compared the acquired FedScore model’s performance with that of other scoring models using the receiver operating characteristic (ROC) analysis. The FedScore model achieved an average area under the curve (AUC) value of 0.763 across all sites, with a standard deviation (SD) of 0.020. We also calculated the average AUC values and SDs for each local model, and the FedScore model showed promising accuracy and stability with a high average AUC value which was closest to the one of the pooled model and SD which was lower than that of most local models.

CONCLUSION: This study demonstrates that FedScore is a privacy-preserving scoring system generator with potentially good generalizability.

PMID:37660960 | DOI:10.1016/j.jbi.2023.104485

Biomed J. 2023 Sep 1:100656. doi: 10.1016/j.bj.2023.100656. Online ahead of print.

ABSTRACT

BACKGROUND: Peri-intubation cardiac arrest (PICA) is an uncommon yet serious complication of intubation. Although some associated risk factors have been identified, the results have been inconsistent. The aim of this study was to systematically review the relevant research and examine the associated risk factors of PICA through meta-analysis.

METHODS: Studies examining the risk factors for PICA before 1 Nov. 2022 were identified through searches in MEDLINE (OvidSP) and EMBASE. The reported adjusted or unadjusted odds ratios (ORs) and risk ratios (RRs) were recorded. We calculated pooled ORs and created forest plots using a random-effects model to identify the statistically significant risk factors. We assessed the certainty of evidence for each risk factor.

RESULTS: Eight studies were included in the meta-analysis. Pre-intubation hypotension, with a pooled OR of 4.96 (95% confidence interval [C.I.]: 3.75-6.57), pre-intubation hypoxemia, with a pooled OR of 4.43 (95% C.I.: 1.24-15.81), and two or more intubation attempts, with a pooled OR of 1.88 (95% C.I.: 1.09-3.23) were associated with a significantly higher risk of PICA. The pooled incidence of PICA was 2.1% (95% C.I.: 1.5%-3.0%).

CONCLUSIONS: Pre-intubation hypotension, hypoxemia, and more intubation attempts are significant risk factors for PICA. The findings could help physicians identify patients at risk under the acute setting.

PMID:37660901 | DOI:10.1016/j.bj.2023.100656

Spine J. 2023 Sep 1:S1529-9430(23)03365-X. doi: 10.1016/j.spinee.2023.08.019. Online ahead of print.

ABSTRACT

BACKGROUND CONTEXT: Anterior cervical discectomy and fusion (ACDF) is the leading surgical treatment for cervical radiculopathy. However, ACDF surgery has been suggested for to accelerate the degeneration of the adjacent cervical discs, which causes so-called adjacent segment disease (ASD). Over the past two decades, total disc replacement (TDR)/cervical disc arthroplasty (CDA) has become an increasingly common method for treating degenerative cervical diseases. The rationale is that a synthetic disc prosthesis may preserve motion at the operated level, which is expected to lead to reduced stress on the other cervical levels and thus decrease the risk of developing ASD. However, since the method was first introduced in the early 2000s, the long-term outcome after it is still not completely understood.

PURPOSE: Our goal was to compare the long-term outcomes of TDR and ACDF procedures.

STUDY DESIGN: Retrospective case-control study.

PATIENT SAMPLE: All patients who underwent TDR due to degenerative cervical disease at Helsinki University Hospital between 2006 and 2012 (38 patients) and matched control patients who underwent ACDF during this period (76 patients) for degenerative disc disease.

OUTCOME MEASURES: The primary outcome measure was the rate of reoperations and further cervical surgeries. Secondary outcome measures included neck symptoms (Neck Disability Index, or NDI), health-related quality of life (EQ-5D-3L), satisfaction with the surgery, radiological outcomes, and employment status.

METHODS: The medical records of all patients who underwent TDR due to degenerative cervical disease at Helsinki University Hospital between 2006 and 2012 and those of the matched control patients were analyzed retrospectively. Questionnaires were sent to all available patients at the end of the follow-up (median 14 years) to evaluate their employment status, levels of satisfaction with the surgery, current neck symptoms, and health-related quality of life. Radiological outcomes were evaluated from the cervical plain radiographs, which were taken either at the end of the follow-up as a part of the present study or earlier on for other clinical reasons, but at least two years after index surgery.

RESULTS: The total rate of reoperations and further cervical surgeries during the follow-up of a median of 14 years was 7/38 (18%) in the TDR group and 6/76 (8%) in the ACDF group (p = 0.096, ns.). TDR patients were reoperated earlier, and the 5-year reoperation rate was significantly higher in the TDR group (11% vs. 1.3%, p=0.026). None of the TDR patients underwent further cervical surgery more than six years after index surgery, whereas 5/6 (83%) of the reoperated ACDF patients were reoperated after that time. There were no significant differences in the NDIs between the patient groups. The employment rate and health-related quality of life were slightly higher in the TDR group, but the differences were statistically non-significant. TDR was significantly better at maintaining the angular range of motion at the operated level, and the fusion rate was significantly lower among this group.

CONCLUSIONS: There were no significant differences in the long-term outcomes of ACDF and TDR when measured by reoperation rates, employment status, NDI, EuroQoL, and satisfaction with surgery. Reoperation rate and, on the other hand, employment rate and health-related quality of life, were higher in the TDR group, but the differences were statistically non-significant. However, TDR patients were reoperated earlier, and the 5-year reoperation rate was significantly higher in the TDR group. Randomized long-term studies in which these methods are compared are needed to further clarify the differences between them.

PMID:37660896 | DOI:10.1016/j.spinee.2023.08.019

Spine J. 2023 Sep 1:S1529-9430(23)03370-3. doi: 10.1016/j.spinee.2023.08.020. Online ahead of print.

ABSTRACT

BACKGROUND CONTEXT: In contrast to cervical discectomy and fusion, total disc replacement (TDR) aims at preserving the motion at the treated vertebral level. Spinal motion is commonly evaluated with the range of motion (ROM). However, more qualitative information about cervical kinematics before and after TDR is still lacking.

PURPOSE: The aim of this in vitro study was to investigate the influence of cervical TDR on ROM, instantaneous centers of rotation (ICR) and three-dimensional helical axes.

STUDY DESIGN: An in vitro study with human spine specimens under pure moment loading was conducted to evaluate the kinematics of the intact cervical spine and compare it to cervical TDR.

METHODS: Six fresh frozen human cervical specimens (C4-5, median age 28 years, range 19-47 years, two female and four male) were biomechanically characterized in the intact state and after implantation of a cervical disc prosthesis (MOVE-C, NGMedical, Germany). To mimic in vivo conditions regarding temperature and humidity, water steam was used to create a warm and humid test environment with 37°C. Each specimen was quasistatically loaded with pure moments up to ±2.5 Nm in flexion/extension (FE), lateral bending (LB) and axial rotation (AR) in a universal spine tester for 3.5 cycles at 1 °/s. For each third cycle of motion the ROM was evaluated and an established method was used to determine the helical axis and COR and to project them into three planar X-rays. Statistical analysis was conducted using a Friedman-test and post hoc correction with Dunn-Bonferroni-tests (p < 0.05).

RESULTS: After TDR, total ROM was increased in FE from 19.1° to 20.1°, decreased in LB from 14.6° to 12.6° and decreased in AR from 17.7° to 15.5°. No statistical differences between the primary ROM in the intact condition and ROM after TDR were detected. Coupled rotation between LB and AR were also maintained. The position and orientation of the helical axes after cervical TDR was in good agreement with the results of the intact specimens in all three motion directions. The ICR in FE and AR before and after TDR closely matched, while in LB the ICR after TDR were more caudal. The intact in vitro kinematics we found also resembled in vivo results of healthy individuals.

CONCLUSION: The results of this in vitro study highlight the potential of artificial cervical disc implants to replicate the quantity as well as the quality of motion of the intact cervical spine.

CLINICAL SIGNIFICANCE: Physiological motion preservation was a driving factor in the development of cervical TDR. Our results demonstrate the potential of cervical TDR to replicate in vivo kinematics in all three motion directions.

PMID:37660895 | DOI:10.1016/j.spinee.2023.08.020

Spine J. 2023 Sep 1:S1529-9430(23)03363-6. doi: 10.1016/j.spinee.2023.08.018. Online ahead of print.

ABSTRACT

BACKGROUND CONTEXT: Anterior cervical discectomy and fusion (ACDF) is a commonly-performed and generally well-tolerated procedure used to treat cervical disc herniation. Rarely, patients require discharge to inpatient rehab, leading to inconvenience for the patient and increased healthcare expenditure for the medical system.

PURPOSE: The objective of this study was to create an accurate and practical predictive model for, as well as delineate associated factors with, rehab discharge following elective ACDF.

STUDY DESIGN: This was a retrospective, single-center, cohort study.

PATIENT SAMPLE: Patients who underwent ACDF between 2012 and 2022 were included. Those with confounding diagnoses or who underwent concurrent, staged, or non-elective procedures were excluded.

OUTCOME MEASURES: Primary outcomes for this study included measurements of accuracy for predicting rehab discharge. Secondary outcomes included associations of variables with rehab discharge.

METHODS: Current Procedural Terminology codes identified patients. Charts were reviewed to obtain additional demographic and clinical characteristics on which an initial univariate analysis was performed. Two logistic regression and two machine learning models were trained and evaluated on the data using cross validation. A multimodel logistic regression was implemented to analyze independent variable associations with rehab discharge.

RESULTS: 466 patients were included in the study. The logistic regression model with minimum corrected Akaike information criterion score performed best overall, with the highest values for area under the receiver operating characteristic curve (0.83), Youden’s J statistic (0.71), balanced accuracy (85.7%), sensitivity (90.3%), and positive predictive value (38.5%). Rehab discharge was associated with a modified frailty index of 2 (p = 0.007), lack of home support (p = 0.002), and having Medicare or Medicaid insurance (p = 0.007) after correction for multiple hypotheses.

CONCLUSIONS: Non-medical social determinants of health, such as having public insurance or a lack of support at home, may play a role in rehab discharge following elective ACDF. In combination with the modified frailty index and other variables, these factors can be used to predict rehab discharge with high accuracy, improving the patient experience and reducing healthcare costs.

PMID:37660894 | DOI:10.1016/j.spinee.2023.08.018

J Shoulder Elbow Surg. 2023 Sep 1:S1058-2746(23)00639-0. doi: 10.1016/j.jse.2023.07.039. Online ahead of print.

ABSTRACT

BACKGROUND: Anatomic and reverse total shoulder arthroplasty (aTSA, rTSA) are well-established treatments for patients with primary osteoarthritis and an intact cuff. However, it is unclear whether aTSA or rTSA provide superior outcomes in patients with preoperative external rotation (ER) weakness.

METHODS: A retrospective review of a prospectively collected shoulder arthroplasty database was performed between 2007-2020. Patients were excluded for preoperative diagnoses of nerve injury, infection, tumor, or fracture. Analysis included 333 aTSAs and 155 rTSAs performed for primary cuff-intact osteoarthritis with 2-year minimum follow-up. Defining preoperative ER weakness as strength ≤7.2 pounds, 3 cohorts were created and matched: 1) weak aTSAs (n = 74) vs normal aTSAs (n = 74), 2) weak rTSAs (n = 38) vs normal rTSAs (n = 38), and 3) weak rTSAs (n = 60) vs weak aTSAs (n = 60). We compared ROM, outcome scores, strength, complications, and revision rates at latest follow-up.

RESULTS: Despite weak aTSAs having poorer preoperative strength in FE and ER (P<.001), neither of these deficits persisted postoperatively compared to the normal cohort. Likewise, weak rTSAs had poorer preoperative strength in FE and ER, overhead motion, and Constant, SPADI, and UCLA scores (P<.029). However, no statistically significant differences were found between preoperatively weak and normal rTSAs. When comparing weak aTSA versus weak rTSA, no differences were found in preoperative and postoperative outcomes, proportion of patients achieving the MCID and SCB, and complication and rate of revision surgery.

CONCLUSION: In preoperatively weak patients with cuff-intact primary osteoarthritis, aTSA leads to similar postoperative strength, ROM, and outcome scores compared to patients with normal preoperative strength, indicating preoperative weakness does not preclude aTSA use. Furthermore, patients who were preoperatively weak in ER demonstrated improved postoperative rotational motion after undergoing aTSA and rTSA, with both groups achieving the MCID and SCB at similar rates.

PMID:37660887 | DOI:10.1016/j.jse.2023.07.039

J Dent. 2023 Sep 1:104684. doi: 10.1016/j.jdent.2023.104684. Online ahead of print.

ABSTRACT

OBJECTIVES: This study aimed to verify the non-inferiority of Endocem MTA Premixed and Well-Root PT, compared with ProRoot MTA in the pulpotomy of primary molars. In addition, we tried to determine the factors that affect the prognosis of pulpotomy in primary molars.

METHODS: This randomized clinical trial enrolled 158 molars of 52 children; 153 teeth were finally included and divided into three groups: ProRoot MTA (n = 50), Endocem MTA Premixed (n = 53), and Well-Root PT (n = 50). Clinical and radiographic follow-up was performed at 3, 6, and 12 months postoperatively and at the last visit post-treatment. Data were analyzed using the Fisher’s exact test, Cox regression analysis, and the Kaplan-Meier survival curve method.

RESULTS: The success rates in the ProRoot MTA, Endocem MTA Premixed, and Well-Root PT were 92%, 84.9, and 82%, respectively. The cumulative survival rates did not differ significantly among the materials. Among the investigated variables, only ΔF and ΔF max significantly affected the success rates. In the multivariate survival tree model, significant unfavorable survival was observed when the ΔF value was -14.4 or less (hazard ratio, 7.56; P = 0.0295).

CONCLUSIONS: Considering the clinical effectiveness of Endocem MTA Premixed and Well-Root PT and the operational convenience as a premixed type, they can be used as advantageous materials in the pulpotomy of primary molars in pediatric patients. The QLF method is a useful diagnostic method that can establish treatment plans and determine the prognosis of pulpotomy based on the ΔF value in primary molars.

CLINICAL SIGNIFICANCE: Endocem MTA Premixed and Well-Root PT can confer high success rates and are non-inferior to ProRoot MTA in pulpotomy for primary molars. We also showed that QLF technology can be applied to predict the success/failure and prognosis of pulpotomies in primary molars.

PMID:37660882 | DOI:10.1016/j.jdent.2023.104684

Environ Res. 2023 Sep 1:117062. doi: 10.1016/j.envres.2023.117062. Online ahead of print.

ABSTRACT

Psoriasis is one of the most common immune-mediated inflammatory diseases (IMIDs). Living in a rural environment during childhood is associated with a decreased risk of certain IMIDs, like asthma, in adulthood. However, its role in other IMIDs, such as psoriasis is still unclear. To evaluate the relationships between different factors related to the environment during childhood and the risk of psoriasis in adulthood we conducted a study in E3N, a French prospective cohort composed of 98 995 women. During the 1990-2018 follow-up of 72 154 study participants, we identified 1967 incident cases of psoriasis from self-reports in self-administered structured questionnaires. During the 2004-2018 follow-up of 67 917 study participants, 188 moderate-to-severe cases of psoriasis were identified through self-reports and from data from a drug reimbursement database. We fitted Cox proportional hazards regression models with age as the time scale and adjusted for putative confounders (aHRs). We found inverse associations with risk of psoriasis for rural birthplace [aHR: 0.89 (95%CI: 0.79-0.96)] and for having farming parents [aHR: 0.84 (95%CI: 0.72-0.97)]. For moderate-to-severe psoriasis we found a nominally similar inverse association with rural birthplace but not with having farming parents. Our results suggest that an exposure to a rural environment during childhood may be associated with a reduced risk of psoriasis. These findings may help to improve our understanding of the pathogenesis of psoriasis.

PMID:37660877 | DOI:10.1016/j.envres.2023.117062