Nevin Manimala

Acta Obstet Gynecol Scand. 2022 Mar 2. doi: 10.1111/aogs.14321. Online ahead of print.

ABSTRACT

INTRODUCTION: Obstetric hemorrhage-related deaths are rare in high income countries. Yet, with increasing incidences of obstetric hemorrhage in these countries, it is of utmost importance to learn lessons from each obstetric hemorrhage-related death to improve maternity care. Our objective was to calculate the obstetric hemorrhage-related maternal mortality ratio (MMR), assess causes of obstetric hemorrhage-related deaths, and identify lessons learned.

MATERIAL AND METHODS: Nationwide mixed-methods prospective case-series with confidential enquiries into maternal deaths due to obstetric hemorrhage in the Netherlands from January 1, 2006 to December 31, 2019.

RESULTS: The obstetric hemorrhage-related MMR in the Netherlands in 2006-2019 was 0.7 per 100 000 livebirths and was not statistically significantly different compared with the previous MMR of 1.0 per 100 000 livebirths in 1993-2005 (odds ratio 0.70, 95% confidence interval 0.38-1.30). Leading underlying cause of hemorrhage was retained placenta. Early recognition of persistent bleeding, prompt involvement of a senior clinician and timely management tailored to the cause of hemorrhage with attention to coagulopathy were prominent lessons learned. Also, timely recourse to surgical interventions, including hysterectomy, in case other management options fail to stop bleeding came up as an important lesson in several obstetric hemorrhage-related deaths.

CONCLUSIONS: The obstetric hemorrhage-related MMR in the Netherlands in 2006-2019 has not substantially changed compared to the MMR of the previous enquiry in 1993-2005. Although obstetric hemorrhage is commonly encountered by maternity care professionals, it is important to remain vigilant for possible adverse maternal outcomes and act upon an ongoing bleeding following birth in a more timely and adequate manner. Our confidential enquiries still led to important lessons learned with clinical advice to professionals as how to improve maternity care and avoid maternal deaths. Drawing lessons from maternal deaths should remain a qualitative and moral imperative.

PMID:35238018 | DOI:10.1111/aogs.14321

J Opioid Manag. 2022 Jan-Feb;18(1):75-83. doi: 10.5055/jom.2022.0697.

ABSTRACT

OBJECTIVE: Primary care physicians (PCPs) are positioned to mitigate opioid morbidity and mortality, but their engagement in primary, secondary, and tertiary opioid-related prevention behaviors is unclear. The objective of this study was to evaluate Tennessee PCPs’ engagement in and intention to engage in multiple opioid-related prevention behaviors.

METHODS: A survey instrument was developed, pretested, and pilot tested with practicing PCPs. Thereafter, a census of eligible Tennessee PCPs was conducted using a modified, four-wave tailored design method approach. Three patient scenarios were employed to assess physician intention to engage in 10 primary, secondary, and tertiary prevention behaviors. Respondents were asked to report, given 10 similar scenarios, the number of times (0-10) they would engage in prevention behaviors. Descriptive statistics were calculated using SPSS version 25.

RESULTS: A total of 296 usable responses were received. Physician intention to engage in prevention behaviors varied across the 10 behaviors studied. Physicians reported frequently communicating risks associated with prescription opioids to patients (8.9 ± 2.8 out of 10 patients), infrequently utilizing brief questionnaires to assess for risk of opioid misuse (1.7 ± 3.3 out of 10 patients), and screening for current opioid misuse (3.1 ± 4.3 out of 10 patients). Physicians reported seldomly co-prescribing naloxone for overdose reversal and frequently discharging from practice patients presenting with an opioid use disorder.

CONCLUSIONS: This study noted strengths and opportunities to increase engagement in prevention behaviors. Understanding PCPs’ engagement in opioid-related prevention behaviors is important to effectively target and implement morbidity and mortality reducing interventions.

PMID:35238016 | DOI:10.5055/jom.2022.0697

Can J Anaesth. 2022 Mar 2. doi: 10.1007/s12630-022-02216-1. Online ahead of print.

ABSTRACT

PURPOSE: The high-thoracic erector spinae plane block (HT-ESPB) has been reported as an effective analgesic modality for the shoulder region without phrenic nerve palsy. The goal of this study was to compare the HT-ESPB as a phrenic nerve-sparing alternative to an interscalene block for total shoulder arthroplasty.

METHODS: Thirty patients undergoing total shoulder arthroplasty at Stanford Health Care (Palo Alto, CA, USA) were enrolled in a double-blind randomized controlled trial. We randomized 28 patients to receive either an interscalene or HT-ESPB perineural catheter preoperatively; 26 patients were included in the final analysis. The study was powered for the primary outcome of incidence of hemidiaphragmatic paralysis in the postanesthesia care unit (PACU). Other outcome measures included incentive spirometry volume, brachial plexus motor and sensory exams, adverse events, pain scores, and opioid consumption.

RESULTS: The incidence of hemidiaphragmatic paralysis in the HT-ESPB catheter group was significantly lower than in the interscalene catheter group (0/12, 0% vs 14/14, 100%; P < 0.001). No statistically significant differences were found in pain scores and opioid consumption (in oral morphine equivalents) between the interscalene and HT-ESPB groups through postoperative day (POD) 2. Nevertheless, the mean (standard deviation) point estimates for opioid consumption for the HT-ESPB group were higher than for the interscalene group in the PACU (HT-ESPB: 24.8 [26.7] mg; interscalene: 10.7 [21.7] mg) and for POD 0 (HT-ESPB: 20.5 [25.0] mg; interscalene: 6.7 [12.0] mg). In addition, cumulative postoperative opioid consumption was significantly higher at POD 0 (PACU through POD 0) in the HT-ESPB group (45.3 [39.9] mg) than in the interscalene group (16.6 [21.9] mg; P = 0.04).

CONCLUSIONS: This study suggests that continuous HT-ESPB can be a phrenic nerve-sparing alternative to continuous interscalene brachial plexus blockade, although the latter provided superior opioid-sparing in the immediate postoperative period. This was a small sample size study, and further investigations powered to detect differences in analgesic and quality of recovery score endpoints are needed.

STUDY REGISTRATION: www.ClinicalTrials.gov (NCT03807505); registered 17 January 2019.

PMID:35237953 | DOI:10.1007/s12630-022-02216-1

J Endocrinol Invest. 2022 Mar 2. doi: 10.1007/s40618-022-01760-3. Online ahead of print.

ABSTRACT

PURPOSE: Girls affected with Turner syndrome (TS) present with low bone mineral density (BMD) and osteopenia/osteoporosis. Thus, they have an increased risk to develop fractures compared to normal population. The aim of this study was to deepen the pathophysiology of skeletal fragility in TS subjects by evaluating the serum levels of Dickkopf-1 (DKK-1) and sclerostin, main regulators of bone mass, as well as the percentage of circulating osteoblast precursors (OCPs).

METHODS: Thirty-four TS girls and 24 controls were recruited. All subjects underwent anthropometric measures (height, weight, body mass index-BMI). A peripheral venous blood sample was collected to determine serum levels of active intact parathyroid hormone (PTH), 25-OH vitamin D, calcium, phosphorus, bone alkaline phosphatase (bALP), osteocalcin, sclerostin, DKK-1, RANKL and OPG. OCPs were detected by flow cytometry. In TS subjects bone mineralization was measured at lumbar spine by dual energy X-ray absorptiometry (DXA).

RESULTS: bALP, 25-OH Vitamin D, and osteocalcin levels were significant lower in TS subjects than in the controls. Statistically significant higher levels of sclerostin, DKK-1 and RANKL were measured in patients compared with the controls. The percentage of OCPs did not show significant differences between patients and controls. Sclerostin and DKK-1 levels were related with anthropometric parameters, bone metabolism markers, HRT, rhGH therapy, RANKL and lumbar BMAD-Z-score.

CONCLUSION: TS patients showed higher levels of sclerostin and DKK-1 than controls which can be related to HRT, and to reduced bone formation markers as well as the increased bone resorption activity.

PMID:35237949 | DOI:10.1007/s40618-022-01760-3

Emerg Radiol. 2022 Mar 3. doi: 10.1007/s10140-022-02031-7. Online ahead of print.

ABSTRACT

PURPOSE: To test the hypothesis that an automated post-processing workflow reduces trauma panscan exam completion times and variability.

METHODS: One-hundred-fifty consecutive trauma panscans performed between June 2018 and December 2019 were included, half before and half after implementation of an automated software-driven post-processing workflow. Acquisition and reconstruction timestamps were used to calculate total examination time (first acquisition to last reformation), setup time (between the non-contrast and contrast-enhanced acquisitions), and reconstruction time (for the contrast-enhanced reconstructions and reformations). The performing technologist was recorded and accounted for in analyses using linear mixed models to assess differences between the pre- and post-intervention groups.

RESULTS: Exam, setup, and recon times were (mean ± standard deviation) 33.5 ± 4.6, 9.2 ± 2.4, and 23.6 ± 4.7 min before and 27.8 ± 1.5, 8.9 ± 1.4, and 18.9 ± 1.7 min after intervention. These reductions of 5.7 and 4.7 min in the mean exam and recon times were statistically significant (p < 0.001) while the setup time was not (p = 0.49). The reductions in standard deviation were statistically significant for exam and recon times (p < 0.0001) but not for setup time (p = 0.13). All automated panscans were completed within 36 min, versus 65% with the traditional workflow.

CONCLUSION: Automation of image reconstruction workflow significantly decreased mean exam and reconstruction times as well as variability between exams, thus facilitating a consistently rapid imaging assessment, and potentially reducing delays in critical management decisions.

PMID:35237937 | DOI:10.1007/s10140-022-02031-7

Atten Percept Psychophys. 2022 Mar 2. doi: 10.3758/s13414-022-02456-9. Online ahead of print.

ABSTRACT

Visual perception is capable of pooling multiple local orientation signals into a single more accurate summary orientation. However, there is still a lack of systematic inquiry into which summary statistics are implemented in that process. Here, the task was to recognize in which direction, clockwise or counter-clockwise, the mean orientation of a set of randomly distributed Gabor patches (N = 1, 2, 4, and 8) was rotated from the implicit vertical. The mean orientation discrimination accuracy did not improve with the increase of the number N of elements in proportion to the square-root-N, as could be expected if noisy internal representations were arithmetically averaged. The Proportion of Informative Elements (PIE), defined as the percentage of elements having an orientation different from the vertical, also affected the discrimination precision, violating the arithmetic averaging rules. The decrease in the orientation discrimination precision with the increase of the PIE would suggest that the orientation pooling could be more adequately described by a quadratic or higher power mean. Thus, we parameterized the averaging process for the power parameter of the generalized mean formula. The results indicate that different pooling rules in different trials may apply, for example, the arithmetic mean in some and the maximal deviation rule in others. It is concluded that pooling of orientation information is a relatively inaccurate process for which different perceptual cues and their combination rules can be used.

PMID:35237931 | DOI:10.3758/s13414-022-02456-9

Neurocrit Care. 2022 Mar 2. doi: 10.1007/s12028-022-01458-7. Online ahead of print.

ABSTRACT

BACKGROUND: Twitter journal clubs are a modern way of highlighting articles published in a scientific journal. The Neurocritical Care journal (NCC) initiated a bimonthly, Twitter-based, online journal club in 2015 to increase the outreach of its published articles. We hypothesize that articles included in the Neurocritical Care Society Twitter Journal Club (NCSTJC) had greater engagement than other articles published during the same time period. We also investigated the relationship between number of citations and Altmetric score to assess whether the enhanced online activity resulted in higher citations.

METHODS: We gathered data in August 2020 on engagement metrics (number of downloads, Altmetric score, relative citation ratio, and number of citations) of all articles published in NCC between 2015 and 2018. Articles were analyzed into two groups: one featured in NCSTJC and the rest that were not (non-NCSTJC1), and the other comprised those that were not in NCSTJC but published under a similar category of articles as NCSTJC (non-NCSTJC2). Results were analyzed using descriptive statistics, and summary measures were used to report the spread. The groups were compared by using the Wilcoxon rank sum test, given that the data were not normally distributed. Spearman’s rank correlation was used to assess correlation between Altmetric score and citations for the articles in the NCSTJC and non-NCSTJC groups. For comparison, the top ten cited articles in NCC were analyzed for similar correlations.

RESULTS: Between 2015 and 2018, NCC published 529 articles, 24 of which were included in the Twitter journal club. A total of 406 articles were published in the same category as the category of articles selected for NCSTJC. The articles discussed as a part of NCSTJC had a statistically significant trend toward a higher number of downloads, Altmetric score, relative citation ratio, and number of citations than rest of the articles published in the journal during the same time period and the rest of the articles published in same categories. Three NCSTJC articles were among the ten most-cited articles published by NCC between 2015 and 2018. We did not find a correlation between Altmetric scores and number of citations in the NCSTJC or non-NCSTJC1 or non-NCSTJC2 group, but there was a strong correlation between these two variables in high performing articles when the top ten cited articles were analyzed.

CONCLUSIONS: Scientific journals are evolving their social media strategies in attempt to increase the outreach of their articles to the medical community. Platforms such as Twitter journal clubs can enhance such engagement. The long-term influence of such strategies on the impact factor of a medical journal and traditional engagement metrics, such as citations, calls for further research.

PMID:35237920 | DOI:10.1007/s12028-022-01458-7

Obes Surg. 2022 Mar 2. doi: 10.1007/s11695-022-05976-3. Online ahead of print.

ABSTRACT

BACKGROUND AND AIM: One of the main causes of mortality among obese patients is cardiovascular disease (CVD). Carotid intima-media thickness (CIMT) is an independent predictor for atherosclerosis and risk of CVD, and has been demonstrated to be related with obesity. This study aimed to evaluate the effect of substantial weight loss after bariatric surgery on CIMT.

METHODS: This prospective study was performed on patients with morbid obesity and standard indications for bariatric surgery in a tertiary referral center in Iran. The mean CIMT values were assessed using B-mode ultrasonography before and 6 months after bariatric surgery.

RESULTS: A total of 32 patients (25 females, 7 males) with a mean age of 38.18 ± 1.18 years were enrolled. Body mass index (BMI) was significantly reduced from 43.66 ± 6.44 to 29.01 ± 2.56 kg/m² during 6 months following surgery (p: 0.001). The mean CIMT values at 6 months after surgery were significantly lower than the baseline (0.53 ± 0.06 vs. 0.50 ± 0.08; p: 0.001). Along with a significant hypertension and metabolic syndrome remission, we observed considerable reduction in FBS (p: 0.019), cholesterol (p: 0.061), triglycerides (p: 0.001), and insulin levels (p: 0.001). Besides, liver stiffness was significantly decreased after surgery (6.15 ± 0.82 vs. 5.26 ± 0.83; p: 0.001). There was no statistically significant correlation between changes in quantitative variables and changes in CIMT.

CONCLUSION: Bariatric surgery results in significant reduction in CIMT, metabolic syndrome factors, and liver stiffness in patients with morbid obesity.

PMID:35237906 | DOI:10.1007/s11695-022-05976-3

Surg Endosc. 2022 Mar 2. doi: 10.1007/s00464-022-09100-5. Online ahead of print.

ABSTRACT

BACKGROUND: The Agency for Healthcare Research and Quality uses Patient Safety Indicators (PSI) to gauge quality of care and patient safety in hospitals. PSI 90 is a weighted combination of several PSIs that primarily comprises perioperative events. This score can affect reimbursement through Medicare and hospital quality ratings. Minimally invasive surgery (MIS) has been shown to decrease adverse events and outcomes. We sought to evaluate individual PSI and PSI 90 outcomes of minimally invasive versus open colorectal surgeries using a large medical database from 5 hospitals.

METHODS: A health system administrative database including all inpatients from 5 acute care hospitals was queried based on ICD 10 PC codes for colon and rectal surgery procedures performed between January 2, 2018 and December 31, 2019. Surgeries were labeled as MIS (laparoscopic) or open colorectal resection surgery. Patient demographics, health information, and case characteristics were analyzed with respect to surgical approach and PSI events. Statistical relationships between surgical approach and PSI were investigated using univariate methods and multivariate logarithmic regression analysis. PSIs of interest were PSI 8, PSI 9 PSI 11, PSI 12, and PSI 13.

RESULTS: There were 1382 operations identified, with 861 (62%) being open and 521 (38%) being minimally invasive. Logistic modeling showed no significant difference between the 2 groups for PSI 3, 6, or 8 through 15.

CONCLUSION: Understanding PSI 90 and its components is important to enhance perioperative patient care and optimize reimbursement rates. We showed that MIS, despite providing known clinical benefits, may not affect scores in the PSI 90. Surgical approach may have little effect on PSIs, and other patient and system components that are more important to these outcome measures should be pursued.

PMID:35237902 | DOI:10.1007/s00464-022-09100-5

Surg Endosc. 2022 Mar 2. doi: 10.1007/s00464-022-09098-w. Online ahead of print.

ABSTRACT

BACKGROUND: Worldwide, trauma-related deaths are one of the main causes of mortality. Appropriate surgical treatment is crucial to prevent mortality, however, in the past decade, general surgery residents’ exposure to trauma cases has decreased, particularly since the COVID-19 pandemic. In this context, accessible simulation-based training scenarios are essential.

METHODS: A low-cost, previously tested OSCE scenario for the evaluation of surgical skills in trauma was implemented as part of a short training boot camp for residents and recently graduated surgeons. The following stations were included bowel anastomosis, vascular anastomosis, penetrating lung injury, penetrating cardiac injury, and gastric perforation (laparoscopic suturing). A total of 75 participants from 15 different programs were recruited. Each station was videotaped in high definition and assessed in a remote and asynchronous manner. The level of competency was assessed through global and specific rating scales alongside procedural times. Self-confidence to perform the procedure as the leading surgeon was evaluated before and after training.

RESULTS: Statistically significant differences were found in pre-training scores between groups for all stations. The lowest scores were obtained in the cardiac and lung injury stations. After training, participants significantly increased their level of competence in both grading systems. Procedural times for the pulmonary tractotomy, bowel anastomosis, and vascular anastomosis stations increased after training. A significant improvement in self-confidence was shown in all stations.

CONCLUSION: An OSCE scenario for training surgical skills in trauma was effective in improving proficiency level and self-confidence. Low pre-training scores and level of confidence in the cardiac and lung injury stations represent a deficit in residency programs that should be addressed. The incorporation of simulation-based teaching tools at early stages in residency would be beneficial when future surgeons face extremely severe trauma scenarios.

PMID:35237901 | DOI:10.1007/s00464-022-09098-w