Nevin Manimala

J Arthroplasty. 2021 Mar 26:S0883-5403(21)00330-2. doi: 10.1016/j.arth.2021.03.047. Online ahead of print.

ABSTRACT

BACKGROUND: A small proportion of patients suffer from isolated lateral osteoarthritis where the sole lateral unicompartmental knee arthroplasty (UKA) is a possible treatment option. There, both a medial and a lateral surgical approach can be considered. This study should answer the question whether the lateral approach is superior to a modified medial approach in terms of implantation accuracy and subjective outcome.

METHODS: In this retrospective study, 175 patients with lateral UKA were included between 2015 and 2020. In 82 patients, the lateral approach was used, and in 93 patients, the medial approach was used. To assess implantation accuracy, different imaging criteria on postoperative radiographs were analyzed. Postoperative patient-related outcome measurements (PROMs) (OKS, LEFS, and EQ5D) were evaluated. Statistical significance was assumed for P < .05.

RESULTS: The tibial implant relation to the tibial plateau diameter in the lateral approach was significantly larger than in the medial approach (23.6% vs 22.2%; P < .001). Significantly more deviations >15° regarding flexion position of the femoral implant (P = .002) and a higher number of deviations of the slope was found (P = .06) in the lateral approach. The lateral approach showed a significantly higher rate of lateral positioning of the femoral component (P = .007). Post-PROMs showed significant improvement in both approaches.

CONCLUSION: The lateral approach is not superior regarding different radiological accuracy criteria. The Hoffa´s fat pad-preserving medial approach showed good results in implantation accuracy and therefore is a good alternative to implant lateral UKA. In addition, significant improvement in PROMs could be demonstrated.

PMID:33867207 | DOI:10.1016/j.arth.2021.03.047

Eur Urol. 2021 Apr 15:S0302-2838(21)00213-X. doi: 10.1016/j.eururo.2021.03.015. Online ahead of print.

ABSTRACT

BACKGROUND: Non-clear cell renal cell carcinoma (nccRCC) accounts for ≤20% of RCC cases. Lenvatinib (a multitargeted tyrosine kinase inhibitor) in combination with everolimus (an mTOR inhibitor) is approved for the treatment of advanced RCC after one prior antiangiogenic therapy.

OBJECTIVE: To determine the safety and efficacy of lenvatinib plus everolimus as a first-line treatment for patients with advanced nccRCC.

DESIGN, SETTING, AND PARTICIPANTS: This open-label, single-arm, multicenter, phase 2 study enrolled patients with unresectable advanced or metastatic nccRCC and no prior anticancer therapy for advanced disease.

INTERVENTION: Lenvatinib (18 mg) plus everolimus (5 mg) orally once daily.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary endpoint was the objective response rate (ORR) as assessed by investigators according to Response Evaluation Criteria in Solid Tumors version 1.1. Secondary endpoints included progression-free survival (PFS), overall survival (OS), and safety assessments. The 95% confidence intervals (CIs) for ORRs were calculated using the two-sided Clopper-Pearson method. Median PFS and median OS were estimated using the Kaplan-Meier product-limit method and their 95% CIs were estimated via a generalized Brookmeyer and Crowley method.

RESULTS AND LIMITATIONS: The study (start date: February 20, 2017) enrolled 31 patients with nccRCC (papillary, n = 20; chromophobe, n = 9; unclassified, n = 2). At the data cutoff date (July 17, 2019), the best overall response was a partial response (eight patients: papillary, n = 3; chromophobe, n = 4; unclassified, n = 1) for an overall ORR of 26% (95% CI 12-45). Median PFS was 9.2 mo (95% CI 5.5-not estimable), and median OS was 15.6 mo (95% CI 9.2-not estimable). The most common treatment-emergent adverse events were fatigue (71%), diarrhea (58%), decreased appetite (55%), nausea (55%), and vomiting (52%). Limitations include the small sample size and single-arm design.

CONCLUSIONS: Lenvatinib plus everolimus showed promising anticancer activity in patients with advanced nccRCC with an ORR of 26% and is worthy of further study. The safety profile was consistent with the established profile of the study-drug combination.

PATIENT SUMMARY: We examined the combination of lenvatinib plus everolimus as the first therapy for 31 patients who had advanced nccRCC. We found that this treatment seemed effective, because most patients had a decrease in tumor size and manageable treatment-related side effects.

CLINICAL REGISTRATION: This trial is registered at ClinicalTrials.Gov as NCT02915783.

PMID:33867192 | DOI:10.1016/j.eururo.2021.03.015

Surgery. 2021 Apr 15:S0039-6060(21)00202-6. doi: 10.1016/j.surg.2021.03.010. Online ahead of print.

ABSTRACT

BACKGROUND: Excessive stress negatively impacts surgical residents’ technical performance. The effect of stress on trainee nontechnical skills, however, is less well studied. Given that nontechnical skills are known to impact clinical performance, the purpose of this study was to assess the relationship between residents’ perceived stress and nontechnical skills during multidisciplinary trauma simulations.

METHODS: First-year surgery and emergency medicine residents voluntarily participated in this study. Residents participated in 3 trauma simulations across 2 training sessions in randomly assigned teams. Each team’s nontechnical skills were evaluated by faculty using the Trauma Nontechnical Skills scale. The Trauma Nontechnical Skills scale consists of 5 items: leadership, cooperation, communication, assessment, and situation awareness/coping with stress. After each scenario, residents completed the 6-item version of the State-Trait Anxiety Inventory and the Surgery Task Load Index to detail their perceived stress and workload during scenarios. Linear regressions were run to assess relationships between stress, workload, and nontechnical skills.

RESULTS: Twenty-five residents participated in the first simulation day, and 24 residents participated in the second simulation day. Results from regressions revealed that heightened stress and workload predicted significantly lower nontechnical skills performance during trauma scenarios. In regard to specific aspects of nontechnical skills, residents’ heightened stress and workload predicted statistically significant lower situation awareness and decision-making during trauma scenarios.

CONCLUSION: Residents’ perceived stress and workload significantly impaired their nontechnical skills during trauma simulations. This finding highlights the need to offer stress management and performance-optimizing mental skills training to trainees to lower their stress and optimize nontechnical skills performance during challenging situations.

PMID:33867169 | DOI:10.1016/j.surg.2021.03.010

Surgery. 2021 Apr 15:S0039-6060(21)00153-7. doi: 10.1016/j.surg.2021.02.033. Online ahead of print.

ABSTRACT

BACKGROUND: The universal Surgical Risk Preoperative Assessment System prediction models for postoperative adverse outcomes have good accuracy for estimating risk in broad surgical populations and for surgical specialties. The accuracy in individual operations has not yet been assessed. The objective of this study was to evaluate the Surgical Risk Preoperative Assessment System in predicting adverse outcomes for selected individual operations.

METHODS: The Surgical Risk Preoperative Assessment System models were applied to the top 2 most frequent common procedural terminology codes in 9 surgical specialties and 5 additional common general surgical operations in the 2009 to 2018 database of the American College of Surgeons National Surgical Quality Improvement Program. Goodness of fit statistics were estimated, including c-indices for discrimination, Hosmer-Lemeshow graphs and P values for calibration, overall observed versus expected event rates, and Brier scores.

RESULTS: The total sample size was 2,020,172, which represented 29% of the 6.9 million operations in the American College of Surgeons National Surgical Quality Improvement Program database. Average c-indices across 12 outcomes were acceptable (≥0.70) for 13 (56.5%) of the 23 operations. Overall observed-to-expected rates were similar for mortality and overall morbidity across the 23 operations. Hosmer-Lemeshow graphs over quintiles of risk comparing observed-to-expected rates of mortality and overall morbidity were similar for 52% and 70% of operations, respectively. Model performance was better in less complex operations and those done in patients with lower preoperative risk.

CONCLUSION: Surgical Risk Preoperative Assessment System displayed accuracy in estimating postoperative adverse events for some of the 23 operations studied, but not all. In the procedures where Surgical Risk Preoperative Assessment System was not accurate, developing disease or operation-specific risk models might be appropriate.

PMID:33867167 | DOI:10.1016/j.surg.2021.02.033

J Prosthet Dent. 2021 Apr 15:S0022-3913(21)00142-6. doi: 10.1016/j.prosdent.2021.02.033. Online ahead of print.

ABSTRACT

STATEMENT OF PROBLEM: Developing tapered implants with the most appropriate angular characteristics requires an improved analysis of the anatomy of premolar roots.

PURPOSE: The purpose of this observational study was to analyze the 3D anatomy of premolar roots by determining the tapered slope and convergent angle (TS/CA), to transform the TS/CA patterns into those in which the tapered implants mimic natural tooth roots, and to provide TS/CA references for future investigations.

MATERIAL AND METHODS: A total of 73 human single-rooted premolars were surveyed and analyzed by microcomputed tomography and an associated software program. The 3D root surface area (RSA), the radius/diameter (R/D) at the planned first to tenth millimeter levels apical to the cementoenamel junction (CEJ), and the TS/CA at corresponding levels were calculated. The results were statistically analyzed by using an independent samples t test to assess the general differences of tested parameters between maxillary and mandibular premolars. A paired t test was used to examine the significant intragroup TS/CA differences between sequential coronoapical levels. One-way ANOVA was applied to study the general significance of developmental patterns in maxillary and/or mandibular groups. Two-way ANOVA was used to inspect the TS/CA significance at various measurements coronoapically between the maxillary and mandibular premolars (α=.05).

RESULTS: Generally, the RSA, root length, R/D, and TS/CA parameters examined for the maxillary premolar roots differed significantly from those for the mandibular roots at the evaluated levels (P<.05). According to the measurements, the maxillary premolar roots generally exhibited nonsignificant RSA and R/D reduction patterns, with a decreasing angle of TS=13.44 degrees and CA=24.53 degrees coronoapically. However, mandibular premolar roots exhibited a significant reduction pattern, with TS=11.25 degrees and CA=21.06 degrees coronoapically according to both individual and general evaluations.

CONCLUSIONS: Based on the developmental patterns of the evaluated TSs/CAs, tapered implants imitating premolar root anatomy should have a conical rather than a cylindrical shape, and the R/D of these models should be reduced to half at the apical third. However, further studies are warranted to identify more TS/CA characteristics related to the tapered implants, including the TSs/CAs of other tooth types.

PMID:33867165 | DOI:10.1016/j.prosdent.2021.02.033

J Pediatr Surg. 2021 Mar 26:S0022-3468(21)00279-7. doi: 10.1016/j.jpedsurg.2021.03.045. Online ahead of print.

ABSTRACT

BACKGROUND/PURPOSE: Gastrostomy tube (GT) placement is a common pediatric procedure with high postoperative resource utilization. We aimed to determine if standardized discharge instructions (SDI) reduced healthcare utilization rates.

METHODS: We performed a retrospective cohort study comparing postoperative hospital utilization of patients who underwent initial GT placement pre- and post-SDI protocol implementation from 2014-2019. Statistical analyses included Chi-square tests, multivariable adjusted logistic regression, adjusted Cox proportion hazard regression, and adjusted Poisson regression models when appropriate.

RESULTS: 197 patients were included, 102 (51.8%) before and 95 (48.2%) after protocol implementation. On primary analysis, SDI patients did not have significantly different total postoperative hospital utilization events at 30-days (48.0% vs. 38.9%, p = 0.25). On secondary analysis, SDI patients had lower rates of ED (8.4% vs. 19.6%, p = 0.026) and office visits (11.6% vs. 25.5%, p = 0.017) at 30-days. Non-SDIs patients had greater odds of ED visits (OR2.7, 95%CI 1.3-5.9, p = 0.01), office visits (OR3.7, 95%CI 1.7-8.1, p = 0.001) and phone calls (OR2.6, 95%CI 1.2-5.7, p = 0.016) at 1-year. The adjusted hazard ratio was 2.0 (95%CI 1.4-3.0, p < 0.001). Incident rate ratio were 1.8 (95%CI 1.2-2.5, p = 0.002) at 30-days and 1.9 (95%CI 1.5-2.4, p < 0.001) at 1-year post-discharge.

CONCLUSIONS: SDIs post-GT placement may reduce multiple aspects of postoperative hospital utilization.

PMID:33867152 | DOI:10.1016/j.jpedsurg.2021.03.045

Injury. 2021 Apr 7:S0020-1383(21)00322-3. doi: 10.1016/j.injury.2021.04.013. Online ahead of print.

ABSTRACT

INTRODUCTION: Tibial plateau fractures are a heterogenous group of injuries with a variable amount of articular injury and are commonly associated with lateral sided articular impaction. Previous work has focused on describing the morphology of tibial plateau fractures, but has neglected description of medial sided articular impaction. The aim of this investigation was to assess the morphology of medial sided articular impaction in tibial plateau fractures, with specific attention directed toward the frequency, location, size, and associated fracture patterns.

METHODS: Skeletally mature patients presenting to a Level I trauma center from 2008-2018 with a tibial plateau fracture (AO/OTA 41B-C) were identified retrospectively. Fractures were classified by AO/OTA and Schatzker type. Radiographs and computed tomography (CT) scans were reviewed to identify and localize medial sided articular impaction. The location and surface area of impaction was characterized by creating frequency diagram heat maps from axial CT scans. Descriptive statistics were performed using standard measures.

RESULTS: Of the 1032 tibial plateau fractures included, 82 (7.9%) were noted to have medial sided articular impaction. Rate of impaction varied by fracture type (p = 0.03): Schatzker II, 2% (7 of 381); Schatzker IV, 21% (19 of 96); and Schatzker VI, 11% (56 of 524). Average total surface area of impaction was 9% of the total and 19% of the medial plateau area. Area of impaction varied by fracture type (p = 0.004): Schatzker II, 6% (95% confidence interval [CI], 4%-7%); Schatzker IV, 11% (95% CI, 9%-13%), and Schatzker VI, 9% (95% CI, 7%-11%). The area of impaction occurred primarily along the lateral aspect of the medial plateau in Schatzker II fractures, in the anteromedial quadrant of Schatzker IV fractures, and was evenly distributed across the medial plateau in Schatzker VI fractures.

CONCLUSIONS: Surgeons should be aware that medial articular impaction is present in approximately 8% of tibial plateau fractures. Schatzker IV fractures are most likely to have medial impaction and a larger proportion of the joint surface involved in these injuries.

PMID:33867150 | DOI:10.1016/j.injury.2021.04.013

Encephale. 2021 Apr 15:S0013-7006(21)00068-3. doi: 10.1016/j.encep.2020.11.009. Online ahead of print.

ABSTRACT

INTRODUCTION: The duration of untreated psychosis has been largely associated with poor outcomes in psychosis. Actual diagnostic tools may be used by very specialized teams and need sustained evaluation. We present a French version of a self-report questionnaire: the 16-item Prodromal Questionnaire (fPQ16). Our objective was to evaluate its predictive value for an ultra-high-risk state (UHR) or psychosis. The population enrolled was consulting in a young adults and adolescents center in Sainte-Anne hospital, Paris, France.

METHODS: PQ16 had first been translated into French and independently back translated and validated by the original authors. Between November 2016 and May 2018, every C’JAAD consulting patient was proposed to fill in the fPQ16. Each patient was next evaluated with the French version of the comprehensive assessment of at-risk mental state (CAARMS), which detects UHR or psychosis. Statistical analysis of fPQ16 concurrent validity was performed using ROC curves. fPQ16 acceptability was studied by four additional questions especially designed for that purpose.

RESULTS: One hundred participants were included. Mean age was 19.85years (SD 3.3 y). Fifty-eight percent of patients included were diagnosed with UHR (40%) or psychotic (18%) state after CAARMS evaluation. Mean score at fPQ16 was 5.7 (SD 3.8). Best cut-off score was 4 positive items, with excellent sensibility (91%) and correct specificity (60%). Positive predictive value of fPQ16 was 76%. Area under the curve was 0.85 (P<0.0001). fPQ16 showed good acceptability.

DISCUSSION: fPQ16 had good screening performances in our population. Cut-off score was lower than in previous studies, but performances were equal or better. As a well-accepted and short questionnaire, the fPQ16 could be a great screening tool in primary care. A version with 18-items, including two items focused on thought content and disorganization that are missing in PQ16, is under evaluation.

PMID:33867141 | DOI:10.1016/j.encep.2020.11.009

ISA Trans. 2021 Apr 9:S0019-0578(21)00203-2. doi: 10.1016/j.isatra.2021.04.006. Online ahead of print.

ABSTRACT

BACKGROUND: The 2019 novel coronavirus disease (COVID-19) has spread rapidly worldwide, and the outbreak of the disease was designated a global pandemic by the World Health Organization. Such outbreaks would certainly be catastrophic for some of the best-ranked health systems and would be more catastrophic in countries with more fragile health systems. Accordingly, the World Health Organization and other organizations have been appealing to donor countries to support a rapid response plan. The primary objectives of this response plan are to appeal for funds from donors and to distribute these funds to the most affected countries based on the requirements.

METHODS: In this study, we developed a mathematical model to provide initial insights into the efficient and equitable distribution of urgent funds to high-priority countries. Three phases were proposed for the construction of this mathematical model. In the first phase, the final epidemic sizes in all the target countries were predicted by using three epidemiological models. In the second phase, the urgent requirements for each country were estimated in parallel with the estimates issued by the humanitarian response plan, based on the size of the epidemic and several other factors. In the third and final phase, a multi-objective optimization model was proposed. The first objective was to maximize the funds from donors to cover all the requirements. The second objective was to minimize the unmet demands by ensuring a fair distribution of the urgent funds based on the requirements of the target countries.

RESULTS: Predictions of the basic reproduction numbers and the final epidemic sizes were calculated for all target countries. The urgent requirements were estimated, and the requirements issued by the humanitarian response plan for all target countries were also considered. Moreover, a proposed response plan for the distribution network was demonstrated. Donors must provide urgent funds exceeding US$ 2,608,084,209 to cover at least 40 % of each target country’s requirements. Overall, results demonstrate the importance of an urgent and fair distribution of funds to the target countries to overcome the outbreak of COVID-19.

CONCLUSIONS: Rapid responses by donor countries to humanitarian appeals will facilitate the immediate and fair distribution of relief supplies to the poorest countries. This distribution may help to support health systems, restrain the spread of COVID-19, and prevent an unlimited catastrophe.

PMID:33867131 | DOI:10.1016/j.isatra.2021.04.006

J Prof Nurs. 2021 Mar-Apr;37(2):306-319. doi: 10.1016/j.profnurs.2020.12.001. Epub 2020 Dec 5.

ABSTRACT

BACKGROUND: Mentoring in nursing education is essential to retaining nurse faculty; whether they are new to academia or experienced, but new to the institution in which they teach. Furthermore, mentoring promotes awareness of faculty roles and responsibilities, decreases ambiguity and increases retention of qualified nurse faculty.

PURPOSE: This study examined whether there was a relationship between nurse educator mentor’s perception of their mentoring effectiveness and nurse educator mentee’s perception of their mentor’s effectiveness.

METHOD: A Spearman’s rho correlation was conducted on a convenience sample of 119 nurse educators who completed the Principles of Adult Mentoring Inventory (PAMI), which measured six core mentoring behaviors. A secondary analysis using an independent samples t-test was also performed.

RESULTS: Statistically significant results were revealed in two of the six mentoring behaviors; relationship emphasis (p = 0.035) and confrontive focus (p = 0.043). The Mentor Role Competency Profile (MRCP), a measure accompanying the PAMI, indicated concerns that could be counterproductive within the mentoring relationship. A secondary analysis using a t-test confirmed concerns as identified in the initial analysis.

CONCLUSION: Continuous improvement and training are critical to acquiring and reinforcing effective mentoring skills. Requiring evaluation and follow up for mentors could result in increased satisfaction for both mentor and mentee and improve retention of new faculty in academia.

PMID:33867085 | DOI:10.1016/j.profnurs.2020.12.001