Nevin Manimala

JAMA Netw Open. 2021 Apr 1;4(4):e215832. doi: 10.1001/jamanetworkopen.2021.5832.

ABSTRACT

IMPORTANCE: Bruising caused by physical abuse is the most common antecedent injury to be overlooked or misdiagnosed as nonabusive before an abuse-related fatality or near-fatality in a young child. Bruising occurs from both nonabuse and abuse, but differences identified by a clinical decision rule may allow improved and earlier recognition of the abused child.

OBJECTIVE: To refine and validate a previously derived bruising clinical decision rule (BCDR), the TEN-4 (bruising to torso, ear, or neck or any bruising on an infant <4.99 months of age), for identifying children at risk of having been physically abused.

DESIGN, SETTING, AND PARTICIPANTS: This prospective cross-sectional study was conducted from December 1, 2011, to March 31, 2016, at emergency departments of 5 urban children’s hospitals. Children younger than 4 years with bruising were identified through deliberate examination. Statistical analysis was completed in June 2020.

EXPOSURES: Bruising characteristics in 34 discrete body regions, patterned bruising, cumulative bruise counts, and patient’s age. The BCDR was refined and validated based on these variables using binary recursive partitioning analysis.

MAIN OUTCOMES AND MEASURES: Injury from abusive vs nonabusive trauma was determined by the consensus judgment of a multidisciplinary expert panel.

RESULTS: A total of 21 123 children were consecutively screened for bruising, and 2161 patients (mean [SD] age, 2.1 [1.1] years; 1296 [60%] male; 1785 [83%] White; 1484 [69%] non-Hispanic/Latino) were enrolled. The expert panel achieved consensus on 2123 patients (98%), classifying 410 (19%) as abuse and 1713 (79%) as nonabuse. A classification tree was fit to refine the rule and validated via bootstrap resampling. The resulting BCDR was 95.6% (95% CI, 93.0%-97.3%) sensitive and 87.1% (95% CI, 85.4%-88.6%) specific for distinguishing abuse from nonabusive trauma based on body region bruised (torso, ear, neck, frenulum, angle of jaw, cheeks [fleshy], eyelids, and subconjunctivae), bruising anywhere on an infant 4.99 months and younger, or patterned bruising (TEN-4-FACESp).

CONCLUSIONS AND RELEVANCE: In this study, an affirmative finding for any of the 3 BCDR TEN-4-FACESp components in children younger than 4 years indicated a potential risk for abuse; these results warrant further evaluation. Clinical application of this tool has the potential to improve recognition of abuse in young children with bruising.

PMID:33852003 | DOI:10.1001/jamanetworkopen.2021.5832

JAMA Netw Open. 2021 Apr 1;4(4):e215902. doi: 10.1001/jamanetworkopen.2021.5902.

ABSTRACT

IMPORTANCE: Psychiatric emergency department (ED) visits may be avoidable if individuals have access to adequate outpatient care, but the extent to which individuals use the ED itself as a key point of access is largely unknown.

OBJECTIVE: To describe the extent to which the ED is a first point of contact for mental health care among adults, and identify key factors associated with this outcome.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study was conducted from 2010 to 2018 in Ontario, Canada. Using health care administrative data, all individuals aged 16 years and older with an incident psychiatric ED visit were included. Statistical analysis was performed from September 2019 to February 2021.

MAIN OUTCOMES AND MEASURES: The primary outcome was no outpatient mental health or addictions contact in the 2 years preceding the incident ED visit. The study also measured predisposing (age, sex, immigrant status, comorbidity), enabling (neighborhood income, rurality, continuity of primary care), and need factors (diagnosis from incident ED visit) associated with the so-called first-contact ED visits, generating adjusted odds ratios (aORs) and 95% CIs.

RESULTS: The cohort included 659 084 patients who visited the ED. Among these patients, 340 354 were female individuals (51.6%), and the mean (SD) age was 39.1 (18.5) years. The incident ED visit was a first contact for 298 924 individuals (45.4%). Patients who had increased odds of first-contact ED visits included older individuals (aged 65-84 years vs 16-24 years; aOR, 1.13; 95% CI, 1.12-1.14), male individuals (aOR, 1.14; 95% CI, 1.13-1.15), immigrants (eg, economic class immigrant vs nonimmigrant status: aOR, 1.20; 95% CI, 1.18-1.21), rural residents (aOR, 1.21; 95% CI, 1.20-1.21), and in those with minimal primary care (aOR, 1.68; 95% CI, 1.67-1.69). All diagnoses had a higher likelihood of first-contact ED visits than mood disorders, particularly substance and alcohol use disorders (aOR, 1.66; 95% CI, 1.65-1.68).

CONCLUSIONS AND RELEVANCE: This study’s results suggest that nearly half of incident psychiatric ED visits were first-contact visits, which may be avoidable. Targeted efforts to improve outpatient access should focus on populations with risk factors for first-contact ED presentations, including men, older adults, rural residents, those with poor primary care connectivity, and those with substance-related diagnoses.

PMID:33852001 | DOI:10.1001/jamanetworkopen.2021.5902

JAMA Psychiatry. 2021 Apr 14. doi: 10.1001/jamapsychiatry.2021.0154. Online ahead of print.

ABSTRACT

IMPORTANCE: Nurses are the largest component of the US health care workforce. Recent research suggests that nurses may be at high risk for suicide; however, few studies on this topic exist.

OBJECTIVES: To estimate the national incidence of suicide among nurses and examine characteristics of nurse suicides compared with physicians and the general population.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used US data from 159 372 suicides reported in the National Violent Death Reporting System from 2007 to 2018. With the use of workforce denominators, sex-specific suicide incidence estimates were generated among nurses, physicians, and the general population (age, ≥30 years). Associations between clinician type and method of suicide and results of toxicology examination at death were calculated, adjusted for sociodemographic characteristics. Statistical analysis was performed from October 16, 2020, to January 10, 2021.

EXPOSURE: Occupation as a nurse or physician.

MAIN OUTCOME AND MEASURES: Suicide incidence and characteristics associated with suicides.

RESULTS: A total of 2374 suicides among nurses (1912 women [80.5%]; mean [SD] age, 52.8 [11.8] years), 857 suicides among physicians (723 men [84.4%]; mean [SD] age, 59.8 [15.3] years), and 156 141 suicides in the general population (121 483 men [77.8%]; mean [SD] age, 53.1 [14.7] years) were identified. Overall, suicide was more common among nurses compared with the general population (sex-adjusted incidence in 2017-2018, 23.8 per 100 000 vs 20.1 per 100 000; relative risk, 1.18 [95% CI, 1.03-1.36]). Among women in 2017-2018, the suicide incidence among nurses was 17.1 per 100 000 (506 among 2 966 048) vs 8.6 per 100 000 (8879 among 103 731 387) in the general female population (relative risk, 1.99 [95% CI, 1.82-2.18]). In absolute terms, being a female nurse was associated with an additional 8.5 suicides per 100 000 (95% CI, 7.0-10.0 per 100 000) compared with the general population of women. By sex, physician suicide rates were not statistically different from the general population other than among female physicians in 2011-2012 (11.7 per 100 000 [95% CI, 6.6-16.8 per 100 000] female physicians vs 7.5 per 100 000 [95% CI, 7.2-7.7 per 100 000] general population; P = .04). In terms of the characteristics of suicides, clinicians were more likely to use poisoning than the general population; for example, 24.9% (95% CI, 23.5%-26.4%) of nurses used poisoning compared with 16.8% (95% CI, 16.6%-17.0%) of the general suicide population. The presence of antidepressants, benzodiazepines, barbiturates, and opiates was more common among clinician suicides than suicides in the general population.

CONCLUSION AND RELEVANCE: This study suggests that, in the US, the risk of suicide compared with the general population was significantly greater for nurses but not for physicians. Further research is needed to assess whether interventions would be associated with benefit in reducing suicide risk among nurses.

PMID:33851982 | DOI:10.1001/jamapsychiatry.2021.0154

J Am Acad Orthop Surg. 2021 Apr 13. doi: 10.5435/JAAOS-D-20-01345. Online ahead of print.

ABSTRACT

Personality plays an important role in performance in medical education and mentorship. Personality assessment can aid in the ability to identify strengths and areas for development by understanding how one’s personality influences their learning and interpersonal relationships. We sought to evaluate personality assessment as an effective tool in mentoring during orthopaedic residency in this prospective, cross-sectional study from two orthopaedic surgery residency programs using the Hogan Personality Inventory (HPI). Participants completed a survey regarding their experience with the assessment. Descriptive statistics were calculated, and two-sample t-tests were used to examine differences between groups. In total, thirty-four individuals completed the survey. Our results showed 82.4% reported that the HPI very accurately represented them and 58.8% reported better understanding potentially perceived strengths and weaknesses. In total, 75.7% and 72.7% were satisfied with their mentorship about development as a clinician and researcher, respectively. Significant differences were seen between participants who did and did not re-review their results, and participants who did and did-not believe their results profile was accurate. We conclude that personality assessments can be valuable in promoting introspection and strengthening relationships within orthopaedic surgery, particularly when they are valued and emphasized by the user. Our results suggest that use of the HPI provided participants with a better understanding of their perceived strengths and weaknesses as they progress through their orthopaedic residency training.

PMID:33851949 | DOI:10.5435/JAAOS-D-20-01345

JBI Evid Synth. 2021 Apr 12. doi: 10.11124/JBIES-20-00223. Online ahead of print.

ABSTRACT

OBJECTIVE: The objective of this systematic review is to identify, appraise, and synthesize the best available evidence on the effectiveness of opioid substitution treatment in reducing HIV risk behavior among African, Caribbean, and Black people.

INTRODUCTION: Substance use plays an important role in HIV transmission among Black people by increasing risky sexual behavior and the risk of HIV acquisition. Opioid substitution treatment, such as methadone maintenance treatment and buprenorphine therapy, has been found to be an effective measure to minimize HIV transmission attributable to opioid addiction.

INCLUSION CRITERIA: The current review considered studies that included African Caribbean and Black adult patients, aged 18 years or over, who have used methadone maintenance treatment or buprenorphine therapies as part of the intervention for opioid use disorders and have been evaluated for sex- and drug-related HIV risk behaviors. This review considered studies that have evaluated the impact of methadone maintenance treatment or buprenorphine therapy on sex- and drug-related HIV risk behaviors.

METHODS: Multiple databases were searched, including Embase, MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials, Open Grey, Grey Matters, New York Academy of Medicine Grey Literature Report, ClinicalTrials.gov, and WHO International Clinical Trials Registry Platform. Two reviewers independently assessed all titles and abstracts, and potentially relevant studies were retrieved in full. Papers selected for retrieval were assessed by two independent reviewers for methodological validity. Data were then extracted from papers. Statistical pooling of quantitative data and meta-analysis was not possible due to heterogeneity of data.

RESULTS: In total, 565 articles were retrieved from databases and unpublished/gray literature searches; 150 duplicates were removed, leaving 415 records. After reviewing titles and abstracts, 368 did not meet our eligibility criteria. Thus, 47 articles were retrieved for full-text assessment of which 42 were excluded, leaving five articles to be included in this review: three randomized control trials, one cohort, and one quasi-experimental study. Four studies focused on methadone maintenance treatment.and one study discussed the effectiveness of buprenorphine intervention. All studies were from the USA. One study enrolled participants in methadone maintenance treatment for heroin injectors, of which 10% of the sample was HIV positive. These papers included studies that reported a significant reduction in sex-related HIV behavior, including having multiple sexual partners, frequency of sexual intercourse, condom use, prostitution and sex trade. Of the five studies, two reported on drug-related HIV risk behaviors, citing a reduction in drug-related HIV risk behaviors. Also, these papers showed unexpected outcomes relating to frequency of sexual intercourse, prostitution, and sex trade. One study reported a significantly higher number of sexual encounters among those not participating in treatment. One study reported decreasing prostitution and sex trade among individuals receiving methadone maintenance treatment intervention.

CONCLUSION: Methadone maintenance treatment or buprenorphine therapy can be effective in reducing sex- and drug-related HIV risk among African, Caribbean, and Black people. However, due to the weaknesses in the body of evidence and the quality of evidence, it is not possible to make strong conclusions about these interventions. Rigorous studies are necessary to generate more findings and reinforce the body of literature.

SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019126954.

PMID:33851941 | DOI:10.11124/JBIES-20-00223

Nat Commun. 2021 Apr 13;12(1):1947. doi: 10.1038/s41467-021-22249-2.

ABSTRACT

Superfund sites could affect life expectancy (LE) via increasing the likelihood of exposure to toxic chemicals. Here, we assess to what extent such presence could alter the LE independently and in the context of sociodemographic determinants. A nationwide geocoded statistical modeling at the census tract level was undertaken to estimate the magnitude of impact. Results showed a significant difference in LE among census tracts with at least one Superfund site and their neighboring tracts with no sites. The presence of a Superfund site could cause a decrease of -0.186 ± 0.027 years in LE. This adverse effect could be as high as -1.22 years in tracts with Superfund sites and high sociodemographic disadvantage. Specific characteristics of Superfund sites such as being prone to flooding and the absence of a cleanup strategy could amplify the adverse effect. Furthermore, the presence of Superfund sites amplifies the negative influence of sociodemographic factors at lower LEs.

PMID:33850131 | DOI:10.1038/s41467-021-22249-2

Rev Esp Salud Publica. 2021 Apr 14;95:e202104053.

ABSTRACT

OBJECTIVE: The disease produced by SARS-CoV-2 has led to severe situations and mortality in elderly people. The objective of this study was to describe the collaboration between hospital professionals and nursing homes when applying preventive measures for the transmission of COVID-19 and in the assistance of institutionalized patients.

METHODS: A descriptive study was carried out in 4 centers with information collected by researchers in two moments of the COVID-19 pandemic. The information collected was related to the resources and knowledge of infection prevention, details about face-to-face and telematic assistance from the hospital team, as well as material, drugs provided, and clinical results. The variables studied were described by means of percentages, absolute frequencies and ratios; statistical chi-square tests and McNemar’test were used.

RESULTS: The study was conducted in 4 centers with a total of 640 residents and an initial occupancy between 62% and 85%. Differences were found regarding the ratio of staff and knowledge of preventive measures of the transmission of SARS-CoV-2 infection, which was improved in the second period of the study. The number of face-to-face visits (from 5 to 22) and telematic visits (between 42 and 109 patients) were different in the 4 nursing homes, as well as the material provided, adapted to the needs of each center. The percentage of infected patients ranged from 6.1% to 90.2%, and the accumulated mortality in the second period ranged from 15.38% to 38.35% of the residents at the beginning of the pandemic.

CONCLUSIONS: The collaboration between the professionals of healthcare centers and the hospital, adapted to the needs of each center, has allowed to improve the assistance to the residents and the coordination between the professionals, optimizing the available resources.

PMID:33850095

Neuroreport. 2021 May 5;32(7):636-642. doi: 10.1097/WNR.0000000000001641.

ABSTRACT

This study aimed to investigate the relationship between levodopa responsiveness and white matter alterations in Parkinson’s disease patients using diffusion tensor imaging (DTI). Twenty-six recruited Parkinson’s disease patients were evaluated using the Mini-Mental State Examination, Hoehn and Yahr scale (H&Y) and Unified Parkinson’s Disease Rating Scale (UPDRS). Each patient underwent a DTI scan and an acute levodopa challenge test. The improvement rate of UPDRS-III was calculated, Parkinson’s disease patients were grouped into a responsive group (improvement rate ≥30%) and a nonresponsive group (improvement rate <30%). The differences in fractional anisotropy, mean diffusivity, axial diffusivity and radial diffusivity between the two groups were measured using tract-based spatial statistics. There was no difference in demographic features or baseline evaluations between groups. The UPDRS-III score after the challenge was higher in the nonresponsive group than that in the responsive group. Compared to the responsive group, patients in the nonresponsive group exhibited decreased fractional anisotropy in the corpus callosum; cingulum; left corona radiata; left internal capsule; left middle frontal gyrus; left superior longitudinal fasciculus and right somatosensory cortex. Mean diffusivity and radial diffusivity were increased in wide-ranging areas in the nonresponsive group. No difference was observed in axial diffusivity. White matter alterations in the abovementioned areas may affect the function of the dopaminergic network and thus may be associated with the levodopa response in Parkinson’s disease patients. Further studies are needed to analyze the specific mechanism and pathological changes underlying these effects.

PMID:33850092 | DOI:10.1097/WNR.0000000000001641

J Contemp Dent Pract. 2020 Nov 1;21(11):1253-1257.

ABSTRACT

AIM AND OBJECTIVE: In the present study, the prepared roots obturated by gutta-percha/AH plus and Resilon/Epiphany were tested and compared for fracture resistance. The study also does a scanning electron microscope (SEM) evaluation of the adaptability of these obturating materials to root canal walls.

MATERIALS AND METHODS: One hundred extracted mandibular premolars were decoronated and the dimensions of the roots were standardized. Each root was prepared to a size of #25 with 6% taper. Roots were gauged after preparation and those requiring more preparation were discarded. Seventy-seven prepared roots were finally selected for the study. The samples were then divided into three groups. Group I with 25 specimens was control group in which no obturation was performed, group II with 26 specimens was obturated by gutta-percha/AH plus sealer, and group III with 26 specimens was filled by Resilon/Epiphany. The method for obturation was cold lateral condensation. The samples were then stored at 100% humidity for 2 weeks. One random sample from groups II and III was subjected to SEM analysis. Groups I, II, and III were then subjected to vertical loading in Instron machine. One-way analysis of variance (ANOVA) test and Tukey’s multiple comparison test were used for statistical analysis.

RESULTS: Group III exhibited the maximum fracture resistance as compared to groups I and II. The least mean fracture resistance of 370.05 N was seen in group II and the maximum mean fracture resistance of 481.05 kN was observed in group III. One-way ANOVA and Tukey’s multiple comparison test between groups I, II, and III, group III showed a highly significant resistance to fracture as compared to groups I and II (p < 0.0001). Scanning electron microscope microphotographs showed a better adaptation of Resilon/Epiphany as compared to gutta-percha/AH plus to the root canal.

CONCLUSION: The Resilon/Epiphany on obturation of root canals creates a monoblock by penetrating inside the dentinal irregularities, which strengthens the root and provides fracture resistance. This fracture resistance was significantly higher in the present study as compared to groups I and II.

CLINICAL SIGNIFICANCE: In the present study, Resilon/Epiphany when used to obturate the prepared canals showed a promising result both in terms of fracture resistance and adaptability to root canal walls. This paves a way for the use of this combination of obturating material not only to strengthen the compromised root strength in clinical scenario but also providing an increased sealing ability which will contribute to the success of root canal treatment.

PMID:33850071

J Contemp Dent Pract. 2020 Nov 1;21(11):1233-1237.

ABSTRACT

AIM AND OBJECTIVE: The present study aimed to assess the formation of microcracks in root dentin post-instrumentation with nickel-titanium (NiTi) hand and rotary file system.

MATERIALS AND METHODS: Totally, 80 freshly extracted mandibular premolar teeth with single roots were chosen for this study. Access opening was performed and #10 K-file was used to attain patency of canal. All specimens were divided into four groups (each group having 20 specimens), i.e., Group I: Unprepared, Group II: NiTi hand K-files, Group III: Self-adjusting file, and Group IV: XP-Shaper single file. Complete irrigation of all the canals was performed after instrumentation. All roots were cut horizontally at three levels [apical third (3 mm), middle third (6 mm), and cervical third (9 mm)] from the apex with diamond disc. A stereomicroscope was used to view the sections under 20× magnification.

RESULTS: Self-adjusting file showed least number of defects with a percentage of 75% followed by XP-Shaper and NiTi hand K-files with a values of 65 and 60%, respectively. Use of hand K-files resulted in greater number of incomplete cracks (30%) and use of XP-Shaper demonstrated greater number of craze lines (15%). A statistically significant difference was found between the experimental groups in the formation of dentinal defects of root at apical third (3 mm) (p < 0.031) and middle third (6 mm) (p < 0.001), whereas the sections at cervical third (9 mm) did not show any statistically significant difference (p > 0.312).

CONCLUSION: The present study concluded that the self-adjusting file system gives promising better results in cleaning ability with minimal incidence of radicular dentin microcracks than XP-Shaper and NiTi hand K-files system.

CLINICAL SIGNIFICANCE: The root dentin may unavoidably get damaged during instrumentation resulting in the formation of dentinal cracks and tiny complicated fractures, thus leading to endodontic failures. Various factors cause dentinal cracks, but the flexibility of file due to heat treatment, kinematics of the file, and the basic architecture of the file are the most significant ones. Self-adjusting file system represented satisfactory results with minimal microcracks defects.

PMID:33850068