Nevin Manimala

Am J Emerg Med. 2022 Jan 17;53:236-239. doi: 10.1016/j.ajem.2022.01.022. Online ahead of print.

ABSTRACT

BACKGROUND: Obesity is a growing epidemic associated with higher rates of metabolic disease, heart disease and all-cause mortality. Heavier patients may require more advanced resources and specialized equipment. We hypothesize that increasing patient weight will be associated with longer prehospital on-scene times.

METHODS: We reviewed electronic patient care records for patients transported by two urban 9-1-1 emergency medical services (EMS) agencies. We collected age, sex, estimated patient weight, vital signs (systolic blood pressure, heart rate, pulse oximetry), provider impression, method of moving patient to ambulance, and on-scene times. We selected patients with time-sensitive diagnoses of stroke, ST-segment elevation myocardial infarction (STEMI), and trauma and compared on-scene times for patients who weighed above or below 300 pounds. We performed descriptive statistics, Mann-Whitney U tests for continuous variables and Chi-square tests for discrete variables. We constructed a generalized linear model to determine the effect of patient weight adjusted for covariates.

RESULTS: For a three-year period (May 1, 2018 to April 30, 2021) 48,203 patients were transported with an EMS impression of stroke, ST-segment elevation myocardial infarction (STEMI), and trauma. 23,654 (49.1%) patients were female, and the median age was 52 (IQR 34-68) years. The median weight was 175.0 (IQR 150.0-205.0) pounds. Patients above a dichotomous weight categorization of 300 pounds experienced a longer median scene time with any time-sensitive diagnosis (12.6 versus 11.9 min p < 0.001), STEMI (16.0 versus 13.1 min, p = 0.014) and blunt trauma (12.6 versus 11.9 min, p < 0.001)). They were more likely to be hypoxic (p < 0.001) and more likely to experience cardiac arrest (p < 0.001). They were less likely to walk to the ambulance (22.1% versus 32.2%, p < 0.001).

CONCLUSION: Patient weight above 300 pounds was associated with significantly longer on-scene time. These patients were more likely to be hypoxic, sustain a cardiac arrest, and less likely to walk to the ambulance.

PMID:35078052 | DOI:10.1016/j.ajem.2022.01.022

Am J Emerg Med. 2022 Jan 19;53:228-235. doi: 10.1016/j.ajem.2022.01.020. Online ahead of print.

ABSTRACT

BACKGROUND: Literature regarding trends for incidence and mortality of scleroderma renal crisis (SRC) in systemic sclerosis (SSc) within the United States (US) emergency departments (EDs) is limited.

OBJECTIVE: To study the mortality of SRC among SSc patient encounters within the US EDs.

METHODS: Data from the National Emergency Department Sample (NEDS) constitutes 20% sample of hospital-owned EDs and inpatient sample in the US were analyzed for SSc with and without SRC using ICD-9 codes. A linear p-trend was used to assess the trends.

RESULTS: Of the total 180,435 encounters with the diagnosis of SSc in NEDS for the years 2009 2014, 771 or 4.27/1000 patients (mean age 59.6 ± 15.5 years, 75.4% females) were recorded with SRC. The numerical differences in mortality among SRC (32 or 4.1%) and non-SRC subgroups (5487 or 3.1%) did not reach statistical significance (p = 0.3). Major complications among SRC in comparison to non-SRC subgroup include ischemic stroke (5.6% vs 0.98%, p = 0.001), new-onset AF (8% vs 6.9%, p = 0.001), new-onset congestive heart failure (24.1% vs 8.8%, p = 0.001), pulmonary arterial hypertension (15.8% vs 10.9%, p = 0.001), respiratory failure (27.5% vs 10.5%, p = 0.001), and deep vein thrombosis (4.7% vs 4.6%, p = 0.001). Congestive heart failure (CHF) was strongly associated with SRC among SSc (OR 4.3 95%CI 2.7-6.7; p < 0.001). The absolute yearly rate of SRC had increased over the study years from 2.11/1000 to 5.79/1000 (linear p-trend 0.002) while the mortality trend remained steady.

CONCLUSION: SRC is a relatively rare medical emergency. Although there has been a significant rise in the rate of SRC among SSc patients over the study years, mortality rates had remained steady. SSc patients with CHF should be considered to have low threshold for admission to inpatient services from EDs.

PMID:35078051 | DOI:10.1016/j.ajem.2022.01.020

Semin Arthritis Rheum. 2022 Jan 11;53:151950. doi: 10.1016/j.semarthrit.2022.151950. Online ahead of print.

NO ABSTRACT

PMID:35078035 | DOI:10.1016/j.semarthrit.2022.151950

J Osteopath Med. 2022 Jan 24. doi: 10.1515/jom-2021-0187. Online ahead of print.

ABSTRACT

CONTEXT: When choosing to incorporate osteopathic manipulative treatment (OMT) into a patient’s care, the risk-to-benefit ratio, the choice of treatment technique, as well as the frequency of treatments are always taken into consideration. This has been even more important during the COVID-19 pandemic, in which social distancing has been the best preventative measure to decrease exposure. By increasing treatment intervals, one could not only limit possible exposure/spread of viruses but also decrease the overall cost to the system as well as to the individual. This is an expansion of a previous study in which quantifiable changes in cervical hysteresis characteristics post-OMT were documented utilizing a durometer (Ultralign SA201^®; Sigma Instruments; Cranberry, PA USA). This study compared two treatment modalities, muscle energy (ME) and high-velocity low-amplitude (HVLA) postcervical treatment. Subjects in this study were allowed to re-enroll, provided that they could be treated utilizing the alternate treatment modality. By allowing repeat subjects, analysis of the data for lasting effects of OMT could be observed.

OBJECTIVES: To determine whether a significant change in cervical hysteresis would be observed after each treatment regardless of a short treatment interval.

METHODS: A total of 34 subjects were retrospectively noted to be repeat subjects from a larger, 213-subject study. These 34 subjects were repeat participants who were treated with two different direct-treatment modalities 7-10 days apart. Each subject was randomly assigned to receive a single-segmental ME or HVLA treatment technique directed toward a cervical (C) segment (C3-C5 only). Subjects were objectively measured pretreatment in all cervical segments utilizing the Ultralign SA201^®, then treated with cervical OMT to a single segment, and finally reassessed at all cervical levels with the Ultralign SA201^® posttreatment to assess for change in cervical hysteresis.

RESULTS: Statistically significant or suggestive changes (p-values 0.01-0.08) with good clinical effect size (0.30 or greater) were noted in all four components of the Ultralign SA201^® at multiple cervical levels after the first treatment, but only one component (frequency) had a statistically significant change after the second treatment (AA cervical level, p-value 0.01) with good clinical effect size (0.45). However, when comparing the post-first-treatment values to the pre-second-treatment values, no statistically significant differences (p-value 0.10 or higher) were observed between them.

CONCLUSIONS: Statistically significant changes were noted after the first treatment; however, when comparing cervical hysteresis changes after the first treatment to the cervical hysteresis values prior to the second treatment delivered 7-10 days later, there were no statistically significant or suggestive changes. This data suggest that several post-OMT changes noted after the first treatment were still in effect and may indicate that follow-up visits for direct manipulation may be deferred for a least two weeks.

PMID:35077638 | DOI:10.1515/jom-2021-0187

J Ayub Med Coll Abbottabad. 2021 Oct-Dec;33(Suppl 1)(4):S769-S772.

ABSTRACT

BACKGROUND: Dental composites are commonly used to restore teeth. However, to ensure adequate physical properties and biocompatibility, they require sufficient light intensity with the help of light curing units (LCU). This study aimed to evaluate the type and intensity of LCU being used in the dental setups of Rawalpindi and Islamabad.

METHODS: Dental clinics were visited and the type of the LCU was noted. Three consecutive intensity measurements were taken using a radiometer. For Quartz tungsten halogen (QTH) LCU, a light intensity below 300mW/cm2 was considered unsatisfactory, while for light-emitting diode (LED) LCU, a reading below 600mW/cm2 was considered unsatisfactory. To analyse the difference between the output intensities of the two LCU, Mann-Whitney U test was used (p<0.05), while Fisher’s Exact test was used for the association between the type of LCU and clinical acceptability of output intensity.

RESULTS: A total of 96 LCU were evaluated, out of which, eight were QTH and 88 were LED. A total of 16.7% LCU were considered unsatisfactory. Amongst them, 62.5% QTH had intensity less than 300mW/cm2, while for LED, 12.5% had intensity below 600mW/cm2. The mean intensity for LED was statistically significant compared to QTH LCU (p<0.05). A statistically significant association existed between the type of LCU and their intensity (p<0.05).

CONCLUSION: A trend towards the use of LED LCU in the dental setups of Islamabad and Rawalpindi was observed. LED LCU showed greater mean light intensity than QTH LCU. Periodic evaluation of LCU using radiometers is suggested to ensure optimal intensity output.

PMID:35077624

J Ayub Med Coll Abbottabad. 2021 Oct-Dec;33(Suppl 1)(4):S734-S737.

ABSTRACT

BACKGROUND: The second premolar is one of the teeth which are crucial both aesthetically as well as functionally and one of the most commonly endodontically treated tooth. Aim of the study was to assess the number of canals in maxillary second premolar by clinical and radiographic evaluation in Pakistani sub population. It was a cross sectional study conducted in Endodontic Department of Rehmat Memorial Dental Teaching Hospital, Abbottabad, from January 2019 to January 2020.

METHODS: One hundred and five patients were selected for the study, based on nonprobability sampling technique. All patients were examined clinically by exploration of pulp chamber followed by intra oral peri-apical radiograph to verify the clinical exploration of canals.

RESULTS: One hundred and five patients (46 males (43.8%) and 59 females (56.2%)} were selected for the study. Out of total 105 patients 47 (44.8%) had one canal and 58 (55.2%) had two canals. Out of 46 males 25 (54.3%) had two canals and out of 59 females 33 (56.9%) had two canals. Statistical analysis showed no significant difference (p=0.1871) of canals arrangements between genders.

CONCLUSION: Clinicians should be careful whenever doing root canal treatment of maxillary second premolars because of the extreme variability of the anatomy of those teeth, there is always risk of missing the second canal. Frequency of two canals was high, which is not age or gender dependant.

PMID:35077618

Neurourol Urodyn. 2022 Jan 25. doi: 10.1002/nau.24877. Online ahead of print.

ABSTRACT

OBJECTIVE: To investigate how aging and menopausal status in absence of pregnancy and childbirth affect the elasticity of the bladder and urethra.

STUDY DESIGN: A single-center prospective observational study including nulliparous 10 pre- and 12 postmenopausal women. Data collection included baseline characteristics, physical examination data, questionnaire scores, PDFI and the Pelvic Floor Impact Questionnaire, and pelvic floor sonographic measurements as well as elastography measurements. The shear wave elastography (SWE) of tissue was measured using Kilopascal (kPa). The elastography measurements were taken over the rhabdosphincter, the suburethra smooth muscle, and the trigonal areas.

RESULTS: A total of 22 nulliparous subjects were enrolled in the study. The cohort’s mean age was 43.5 years, the mean body mass index (BMI) was 26.8, and 86% were of Caucasian ethnicity. The postmenopausal group was older and with higher BMI (p < 0.001 and p = 0.05). They also had higher scores in all the questionnaires (p < 0.05 for all) and did not demonstrate prolapse in any compartments. The SWE results for the whole group were 35.2 kPa in the rhabdosphincter measuring point, 40.2 kPa in the sub-urethra point, and 20.6 kPa in the trigone point. Comparing the premenopause and postmenopause groups, we found lower measurements in the rhabdosphincter area and equivocal measurements for the suburethral zone. No statistically significant differences were found between the groups CONCLUSIONS: The elastic properties of the different bladder components and the urethra change with age and menopause. Using elastic properties of the tissues, we can further explore both stress urinary incontinence and overactive bladder.

PMID:35077600 | DOI:10.1002/nau.24877

J Magn Reson Imaging. 2022 Jan 25. doi: 10.1002/jmri.28066. Online ahead of print.

ABSTRACT

BACKGROUND: Venous blood oxygenation (Yv), which can be derived from venous blood T₂ (T₂ b), combined with oxygen-extraction fraction (OEF) and cerebral metabolic rate of oxygen, is considered indicative for tissue viability and brain functioning and frequently assessed in patients with sickle cell disease. Recently, T₂ -Prepared-Blood-Relaxation-Imaging-with-Inversion-Recovery (T₂ -TRIR) was introduced allowing for simultaneous measurements of blood T₂ and T₁ (T₁ b), potentially improving Yv estimation by overcoming the need to estimate hematocrit.

PURPOSE: To optimize and compare T₂ -TRIR with T₂ -relaxation-under-spin-tagging (TRUST) sequence.

STUDY TYPE: Prospective.

POPULATION: A total of 12 healthy volunteers (six female, 27 ± 3 years old) and 7 patients with sickle cell disease (five female, 32 ± 12 years old).

FIELD STRENGTH/SEQUENCE: 3 T; turbo field echo planar imaging (TFEPI), echo planar imaging (EPI), and fast field echo (FFE).

ASSESSMENT: T₂ b, Yv, and OEF from TRUST and T₂ -TRIR were compared and T₂ -TRIR-derived T₁ b was assessed. Within- and between-session repeatability was quantified in the controls, whereas sensitivity to hemodynamic changes after acetazolamide (ACZ) administration was assessed in the patients.

STATISTICAL TESTS: Shapiro-Wilk, one-sample and paired-sample t-test, repeated measures ANOVA, mixed linear model, Bland-Altman analysis and correlation analysis. Sidak multiple-comparison correction was performed. Significance level was 0.05.

RESULTS: In controls, T₂ b from T₂ -TRIR (70 ± 11 msec) was higher compared to TRUST (60 ± 8 msec). In patients, T₂ b values were lower pre- compared to post-ACZ administration (TRUST: 80 ± 15 msec and 106 ± 23 msec and T₂ -TRIR: 95 ± 21 msec and 125 ± 36 msec). Consequently, Yv and OEF were lower and higher pre- compared to post-ACZ administration (TRUST Yv: 68% ± 7% and 77% ± 8%, T₂ -TRIR Yv: 74% ± 8% and 80% ± 6%, TRUST OEF: 30% ± 7% and 21% ± 8%, and T₂ -TRIR OEF: 25% ± 8% and 18% ± 6%).

DATA CONCLUSION: TRUST and T₂ -TRIR are reproducible, but T₂ -TRIR-derived T₂ b values are significantly higher compared to TRUST, resulting in higher Yv and lower OEF estimates. This bias might be considered when evaluating cerebral oxygen homeostasis.

EVIDENCE LEVEL: 2 TECHNICAL EFFICACY: Stage 2.

PMID:35077595 | DOI:10.1002/jmri.28066

Cancer. 2022 Jan 25. doi: 10.1002/cncr.34087. Online ahead of print.

ABSTRACT

BACKGROUND: Patients with renal cell carcinoma (RCC) brain metastases are frequently treated with immune checkpoint inhibitors (ICIs) and stereotactic radiosurgery (SRS). However, data reporting on the risk of developing radiation necrosis (RN) are limited.

METHODS: RN rates were compared for concurrent therapy (ICI/SRS administration within 4 weeks of one another) and nonconcurrent therapy with the χ² test. Univariable logistic regression was used to identify factors associated with developing RN.

RESULTS: Fifty patients (23 concurrent and 27 nonconcurrent) with 395 brain metastases were analyzed. The median follow-up was 12.1 months; the median age was 65 years. The median margin dose was 20 Gy, and 4% underwent prior whole-brain radiation therapy (WBRT). The median treated tumor volume was 3.32 cm³ (range, 0.06-42.38 cm³ ); the median volume of normal brain tissue receiving a dose of 12 Gy or higher (V12 Gy) was 8.42 cm³ (range, 0.27-111.22 cm³ ). Any-grade RN occurred in 17.4% and 22.2% in the concurrent and nonconcurrent groups, respectively (P = .67). Symptomatic RN occurred in 4.3% and 14.8% in the concurrent and nonconcurrent groups, respectively (P = .23). Increased tumor volume during SRS (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.01-1.19; P = .04) was associated with developing RN, although V12 Gy (OR, 1.03; 95% CI, 0.99-1.06; P = .06), concurrent therapy (OR, 0.74; 95% CI, 0.17-2.30; P = .76), prior WBRT, and ICI agents were not statistically significant.

CONCLUSIONS: Symptomatic RN occurs in a minority of patients with RCC brain metastases treated with ICI/SRS. The majority of events were grade 1 to 3 and were managed medically. Concurrent ICI/SRS does not appear to increase this risk. Attempts to improve dose conformality (reduce V12) may be the most successful mitigation strategy in single-fraction SRS.

PMID:35077586 | DOI:10.1002/cncr.34087

Paediatr Perinat Epidemiol. 2022 Jan 25. doi: 10.1111/ppe.12863. Online ahead of print.

ABSTRACT

BACKGROUND: Large-scale evaluation of COVID-19 is likely to rely on the quality of ICD coding. However, little is known about the validity of ICD-coded COVID-19 diagnoses.

OBJECTIVES: To evaluate the performance of diagnostic codes in detecting COVID-19 during pregnancy.

METHODS: We used data from a national cohort of 78,283 individuals with a pregnancy ending between 11 March 2020 and 31 January 2021 in the OptumLabs^® Data Warehouse (OLDW). OLDW is a longitudinal, real-world data asset with de-identified administrative claims and electronic health record data. We identified all services with an ICD-10-CM diagnostic code of U07.1 and all laboratory claims records for COVID-19 diagnostic testing. We compared ICD-coded diagnoses to testing results to estimate positive and negative predictive values (PPV and NPV). To evaluate impact on risk estimation, we estimated risk of adverse pregnancy outcomes by source of exposure information.

RESULTS: Of 78,283 pregnancies, 5644 had a laboratory test result for COVID-19. Testing was most common among older individuals, Hispanic individuals, those with higher socioeconomic status and those with a diagnosed medical condition or pregnancy complication; 52% of COVID-19 cases was identified through ICD-coded diagnosis alone, 19% from laboratory test results alone and 29% from both sources. Agreement between ICD-coded diagnosis and laboratory testing records was high 91% (95% confidence interval [CI] 90, 92). However, the PPV of ICD-code diagnosis was low (36%; 95% CI 33, 39). We observed up to a 50% difference in risk estimates of adverse pregnancy outcomes when exposure was based on laboratory testing results or diagnostic coding alone.

CONCLUSIONS: More than one-in-five COVID-19 cases would be missed by using ICD-coded diagnoses alone to identify COVID-19 during pregnancy. Epidemiological studies exclusively relying on diagnostic coding or laboratory testing results are likely to be affected by exposure misclassification. Research and surveillance should draw upon multiple sources of COVID-19 diagnostic information.

PMID:35077581 | DOI:10.1111/ppe.12863