Tag: nevin manimala

BMJ Open Qual. 2024 Aug 15;13(3):e002848. doi: 10.1136/bmjoq-2024-002848.

ABSTRACT

BACKGROUND: Adverse medical events affect 10% of American households annually, inducing a variety of harms and attitudinal changes. The impact of adverse events on perceived abandonment by patients and their care partners has not been methodically assessed.

OBJECTIVE: To identify ways in which providers, patients and families responded to medical mishaps, linking these qualitatively and statistically to reported feelings of abandonment and sequelae induced by perceived abandonment.

METHODS: Mixed-methods analysis of responses to the Massachusetts Medical Errors Recontact survey with participants reporting a medical error within the past 5 years. The survey consisted of forty closed and open-ended questions examining adverse medical events and their consequences. Respondents were asked whether they felt ‘that the doctors abandoned or betrayed you or your family’. Open-ended responses were analysed with a coding schema by two clinician coders.

RESULTS: Of the 253 respondents, 34.5% initially and 20% persistently experienced abandonment. Perceived abandonment could be traced to interactions before (18%), during (34%) and after (45%) the medical mishap. Comprehensive post-incident communication reduced abandonment for patients staying with the provider associated with the mishap. However, 68.4% of patients perceiving abandonment left their original provider; for them, post-error communication did not increase the probability of resolution. Abandonment accounted for half the post-event loss of trust in clinicians.

LIMITATIONS: Survey-based data may under-report the impact of perceived errors on vulnerable populations. Moreover, patients may not be cognizant of all forms of adverse events or all sequelae to those events. Our data were drawn from a single state and time period.

CONCLUSION: Addressing the deleterious impact of persisting abandonment merits attention in programmes responding to patient safety concerns. Enhancing patient engagement in the aftermath of an adverse medical event has the potential to reinforce therapeutic alliances between patients and their subsequent clinicians.

PMID:39147403 | DOI:10.1136/bmjoq-2024-002848

Aesthet Surg J. 2024 Aug 16;44(Supplement_1):S3-S14. doi: 10.1093/asj/sjae082.

ABSTRACT

The adoption of enhanced recovery after surgery (ERAS) protocols in multiple surgical disciplines has revolutionized perioperative care, demonstrating reduced complications and shorter hospital stays across surgical specialties. ERAS protocols have increasingly been incorporated in plastic surgery, yet a notable gap in the literature on ERAS for gender-affirming surgery (GAS) still exists. A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies on ERAS protocols in GAS. The aim of this review was to assess the current status of ERAS adoption in GAS, evaluate its impact on perioperative care, and provide recommendations for future research and clinical practice. While there is an overall scarcity of evidence-based ERAS protocols across GAS, published studies on the application of ERAS in GAS have demonstrated promising early outcomes and illustrate an area for further investigation and innovation in plastic surgery.

PMID:39147383 | DOI:10.1093/asj/sjae082

Aesthet Surg J. 2024 Aug 16;44(Supplement_1):S15-S21. doi: 10.1093/asj/sjae003.

ABSTRACT

BACKGROUND: Enhanced recovery after surgery (ERAS) pathways have been widely shown to yield positive outcomes, including in plastic surgery. Our group has previously validated ERAS in our deep inferior epigastric perforator flap breast reconstruction population.

OBJECTIVES: We evaluated whether the ERAS protocol and addition of liposomal bupivacaine affected patient outcomes at the time of mastectomy and first-stage tissue expander reconstruction.

METHODS: All patients treated between July 2021 and May 2022 were reviewed retrospectively. The ERAS protocol was implemented in December 2021. Two patient groups were compared: pre-ERAS and ERAS. The ERAS protocol included use of liposomal bupivacaine in the pectoralis nerve block 1/2 planes. Primary outcomes were observed with postoperative length of stay and hospital narcotic use.

RESULTS: Eighty-one patients were analyzed in this cohort. The pre-ERAS group was composed of 41 patients, the ERAS group was composed of 83 patients. Postoperative length of stay was significantly reduced in the ERAS group (1.7 pre-ERAS vs 1.1 ERAS, P = .0004). When looking at morphine equivalents during the hospital stay, the degree of narcotics in the recovery room was relatively similar. Average PACU pain morphine equivalents were 6.1 pre-ERAS vs 7.1 ERAS (P = .406). However, total hospital morphine equivalents were significantly lower in the ERAS group (65.0 pre-ERAS vs 26.2 ERAS, P = <.001).

CONCLUSIONS: The introduction of an enhanced recovery after surgery protocol with liposomal bupivacaine pectoralis 1/2 nerve blocks decreased postoperative opioid consumption and hospital length of stay in mastectomy patients undergoing tissue expander-based reconstruction.

PMID:39147381 | DOI:10.1093/asj/sjae003

Benef Microbes. 2024 Aug 14:1-10. doi: 10.1163/18762891-bja00030. Online ahead of print.

ABSTRACT

The aim of this animal study was to compare the primary/secondary stability and micro-CT bone and tissue volumes of implants that were immersed in Limosilactobacillus reuteri, cholecalciferol-D3 (vitamin D) and injectable platelet-rich fibrin (i-PRF) suspensions/solutions before placement in bone. 40 implants (10 in each group) were placed in the iliac crest of 5 sheep. The implants were immersed in L. reuteri, vitamin D or i-PRF solutions for five minutes before placement or left unsoaked as controls. Implant stability was determined by ISQ values and bone volume around implants was histomorphometrically analysed by micro-CT evaluation. At 4 weeks, implants in the L. reuteri group showed the highest secondary stability and 2- and 3D BV/TV values. Both L. reuteri and vitamin D immersed implants had higher osseointegration values compared to the implants in the i-PRF group and controls. There were no statistical differences between L. reuteri and vitamin D immersed implants. Within the limits of the study, the results suggest that immersing implants in L. reuteri or vitamin D suspensions/solutions before implant placement in bone may have beneficial effects on osseointegration.

PMID:39147374 | DOI:10.1163/18762891-bja00030

Obstet Gynecol. 2024 Aug 15. doi: 10.1097/AOG.0000000000005697. Online ahead of print.

ABSTRACT

OBJECTIVE: To measure what patients with Spanish language preference and limited English proficiency value most when selecting a prenatal care clinician.

METHODS: A discrete choice experiment was administered at two large academic medical centers in Boston, Massachusetts. Participants were identified by electronic medical record, had preferred Spanish language and self-identified limited English proficiency, and either were pregnant with a completed fetal anatomy scan or had given birth within the past 12 months at the time of the study. The discrete choice experiment consisted of eight attributes to consider when selecting a prenatal care clinician: clinician Spanish proficiency, type of interpreter used, interpersonal dynamics (ie, making patients feel seen, heard, and cared for), cultural concordance, continuity of care, shared decision making, distance from home, and wait times for appointments. Descriptive statistics of demographic variables were calculated. Hierarchical Bayesian models were used to analyze discrete choice experiment data.

RESULTS: The attributes that were most important to 166 participants when choosing their prenatal care clinician were interpersonal dynamics within the patient-clinician dyad and clinician Spanish language proficiency (average importance 21.4/100 and 20.8/100, respectively). Of lowest importance were wait time to receive an appointment and continuity of care (average importance 5.1 and 6.1, respectively). Although participants highly preferred that their clinician be “fluent or near fluent in Spanish,” the second most preferred option was having a clinician with only basic Spanish proficiency rather than a more advanced level of Spanish proficiency with some misunderstandings.

CONCLUSION: Our study demonstrates the importance of positive clinician-patient interpersonal dynamics and language-concordant care for patients with Spanish language preference in prenatal care. Promoting equitable patient-centered care for patients with limited English proficiency requires responding to preferences regarding clinician language proficiency and demonstrating attentiveness, empathy, and concern for prenatal care experiences.

PMID:39147367 | DOI:10.1097/AOG.0000000000005697

Microvasc Res. 2024 Aug 13:104732. doi: 10.1016/j.mvr.2024.104732. Online ahead of print.

ABSTRACT

Fluorescence intravital microscopy captures large data sets of dynamic multicellular interactions within various organs such as the lungs, liver, and brain of living subjects. In medical imaging, edge detection is used to accurately identify and delineate important structures and boundaries inside the images. To improve edge sharpness, edge detection frequently requires the inclusion of low-level features. Herein, a machine learning approach is needed to automate the edge detection of multicellular aggregates of distinctly labeled blood cells within the microcirculation. In this work, the Structured Adaptive Boosting Trees algorithm (AdaBoost.S) is proposed as a contribution to overcome some of the edge detection challenges related to medical images. Algorithm design is based on the observation that edges over an image mask often exhibit special structures and are interdependent. Such structures can be predicted using the features extracted from a bigger image patch that covers the image edge mask. The proposed AdaBoost.S is applied to detect multicellular aggregates within blood vessels from the fluorescence lung intravital images of mice exposed to e-cigarette vapor. The predictive capabilities of this approach for detecting platelet-neutrophil aggregates within the lung blood vessels are evaluated against three conventional machine learning algorithms: Random Forest, XGBoost and Decision Tree. AdaBoost.S exhibits a mean recall, F-score, and precision of 0.81, 0.79, and 0.78, respectively. Compared to all three existing algorithms, AdaBoost.S has statistically better performance for recall and F-score. Although AdaBoost.S does not outperform Random Forest in precision, it remains superior to the XGBoost and Decision Tree algorithms. The proposed AdaBoost.S is widely applicable to analysis of other fluorescence intravital microscopy applications including cancer, infection, and cardiovascular disease.

PMID:39147360 | DOI:10.1016/j.mvr.2024.104732

J Allergy Clin Immunol. 2024 Aug 13:S0091-6749(24)00817-0. doi: 10.1016/j.jaci.2024.07.024. Online ahead of print.

ABSTRACT

BACKGROUND: Asthma is often accompanied by type 2 immunity rich in IL-4, IL-5 and IL-13 cytokines produced by T_H2 lymphocytes or type 2 innate lymphoid cells (ILC2s). Interleukin-2 family cytokines play a key role in the differentiation, homeostasis and effector function of innate and adaptive lymphocytes.

OBJECTIVE: IL-9 and IL-21 boost the activation and proliferation of T_H2 and ILC2s, but the relative importance and potential synergism between these γc cytokines is currently unknown.

METHODS: Using newly generated antibodies, we inhibited IL-9 and IL-21 alone or in combination, in various murine models of asthma. In a translational approach using segmental allergen challenge, we recently described elevated IL-9 levels in human allergic asthmatics in comparison to non-asthmatic controls. Here, we also measured IL-21 in both groups.

RESULTS: IL-9 played a central role in controlling innate IL-33 induced lung inflammation by promoting proliferation and activation of ILC2s, in an IL-21 independent manner. Conversely, chronic house dust mite induced airway inflammation, mainly driven by adaptive immunity, was solely dependent on IL-21, that controlled T_H2 activation, eosinophilia, total serum IgE and formation of tertiary lymphoid structures. In a model of innate on adaptive immunity driven by papain allergen, a clear synergy was found between both pathways, since combined anti-IL-9 or anti-IL-21 blockade was superior in reducing key asthma features. In human bronchoalveolar lavage (BAL) samples we measured elevated IL-21 protein within the allergic asthmatic group, compared with the allergic control group. We also found increased IL21R transcripts and predicted IL-21 ligand activity in various disease-associated cell subsets.

CONCLUSION: IL-9 and IL-21 play important and non-redundant roles in allergic asthma by boosting ILC2s and T_H2 cells, revealing a dual IL-9 and IL-21 targeting strategy as a new and testable approach.

PMID:39147327 | DOI:10.1016/j.jaci.2024.07.024

J Shoulder Elbow Surg. 2024 Aug 14:S1058-2746(24)00466-X. doi: 10.1016/j.jse.2024.05.020. Online ahead of print.

ABSTRACT

BACKGROUND: Proximal humerus nonunion is a challenging complication of fractures that can be treated surgically with either open reduction internal fixation (ORIF) or reverse total shoulder arthroplasty (RTSA). The few studies published on this subject have shown high rates of complications and revision surgery when RTSA has been performed for proximal humerus nonunion. The purpose of this study was to determine the rates of complications and revision of this procedure at our institution, as well as to identify any variables that may impact risks of complications and reoperations.

METHODS: A single-institution retrospective review of all patients who underwent RTSA for proximal humerus nonunion between 2005 and 2021 was performed. Nonunion was defined as imaging evidence of lack of union, at least 90 days after the index fracture. Patients with less than one year of clinical follow-up were excluded. Fifty patients were included, with the majority being female (78%). The mean age at time of RTSA was 71 (range: 54-86) years and most patients were initially treated nonoperatively (74%). Mean total follow-up was 49 (range: 11-130) months. Demographic and surgical variables were recorded. Primary outcomes were complications and reoperations. Complications were divided into surgical (those directly related to RTSA), or other (those unrelated to RTSA). Secondary outcomes included VAS pain scores and range of motion.

RESULTS: A total of 17 shoulders (34%) sustained complications after RSA, with 10 (20%) requiring reoperation. Six patients (12%) sustained dislocations and 5 (10%) had radiographic evidence of humeral loosening. No variables examined, including nonoperative vs surgical management of the index fracture, prosthesis type, or management of tuberosities, influenced the risk of dislocation. Survivorship free from reoperation at 2 years was 73%. Younger age at time of RTSA and the presence of diabetes mellitus both increased the risk of reoperation significantly (p=0.013 and p=0.037, respectively). There was a trend towards increased risk of reoperation in patients who were treated with initial ORIF (HR=2.95); however, this did not reach statistical significance (p=0.088). Three patients (6%) sustained a periprosthetic fracture after a fall.

CONCLUSION: RTSA provides improved pain and function for properly selected patients with proximal humerus nonunion. Dislocation, humeral loosening, and reoperation rates remain high when RTSA is performed for nonunion compared to other diagnoses. In this study, younger age and diabetes mellitus increased the odds of reoperation. Every effort must be made to optimize implant stability and humeral component fixation when RTSA is performed for proximal humerus nonunion.

PMID:39147268 | DOI:10.1016/j.jse.2024.05.020

Int J Radiat Oncol Biol Phys. 2024 Aug 13:S0360-3016(24)03230-9. doi: 10.1016/j.ijrobp.2024.08.007. Online ahead of print.

ABSTRACT

PURPOSE: 5-FU/cisplatin and twice-daily radiation (FCT) or gemcitabine and once daily radiation (GD) are effective chemoradiation (CRT) regimens for bladder sparing treatment of muscle-invasive bladder cancer (MIBC). This trial evaluated these regimens and demonstrated efficacy with either regimen at 3 years. With further follow-up, longer term results are reported here.

METHODS AND MATERIALS: Patients with cT2-4a MIBC were randomized to FCT or GD. Patients had a transurethral resection and induction CRT to 40 Gy. Patients with a complete response (CR) received consolidation CRT to 64 Gy. Others had cystectomy. Adjuvant gemcitabine/cisplatin chemotherapy was administered. The primary endpoint was freedom from distant metastasis (FDM). This updated analysis reports 7-year data. Toxicity and efficacy endpoints, including bladder intact distant metastasis free survival (BI-DMFS) were also assessed.

RESULTS: From 12/2008 to 4/2014, 70 patients were enrolled; 66 eligible for analysis, 33 per arm. Median follow-up was 9.1 years for eligible living patients. At 7 years, FDM was 65% and 73% for FCT and GD, respectively. BI-DMFS was 58% (95% CI: 41 – 76) and 68% (95% CI: 51-84), respectively. The post-hoc hazard ratio of 0.75 (95% CI: 0.37-1.55) showed no difference between treatments (p=0.44). Overall survival at 7 years was 48% and 59%. There were 4 and 5 cystectomies performed for FCT and GD, respectively. In the FCT arm, there were 5 (16%), 1 (3%) and 0 grade 3, 4 and 5 late toxicities reported. In the GD arm, there were 7 (23%), 0 and 0.

CONCLUSIONS: Both regimens maintained high FDM rates at 7 years. Cystectomy rates were low and overall survival rates high on both arms. Late toxicity rates were low. Either gemcitabine and daily radiation or a cisplatin-based regimen are effective bladder sparing therapies.

PMID:39147209 | DOI:10.1016/j.ijrobp.2024.08.007

Int J Radiat Oncol Biol Phys. 2024 Aug 13:S0360-3016(24)03206-1. doi: 10.1016/j.ijrobp.2024.07.2335. Online ahead of print.

ABSTRACT

BACKGROUND/PURPOSE: Ependymomas are the third most common brain tumors in children. Standard of care is surgery followed by adjuvant radiotherapy. Controversy in the literature still exists over optimal radiotherapy dose. We completed a systematic review and meta-analysis to determine the optimal dose for local control (LC), event-free survival (EFS), and overall survival (OS) in pediatric patients.

MATERIALS & METHODS: We searched MEDLINE (PubMed), Cochrane Database of Systematic Reviews, and Web of Science through January 2024. We included cohort studies that compared adjuvant radiotherapy of ≤54Gy to >54Gy in pediatric patients (≤22 years) with non-metastatic intracranial ependymomas. We assessed study quality using the Newcastle-Ottawa Quality Assessment Scale of Cohort Studies. We pooled studies using a random effects meta-analysis for hazard ratios (HR), 95% confidence intervals (CI), and assessed statistical heterogeneity via I². When HRs were unavailable, we transformed risks using established methods. We narratively summarized qualitative outcomes.

RESULTS: Seven studies met our inclusion criteria, covering a combined 1321 patients. Studies included a range of doses from 45-66.6Gy. Compared with >54Gy, we found no difference in LC for those receiving ≤54Gy (HR=0.83, 95% CI 0.56-1.24, I²=49.1%), in EFS (HR=1.02, 95% CI 0.95-1.09, I²=0.00%), and OS (HR=0.99, 95% CI 0.82-1.20, I²=37.5%). Two studies reported on subtotal resection by radiotherapy dose, neither study reporting statistical differences in LC, EFS, or OS, though the number of patients was small (n≤30). Five studies reported on late effects, with brainstem radionecrosis, radiation-induced vasculopathy, and secondary tumors being the most frequent. Overall study quality was high, though lower scores were consistently seen in comparability of cohorts. No studies reported on molecular subgroups.

CONCLUSIONS: We found no difference in LC, EFS, or OS for those treated with ≤54Gy compared to >54Gy. There was insufficient data to complete a subgroup meta-analysis on radiotherapy dosing based on extent of resection or molecular subgroups.

PMID:39147207 | DOI:10.1016/j.ijrobp.2024.07.2335