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11.
Jennifer M. Sasaki Russell Gregory A. Chinn Deenu Maharjan Yasmine Eichbaum Jeffrey W. Sall 《British journal of anaesthesia》2019,122(4):490-499
Background
The factors determining peak susceptibility of the developing brain to anaesthetics are unclear. It is unknown why postnatal day 7 (P7) male rats are more vulnerable to anaesthesia-induced memory deficits than littermate females. Given the precocious development of certain regions in the female brain during the neonatal critical period, we hypothesised that females are susceptible to anaesthetic brain injury at an earlier time point than previously tested.Methods
Female rats were exposed to isoflurane (Iso) 1 minimum alveolar concentration or sham anaesthesia at P4 or P7. Starting at P35, rats underwent a series of behavioural tasks to test their spatial and recognition memory. Cell death immediately after anaesthesia was quantified by Fluoro-Jade C staining in select brain regions, and developmental expression of the chloride transporters KCC2 and NKCC1 was analysed by immunoblotting in male and female rats at P4 and P7.Results
Female rats exposed to Iso at P4 displayed impaired spatial, object-place, -context, and social recognition memory, and increased cell death in the hippocampus and laterodorsal thalamus. Female rats exposed at P7 exhibited only decreased performance in object-context compared with control. The ratio of NKCC1/KCC2 expression in cerebral cortex was higher in P4 females than in P7 females, and similar to that in P7 males.Conclusions
Female rats exposed to Iso at P4 are sensitive to anaesthetic injury historically observed in P7 males. This is consistent with a comparably immature developmental state in P4 females and P7 males. The window of anaesthetic vulnerability correlates with sex-specific cortical expression of chloride transporters NKCC1 and KCC2. These findings suggest that both sex and developmental age play important roles in determining the outcome after early anaesthesia exposure. 相似文献12.
Background
Total knee arthroplasty is a treatment option for debilitating arthritis. In the postoperative period, patients experience moderate to severe pain affecting the rehabilitation, hospital stay, and patient satisfaction. This study aims at utilizing current best evidence to determine whether adductor canal block (ACB) or periarticular injection (PAI) is a better modality for managing short-term postoperative pain and opioid consumption.Methods
Embase, MEDLINE, HealthStar, Emcare, and PubMed were searched for randomized controlled trials from 1946 to August 2018, for literature addressing the comparison of ACB and PAI for pain management in the setting of total knee arthroplasty. A systematic review and meta-analysis were performed.Results
Six studies were included in our meta-analysis. When examining the combined visual analog scale (VAS) pain values for each group, analysis demonstrated greater reduction in scores for the PAI group, and the difference was statistically significant (P = .001). When comparing the VAS scores of subgroups analyzed at specific periods in time, there was a trend toward lower VAS scores in subgroups analyzed at 24 hours and 48 hours postoperatively (at rest and at movement) in the PAI group. Overall opioid consumption was lower in the PAI group, with demonstrated statistical significance (P = .03). When comparing the postoperative subgroups, there was a trend toward decreased opioid use in the PAI group, with 13.25% less opioid use at 48 hours and 9.5% less opioid use at 24 hours.Conclusion
PAI could significantly improve postoperative pain and opioid consumption when compared with ACB. Additional, high-quality studies are required to further address this topic. 相似文献13.
Michelle Lerman Julia A. Gaebler Sunday Hoy Jessica Izhakoff Laura Gullett Timothy Niecko Pinar Karaca-Mandic Thomas O&#x;Donnell Stanley G. Rockson 《Journal of vascular surgery》2019,69(2):571-580
Objective
Phlebolymphedema (chronic venous insufficiency-related lymphedema) is a common and costly condition. Nevertheless, there is a dearth of evidence comparing phlebolymphedema therapeutic interventions. This study sought to examine the medical resource utilization and phlebolymphedema-related cost associated with Flexitouch (FLX; Tactile Medical, Minneapolis, Minn) advanced pneumatic compression devices (APCDs) relative to conservative therapy (CONS) alone, simple pneumatic compression devices (SPCDs), and other APCDs in a representative U.S. population of phlebolymphedema patients.Methods
This was a longitudinal matched case-control analysis of deidentified private insurance claims. The study used administrative claims data from Blue Health Intelligence for the complete years 2012 through 2016. Patients were continuously enrolled for at least 18 months, diagnosed with phlebolymphedema, and received at least one claim for CONS either alone or in addition to pneumatic compression (SPCDs or APCDs). The main outcomes included direct phlebolymphedema- and sequelae-related medical resource utilization and costs.Results
After case matching, the study included 86 patients on CONS (87 on FLX), 34 on SPCDs (23 on FLX), and 69 on other APCDs (67 on FLX). Compared with CONS, FLX was associated with 69% lower per patient per year total phlebolymphedema- and sequelae-related costs net of any pneumatic compression device-related costs ($3839 vs $12,253; P = .001). This was driven by 59% fewer mean annual hospitalizations (0.13 vs 0.32; P < .001) corresponding to 82% lower inpatient costs and 55% lower outpatient hospital costs. FLX was also associated with 52% lower outpatient physical therapy and occupational therapy costs and 56% lower other outpatient-related costs. Compared with SPCDs, FLX was associated with 85% lower total costs ($1153 vs $7449; P = .008) driven by 93% lower inpatient costs ($297 vs $4215; P = .002), 84% lower outpatient hospital costs ($368 vs $2347; P = .020), and 85% lower other outpatient-related costs ($353 vs $2313; P = .023). Compared with APCDs, FLX was associated with 53% lower total costs ($3973 vs $8436; P = .032) because of lower outpatient costs and lower rates of cellulitis (22.4% vs 44.9% of patients; P = .02).Conclusions
This analysis indicates significant benefits attributable to FLX compared with alternative compression therapies that can help reduce the notable economic burden of phlebolymphedema. 相似文献14.
Julia H. Vermylen Gordon J. Wood Elaine R. Cohen Jeffrey H. Barsuk William C. McGaghie Diane B. Wayne 《Journal of pain and symptom management》2019,57(3):682-687
Introduction
Physician communication impacts patient outcomes. However, communication skills, especially around difficult conversations, remain suboptimal, and there is no clear way to determine the validity of entrustment decisions. The aims of this study were to 1) describe the development of a simulation-based mastery learning (SBML) curriculum for breaking bad news (BBN) conversation skills and 2) set a defensible minimum passing standard (MPS) to ensure uniform skill acquisition among learners.Innovation
An SBML BBN curriculum was developed for fourth-year medical students. An assessment tool was created to evaluate the acquisition of skills involved in a BBN conversation. Pilot testing was completed to confirm improvement in skill acquisition and set the MPS.Outcomes
A BBN assessment tool containing a 15-item checklist and six scaled items was developed. Students' checklist performance improved significantly at post-test compared to baseline (mean 65.33%, SD = 12.09% vs mean 88.67%, SD = 9.45%, P < 0.001). Students were also significantly more likely to have at least a score of 4 (on a five-point scale) for the six scaled questions at post-test. The MPS was set at 80%, requiring a score of 12 items on the checklist and at least 4 of 5 for each scaled item. Using the MPS, 30% of students would require additional training after post-testing.Comments
We developed a SBML curriculum with a comprehensive assessment of BBN skills and a defensible competency standard. Future efforts will expand the mastery model to larger cohorts and assess the impact of rigorous education on patient care outcomes. 相似文献15.
Christopher N. Cooley Tyler J. Beranek Matthew A. Warpinski Robert Alexander Amanda O. Esquivel 《The American journal of emergency medicine》2019,37(2):199-203
Introduction
In the United States there has been a large increase in participation in lacrosse for both males and females. The purpose of this study was to analyze the number of head injuries, injury rates (calculated using the reported number of participants) and types of head injuries that are seen in emergency departments in the United States.Methods
We compared injuries between male and female lacrosse participants. This was a retrospective study using a publicly available database produced by the US Consumer Product Safety Commission and information about lacrosse participation from US Lacrosse.Results
A linear regression was performed and showed a positive correlation between number of head injuries to males and time from 2002 to 2010 (R2?=?0.823; p?=?0.001). While the number of injuries to the head in female lacrosse participants was not significant. There was a negative correlation between the number of head injuries to males from 2010 to 2016 (R2?=?0.800; p?=?0.007), but again, there was no significance for female injury count (R2?=?0.417; p?=?0.117). Other significant differences between head injuries in males and females included the mechanism of injury and the type of injury recorded.Conclusion
The most recent data from 2010 to 2016, suggest that both males and females have had a decrease in injury rate. However the total number of female head injuries is not significantly decreasing and as the sport continues to grow there will likely be more total head injuries and visits to the emergency department. 相似文献16.
Background
Atypical hemolytic uremic syndrome (aHUS) is a complement-mediated disease manifesting in thrombocytopenia, microangiopathic hemolytic anemia, and acute kidney injury. It has a higher incidence of extrarenal manifestations, including central nervous system findings like seizure or stroke, pancreatitis, and cardiac manifestations.Case Report
We present a case of an unimmunized 14-month-old girl presenting with generalized seizure and ultimately diagnosed with aHUS.Why Should an Emergency Physician Be Aware of This?
These atypical neurological symptoms can cause the diagnosis to be commonly missed in the emergency department. The etiology of approximately 60% of patients with aHUS can be attributed to genetic mutations in complement regulators including factor H, membrane cofactor protein, factor I, activator factor B, or C3. Although previously treated with plasma transfusion and immunosuppressants, eculizumab is a newer treatment that has been changing prognosis and management of aHUS, but it should be administered within 48 h of symptom onset for best efficacy. 相似文献17.
Sophia A. Traven Russell A. Reeves Molly G. Sekar Harris S. Slone Zeke J. Walton 《The Journal of arthroplasty》2019,34(1):140-144
Background
While the 11-factor modified frailty index (mFI) has been shown to predict adverse outcomes in patients undergoing total joint arthroplasty, the 5-factor index has not been evaluated in this patient population. The goal of this study was to evaluate the utility of the mFI-5 as a predictor of morbidity and mortality in patients undergoing primary total hip and knee arthroplasty.Methods
A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program's database for patients undergoing total hip arthroplasty and total knee arthroplasty between the years 2005 and 2016 was conducted. The 5-factor score, which includes the presence of comorbid diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functional status, was calculated for each patient. Multivariate logistic regression models were used to assess the relationship between the mFI-5 and postoperative complications while controlling for demographic variables.Results
One hundred forty thousand one hundred fifty-eight patients undergoing total hip arthroplasty and 226,398 patients undergoing total knee arthroplasty were identified. After adjusting for demographic variables and comorbid conditions, logistic regression analyses revealed that the mFI-5 was a strong predictor for total complications, Clavien-Dindo grade IV complications (cardiac arrest, myocardial infarction, septic shock, pulmonary embolism, postoperative dialysis, reintubation, and prolonged ventilator requirement), surgical site infections, readmission, and 30-day mortality (P < .001).Conclusions
The mFI-5 is an independent predictor of postoperative complications including life-threatening medical complications, surgical site infections, hospital readmission, and 30-day mortality after primary hip and knee arthroplasty. This clinical tool can be used to identify high-risk surgical patients and guide preoperative counseling to optimize outcomes.Level of Evidence
III. 相似文献18.
Vishnu Ambur Peter Park John P. Gaughan Scott Golarz Frank Schmieder Paul Van Bemmelen Eric Choi Ravi Dhanisetty 《Journal of vascular surgery》2019,69(2):491-496
Objective
Patient selection for open lower extremity revascularization in patients with chronic kidney disease (CKD) remains a clinical challenge. This study investigates the impact of CKD on early graft failure, postoperative complications, and mortality in patients undergoing lower extremity bypass for critical limb ischemia.Methods
The National Surgical Quality Improvement Program database was queried for all patients with critical limb ischemia from 2012 to 2015 who underwent lower extremity bypass using the targeted vascular set. The glomerular filtration rate was calculated using the Chronic Kidney Disease Epidemiology Collaboration Study equation. CKD categories were determined from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative staging criteria. Patients were classified into three groups: CKD stages 3 or lower (mild to moderate CKD), CKD stages 4 or 5 (severe CKD), and on hemodialysis (HD). Multiple variable analysis was used to examine graft failure, mortality, and postoperative complications.Results
The Surgical Quality Improvement Program database identified 6978 patients who underwent infrainguinal lower extremity arterial bypass during the study period. There were 6101 patients (87.4%) with mild to moderate CKD, 327 (4.7%) with severe CKD, and 550 (7.9%) on HD. Patients with severe CKD and on HD were more likely to have revascularization for tissue loss (54.9% vs 68.8% and 74.7%; P < .01). Patients with severe CKD and those on HD had higher rates of early graft failure, postoperative myocardial infarction, and rates of reoperation. Multiple variable analysis confirmed these results showing that HD was associated with postoperative myocardial infarction, readmission, and increased mortality. It also demonstrated that severe CKD was associated with graft failure (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.12-2.50; P = .01), postoperative myocardial infarction (OR, 2.16; 95% CI, 1.35-3.45; P < .01), and readmission (OR, 1.38; 95% CI, 1.06-1.80; P = .02). Other factors associated with graft failure include functional status (OR, 1.39; 95% CI, 1.08-1.80; P = .01), African American race (OR, 1.72; 95% CI, 1.39-2.13; P < .01), and distal bypass (OR, 1.33; 95% CI, 1.09-1.61; P < .01).Conclusions
CKD is a significant predictor of perioperative morbidity after lower extremity bypass. Patients with severe CKD have worse postoperative outcomes without increased mortality. Those on HD have worse survival and postoperative outcomes. 相似文献19.
Spyridon G. Deftereos Dimitrios A. Vrachatis Christos Angelidis Agathi-Rosa Vrettou Eleni K. Sarri Sotiria G. Giotaki Efthymia Varytimiadi Charalampos Kossyvakis Eleana Kotsia Gerasimos S. Deftereos Konstantinos Doudoumis Georgios Giannopoulos 《Clinical therapeutics》2019,41(1):21-29
Purpose
The goal of this review was to summarize, analyze, and compare trials studying the efficacy of colchicine in the prevention of atrial fibrillation (AF) post-operatively (POAF) and post–catheter ablation. Ongoing studies and current guidelines are also presented and reviewed.Methods
Published studies on the field were identified through a literature search of the PubMed and clinicaltrials.gov databases.Findings
Four original studies regarding POAF, two original studies regarding post–catheter ablation AF, and six meta-analyses were identified. In addition, the 3 most recent guidelines/expert consensus documents were scrutinized.Implications
AF occurs frequently after cardiac surgery (POAF) and catheter pulmonary vein isolation (postablation AF) and is associated with increased cardiovascular morbidity. A number of trials over the last few years have investigated the role of colchicine in the prevention of POAF and postablation AF targeting the local and systemic inflammatory process that leads to initiation and maintenance of AF. Available data imply that colchicine may have a preventive role in POAF and/or postablation AF. However, certain limitations of these studies underline the need for further investigation. 相似文献20.
Optimizing glycemic control remains a shared challenge for clinicians and their patients with diabetes. Flash continuous glucose monitoring (CGM) provides immediate information about an individual’s current and projected glucose level, allowing users to respond promptly to mitigate or prevent pending hypoglycemia or hyperglycemia. Large randomized controlled trials (RCTs) have demonstrated the glycemic benefits of flash CGM use in both type 1 and type 2 diabetes. However, whereas RCTs are mostly focused on the efficacy of this technology in defined circumstances, real-world studies can assess its effectiveness in wider clinical settings. This review assesses the most recent real-world studies demonstrating the effectiveness of flash CGM use to improve clinical outcomes and health care resource utilization in populations with diabetes.During the past 5 years, increasing numbers of people with type 1 or type 2 diabetes have integrated continuous glucose monitoring (CGM) into their diabetes self-management regimens. Unlike traditional blood glucose meters, CGM systems provide immediate information about the concentration and the direction and rate of change of interstitial glucose. This information enables patients to intervene promptly to prevent or reduce acute hypoglycemia or hyperglycemia.Flash CGM is among the most recent CGM technologies. Currently, the FreeStyle Libre 14-day system (Abbott Diabetes Care) and FreeStyle Libre 2 are the only flash CGM systems available, and these systems are being adopted rapidly. Large randomized controlled trials (RCTs) have confirmed the glycemic benefits of flash CGM use in people with type 1 diabetes (1,2) and those with type 2 diabetes (3–6). However, because RCTs are mostly focused on measures of efficacy in defined circumstances, real-world studies can usefully assess the effectiveness of flash CGM in wider clinical settings.Although adoption of flash CGM continues to expand within endocrinology and diabetes specialty practices, primary care providers may be less familiar with this technology and how it can benefit patients with diabetes. This review assesses recent real-world studies demonstrating the impact of flash CGM use on clinical outcomes and health care resource utilization in both type 1 and type 2 diabetes populations. 相似文献