bluuebunny/crossref_metadata_2025 huggingface dataset:
Anatomic Variation of Sacral Mesh Attachment During Minimally Invasive Sacrocolpopexy
Authors: Glass Clark Stephanie , Dang Rachel , Bonnet Sarah , Zyczynski Halina M. , Giugale Lauren
Published: February 2023

Importance

Although anatomic level of mesh attachment to the sacrum varied during minimally invasive sacrocolpopexy with a large proportion above S1, this was not associated with pelvic organ prolapse recurrence.

Objective

This study aimed to describe the anatomic level of sacral mesh attachment and its association with prolapse recurrence after minimally invasive sacrocolpopexy.

Study Design

This study included a retrospective cohort of women who underwent minimally invasive sacrocolpopexy with subsequent abdominal and pelvic imaging (magnetic resonance imaging or computed tomography) between 2010 and 2019 at a single academic institution. Anatomic level of attachment was determined by a radiologist. Prolapse recurrence was defined as a composite of self-reported bulge symptoms, any prolapse measure beyond the hymen, and any retreatment with pessary or surgery. χ2 Tests were used for comparative outcomes.

Results

Analyses included 212 women. The mean ± SD age was 58.8 ± 9.9 years, the majority have preoperative stage III/IV prolapse (81.1%), and the median follow-up was 269 days (interquartile range, 57–825 days). Mesh was attached using titanium tacks (n = 136 [64.2%]) and suture (n = 76 [35.8%]) at the level of the L5-S1 intervertebral space (n = 113 [53.3%]) or overlying S1 (n = 89 [42.0%]).The surgical approach was significantly associated with attachment location with a greater proportion of laparoscopy cases demonstrating mesh attachment above S1 (85 [62.5%] vs robotically, 30 [39.5%]; P < 0.01). Dichotomized level of attachment was not associated with composite prolapse recurrence (above S1, n = 18 [22.2%] vs below S1, n = 24 [24.7%]; P = 0.69) or any compartment recurrence (P ≥ 0.36).

Conclusions

Mesh was primarily attached to the anterior longitudinal ligament at the level of the L5-S1 intervertebral space or S1. Level of mesh attachment was not associated with composite prolapse recurrence.
The Impact of Facial Personal Protective Equipment on Speech Intensity
Authors: Krishnan Tara , Rudy Paul , Viswanathan Navin , Brommelsiek Margaret , Bachar Austin , Sutkin Gary
Published: February 2023

Importance

Facial personal protective equipment (FPPE) filters small particles in the operating room (OR) but also affects speech production, diminishing the effective transfer of information among OR team members.

Objective

The aim of the study is to assess the attenuating effects of different combinations of layered FPPE on speech intensity, including potential differences in the effect of talkers with varying backgrounds and speaking volumes.

Study Design

We recruited 30 speakers from health and nonhealth occupations with English as either their first or second language. All participants spoke unmasked, at varying voice levels into a portable Zoom H4n device 12 inches from the microphone. These no-mask recordings were played from a Styrofoam head, fitted with 7 combinations of FPPE commonly worn in the COVID-19 era, with the attenuated signals assessed for digital average signal levels. We submitted these attenuation values to an omnibus mixed analysis of variance and performed a spectral analysis on signal attenuation stratified by typical speech frequency bands.

Results

Signal attenuation was strongly determined by FPPE combination, regardless of talker sex, first language, and occupation (P < 0.01, η2
p = 0.881). The effects of vocal output were also significant (P < 0.01, η2
p = 0.881). Soft talkers experienced particularly high attenuation at frequency bands higher than 2,000 Hz. The signal of the softest talkers, when asked to speak loudly, was similar to the loud talkers’ signal.

Conclusions

Layered FPPE in the OR protects the surgical team from small particle exposure but may increase communication failures. Our data can help OR staff choose FPPE and alter their vocal volume accordingly.
Time to early resuscitative intervention association with mortality in trauma patients at risk for hemorrhage
Authors: Deeb Andrew-Paul , Guyette Francis X. , Daley Brian J. , Miller Richard S. , Harbrecht Brian G. , Claridge Jeffrey A. , Phelan Herb A. , Eastridge Brian J. , Joseph Bellal , Nirula Raminder , Vercruysse Gary A. , Sperry Jason L. , Brown Joshua B.
Published: February 2023

BACKGROUND

Hemorrhage is the leading cause of preventable death after injury. Others have shown that delays in massive transfusion cooler arrival increase mortality, while prehospital blood product resuscitation can reduce mortality. Our objective was to evaluate if time to resuscitation initiation impacts mortality.

METHODS

We combined data from the Prehospital Air Medical Plasma (PAMPer) trial in which patients received prehospital plasma or standard care and the Study of Tranexamic Acid during Air and ground Medical Prehospital transport (STAAMP) trial in which patients received prehospital tranexamic acid or placebo. We evaluated the time to early resuscitative intervention (TERI) as time from emergency medical services arrival to packed red blood cells, plasma, or tranexamic acid initiation in the field or within 90 minutes of trauma center arrival. For patients not receiving an early resuscitative intervention, the TERI was calculated based on trauma center arrival as earliest opportunity to receive a resuscitative intervention and were propensity matched to those that did to account for selection bias. Mixed-effects logistic regression assessed the association of 30-day and 24-hour mortality with TERI adjusting for confounders. We also evaluated a subgroup of only patients receiving an early resuscitative intervention as defined above.

RESULTS

Among the 1,504 propensity-matched patients, every 1-minute delay in TERI was associated with 2% increase in the odds of 30-day mortality (adjusted odds ratio [aOR], 1.020; 95% confidence interval [CI], 1.006–1.033; p < 0.01) and 1.5% increase in odds of 24-hour mortality (aOR, 1.015; 95% CI, 1.001–1.029; p = 0.03). Among the 799 patients receiving an early resuscitative intervention, every 1-minute increase in TERI was associated with a 2% increase in the odds of 30-day mortality (aOR, 1.021; 95% CI, 1.005–1.038; p = 0.01) and 24-hour mortality (aOR, 1.023; 95% CI, 1.005–1.042; p = 0.01).

CONCLUSION

Time to early resuscitative intervention is associated with morality in trauma patients with hemorrhagic shock. Bleeding patients need resuscitation initiated early, whether at the trauma center in systems with short prehospital times or in the field when prehospital time is prolonged.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.
Outcomes of Surgical vs Non-Surgical Treatment for Multiple Rib Fractures: A US Hospital Matched Cohort Database Analysis
Authors: Shiroff Adam M. , Wolf Simone , Wu Alex , Vanderkarr Mollie , Anandan Manoranjith , Ruppenkamp Jill W. , Galvain Thibaut , Holy Chantal E.
Published: February 2023

Background

Treatment for multiple rib fractures (MRF) includes surgical stabilization of rib fractures (SSRF) or non-operative management (NOM). Meta-analyses have demonstrated that SSRF results in faster recovery and lower long-term complication rates vs NOM. Our study evaluated post-operative outcomes for MRF patients following SSRF vs NOM in a real world, all-comer study design.

Methods

MRF Patients with inpatient admissions in the PREMIER hospital database from 10/01/2015 to 09/30/2020 were identified. Outcomes included discharge disposition and 3- and 12-month lung-related readmissions. Demographics, comorbidities, concurrent injuries at index, abbreviated injury scale and injury severity scores, and provider characteristics, were determined for all patients. Patients were excluded from the cohort if they had a thorax AIS < 2 (low severity patient) or a Glasgow coma score ≤ 8 (extreme high severity patient). Stratum matching between SSRF and NOM patients was performed using fine stratification and weighting, so that all patient data was kept in the final analysis. Outcomes were analyzed using generalized linear models with quasinormal distribution and logit links.

Results

203,450 patients were included, of which 200,580 NOM and 2,870 SSRF. SSRF patients had higher rates of home discharge (62% SSRF vs 58% NOM), and lower rates of lung-related readmissions (3 months: 3.1% SSRF vs 4.0% NOM; 12 months: 6.2% SSRF vs 7.6% NOM). The odds ratio (OR) for home or home health discharge in patients with SSRF vs NOM was 1.166 (95% confidence interval (CI): 1.073-1.266, p = 0.0002). Similarly, odd ratios for lung-related readmission at 3- and 12-month were statistically lower in the patients treated with SSRF vs NOM (OR (3 month): 0.764 (95%CI: 0.606-0.963), p = 0.0227 and OR (12 months): 0.799 (95%CI: 0.657-0.971), p = 0.0245).

Conclusion

SSRF results in greater odds of home discharge and lower rates of lung-related readmissions compared to NOM at 12 months follow-up.

Level of Evidence

III
Detection of pneumothorax on ultrasound using artificial intelligence
Authors: Montgomery Sean , Li Forrest , Funk Christopher , Peethumangsin Erica , Morris Michael , Anderson Jess T. , Hersh Andrew M. , Aylward Stephen
Published: February 2023

BACKGROUND

Ultrasound (US) for the detection of pneumothorax shows excellent sensitivity in the hands of skilled providers. Artificial intelligence may facilitate the movement of US for pneumothorax into the prehospital setting. The large amount of training data required for conventional neural network methodologies has limited their use in US so far.

METHODS

A limited training database was supplied by Defense Advanced Research Projects Agency of 30 patients, 15 cases with pneumothorax and 15 cases without. There were two US videos per patient, of which we were allowed to choose one to train on, so that a limited set of 30 videos were used. Images were annotated for ribs and pleural interface. The software performed anatomic reconstruction to identify the region of interest bounding the pleura. Three neural networks were created to analyze images on a pixel-by-pixel fashion with direct voting determining the outcome. Independent verification and validation was performed on a data set gathered by the Department of Defense.

RESULTS

Anatomic reconstruction with the identification of ribs and pleura was able to be accomplished on all images. On independent verification and validation against the Department of Defense testing data, our program concurred with the SME 80% of the time and achieved a 86% sensitivity (18/21) for pneumothorax and a 75% specificity for the absence of pneumothorax (18/24). Some of the mistakes by our artificial intelligence can be explained by chest wall motion, hepatization of the underlying lung, or being equivocal cases.

CONCLUSION

Using learning with limited labeling techniques, pneumothorax was identified on US with an accuracy of 80%. Several potential improvements are controlling for chest wall motion and the use of longer videos.

LEVEL OF EVIDENCE

Diagnostic Tests; Level III.
Variation in tracheostomy placement and outcomes following pediatric trauma among adult, pediatric, and combined trauma centers
Authors: Killien Elizabeth Y. , Grassia Kalee L. , Butler Elissa K. , Mooney Stephen J. , Watson R. Scott , Vavilala Monica S. , Rivara Frederick P.
Published: February 2023

BACKGROUND

Tracheostomy placement is much more common in adults than children following severe trauma. We evaluated whether tracheostomy rates and outcomes differ for pediatric patients treated at trauma centers that primarily care for children versus adults.

METHODS

We conducted a retrospective cohort study of patients younger than 18 years in the National Trauma Data Bank from 2007 to 2016 treated at a Level I/II pediatric, adult, or combined adult/pediatric trauma center, ventilated >24 hours, and who survived to discharge. We used multivariable logistic regression adjusted for age, insurance, injury mechanism and body region, and Injury Severity Score to estimate the association between the three trauma center types and tracheostomy. We used augmented inverse probability weighting to model the likelihood of tracheostomy based on the propensity for treatment at a pediatric, adult, or combined trauma center, and estimated associations between trauma center type with length of stay and postdischarge care.

RESULTS

Among 33,602 children, tracheostomies were performed in 4.2% of children in pediatric centers, 7.8% in combined centers (adjusted odds ratio [aOR], 1.47; 95% confidence interval [CI], 1.20–1.81), and 11.2% in adult centers (aOR, 1.81; 95% CI, 1.48–2.22). After propensity matching, the estimated average tracheostomy rate would be 62.9% higher (95% CI, 37.7–88.1%) at combined centers and 85.3% higher (56.6–113.9%) at adult centers relative to pediatric centers. Tracheostomy patients had longer hospital stay in pediatric centers than combined (−4.4 days, −7.4 to −1.3 days) or adult (−4.0 days, −7.2 to −0.9 days) centers, but fewer children required postdischarge inpatient care (70.1% pediatric vs. 81.3% combined [aOR, 2.11; 95% CI, 1.03–4.31] and 82.4% adult centers [aOR, 2.51; 95% CI, 1.31–4.83]).

CONCLUSION

Children treated at pediatric trauma centers have lower likelihood of tracheostomy than children treated at combined adult/pediatric or adult centers independent of patient or injury characteristics. Better understanding of optimal indications for tracheostomy is necessary to improve processes of care for children treated throughout the pediatric trauma system.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.
Implementation science approaches to optimizing venous thromboembolism prevention in patients with traumatic injuries: Findings from the 2022 Consensus Conference to Implement Optimal Venous Thromboembolism Prophylaxis in Trauma
Authors: Ratnasekera Asanthi , Geerts William , Haut Elliott R. , Price Michelle , Costantini Todd , Murphy Patrick
Published: February 2023

Disease burden of venous thromboembolism (VTE) without pharmacologic prophylaxis is high in trauma patients. Although VTE prophylaxis guidelines exist, studies on real-world use of VTE prophylaxis in trauma shows limited uptake of guideline recommendations. Despite existing guidelines, reports indicate that VTE prophylaxis implementation across trauma centers is lagging. Implementation barriers of VTE prophylaxis in trauma are multifactorial, and VTE prescribing practices require further optimization. Implementation science methods can help standardize and improve care; well-established approaches in medical and surgical hospitalized patients and their effects on clinical outcomes such as VTE and bleeding complications must be investigated because they apply to trauma patients. Nonadministration of VTE prophylaxis medications in hospitalized patients is associated with VTE events and remains a barrier to providing optimal defect-free care. Further investigations are required for VTE prophylaxis implementation across all trauma populations.
Multiyear experience with mobile online platform for documentation of acute care surgery fellows supervision
Authors: Gunter Oliver L. , Devasahayam Rebekah J. , Dennis Bradley M. , Gondek Stephen P. , Adams Raeanna C. , Guillamondegui Oscar D.
Published: February 2023

BACKGROUND

There is currently no standard for documenting supervision of acute care surgery (ACS) fellows. To accomplish this goal, we developed a web-based survey that is accessible via mobile platform. We hypothesize that our mobile access survey is an effective, reproducible tool for assessing fellow clinical performance.

METHODS

A retrospective review from 2016 to 2022 of all data captured in an encrypted database on all ACS fellows at our institution was performed. Supervision was defined as: Type 1 direct face-to-face, Type 2a immediately available in-house, Type 2b available after notification via phone with remote electronic medical record access, and Type 3 retrospective review. Data were collected by supervising faculty using a web-based clinical performance survey created by fellowship program leadership. Survey data collected included clinical summary, trainee, proctoring faculty, clinical service, operative/nonoperative, supervision type, Zwisch autonomy scale, time to input data, and graduate medical education milestone performance. Data were analyzed using descriptive statistics.

RESULTS

A total of 883 proctoring events were identified, including the majority as Type 1 (97.4%). Trauma comprised 64% of evaluations. Fifty-two percent of the proctoring events were surgical cases. Complexity was graded as average (77%), hardest (16%), basic (7%). Guidance included supervision only, 491 of 666 (74%), with 26% requiring faculty intervention. Fellow performance was graded as average (66%), above average (31%), and below average/critical deficiency (3%). Graduate medical education performance was available for 247 of 883 interactions identifying 31 events with potential for improvement. Average evaluation completion time: 2 minutes (n = 134).

CONCLUSION

A mobile web-based survey is a convenient and reliable tool for documenting ACS fellow clinical activity and was effectively used by all ACS faculty to record supervision. A combination of clinical and objective data is useful to determine ACS fellows' performance and to provide targeted education and remediation.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.
Is perioperative COVID-19 really associated with worse surgical outcomes? A nationwide COVIDSurg propensity-matched analysis
Authors: Argandykov Dias , Dorken-Gallastegi Ander , El Moheb Mohamad , Gebran Anthony , Proaño-Zamudio Jefferson A. , Bokenkamp Mary , Renne Angela M. , Nepogodiev Dmitri , Bhangu Aneel , Kaafarani Haytham M.A. ,   on behalf of the COVIDSurg Collaborative
Published: February 2023

BACKGROUND

Patients undergoing surgery with perioperative COVID-19 are suggested to have worse outcomes, but whether this is COVID-related or due to selection bias remains unclear. We aimed to compare the postoperative outcomes of patients with and without perioperative COVID-19.

METHODS

Patients with perioperative COVID-19 diagnosed within 7 days before or 30 days after surgery between February and July 2020 from 68 US hospitals in COVIDSurg, an international multicenter database, were 1:1 propensity score matched to patients without COVID-19 undergoing similar procedures in the 2012 American College of Surgeons National Surgical Quality Improvement Program database. The matching criteria included demographics (e.g., age, sex), comorbidities (e.g., diabetes, chronic obstructive pulmonary disease, chronic kidney disease), and operation characteristics (e.g., type, urgency, complexity). The primary outcome was 30-day hospital mortality. Secondary outcomes included hospital length of stay and 13 postoperative complications (e.g., pneumonia, renal failure, surgical site infection).

RESULTS

A total of 97,936 patients were included, 1,054 with and 96,882 without COVID-19. Prematching, COVID-19 patients more often underwent emergency surgery (76.1% vs. 10.3%, p < 0.001). A total of 843 COVID-19 and 843 non–COVID-19 patients were successfully matched based on demographics, comorbidities, and operative characteristics. Postmatching, COVID-19 patients had a higher mortality (12.0% vs. 8.1%, p = 0.007), longer length of stay (6 [2–15] vs. 5 [1–12] days), and higher rates of acute renal failure (19.3% vs. 3.0%, p < 0.001), sepsis (13.5% vs. 9.0%, p = 0.003), and septic shock (11.8% vs. 6.0%, p < 0.001). They also had higher rates of thromboembolic complications such as deep vein thrombosis (4.4% vs. 1.5%, p < 0.001) and pulmonary embolism (2.5% vs. 0.4%, p < 0.001) but lower rates of bleeding (11.6% vs. 26.1%, p < 0.001).

CONCLUSION

Patients undergoing surgery with perioperative COVID-19 have higher rates of 30-day mortality and postoperative complications, especially thromboembolic, compared with similar patients without COVID-19 undergoing similar surgeries. Such information is crucial for the complex surgical decision making and counseling of these patients.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level IV.
The Utah Pediatric Trauma Network, a statewide pediatric trauma collaborative can safely help nonpediatric hospitals admit children with mild traumatic brain injury
Authors: Fenton Stephen J. , Swendiman Robert A. , Eyre Matthew , Larsen Kezlyn , Russell Katie W.
Published: February 2023

BACKGROUND

Created in 2019, the Utah Pediatric Trauma Network (UPTN) is a transparent noncompetitive collaboration of all hospitals in Utah with the purpose of improving pediatric trauma care. The UPTN implements evidence-based guidelines based on hospital resources and capabilities with quarterly review of data collected in a network-specific database. The first initiative was to help triage the care of traumatic brain injury (TBI) to prevent unnecessary transfers while ensuring appropriate care. The purpose of this study was to review the effectiveness of this network wide guideline.

METHODS

The UPTN REDCap database was retrospectively reviewed between January 2019 and December 2021. Comparisons were made between the pediatric trauma center (PED1) and nonpediatric hospitals (non-PED1) in admissions of children with very mild, mild, or complicated mild TBI.

RESULTS

Of the total 3,315 cases reviewed, 294 were admitted to a non-PED1 hospital and 1,061 to the PED1 hospital with very mild/mild/complicated mild TBI. Overall, kids treated at non-PED1 were older (mean, 14.9 vs. 7.7 years; p = 0.00001) and more likely to be 14 years or older (37% vs. 24%, p < 0.00001) compared with those at PED1. Increased admissions occurred post-UPTN at non-PED1 hospitals compared with pre-UPTN (43% vs. 14%, p < 0.00001). Children admitted to non-PED1 hospitals post-UPTN were younger (9.1 vs. 15.7 years, p = 0.002) with more kids younger than 14 years (67% vs. 38%, p = 0.014) compared with pre-UPTN. Two kids required next-day transfer to a higher-level center (1 to PED1), and none required surgery or neurosurgical evaluation. The mean length of stay was 21.8 hours (interquartile range, 11.9–25.4). Concomitantly, less children with very mild TBI were admitted to PED1 post-UPTN (6% vs. 27%, p < 0.00001) and more with complicated mild TBI (63% vs. 50%, p = 0.00003) than 2019.

CONCLUSION

Implementation of TBI guidelines across the UPTN successfully allowed nonpediatric hospitals to safely admit children with very mild, mild, or complicated mild TBI. In addition, admitted kids were more like those treated at the PED1 hospital.

LEVEL OF EVIDENCE

Prognostic/Epidemiological; Level IV.
Is the use of nonsteroidal anti-inflammatories after bowel anastomosis in trauma safe?
Authors: Clements Thomas W. , Van Gent Jan-Michael , Hatton Gabrielle E. , Estrada Michelle , Agarwal Amit K. , Cotton Bryan A.
Published: February 2023

BACKGROUND

With an increasing interest in multimodal and opioid-reducing pain strategies, nonsteroidal anti-inflammatory drugs (NSAIDs) have become common place in the care of injured patients. Long-standing concerns of increased anastomotic leak (AL) rate with the use of NSAIDs, however, have persisted. We hypothesized that there would be no significant risk associated with NSAID use after bowel anastomosis in trauma patients.

METHODS

All patients presenting to a level 1 trauma center who required intestinal resection and anastomosis from 2011 to 2017 were reviewed. Patients receiving NSAIDs were compared with those managed without NSAIDs. Primary outcome of interest was anastomosis-related complications (AL, intra-abdominal abscess, anastomotic bleed, fascial dehiscence, fascial dehiscence, and enterocutaneous fistula). Multivariable logistic regression analyses were performed with propensity adjustment for inverse probability of NSAID treatment weights.

RESULTS

A total of 295 patients met the inclusion criteria with 192 receiving NSAIDs. Patients receiving NSAIDs had lower abdominal Abbreviated Injury Scale and Injury Severity Score (p < 0.046). Arrival systolic blood pressure, diastolic blood pressure, and Glasgow Coma Scale were higher in the NSAID group (p < 0.013). After propensity weighting, NSAID use was not a major predictor of anastomotic complication (p = 0.39). There was an increased risk of AL with perioperative vasopressor exposure (odds ratio [OR], 3.33; 95% confidence interval [CI], 1.17–9.05; p < 0.001). Increasing red blood cell transfusions in the first 24 hours were associated with intra-abdominal complications (OR, 1.02; 95% CI, 1.00–1.04; p = 0.05). Nonsteroidal anti-inflammatory drug exposure demonstrated a weak association with AL (OR, 1.92; 95% CI, 0.97–3.90; p = 0.06).

CONCLUSION

Consistent with previous studies, perioperative vasopressor exposure and increased number of red blood cell transfusions are risk factors for ALs and intra-abdominal complications, respectively. Nonsteroidal anti-inflammatory drug use in trauma patients with multiple risk factors may be associated with an increased risk of AL and should be used with caution in the setting of other established risk factors.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.
Association of race and socioeconomic status with time to pain control among pediatric trauma patients managed nonoperatively
Authors: Trinidad Stephen , Jenkins Todd , Falcone Kelly , Denning Jaime Rice , Chidambaran Vidya , Kotagal Meera
Published: February 2023

BACKGROUND

Few studies have evaluated racial/ethnic inequities in acute pain control among hospitalized injured children. We hypothesized that there would be inequities in time to pain control based on race/ethnicity and socioeconomic status.

METHODS

We performed a retrospective cohort study of all injured children (7–18 years) admitted to our level 1 trauma center between 2010 and 2019 with initial recorded numerical rating scale (NRS) scores of >3 who were managed nonoperatively. A Cox regression survival analysis was used to evaluate the time to pain control, defined as achieving an NRS score of ≤3.

RESULTS

Our cohort included 1,787 admissions. The median age was 14 years (interquartile range, 10–18), 59.5% were male, 76.6% identified as White, 19.9% as Black, and 2.4% as Hispanic. The median initial NRS score was 7 (interquartile range, 5–9), and the median time to pain control was 4.9 hours (95% confidence interval, 4.6–5.3). Insurance status, as a marker of socioeconomic status, was not associated with time to pain control (p = 0.29). However, the interaction of race/ethnicity and deprivation index was significant (p = 0.002). Specifically, the socioeconomic deprivation of a child's home neighborhood was an important predictor for non-White children (p <0.003) but not for White children (p = 0.41) and non-White children from higher deprivation neighborhoods experienced greater times to pain control (hazard ratio, 1.55; 95% confidence interval, 1.16–2.07). Being female, older, presenting with higher initial NRS scores, and having history of attention-deficit/hyperactivity disorder were all associated with longer times to pain control. Other injury characteristics and psychiatric history were evaluated but ultimately excluded, as they were not significant.

CONCLUSION

Greater neighborhood socioeconomic deprivation was associated with prolonged time to pain control for non-White children admitted after injury and managed nonoperatively. Further work is needed to understand inequities in pain control for injured patients.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.
Evaluating associations between level of trauma care and outcomes of patients with specific severe injuries: A systematic review and meta-analysis
Authors: Van Ditshuizen Jan C. , Rojer Leonne A. , Van Lieshout Esther M.M. , Bramer Wichor M. , Verhofstad Michiel H.J. , Sewalt Charlie A. , Den Hartog Dennis
Published: February 2023

BACKGROUND

Trauma networks have multiple designated levels of trauma care. This classification parallels concentration of major trauma care, creating innovations and improving outcome measures.

OBJECTIVES

The objective of this study is to assess associations of level of trauma care with patient outcomes for populations with specific severe injuries.

METHODS

A systematic literature search was conducted using six electronic databases up to April 19, 2022 (PROSPERO CRD42022327576). Studies comparing fatal, nonfatal clinical, or functional outcomes across different levels of trauma care for trauma populations with specific severe injuries or injured body region (Abbreviated Injury Scale score ≥3) were included. Two independent reviewers included studies, extracted data, and assessed quality. Unadjusted and adjusted pooled effect sizes were calculated with random-effects meta-analysis comparing Level I and Level II trauma centers.

RESULTS

Thirty-five studies (1,100,888 patients) were included, of which 25 studies (n = 443,095) used for meta-analysis, suggesting a survival benefit for the severely injured admitted to a Level I trauma center compared with a Level II trauma center (adjusted odds ratio [OR], 1.15; 95% confidence interval [CI], 1.06–1.25). Adjusted subgroup analysis on in-hospital mortality was done for patients with traumatic brain injuries (OR, 1.23; 95% CI, 1.01–1.50) and hemodynamically unstable patients (OR, 1.09; 95% CI, 0.98–1.22). Hospital and intensive care unit length of stay resulted in an unadjusted mean difference of −1.63 (95% CI, −2.89 to −0.36) and −0.21 (95% CI, −1.04 to 0.61), respectively, discharged home resulted in an unadjusted OR of 0.92 (95% CI, 0.78–1.09).

CONCLUSION

Severely injured patients admitted to a Level I trauma center have a survival benefit. Nonfatal outcomes were indicative for a longer stay, more intensive care, and more frequently posthospital recovery trajectories after being admitted to top levels of trauma care. Trauma networks with designated levels of trauma care are beneficial to the multidisciplinary character of trauma care.

LEVEL OF EVIDENCE

Systematic review and meta-analysis; Level III.
Disparities in advance care planning rates persist among emergency general surgery patients: Current state and recommendations for improvement
Authors: Johnson Christopher L. , Colley Alexis , Pierce Logan , Lin Joseph A. , Bongiovanni Tasce , Roman Sanziana , Sudore Rebecca L. , Wick Elizabeth
Published: February 2023

BACKGROUND

Unanticipated changes in health status and worsening of chronic conditions often prompt the need to consider emergency general surgery (EGS). Although discussions about goals of care may promote goal-concordant care and reduce patient and caregiver depression and anxiety, these conversations, as well as standardized documentation, remain infrequent for EGS patients.

METHODS

We conducted a retrospective cohort study using electronic health record data from patients admitted to an EGS service at a tertiary academic center to determine the prevalence of clinically meaningful advance care planning (ACP) documentation (conversations and legal ACP forms) during the EGS hospitalization. Multivariable regression was performed to identify patient, clinician, and procedural factors associated with the lack of ACP.

RESULTS

Among 681 patients admitted to the EGS service in 2019, only 20.1% had ACP documentation in the electronic health record at any time point during their hospitalization (of those, 75.5% completed before and 24.5% completed during admission). Two thirds (65.8%) of the total cohort had surgery during their admission, but none of them had a documented ACP conversation with the surgical team preoperatively. Patients with ACP documentation tended to have Medicare insurance (adjusted odds ratio, 5.06; 95% confidence interval, 2.09–12.23; p < 0.001) and had greater burden of comorbid conditions (adjusted odds ratio, 4.19; 95% confidence interval, 2.55–6.88; p < 0.001).

CONCLUSION

Adults experiencing a significant, often abrupt change in health status leading to an EGS admission are infrequently engaged in ACP conducted by the surgical team. This is a critical missed opportunity to promote patient-centered care and to communicate patients' care preferences to the surgical and other inpatient medical teams.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.
Commentary on “Consciousness as a Memory System” by Budson, Richman, and Kensinger (2022)
Authors: Kirshner Howard S.
Published: February 2023

Consciouness is a phenomenon that has eluded explanation by generations of physicians and scientists. Many discussions, experiments, and theories about consciousness have been published, but none has adequately explained the phenomenon. In the previous issue, Budson and colleagues (2022) present a theory of consciousness based on explicit memory processes, with consciousness developing in the context of memory function. In the authors’ view, consciousness accompanying other cortical processes such as language or visual-spatial function developed only later in evolution. The evidence presented for this evolutionary sequence, however, is very limited. Furthermore, no discussion is directed toward the theory that consciousness involves the intersection between external perceptions and internal bodily states. The authors also develop the concept that most of our actions, and even our personality, are conscious only after the fact; immediate decisions are taken by the unconscious mind—the “horse” rather than the “rider.” There is empirical evidence that rapid decisions and responses occur before they become conscious. However, Budson and colleagues (2022) extend the concept of unconscious decision-making to virtually all actions; in so doing, not only do they minimize the phenomenon of self-conscious awareness, but their theory has disturbing ethical implications for personal responsibility, criminal law, free will, and personality.
Empty Sella in Neuro-Ophthalmology Patients Without Raised Intracranial Pressure
Authors: Sayal Aman P. , Jhaveri Aaditeya , Diouf Ange A. , Lam Cindy T. Y. , Suthiphosuwan Suradech , Micieli Jonathan A.
Published: February 2023

Background:

Empty sella often supports a diagnosis of raised intracranial pressure (ICP) but is also seen in normal individuals. This study's objective was to determine the prevalence of empty and partially empty sella in neuro-ophthalmology patients undergoing MRI for indications other than papilledema or raised ICP.

Methods:

Consecutive patients without papilledema or suspected raised ICP who underwent brain MRI between August 2017 and May 2021 were included in this study. Sagittal T1 images were evaluated by 2 independent, blinded neuroradiologists who graded the sella using the published criteria (Categories 1–5, with 1 being normal and 5 showing no visible pituitary tissue). Clinical parameters were also collected.

Results:

A total of 613 patients (309 men; average age 56.69 ± 18.06 years) were included in this study with optic neuropathy as the most common MRI indication. A total of 176 patients had moderate concavity of the pituitary gland (Category 3), 81 had severe concavity (Category 4), and 26 had no visible pituitary tissue (Category 5). Sella appearance was mentioned in 92 patients' radiology reports (15%). There was a statistically significant difference in age between composite Categories 1 and 2 (mean 52.89 ± 18.91; P < 0.001) and composite Categories 4 and 5 (mean 63.41 ± 15.44), but not the other clinical parameters.

Conclusion:

Empty sella is common in neuro-ophthalmology patients without raised ICP; 17.4% of patients have severe concavity or no pituitary tissue visible. An isolated finding of empty or partially empty sella on imaging is therefore of questionable clinical value in this patient population.
Vascular Risk Factors in Isolated Microvascular Ischemic Third Nerve Palsy: A Population-Based Study
Authors: Zhao Bingying , Bhatti M. Tariq , Fang Chengbo , Hodge David O. , Holmes Jonathan M. , Mohney Brian G. , Chen John J.
Published: February 2023

Background:

Although presumed microvascular third nerve palsies (TNP) have been associated with vascular risk factors and/or stroke, these associations have not been explored in a population-based cohort. The purpose of this population-based case–control study was to determine whether these factors are associated with TNPs that had been classified as isolated microvascular ischemic events and determine future risk of mortality.

Methods:

Participants were subjects >18 years old with new onset of isolated TNP attributed to presumed microvascular ischemia (n = 55) while residing in Olmsted County, Minnesota, from January 1, 1978 to December 31, 2014. Control subjects (n = 55) were randomly selected from the same population and matched for gender, age, and length of medical follow-up. We identified all cases of new-onset isolated presumed microvascular ischemic TNP using the Rochester Epidemiology Project, a record-linkage system of medical records for all patient–physician encounters in Olmsted County, Minnesota. All medical records of cases and controls were reviewed for potential risk factors, including diabetes mellitus, diabetic retinopathy, hypertension, hyperlipidemia, smoking, and symptomatic ischemic stroke. Multivariable and univariate logistic regression analyses were used to compare the prevalence of potential risk factors between microvascular ischemic cases and controls according to the number of subjects, and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Kaplan–Meier curves were used to compare mortality between cases and controls.

Results:

The annual incidence of microvascular ischemic TNP was 1.7 per 100,000. Univariate analysis demonstrated that hypertension (P < 0.001; OR, 4.80; 95% CI, 2.11–11.58), diabetes mellitus (P < 0.001; OR, 6.55; 95% CI, 2.72–17.32), diabetic retinopathy (P = 0.014; OR, 13.50; 95% CI, 2.48–251.55), coronary artery disease (P = 0.047; OR, 2.27; 95% CI, 1.02–5.18), and symptomatic ischemic stroke (P = 0.039; OR, 3.56; 95% CI, 1.07–11.85) all occurred more frequently in patients with microvascular ischemic TNP than controls. In multivariate analysis, only hypertension (OR of 4.14, 95% CI, 1.61–10.65, P < 0.001) and diabetes (OR of 4.12, 95% CI, 1.43–11.92, P = 0.003) remained independently statistically significant. There was numerically higher mortality in microvascular cases than in controls, but it did not reach statistical significance.

Conclusions:

There are multiple cardiovascular diseases that are associated with isolated microvascular ischemic TNP, including hypertension, coronary artery disease, diabetes mellitus, diabetic retinopathy, and symptomatic ischemic stroke. Given that the main drivers of this association seem to be diabetes and hypertension, patients with microvascular ischemic TNP should be evaluated for these conditions.
Rates of Visual Field Change in Eyes With Optic Disc Drusen
Authors: Estrela Tais , Jammal Alessandro A. , El-Dairi Mays , Medeiros Felipe A.
Published: February 2023

Background:

Optic disc drusen (ODD) are calcified deposits in the prelaminar portion of the optic nerve head. Although often asymptomatic, these deposits can cause progressive visual field defects and vision loss. The purpose of this study was to evaluate rates of functional loss in eyes with ODD and to investigate risk factors associated with rates of visual field progression.

Methods:

This was a retrospective cohort study including 65 eyes of 43 patients with ODD from the Duke Ophthalmic Registry. All eyes had at least 12 months of follow-up and at least 3 reliable standard automated perimetry (SAP) tests. Linear mixed models were used to estimate rates of SAP mean deviation (MD) loss over time. Univariable and multivariable models were used to assess the effect of clinical variables and intraocular pressure (IOP) on rates of change.

Results:

Subjects were followed for an average of 7.6 ± 5.3 years. The mean rate of SAP MD change was −0.23 ± 0.26 dB/year, ranging from −1.19 to 0.13 dB/year. Fifty-seven eyes (87.7%) had slow progression (slower than −0.5 dB/year), 6 eyes (9.2%) had moderate progression (between −0.5 dB/year and −1 dB/year), and 2 eyes (3.1%) had fast progression (faster than −1 dB/year). In multivariable models, older age and worse SAP MD at baseline were significantly associated with faster rates of change. Mean IOP was not associated with faster rates of MD change in both univariable and multivariable analyses.

Conclusions:

Most eyes with ODD had slow rates of visual field loss over time. Age and baseline severity were significantly associated with faster rates of visual field loss.
The Taxonomy Dictionary. A resource for correct spelling of taxa.
Authors: Bagge Kristian
Published: February 2023

This article describes "The Taxonomy Dictionary". A resource that can enhance the spelling engine of a text editor like Word, so it correctly can spell every taxon described and enlisted in the largest taxonomy databases. It contains around 1.4 million unique words, and once installed a wrongly spelled taxon will be marked by the spelling engine and it will suggest possibly correct spellings. Installation instructions for Firefox, LibreOffice and Microsoft Word can be found on the GitHub repository. The software is licensed with a GPL3 license.
Streptococcus parasanguinis : An emerging pathogen causing neonatal endocarditis: A case report
Authors: Shrimali Twishi , Malhotra Shikhir , Relhan Nidhi , Tak Vibhor , Choudhary Sushil Kumar , Gupta Neeraj , Singh Arun Kumarendu
Published: February 2023

Abstract-
Background
Infective Endocarditis (IE), the microbial infection of the endocardium, is typically classified on the basis of anatomy, valve nativity and microbiology. Talking of microbiology, Staphylococcus aureus is the most common microorganism responsible to cause IE, Streptococcus group accounts for a smaller percentage of IE. However this doesn’t give us liberation of ignoring the high mortality and morbidity associated with this pathogen.
Case presentation
We report an unusual case of neonatal sepsis complicated with endocarditis, caused by penicillin resistant Streptococcus parasanguinis, born to a mother with gestational diabetes mellitus who died of the same despite all efforts.
Conclusion
High index of clinical suspicion and prompt diagnosis are the most important factors of patient management especially in cases of life threatening neonatal infections; for which a coordinated interdepartmental approach is needed.
Association between increased anterior cingulate glutamate and psychotic-like symptoms, but not autistic traits
Authors: Demler Verena F , Sterner Elisabeth F. , Wilson Martin , Zimmer Claus , Knolle Franziska
Published: February 2023

Despite many differences, autism spectrum disorder and schizophrenia spectrum disorder share environmental risk factors, genetic predispositions as well as neuronal abnormalities, and show similar cognitive deficits in working memory, perspective taking, or response inhibition. These alterations are already present in subclinical traits of these disorders. The literature proposes that alterations in the inhibitory GABAergic and the excitatory glutamatergic system could explain underlying neuronal commonalities and differences. Using magnetic resonance spectroscopy (1H-MRS), we investigated the associations between glutamate concentrations in the anterior cingulate cortex (ACC), the left/right putamen, and left/right dorsolateral prefrontal cortex and psychotic-like experiences (schizotypal personality questionnaire) and autistic traits (autism spectrum quotient) in 53 healthy individuals (28 women). To investigate the contributions of glutamate concentrations in different cortical and subcortical regions to symptom expression and their interactions, we used linear regression and moderation analyses. We found that glutamate concentration in the ACC but in none of the other regions predicted positive-like symptoms. None of the other clinical scores was associated with altered levels of glutamate. Specifying this finding, the moderation analysis showed that increased ACC glutamate was predictive of positive-like symptoms when glutamate concentrations in the right putamen were reduced, and that increased ACC glutamate was predictive of positive-like symptoms when disorganized traits were attenuated. This study provides evidence that an imbalance in the glutamatergic neurotransmitter system involving cortical and subcortical regions is linked to the expression of psychotic-like experiences, especially positive-like symptoms. These findings may facilitate the detection of individuals transitioning into an acute episode of psychosis.
ADO-MEDIATED SYNTHESIS OF TAURINE ALTERS THE CHROMATIN LANDSCAPE OF INGUINAL ADIPOSE TISSUE TO ENHANCE NON-SHIVERING THERMOGENESIS
Authors: Tsai Pei-Yin , Shui Bo , Lee Seoyeon , Liu Yang , Qu Yue , Cheng Chloe , Edwards Kaydine , Wong Callie , Meng-Killeen Ryan , Soloway Paul , Barrow Joeva J
Published: February 2023

Non-shivering thermogenesis (NST) has strong potential to combat obesity, however, a safe molecular approach to activate this process has not yet been identified. The sulfur amino acid taurine has the ability to safely activate NST and confer protection against obesity and metabolic disease in both mice and humans, but the mechanism of action is unknown. In this study, we discover that a suite of taurine biosynthetic enzymes, especially that of cysteamine dioxygenase (ADO), significantly increases in response to β3adrenergic signaling in inguinal tissues (IWAT) in order increase intracellular concentrations of taurine. We further show that ADO is critical for thermogenic mitochondrial function as its ablation in thermogenic adipocytes significantly reduces taurine levels which lead to declines in mitochondrial oxygen consumption rates. Finally, we demonstrate via assay for transposase-accessible chromatin with sequencing (ATAC-Seq) that taurine supplementation has the ability to remodel the chromatin landscape to increase the chromatin accessibility and transcription of genes, such as glucose-6-phosphate isomerase 1 (Gpi1), that are critical for NST. Taken together, our studies highlight a potential mechanism for taurine in the activation of NST that can be leveraged toward the treatment of obesity and metabolic disease.
Quercetin selectively reduces expanded repeat RNA levels in models of myotonic dystrophy
Authors: Mishra Subodh K. , Hicks Sawyer M. , Frias Jesus A. , Vangaveti Sweta , Nakamori Masayuki , Cleary John D. , Reddy Kaalak , Berglund J. Andrew
Published: February 2023

Myotonic dystrophy is a multisystemic neuromuscular disease caused by either a CTG repeat expansion inDMPK(DM1) or a CCTG repeat expansion inCNBP(DM2). Transcription of the expanded alleles produces toxic gain-of-function RNA that sequester the MBNL family of alternative splicing regulators into ribonuclear foci, leading to pathogenic mis-splicing. There are currently no approved treatments that target the root cause of disease which is the production of the toxic expansion RNA molecules. In this study, using our previously established HeLa DM1 repeat selective screening platform, we identified the natural product quercetin as a selective modulator of toxic RNA levels. Quercetin treatment selectively reduced toxic RNA levels and rescued MBNL dependent mis-splicing in DM1 and DM2 patient derived cell lines and in theHSALRtransgenic DM1 mouse model where rescue of myotonia was also observed. Based on our data and its safety profile for use in humans, we have identified quercetin as a priority disease-targeting therapeutic lead for clinical evaluation for the treatment of DM1 and DM2.

One Sentence Summary

The natural product quercetin reduces toxic RNA in myotonic dystrophy.