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Recent Research Articles from JPS Health Network
Diabetes as a Risk Factor for Orthopedic Implant Surface Performance: A Retrieval and <em>In Vitro</em> Study
J Bio Tribocorros. 2021 Jun;7(2):51. doi: 10.1007/s40735-021-00486-8. Epub 2021 Feb 22.
Orthopedic devices are often associated with increased risk for diabetic patients due to impaired wound healing capabilities. Adverse biological responses for immunocompromised patients at the implant-tissue interface can lead to significant bone resorption that may increase failure rates. The goal of this study was to characterize the surface of implants removed from diabetic patients to determine underlying mechanisms of diabetes-induced impaired osseointegration. Thirty-nine retrieved titanium and stainless-steel orthopedic devices were obtained from diabetic and non-diabetic patients, and compared to non-implanted controls. Optical Microscopy, Scanning Electron Microscopy, Energy Dispersive X-ray Spectroscopy, and X-ray Photoelectron Spectroscopy revealed changes in morphology, chemical composition, oxidation state, and oxide thickness of the retrieval specimens, respectively. Additionally, titanium disks were immersed for 28 days in simulated in vitro diabetic conditions followed by Inductively Coupled Plasma-Optical Emission Spectroscopy to quantify metal dissolution. Electrochemical testing was performed on specimens from retrievals and in vitro study. Aside from biological deposits, retrievals demonstrated surface discoloration, pit-like formations and oxide thinning when compared to non-implanted controls, suggesting exposure to unfavorable acidic conditions. Cyclic load bearing areas on fracture-fixation screws and plates depicted cracking and delamination. The corrosion behavior was not significantly different between diabetic and non-diabetic conditions of immersed disks or implant type. However, simulated diabetic conditions elevated aluminum release. This elucidates orthopedic implant failures that potentially arise from diabetic environments at the implant-tissue interface. Design of new implant surfaces should consider specific strategies to induce constructive healing responses in immunocompromised patients while also mitigating corrosion in acidic diabetic environments.
Monotherapy Anticoagulation to Expedite Home Treatment of Patients Diagnosed With Venous Thromboembolism in the Emergency Department: A Pragmatic Effectiveness Trial
Circ Cardiovasc Qual Outcomes. 2021 Jun 21:CIRCOUTCOMES120007600. doi: 10.1161/CIRCOUTCOMES.120.007600. Online ahead of print.
BACKGROUND: The objective was to test if low-risk emergency department patients with vitamin K antagonist (venous thromboembolism [VTE]; including venous thrombosis and pulmonary embolism [PE]) can be safely and effectively treated at home with direct acting oral (monotherapy) anticoagulation in a large-scale, real-world pragmatic effectiveness trial.
METHODS: This was a single-arm trial, conducted from 2016 to 2019 in accordance with the Standards for Reporting Implementation Studies guideline in 33 emergency departments in the United States. Participants had newly diagnosed VTE with low risk of death based upon either the modified Hestia criteria, or physician judgment plus the simplified PE severity index score of zero, together with nonhigh bleeding risk were eligible. Patients had to be discharged within 24 hours of triage and treated with either apixaban or rivaroxaban. Effectiveness was defined by the primary efficacy and safety outcomes, image-proven recurrent VTE and bleeding requiring hospitalization >24 hours, respectively, with an upper limit of the 95% CI for the 30-day frequency of VTE recurrence below 2.0% for both outcomes.
RESULTS: We enrolled 1421 patients with complete outcomes data, including 903 with venous thrombosis and 518 with PE. The recurrent VTE requiring hospitalization occurred in 14/1421 (1.0% [95% CI, 0.5%-1.7%]), and bleeding requiring hospitalization occurred in 12/1421 (0.8% [0.4%-1.5%). The rate of severe bleeding using International Society for Thrombosis and Haemostasis criteria was 2/1421 (0.1% [0%-0.5%]). No patient died, and serious adverse events occurred in 2.5% of venous thrombosis patients and 2.3% of patients with PE. Medication nonadherence was reported by patients in 8.0% (6.6%-9.5%) and was associated with a risk ratio of 6.0 (2.3-15.2) for VTE recurrence. Among all patients diagnosed with VTE in the emergency department during the period of study, 18% of venous thrombosis patients and 10% of patients with PE were enrolled.
CONCLUSIONS: Monotherapy treatment of low-risk patients with venous thrombosis or PE in the emergency department setting produced a low rate of bleeding and VTE recurrence, but may be underused. Patients with venous thrombosis and PE should undergo risk-stratification before home treatment. Improved patient adherence may reduce rate of recurrent VTE.
REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03404635.
JBJS Case Connect. 2021 Jun 15;11(2). doi: 10.2106/JBJS.CC.20.00778.
CASE: A 29-year-old man presented with a displaced medial clavicle fracture. Surgical repair was performed using a precontoured plate designed for the contralateral distal clavicle, and medial fixation was accomplished at the sternum. The patient had no complications and demonstrated full strength and range of motion at the 8-month follow-up.
CONCLUSION: Medial clavicle fractures with a small medial fragment can be immobilized using a plate designed for the contralateral distal clavicle that crosses the sternoclavicular joint to obtain medial fixation in the sternum. This technique may provide a viable treatment modality for this unique fracture pattern.
Oral Maxillofac Surg Clin North Am. 2021 Jun 8:S1042-3699(21)00037-6. doi: 10.1016/j.coms.2021.04.008. Online ahead of print.
Although a rare sequala of soft tissue injury, salivary gland trauma may result in significant morbidity. Salivary gland injury can involve the major as well as the minor glands. Because of the proximity of adjacent vital structures, a thorough history and physical examination are mandatory during patient evaluation. Trauma to the major salivary glands may involve the parenchyma, duct, or neural injury. Treatment requires adherence to primary principles of soft tissue management. Ductal and neural injury should be repaired primarily. Sialocele and fistula are potential complications of repaired and unrepaired salivary gland injury.
Pharmacological and Non-Pharmacological Methods of Post-Operative Pain Control Following Oral and Maxillofacial Surgery: A Scoping Review
J Oral Maxillofac Surg. 2021 Apr 29:S0278-2391(21)00408-0. doi: 10.1016/j.joms.2021.04.022. Online ahead of print.
PURPOSE: To conduct a scoping review regarding current pharmacological and non-pharmacological methods of post-operative pain control following oral and maxillofacial surgery.
MATERIALS AND METHODS: PubMed was used to conduct research for this study. Identification criteria included surgery: patients undergoing the extraction of third molars; therapy: pharmacological or non-pharmacological methods; and outcomes: post-operative pain control. The search included full-text RCTs published after October 13, 2014, that were electronically accessible on PubMed and in the English language. After assessing quality, a scoping review was performed.
RESULTS: 35 RCTs were evaluated, which included a total of 3791 subjects. The studies evaluated patients' post-operative pain by either utilizing a visual analogue scale (VAS), measuring the time between surgery and when rescue analgesics were used, measuring the amount of rescue analgesics used, or by distributing questionnaires.
CONCLUSION: COX-2 inhibitors may provide greater analgesic effects compared to traditional nonsteroidal anti-inflammatory drugs (NSAIDs). Additionally, although the supplementation of an opioid analgesic to a NSAID regimen provides an increase in pain control, it does not further reduce pain levels in a patient alternating between ibuprofen and acetaminophen. Other methods of post-operative pain control mentioned in this review should be further explored in studies that contain larger sample sizes and that evaluate side effects of the treatment.
Augmented Renal Clearance Following Traumatic Injury in Critically Ill Patients Requiring Nutrition Therapy
Nutrients. 2021 May 15;13(5):1681. doi: 10.3390/nu13051681.
The intent of this study was to ascertain the prevalence of augmented renal clearance (ARC) in patients with traumatic injuries who require nutrition therapy and identify factors associated with ARC. Adult patients admitted to the trauma intensive care unit from January 2015 to September 2016 who received enteral or parenteral nutrition therapy and had a 24 h urine collection within 4 to 14 days after injury were retrospectively evaluated. Patients with a serum creatinine concentration > 1.5 mg/dL, required dialysis, or had an incomplete urine collection were excluded. ARC was defined as a measured creatinine clearance > 149 mL/min/1.73 m2. Two hundred and three patients were evaluated. One hundred and two (50%) exhibited ARC. A greater proportion of patients with ARC were male (86% vs. 67%; p = 0.004), had traumatic brain injury (33% vs. 9%; p = 0.001), a higher injury severity score (30 ± 11 vs. 26 ± 12; p = 0.015), were younger (36 ± 15 vs. 54 ± 17 years; p = 0.001), had a lower serum creatinine concentration (0.7 ± 2 vs. 0.9 ± 0.2 mg/dL; p = 0.001) and were more catabolic (nitrogen balance of -10.8 ± 13.0 vs. -6.2 ± 9.2 g/d; p = 0.004). The multivariate analysis revealed African American race and protein intake were also associated with ARC. Half of critically ill patients with traumatic injuries experience ARC. Patients with multiple risk factors for ARC should be closely evaluated for dosing of renally-eliminated electrolytes, nutrients, and medications.
Tech Hand Up Extrem Surg. 2021 May 27. doi: 10.1097/BTH.0000000000000358. Online ahead of print.
Ray amputations of the hand are procedures performed for traumatic injuries, infection, neoplasm, and certain deformities. When performed for the central digits, the gap created between the remaining digits can significantly impact hand function. Multiple deep transverse metacarpal ligament reconstruction techniques and bone transposition have been described to address this issue. The purpose of this case series is to describe a novel technique utilizing a knotless suture anchor reconstruction of the deep transverse metacarpal ligament after central digit ray amputation. We present a novel knotless suture anchor reconstruction technique through a single incision which allowed for an immediate range of motion. We present 2 cases where this technique was utilized with satisfactory cosmetic and functional outcomes. Knotless webspace reconstruction for central metacarpal ray resection reconstruction is technically simple and allowed for immediate motion with satisfactory cosmetic and functional patient outcomes. Level of Evidence: Level IV-therapeutic.
J Oral Maxillofac Surg. 2021 Apr 19:S0278-2391(21)00326-8. doi: 10.1016/j.joms.2021.04.005. Online ahead of print.
PURPOSE: The placement of immediate implants and teeth during jaw reconstruction using a fibula free flap has increased in recent years. Modifications of traditional fibula reconstructive techniques are needed to maximize success. This technique has not been described in patients requiring simultaneous soft tissue reconstruction. Our patient cohort includes cases with malignant pathology and those requiring skin paddles. With digital workflows and point-of-care 3D printing, surgery is no longer delayed weeks for prosthesis fabrication. The purpose of this case series is to demonstrate a single institution's experience with expanded clinical applications and surgical techniques that enable predictable outcomes for immediate teeth in fibula flaps.
MATERIALS AND METHODS: Ninety-five implants were placed in 22 patients undergoing fibula reconstruction of the jaw with immediate implants and an immediate dental prosthesis. Skin paddles were used in 10 patients while 12 patients had native mucosa. Six patients were treated for malignancies and underwent postoperative radiation. Implant success and complications were compared between implants with skin paddles and implants with native mucosa.
RESULTS: Of 95 implants, 92 implants integrated for a 97% integration rate. All 13 radiated implants in 4 patients integrated. All 36 implants adjacent to skin paddles in 10 patients integrated. Seven implants were lost in a delayed fashion 9 to 15 months postoperatively resulting in a 93% overall implant success rate. Of the 22 patients, diagnoses were benign pathology for 11 patients, malignant pathology for 6 patients, gunshot wounds for 3 patients, and osteoradionecrosis for 2 patients.
CONCLUSION: Immediate placement of dental prostheses on immediate implants during fibula reconstruction of the jaws can be performed with a high rate of predictability. This technique can be expanded to select patients needing skin paddles. Modifications of traditional fibula reconstructive techniques are helpful to minimize soft tissue and prosthetic challenges.
A Simplified Comorbidity Evaluation Predicting Clinical Outcomes Among Patients With Coronavirus Disease 2019
J Clin Med Res. 2021 Apr;13(4):237-244. doi: 10.14740/jocmr4476. Epub 2021 Apr 27.
BACKGROUND: Patients with coronavirus disease 2019 (COVID-19) have shown a range of clinical outcomes. Previous studies have reported that patient comorbidities are predictive of worse clinical outcomes, especially when patients have multiple chronic diseases. We aim to: 1) derive a simplified comorbidity evaluation and determine its accuracy of predicting clinical outcomes (i.e., hospital admission, intensive care unit (ICU) admission, ventilation, and in-hospital mortality); and 2) determine its performance accuracy in comparison to well-established comorbidity indexes.
METHODS: This was a single-center retrospective observational study. We enrolled all emergency department (ED) patients with COVID-19 from March 1, 2020, to December 31, 2020. A simplified comorbidity evaluation (COVID-related high-risk chronic condition (CCC)) was derived to predict different clinical outcomes using multivariate logistic regressions. In addition, chronic diseases included in the Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI) were scored, and its accuracy of predicting COVID-19 clinical outcomes was also compared with the CCC.
RESULTS: Data were retrieved from 90,549 ED patient visits during the study period, among which 3,864 patients were COVID-19 positive. Forty-seven point nine percent (1,851/3,864) were admitted to the hospital, 9.4% (364) patients were admitted to the ICU, 6.2% (238) received invasive mechanical ventilation, and 4.6% (177) patients died in the hospital. The CCC evaluation correlated well with the four studied clinical outcomes. The adjusted odds ratios of predicting in-hospital death from CCC was 2.84 (95% confidence interval (CI): 1.81 - 4.45, P < 0.001). C-statistics of CCC predicting in-hospital all-cause mortality was 0.73 (0.69 - 0.76), similar to those of the CCI's (0.72) and ECI's (0.71, P = 0.0513).
CONCLUSIONS: CCC can accurately predict clinical outcomes among patients with COVID-19. Its performance accuracies for such predictions are not inferior to those of the CCI or ECI's.
Role of HEART score in evaluating clinical outcomes among emergency department patients with different ethnicities
J Int Med Res. 2021 Apr;49(4):3000605211010638. doi: 10.1177/03000605211010638.
OBJECTIVE: We aimed to examine the role of the HEART (history, EKG, age, risk factors, and troponin) score in the evaluation of six clinical outcomes among three groups of patients in the emergency department (ED).
METHODS: We performed a retrospective observational study among three ED patient groups including White, Black, and Hispanic patients. ED providers used the HEART score to assess the need for patient hospital admission and for emergent cardiac imaging tests (CITs). HEART scores were measured using classification accuracy rates. Performance accuracies were measured in terms of HEART score in relation to four clinical outcomes (positive findings of CITs, ED returns, hospital readmissions, and 30-day major adverse cardiac events [MACE]).
RESULTS: A high classification accuracy rate (87%) was found for use of the HEART score to determine hospital admission. HEART scores showed moderate accuracy (area under the receiver operating characteristic curve 0.66-0.78) in predicting results of emergent CITs, 30-day hospital readmissions, and 30-day MACE outcomes.
CONCLUSIONS: Providers adhered to use of the HEART score to determine hospital admission. The HEART score may be associated with emergent CIT findings, 30-day hospital readmissions, and 30-day MACE outcomes, with no differences among White, Black, and Hispanic patient populations.
Am J Emerg Med. 2021 Apr 18:S0735-6757(21)00318-1. doi: 10.1016/j.ajem.2021.04.032. Online ahead of print.
Transdermal absorption of isopropyl alcohol (IPA) can cause toxicity at high doses, but case reports of this phenomenon are limited. This is a single patient encounter and chart review describing a 33-year-old previously healthy female who presented obtunded, wrapped in IPA soaked round cotton pads with overlying shrink wrap, her family's home remedy for a mild persistent rash. This case highlights several interesting aspects of IPA toxicity, including evidence that toxic doses of IPA are possible through transdermal absorption and creatinine may be falsely elevated due to acetone's interference with the measurement of creatinine on some assays.
Assessing the cone of economy in patients with spinal disease using only a force plate: an observational retrospective cohort study
Eur Spine J. 2021 Apr 20. doi: 10.1007/s00586-021-06836-x. Online ahead of print.
STUDY DESIGN: This is a retrospective cohort with multiple regression modeling.
OBJECTIVE: The aim is to develop a new method for estimating cone of economy (CoE) using a force plate rather than traditional motion capture.
BACKGROUND: Currently, most spinal deformity surgeons rely on static radiographic parameters for alignment, balance, and outcomes data alongside patient-reported outcome measures. The CoE, the stable region of upright posture, can be objectively measured to determine the efficiency and balance of the spine. Motion capture technology is currently used to collect data to calculate CoE, but this requires expensive and complex equipment, which is a barrier to widespread adoption and clinical use of CoE measurements. Force plates, which measure pressure, are less expensive and can be used in a clinical setting.
METHODS: Motion capture and a force plate were used to quantify the CoE of 473 subjects (423 spinal surgical candidates; 50 healthy controls; 271 females; age: 58.60 ± 15.27; height: 1.69 ± 0.13; weight: 81.07 ± 20.91), and a linear multiple regression model was used to predict CoE using force plate data in a human motion laboratory setting. Patients were required to stand erect with feet together and eyes open in their self-perceived balanced and natural position for a full minute while measures of sway and center of pressure (CoP) were recorded.
RESULTS: The CoP variable regression model successfully predicted CoE measurements. The variables that were used to predict vertical CoE were CoP coronal sway, CoP sagittal sway, and CoP total sway in several combinations. The coefficient of determination for the head total sway model indicated a 87.0% correlation (F(3,469) = 1044.14, p < 0.001). The coefficient of determination for the head sagittal sway model indicated a 69.2% correlation (F(3,469) = 351.70, p < 0.001). The coefficient of determination for the head coronal sway model indicated a 85.2% correlation (F(3,469) = 899.27, p < 0001).
CONCLUSION: Cone of economy was estimated from force plate data using center of pressure with high correlation without the use of motion capture in healthy controls and a variety of spine patients. This could lower the entry burden for measurement of the CoE in patients, enabling widespread use. This would provide surgeons objective global balance data, along with Haddas' CoE classification system, that could assist with surgical decision-making and facilitate objective monitoring surgical outcomes.
Clin Exp Emerg Med. 2021 Mar;8(1):55-64. doi: 10.15441/ceem.20.074. Epub 2021 Mar 31.
OBJECTIVE: Burnout is a common occurrence among healthcare providers and has been associated with provider wellness culture. However, this association has not been extensively studied among emergency medicine (EM) providers. We aim to determine the association between EM provider burnout and their culture of wellness, and to elicit the independent wellness culture domains most predictive of burnout prevention.
METHODS: This was a multi-center observational study. We enrolled EM physicians and advanced practice providers from sixteen different emergency departments (EDs). Provider wellness culture and burnout surveys were performed. The wellness culture domains included in this study are personal/organizational value alignment, provider appreciation, leadership quality, self-controlled scheduling, peer support, and family support. Correlations between each wellness culture domain and burnout were analyzed by Pearson correlation co-efficiency, and their associations were measured by multivariate logistic regression with adjustments of other confounders.
RESULTS: A total of 242 ED provider surveys were entered for final analysis. The overall burnout rate was 54% (130/242). Moderate correlations were found between burnout and two wellness culture domains (value alignment: r=-0.43, P<0.001 and provider appreciation: r=-0.49, P<0.001). The adjusted odds ratio of provider appreciation associated with burnout was 0.44 (95% confidence interval, 0.25-0.77; P=0.004), adjusted odds ratio of family support was 0.67 (95% confidence interval, 0.48-0.95; P=0.025).
CONCLUSION: ED providers have a relatively high burnout rate. Provider burnout might have certain associations with wellness culture domains. Provider appreciation and family support seem to play important roles in burnout protection.
J Womens Health (Larchmt). 2021 Apr 7. doi: 10.1089/jwh.2020.8610. Online ahead of print.
Background: Women bear a heavier burden of the consequences related to prescription opioid use compared to their male counterparts; however, there has been little attention in the literature regarding prescription opioid use among women. We aimed to examine risk factors for prescription opioid use among women. Methods: Demographics, health status, and substance use data, including prescription opioid use, were collected through a community engagement program, HealthStreet, during a health needs assessment. Women older than 18 years were classified by opioid use: past 30-day, lifetime, but not past 30-day, or no lifetime prescription opioid use. Descriptive statistics and chi-square tests were calculated, and multinomial logistic regression was used to calculate adjusted odds ratios (aORs; confidence interval [CI]). Results: Among 5,549 women assessed, 15% reported past 30-day use and 41% reported lifetime use of prescription opioids. While prescription sedative use was the strongest risk factor for past 30-day use among younger women (aOR = 4.84; 95% CI, 3.59-6.51), past 6-month doctor visits was the strongest risk factor for past 30-day use among older women (aOR = 4.15; 95% CI, 2.62-6.60). Conclusions: We found higher rates of prescription opioid use in this community sample of women compared to national rates. Risk factors for recent prescription opioid use (past 30-day use) differed among older and younger women. Clinicians should be more vigilant about prescribing opioids as the medical profile for women may change through age, especially the co-prescribing of opioids and sedatives.
Resuscitation. 2021 Mar 30:S0300-9572(21)00125-8. doi: 10.1016/j.resuscitation.2021.03.021. Online ahead of print.
BACKGROUND: Large racial and socioeconomic inequalities exist for out-of-hospital cardiac arrest (OHCA) care and outcomes. We sought to characterize racial, ethnic, and socioeconomic disparities in OHCA care and outcomes in Texas.
METHODS: We analyzed 2014-2018 Texas-Cardiac Arrest Registry to Enhance Survival (CARES) data. Using census tracts, we defined race/ethnicity neighborhoods based on majority race/ethnicity composition: non-Hispanic/Latino white, non-Hispanic/Latino black, and Hispanic/Latino. We also stratified neighborhoods into socioeconomic categories: above and below the median for household income, employment rate, and high school graduation. We defined outcomes as bystander CPR rates, public bystander AED use, and survival to hospital discharge. Using mixed models, we analyzed the associations between outcomes and neighborhood (1) racial/ethnic categories and (2) socioeconomic categories.
RESULTS: We included data on 18,488 OHCAs. Relative to white neighborhoods, black neighborhoods had lower rates of AED use (OR 0.3, CI 0.2-0.4), and Hispanic/Latino neighborhoods had lower rates of bystander CPR (OR 0.7, CI 0.6-0.8), AED use (OR 0.4, CI 0.3-0.6), and survival (OR 0.8, CI 0.7-0.8). Lower income was associated with a lower rates of bystander CPR (OR 0.8, CI 0.7-0.8), AED use (OR 0.5, CI 0.4-0.8), and survival (OR 0.9, CI 0.9-0.98). Lower high school graduation was associated with a lower rate of bystander CPR (OR 0.8, CI 0.7-0.9) and AED use (OR 0.6, CI 0.4-0.9). Higher unemployment was associated with lower rates of bystander CPR (OR 0.9, CI 0.8-0.94) and AED use (OR 0.7, CI 0.5-0.99).
CONCLUSION: Minority and poor neighborhoods in Texas experience large and unacceptable disparities in OHCA bystander response and outcomes.
J Trauma Acute Care Surg. 2021 Mar 12. doi: 10.1097/TA.0000000000003173. Online ahead of print.
BACKGROUND: Prehospital plasma transfusion in trauma reduces mortality. However, the underlying mechanism remains unclear. Reduction in shock severity may play a role. Lactate correlates with physiologic shock severity and mortality after injury. Our objective was to determine if prehospital plasma reduces lactate, and if this contributes to the mortality benefit of plasma.
METHODS: Patients in the Prehospital Air Medical Plasma trial in the upper quartile of injury severity (ISS>30) were included to capture severe shock. Trial patients were randomized to prehospital plasma or standard care resuscitation (crystalloid +/- PRBC). Regression determined the associations between admission lactate, 30-day mortality, and plasma while adjusting for demographics, prehospital crystalloid, time, mechanism, and injury characteristics. Causal mediation analysis determined what proportion of the effect of plasma on mortality is mediated by lactate reduction.
RESULTS: 125 patients were included. The plasma group had a lower adjusted admission lactate than standard of care group (coeff -1.64; 95%CI -2.96, -0.31, p=0.02). Plasma was associated with lower odds of 30-day mortality (OR 0.27; 95%CI 0.08-0.90, p=0.03). When adding lactate to this model, the effect of plasma on 30-day mortality was no longer significant (OR 0.36; 95%CI 0.07-1.88, p=0.23), while lactate was associated with mortality (OR 1.74 per 1mmol/L increase; 95%CI 1.10-2.73, p=0.01). Causal mediation demonstrated 35.1% of the total effect of plasma on 30-day mortality was mediated by the reduction in lactate among plasma patients.
CONCLUSION: Prehospital plasma is associated with reduced 30-day mortality and lactate in severely injured patients. Over one-third of the effect of plasma on mortality is mediated by a reduction in lactate. Thus, reducing the severity of hemorrhagic shock appears to be one mechanism of prehospital plasma benefit. Further study should elucidate other mechanisms and if a dose response exists.
LEVEL OF EVIDENCE: II, therapeutic.
Prehosp Emerg Care. 2021 Mar 29:1-10. doi: 10.1080/10903127.2021.1907007. Online ahead of print.
BackgroundLarge and unacceptable variation exists in cardiac resuscitation care and outcomes across communities. Texas is the second most populous state in the US with wide variation in community and emergency response infrastructure. We utilized the Texas-CARES registry to perform the first Texas state analysis of out-of-hospital cardiac arrest (OHCA) in Texas, evaluating for variations in incidence, care, and outcomes.MethodsWe analyzed the Texas-CARES registry, including all adult, non-traumatic OHCAs from 1/1/2014 through 12/31/2018. We analyzed the incidence and characteristics of OHCA care and outcome, overall and stratified by community. Utilizing mixed models accounting for clustering by community, we characterized variations in bystander CPR, bystander AED in public locations, and survival to hospital discharge across communities, adjusting for age, gender, race, location of arrest, and rate of witnessed arrest (bystander and 911 responder witnessed).ResultsThere were a total of 26,847 (5,369 per year) OHCAs from 13 communities; median 2,762 per community (IQR 444-2,767, min 136, max 9161). Texas care and outcome characteristics were: bystander CPR (43.3%), bystander AED use (9.1%), survival to discharge (9.1%), and survival with good neurological outcomes (4.0%). Bystander CPR rate ranged from 19.2% to 55.0%, and there were five communities above and five below the adjusted 95% confidence interval. Bystander AED use ranged from 0% to 19.5%, and there was one community below the adjusted 95% confidence interval. Survival to hospital discharge ranged from 6.7% to 14.0%, and there were three communities above and two below the adjusted 95% confidence interval.ConclusionWhile overall OHCA care and outcomes were similar in Texas compared to national averages, bystander CPR, bystander AED use, and survival varied widely across communities in Texas. These variations signal opportunities to improve OHCA care and outcomes in Texas.
Neurocognitive effects associated with proprotein convertase subtilisin-kexin type 9 inhibitor use: a narrative review
Ther Adv Drug Saf. 2021 Mar 8;12:2042098620959271. doi: 10.1177/2042098620959271. eCollection 2021.
Neurocognitive adverse events have been observed with the widespread use of 3-hydroxy-3-methylglutaryl-CoA reductase inhibitors or "statins," which reduce low-density lipoprotein cholesterol (LDL-C) levels and subsequently cardiovascular risk. The United States Food and Drug Association directed manufacturers of proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors to monitor for neurocognitive adverse events due to their potent effects on LDL-C reduction, which is a proposed mechanism for neuronal cell dysfunction. Other proposed mechanisms for PCSK9 inhibitor-associated neurocognitive adverse events include N-methyl-d-aspartate receptor modulation, dysregulation of lipid and glucose metabolism, and patient-specific risk factors for cognitive impairment. The purpose of this narrative review article is to describe the proposed mechanisms, incidence of neurocognitive adverse events from phase II and III trials for PCSK9 inhibitors, neurocognitive assessments utilized in clinical trials, and clinical implications. Given the increasing prevalence of PCSK9 inhibitor use and the neurocognitive adverse events observed with prior lipid-lowering therapies, clinicians should be aware of the risks associated with PCSK9 inhibitors, especially when therapy is indicated for patients at high risk for cardiovascular events. Overall, the incidence of PCSK9 inhibitor-associated neurocognitive appears to be uncommon. However, additional prospective studies evaluating cognitive impairment may be beneficial to determine the long-term safety of these agents.
What do we mean, 'necessary'?-Achieving balance and recognizing limits in primary healthcare and universal healthcare
J Eval Clin Pract. 2021 Mar 24. doi: 10.1111/jep.13545. Online ahead of print.
Sturmberg and Martin make a compelling case for primary healthcare (PHC) to be the foundation for universal healthcare (UHC). They state that a system should have necessary resources, but what does that mean? Basic economic theory postulates that all resources are limited and that choices must be made between competing options. For a UHC system to be successful and resilient, it must accept that healthcare is a limited right, there will always be inequalities in healthcare delivery and outcomes, primary care physicians and their teams must accept the added burden of balancing the needs of their personal patients with the greater system, leaders and observers of healthcare systems must accept that moderation and balance will often be the best outcome even though they are difficult to measure, and leaders of healthcare systems must accept that they cannot control the system, but contribute by providing context and limited constraints, information, and resources. A deeper understanding of complex adaptive systems will best guide these necessary changes.