Search this website

Recent Research Articles from JPS Health Network

Immediate Teeth in Fibulas: Expanded Clinical Applications and Surgical Technique

Mon, 05/24/2021 - 05:00

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.

PMID:34029526 | DOI:10.1016/j.joms.2021.04.005

A Simplified Comorbidity Evaluation Predicting Clinical Outcomes Among Patients With Coronavirus Disease 2019

Wed, 05/19/2021 - 05:00

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.

PMID:34007362 | PMC:PMC8110217 | DOI:10.14740/jocmr4476

Role of HEART score in evaluating clinical outcomes among emergency department patients with different ethnicities

Fri, 04/30/2021 - 05:00

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.

PMID:33926275 | DOI:10.1177/03000605211010638

A case of toxic transdermal absorption of isopropyl alcohol with falsely elevated creatinine

Tue, 04/27/2021 - 05:00

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.

PMID:33902960 | DOI:10.1016/j.ajem.2021.04.032

Assessing the cone of economy in patients with spinal disease using only a force plate: an observational retrospective cohort study

Tue, 04/20/2021 - 05:00

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.

PMID:33877453 | DOI:10.1007/s00586-021-06836-x

Association between burnout and wellness culture among emergency medicine providers

Mon, 04/12/2021 - 05:00

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.

PMID:33845524 | DOI:10.15441/ceem.20.074

Prescription Opioid Use Among a Community Sample of Older and Younger Women

Wed, 04/07/2021 - 05:00

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.

PMID:33826866 | DOI:10.1089/jwh.2020.8610

Suicide risk and perceived burden among adult medical inpatients

Sat, 04/03/2021 - 05:00

Gen Hosp Psychiatry. 2021 Jan 20:S0163-8343(21)00011-6. doi: 10.1016/j.genhosppsych.2021.01.007. Online ahead of print.


PMID:33810884 | DOI:10.1016/j.genhosppsych.2021.01.007

Community Disparities in Out of Hospital Cardiac Arrest Care and Outcomes in Texas

Fri, 04/02/2021 - 05:00

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.

PMID:33798624 | DOI:10.1016/j.resuscitation.2021.03.021


Fri, 04/02/2021 - 05:00

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.

PMID:33797485 | DOI:10.1097/TA.0000000000003173

Community Variations in Out-of-Hospital Cardiac Arrest Care and Outcomes in Texas

Mon, 03/29/2021 - 05:00

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.

PMID:33779479 | DOI:10.1080/10903127.2021.1907007

Neurocognitive effects associated with proprotein convertase subtilisin-kexin type 9 inhibitor use: a narrative review

Thu, 03/25/2021 - 05:00

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.

PMID:33763200 | PMC:PMC7944525 | DOI:10.1177/2042098620959271

What do we mean, 'necessary'?-Achieving balance and recognizing limits in primary healthcare and universal healthcare

Wed, 03/24/2021 - 05:00

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.

PMID:33760312 | DOI:10.1111/jep.13545

Financial constraints on genetic counseling and further risk-management decisions among U.S. women at elevated breast cancer risk

Mon, 03/22/2021 - 05:00

J Genet Couns. 2021 Mar 21. doi: 10.1002/jgc4.1413. Online ahead of print.


Clinical guidelines recommend that women at high risk of breast cancer should consider various risk-management options, which remain widely underutilized. We conducted semi-structured, qualitative interviews with 50 high-risk women to understand how financial constraints affect use of genetic counseling, genetic testing, and further risk-management decisions. Inductive analyses revealed three categories of health-related financial constraint: (a) lack of insurance, (b) underinsurance, and (c) other financial constraints (e.g., medical debt, raising children, managing comorbidities). Various breast cancer risk-management actions were limited by these financial constraints, including genetic counseling, genetic testing, enhanced screening, and prophylactic surgeries. Women's narratives also identified complex relationships between financial constraint and perceptions of healthcare providers and insurance companies, particularly as related to bias, price transparency, and potential genetic discrimination. Results from this study have implications for further research and expansion of genetic counseling services delivery to more economically and racially diverse women.

PMID:33749063 | DOI:10.1002/jgc4.1413

Plantar Fasciitis/Fasciosis

Mon, 03/22/2021 - 05:00

Clin Podiatr Med Surg. 2021 Apr;38(2):193-200. doi: 10.1016/j.cpm.2020.12.005. Epub 2021 Feb 13.


Many randomized controlled trials demonstrate the effectiveness of conservative treatment of plantar fasciitis. Patients with acute plantar fasciitis generally respond to treatment more rapidly and more predictably than patients with chronic plantar fasciitis. If conservative treatment fails, endoscopic plantar fasciotomy offers patients a more prompt return to activity compared with open procedures.

PMID:33745651 | DOI:10.1016/j.cpm.2020.12.005

Adverse drug reactions in the era of COVID-19

Sat, 03/13/2021 - 05:00

Intern Emerg Med. 2021 Mar 13. doi: 10.1007/s11739-020-02603-w. Online ahead of print.


PMID:33713283 | DOI:10.1007/s11739-020-02603-w

Intraosseous versus intravenous vascular access during cardiopulmonary resuscitation for out-of-hospital cardiac arrest: a systematic review and meta-analysis of observational studies

Tue, 03/09/2021 - 05:00

Scand J Trauma Resusc Emerg Med. 2021 Mar 8;29(1):44. doi: 10.1186/s13049-021-00858-6.


INTRODUCTION: This study is aimed to investigate the association of intraosseous (IO) versus intravenous (IV) route during cardiopulmonary resuscitation (CPR) with outcomes after out-of-hospital cardiac arrest (OHCA).

METHODS: We systematically searched PubMed, Embase, Cochrane Library and Web of Science from the database inception through April 2020. Our search strings included designed keywords for two concepts, i.e. vascular access and cardiac arrest. There were no limitations implemented in the search strategy. We selected studies comparing IO versus IV access in neurological or survival outcomes after OHCA. Favourable neurological outcome at hospital discharge was pre-specified as the primary outcome. We pooled the effect estimates in random-effects models and quantified the heterogeneity by the I2 statistics. Time to intervention, defined as time interval from call for emergency medical services to establishing vascular access or administering medications, was hypothesized to be a potential outcome moderator and examined in subgroup analysis with meta-regression.

RESULTS: Nine retrospective observational studies involving 111,746 adult OHCA patients were included. Most studies were rated as high quality according to Newcastle-Ottawa Scale. The pooled results demonstrated no significant association between types of vascular access and the primary outcome (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.27-1.33; I2, 95%). In subgroup analysis, time to intervention was noted to be positively associated with the pooled OR of achieving the primary outcome (OR: 3.95, 95% CI, 1.42-11.02, p: 0.02). That is, when the studies not accounting for the variable of "time to intervention" in the statistical analysis were pooled together, the meta-analytic results between IO access and favourable outcomes would be biased toward inverse association. No obvious publication bias was detected by the funnel plot.

CONCLUSIONS: The meta-analysis revealed no significant association between types of vascular access and neurological outcomes at hospital discharge among OHCA patients. Time to intervention was identified to be an important outcome moderator in this meta-analysis of observation studies. These results call for the need for future clinical trials to investigate the unbiased effect of IO use on OHCA CPR.

PMID:33685486 | DOI:10.1186/s13049-021-00858-6

Nephrotoxicity and antibiotics

Wed, 03/03/2021 - 05:00

Intern Emerg Med. 2021 Mar 3. doi: 10.1007/s11739-021-02673-4. Online ahead of print.


PMID:33656684 | DOI:10.1007/s11739-021-02673-4

Approach to Formalized Ultrasound Credentialing in a Community Hospital Health System with both Academic and Non-Academic Clinical Settings

Wed, 03/03/2021 - 05:00

Spartan Med Res J. 2020 Jun 8;5(1):12748.


INTRODUCTION: In the US, ultrasound in Emergency Medicine (EM) is widely considered the standard of care in clinical practice amongst most Emergency Department providers. At the authors' institution and affiliates, there were a variety of health care providers utilizing ultrasound for clinical practice, and their skill levels varied, dependent on training and exposure. As an attempt to standardize credentialing practice and determine need for additional training thresholds, the authors endeavored to perform a skills assessment utilizing both written and clinical based practical assessments.

METHODS: A 7 point questionnaire was administered to a convenience sample of providers requesting formal training information, number of ultrasounds performed, and self-assessed competency. A 10 point written assessment with ultrasound knowledge and clinical application questions was also administered. A subsequent clinical assessment on live humans and models was then performed with multiple stations assessing 15 different instrumentation skills and technique, as well as image interpretation and evaluation.

RESULTS: A total of 23 attending EM board-certified physicians, and four advanced practice providers (PA and NP) took the credentialing assessments scoring an average of 7.3 out of 10 (SD 0.83) for the written assessment. Twenty (71%) of the 28 tested passed the clinical evaluation on their initial attempt. Five (17%) passed on a first remediation. Three (10%) required more than one initial revision attempt. All those who did remediate were able to complete the revision with a passing score.

CONCLUSIONS: Overall, the testing was considered a successful process. This program appears to have offered a level of standardization that was appealing to the credentialing body at our institution. We were able to assess to a level of competence considered standard of care by national credentialing bodies.

PMID:33655179 | PMC:PMC7746098

A slow-growing anterior maxillary mass

Mon, 03/01/2021 - 05:00

Oral Surg Oral Med Oral Pathol Oral Radiol. 2021 Jan 29:S2212-4403(21)00068-7. doi: 10.1016/j.oooo.2021.01.021. Online ahead of print.


A 43-year-old-male with no medical conditions presented to his dentist with a left maxillary swelling present for 1 year. His physical exam revealed a 2-cm × 2-cm, poorly demarcated, firm mass in the left anterior maxilla causing mobility of the associated teeth. He had a bluish discoloration of the anterior maxillary mucosa. A computed tomographic scan demonstrated a homogeneous and uniformly radiolucent, well-defined mass in the left anterior maxilla primarily involving the alveolus and the roots of teeth 7-12. The mass caused expansion and tooth displacement. An incisional biopsy was done and MUC 4 staining was diffusely positive so the diagnosis of low-grade fibromyxoid sarcoma (LGFMS) was made. He underwent wide local excision and reconstruction with a fibula free flap and a three-dimensionally printed, implant-retained prosthesis. The final pathology confirmed the diagnosis of LGFMS, stage pT4aN0M0, with negative margins. The patient had no evidence of recurrence at 1-year follow-up.

PMID:33642230 | DOI:10.1016/j.oooo.2021.01.021