Clinical Outcomes of Early Versus Late Enteral Nutrition Support in Critically Ill Trauma Patients With Isolated Traumatic Brain Injury

INTRODUCTION

This study aims to compare the impact of early initiation of enteral feeding initiation on clinical outcomes in critically ill adult trauma patients with isolated traumatic brain injuries (TBI).

METHODS

A retrospective cohort analysis of the American College of Surgeons Trauma Quality Program Participant Use File 2017-2021 dataset of critically ill adult trauma patients with moderate to severe blunt isolated TBI. Outcomes included ICU length of stay (ICU-LOS), ventilation-free days (VFD), and complication rates. Timing cohorts were defined as very early (<6 hours), early (6-24 hours), intermediate (24-48 hours), and late (>48 hours).

RESULTS

9210 patients were included in the analysis, of which 952 were in the very early enteral feeding initiation group, 652 in the early, 695 in intermediate, and 6938 in the late group. Earlier feeding was associated with significantly shorter ICU-LOS (very early: 7.82 days; early: 11.28; intermediate 12.25; late 17.55; P < .001) and more VFDs (very early: 21.72 days; early: 18.81; intermediate 18.81; late 14.51; P < .001). Patients with late EF had a significantly higher risk of VAP than very early (OR .21, CI 0.12-.38, P < .001) or early EF (OR .33, CI 0.17-.65, P = .001), and higher risk of ARDS than the intermediate group (OR .23, CI 0.05-.925, P = .039).

CONCLUSION

Early enteral feeding in critically ill adult trauma patients with moderate to severe isolated TBI resulted in significantly fewer days in the ICU, more ventilation-free days, and lower odds of VAP and ARDS the sooner enteral feeding was initiated, with the most optimized outcomes within 6 hours.

National Analysis of Clinical Outcomes Associated With Cirrhotic Blunt Trauma Patients Undergoing Emergency Laparotomy Versus Non-operative Management: A Propensity Case-Matched Analysis

INTRODUCTION

This study aims to evaluate clinical outcomes among severely injured trauma patients presenting with isolated blunt abdominal solid organ injuries with a pre-diagnosis of liver cirrhosis (LC) undergoing emergency laparotomy vs nonoperative management (NOM).

METHODS

This retrospective cohort study utilized the American College of Surgeons Trauma Quality Program Participant Use File (ACS-TQIP-PUF) dataset from 2017 to 2021. Adults (≥18 years) with a pre-existing diagnosis of LC who presented with severe blunt (ISS ≥ 16) isolated solid organ abdominal injuries and underwent laparotomy or NOM were included. Outcomes of interest included in-hospital mortality, intensive care unit length of stay (ICU-LOS), and in-hospital complications such as acute renal failure and deep vein thrombosis.

RESULTS

929 patients were included in this analysis, with 355 undergoing laparotomy and 574 managed nonoperatively. Laparotomy patients suffered greater in-hospital mortality (n = 186, 52.3% vs n = 115, 20.0%; P < .01), required significantly more blood within 4 hours (8.9 units vs 4.3 units, P < .01), and had a significantly longer ICU-LOS (10.2 days vs 6.7 days, P < .01). In the 1:1 propensity score matched analysis of 556 matched patients, in-hospital mortality was greater for laparotomy patients (52.3% vs 20.0%, P < .01).

CONCLUSION

Laparotomy was associated with significantly higher in-hospital mortality in propensity-matched trauma patients, longer ICU-LOS, and more blood products given at 4 hours compared to NOM. These findings illustrate that NOM may be a safe approach in managing severely injured trauma patients with isolated blunt abdominal solid organ injuries and a pre-diagnosis of LC.

Clinical Surveillance vs Anticoagulation Therapy for Isolated Subsegmental Pulmonary Embolism: A Systematic Review of Clinical Outcomes

BACKGROUND

This systematic review aims to evaluate and compare differences in clinical outcomes for adult patients diagnosed with ISSPE who were managed with anticoagulation vs clinical surveillance.

METHODS

PubMed, Embase, ProQuest, Cochrane, and Google Scholar were searched to identify studies evaluating the use of anticoagulation and/or clinical surveillance in patients diagnosed with ISSPE. The search included studies published up to August 3, 2023. Outcomes of interest included 90-day recurrent venous thromboembolism (VTE), major bleeding, and all-cause mortality rates.

RESULTS

Ten studies were included with a total of 1224 patients. Of these patients, 791 were treated with anticoagulation and 433 underwent surveillance. Studies found no difference in recurrent VTE rates, with the majority of studies reporting no recurrence. Of the studies that reported VTE recurrence, rates were .5% to 1.4% for the anticoagulation groups and 3.1% to 3.2% for the surveillance groups. Major bleeding rates were also similar. In anticoagulated patients, major bleeding rates ranged from 1% to 10%. In clinical surveillance patients, the majority found no rate of major bleeding, with 2 studies reporting rates of .8% to 3.2%. Mortality rates ranged widely with no significant differences reported.

CONCLUSION

Clinical surveillance appears to be a safe and effective alternative to anticoagulation in patients with ISSPE. Ninety-day rates of recurrent VTE, major bleeding, and mortality were comparable between groups. These findings highlight the need for updated practice management guidelines to improve patient outcomes.

Racial Distribution and Associated Outcomes for Patients With and Without Severe-Isolated Traumatic Brain Injuries Following Venous Thromboembolism Prophylaxis

INTRODUCTION

Disparities in venous thromboembolism (VTE) incidence and prophylaxis have been observed across racial groups. This study investigates the relationship between race, injury type, and the timing of VTE prophylaxis in severe trauma patients, both with and without isolated traumatic brain injuries. The primary goal is to analyze how these factors interact and their potential impact on clinical outcomes.

METHODS

A retrospective cohort study of the American College of Surgeons Trauma Quality Program Participant Use File (ACS-TQIP-PUF) from 2018 to 2021. Patient demographics, injury categories, VTE prophylaxis timing, injury severity, and in-hospital complications were collected. Multivariable regression models explored associations between race, injury type, VTE prophylaxis, and in-hospital mortality. Groups were analyzed by injury profile (isolated TBI vs non-TBI) and then by VTE prophylaxis timing (early ≤24 hours, late >24 hours).

RESULTS

Of 68,504 trauma patients analyzed, the majority were non-Hispanic or Latino (83.3%), White (71.2%), and male (69.6%). Patients receiving late VTE prophylaxis had higher rates of DVT and PE across race groups than patients with early prophylaxis. Logistic regression showed Asian patients with TBI receiving early prophylaxis were significantly more likely to have in-hospital mortality (OR 16.27, CI = 1.11-237.43, P = .04) than other races.

CONCLUSION

Patients who received late prophylaxis had higher VTE rates than early prophylaxis, independent of injury pattern or race. Additionally, assessing the implications of race in early VTE prophylaxis for isolated TBI showed that adult Asian patients had 16 times higher odds of in-hospital mortality compared to other races.

Evaluating the Effectiveness of Trauma-Informed Care Frameworks in Provider Education and the Care of Traumatized Patients

INTRODUCTION

Trauma-informed care (TIC) spans many different health care fields and is essential in promoting the well-being and recovery of traumatized individuals. This review aims to assess the efficacy of TIC frameworks in both educating providers and enhancing care for adult and pediatric patients.

METHODS

A literature search was conducted using PubMed, EMBASE, Proquest, Cochrane, and Google Scholar to identify relevant articles up to September 28, 2023. Studies implementing TIC frameworks in health care settings as a provider education tool or in patient care were included. Studies were further categorized based on adult or pediatric patient populations and relevant outcomes were extracted.

RESULTS

A total of 36 articles were included in this review, evaluating over 7843 providers and patients. When implemented as a provider education tool, TIC frameworks significantly improved provider knowledge, confidence, awareness, and attitudes toward TIC (P < 0.05 to P < 0.001). Trauma screenings and assessments also increased (P < 0.001). When these frameworks were applied in adult patient care, there were positive effects across a multitude of settings, including women's health, intimate partner violence, post-traumatic stress disorder, and inpatient mental health. Findings included reduced depression and anxiety (P < 0.05), increased trauma disclosures (5%-30%), and enhanced mental and physical health (P < 0.001).

CONCLUSIONS

This review underscores the multifaceted effectiveness of TIC frameworks, serving both as a valuable educational resource for providers and as a fundamental approach to patient care. Providers reported increased knowledge and comfort with core trauma principles. Patients were also found to derive benefits from these approaches in a variety of settings. These findings demonstrate the extensive applicability of TIC frameworks and highlight the need for a more comprehensive understanding of their applications and long-term effects.

Evaluating the effectiveness and outcomes associated with direct peritoneal resuscitation in damage control surgery patients with and without hemorrhagic shock

INTRODUCTION

This narrative review aims to evaluate the efficacy of adjunct direct peritoneal resuscitation (DPR) in the treatment of adult damage control surgery (DCS) patients both with and without hemorrhagic shock, and its impact on associated outcomes.

METHODS

PubMed, Google Scholar, EMBASE, ProQuest, and Cochrane were searched for relevant articles published through April 13th, 2023. Studies assessing the utilization of DPR in adult DCS patients were included. Outcomes included time to abdominal closure, intra-abdominal complications, in-hospital mortality, and ICU length of stay (ICU LOS).

RESULTS

Five studies evaluating 437 patients were included. In patients with hemorrhagic shock, DPR was associated with reduced time to abdominal closure (DPR 4.1 days, control 5.9 days, p = 0.002), intra-abdominal complications including abscess formation (DPR 27 %, control 47 %, p = 0.04), and ICU LOS (DPR 8 days, control 11 days, p = 0.004). Findings in patients without hemorrhagic shock were conflicting. Closure times were decreased in one study (DPR 5.9 days, control 7.7 days, p < 0.02) and increased in another study (DPR 3.5 days, control 2.5 days, p = 0.02), intra-abdominal complications were decreased in one study (DPR 27 %, control 47 %, p = 0.04) and similar in another, and ICU LOS was decreased in one study (DPR 17 days, control 24 days, p < 0.002) and increased in another (DPR 13 days, control 11.4 days, p = 0.807).

CONCLUSION

In patients with hemorrhagic shock, adjunct DPR is associated with reduced time to abdominal closure, intra-abdominal complications such as abscesses, fistula, bleeding, anastomotic leak, and ICU LOS. Utilization of DPR in patients without hemorrhagic shock showed promising but inconsistent findings.

Enhancing safety & reducing fatalities in U.S. national parks: An evaluation of injury trends and policy implications in the ten most visited parks

INTRODUCTION

National parks in the United States experience a significant number of annual visits, and with increasing popularity, injuries are expected to rise. This study aims to assess fatal injuries in the top ten most visited U.S. national parks from 2013 to 2022 to improve current policies and develop effective prevention strategies.

METHODS

A cross-sectional study was conducted using public National Park Service data. Data including visitor demographics, injury cause, and location, were collected. Fatal injuries were categorized by season, age group, and gender.

RESULTS

Summer had the highest total number of fatal injuries. The winter season had the highest rate of fatal injuries per 10 million visitors. The number of fatal injuries per 10 million visitors decreased from 2013 to 2022 for most parks. The South Region reported the highest total number of fatalities. The West Region demonstrated higher rates when adjusted for visitor volume. Fatal injuries were most prevalent in the 35-44 age group, followed by the 15-24 and 25-34 age groups, with the least incidents in the 0-14 age group, and were more common among males (71.5 % of total injuries).

CONCLUSION

This study found the highest number of total injuries occurring in summer; however, winter presented a higher risk per visitor. Slips and falls were the most common cause of injuries, requiring targeted safety measures. Males in the 35-44 age group reported the highest fatality rates. These findings highlight the necessity for improved monitoring and reporting to better understand injury causes and formulate specific, evidence-based policies for prevention.

Evaluating Mortality Outcomes, Transfusion Characteristics, and Risk Factors Associated With Cirrhotic Trauma Patients Undergoing Emergency Laparotomy Versus Non-Operative Management: A National Analysis

BACKGROUND

Patients with liver cirrhosis (LC) demonstrate significantly elevated mortality rates following a traumatic event. This study aims to examine and compare the clinical outcomes in adult trauma patients with pre-existing LC undergoing laparotomy or non-operative management (NOM). Additionally, the study aims to investigate various patient outcomes, including mortality rate based on transfusion needs and timing.

METHODS

This retrospective cohort study utilized the American College of Surgeons Trauma Quality Program Participant Use File (ACS-TQIP-PUF) 2017-21 to compare laparotomy vs NOM in adults (≥18 years) with pre-existing LC who presented to trauma facilities with isolated blunt solid organ abdominal injuries (Injury Severity Score ≥16, Abbreviated Injury Scale solid organ abdomen ≥3).

RESULTS

Among 929 patients, 38.2% underwent laparotomy, while 61.7% received NOM. The in-hospital mortality rate was lower for patients who received NOM (52.3% vs 20.0%, P < .01). The risk of in-hospital mortality was significantly associated with laparotomy (OR 5.22, 95% CI: 2.06-13.18, P < .01) and sepsis (OR 99.50, 95% CI: 6.99-1415.28, P < .01). On average an increase in blood units in 4 hours was observed among those who experienced an in-hospital mortality (OR 5.65, 95% CI: 3.05-8.24, P < .01) and those who underwent laparotomy (OR 3.85, 95% CI: 1.36-6.34, P < .01).

CONCLUSION

Trauma patients with moderate to severe isolated organ injury and Liver cirrhosis had significantly higher mortality rates, acute renal failure, whole blood units received, as well as longer ICU-LOS when undergoing laparotomy compared to non-operative management.

Assessing Effectiveness and Efficiency of Need for Trauma Intervention (NFTI) and Modified NFTI in Identifying Overtriage and Undertriage Rates and Associated Outcomes

INTRODUCTION

Limited research has assessed the effectiveness of Need for Trauma Intervention (NFTI) and Modified NFTI (MNFTI) criteria in accurately identifying triage rates in major trauma. We aim to evaluate the predictive capability of NFTI/MNFTI in determining rates of overtriage and undertriage, as well as associated outcomes.

METHODS

A literature search was conducted utilizing PubMed, Google Scholar, EMBASE, ProQuest, and Cochrane from conception to April 13th, 2023. Studies assessing the utilization of NFTI/MNFTI in identifying over and undertriage rates were included. Additional outcomes including mortality, ICU LOS, and resource allocation were evaluated. Outcomes were compared between NFTI/MNFTI and other triage metrics.

RESULTS

A total of 8 articles, including 175,650 trauma patients, were evaluated. NFTI utilization was associated with reduced overtriage rates compared to numerous tools including trauma triage matrix (TTM) and need for emergent intervention within 6 h (NEI-6) (NFTI 32.15%, TTM 44.5%, NEI-6 42.23%). Regarding undertriage, NFTI had lower rates than the secondary triage assessment tool (STAT) and TTM (NFTI 14.0%, STAT, 22.3%, TTM 14.3%) as well as Cribari Matrix Method (CMM) (NFTI .8%, CMM 7.6%, P < .0003). Additionally, the utilization of NFTI in combination with CMM yielded a significant reduction in undertriage rates compared to either tool alone (CMM/NFTI 2.7%, NFTI 4.6%, CMM 8.2%).

CONCLUSION

Implementation of NFTI/MNFTI resulted in more accurately capturing over and undertriage rates. Similar trends were identified when NFTI was used in combination with CMM. When compared to other triage tools, NFTI outperformed CMM, TTM, STAT, and NEI-6 in overtriage and/or undertriage rates.

Closed Incision Negative Pressure Therapy Versus Traditional Dressings for Low Transverse Abdominal Incisions Healing by Primary Closure: A Systematic Review and Meta-Analysis

Background: Closed incision negative pressure therapy (ciNPT) devices may reduce wound healing complications when applied to closed surgical incisions. The aim of this review was to assess the effects of ciNPT versus standard dressings in patients undergoing primary closure of high tension, lower transverse abdominal incisions. Methods: This review was registered a priori on PROSPERO (CRD42021252048). A search of the following databases was performed in February 2021: Medline, EMBASE, and CENTRAL. Unpublished trials were searched using clinicaltrials.gov. All randomized and nonrandomized studies comparing ciNPT to standard dressings were included. Two independent reviewers performed screening and data extraction. Outcomes evaluated the incidence of wound dehiscence, surgical site infection, total abdominal complications, time to drain removal, and seroma formation. Main Results: Ten studies were included in quantitative and narrative synthesis. Observational study evidence suggests ciNPT likely reduces the incidence of wound dehiscence (odds ratio [OR] 0.57 [0.44-0.96], P = .03) and total abdominal complications (OR 0.34 [0.21-0.54], P < .01). Decreased incidence of seroma formation favored ciNPT (OR 0.65 [0.24-1.76], P = .40); however, this did not achieve significance. Randomized and non-randomized study evidence was very uncertain about the effect of ciNPT on the remaining outcomes. Conclusions: The current best randomized study evidence is very uncertain about the effect of ciNPT on these outcomes. Observational study evidence suggests ciNPT likely results in a statistically significant reduction in abdominal wound dehiscence and total abdominal complications. Additional randomized trials are warranted to limit the impact of bias on the overall certainty of the evidence.

Understanding COVID-19 vaccine hesitancy in health care professionals in Central and West Asia: lessons for future emergency mass vaccination campaigns

A Quick Assessment of Vaccine Hesitancy approach was developed to collect population insights on vaccination hesitancy for low resource environments. Insights into COVID-19 vaccine hesitancy were collected through online webinars with heads of healthcare departments and anonymized online surveys of healthcare managers (HCM) and primary healthcare workers (HCW) in four countries in Central and West Asia (Armenia, Georgia, Tajikistan, and Kyrgyzstan) between 28 February 2022 and 29 March 2022. From the responses to the survey some key themes identified that underpinned in vaccine hesitancy across the region were perceived understanding of vaccine efficacy, conflict with individual religious beliefs, concerns for side effects, and the relatively rapid development of the vaccine and that improving communications strategies to address these concerns would be critical in combatting vaccine hesitancy through any future public health emergencies.

Denervation as a Treatment for Arthritis of the Hands: A Systematic Review of the Current Literature

Joint denervation has been proposed as a less invasive option for surgical management of hand arthritis that preserves joint anatomy while treating pain and decreasing postoperative recovery times. The purpose of this systematic review was to investigate the efficacy and safety of surgical joint denervation for osteoarthritis in the joints of the hand. EMBASE, MEDLINE, and PubMed databases were searched from January 2000 to March 2019. Studies of adult patients with rheumatoid arthritis or osteoarthritis of the hand who underwent joint denervation surgery were included. Two reviewers performed the screening process, data abstraction, and risk of bias assessment (Methodological Index for Non-Randomized Studies). This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered with PROSPERO (#125811). Ten studies were included, 9 case series and 1 cohort study, with a total of 192 patients. In all studies, joint denervation improved pain and hand function at follow-up (M = 36.8 months, range = 3-90 months). Pooled analysis of 3 studies on the first carpometacarpal joint showed a statistically significant (P < .001) reduction in pain scores from baseline (M = 6.61 ± 2.03) to postoperatively (M = 1.69 ± 1.27). The combined complication rate was 18.8% (n = 36 of 192), with neuropathic pain or unintended sensory loss (8.8%, n = 17 of 192) being the most common. This review suggests that denervation may be an effective and low-morbidity procedure for treating arthritis of the hand. Prospective, comparative studies are required to further understand the outcomes of denervation compared with traditional surgical interventions.

Pericardial Tamponade in a Patient With a History of Pneumonectomy

Shock is the clinical presentation of circulatory failure with impaired perfusion that results in inadequate cellular oxygen utilization. Treatment requires properly identifying the type of shock that is impacting the patient (obstructive, distributive, cardiogenic, and/or hypovolemic). Complex cases may involve numerous contributors to each type of shock and/or multiple types of shock which can present interesting diagnostic and management challenges to the clinician. In this case report, we present a 54-year-old male with a remote history of a right lung pneumonectomy presenting with multifactorial shock including cardiac tamponade, with initial compression of the expanding pericardial effusion by the postoperative fluid accumulation within the right hemithorax. While in the emergency department, the patient gradually became hypotensive with worsening tachycardia and dyspnea. A bedside echocardiogram revealed an increase in size of the pericardial effusion. An emergent ultrasound-guided pericardial drain was inserted with gradual improvement of his hemodynamics followed by placement of thoracostomy tube. This unique case highlights the importance of utilizing point-of-care ultrasound along with emergent intervention in critical resuscitation.

Intensity of physical therapy services: Association with work and health outcomes in injured workers with back pain in Washington State

BACKGROUND

Associations between the intensity of physical therapy (PT) treatments and health outcomes among individuals with back pain have been examined in the general population; however, few studies have explored these associations in injured workers. Our study objective was to examine whether intensity of PT treatments is positively associated with work and health outcomes in injured workers with back pain.

METHODS

We conducted a secondary analysis of prospective data collected from the Washington State Workers' Compensation (WC) Disability Risk Identification Study Cohort (D-RISC). D-RISC combined survey results with WC data from the Washington State Department of Labor and Industries. Workers with a State Fund WC claim for back injuries between June 2002 and April 2004 and who received PT services within the first year of injury were eligible. Intensity of PT treatment was measured as the type and amount of PT services within 28 days from the first PT visit. Outcome measures included work disability and self-reported measures for working for pay, pain intensity, and functional status at 1-year follow-up. We conducted linear and logistic regression models to test associations.

RESULTS

We identified 662 eligible workers. In adjusted models, although the intensity of PT treatment was not significantly associated with work disability at 1-year follow-up, it was associated with lower odds of working for pay, decreased pain intensity, and improved functional status.

CONCLUSIONS

Our findings suggest that there may be small benefits from receiving active PT, manual therapy, and frequent PT treatments within 28 days of initiating PT care.

Vaccine research and development capacity in Central and West Asia: A path toward sustainable vaccine R&D programs

The ability to support a comprehensive vaccine research and development (R&D) portfolio from a health security perspective has taken on enhanced significance over the past 3 years whereby countries that had existing vaccine R&D infrastructure (G7, Russia and China) have been at the forefront of global efforts to combat COVID-19. Few countries outside of these key players have the infrastructure necessary to develop national vaccine programs, though this is beginning to change with investment across many low- and middle-income countries. These same opportunities exist for countries in Central and West Asia, and in this perspective, we highlight the existing infrastructure and expertise across seven countries (Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Tajikistan, and Uzbekistan) and propose opportunities for enhanced collaboration along with a bold proposal for establishing a new-build, regional vaccine translational research institute to facilitate the development of a robust, regional vaccine R&D environment to combat existing and future health challenges.

Surgery for chronic arthropathy in people with haemophilia

BACKGROUND

Chronic arthropathy is a potentially debilitating complication for people with haemophilia - a genetic, X-linked, recessive bleeding disorder, characterised by the absence or deficiency of a clotting factor protein. Staging classifications, such as the Arnold-Hilgartner classification for haemophilic arthropathy of the knee, radiologically reflect the extent of knee joint destruction with underlying chronic synovitis. Management of this highly morbid disease process involves intensive prophylactic measures, and chemical or radioisotope synovectomy in its early stages. However, failure of non-surgical therapy in people with progression of chronic arthropathy often prompts surgical management, including synovectomy, joint debridement, arthrodesis, and arthroplasty, depending on the type of joint and extent of the damage. To date, management of people with mild to moderate chronic arthropathy from haemophilia remains controversial; there is no agreed standard treatment. Thus, the benefits and disadvantages of non-surgical and surgical management of mild to moderate chronic arthropathy in people with haemophilia needs to be systematically reviewed.  OBJECTIVES: To assess the efficacy and safety of surgery for mild to moderate chronic arthropathy in people with haemophilia A or B.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, and two trial registers to August 2022. We also handsearched relevant journals and conference abstract books.

SELECTION CRITERIA

Randomized controlled trials (RCTs) and quasi-RCTs comparing surgery and non-surgical interventions, for any joint with chronic arthropathy, in people with haemophilia, who were at least 12 years old.

DATA COLLECTION AND ANALYSIS

The review authors did not identify any trials to include in this review.

MAIN RESULTS

The review authors did not identify any trials to include in this review.

AUTHORS' CONCLUSIONS

The review authors did not identify any trials to include in this review. Due to a lack of research in this particular area, we plan to update the literature search every two years, and will update review if any new evidence is reported. There is a need for a well-designed RCT that assesses the safety and efficacy of surgical versus non-surgical interventions for chronic arthropathy in people with haemophilia.

Coping strategies moderate the effect of perceived stress on sleep and health in older adults during the COVID-19 pandemic

Stress in the context of the COVID-19 pandemic may have a significant impact on health, including sleep health. Older adults may be particularly vulnerable. This study examined associations between perceived stress and sleep health, mental health, physical health, and overall perceived health outcomes among older adults. We also examined whether specific coping strategies moderate these associations. Older adults (n = 115; M_age  = 68.62) reported perceived stress, coping strategies, global sleep quality, depressive symptoms, and perceived mental, physical, and overall health before and during the COVID-19 pandemic. Stress-health relationships were modelled with hierarchical linear regression. Higher perceived stress was associated with greater depressive symptoms and poorer mental health concurrently and longitudinally. Coping strategies moderated the association of perceived stress with physical health and overall perceived health. For example, higher perceived stress was associated with poorer overall perceived health among those with lower problem-focussed coping, but not among those with higher problem-focussed coping. Older adults may benefit from prevention and intervention strategies targeting stress management. Furthermore, identifying people with low problem-focussed coping might be a useful strategy to prevent worsening health in future public health crises.

External Ventricular Drain (EVD) Placement Using a Hands-On Training Session on a Simple Three-Dimensional (3D) Model

Neurosurgery is a demanding field with small margins of error within the operative field. Small errors can yield devastating consequences. Simulation has been proposed as a methodology for improving surgical skills within the neurosurgical realm. This study was conducted to investigate a novel realistic design for a clinical simulation based, low-cost alternative of external ventricular drain (EVD) placement, an essential basic neurosurgical procedure that is necessary for clinicians to master. A low-cost three-dimensional (3D) printed head using thermoplastic polylactic acid was designed with the tactile feedback of outer table, cancellous bone, and inner tables for drilling with replaceable frontal bones pieces for multi-use purposes. An agar gel filled with water was designed to simulate tactile passage through the cortex and into the ventricles. Neurosurgical and emergency resident physicians participated in a didactic session and then attempted placement of an EVD using the model to gauge the simulated model for accuracy and realism. Positioning, procedural time, and realism was evaluated. Improvements in procedural time and positioning were identified for both neurosurgical and emergency medicine (EM) residents. Catheter placement was within ideal position for all participants by the third attempt. All residents stated they felt more comfortable with placement with subsequent attempts. Neurosurgical residents subjectively noted similarities in tactile feedback during drilling compared to in-vivo. A low-cost realistic 3D printed model simulating basic neurosurgical procedures demonstrated improved procedural times and precision with neurosurgical and EM residents. Further, similarities between in-vivo tactile feedback and the low-cost simulation technology was noted. This low cost-model may be used as an adjunct for teaching to promote early procedural competency in neurosurgical techniques to promote learning without predisposition to patient morbidity.

Managing the challenges associated with decreasing demand for COVID-19 vaccination in Central and West Asia

Since the first administration of COVID-19 vaccine in December 2020, countries have experienced a range of challenges at different phases of their COVID-19 vaccination programmes. Initially, with limited global COVID-19 vaccine supply, the WHO called for vaccine equity to ensure the most vulnerable people in every country globally had access to vaccine, and COVID-19 Vaccines Global Access was established to facilitate equitable access to COVID-19 vaccine. However, the aims of these initiatives were challenged as many countries secured earlier access to COVID-19 vaccine with direct agreements with manufacturers. During the early stages of COVID-19 vaccination programmes, the rate of vaccine uptake was determined by number of COVID-19 vaccines approved for use and the manufacturing capacity of the manufacturers of these vaccines. It is a very different situation in 2022, where COVID-19 vaccination coverage is no longer determined by access to supply and manufacturers are reducing or stopping production of vaccines completely. Uptake of COVID-19 vaccination in 2022 is dependent on complex issues like vaccine hesitancy. This paper focuses on the Central and West Asia region, where the authors have been supporting COVID-19 vaccination programmes across seven countries in this region. In this paper, we outline and describe the different phases of demand for COVID-19 vaccination as well as the risks and strategies to consider in each of these phases.

0176 Comparing Sleep and Homeostatic Sleep Drive Between Retired Night Shift Workers and Retired Day Workers

Introduction

Retired night shift workers report poorer sleep quality compared to retired day workers, even after returning to a nocturnal sleep schedule, suggesting a potential “scarring” of night shift work on sleep. History of sleep deprivation and sleep at an unfavorable circadian phase may compromise sleep and homeostatic sleep regulation, potentially contributing to poor sleep quality in retired night shift workers. This study compared sleep efficiency and homeostatic sleep regulation in response to sleep deprivation (delta EEG power during NREM sleep, theta EEG power during wakefulness) between retired night shift workers and retired day workers.

Methods

Participants (N = 75, mean age: 68.3 +/-5.5 years, 51% females, 87% non-Hispanic White) were 35 retired night shift workers and 40 age-, sex-, and race-equated retired day workers. Participants completed a 60-hour laboratory study including one baseline night of sleep, followed by 36 hours of sleep deprivation, followed by one recovery night of sleep. Sleep efficiency and NREM delta EEG power were measured by polysomnography on both nights, and waking theta EEG power was measured every other hour during the 36-hour sleep deprivation period. We analyzed the effects of group (retired night shift workers vs. retired day workers), time (baseline vs. recovery night for sleep efficiency and delta EEG power, hour for theta EEG power), and their interaction on each outcome using linear mixed models.

Results

Groups did not differ in sleep efficiency averaged across nights (F=1.48, p&gt;0.05) or from baseline to recovery nights (F=0.05, p&gt;0.05). Delta EEG responses to sleep deprivation did not differ by group (F=0.33, p&gt;0.05). Compared to retired day workers, retired night shift workers showed greater overall waking EEG theta power during sleep deprivation (F=13.20, p&lt;0.001). The group by time interaction was not significant (F=0.36, p&gt;0.05), suggesting that group differences in theta EEG power were not due to increased sleep deprivation.

Conclusion

Sleep efficiency and homeostatic sleep regulation appeared to be preserved in retired night shift workers. Theta EEG power findings suggested greater sleep propensity during wakefulness in retired night shift workers. Interventions to improve sleep quality in retired night shift workers may leverage intact homeostatic sleep regulation mechanisms.

Support (If Any)

R01AG047139, T32HL082610, T32HL07560, T32MH019986

Caspase-6-cleaved tau is relevant in Alzheimer's disease and marginal in four-repeat tauopathies: diagnostic and therapeutic implications

AIM

Tau truncation (tr-tau) by active caspase-6 (aCasp-6) generates tau fragments that may be toxic. Yet, the relationship between aCasp-6, different forms of tr-tau, and hyperphosphorylated tau (p-tau) accumulation in human brains with Alzheimer's disease (AD) and other tauopathies remains unclear.

METHODS

We generated two neoepitope monoclonal antibodies against tr-tau sites (D402 and D13) targeted by aCasp-6. Then, we used 5-plex immunofluorescence to quantify the neuronal and astroglial burden of aCasp-6, tr-tau, p-tau, and their co-occurrence in healthy controls, AD, and primary tauopathies.

RESULTS

Casp-6 activation was strongest in AD and Pick's disease (PiD), but almost absent in 4-repeat (4R) tauopathies. In neurons, the tr-tau burden was much more abundant in AD and PiD than in 4R tauopathies and disproportionally higher when normalizing by p-tau pathology. Tr-tau astrogliopathy was detected in low numbers in 4R tauopathies. Unexpectedly, about half of tr-tau positive neurons in AD and PiD lacked p-tau aggregates, a finding we confirmed using several p-tau antibodies.

CONCLUSIONS

Early modulation of aCasp-6 to reduce tr-tau pathology is a promising therapeutic strategy for AD and PiD, but is unlikely to benefit 4R tauopathies. The large percentage of tr-tau-positive neurons lacking p-tau suggests that many vulnerable neurons to tau pathology go undetected when using conventional p-tau antibodies. Therapeutic strategies against tr-tau pathology could be necessary to modulate the extent of tau abnormalities in AD. The disproportionally higher burden of tr-tau in AD and PiD supports the development of biofluid biomarkers against tr-tau to detect AD and PiD and differentiate them from 4R tauopathies at a patient level.

Evaluation of "Spin" in the Abstracts of Systematic Reviews and Meta-analyses of Therapeutic Interventions Published in High-Impact Plastic Surgery Journals: A Systematic Review

BACKGROUND

"Spin" is a form of reporting bias where there is an misappropriated presentation of study results, often overstating efficacy or understating harms. Abstracts of systematic reviews in other clinical domains have been demonstrated to employ spin, which may lead to clinical recommendations that are not justified by the literature.

OBJECTIVES

The objective of this study was to determine the prevalence of spin strategies in abstracts of plastic surgery systematic reviews.

METHODS

A literature search was conducted using MEDLINE, Embase, and CENTRAL, to identify all systematic reviews published in the top five plastic surgery journals from 2015-2021. Screening, data extraction, and spin analysis were performed by two independent reviewers. Data checking of the spin analysis was performed by a plastic surgery resident with graduate level training in clinical epidemiology.

RESULTS

From an initial search of 826 systematic reviews, 60 systematic reviews and meta-analyses were included in this study. Various types of spin were identified in 73% of systematic review abstracts (n=44). "Conclusion claims the beneficial effect of the experimental treatment despite high risk of bias in primary studies," was the most prevalent type of spin and was identified in 63% of systematic reviews (n=38). There were no significant associations between the presence of spin and study characteristics.

CONCLUSIONS

The present study found that 73% of abstracts in plastic surgery systematic reviews contain spin. Although systemic reviews represent the highest level of evidence, readers should be aware of types of "spin" when interpreting results and incorporating recommendations into patient care.

Physiological bases of secure base support provision in a longitudinal study of married older adult couples

Close others often serve as a source of support for our pursuit of personal goals. Although social psychological research indicates that individuals and relationships benefit when couple members provide each other with secure base support for personal goals, few studies have investigated the physiological bases of these types of support interactions. This study of married older adults examined support providers' cardiovascular challenge‐threat responses while they engaged in a laboratory social interaction about the most important goal that their partner (the target) wanted to make progress toward during the next year. Consistent with our hypothesis, support providers' cardiovascular challenge responses were positively associated with targets' ratings of their secure base support provision during the discussion. This study also used structural equation modeling to test a theoretical model of support providers' cardiovascular challenge responses as a physiological basis of secure base support provision that promotes targets' goal progress and thriving over time. Consistent with our theory, support providers' cardiovascular challenge responses were positively associated with targets' goal progress at Year 2 follow‐up. In turn, targets' goal progress at Year 2 predicted increases in targets' overall thriving from Year 1 to Year 3. This investigation provides novel evidence for attachment theory's assertion that biobehavioral caregiving system activation facilitates the provision of secure base support that promotes close others' goal progress and thriving over time. Results of this study also contribute to recent evidence that cardiovascular challenge responses are associated with social behaviors during dyadic interactions.

Our investigation implicates cardiovascular challenge‐threat responses as underlying the provision of secure base support. We advance earlier research on attachment theory by providing longitudinal evidence that support providers‘ cardiovascular challenge responses during a laboratory goal discussion represent activation of the biobehavioral caregiving system, which theoretically facilitates partners‘ goal progress (exploration) and thriving over time. These findings contribute to scarce research examining cardiovascular challenge‐threat response during social interactions and scarce research on attachment relationships and physiology in older adulthood.

An audit on coronary artery calcium scoring in the mercy university hospital, co. cork, ireland

Funding Acknowledgements

Type of funding sources: None.

Background

Coronary artery calcium (CAC) testing is an imaging technique used to non-invasively assess calcification within the coronary arteries. It has emerged as a reliable surrogate measure of coronary artery disease where higher risk individuals are more likely to benefit from medications such as aspirin and statins. A high calcium score should prompt further diagnostic tests for coronary artery disease. This was a single centre audit designed to assess the current role and the clinical implications of CAC testing in our university hospital, Ireland.

Methods

This was a retrospective chart review of all patients who underwent CAC testing in MUH from 1st January 2019 to 31st December 2020. Patients were recruited from the CAC database within the hospital radiology department. Demographic data, indication for CAC testing, medication records and results of invasive coronary angiography were obtained from the medical records. Assessment of CAC scores and percentiles from all patients were recorded from the radiology results system.

Results

Of the 218 participants, 48.6% were male and the mean age was 53.7 (± 9.7) years. The most common risk factors were hypercholesterolaemia (65.1%), family history of premature coronary artery disease (48.6%) and hypertension (31.2%). CAC results were as follows: 50.5% had a score of 0, 25.2% had a score of 1-99, 12.4% had a score of 100-399, 6.4% had a score of 400-999, and 5.5% had a score of ≥1000. The most common indications for CAC testing were risk factors (45.5%) and symptoms (38.0%). CAC testing indications were unretrievable on the database for 31 patients (14.2%). CT coronary angiography was performed in 57 patients (26.1%), while 30 patients (13.8%) had invasive coronary angiography. On invasive coronary angiography, 8 patients (3.7%) were reported to have obstructive disease and 25 patients (11.5%) had non-obstructive disease. Following CAC testing, antiplatelet therapy was started in 15 patients (6.9%). Statin therapy was started in 28 patients (12.4%). The maintenance and modification of previous statin therapy was noted in 67 patients (30.3%).

Conclusion

CAC testing is a useful non-invasive diagnostic test which can be used to identify individuals at risk of obstructive coronary artery disease and guide initiation of risk modifying therapy. The cohort of patients currently undergoing CAC testing in our hospital are largely asymptomatic patients with cardiovascular risk factors. The results of these tests led to commencement of risk modifying treatment in less than 20% of patients and only a small proportion of patients required follow-on invasive coronary angiography for further investigation of their coronary artery anatomy. These results show that CAC testing use in our hospital is in line with international guidelines and suggest that the use of CAC testing decreases the requirement for invasive coronary angiography in low-risk, asymptomatic patients.

Acute Inhalant-Induced Atrial Fibrillation With Severe Hypocalcemia: A Case Report and Review of the Pathophysiology

The recreational use of inhalants is associated with various detrimental health effects ranging from inebriation to cardiac arrest. It also presents a challenging clinical problem as the diagnosis is made by the presentation and patient’s history, which is often difficult to obtain in an intoxicated or obtunded individual. The incidence of inhalant use is relatively high. National surveys have reported that nearly 21.7 million Americans aged 12 and older have used inhaled substances at least once in their lives. There is no reversal agent or antidote for inhalants and supportive care is generally recommended. We present a case of a young patient presenting with acute inhalant toxicity accompanied by atrial fibrillation with a rapid ventricular response and severe hypocalcemia.

Nerve Grafting for Chronic PIN Palsy Due to Radiocapitellar Joint Entrapment 2 Years Following Closed Reduction of a Pediatric Monteggia Fracture-Dislocation: A Case Report With 1-Year Follow-up

This article describes the first case of successful nerve grafting for posterior interosseous nerve (PIN) palsy secondary to radiocapitellar joint entrapment 2 years following closed reduction (CR) of a pediatric Monteggia fracture-dislocation (MFD). Patient notes were examined. The literature was reviewed to determine whether similar cases or techniques had been reported. A 5-year-old girl presented with a PIN palsy 2 years following CR of an MFD, demonstrating Medical Research Council (MRC) grade 4 wrist and MRC grade 2 finger and thumb extension. Nerve exploration at 27 months revealed a PIN crushed in the radiocapitellar joint with a proximal neuroma-in-continuity and no response to electrical stimulation. Neurolysis and lateral antebrachial cutaneous nerve cable grafting were performed. The decision to pursue nerve grafting was based on the intraoperative appearance of an atrophic PIN with no response to stimulation, but with minimal muscle atrophy, short distance to target muscles, and pediatric patient with extended reinnervation timeline. Full recovery (MRC grade 5 wrist extension and MRC grade 4+ finger and thumb extension) was achieved at 1-year follow-up. We present the first case of successful nerve grafting for PIN palsy secondary to radiocapitellar joint entrapment 2 years following CR of a type III MFD. Even with significant treatment delay, nerve reconstruction should be considered in the pediatric population.

649 Coping strategies moderate the effect of perceived stress on sleep and health in older adults during the COVID-19 pandemic

Introduction

The COVID-19 pandemic is an enormous stressor that can impact various dimensions of health, including sleep health. Older adults may be particularly vulnerable. Coping strategies to manage stress can also impact health outcomes by modifying the relationships between perceived stress and health outcomes. This study examined concurrent and longitudinal associations between perceived stress and sleep health, mental health, physical health, and overall perceived health outcomes among older adults. We also examined whether coping strategies moderate these associations.

Methods

Older adults (n = 115; Mage = 68.62, 58.3% female) reported perceived stress (PSS), coping strategies (Brief COPE), global sleep quality (PSQI global sleep quality score and dichotomous good/poor sleep quality), depressive symptoms (CES-D), and perceived mental, physical, and overall health (RAND-12) before and during the COVID-19 pandemic.

Results

The number of individuals with poor sleep quality was greater during the COVID-19 pandemic than before (50% vs. 36.5%). Participants also reported poorer physical health during the COVID-19 pandemic than before. Hierarchical linear regression and hierarchical logistic regression revealed that higher perceived stress was cross-sectionally associated with poorer sleep (e.g., higher total PSQI score and dichotomous sleep quality category). Higher perceived stress was associated with worse depressive symptoms and global mental health concurrently and longitudinally. Coping strategies moderated the relationships between perceived stress and physical health and overall perceived health. For example, higher perceived stress was associated with poorer overall perceived health for those who have lower problem-focused coping—but not for those with higher problem-focused coping—both concurrently and longitudinally.

Conclusion

Perceived stress influences cross-sectional and longitudinal measures of sleep health and general health among older adults during the COVID-19 pandemic. Coping strategies can moderate the effects of perceived stress on health outcomes. Older adults may benefit from prevention and intervention strategies targeting stress management and problem-focused coping strategies.

Support (if any)

This research was supported by the National Institute of Aging (R01AG047139), the National Heart, Lung, and Blood Institute (T32HL007560; T32HL082610), and the National Institute of Mental Health (T32MH019986)

221 Social Integration and Sleep Quality during the COVID-19 Pandemic: Prospective Evidence from a Study of Retired Older Adults

Introduction

Growing evidence has documented the adverse impact of the global coronavirus pandemic on sleep quality. Older adults may be especially susceptible to declines in sleep quality for multiple reasons, including their elevated risk of social isolation and loneliness during the pandemic. Given the adverse health consequences of poor sleep, there is a need to identify resilience factors that help protect older adults against decreased sleep quality. Social integration is a plausible resilience factor because involvement in a broad range of social relationships is thought to promote psychological well-being (e.g., meaning, purpose in life), as well as reduce the intensity and duration of negative psychological states. Social integration may also assume increased importance during the coronavirus pandemic because of normative declines in overall social contact. This prospective study assessed the impact of the coronavirus pandemic on older adults’ sleep quality and tested whether social integration moderated the impact of the pandemic on sleep quality.

Methods

A sample of 115 retired older adults (mean age = 68.6, 58% female, 89% white) completed self-report assessments of their social integration (number of roles on Cohen’s Social Network Index) and sleep quality (global score on Pittsburgh Sleep Quality Index) before and after the onset of the coronavirus pandemic (mean duration of follow-up = 2.3 years).

Results

Multilevel analyses indicated that social integration moderated the impact of the coronavirus pandemic on sleep quality; there was no main effect of time. Older adults with low social integration had reduced sleep quality from Time 1 to Time 2 (b=.94, p=.02), whereas older adults with high social integration showed no changes in sleep quality over time (b=-.38, p=.37).

Conclusion

Broader social networks confer resilience against pandemic-related declines in sleep quality among older adults. The level of social integration should be addressed when studying or treating sleep complaints during the coronavirus pandemic. Additional research is warranted to determine whether psychosocial interventions targeted towards older adults with low social integration can reduce observed differences in sleep quality.

Support (if any)

This research was supported by R01AG047139, T32HL007560, T32HL082610, T32MH019986.

Comparing digital replantation versus revision amputation patient reported outcomes for traumatic digital amputations of the hand: A systematic review and meta-analysis

PURPOSE

Adults with traumatic digital amputation (TDA) of the hand may be managed with replantation or revision amputation. To date, there is no systematic review evaluating patient reported outcomes (PROs) comparing replantation versus revision amputation.

METHODS

Three databases (MEDLINE, EMBASE, and PubMed) were systematically searched in duplicate from inception until June 13, 2019 using Covidence software. Studies comparing replantation versus revision amputation outcomes were considered for inclusion. Methodological quality was assessed using Methodologic Index for Nonrandomized Studies (MINORS) criteria. Data were pooled in a random-effects meta-analysis model using Revman software. Certainty of evidence was evaluated using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE).

RESULTS

Of 4350 studies identified, 12 retrospective cohort studies met inclusion criteria and compared TDA outcomes for replantation (n = 717; 82.9% male; mean age 40.3) versus revision amputation (n = 1046; 79.8% male; mean age 41.7). The overall replantation survival rate was 85.3%. The average MINORS score was 57% (13.75/24). Replantation of the thumb had a superior Michigan Hand Questionnaire (MHQ) score (+11.88, 95% CI [7.78-15.99], I² = 21%) compared with revision amputation. Replantation of single non-thumb digits had a superior MHQ score (+5.31, 95% CI [3.10-7.51], I² = 67%) and Disability of Arm, Shoulder, and Hand (DASH) score (-5.16, 95% CI [-8.27 to -2.06], I² = 0%) compared with revision amputation. Most patients in the meta-analysis were from Asian populations (87.9%).

CONCLUSION

There is low-quality evidence that thumb replantation achieves superior PROs compared with revision amputation, which may be clinically important. Replantation of single non-thumb digits also yielded superior PROs, which is likely not clinically important and based on very low-quality evidence. Future studies with populations outside Asia are required to determine if PROs vary based on cultural differences toward digital amputation.

Medical claims paid by workers' compensation insurance among US Medicare beneficiaries, 1999-2016

BACKGROUND

Workers' compensation claims among Medicare beneficiaries have not been described previously. To examine the healthcare burden of work-related injury and illness among Medicare beneficiaries, we assessed the characteristics, healthcare utilization, and financial costs among Medicare beneficiaries with claims for which workers' compensation was the primary payer.

METHODS

We extracted final action fee-for-service Medicare claims from 1999 to 2016 where workers' compensation had primary responsibility for claim payment and beneficiary, claim type, diagnoses, and cost information from these claims.

RESULTS

During 1999-2016, workers' compensation was the primary payer for 2,010,200 claims among 330,491 Medicare beneficiaries, and 58.7% of these beneficiaries had more than one claim. Carrier claims submitted by noninstitutional providers constituted the majority (94.5%) of claims. Diagnosis codes indicated 19.4% of claims were related to diseases of the musculoskeletal system and connective tissue and 12.9% were related to disease of the circulatory system. Workers' compensation insurance paid $880.4 million for these claims while Medicare paid $269.7 million and beneficiaries paid $37.4 million.

CONCLUSIONS

Workers' compensation paid 74% of the total amount to providers for these work-related medical claims among Medicare beneficiaries. Claim diagnoses were similar to those of all workers' compensation claims in the United States. Describing these work-related claims helps identify the healthcare burden due to occupational injury and illness among Medicare beneficiaries resulting from employment and identifies a need for more comprehensive collection and surveillance of work-related medical claims.

Mindfulness interventions improve momentary and trait measures of attentional control: Evidence from a randomized controlled trial

Mindfulness interventions have been shown to improve several subcomponents of attention; however, the psychological mechanisms driving these improvements are unknown. Mindfulness interventions train individuals to monitor present moment experiences while adopting an attitude of acceptance toward these experiences. We conducted a theoretically driven randomized controlled trial to test the putative mechanisms of mindfulness training that drive improvements in attentional control. Participants were randomly assigned to 1 of 3 conditions: (a) monitor and accept (MA) training, a standard 8-week mindfulness-based stress reduction (MBSR) intervention that included cultivation of both monitoring and acceptance skills; (b) monitor only (MO) training, a well-matched modified 8-week MBSR-adapted intervention that focused on monitoring skills only; or (c) no treatment (NT) control. Momentary attentional control was measured via ecological momentary assessment for 3 days at baseline and postintervention. Trait attentional control was assessed at baseline and postintervention using traditional self-report. Participants also completed a dichotic listening task to assess sustained attention at baseline and postintervention. We found that MA and MO participants improved in momentary and trait attentional control (but not attention task performance) relative to NT participants. Analyses of indirect effects were consistent with the possibility that increased momentary attentional control partially accounts for MA/MO intervention-related increases in trait attentional control. This randomized controlled trial provides one of the first experimental tests of the mechanisms of mindfulness interventions that drive improvements in attention outcomes. These findings support the notion that present-focused monitoring skills training drives mindfulness intervention-related improvements in momentary attentional control, which in turn fosters greater trait attentional control. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Correction to: Association of Time since Migration from Rural to Urban Slums and Maternal and Child Outcomes: Dhaka (North and South) and Gazipur City Corporations

There is an error in Fig 2 in this article: There should not be a box indicating p-values.

Impact evaluation of contracting primary health care services in urban Bangladesh

BACKGROUND

The Urban Primary Health Care Project (UPHCP) was implemented by the Government of Bangladesh in response to rapid urbanization and growing inequalities in access to and quality of primary health care. The goal of the project was to improve health status of the urban poor living in city corporations and municipalities through the provision of health care services by NGOs that are contracted through public-private partnership. The first phase of the project started in 1998 and the project is currently in its fourth phase covering more urban areas than the first three phases. This study evaluates the impact of the second phase project (UPHCP-II) on health outcomes, mainly child diarrhea, acute respiratory infection, antenatal and postnatal care, skilled birth attendance, breastfeeding prevalence, contraceptive prevalence, sexually transmitted infections, and HIV/AIDS awareness.

METHODS

The effect of the project was estimated through propensity score matching between project and non-project areas comparing baseline and endline surveys over a six-year period from 2006 to 2012. An innovation of this study is the recalibration of the sampling weights that allows the use of these two independent surveys in impact evaluation.

RESULTS

Over the six-year period, UPHCP-II improved the health status of the population in project areas compared to non-project areas. The study found significant improvement in health outcomes in terms of reduced diarrhea and acute respiratory infection in children, which explains the downward trend in child mortality rate. Moreover, the project also improved antenatal care and skilled birth attendance. Contraceptive prevalence and HIV/AIDS awareness and avoidance increased, and sexually transmitted infections decreased.

CONCLUSIONS

UPHCP-II was effective in achieving its health outcome targets, while previous studies show that it was efficient in the delivery of health care and clients were highly satisfied because health facilities were in close proximity, and doctors and staff were perceived as responsive in delivering high quality of care. The results of this study could help inform future design and implementation of urban health interventions that involve contracting primary health care service delivery in Bangladesh and other similar settings.

Health-care investments for the urban populations, Bangladesh and India

Objective

To estimate the costs and mortality reductions of a package of essential health interventions for urban populations in Bangladesh and India.

Methods

We used population data from the countries’ censuses and United Nations Population Division. For causes of mortality in India, we used the Indian Million Death Study. We obtained cost estimates of each intervention from the third edition of Disease controlpriorities. For estimating the mortality reductions expected with the package, we used the Disease control priorities model. We calculated the benefit–cost ratio for investing in the package, using an analysis based on the Copenhagen Consensus method.

Findings

Per urban inhabitant, total costs for the package would be 75.1 United States dollars (US$) in Bangladesh and US$ 105.0 in India. Of this, prevention and treatment of noncommunicable diseases account for US$ 36.5 in Bangladesh and U$ 51.7 in India. The incremental cost per urban inhabitant for all interventions would be US$ 50 in Bangladesh and US$ 75 in India. In 2030, the averted deaths among people younger than 70 years would constitute 30.5% (1027/3362) and 21.2% (828/3913) of the estimated baseline deaths in Bangladesh and India, respectively. The health benefits of investing in the package would return US$ 1.2 per dollar spent in Bangladesh and US$ 1.8 per dollar spent in India.

Conclusion

Investing in the package of essential health interventions, which address health-care needs of the growing urban population in Bangladesh and India, seems beneficial and could help the countries to achieve their 2030 sustainable development goals.

Socio-demographic, health and institutional determinants of caesarean section among the poorest segment of the urban population: Evidence from selected slums in Dhaka, Bangladesh

Caesarean sections (CS) is the most common lifesaving surgeries for obstructed labour and other emergency obstetrical conditions. The WHO had recommended ideal rate for CS to be between 5% and 15%. The rate higher than 15% indicates overused other than lifesaving. Bangladesh has experienced a dramatic increase in CS delivery from 4% in 2004 to 23% in 2014. This increase is elevated by the several factors including maternal education, maternal request or elective CS, and by the urban richest population. However, little is known about the use CS by the urban poorest population. Therefore, the study aimed to examine and identify the factors associated with CS among the urban disadvantaged section of the population. A total of 1063 randomly chosen women aged 15-49 years from the population of 121,912 residing five-different slums were interviewed during November-December 2016. CS delivery was considered as outcome variable. Both bivariate and multivariable statistical analyses were carried-out. We performed logistic regression analyses to examine the net-effect of independent variables on outcome variable. Over 25% of total deliveries and 50% of facility-based deliveries were CS. The odds of CS delivery was 3.4-fold greater among better-off women than poorest. Women who had 4 + ANC checks-up during pregnancy had a 2-fold higher odds of CS delivery than women of ANC check-up. In private facilities, 76% of births were delivered as CS, followed by 51% in public facilities and 24% in NGO facilities. The likelihood of CS delivery in private facilities was 9.2-fold greater than NGO facilities after controlling for women socio-demographic, pregnancy and delivery characteristics. Thus, the high use of CS is largely associated with private facility, ANC visits and household wealth. Therefore, the Government of Bangladesh should take immediate actions by designing new policies and regulations to ensure CS for the lifesaving condition, not for financial gain.

Mindfulness training and systemic low-grade inflammation in stressed community adults: Evidence from two randomized controlled trials

Mindfulness interventions have garnered significant attention as a complementary health treatment for many physical and psychological conditions. While some research has shown that mindfulness training can decrease psychological and physiological stress responses, it remains unclear whether mindfulness training impacts inflammation—a predictor of poor health outcomes. In addition, little research has examined the active components of mindfulness that may drive health-related improvements. Here, we provide data from two 3-arm randomized controlled trials that examined the effect of mindfulness training on inflammation in stressed community adults. Specifically, we examined whether training individuals to have an accepting attitude towards present moment experiences is a key emotion regulation skill that can lead to decreases in inflammation. Both studies randomly assigned participants to one of three conditions: mindfulness training that taught both attention monitoring and acceptance skills (Monitor+Accept); mindfulness training teaching monitoring without the acceptance component (Monitor Only); or a control condition. Study 1 employed a novel 2-week smartphone-based intervention and Study 2 employed a standard 8-week Mindfulness-Based Stress Reduction (MBSR) intervention. We hypothesized that Monitor+Accept training would lead to reductions in the inflammatory biomarker C-Reactive Protein (CRP) compared to Monitor Only training and control groups. Contrary to this hypothesis, we found that Monitor+Accept mindfulness training did not lead to reductions in CRP. Exploratory analyses combining study subsamples, however, suggest that both mindfulness interventions may reduce CRP in populations at risk for systemic inflammation—midlife-to-older adults and individuals with high BMI. Overall, the present studies contribute significantly to the question of whether mindfulness interventions can reduce systemic markers of low-grade inflammation.

Psychological mechanisms driving stress resilience in mindfulness training: A randomized controlled trial

OBJECTIVE

Mindfulness interventions have been shown to reduce stress; however, the mechanisms driving stress resilience effects are not known. Mindfulness interventions aim to teach individuals how to: (a) use attention to monitor present moment experiences; with (b) an attitude of acceptance and equanimity. A randomized controlled dismantling trial (RCT) was conducted to test the prediction that the removal of acceptance skills training would eliminate stress-reduction benefits of a mindfulness intervention.

METHOD

This preregistered RCT randomly assigned stressed community adults to 1 of 3 conditions: (a) Monitor and Accept (MA) mindfulness training, a standard 8-week Mindfulness-Based Stress Reduction (MBSR) intervention that provided explicit instruction in developing both monitoring and acceptance skills; (b) Monitor Only (MO) mindfulness training, a well-matched 8-week MBSR intervention that taught monitoring skills only; or (c) No Treatment (NT) control. Stress and nonjudgment were measured using ecological momentary assessment (EMA) for 3 days at baseline and 3 days at postintervention.

RESULTS

Consistent with predictions, MA participants increased in nonjudgment and decreased in both stress ratings and the proportion of assessments that they reported experiencing feelings of stress in daily life, relative to both MO and NT participants.

CONCLUSIONS

This RCT provides one of the first experimental tests of the mechanisms linking mindfulness interventions with stress resilience. These findings suggest that acceptance skills training may be a necessary active ingredient and support the value of integrating acceptance skills training into stress-reduction interventions. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

How mindfulness training promotes positive emotions: Dismantling acceptance skills training in two randomized controlled trials

Mindfulness meditation interventions-which train skills in monitoring present-moment experiences with a lens of acceptance-have shown promise for increasing positive emotions. Using a theory-based approach, we hypothesized that learning acceptance skills in mindfulness interventions helps people notice more positive experiences in daily life, and tested whether removing acceptance training from mindfulness interventions would eliminate intervention-related boosts in positive affect. In 2 randomized controlled trials (RCTs) of stressed community adults, mindfulness skills were dismantled into 2 structurally equivalent interventions: (a) training in both monitoring and acceptance (Monitor + Accept) and (b) training in monitoring only (Monitor Only) without acceptance training. Study 1 tested 8-week group-based Monitor + Accept and Monitor Only interventions compared with a no treatment control group. Study 2 tested 2-week smartphone-based Monitor + Accept and Monitor Only interventions compared with an active control training. In both studies, end-of-day and momentary positive affect and negative affect were measured in daily life for 3 days pre- and post-intervention using ambulatory assessments. As predicted, across 2 RCTs, Monitor + Accept training increased positive affect compared with both Monitor Only and control groups. In Study 1, this effect was observed in end-of-day positive affect. In Study 2, this effect was found in both end-of-day and momentary positive affect outcomes. In contrast, all active interventions in Studies 1 and 2 decreased negative affect. These studies provide the first experimental evidence that developing an orientation of acceptance toward present-moment experiences is a central mechanism of mindfulness interventions for boosting positive emotions in daily life. (PsycINFO Database Record (c) 2018 APA, all rights reserved).