Evolving Endotracheal Tube Preferences and Practices: Intensivist Knowledge Gaps and Sex Disparities

OBJECTIVES

The complex management of intubation-related laryngeal injury makes prevention vital. The purpose of this study is to assess endotracheal tube (ETT) practices and preferences among intensivists at our institution.

METHODS

Chart review of intubated patients and intensivist survey were simultaneously performed in January 2016 and August 2022. A height-to-ETT size ratio (H:ETT) was calculated for each patient in the 2022 cohort. Intubated patients were followed until tracheostomy, extubation, or death occurred. Surveys assessed intensivist preferences for ETT size and management of intubated patients.

RESULTS

300 ICU patients were included. The mean ETT size for males decreased from 7.73 ± 0.30 in 2016 to 7.57 ± 0.25 in 2022 (p < 0.001). The average H:ETT of men was higher than females (p = 0.004), indicating that females in this population were intubated with larger ETTs relative to their height compared to males. Whereas the majority (66.7%) of intensivists endorse 7.0 ETTs as the standard for women, the majority (70%) of women at our institution are intubated with a 7.5 ETT or larger. Of intubated patients in the ICU, 23 (19.5%) were intubated for 11 days or longer.

CONCLUSIONS

Compared to men, women are intubated with larger-than-preferred ETTs relative to height. Additionally, patients in our study were intubated for longer than preferred based on intensivist surveys, putting this population at higher risk for acute laryngeal injury (AlgI)-related laryngotracheal stenosis (LTS). Further studies should seek to identify similar trends and barriers to reducing ALgI-related LTS.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:3080-3086, 2023.

Expanded statistical analysis plan for legacy and long-term effects of aspirin in the ASPREE-XT observational follow-up study of participants in the ASPREE randomized trial

The ASPREE randomized controlled trial (2010-2017) of 19,114 community-dwelling older adults without cardiovascular disease and significant disability compared daily 100mg aspirin to placebo. A total of 16,317 (93%) of 17,546 surviving and non-withdrawn participants agreed to continue regular study follow-up visits in the post-trial phase, named ASPREE-XT (2017-2024). We present a statistical analysis plan to underpin three main papers to report aspirin effects through to the fourth post-trial ASPREE-XT study visit with focus areas of: (1) death, dementia, and disability, (2) CVD events and bleeding, and (3) cancer. The focus of the plan is to estimate long-term (entire timespan of RCT plus post-trial) and legacy (post-trial period only) effects of aspirin in the setting of primary prevention for older individuals. Preliminary insights to these effects are presented that are based on data that has been reported to the study's observational study monitoring board however formal data lock is not expected until October 2023.

Locoregional control and toxicity following high-dose hypofractionated and accelerated palliative radiotherapy regimens in breast cancer

AIMS

For patients with locally advanced primary/recurrent breast cancer, radiotherapy is an effective treatment for locoregional control. 36 Gy in 6 Gy once-weekly fractions is a commonly used schedule, but there are no data comparing local control and toxicity between 36 Gy delivered once-weekly versus accelerated schedules of multiple 6 Gy fractions per week. This retrospective study compared local control rates and acute and late toxicity in patients undergoing 30-36 Gy in 6 Gy fractions over 6 weeks versus more accelerated schedules over 2-3 weeks for an unresected breast cancer.

MATERIALS AND METHODS

Patients who received 30-36 Gy in 6 Gy fractions to an unresected breast cancer ± involved lymph nodes between December 2011 and August 2020 were identified. Patients were grouped into once-weekly versus accelerated fractionation schedules. Response rates, local control and toxicity data were analysed.

RESULTS

In total, 109 patients were identified. The median follow-up duration was 46 months. Forty-seven patients (43%) received once-weekly fractions and 62 patients (57%) received accelerated fractionation schedules. There were no significant differences in baseline tumour characteristics between the groups. Eighty-seven per cent of patients had an objective (complete or partial) response (81% in the once-weekly group; 91% in the accelerated group). The median time to local progression was 23.5 months overall (95% confidence interval 17.8-29.2); 23.5 months (95% confidence interval 18.8-28.1) in the once-weekly group and 19.0 months (95% confidence interval 7.0-31.1) in the accelerated group (P = 0.99). Acute toxicity of any grade occurred in 75% of patients (76% in the once-weekly group; 74% in the accelerated group) and grade 3 toxicity occurred in 7% of patients (7% in the once-weekly group; 8% in the accelerated group). There were no associations between the groups and acute or late toxicity grade (P = 0.78 and P = 0.26, respectively), although one grade 4 late toxicity (skin radionecrosis) occurred in a patient who received five fractions a week and therefore this regimen is not recommended. Study limitations included a lack of statistical power analysis, the necessary grouping of all accelerated patients for analysis and a high rate of censored data.

CONCLUSION

There were no apparent differences in response rate, time to local progression or toxicity between patients who received 30-36 Gy in 6 Gy fractions once-weekly compared with twice-weekly as palliative treatment for locally advanced breast cancer. This regimen appears to be a safe alternative and may be preferred by patients.

Persistent Disability Six Months after Initial Disability Less Likely in Older Women

Many community-dwelling older adults develop activity of daily living (ADL) disability and subsequently regain function. Using data from the ASPirin in Reducing Events in the Elderly (ASPREE) clinical trial, we examined the relationship of gender, incident disability, and persistent disability 6 months after the incident disability. Walking, bathing, dressing, transferring, toileting, and eating were assessed as ADLs, at bi-annual interviews. ADL disability was defined as requiring help with or inability to do or severe difficulty with ≥1 ADL; persistent disability was an ADL loss at 6 months after a first (incident) ADL disability. Discrete time, multivariable Cox proportional hazards regression was utilized to estimate associations with developing incident ADL disability described as cause-specific hazard ratios, with death as a competing outcome. For persons with incident ADL disability, odds of developing persistent disability at 6 months as compared to recovery was determined using multivariable logistic regression. These analyses included 18,414 (51.6% women) ASPREE participants in the United States and Australia aged 70+ years (65+ years if U.S. ethnic minority) without ADL disability at trial entry. During a median follow-up of 4.7 years, 1,485 participants (63.2% women) developed an incident ADL disability, and, of those, 272 (57.0% women) met criteria for persistent disability at 6 months. Women had an increased risk (HR=1.17, 95% CI=1.05 to 1.32) of developing incident ADL disability; however, women were less likely to have persistent disability versus recovery 6 months later (OR=0.66, 95% CI=0.49 to 0.89). Why persistent disability development is lower in older women needs further exploration.

P046 A review and retrospective case series of paediatric Sjögren’s syndrome from Southern Africa

Background

Paediatric Sjögren’s syndrome (pSS) is an uncommon autoimmune paediatric disease, rarely reported in children in Africa. It remains an important consideration in a child with parotid swelling. Here, we present a retrospective case-series of four patients from a paediatric rheumatology clinic in South Africa and discuss some of the difficulties of diagnosis in our context.

Methods

We performed a retrospective analysis of patients who attend the Red Cross War Memorial Hospital Paediatric Rheumatology clinic between 2010 and 2019.

Result

The four patients diagnosed with Sjögren’s all had varied presentations and disease courses. There were 3 females and 1 male and the ages at diagnosis ranged from 6 to 19 years old. The time to diagnosis was prolonged and ranged from 1 month to 10 years. Two patients with primary pSS presented with extra-articular manifestations of arthritis, abdominal pain and fatigue, followed by dry mouth, dry eyes, parotid swelling and and suggestive histopathology. The remaining 2 patients had a secondary pSS due to juvenile onset SLE and tuberculosis respectively.

Conclusion

In less resourced settings the diagnosis of pSS is often delayed. Both patients with primary pSS had preceding extra-glandular manifestations. In less resourced settings, infectious diseases may present as pSS and associated rheumatic diseases causing secondary pSS must be considered.

Psychosocial outcomes of peer support for patients with an inherited cardiac condition

Funding Acknowledgements

Type of funding sources: None.

Introduction

Inherited cardiac conditions (ICCs) are feared for their risk of sudden death. Individuals are often young and diagnosed after the sudden death of an apparently healthy family member. A diagnosis can have a profound psychological impact and negative effect on quality of life. Uncertainty surrounding the natural history of some diseases causes anxiety and concern about existing children or starting a family. Necessary lifestyle adjustments are often associated with a sense of isolation during social engagement with peers. Psychological support for such patients is scarce. However, a specialist nurse led peer group support within the ICC service may improve psychological outcomes and empower patients to support others. 

Purpose

To determine the effect of a nurse led peer support group on subjective psychological symptoms for patients with ICCs.

Methods

A pilot specialist nurse support group was established in February 2020 including 30 patients with ICCs. This consisted of a meeting in person followed by 6 subsequent 2 monthly online video meetings. Each session lasted 2 hours and included a talk by a healthcare professional on an ICC related topic, followed by an open forum for group discussion facilitated by the specialist nurse. An online social media chat forum was also developed. After 1 year, a bespoke questionnaire was distributed to all participants enquiring about the effect of group support on anxiety level, sense of isolation, knowledge about their condition and empowerment to support themselves and others. 

Results

21 (70%) patients aged between 20 and 65 years old (mean age 49) responded. Diagnoses included Brugada syndrome, arrhythmogenic cardiomyopathy, dilated cardiomyopathy, hypertrophic cardiomyopathy and long QT syndrome. All participants agreed that the group provided a comfortable platform to ask questions about their condition. 95% of participants were keen to know more about their condition after diagnosis of which 86% agreed that knowledge about their condition had improved since joining the group. 90% of participants experienced anxiety related to their condition before joining the group of which 76% reported reduced levels since joining. 76% felt isolated after their diagnosis of which 86% reported that these feelings had lessened since joining the group. 86% of the group agreed that group discussion empowered them and helped them support other affected individuals. 

Conclusion

A pilot study support group for patients with ICCs reduced anxiety and sense of isolation, improved knowledge, and sense of empowerment and willingness to support other patients in ≥ 80% of attendees. There is potential that patient support groups can be kick started by specialist nurses and subsequently allowed to run by patients themselves. Apart from improving psychological outcomes, such practice may reduce the workload for the ICC multidisciplinary team.

Treating the Lips and Its Anatomical Correlate in Respect to Vascular Compromise

Treating the lips to increase facial attractiveness and youthfulness is challenging when trying to consider ethnic differences in an increasingly more diverse society. Multiple injection techniques are currently available for treating lip contour and volume, but a validation in the cadaveric model under the aspects of safety has not been performed yet. The injection techniques presented in this study are based on the experience and personal selection of the authors. The authors have assessed, treated, and evaluated for more than 20 years patients from the Middle East and Central Europe. Cadaveric verification was performed for each of the presented techniques to identify the positioning of the injected product inside the lips and its relation to the superior/inferior labial arteries. The results of the anatomic analyses revealed that in 58.3% of the performed injections, the product was placed close to the superior/inferior labial arteries. In 60.0% of the cases, applications using a needle placed the injected product in endangered locations, whereas 57.1% of the cases using cannulas placed the product in endangered locations (i.e., in the vicinity of the superior/inferior labial arteries). This anatomic study revealed that injected material into the lips is frequently placed in close proximity to labial arteries representing a high risk for intra-arterial applications, leading to tissue loss (necrosis) and potential end-arterial embolism (potential blindness). Nevertheless, treatment of the lips should be a multistep approach focusing first on the far (upper and middle face) and close (labiomandibular and labiomental) perioral regions.

The prevalence of community programmes and policies to prevent childhood obesity in a diverse sample of US communities: the Healthy Communities Study

INTRODUCTION

This manuscript describes the prevalence and attributes of community programmes and policies (CPPs) to address childhood obesity documented as occurring in 130 diverse US communities.

METHODS

Key informant interviews (N = 1420) and document abstraction were used to identify and characterize CPPs to promote physical activity and healthy nutrition occurring during a 10-year retrospective study period. Data were collected in 2013-2015 and analysed in 2016.

RESULTS

Across all 130 communities, 9681 distinct CPPs were reported as occurring by key informants. Of these, 5574 (58%) focused on increasing physical activity, 2596 (27%) on improving nutrition and 1511 (16%) on both behaviours. The mean number of CPPs per community was 74.0, with a range of 25 to 295 across all communities. Most CPPs occurred more than once (63%) and on average lasted 6.1 years. The greatest number of reported CPPs occurred in school settings (44%).

CONCLUSIONS

Communities showed a wide range of investment in the amount of CPPs occurring in settings that affect opportunities for children to engage in physical activity and healthy nutrition. The pattern of implementation of CPPs showed variation over time, with an increase in more recent years. This observational study provides new and valuable information about what US communities are doing to prevent childhood obesity.

The longitudinal relationship between community programmes and policies to prevent childhood obesity and BMI in children: the Healthy Communities Study

BACKGROUND

Although a national epidemic of childhood obesity is apparent, how community-based programmes and policies (CPPs) affect this outcome is not well understood.

OBJECTIVES

This study examined the longitudinal relationship between the intensity of CPPs in 130 communities over 10 years and body mass index (BMI) of resident children. We also examined whether these relationships differ by key family or community characteristics.

METHODS

Five thousand one hundred thirty-eight children in grades K-8 were recruited through 436 schools located within 130 diverse US communities. Measures of height, weight, nutrition, physical activity and behavioural and demographic family characteristics were obtained during in-home visits. A subsample of families consented to medical record review; these weight and height measures were used to calculate BMI over time for 3227 children. A total of 9681 CPPs were reported during structured interviews of 1421 community key informants, and used to calculate a time series of CPP intensity scores within each community over the previous decade. Linear mixed effect models were used to assess longitudinal relationships between childhood BMI and CPP intensity.

RESULTS

An average BMI difference of 1.4 kg/m² (p-value < 0.01) was observed between communities with the highest and lowest observed CPP intensity scores, after adjusting for community and child level covariates. BMI/CPP relationships differed significantly by child grade, race/ethnicity, family income and parental education; as well as community-level race/ethnicity.

CONCLUSIONS

These results indicate that, over time, more intense CPP interventions are related to lower childhood BMI, and that there are disparities in this association by sociodemographic characteristics of families and communities.

A Simplified Approach to Select Exercise Endurance Intensity for Interventional Studies in COPD

Time to exercise limitation (Tlim) in response to constant work rate (CWR) is sensitive to interventions in chronic obstructive pulmonary disease (COPD). This is particularly true when the pre-intervention test lasts between 3 and 8 min (Tlim_3'-8'). There is, however, no simple method to select a work rate which is consistently associated with Tlim_3'-8' across the spectrum of COPD severity. We assessed 59 GOLD stages II-IV patients who initially cycled to Tlim at 75% peak. In case of short (<3 min, low-endurance) or long (>8 min, high-endurance) tests, patients exercised after 60 min at 50% or 90%, respectively (CWR_{50%⇐75%⇒90%}). Critical mechanical constraints and limiting dyspnea at 75% were reached within the desired timeframe in 27 "mid-endurance" patients (46%). Increasing work rate intensity to 90% hastened the mechanical-ventilatory responses leading to Tlim_3'-8' in 23/26 (88%) "high-endurance" patients; conversely, decreasing exercise intensity to 50% slowed those responses leading to Tlim_3'-8' in 5/6 (83%) "high-endurance" patients. Repeating the tests at higher (60%) or lower (80%) intensities fail to consistently produce Tlim_3'-8' in "low-" and "high-endurance", respectively (p > 0.05). Compared to a fixed work rate at 75%, CWR_{50%⇐75%⇒90%} significantly decreased Tlim's coefficient of variation; consequently, the required N to detect 100 s or 33% improvement in Tlim decreased from 82 to 26 and 41 to 14, respectively. This simplified approach to individualized work rate adjustment (CWR_{50%⇐75%⇒90%}) might allow greater sensitivity in evaluating interventional efficacy in improving respiratory mechanics and exercise tolerance while simultaneously reducing sample size requirements in patients with COPD.

The Effects of Scaphoid and Colles Casts on Hand Function

Although necessary for bone healing, immobilisation temporarily prevents hand function and may necessitate corrective physiotherapy later. Scaphoid and Colles casts are both commonly used to immobilize scaphoid fractures. Non-union rates are comparable with both casts. The Scaphoid cast incorporates the thumb, whereas the Colles cast leaves the thumb free. We compared the effect of the two casts on hand function in 20 healthy right-hand-dominant volunteers using the Jebsen–Taylor Hand Function Test. Data were obtained through a mixed between and within subject design. Both casts prolonged the time taken to complete the hand function test compared to controls. Testing in the Scaphoid cast took significantly longer than in the Colles cast.

Chronic obstructive pulmonary disease: clinical integrative physiology

Peripheral airway dysfunction, inhomogeneous ventilation distribution, gas trapping, and impaired pulmonary gas exchange are variably present in all stages of chronic obstructive pulmonary disease (COPD). This article provides a cogent physiologic explanation for the relentless progression of activity-related dyspnea and exercise intolerance that all too commonly characterizes COPD. The spectrum of physiologic derangements that exist in smokers with mild airway obstruction and a history compatible with COPD is examined. Also explored are the perceptual and physiologic consequences of progressive erosion of the resting inspiratory capacity. Finally, emerging information on the role of cardiocirculatory impairment in contributing to exercise intolerance in patients with varying degrees of airway obstruction is reviewed.

Survival outcomes and prognostic factors in mycosis fungoides/Sézary syndrome: validation of the revised International Society for Cutaneous Lymphomas/European Organisation for Research and Treatment of Cancer staging proposal

PURPOSE

We have analyzed the outcome of mycosis fungoides (MF) and Sézary syndrome (SS) patients using the recent International Society for Cutaneous Lymphomas (ISCL)/European Organisation for Research and Treatment of Cancer (EORTC) revised staging proposal.

PATIENTS AND METHODS

Overall survival (OS), disease-specific survival (DSS), and risk of disease progression (RDP) were calculated for a cohort of 1,502 patients using univariate and multivariate models.

RESULTS

The mean age at diagnosis was 54 years, and 71% of patients presented with early-stage disease. Disease progression occurred in 34%, and 26% of patients died due to MF/SS. A significant difference in survival and progression was noted for patients with early-stage disease having patches alone (T1a/T2a) compared with those having patches and plaques (T1b/T2b). Univariate analysis established that (1) advanced skin and overall clinical stage, increased age, male sex, increased lactate dehydrogenase (LDH), and large-cell transformation were associated with reduced survival and increased RDP; (2) hypopigmented MF, MF with lymphomatoid papulosis, and poikilodermatous MF were associated with improved survival and reduced RDP; and (3) folliculotropic MF was associated with an increased RDP. Multivariate analysis established that (1) advanced skin (T) stage, the presence in peripheral blood of the tumor clone without Sézary cells (B0b), increased LDH, and folliculotropic MF were independent predictors of poor survival and increased RDP; (2) large-cell transformation and tumor distribution were independent predictors of increased RDP only; and (3) N, M, and B stages; age; male sex; and poikilodermatous MF were only significant for survival.

CONCLUSION

This study has validated the recently proposed ISCL/EORTC staging system and identified new prognostic factors.

Molecular characterisation of 'strangles' outbreaks in the UK: the use of M-protein typing of Streptococcus equi ssp. equi

REASONS FOR PERFORMING STUDY

Strangles is the most commonly diagnosed and important infectious disease of horses worldwide. Very little is known about the temporo-spatial and molecular epidemiology of strangles. The disease is not notifiable in the UK and there are few published data on the geographical locations of outbreaks.

OBJECTIVE

To investigate whether typing of a surface protein (SeM) of Streptococcus equi ssp. equi (S. equi), the causative agent of strangles, is a useful epidemiological tool.

METHODS

The variable region of the SeM gene was amplified from 145 isolates of S. equi by PCR and sequenced. Different SeM gene alleles were assigned based on the SeM database, grouped into phylogenetic clusters using split decomposition analysis and plotted against the submitting veterinary practices.

RESULTS

In this study 21 S. equi SeM alleles were found, including 9 previously unidentified alleles and representing 4 phylogenetic groups. S. equi containing SeM alleles 9 and 7 were the most commonly isolated and there was a high number of low frequency alleles. The occurrence of an outbreak cluster in the north-west of the UK is also reported.

CONCLUSIONS

Strangles outbreaks can be differentiated on the basis of their SeM allele sequences. The data provide further evidence of SeM mutation leading to the emergence of novel, but related SeM alleles that are geographically linked. Sequencing of the SeM gene is a useful tool for the elucidation of strangles epidemiology at a regional and a national level.

POTENTIAL RELEVANCE

This technique may allow differentiation or linkage of strangles outbreaks and as such may be an effective tool for local as well as national and international disease surveillance.