ID: 57: PRE-GESTATIONAL DIABETES AND PREECLAMPSIA IN BANGLADESHI PATIENTS: A RETROSPECTIVE STUDY

Objective

Preeclampsia (PreE) is one of considerable public health threat particularly in developing countries globally affecting approximately 8% of all pregnancies. PreE is a pregnancy-specific condition that increases maternal and infant mortality and morbidity, but the etiology remains unknown. Despite numerous basic, clinical, and epidemiologic studies that have been conducted over the past half century, knowledge of the etiology and pathogenesis of preeclampsia remains elusive. It is diagnosed by new onset increased blood pressure and proteinuria during second or third trimester of gestation; key features of the preeclampsia category include a cut-off blood pressure of 140/90 mm Hg or higher and absolute requirement of proteinuria. Approximately 20% of the diabetic pregnant women develop preE. The mechanisms contributing to this effect is not well characterized. In a recent study, we have shown that hyperglycemia impairs cytotrophoblast (CTB) function via stress signaling. Several researchers demonstrate a direct link between preE and diabetes. The objective of the study was to evaluate potential linkage between the risk of developing preE and the presence of diabetes in pregnant patients in Bangladesh.

Methods

This is a cross-sectional study of 351 pregnant women performed to evaluate the prevalence of PreE with respect to different risk factors such as previous pregnancy, presence of Antiphospholipid antibodies, pre-existing diabetes (before this pregnancy), multiple gestation / singleton, family history of preE in first degree relative (mother, sister and daughters; most commonly mother), maternal age of 40 or greater. The study was conducted in selected hospitals of Dhaka city, Bangladesh during December 2013 to December 2015.

Results

The key study findings revealed that the overall rate of development of PreE in Bangladeshi pre-gestational diabetic patients is 22.6 percent. We gave special emphasis on the occurrence of PreE in pre-gestational diabetic patients. Among 351 respondents, 145 Patients (25.5%) with either DM prior to pregnancy or developing gestational diabetes or without diabetes were older (age >35 years) pregnant women (13.1%). Prevalence of PreE is 25.5 (n=145) and 19.6 (n=199) percent among those who developed pre-gestational diabetes and without diabetes prior to pregnancy. Of the respondents 17.2 percent have both systolic and diastolic hypertension those who developed DM prior to this pregnancy and 13 percent among those who does not developed DM prior to this pregnancy. Occurrence of abortion was up to 3 percentage before this pregnancy 45 percentage who developed DM prior to this pregnancy and 35 percent who does not have diabetes among the respondents.

Conclusions

There is an association has been found between the risk of developing preE and the presence of diabetes in pregnant patients in Bangladesh.

Duplicate orders: an unintended consequence of computerized provider/physician order entry (CPOE) implementation: analysis and mitigation strategies

OBJECTIVE

Computerized provider/physician order entry (CPOE) with clinical decision support (CDS) is designed to improve patient safety. However, a number of unintended consequences which include duplicate ordering have been reported. The objective of this time-series study was to characterize duplicate orders and devise strategies to minimize them.

METHODS

Time series design with systematic weekly sampling for 84 weeks. Each week we queried the CPOE database, downloaded all active orders onto a spreadsheet, and highlighted duplicate orders. We noted the following details for each duplicate order: time, order details (e.g. drug, dose, route and frequency), ordering prescriber, including position and role, and whether the orders originated from a single order or from an order set (and the name of the order set). This analysis led to a number of interventions, including changes in: order sets, workflow, prescriber training, pharmacy procedures, and duplicate alerts.

RESULTS

Duplicates were more likely to originate from different prescribers than from same prescribers; and from order sets than from single orders. After interventions, there was an 84.8% decrease in the duplication rate from weeks 1 to 84 and a 94.6% decrease from the highest (1) to the lowest week (75). Currently, we have negligible duplicate orders.

CONCLUSIONS

Duplicate orders can be a significant unintended consequence of CPOE. By analyzing these orders, we were able to devise and implement generalizable strategies that significantly reduced them. The incidence of duplicate orders before CPOE implementation is unknown, and our data originate from a weekly snapshot of active orders, which serves as a sample of total active orders. Thus, it should be noted that this methodology likely under-reports duplicate orders.

Optimizing effectiveness of laser tympanic membrane fenestration in chronic otitis media with effusion. Clinical and technical considerations

OBJECTIVE

To describe the patient, disease and clinical characteristics that optimize the effectiveness of laser tympanic membrane fenestration (LTMF) to treat chronic otitis media with effusion (OME).

SETTING

Four pediatric otolaryngology tertiary referral centers. IRB approved; participation by informed consent.

METHODS

An observational clinical effectiveness trial was conducted in 164 ears (94 children), who had chronic OME. All patients were candidates for insertion of pressure equalization tubes (PETs) but agreed to undergo LTMF instead. Clinical and audiologic follow-up are reported at 90 days after LTMF.

OUTCOME MEASURES

Clinical effectiveness was defined as an effusion free middle ear at otoscopy with A or C1 tympanogram and normal hearing.

RESULTS

At 90 days, 66% of the 95 evaluable ears were effusion free, all with normal hearing. Children younger than 4 years (P<0.04), who had shorter durations of effusion (P<0.009), and who experienced longer duration of fenestration patency (FP) (P<0.009) correlated to improved outcomes.

CONCLUSIONS

The use of LTMF to create 2--3 weeks of middle ear ventilation in patients with chronic OME (middle ear effusion (MEE) for 3 months or greater) is effective in 66% of 95 (58%) of ears evaluable at 90 days follow-up. This study provides basic information needed to optimize the use of LTMF today and enhance research efforts in the future.

Office-based laser assisted tympanic membrane fenestration in adults and children: pilot data to support an alternative to traditional approaches to otitis media

OBJECTIVES

To determine the role of intermediate duration ( approximately 3 weeks) middle ear ventilation using office-based laser assisted tympanic membrane fenestration in resolving an episode of otitis media with effusion in adults and children who otherwise would have been treated with insertion of pressure equalization tubes.

METHODS

A retrospective chart review of 92 patients (162 ears) was conducted to identify the utility and technical challenges associated with laser assisted tympanic membrane fenestration in an office setting. Clinical characteristics reviewed included: age, gender, duration of effusion, season performed, and hearing and health status of middle ear upon healing of the fenestration.

RESULTS

69% of all patients were effusion free upon closure of the fenestration; 68% of those <3 years; 70% of those 3-7 years; and 70% of those 25-80 years. Some episodes recurred and at final follow-up 64% had normal middle ear structure and function (range of follow-up =1-18 months, mean 2.5 months, median 2.0). Shorter duration of effusion pre-fenestration was more often associated with return to normal middle ear structure and function (P<0.01). Season performed, number of previous episodes of otitis media and pre-treatment tympanometry were not predictive of result. No significant complications were observed.

CONCLUSIONS

The use of office-based laser assisted tympanic membrane fenestration is a reasonably safe and effective procedure for the treatment of otitis media in most adults and children. As a minimally invasive otologic procedure, laser assisted tympanic membrane fenestration has great potential to decrease the rates of both antibiotic usage and insertion of ear tubes.

Office-based insertion of pressure equalization tubes: the role of laser-assisted tympanic membrane fenestration

OBJECTIVE

To describe the role of the hand-held otoscope combined with a flashscanner CO2 laser, OtoLAM (ESC/Sharplan, Yokneam, Israel), for pressure equalization tube (PET) insertion in an office setting.

STUDY DESIGN

Prospective, multisite, clinical cohort trial (Institutional Review Board approved; informed consent) in the setting of pediatric otolaryngology outpatient departments at four tertiary care children's hospitals.

METHODS

Selected for the study were 54 patients (96 ears), ages 6 months to 23 years, who met standard indications for PET insertion using cold-knife myringotomy and tube insertion under general anesthesia. PETs were indicated for recurrent otitis media, chronic otitis media with effusion, and eustachian tube dysfunction-all unresponsive to medical therapy. Topical anesthesia was achieved with iontophoresis (n = 1) or topical anesthesia: 8% tetracaine on an Otowick (Xomed Surgical Products, Jacksonville, FL, catalogue No. 400141) against the tympanic membrane for 45 to 180 minutes (n = 53). Laser-assisted tympanic membrane fenestration was performed with the OtoLAM set at single pulse, 2.0- to 2.6-mm spot size, and between 3 and 18 W. Insertion of grommets was accomplished using the otomicroscope and an "alligator" microforceps. Restraints with papoose were used in 79% of children with a mean age of 34.4 months (SD = 60.9 mo). Clinical, parent/patient, and physician satisfaction and comparative cost impact outcomes are described.

RESULTS

All ears but three (3%) underwent successful placement of a PET. Pain was described as "absent" in 39%, "present but tolerable" in 30%, and "severe" in 30% of children at the time of procedure; 5 minutes after the procedure pain was described as "absent" in 75%, "present but tolerable" in 22%, and "severe" in 3%. Tube plugging (3 of 74 available ears; 4%) or persistent otorrhea (1 of 74 ears; 1.4%) occurred infrequently at the 1-month follow-up. Before PET insertion, hearing loss was noted in 66% of cases (mild, 38%; moderate, 22%; and severe, 6%). Mild hearing loss was noted in only 8% and moderate hearing loss in 2% of 47 (50%) of the ears at the 3-month follow-up. Ninety-two percent of parents were highly satisfied with the procedure in preference to PETs in the operating room under general anesthesia, and 97% preferred OtoLAM with PET insertion, rather than further courses of antibiotics; only one parent would rather have had the PET insertion under general anesthesia. Cost savings to health care organizations, particularly payers, and to parents are substantial (32%-48%) and warrant attention. Cost to the physician is manageable only if an appropriate approach to the third party payers results in a substantial increase in reimbursements.

CONCLUSIONS

The data indicate excellent clinical effectiveness, reduced risk, and high parent and physician satisfaction. Strong incentives for physicians to use this technique are in all stakeholders' best interests. These incentives need to evolve as soon as possible for the more widespread acceptance of OtoLAM with PET insertion in an office setting for appropriately selected patients.

Predicting return to work. A long-term follow-up study of railroad workers after low back injuries

STUDY DESIGN

Evaluation of the long-term outcomes of 178 railroad employees with low back injury who had completed a multidisciplinary rehabilitation program.

OBJECTIVES

To study two major areas: 1) outcomes of the rehabilitation program in terms of the patient's improvement in function and rate of return to work and 2) factors that predict long-term retention at work, both at the railroad and elsewhere.

SUMMARY OF BACKGROUND DATA

Several studies have been published examining rehabilitation outcomes of individuals covered under workers' compensation law, but few exist that have examined railroad workers covered by the Federal Employers Liability Act, and few studies exist with follow-up periods longer than 3 years.

METHODS

Physical/medical, self-reported, and employment/financial data were collected on each patient from medical and employment records. Follow-up data regarding employment status were obtained either from the employer or from the patient by telephone interview.

RESULTS

On average, the patients improved in all objective and subjective measures after rehabilitation. Improvements in these measures were not predictive of return to work. At follow-up examination, 89% of the contacted patients were employed--61% still at the rail-road. The employment factors of lost work days and length of employment and the financial factor of wage rate were the most predictive of long-term work status.

CONCLUSIONS

The multidisciplinary program in the current study was found to improve patient physical functioning and reduce pain. However, success in these measures was not predictive of long-term work status, suggesting that other factors have an impact on work status. Clinicians must be aware that employment and financial factors may have a strong influence on return-to-work outcomes.