Geographical accessibility to functional emergency obstetric care facilities in urban Nigeria using closer-to-reality travel time estimates: a population-based spatial analysis

BACKGROUND

Better accessibility for emergency obstetric care facilities can substantially reduce maternal and perinatal deaths. However, pregnant women and girls living in urban settings face additional complex challenges travelling to facilities. We aimed to assess the geographical accessibility of the three nearest functional public and private comprehensive emergency obstetric care facilities in the 15 largest Nigerian cities via a novel approach that uses closer-to-reality travel time estimates than traditional model-based approaches.

METHODS

In this population-based spatial analysis, we mapped city boundaries, verified and geocoded functional comprehensive emergency obstetric care facilities, and mapped the population distribution for girls and women aged 15-49 years (ie, of childbearing age). We used the Google Maps Platform's internal Directions Application Programming Interface to derive driving times to public and private facilities. Median travel time and the percentage of women aged 15-49 years able to reach care were summarised for eight traffic scenarios (peak and non-peak hours on weekdays and weekends) by city and within city under different travel time thresholds (≤15 min, ≤30 min, ≤60 min).

FINDINGS

As of 2022, there were 11·5 million girls and women aged 15-49 years living in the 15 studied cities, and we identified the location and functionality of 2020 comprehensive emergency obstetric care facilities. City-level median travel time to the nearest comprehensive emergency obstetric care facility ranged from 18 min in Maiduguri to 46 min in Kaduna. Median travel time varied by location within a city. The between-ward IQR of median travel time to the nearest public comprehensive emergency obstetric care varied from the narrowest in Maiduguri (10 min) to the widest in Benin City (41 min). Informal settlements and peripheral areas tended to be worse off compared to the inner city. The percentages of girls and women aged 15-49 years within 60 min of their nearest public comprehensive emergency obstetric care ranged from 83% in Aba to 100% in Maiduguri, while the percentage within 30 min ranged from 33% in Aba to over 95% in Ilorin and Maiduguri. During peak traffic times, the median number of public comprehensive emergency obstetric care facilities reachable by women aged 15-49 years under 30 min was zero in eight (53%) of 15 cities.

INTERPRETATION

Better access to comprehensive emergency obstetric care is needed in Nigerian cities and solutions need to be tailored to context. The innovative approach used in this study provides more context-specific, finer, and policy-relevant evidence to support targeted efforts aimed at improving comprehensive emergency obstetric care geographical accessibility in urban Africa.

FUNDING

Google.

Advances in Gluten Hypersensitivity: Novel Dietary-Based Therapeutics in Research and Development

Gluten hypersensitivity is characterized by the production of IgE antibodies against specific wheat proteins (allergens) and a myriad of clinical allergic symptoms including life-threatening anaphylaxis. Currently, the only recommended treatment for gluten hypersensitivity is the complete avoidance of gluten. There have been extensive efforts to develop dietary-based novel therapeutics for combating this disorder. There were four objectives for this study: (i) to compile the current understanding of the mechanism of gluten hypersensitivity; (ii) to critically evaluate the outcome from preclinical testing of novel therapeutics in animal models; (iii) to determine the potential of novel dietary-based therapeutic approaches under development in humans; and (iv) to synthesize the outcomes from these studies and identify the gaps in research to inform future translational research. We used Google Scholar and PubMed databases with appropriate keywords to retrieve published papers. All material was thoroughly checked to obtain the relevant data to address the objectives. Our findings collectively demonstrate that there are at least five promising dietary-based therapeutic approaches for mitigating gluten hypersensitivity in development. Of these, two have advanced to a limited human clinical trial, and the others are at the preclinical testing level. Further translational research is expected to offer novel dietary-based therapeutic options for patients with gluten hypersensitivity in the future.

Incidence of Pneumonia, Related Hospitalization, and Mortality Among Younger Unvaccinated IBD Patients in a Nationwide Cohort

BACKGROUND AND GOALS

Community Acquired Pneumonia (CAP) is among the most common infections among Inflammatory Bowel Disease (IBD) patients. Our aim was to determine the absolute and relative risk of CAP, related hospitalization, and death among younger (age < 65) unvaccinated IBD patients exposed and unexposed to immunosuppressive medications.

MATERIALS AND METHODS

We conducted a retrospective cohort study among a nationwide cohort of younger IBD unvaccinated patients in the VAHS. Exposure was administration of any immunosuppressive medication. The primary outcome was the first occurrence of pneumonia; secondary outcomes being pneumonia related hospitalization and mortality. We reported event rate per 1000 person-years, hazard ratio, and 95% confidence intervals (CIs) for each outcome.

RESULTS

Among a total of 26,707 patients, 513 patients developed pneumonia. Mean age in years (SD) was 51.67 (11.34) for the exposed and 45.91 (12.34) for the unexposed group. The overall crude incidence rate was 3.2 per 1000 patient-years (PYs) [4.04/1000 PYs in the exposed versus 1.45/1000 PYs in the unexposed]. The overall crude incidence rates for pneumonia-related-hospitalization and mortality 1.12 and 0.09 per 1000 PYs, respectively. In Cox regression, the exposed group was associated with an increased risk of pneumonia (AHR 2.85; 95% CI: 2.21 to 3.66, P < 0.001) and pneumonia-related-hospitalization (AHR 3.46; 95% CI: 2.20 to 5.43, P < 0.001).

CONCLUSIONS

Overall incidence of CAP among younger unvaccinated IBD patients was 3.2 per 1000 PYs. The overall associated hospitalization rates were low, however, higher amongst those exposed to immunosuppressive medications. This data will help patients and physicians make informed decisions regarding pneumococcal vaccine recommendations.

Socio-spatial equity analysis of relative wealth index and emergency obstetric care accessibility in urban Nigeria

BACKGROUND

Better geographical accessibility to comprehensive emergency obstetric care (CEmOC) facilities can significantly improve pregnancy outcomes. However, with other factors, such as affordability critical for care access, it is important to explore accessibility across groups. We assessed CEmOC geographical accessibility by wealth status in the 15 most-populated Nigerian cities.

METHODS

We mapped city boundaries, verified and geocoded functional CEmOC facilities, and assembled population distribution for women of childbearing age and Meta's Relative Wealth Index (RWI). We used the Google Maps Platform's internal Directions Application Programming Interface to obtain driving times to public and private facilities. City-level median travel time (MTT) and number of CEmOC facilities reachable within 60 min were summarised for peak and non-peak hours per wealth quintile. The correlation between RWI and MTT to the nearest public CEmOC was calculated.

RESULTS

We show that MTT to the nearest public CEmOC facility is lowest in the wealthiest 20% in all cities, with the largest difference in MTT between the wealthiest 20% and least wealthy 20% seen in Onitsha (26 vs 81 min) and the smallest in Warri (20 vs 30 min). Similarly, the average number of public CEmOC facilities reachable within 60 min varies (11 among the wealthiest 20% and six among the least wealthy in Kano). In five cities, zero facilities are reachable under 60 min for the least wealthy 20%. Those who live in the suburbs particularly have poor accessibility to CEmOC facilities.

CONCLUSIONS

Our findings show that the least wealthy mostly have poor accessibility to care. Interventions addressing CEmOC geographical accessibility targeting poor people are needed to address inequities in urban settings.

A geospatial database of close-to-reality travel times to obstetric emergency care in 15 Nigerian conurbations

Travel time estimation accounting for on-the-ground realities between the location where a need for emergency obstetric care (EmOC) arises and the health facility capable of providing EmOC is essential for improving pregnancy outcomes. Current understanding of travel time to care is inadequate in many urban areas of Africa, where short distances obscure long travel times and travel times can vary by time of day and road conditions. Here, we describe a database of travel times to comprehensive EmOC facilities in the 15 most populated extended urban areas of Nigeria. The travel times from cells of approximately 0.6 × 0.6 km to facilities were derived from Google Maps Platform's internal Directions Application Programming Interface, which incorporates traffic considerations to provide closer-to-reality travel time estimates. Computations were done to the first, second and third nearest public or private facilities. Travel time for eight traffic scenarios (including peak and non-peak periods) and number of facilities within specific time thresholds were estimated. The database offers a plethora of opportunities for research and planning towards improving EmOC accessibility.

Situational analysis of women empowerment in urban field practice area of Dr. M. K. Shah Medical College and Research Center, Ahmedabad

Introduction

Women empowerment in society and family are closely linked to decision-making. Empowerment of women is essentially the process of upliftment of economic, social, and political status of women, the traditionally underprivileged ones, in society. It involves the building up of a society wherein women can breathe without the fear of oppression, exploitation, apprehension, discrimination, and the general feeling of persecution which goes with being a woman in a traditionally male dominated society. The present study was conducted to assess women's empowerment status and factors affecting it.

Material and Method

Community-based cross-sectional study was carried out among 175 women residing in urban field practice area of Dr. M. K. Shah Medical College and Research Centre, Ahmedabad. A pre-designed questionnaire was used for data collection by interviewing the women through house to house survey. Data were entered in Microsoft Excel and analyzed using (Statistical Package for the Social Sciences (SPSS).

Result

Around 85.71% of women were involved in decisions regarding trivial issues. A total of 17.72% of the women reported that they had suffered some form of domestic violence in their life. Around 23% of the women were not involved in any financial decisions of the family. Association between education of the women and involvement in decision-making was found statistically significant. Employment increases the participation of women in financial decision-making. 88.89% of employed women participated in financial decisions, while 71.42% of housewives were participating in these decisions.

Conclusion

Education and employment were found to have impact on decision-making. So, education of girls should be given the priority.

Retraction: The Consequences of COVID-19 on Breast Cancer Screenings in an Underserved Urban Population and the Screening Access of Value for Essex Program's Efforts to Control the Damage

[This retracts the article DOI: 10.7759/cureus.42338.].

Evaluating Health Disparities in Radiology Practices in New Jersey: Exploring Radiologist Geographical Distribution

OBJECTIVE

This study aimed to determine if a disproportionate number of radiologists practice in high-income versus low-income counties in New Jersey (NJ), identify which vulnerable populations are most in need of more radiologists, and discuss how these relative differences can ultimately influence health outcomes.

METHODS

The NJ Health Care Profile, a database overseen and maintained by the Division of Consumer Affairs, was queried for all actively practicing radiologists within the state of NJ. These results were grouped into diagnostic and interventional radiologists followed by further stratification of physicians based on the counties where they currently practice. The median household income and population size of each county for 2021 were obtained from the US Census database. The ratio of the population size of each county over the number of radiologists in that county was used as a surrogate marker for disparities in patient care within the state and was compared between counties grouped by levels of income.

RESULTS

Of the 1,186 board-certified radiologists actively practicing within the state of NJ, 86% are solely diagnostic radiologists and 14% are interventional radiologists. About 44% of radiologists practice within counties that are within the top one-third of median household income in NJ, 25% practice within counties in the middle one-third, and 31% practice within counties in the bottom one-third.

CONCLUSIONS

There is a disproportionate number of radiologists practicing in high-income counties as opposed to lower-income counties. A contradiction to this trend was noted in three low-income counties: Essex, Camden, and Atlantic County, all of which exhibited low numbers of individuals per radiologist that rivaled those of higher-income counties. This finding is a concrete measure of successful radiologist recruitment efforts within these counties during the past few years to combat the increased prevalence of disease and associated complications that historically marginalized communities tend to disproportionately exhibit. Other low-income counties should look to what Essex, Camden, and Atlantic County have done to increase radiologist recruitment to levels that rival those of high-income areas.

Effectiveness of resin infiltration (ICON) and microabrasion-remineralization technique with two remineralizing agents (Tooth Mousse and Toothmin) on permanent incisor hypoplasia - A randomized clinical trial

Aims

The study aims to compare the effect of resin infiltration and microabrasion-remineralization (MAb-Re) with Tooth Mousse and Toothmin on permanent incisor hypoplasia.

Materials and Methods

The study included children with permanent incisor hypoplasia above 9 years of age, 171 teeth divided randomly into four groups: Group A - ICON, Group B - MAb-Re using Tooth Mousse, Group C - MAb-Re using Toothmin, and Group D - control group. Process involved taking standardized photographs at T1 - before intervention, T2 - immediately after treatment, and T3 - 6-month follow-up. Color evaluation, area calculation, participant and expert opinion using a Likert scale, treatment time, and cost-effectiveness were all taken into consideration during the assessment.

Statistical Analysis Used

Data were collected, entered into a computer, and analyzed; one-way ANOVA was used for intergroup assessment.

Results

Overall color change was evident immediately after treatment in the ICON group compared to other groups (P < 0.05). However, no significant difference in color change was visible between the groups after 6 months. Reduction in hypoplastic area was seen in all the groups. The mean time was similar for all the groups. Toothmin was found to be the most cost-effective in comparison with the other two interventions.

Conclusions

ICON proved to be more effective immediately after treatment for masking incisor hypoplasia. However, at 6-month follow-up interval, all the groups gave similar results.

The Consequences of COVID-19 on Breast Cancer Screenings in an Underserved Urban Population and the Screening Access of Value for Essex Program's Efforts to Control the Damage

OBJECTIVE

This study aims to examine the impact of the COVID-19 pandemic on breast cancer screening in an underserved population, identify patient barriers, and discuss strategies to promote the importance of screening. Methods/operations: The Rutgers New Jersey Medical School Screening Access of Value for Essex (SAVE) program delivers cancer prevention services to the most vulnerable population in Essex County, New Jersey. The SAVE program was shut down from March 2020 to June 2020 due to COVID-19. The number of mammograms performed 18 months before the pandemic (September 2018 to March 2020) and 18 months after the shutdown of the program (July 2020 to December 2021) were recorded. A calling project was created in response to the pandemic to educate patients about COVID-19 precautions and provide healthcare and social services resources.

RESULTS

There was a 15.4% reduction in screening mammograms during the post-shutdown period (1,459 pre-COVID-19 versus 1,234 post-shutdown). The number of diagnostic mammograms increased from 264 to 272. The calling project spoke with 1,548 patients and identified the following concerns: exposure to COVID-19, language barriers, and lack of health insurance.

CONCLUSION

Although COVID-19 had a profound impact on most patients, especially in the realm of breast cancer screening, the implementation of the SAVE program's strategies such as transitioning to an appointment-only system has helped minimize the negative impacts. Reaching out to the patients, partnering with community organizations, and promoting SAVE services have played a vital role in encouraging more patients to have screening done.

Multiparametric MRI is not sufficient for prostate cancer staging: A single institutional experience validated by a multi-institutional regional collaborative

OBJECTIVE

Multiparametric magnetic resonance imaging (mpMRI) has been increasingly utilized in prostate cancer (CaP) diagnosis and staging. While Level 1 data supports MRI utility in CaP diagnosis, there is less data on staging utility. We sought to evaluate the real-world accuracy of mpMRI in staging localized CaP.

MATERIALS AND METHODS

Men who underwent radical prostatectomy (RP) for CaP in 2021 at our institution were identified. Sensitivity, specificity, positive predictive value and negative predictive value of mpMRI in predicting pT2N0 organ confined disease , extracapsular extension , seminal vesicle invasion , lymph node involvement, and bladder neck invasion were evaluated. Associations between MRI accuracy and AUA risk stratification (AUA RS), MRI institution (MRI-I), MRI strength (1.5 vs. 3T) (MRI-S), and MRI timing (MRI-T) were assessed. These analyses were repeated using Pennsylvania Urologic Regional Collaborative (PURC) data.

RESULTS

Institutional and community mpMRI CaP staging data demonstrated poor sensitivity (2.9%-49.2%% vs. 16.8%-24.4%), positive predictive value (40%-100% vs. 35.8%-68.2%), and negative predictive value (56.3%-94.3% vs. 68.4%-96.2%) in predicting surgical pathologic features - in contrast, specificity (89.1%-100% vs. 93.9%-98.6%) was adequate. mpMRI accuracy for extracapsular extension, seminal vesicle invasion, and lymph node involvement was significantly (p < 0.001) associated with AUA RS. There was no association between mpMRI accuracy and MRI-I, MRI-S, and MRI-T.

CONCLUSION

Despite enthusiasm for its use, in a real-world setting, mpMRI appears to be a poor staging study for localized CaP and is unreliable as the sole means of staging patients prior to prostatectomy. mpMRI should be used cautiously as a staging tool for CaP, and should be interpreted considering individual patient risk strata.

Evaluation of Consumer Health Information Available to Patients on Twitter About Bariatric Surgery

INTRODUCTION

Patients are increasingly utilizing social media to help them make medical decisions. Previous studies have examined Facebook for the quality of bariatric-related content; however, no research has examined Twitter, a globally favored platform, in this context. The goal of this study is to investigate the quality of bariatric-related content on Twitter that patients use to inform their decisions regarding bariatric surgery.

METHODS

Six comprehensive terms were searched on six Twitter accounts for 4 wk. Each keyword generated corresponding tweets that were classified as being either informational or noninformational. The top ten informational posts for each search term were categorized based on content type, tweet posters, and type of evidence used. A DISCERN score was calculated for each tweet to determine its quality of consumer health information.

RESULTS

A total of 7531 tweets about bariatric surgery were collected over the course of approximately 1 mo. We found that 58.9% of tweets pertained to surgical interventions, 16.2% were nutrition-related, 11.3% were progress posts, 7.8% were inspirational posts, and 5.9% pertained to lifestyle. Of the tweets pertaining to surgical interventions, 26% were posted by physicians, and 13.7% of those physicians used scientific evidence. The relationship between the average total DISCERN scores and each variable was statistically significant.

CONCLUSIONS

Even though physicians posted the highest quality consumer information, that information still correlated with an average DISCERN score of "very poor". Twitter may provide a good way to foster community and get anecdotal information but is not a place to gather high-quality scientific consumer health information.

Pre-transplant Biomarkers of Immune Dysfunction Improve Risk Assessment of Post-transplant Mortality Compared to Conventional Clinical Risk Scores

Introduction

There is a critical need to accurately stratify liver transplant (LT) candidates' risk of post-LT mortality prior to LT to optimize patient selection and avoid futility. Here, we compare previously described pre-LT clinical risk scores with the recently developed Liver Immune Frailty Index (LIFI) for prediction of post-LT mortality. LIFI measures immune dysregulation based on pre-LT plasma HCV IgG, MMP3 and Fractalkine. LIFI accurately predicts post-LT mortality, with LIFI-low corresponding to 1.4% 1-year post-LT mortality compared with 58.3% for LIFI-high (C-statistic=0.85).

Methods

LIFI was compared to MELD, MELD-Na, MELD 3.0, D-MELD, MELD-GRAIL, MELD-GRAIL-Na, UCLA-FRS, BAR, SOFT, P-SOFT, and LDRI scores on 289 LT recipients based on waitlist data at the time of LT. Survival, hazard of early post-LT death, and discrimination power (C-statistic) were assessed.

Results

LIFI showed superior discrimination (highest C-statistic) for post-LT mortality when compared to all other risk scores, irrespective of biologic MELD. On univariate analysis, the LIFI showed a significant correlation with mortality 6-months, as well as 1-, 3-, and 5-years. No other pre-LT scoring system significantly correlated with post-LT mortality. On bivariate adjusted analysis, African American race (p<0.05) and pre-LT cardiovascular disease (p=0.053) were associated with early- and long-term post-LT mortality. Patients who died within 1-yr following LT had a significantly higher incidence of infections, including 30-day and 90-day incidence of any infection, pneumonia, abdominal infections, and UTI (p<0.05).

Conclusions

LIFI, which measures pre-LT biomarkers of immune dysfunction, more accurately predicts risk of post-LT futility compared with current clinical predictive models. Pre-LT assessment of immune dysregulation may be critical in predicting mortality after LT and may optimize selection of candidates with lowest risk of futile outcomes.

Pre-transplant Biomarkers of Immune Dysfunction Improve Risk Assessment of Post-transplant Mortality Compared to Conventional Clinical Risk Scores

Introduction: There is a critical need to accurately stratify liver transplant (LT) candidates' risk of post-LT mortality prior to LT to optimize patient selection and avoid futility. Here, we compare previously described pre -LT clinical risk scores with the recently developed Liver Immune Frailty Index (LIFI) for prediction of post -LT mortality. LIFI measures immune dysregulation based on pre-LT plasma HCV IgG, MMP3 and Fractalkine. LIFI accurately predicts post-LT mortality, with LIFI-low corresponding to 1.4% 1-year post-LT mortality compared with 58.3% for LIFI-high (C-statistic=0.85). Methods : LIFI was compared to MELD, MELD-Na, MELD 3.0, D-MELD, MELD-GRAIL, MELD-GRAIL-Na, UCLA-FRS, BAR, SOFT, P-SOFT, and LDRI scores on 289 LT recipients based on waitlist data at the time of LT. Survival, hazard of early post-LT death, and discrimination power (C-statistic) were assessed. Results : LIFI showed superior discrimination (highest C-statistic) for post-LT mortality when compared to all other risk scores, irrespective of biologic MELD. On univariate analysis, the LIFI showed a significant correlation with mortality 6-months, as well as 1-, 3-, and 5-years. No other pre-LT scoring system significantly correlated with post-LT mortality . On bivariate adjusted analysis, African American race (p<0.05) and pre-LT cardiovascular disease (p=0.053) were associated with early- and long-term post-LT mortality. Patients who died within 1-yr following LT had a significantly higher incidence of infections, including 30-day and 90-day incidence of any infection, pneumonia, abdominal infections, and UTI (p<0.05). Conclusions : LIFI, which measures pre-LT biomarkers of immune dysfunction, more accurately predicts risk of post-LT futility compared with current clinical predictive models. Pre-LT assessment of immune dysregulation may be critical in predicting mortality after LT and may optimize selection of candidates with lowest risk of futile outcomes.

Perioperative outcomes of radical prostatectomy for advanced stage, node positive, and metastatic prostate cancer

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Background: Historically, surgical management with radical prostatectomy (RP) has been a definitive treatment option only for localized prostate cancer (PCa). However, recent studies suggest an overall survival benefit to treating the primary tumor with radiation therapy in metastatic PCa (mPCa). Therefore, RP may have a role in treating mPCa, but the perioperative safety of that remains unclear. Here, we aim to compare the perioperative outcomes of RP for locally advanced, node positive, and metastatic PCa using the National Surgical Quality Improvement Project (NSQIP) database. Methods: RPs performed between 2019-2020 were identified in NSQIP and the corresponding Prostatectomy-Targeted Participant Use File. Cases were grouped into six distinct categories: T1N0M0-T2N0M0; T3N0M0; T4N0M0; T1-3N1M0; T4N1M0; and T1-4N0-1M1. Baseline age, race, and medical comorbidities were compared between the groups. Patients were then further grouped into T1-2N0M0 versus T3-4N0M0 cases to compare the effect of locally advanced disease, TanyN1M0 versus TanyN0M0 to compare the effect of node-positivity, and TanyN0M1 versus TanyN0M0 to compare the effect of metastases. 30-day outcomes, operative time, hospital length-of-stay, 30-day mortality, readmissions, reoperations, major complications, minor complications, and surgery-specific complications were compared between groups. Results: Pathologic staging was available for 5,248 RPs. Baseline demographics were largely similar, with the exceptions of increased Black race, diabetes, and smoking in the node-positive-group and increased age in the T4 group. There was a slightly higher rate of minor complications in the locally advanced (T3-4N0M0) versus localized (T1-2N0M0) group, but no significant difference in major complications, 30-day mortality, readmissions, or rectal injuries. In comparison to node-negative patients (T1-4N0M0), node-positivity (T1-4N1M0) was associated with longer operative time, LOS, and incidence of 30-day renal failure, but was otherwise not associated with a higher rate of any complication. Compared to non-metastatic cases (T1-4N0M0), metastatic cases (T1-4N0M1) were associated with a higher rate of bleeding, prolonged-NG-tube use, ureteral obstruction, and LOS. Conclusions: RP for patients with locally advanced, node positive, and metastatic prostate cancer appears to be safe; it is not associated with significantly higher rates of 30-day mortality or major complications compared to RP for localized prostate cancer. Given the potential survival benefit in treating the primary tumor in advanced disease, there may be a role for RP in treating patients with advanced PCa.

Predicting perioperative complications for partial versus radical nephrectomy in T1b-T2 renal cell carcinoma

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Background: The standard of care for larger localized RCC lesions is radical (RN) or partial (PN) nephrectomy. RN is increasingly utilized to maximize oncologic benefit in complex tumors. Although PN is a more technically complex procedure, its nephron-sparing nature confers lasting renal and cardiovascular benefits. We utilized the National Surgical Quality Improvement Program (NSQIP) database to elucidate predictors of perioperative morbidity in T1b-T2 RCC patients. Methods: Using the NSQIP Nephrectomy-Targeted PUF, 2,094 patients undergoing nephrectomy between 2019-2020 for localized T1b-T2 RCC were identified. Variables of interest included surgical procedure and approach, tumor stage, demographics, pre-operative laboratory values, comorbidities, infection and venothromboembolism (VTE) prophylaxis techniques, peri-operative complications, operative time, length of hospital stay, 30-day reoperations, and 30-day readmissions. Chi square test was used to analyze univariate associations between certain comorbidities and complications. Multivariate regression analysis was utilized to compare complication rates between PN and RN after adjusting for baseline characteristics and surgical approach. p<0.05 was considered statistically significant. Results: 816 patients received PN while 1,278 received RN. PN patients had an increase in the following events: 30-day readmissions (7.0% vs. 4.7%, p=0.026), major bleeds (9.19% vs. 5.56%, p=0.001), renal failure requiring dialysis (1.23% vs. 0.31%, p=0.013), and urine leak or ureteric fistulae (1.10% vs. 0.31%, p=0.025). Open surgery was associated with increased VTE, renal failure, bleeds, urine leaks or ureteric fistulae, readmissions, and reoperations. Multivariate analysis revealed that PN remained predictive of all four aforementioned events, although further adjustment for robotic approach led to a loss of significance for renal failure and ureteric fistulae. Additional patient-specific predictors of relevant complications across procedure type included bleeding disorder and dialysis for bleeds, and renal failure, steroid use, and COPD for readmissions. Conclusions: This is the first study to evaluate the new NSQIP Nephrectomy-Targeted PUF. This population-based cohort provides unique insights into nephrectomy for pT1b-T2 localized RCC. We demonstrate significant associations between PN and specific complications, modulated by particular comorbidities, although both PN and RN were exceedingly safe. This analysis supports the development of novel risk stratification tools which account for specific patient comorbidities in predicting near term risk. Improved understanding of case-specific determinants of morbidity following PN or RN may facilitate shared decision making in localized RCC management.

Risk analysis of open vs. robotic assisted radical cystectomy

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Background: Radical cystectomy (RC) is standard of care for muscle-invasive bladder cancer, but it comes with significant perioperative risk with half of patients experiencing major postoperative complications. Robot-assisted radical cystectomies (RARC) have aimed to decrease patient morbidity and have become increasingly adopted in North America. Currently, both open radical cystectomies (ORC) and RARC are frequently performed. To contribute to the existing literature using newly available data from the American College of Surgeons National Surgical Quality Improvement Project (NSQIP), representing one of the most recent, largest multi-institutional studies, while uniquely accounting for a variety of factors including type of urinary diversion, cancer staging, and neoadjuvant chemotherapy. Methods: RC procedures performed between 2019-2020 were identified in NSQIP and the corresponding Cystectomy Targeted database. Cases in the ORC group were planned open procedures, and cases in the RARC group were robotic with intra- or extracorporeal diversions, including unplanned conversion to open cases for intention-to-treat. Chi-square and t-tests were performed to compare baseline demographics and operative parameters. Multivariate analysis was performed for outcomes including major complications, minor complications, and 30-day mortality, while adjusting for operative approach, medical comorbidities, functional status, age, race, sex, BMI, ASA-classification, preoperative labs, type of urinary diversion, pathological staging, prior pelvic surgery or radiation, need for preoperative transfusion, preoperative sepsis, emergent or elective surgery, and recent chemotherapy. Results: 4,022 RC cases were identified. Of these, 3,146 (78.2%) received planned ORC while 876 (21.8%) received RARC. Baseline demographics of the patients who received ORC versus RARC were largely similar, with no significant difference in age or medical comorbidities. RARC was associated with longer operative times and shorter hospital length of stay compared to ORC. On multivariate analysis, ORC was associated with a higher rate of 30-day mortality [OR 3.1; 95% CI 1.3-7.2; p=0.009], reintubation, cardiac arrest, superficial wound infection, bleeding requiring transfusion [OR 4.7; 95%CI 3.6 - 6.1; p<0.001], prolonged postoperative nasogastric tube use, rectal injury, and ureteral fistula or urine leak compared to RARC. Conclusions: In the NSQIP database, ORC is associated with higher rates of 30-day mortality and operative complications, most notably bleeding, compared to RARC. This study is unique in the size of the cohorts compared, the timeliness of the data (2019-2020), and the ability to control for factors, such as type of urinary diversion, pathological bladder cancer staging, and use of neoadjuvant chemotherapy.

Impact of neoadjuvant chemotherapy on 30-day radical cystectomy outcomes

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Background: Neoadjuvant chemotherapy (NAC), often with a cisplatin-based regimen, is recommended before radical cystectomy (RC), as studies have shown a modest survival benefit. However, NAC may confer toxicity and augment preoperative frailty, affecting perioperative outcomes. We investigated the relationship between NAC and 30-day RC outcomes using the National Surgical Quality Improvement Program (NSQIP). Methods: RCs performed between 2019-2020 were identified in NSQIP and the corresponding cystectomy-targeted database. Baseline demographics, comorbidities, and operative parameters were compared via Pearson’s chi-square and t-tests between patients who received NAC before RC and RC alone (RCA) groups. Patient frailty was compared using the NSQIP frailty index (mFI-5), a validated 5-item score including points for diabetes, functional status, chronic obstructive pulmonary disease, heart failure, and hypertension. Multivariable logistic regression was used to compare outcomes, adjusting for age, race, robotic or open approach, urinary diversion type, comorbidities, ASA classification, and functional status. Minor complications included superficial SSI, pneumonia, UTI, bleeding requiring transfusion, AKI, or C.diff infection. Major 30-day complications included sepsis, DVT, stroke, reintubation, renal failure, MI, PE, septic shock, wound dehiscence, deep wound infection, cardiac arrest, readmission, reoperation, or mortality. All statistical tests were two tailed, p<0.05 considered significant. Results: 4,482 RCs were identified. Of these, 1889 (42%) patients received NAC. Compared to RCA, NAC patients were younger (66.9 years vs 70.4 years, p<0.001), had higher rates of white race, being functionally independent, preoperative weight loss, and cigarette use. NAC also had lower ASA class, fewer comorbidities, and lower frailty (mFI-5 0.8 vs 0.9, p<0.001). Compared to RCA, NAC patients had more robotic cystectomies (23% vs 19%, p=0.0003), received more continent diversions, had a shorter length of stay (7.1 vs 7.8 days, p<0.001), and more commonly had pT0 tumors compared to RCA (18.4% vs 5.9%, p<0.001). On MVA, NAC patients had higher rates of minor complications, most notably increased bleeding requiring transfusion [OR 1.8; 95%CI 1.6-2.1; p<0.001]. There was no difference in major complications between NAC and RCA, except NAC was associated with higher rates of sepsis [OR 1.4; 95%CI 1.1-1.8; p=0.003]. There was no difference in 30-day need for reoperation, readmission, or mortality. Conclusions: In the largest study to date on this topic, we found that NAC for RC is often given to younger, healthier patients, and is not associated with higher rates of major complications or mortality. NAC is associated with higher rates of bleeding and sepsis, which may be related to the immunosuppressive effects of chemotherapeutics. Providers should discuss with patients the benefits and risks of NAC before RC.

Modelling COVID-19 transmission in the United States through interstate and foreign travels and evaluating impact of governmental public health interventions

Background: The first case of COVID-19 was reported in Wuhan, China in December 2019. The disease has spread to 210 countries and has been labelled as a pandemic by the World Health Organization (WHO). Modelling, evaluating, and predicting the rate of disease transmission is crucial in understanding optimal methods for prevention and control. Our aim is to assess the impact of interstate and foreign travel and public health interventions implemented by the United States government in response to the COVID-19 pandemic. Methods: A disjoint mutually exclusive compartmental model was developed to study transmission dynamics of the novel coronavirus. A system of nonlinear differential equations was formulated and the basic reproduction number R 0 was computed. Stability of the model was evaluated at the equilibrium points. Optimal controls were applied in the form of travel restrictions and quarantine. Numerical simulations were conducted. Results: Analysis shows that the model is locally asymptomatically stable, at endemic and foreigners free equilibrium points. Without any mitigation measures, infectivity and subsequent hospitalization of the population increased. When interstate and foreign travel was restricted and the population placed under quarantine, the probability of exposure and subsequent infection decreased significantly; furthermore, the recovery rate increased substantially. Conclusion: Interstate and foreign travel restrictions, in addition to quarantine, are necessary in effectively controlling the pandemic. The United States has controlled COVID-19 spread by implementing quarantine and restricting foreign travel. The government can further strengthen restrictions and reduce spread within the nation more effectively by implementing restrictions on interstate travel.

Overcoming the cardiac toxicities of cancer therapy immune checkpoint inhibitors

Immune checkpoint inhibitors (ICIs) have led recent advances in the field of cancer immunotherapy improving overall survival in multiple malignancies with abysmal prognoses prior to their introduction. The remarkable efficacy of ICIs is however limited by their potential for systemic and organ specific immune-related adverse events (irAEs), most of which present with mild to moderate symptoms that can resolve spontaneously, with discontinuation of therapy or glucocorticoid therapy. Cardiac irAEs however are potentially fatal. The understanding of autoimmune cardiotoxicity remains limited due to its rareness. In this paper, we provide an updated review of the literature on the pathologic mechanisms, diagnosis, and management of autoimmune cardiotoxicity resulting from ICIs and their combinations and provide perspective on potential strategies and ongoing research developments to prevent and mitigate their occurrence.

Genetic and pharmacologic suppression of PPARγ enhances NELL-1-stimulated bone regeneration

Recent investigations into mechanisms behind the development of osteoporosis suggest that suppressing PPARγ-mediated adipogenesis can improve bone formation and bone mineral density. In this study, we investigated a co-treatment strategy to enhance bone formation by combining NELL-1, an osteogenic molecule that has been extensively studied for its potential use as a therapeutic for osteoporosis, with two methods of PPARγ suppression. First, we suppressed PPARγ genetically using lentiviral PPARγ-shRNA in immunocompromised mice for a proof of concept. Second, we used a PPARγ antagonist to suppress PPARγ pharmacologically in immunocompetent senile osteopenic mice for clinical transability. We found that the co-treatment strategy significantly increased bone formation, increased the proliferation stage cell population, decreased late apoptosis of primary mouse BMSCs, and increased osteogenic marker mRNA levels in comparison to the single agent treatment groups. The addition of PPARγ suppression to NELL-1 therapy enhanced NELL-1's effects on bone formation by upregulating anabolic processes without altering NELL-1's inhibitory effects on osteoclastic and adipogenic activities. Our findings suggest that combining PPARγ suppression with therapeutic NELL-1 may be a viable method that can be further developed as a novel strategy to reverse bone loss and decrease marrow adiposity in age-related osteoporosis.

Effectiveness of self-designed dental storybook as behavior modification technique in 5 - 7 year-old children: A randomized controlled study

BACKGROUND

Dental anxiety is one of the key factors that prevent children from obtaining dental treatment and raises anxiety levels in children. The first dental visit is usually fearful for the child and contributes to managing the child patient in a dental operatory. A pediatric dentist's role is to perform effective treatment using various nonpharmacological behavior management techniques.

AIMS

The aim of the study was to evaluate and compare the effect of self-designed dental storybook on behavior and pulse rate before and after dental procedures in 57-year-old children.

SETTINGS AND DESIGN

The study was a prospective, randomized, controlled trial.

MATERIALS AND METHODS

The study was conducted on 380 aged 57 years. Children were randomly allocated into two groups, namely, Group A - Behavior modification using a self-designed dental storybook and Group B - Behavior modification without storybook. Research was carried out in two dental visits (screening, examination, and preventive and restorative treatment) wherein, before and after intervention, pulse rate, Facial Image Scale (FIS), and Venham Scale (VS) were recorded. Descriptive statistical analyses followed by the paired t-test and Wilcoxon signed-rank test were applied and tabulated using the SPSS software version 23.0.

RESULTS

There was a significant difference observed in the interventional group as compared to the control group for pulse rate, FIS, and VS.

CONCLUSION

Self-designed dental storybook as an adjuvant was found to be promising behavior modification technique for 57-year-old children.

Tenofovir-induced distal renal tubular acidosis: A rare cause of recurrent hypokalaemic paralysis

Introduction:

Tenofovir disoproxil fumarate was the first nucleotide analogue reverse transcriptase inhibitor to be approved for treatment of human immunodeficiency virus infection. It is a relatively safe drug but can present with nephrotoxicity.

Case presentation:

We report a case of 36-year-old male who presented with acute onset flaccid paraparesis. He was a diagnosed case of acquired immunodeficiency syndrome for 9 years ago and was on tenofovir-based antiretroviral therapy for last 6 months. As the patient had normal anion gap metabolic acidosis, hypokalaemia and urine pH > 5.5, distal renal tubular acidosis (RTA) was suspected. He improved dramatically within 24 h of hospitalisation after potassium correction to regain normal power.

Conclusion:

Tenofovir-induced distal RTA presenting as hypokalaemic paralysis is a very rare complication of tenofovir; hence, we are reporting this case. In addition, we suggest regular follow-up of patients taking tenofovir with urine analysis and serum potassium to detect this complication earlier as it is reversible.

Trends of Age and Geographical Location in Microsurgical Treatment of Obstetric Brachial Plexus Palsy

BACKGROUND

Debate over the optimal age at time of surgery for treatment of brachial plexus birth injury (BPBI) remains controversial, and there exists geographical varia- tion in surgical preference for age at time of surgery. The objective of this review was to analyze trends in age and geography in brachial plexus microsurgery for treatment of brachial plexus birth injury (BPBI) over time.

METHODS

Review of the literature in this study was con- ducted according to the Preferred Reporting Items for Sys- tematic Reviews and Meta-Analysis (PRISMA) guidelines. PubMed, Cochrane, Web of Science, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched.

RESULTS

Pediatric patients undergoing brachial plexus microsurgery described in published reports before 2011 had a mean of 7.15 ± 6.56 months of age, while pediatric patients undergoing brachial plexus microsurgery surgery described in published reports after 2011 had a mean of 11.23 ± 9.76 months of age (p < 0.05). The mean age at surgery was lower in publications from Asian countries (6.29 months) than in publications from North America (11.34 months; p < 0.05).

CONCLUSIONS

Age at time of microsurgery for treatment of BPBI is increasing, with mean age at surgeries occurring in and after 2011 being 4 months higher than thos occuring before 2011. The mean age at surgery was about 5 months higher in North American publications than in Asian pub- lications.

An Analysis of the Quality, Reliability, and Popularity of YouTube Videos on Glaucoma

PURPOSE

To evaluate the quality, reliability, and popularity of videos relating to glaucoma on YouTube.

DESIGN

Retrospective, cross-sectional study of YouTube videos about glaucoma.

PARTICIPANTS

One hundred YouTube videos were analyzed for this study.

METHODS

An online YouTube search for glaucoma videos was conducted simulating a user search using the keywords glaucoma, high eye pressure, and high intraocular pressure. The first 100 videos were analyzed, and each video was evaluated by 2 independent reviewers using the modified DISCERN (scale, 1-5), Journal of the American Medical Association (JAMA; scale, 0-4), and Global Quality (GQ; scale, 1-5) criteria to assess quality and reliability. Videos were categorized further into 3 groups depending on the source of their upload. Group 1 comprised videos uploaded by academic or government institutions, group 2 comprised videos uploaded by private medical practices, and group 3 comprised videos uploaded by independent users.

MAIN OUTCOME MEASURES

Modified DISCERN, JAMA, and GQ scores for quality and reliability of information and video power index (VPI) for video popularity.

RESULTS

No substantial difference in scoring was observed between the 2 independent reviewers. The overall mean ± standard error (SE) scores were modified DISCERN score, 3.81 ± 0.06; JAMA score, 2.93 ± 0.07; and GQ score, 3.98 ± 0.06. The overall mean ± SE VPI score was 9.9 ± 2.9. Significant positive correlations were found between video popularity and quality of information for all 3 criteria (P < 0.05). The videos in groups 1 and 2 showed higher modified DISCERN scores than those in group 3, but did not score higher with either the JAMA or GQ criteria. Videos in group 3 were the most popular when compared with videos in groups 1 or 2 (P < 0.01).

CONCLUSIONS

Overall, many of the videos had adequate quality and reliability scores. No difference was found among groups 1 through 3 for 2 of the 3 criteria used, suggesting a similar quality of information provided among academic, private, and independent sources.

Prevalence of SARS-COV-2 Vaccination and Factors Impacting Likelihood of Vaccination in a Nationwide Veterans Affairs Cohort of IBD Patients

Despite all efforts, about one-third of IBD patients are still not vaccinated. Although there is an emphasis on the booster dose, there is still a large population that has received no vaccination. Younger, healthy smokers with CD and on anti-TNF agents residing in the South and Midwest are less likely to get vaccinated. Targeted efforts should be made at this subset of IBD patients to increase vaccination rates.

A Novel Device for the Quantification of Synovial Fluid Viscosity via Magnetic Deflection

Changes in synovial fluid viscosity may be used to detect joint disease; however, methods to evaluate these changes at the point of care are rudimentary. Previously, we demonstrated magnetic particle translation through synovial fluid could serve as a surrogate marker of synovial fluid mechanics. In this work, the relationship of magnetic deflection of a stream of particles is examined in relation to synovial fluid mechanics. A flow device was designed to assess the deflection of a magnetic particle stream as it flows past a fixed permanent magnet. Deflection is recorded via a camera, measuring the deflection distance of the particle stream at a given distance. Theoretically, as fluid viscosity decreases, the deflection of the particle stream should increase. To validate this approach, particle deflection was first measured in Newtonian glycerol solutions of varying viscosity under different flow conditions. Next, the device was used to test synovial fluid viscosity in bovine synovial fluid that was progressively degraded using ultrasonication. A strong correlation was observed between the deflection of the magnetic particles and the viscosity of the glycerol solutions (R2=0.987) and the degradation of synovial fluid (R2=0.7045). Moreover, this approach does not require particles to be separated from the fluid for quantification and serves as a proof-of-principle for future lab-on-a-chip assessments of synovial fluid biomechanics.

1219 Patient Satisfaction with Virtual Orthopaedic Clinics During the COVID-19 Pandemic

Background

The COVID-19 pandemic has elicited the need to deliver consultation appointments remotely due to social-distancing measures, as well as some individuals having to shield. Virtual clinics are not a familiar setting for orthopaedic surgeons or their patients, but it is a necessity in the current climate and potentially also in the future.

Aim

This study aims to determine patient satisfaction of virtual orthopaedic consultations, during the COVID-19 pandemic and for the future.

Method

A 10-question survey assessed the satisfaction level of both new and follow-up patients towards virtual clinics for consultations with orthopaedic surgeons.

Results

Based on 100 patients who completed the surveys in a 6-month study during the pandemic, it was found that a majority (90%) of patients reported being satisfied (either very satisfied or satisfied) with the telephone clinics and would be content on having virtual clinics in the future.

Conclusions

Many patients view virtual clinics as an acceptable substitute for face-to-face appointments, specifically during the pandemic. However, it was also reported that a majority of patients would still prefer a physical examination as well. If virtual consultations are to persist beyond the COVID-19 pandemic, further exploration would need to be carried out to determine the efficacy.

Emerging technologies in Indian mining industry: an exploratory empirical investigation regarding the adoption challenges

Purpose

Emerging technologies have been transforming most industries. A wide range of emerging technologies such as blockchain, internet of things (IoT), artificial intelligence (AI), machine learning (ML), robotics and many others have changed the way in which firm value chain activities or processes were executed traditionally. The mining industry has also witnessed the introduction of these emerging technologies in various processes from the exploration stage to the final processing of ores. The purpose of this paper is to understand the pace of adoption of emerging technologies in the Indian mining industry and identify the challenges that managers confront while adopting emerging technologies.

Design/methodology/approach

The authors undertook qualitative research. Data collection was done in two stages. Secondary research was conducted to arrive at a repository of use cases of the adoption of emerging technologies in the global mining industry. Primary data collection was also done. The insights on emerging technology adoption and challenges faced in the Indian mining industry were captured by in-depth interviewing of subject matter experts. The authors interviewed 21 mining subject matter experts with a semi-structured open-ended questionnaire. The responses were content analyzed by thematic content analysis. Technological-organizational-environmental (TOE) and diffusion of innovation (DOI) frameworks were applied to segregate different factors affecting the adoption of emerging technologies in the Indian mining industry.

Findings

Emerging technologies such as blockchain, IoT, AI, ML, robotics has been applied across various mining engineering value chain activities such as in drilling, blasting, excavation and ore hauling. However, emerging technologies adoption was hindered because of a lack of managerial awareness, cultural inertia, substantive upfront investments and the nature of intangible benefits in the short run.

Research limitations/implications

The research applied technology adoption frameworks in the mining industry. The authors used TOE and DOI frameworks to understand the challenges faced by Indian mining firms. The research findings, thus added to the conversation of TOE and DOI frameworks in the context of the Indian mining industry.

Practical implications

The research finding would help mining firm managers to anticipate the challenges with respect to technology adoption. This would allow mining executives to create a proper technology adoption plan and intervene proactively. The research would also provide information about the steps taken by competing firms with respect to emerging technologies adoption. The research would help managers to decide technology implementation steps in drilling, blasting, excavation and ore hauling to be undertaken for successful adoption of emerging technologies. Technology firms could gain insights into the issues faced by mining firms in adopting emerging technologies. This research would help managers to influence organizational technology policy and endorse the addition of pro-technology policies in mining activities. Policymakers involved in the mining sector could also incorporate industry-level policy decisions so as to facilitate the adoption of emerging technologies among mining firms and remove the barriers to the adoption of emerging technologies. This would create an opportunity for technology providers to redesign product offerings, which could be a good fit for Indian mining firms.

Originality/value

Indian mining industry contributed significantly to the Indian economy. Despite this, limited focus has been put regarding the adoption of emerging technologies in the mining industry. Mining managers did not have any framework to understand the challenges faced in the adoption of technologies across the mining value chain that is in drilling, blasting, excavation and ore hauling. This study focused on identifying those challenges through the use of technology adoption frameworks. This research was one of the first studies to gain insights on emerging technologies adoption in the context of the mining industry through the theoretical lens of TOE and DOI frameworks.

Iron deficiency anemia in IBD: an overlooked comorbidity

Introduction: Iron Deficiency Anemia (IDA) is a leading cause of anemia in Inflammatory Bowel disease (IBD). IDA affects quality of life (QoL) and lead to developmental and cognitive abnormalities. Diagnosis of IDA in IBD is complicated as biochemical tests available at present cannot help distinguish between IDA and anemia of chronic disease. Soluble transferrin receptor ferritin index has been gaining popularity as it can diagnose IDA in presence of chronic inflammation. ECCO guidelines recommend a Hb increase of >2 g/dL and a TfS of >30% within 4 weeks as adequate therapeutic response. IV iron is preferred over oral iron as it bypasses gastrointestinal tract, rapidly increases haemoglobin, and is not associated with intestinal inflammation. Our aim in this review is to provide apathway for physicians to help them diagnose and appropriately treat IDA in IBD.Areas covered: In this review article, we have discussed current diagnosis and treatment in detail and have proposed new directions on how future research can help manage IDA in IBD effectively.Expert opinion: Understanding the pathogenesis of IDA in IBD will further lead to exploring new potential diagnostic tests and treatment regimens for effective management of IDA in IBD.

Experimental investigation of indoor aerosol dispersion and accumulation in the context of COVID-19: Effects of masks and ventilation

The ongoing COVID-19 pandemic has highlighted the importance of aerosol dispersion in disease transmission in indoor environments. The present study experimentally investigates the dispersion and build-up of an exhaled aerosol modeled with polydisperse microscopic particles (approximately 1 μm mean diameter) by a seated manikin in a relatively large indoor environment. The aims are to offer quantitative insight into the effect of common face masks and ventilation/air purification, and to provide relevant experimental metrics for modeling and risk assessment. Measurements demonstrate that all tested masks provide protection in the immediate vicinity of the host primarily through the redirection and reduction of expiratory momentum. However, leakages are observed to result in notable decreases in mask efficiency relative to the ideal filtration efficiency of the mask material, even in the case of high-efficiency masks, such as the R95 or KN95. Tests conducted in the far field ( 2   m distance from the subject) capture significant aerosol build-up in the indoor space over a long duration ( 10   h ). A quantitative measure of apparent exhalation filtration efficiency is provided based on experimental data assimilation to a simplified model. The results demonstrate that the apparent exhalation filtration efficiency is significantly lower than the ideal filtration efficiency of the mask material. Nevertheless, high-efficiency masks, such as the KN95, still offer substantially higher apparent filtration efficiencies (60% and 46% for R95 and KN95 masks, respectively) than the more commonly used cloth (10%) and surgical masks (12%), and therefore are still the recommended choice in mitigating airborne disease transmission indoors. The results also suggest that, while higher ventilation capacities are required to fully mitigate aerosol build-up, even relatively low air-change rates ( 2   h - 1 ) lead to lower aerosol build-up compared to the best performing mask in an unventilated space.

[Telemedicine in stroke-pertinent to stroke care in Germany]

BACKGROUND AND OBJECTIVE

Telemedical stroke networks improve stroke care and provide access to time-dependent acute stroke treatment in predominantly rural regions. The aim is a presentation of data on its utility and regional distribution.

METHODS

The working group on telemedical stroke care of the German Stroke Society performed a survey study among all telestroke networks.

RESULTS

Currently, 22 telemedical stroke networks including 43 centers (per network: median 1.5, interquartile range, IQR, 1-3) as well as 225 cooperating hospitals (per network: median 9, IQR 4-17) operate in Germany and contribute to acute stroke care delivery to 48 million people. In 2018, 38,211 teleconsultations (per network: median 1340, IQR 319-2758) were performed. The thrombolysis rate was 14.1% (95% confidence interval 13.6-14.7%) and transfer for thrombectomy was initiated in 7.9% (95% confidence interval 7.5-8.4%) of ischemic stroke patients. Financial reimbursement differs regionally with compensation for telemedical stroke care in only three federal states.

CONCLUSION

Telemedical stroke care is utilized in about 1 out of 10 stroke patients in Germany. Telemedical stroke networks achieve similar rates of thrombolysis and transfer for thrombectomy compared with neurological stroke units and contribute to stroke care in rural regions. Standardization of network structures, financial assurance and uniform quality measurements may further strengthen the importance of telestroke networks in the future.

Length of stay linked to neurodiagnostic workup for seizures presenting to the pediatric emergency department

INTRODUCTION

Patients presenting to the pediatric emergency department (ED) often undergo unnecessary testing that leads to prolonged ED visits. Lower ED length of stay has been linked to improved patient experience and may reduce ED overcrowding, a costly burden on a health system.

METHODS

This is a retrospective cohort study involving patient records over the period of 6 months at an urban tertiary children's hospital who presented with seizures. Febrile seizures, seizures associated with trauma, and charts of patients who did not present initially through our ED were excluded.

RESULTS

328 charts were obtained through this search criteria. Head imaging was performed in 52 (16%) patients and consisted of 81% CT (n = 42) and 19% (n = 10) magnetic resonance imaging (MRI). Obtaining an MRI was associated with a 3.5 h longer ED visit (p = 0.07); obtaining a CT was associated with a 1.5 h longer ED visit (p = 0.005). An Electroencephalogram (EEG) was obtained for 67 (20%) visits and was associated with a 3.0 h longer ED length of stay (p < 0.001). Ten % of the CT scans showed new or progressive findings and 40% of the MRIs done provided useful information for management. Thirty-seven % of EEGs performed in new onset seizure patients revealed epileptiform findings and 5% of EEGs in established seizure patients provided meaningful findings important to management.

CONCLUSION

Obtaining neurodiagnostic studies significantly prolongs duration of stay in the ED. Electroencephalograms appear to have the greatest yield in new onset seizure patients and can help make a diagnosis of an epilepsy syndrome in children.

The Double Burden of COVID-19 and Dengue in Nepal: The challenges ahead

Coronavirus disease 2019 (COVID-19) pandemic has caused significant impact on the health care system. As a consequence, diagnosis and treatment of vector borne diseases including dengue has been equally affected. Nepal is no exception to this, where COVID-19 cases is exponentially increased and all resources are concentrated on its prevention, control and management. Dengue, one of the major vector-borne diseases in Nepal, is apparently overlooked despite approaching the peak season of the disease. The aim of this paper is to describe the double burden of COVID-19 and dengue in Nepal, particularly highlighting the co-circulation and possible coinfections. This has posed higher risk of increased severity, more severe cases and deaths in Nepal. Moreover, potential misdiagnosis of these viral diseases may lead to delayed or, inappropriate treatment and poor allocation of resources.

Overlap Between Medicare's Comprehensive Care for Joint Replacement Program and Accountable Care Organizations

BACKGROUND

Overlap between Medicare's Comprehensive Care for Joint Replacement (CJR) model and accountable care organizations (ACOs) may result in positive or negative synergies. In this study, we describe the overlap between the programs at the beneficiary and hospital levels.

METHODS

We conducted a retrospective study of patient and hospital characteristics using data from 2016 Medicare claims, the US Census Bureau, the American Hospital Association annual survey, Hospital Compare, and the Centers for Medicare & Medicaid Services Improving Medicare Post-Acute Care Transformation file. On the beneficiary level, we conducted 2 comparisons: (1) among patients who received joint replacement at CJR hospitals, ACO patients (overlap) vs not (CJR-only) and 2) among patients who received joint replacement elsewhere, ACO patients (ACO-only) vs not (neither). On the hospital level, we compared hospitals in the top quartile of overlap rate (high overlap) vs those in the bottom 3 (low overlap).

RESULTS

We studied 14,519 overlap, 38,972 CJR-only, 26,872 ACO-only, and 68,945 neither beneficiaries. Compared with CJR-only patients, the overlap group was less likely to be older than 85, of black race, of low socioeconomic status, and burdened with clinical complications. Similar results were observed when the ACO-only group was compared with the neither group. Compared with low overlap hospitals, high overlap ones were more likely to be of nonprofit and less likely to be of safety net.

CONCLUSION

CJR-ACO overlap is associated with differences in beneficiary and hospital characteristics, which raises key issues for providers and policymakers.

Sealing Ability of Three Different Surface Coating Materials on Conventional and Resin Modified Glass Ionomer Restoration in Primary Anterior Teeth: An In vitro Study

Introduction: Microleakage is an important property that has been used in assessing the success of any restorative material used in restoring a tooth. Immediate application of a surface coating agent is suggested to protect glass ionomer cement against moisture contamination and dehydration during early setting. Aim: To compare marginal microleakage of two different Glass Ionomer Cement (GIC)- Conventional GIC and Resin Modified GIC in primary anterior teeth using three surface coating materials. Materials and Methods: An in vitro study was conducted between January 2014 to October 2017 on freshly extracted 40 anterior primary teeth which were randomly assigned into two main groups (Fuji II GIC and Fuji II LC GIC) with four subgroups (control-no surface coating, A=GC Fují Varnish II, B=GC G-Coat Plus, C=Icon). A standardised Class V cavity preparation was prepared on the labial surface of each tooth. Specimens were coated with two layers of nail varnish, leaving a 1 mm window around the cavity margins and placed in a solution of Methylene blue Dye for 24 hour at 37°C. The teeth were sectioned longitudinally in a buccolingual direction of the restorations and evaluated under stereomicroscope to check extent of dye penetration. The results were analysed by ANOVA and Tukey’s post-hoc test (p≤0.05). Results: It was found that maximum microleakage was seen in group 1 (Fuji II GIC) as compared to group 2 (Fuji II LC GIC) and it was non-significant (p=0.53). Ascending order for mean microleakage for Group 1 was as follows: Control >GC Fuji Varnish >Icon DMG >GC G-Coat and for Group 2: Control >GC Fuji Varnish >Icon DMG >GC G-Coat. Icon when compared with Gc coat and Varnish also showed non-significant (p=0.137) difference in Group 2. Conclusion: All three different surface coatings can seal glass ionomer restorations. The GC G-Coat Plus has the least microleakage on Resin-Modified GIC (RMGIC) compared to the other surface coatings. This would aid the clinicians to make appropriate decision regarding the choice of material to be used for restoration and coating in anterior primary teeth.

Dendritic morphology and inhibitory regulation distinguish dentate semilunar granule cells from granule cells through distinct stages of postnatal development

Semilunar granule cells (SGCs) have been proposed as a morpho-functionally distinct class of hippocampal dentate projection neurons contributing to feedback inhibition and memory processing in juvenile rats. However, the structural and physiological features that can reliably classify granule cells (GCs) from SGCs through postnatal development remain unresolved. Focusing on postnatal days 11-13, 28-42, and > 120, corresponding with human infancy, adolescence, and adulthood, we examined the somato-dendritic morphology and inhibitory regulation in SGCs and GCs to determine the cell-type specific features. Unsupervised cluster analysis confirmed that morphological features reliably distinguish SGCs from GCs irrespective of animal age. SGCs maintain higher spontaneous inhibitory postsynaptic current (sIPSC) frequency than GCs from infancy through adulthood. Although sIPSC frequency in SGCs was particularly enhanced during adolescence, sIPSC amplitude and cumulative charge transfer declined from infancy to adulthood and were not different between GCs and SGCs. Extrasynaptic GABA current amplitude peaked in adolescence in both cell types and was significantly greater in SGCs than in GCs only during adolescence. Although GC input resistance was higher than in SGCs during infancy and adolescence, input resistance decreased with developmental age in GCs, while it progressively increased in SGCs. Consequently, GCs' input resistance was significantly lower than SGCs in adults. The data delineate the structural features that can reliably distinguish GCs from SGCs through development. The results reveal developmental differences in passive membrane properties and steady-state inhibition between GCs and SGCs which could confound their use in classifying the cell types.

Tobacco cessation effects on oral health by group and individualized motivational therapy in 12 to 18 years old boys - A randomized controlled study

BACKGROUND/INTRODUCTION

Adolescents are the most vulnerable population to initiate tobacco use. It is now well established that most of the adult users of tobacco start tobacco use in their childhood or adolescence.

AIM

The purpose of this study is to compare and evaluate the Group Motivational Therapy (GMT) and Individualised Motivational therapy (IMT) for tobacco cessation in adolescents.

METHODOLOGY

Oral screening was done in a village named Vehra Khadi near Anand. One hundred and eight adolescents aged between 12 and 18 years were included in the study. They were randomly divided into three groups namely Group 1 - Interventional group consisting of 36 adolescents who were given GMT; Group 2 - Interventional group consisting of 36 adolescents who were given IMT; and Group 3 -3 6 age - matched Negative control group. Hence, a total sample size of 108 was evaluated for tobacco consumption frequency, passive smoking, gingival index, and stain index and followed up for 9 months for the effect of both interventional group as well as positive control.

RESULTS

Frequency of tobacco consumption was reduced from baseline to 9 months' follow-up for both the interventional groups, which was statistically significant with <0.001 percent P value showing 84.38% change by intervention 1 and 98.30% in intervention 2.

CONCLUSION

Group and individualized motivation serves as an effective means for tobacco cessation among adolescents. Improvement in gingival health and reduction of the tobacco consumption was observed with motivational intervention.

Identification of the Most Cost-effective Position of Vedolizumab Among the Available Biologic Drugs for the Treatment of Ulcerative Colitis

BACKGROUND AND AIMS

There are limited data on the most cost-effective sequencing of biologics for ulcerative colitis [UC].

METHODS

We used Markov modelling to identify the most cost-effective position for vedolizumab among biologics for steroid-dependent UC, with a base-case of a 35-year-old male. We assessed three treatment algorithms, with vedolizumab use: prior to an initial anti-tumour necrosis factor alpha [anti-TNFα] and azathioprine [Algorithm 1]; prior to a second anti-TNF and azathioprine [Algorithm 2]; and prior to colectomy [Algorithm 3]. The initial anti-TNF could be either infliximab or adalimumab. Transition probabilities, costs, and quality-adjusted life-year estimates were derived from published estimates, Medicare, and the Nationwide Inpatient Sample. Primary analyses included 100 trials of 100 000 individuals over 1 year, with a willingness-to-pay threshold of US$100,000. Multiple sensitivity analyses were conducted to assess our findings.

RESULTS

From a population perspective, when both infliximab and adalimumab are available, vedolizumab was preferred as the first biologic if ≥14% of initial anti-TNF use was adalimumab. If infliximab is the primary biologic, vedolizumab use after infliximab [Algorithm 2] and prior to adalimumab was the most cost-effective strategy. All models were sensitive to biologic pricing.

CONCLUSIONS

This simulation demonstrated that the most cost-effective strategy in UC depends on the proportion of patients using adalimumab as the initial anti-TNF. If adalimumab was ≥14%, vedolizumab was preferred as the first biologic. When only infliximab was available for first-line therapy, the most cost-effective position of vedolizumab was prior to cycling to adalimumab.

0923 Doxepin in Children and Adolescents With Symptoms of Insomnia: A Single Center Experience

Introduction

Pediatric insomnia is a widespread problem and especially difficult to manage in children with neurodevelopmental disorders. There are currently no FDA- approved medications for pediatric patients to use once first line therapy fails. Doxepin is FDA-approved at low doses for use in transient or chronic sleep maintenance insomnia in adults. The objective of this study is to determine the tolerability and efficacy of doxepin in the pediatric population.

Methods

This is a retrospective single center chart review of children and adolescents (2-17 years of age) whose sleep failed to improve with behavioral intervention and melatonin who were then trialed on doxepin. Treatment was initiated at a median starting dose of 2mg and slowly escalated to a median maintenance dose of 10mg. Improvement in sleep was recorded using a 4-point Likert scale reported by parents on follow up visits.

Results

Total of 29 patients were included in analysis. Mean follow-up duration was 6.5 months (±3.5). Out of 29 patients, 4 (13.8%) patients discontinued doxepin due to lack of efficacy or side effects. 8 (27.6%) patients showed significant improvement of their insomnia, 8 (27.6%) showed moderate, 10 (34.5%) showed mild and 3 (10.3%) showed minimal to no improvement on treatment with doxepin (P&lt;0.05) Only two patients (6.8%) experienced adverse effects in the form of behavioral side effects (aggression) and enuresis.

Conclusion

Our data suggests that doxepin is effective, safe and well-tolerated in the treatment of sleep initiation and maintenance insomnia as well as psychophysiological insomnia in child and adolescents with Ausitsm specutrm disorder, other neuro-developmental disorders and attention deficit hyperactivity disorder. It is also an effective, safe, and well-tolerated alternative in children suffering from chronic persistent insomnia. The results of this study suggests a promising emerging therapy for the treatment of insomnia in the pediatric population.

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