Association of sociodemographic characteristics with the timeliness of surgery for patients with open tibial fractures.

BACKGROUND: The American College of Surgeons recommends operative debridement of open tibial fractures within 24 h of presentation. It is unknown what the compliance rates are with this recommendation and what factors contribute to delays to operation. METHODS: To determine the characteristics associated with delays to operation for open tibial fractures, we conducted a retrospective cohort study utilizing American College of Surgeons Trauma Quality Improvement Program data from 2017 to 2021. Individuals aged 18 and older presenting to a trauma center with an open tibial fracture were included. Associations were determined with a hierarchal regression model nesting patients within facilities. RESULTS: Of the 24,102 patients presenting to 491 trauma centers, 66.3 % identified as White, 21.7 % as Black, 1.5 % as Asian, 1.1 % as American Indian, and 10.6 % as Other race. In total, 15.8 % identified as Hispanic. Patients were most often men (75.9 %) and privately insured (47.6 %). The median time to OR was 10.2 h (IQR 4.4-17.7) with 84.6 % receiving surgery within 24 h. In adjusted analyses, Black and American Indian patients had 5.5 % (CI 1.3 %-9.9 %) and 17.8 % (CI 2.2 %-35.8 %) longer wait times, respectively, and a decreased odds of receiving surgery within 24 h (AOR 0.85, CI 0.8-0.9; AOR 0.69, CI 0.5-0.9) when compared to White patients. Female patients had 6.5 % (CI 3.0 %-10.2 %) longer wait times than men. Patients with Medicaid had 5.5 % (CI 1.2 %-9.9 %) longer wait times than those with private insurance. Greater time to OR was associated with increasing age (p < 0.001), increasing injury severity (p < 0.001), and the presence of altered mentation (p < 0.001). CONCLUSION: We identified longer wait times to operative irrigation and debridement of open tibial fractures for Black and American Indian patients, women, and those with Medicaid. The implementation of health equity focused quality metrics may be necessary to achieve equity in trauma care.

Evaluating the impact of stay-at-home orders on the time to reach the peak burden of Covid-19 cases and deaths: does timing matter?

BACKGROUND: The economic, psychological, and social impact of pandemics and social distancing measures prompt the urgent need to determine the efficacy of non-pharmaceutical interventions (NPIs), especially those considered most stringent such as stay-at-home and self-isolation mandates. This study focuses specifically on the impact of stay-at-home orders, both nationally and internationally, on the control of COVID-19. METHODS: We conducted an observational analysis from April to May 2020 and included both countries and US states with known stay-at-home orders. Our primary exposure was the time between the date of the first reported case of COVID-19 to an implemented stay-at-home mandate for each region. Our primary outcomes were the time from the first reported case to the highest number of daily cases and daily deaths. We conducted linear regression analyses, controlling for the case rate of the outbreak in each respective region. RESULTS: For countries and US states, a longer period of time between the first reported case and stay-at-home mandates was associated with a longer time to reach both the peak daily case and death counts. The largest effect was among regions classified as the latest 10% to implement a mandate, which in the US, predicted an extra 35.3 days (95% CI: 18.2, 52.5) to the peak number of cases, and 38.3 days (95% CI: 23.6, 53.0) to the peak number of deaths. CONCLUSIONS: Our study supports the association between the timing of stay-at-home orders and the time to peak case and death counts for both countries and US states. Regions in which mandates were implemented late experienced a prolonged duration to reaching both peak daily case and death counts.

[Validity of the assessment of urinary protein excretion by spot urine in patients with chronic kidney disease].

AIM: We investigate the validity of the assessment of urinary protein excretion by spot urine samples collected by different methods in outpatients with chronic kidney disease (CKD). SUBJECTS AND METHODS We obtained 24-hour urine and two spot urine samples, including the first morning urine and daytime urine in 159 CKD patients. Urinary protein excretion was assessed by the protein/creatinine ratio from spot urine samples (morning: m-UP (g/gCr), daytime: d-UP (g/gCr) ]. We examined the correlations and the differences among m-UP, d-UP and the actual urinary protein excretion obtained by 24-hour urine (a-UP(g/day) . RESULTS: Significant correlations were found between m-UP and a-UP, and between d-UP and a-UP (r = 0.88, 0.85; p < 0.001). Correlations between m-UP and a-UP were greater relative to those between d-UP and a-UP in patients with less than 3.5 g/day of a-UP and in patients with CKD stages 1 to approximately 3. The percent difference between m-UP and a-UP was--16.0 +/- 40.5%, and that between d-UP and a-UP was 27.1 +/- 72.9%. The absolute value of the percent difference between d-UP and a-UP tended to be greater than that between m-UP and a-UP (34.9 +/- 25.9% vs. 49.9 +/- 59.9%, p = 0.06). CONCLUSION: Urinary protein/creatinie ratio of the first morning urine is better approximate the urinary protein excretion obtained by 24-hour urine compared with that of spot urine in the daytime.

Triple therapy with single daily dose of cyclosporine in Japanese patients with idiopathic membranous nephropathy.

OBJECTIVE: The optimal therapeutic approach to patients with idiopathic membranous nephropathy (IMN) remains controversial. In this study, we assessed the efficacy of single daily dose cyclosporine (CsA) combined with low-dose prednisolone (PSL) and an angiotensin II receptor blocker (ARB) in patients with IMN. METHODS: We studied 13 nephrotic patients (8 men, 5 women) with IMN diagnosed on biopsy. An initial single daily dose of 2 mg/kg, but not exceeding 150 mg, CsA was given for 12 months, tapered by a 25 mg reduction every 2 months. An initial twice-daily dose of 0.5 mg/kg PSL was given for 2 months and was also tapered. An ARB was given to all patients and the same dosage was used throughout the study. Patients were followed up for 6 to 66 months. RESULTS: Nine patients achieved complete remission at 6.7±2.9 months, and incomplete remission was obtained in the remaining patients. After a follow-up period of 32.7±20.0 months, their serum creatinine and estimated glomerular filtration rate values were similar to baseline levels. The 9 patients who completed the treatment course have not relapsed. Moreover, there were no adverse effects requiring discontinuation of this triple therapy. CONCLUSION: A single daily dose of CsA combined with a low dose of PSL and an ARB in new-onset nephrotic patients with IMN induced a high remission rate of nephrotic syndrome, with a low incidence of relapse and a low risk of adverse effects. The triple therapy and prospective follow-up shows potential as a treatment approach for patients with IMN.

Ratio of urinary potassium to urinary sodium and the potassium and edema status in nephrotic syndrome.

OBJECTIVE: This study aimed to evaluate the relevance of ratios of urinary potassium to urinary sodium + potassium (U(K)/U(Na + K)) to edema status in minimal-change nephrotic syndrome (MCNS). METHODS: We retrospectively studied 26 adults with newly diagnosed MCNS with significant pitting edema. On the basis of mean value (0.46±0.21) of U(K)/U(Na + K) determined from spot urine samples on admission, patients were classified into 2 groups. RESULTS: On admission, 12 of 26 patients had U(K)/U(Na + K) >0.46 (0.65±0.16, Group H), 14 patients had U(K)/U(Na + K) <0.46 (0.29±0.08, Group L). The level of serum albumin was similarly decreased in these 2 groups. Noteworthy were lower urine volume, fractional excretion of sodium (FENa), serum sodium, and higher hematocrit in the group H as compared with the group L. The group H had a shorter mean time required from onset of edema to hospitalization, and tended to have a longer mean time to complete remission than group L. High U(K)/U(Na + K) levels in group H decreased significantly after remission, eventually becoming equal to those of group L (0.24±0.05 vs. 0.25±0.05). CONCLUSION: U(K)/U(Na + K) determined from spot urine sample on admission relates to laboratory or clinical indices to distinguish edema status in adult patients with MCNS.