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OBJECTIVES: To inform development of a preintubation checklist for pediatric emergency departments via multicenter usability testing of a prototype checklist. METHODS: This was a prospective, mixed methods study across 7 sites in the National Emergency Airway Registry for Pediatric Emergency Medicine (NEAR4PEM) collaborative. Pediatric emergency medicine attending physicians and senior fellows at each site were first oriented to a checklist prototype, including content previously identified using a modified Delphi approach. Each site used the checklist in 2 simulated cases: an "easy airway" and a "difficult airway" scenario. Facilitators recorded verbalization, completion, and timing of checklist items. After each simulation, participants completed an anonymous usability survey. Structured debriefings were used to gather additional feedback on checklist usability. Comments from the surveys and debriefing were qualitatively analyzed using a framework approach. Responses informed human factors-based optimization of the checklist. RESULTS: Fifty-five pediatric emergency medicine physicians/fellows (4-13 per site) participated. Participants found the prototype checklist to be helpful, easy to use, clear, and of appropriate length. During the simulations, 93% of checklist items were verbalized and more than 80% were completed. Median time to checklist completion was 6.2 minutes (interquartile range, 4.8-7.1) for the first scenario and 4.2 minutes (interquartile range, 2.7-5.8) for the second. Survey and debriefing data identified the following strengths: facilitating a shared mental model, cognitively offloading the team leader, and prompting contingency planning. Suggestions for checklist improvement included clarifying specific items, providing more detailed prompts, and allowing institution-specific customization. Integration of these data with human factors heuristic inspection resulted in a final checklist. CONCLUSIONS: Simulation-based, human factors usability testing of the National Emergency Airway Registry for Pediatric Emergency Medicine Preintubation Checklist allowed optimization prior to clinical implementation. Next steps involve integration into real-world settings utilizing rigorous implementation science strategies, with concurrent evaluation of the impact on patient outcomes and safety.
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Lista de Verificación , Intubación Intratraqueal , Humanos , Estudios Prospectivos , Intubación Intratraqueal/métodos , Servicio de Urgencia en Hospital , Sistema de Registros , Entrenamiento Simulado/métodos , Medicina de Emergencia , Encuestas y Cuestionarios , Masculino , Femenino , ErgonomíaRESUMEN
Rhinoviruses have persisted throughout the COVID-19 pandemic, despite other seasonal respiratory viruses (influenza, parainfluenza, respiratory syncytial virus, adenoviruses, human metapneumovirus) being mostly suppressed by pandemic restrictions, such as masking and other forms of social distancing, especially during the national lockdown periods. Rhinoviruses, as nonenveloped viruses, are known to transmit effectively via the airborne and fomite route, which has allowed infection among children and adults to continue despite pandemic restrictions. Rhinoviruses are also known to cause and exacerbate acute wheezing episodes in children predisposed to this condition. Noninfectious causes such as air pollutants (PM2.5 , PM10 ) can also play a role. In this retrospective ecological study, we demonstrate the correlation between UK national sentinel rhinovirus surveillance, the level of airborne particulates, and the changing patterns of pediatric emergency department presentations for acute wheezing, before and during the COVID-19 pandemic (2018-2021) in a large UK teaching hospital.
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COVID-19 , Infecciones por Enterovirus , Virus Sincitial Respiratorio Humano , Infecciones del Sistema Respiratorio , Adulto , COVID-19/epidemiología , Niño , Control de Enfermedades Transmisibles , Infecciones por Enterovirus/epidemiología , Humanos , Pandemias , Ruidos Respiratorios/etiología , Estudios Retrospectivos , RhinovirusRESUMEN
BACKGROUND: Atopic dermatitis (AD) is a pruritic, inflammatory skin disease associated with various comorbidities. However, comprehensive analyses of real-world comorbidities in adult patients with AD are limited. OBJECTIVE: To characterize the real-world comorbidities associated with adult AD in an ambulatory population. METHODS: We queried the MarketScan Commercial Claims and Encounters database from January 1, 2017 to December 31, 2017. Multivariable logistic regressions were performed to compare comorbidities in adult patients with AD versus age- and sex-matched controls. RESULTS: A total of 39,779 patients with AD and 353,743 controls were identified. Increased odds of psychiatric conditions, including anxiety (odds ratio [OR] 1.44) and mood disorders (OR 1.31), were observed in patients with AD. Patients with AD had higher likelihoods of autoimmune diseases, including vitiligo (OR 4.44) and alopecia areata (OR 6.01). Adult AD was also associated with infections, including impetigo (OR 9.72), methicillin-resistant Staphylococcus aureus (OR 3.92), and cellulitis (OR 2.52). Patients with AD were more likely to have systemic conditions, including lymphoid/hematopoietic malignancy (OR 1.91), atherosclerosis (OR 1.69), and metabolic syndrome (OR 1.47). For all the above, P < .001. LIMITATIONS: Retrospective analysis of health care claims data. CONCLUSION: Adult AD is associated with various psychiatric and systemic comorbidities, emphasizing the systemic nature of AD and the need for the collaborative management of these patients.
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Dermatitis Atópica , Staphylococcus aureus Resistente a Meticilina , Adulto , Comorbilidad , Dermatitis Atópica/epidemiología , Humanos , Estudios RetrospectivosRESUMEN
OBJECTIVES: Open hand fractures may be difficult to recognize and treat. There is variability in management and administration of antibiotics for these types of injuries. Unlike open long bone fractures, there is no standardized protocol for antibiotic administration for open hand fractures in children. The objective of this study is to assess the variability of antibiotic management of open hand fractures in children. METHODS: We performed a retrospective chart review at a tertiary hospital in New York of patients with hand injuries between ages 0 and 18 years presenting to the emergency department during January 2019 and December 2020. Patient encounters were reviewed for open fractures of the hand. Descriptive statistics were included for demographic and physical characteristics. RESULTS: There were 80 encounters with open hand fractures, of which the most common being tuft fractures (77.5%). The mean age was 7.6 years (SD, 4.7 years) with male predominance (58.8%). Crush injuries were the most common mechanism of injury (78.8%). Bedside repair was performed on 62 encounters (77.5%), of which 45 (72.5%) required nail bed repair, 56 (90.3%) required suturing, and 24 (38.7%) required reduction. Antibiotics were given to 62 (77.5%) encounters, most commonly oral cefalexin (45.2%), oral amoxicillin-clavulanic acid (27.4%), and intravenous cefazolin (14.5%). Median time to antibiotics from emergency department registration to administration was 150 minutes (interquartile range, 92-216 minutes). Antibiotic prescriptions were sent for 71 encounters (88.8%). Seventy seven (96.3%) of the encounters were discharged home. CONCLUSIONS: Pediatric open hand fractures have a variability of type and timing to antibiotics. Future initiatives should attempt to create standardized guidelines for management of open hand fractures.
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Fracturas Abiertas , Adolescente , Combinación Amoxicilina-Clavulanato de Potasio , Antibacterianos/uso terapéutico , Cefazolina , Cefalexina , Niño , Preescolar , Servicio de Urgencia en Hospital , Femenino , Fracturas Abiertas/tratamiento farmacológico , Fracturas Abiertas/cirugía , Humanos , Lactante , Recién Nacido , Masculino , Estudios RetrospectivosRESUMEN
Purpose: The purpose of this study was to evaluate the cost effectiveness of argatroban compared to heparin during extracorporeal membrane oxygenation (ECMO) therapy. Methods: This was a retrospective study of patients who received argatroban or heparin infusions with ECMO therapy at a community hospital between January 1, 2017 and June 30, 2018. Adult patients who received heparin or argatroban for at least 48 hours while on venovenous (VV) or venoarterial (VA) ECMO were included. Patients with temporary mechanical circulatory assist devices were excluded. Each continuous course of anticoagulant exposure that met the inclusion criteria was evaluated. The primary endpoint was the total cost of anticoagulant therapy for heparin versus argatroban, including all administered study drugs, blood or factor products, and associated laboratory tests. Secondary endpoints included safety and efficacy of anticoagulation with each agent during ECMO. Documentation of bleeding events, circuit clotting, and ischemic events were noted. Partial thromboplastin time (PTT) values were evaluated for time to therapeutic range and percentage of therapeutic PTTs. Results: A total of 11 courses of argatroban and 24 courses of heparin anticoagulation were included in the study. The average cost per course of argatroban was less than the average cost per course of heparin ($7,091.98 vs $15,323.49, respectively; P value = 0.15). Furthermore, argatroban was not associated with an increased incidence of bleeding, thrombotic, or ischemic events. Conclusion: Argatroban may be more cost-effective during ECMO therapy in patients with low antithrombin III levels without increased risk of adverse events.
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As part of on-going efforts to control hookworm infection, the "human hookworm vaccine initiative" has recognised blood feeding as a feasible therapeutic target for inducing immunity against hookworm infection. To this end, molecular approaches have been used to identify candidate targets, such as Necator americanus (Na) haemoglobinase aspartic protease-1 (APR-1), with immunogenicity profiled in canine and hamster models. We sought to accelerate the immune analysis of these identified therapeutic targets by developing an appropriate mouse model. Here we demonstrate that Nippostrongylus brasiliensis (Nb), a phylogenetically distant strongylid nematode of rodents, begins blood feeding early in its development and that immunisation with Na-APR-1 can block its growth and completion of its life cycle. Furthermore, we identify a new haem detoxification pathway in Nb required for blood feeding that can be blocked by drugs of the quinolone family, reducing both infection burden and the associated anaemia in rodents. Collectively, our findings show that haem metabolism has potential as a checkpoint for interrupting hookworm development in early stages of the hookworm life cycle and that the Nippostrongylus brasiliensis rodent model is relevant for identifying novel therapeutic targets against human hookworm.
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Anticuerpos Antihelmínticos/farmacología , Ácido Aspártico Endopeptidasas/antagonistas & inhibidores , Eritrocitos/efectos de los fármacos , Infecciones por Uncinaria/prevención & control , Necator americanus/enzimología , Nippostrongylus/crecimiento & desarrollo , Infecciones por Strongylida/prevención & control , Ancylostomatoidea/efectos de los fármacos , Ancylostomatoidea/crecimiento & desarrollo , Animales , Antígenos Helmínticos/inmunología , Ácido Aspártico Endopeptidasas/inmunología , Eritrocitos/parasitología , Femenino , Infecciones por Uncinaria/parasitología , Estadios del Ciclo de Vida , Masculino , Ratones , Ratones Endogámicos C57BL , Nippostrongylus/efectos de los fármacos , Infecciones por Strongylida/parasitologíaRESUMEN
There is emerging evidence for the role of posaconazole in the management of Aspergillus-related cystic fibrosis (CF) lung disease. The tolerability and efficacy of posaconazole in paediatric CF is not well established. We report a prospective study over a fifty-three month period evaluating the safety, tolerability, and efficacy of posaconazole in pediatric CF. Fourteen children (seven males, median age 13 years, range 3-17 years) received a total of twenty-three courses of posaconazole (13 oral suspension and 10 tablet formulation). Of these patient episodes, nine received posaconazole for emerging or active allergic bronchopulmonary aspergillosis (ABPA) and two required a combination of posaconazole and systemic corticosteroids for difficult-to-treat ABPA. A subgroup of patients (n = 12) with persistent isolates of Aspergillus fumigatus, in the absence of serological markers of ABPA, received posaconazole monotherapy for pulmonary exacerbations not responding to conventional broad-spectrum antibiotic treatment. Posaconazole levels, full blood count, electrolytes, and liver function were monitored on day 7 of treatment and then monthly. Posaconazole was well tolerated in all but three patients. Therapeutic plasma levels >1 mg/l were achieved in all receiving the tablet formulation in comparison to 60% on the liquid preparation. There was a modest but significant improvement in FEV1 (% predicted) demonstrated for the cohort as a whole (p = 0.015) following posaconazole therapy. Posaconazole is well tolerated in children as young as six years old, improvements in lung function are observed, and therapeutic plasma levels are readily achieved in patients taking the tablet formulation and in adherent patients taking the liquid formulation.
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Antifúngicos/uso terapéutico , Aspergilosis Broncopulmonar Alérgica/tratamiento farmacológico , Fibrosis Quística/complicaciones , Triazoles/uso terapéutico , Adolescente , Corticoesteroides/uso terapéutico , Antifúngicos/sangre , Aspergillus , Niño , Fibrosis Quística/tratamiento farmacológico , Fibrosis Quística/microbiología , Femenino , Humanos , Pulmón/microbiología , Pulmón/patología , Masculino , Estudios Prospectivos , Triazoles/sangreRESUMEN
Drug shortages have become all too familiar in the health care environment, with over 200 drugs currently on shortage. In the wake of Hurricane Maria in September 2017, hospitals across the USA had to quickly and creatively adjust medication preparation and administration techniques in light of decreased availability of intravenous (IV) bags used for compounding a vast amount of medications. Amino acid preparations, essential for compounding parenteral nutrition, were also directly impacted by the hurricane. Upon realization of the impending drug shortages, hospitals resorted to alternative methods of drug administration, such as IV push routes, formulary substitutions, or alternative drug therapies in hopes of preserving the small supply of IV bags available and prioritizing them for them most critical needs. In some cases, alternative drug therapies were required, which increased the risk of medication errors due to the use of less-familiar treatment options. Clinical pharmacists rounding with medical teams provided essential, patient-specific drug regimen alternatives to help preserve a dwindling supply while ensuring use in the most critical cases. Drug shortages also frequently occur in the setting of manufacturing delays or discontinuation and drug recalls, with potential to negatively impact patient care. The seriousness of the drug shortage crisis reached public attention by December 2017, when political and pharmacy organizations called for response to the national drug shortage crisis. In this article, we review institutional mitigation strategies in response to drug shortages and discuss downstream effects of these shortages, focusing on medications commonly prescribed in neurocritical care patients.
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Enfermedades del Sistema Nervioso Central/terapia , Cuidados Críticos , Sustitución de Medicamentos , Preparaciones Farmacéuticas/provisión & distribución , Soluciones Farmacéuticas/provisión & distribución , Analgésicos Opioides/provisión & distribución , Analgésicos Opioides/uso terapéutico , Anticonvulsivantes/provisión & distribución , Anticonvulsivantes/uso terapéutico , Antifibrinolíticos/provisión & distribución , Antifibrinolíticos/uso terapéutico , Antihipertensivos/provisión & distribución , Antihipertensivos/uso terapéutico , Conducta Cooperativa , Composición de Medicamentos , Humanos , Unidades de Cuidados Intensivos , Servicio de Farmacia en Hospital , Soluciones para Rehidratación/provisión & distribución , Soluciones para Rehidratación/uso terapéutico , Soluciones/provisión & distribución , Soluciones/uso terapéuticoRESUMEN
BACKGROUND: Caregiver-oriented quality of life (QoL) research in alopecia areata is limited. No study has used a parent-tailored survey to examine the relationship between QoL and severity of alopecia as measured by Severity of Alopecia Tool (SALT) scores. OBJECTIVES: This is a prospective study that describes QoL in parents of pediatric patients with all subtypes of alopecia areata and investigates the relationship between QoL and severity of disease, duration of disease, and age of patients. METHODS: Pediatric patients and their parents were invited to participate during clinic visits. Participating parents completed the Quality of Life in a Child's Chronic Disease Questionnaire (QLCCDQ) and the Family Dermatology Life Quality Index (FDLQI). A subset of children completed the Children's Dermatologic Life Quality Index (CDLQI). SALT scores at time of survey completion were recorded. RESULTS: In total, 153 patients were included. Significant mild-to-moderate negative correlations were found between SALT scores and FDLQI scores, QLCCDQ scores, and QLCCDQ emotional domain scores. Age of child correlated negatively with QLCCDQ scores but not FDLQI scores. No significant correlation was found between duration of disease and FDLQI scores, QLCCDQ scores, or QLCCDQ emotional domain scores. LIMITATIONS: This study is limited by its small sample size and cross-sectional design. CONCLUSIONS: Impaired parent QoL might be associated with increasing severity of disease and age of affected child but not duration of disease. Providers should tailor counseling accordingly and help parents set realistic expectations for long-term experience with the disease.
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Alopecia Areata/psicología , Alopecia/psicología , Padres/psicología , Calidad de Vida , Adolescente , Adulto , Factores de Edad , Niño , Preescolar , Estudios Transversales , Emociones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Encuestas y Cuestionarios , Factores de Tiempo , Adulto JovenRESUMEN
BACKGROUND/OBJECTIVES: Severe atopic dermatitis (AD) may require systemic immunomodulatory agents to control symptoms. A lack of evidence and guidelines for systemic AD therapy in children has led to variability in agents selected and uncertainty in their comparative efficacy and safety. Evaluation of the efficacy of methotrexate in children with severe AD was performed. METHODS: We performed a retrospective chart review of 55 pediatric patients seen at Children's Hospital of Philadelphia that measured improvement using the Investigator's Global Assessment (IGA), a scale that rates AD symptoms from 0 to 5. RESULTS: About 76% of patients showed improvement with methotrexate. Mean baseline IGA of all patients was 4.18. After 6-9 months of treatment, this improved to 2.94. There was additional improvement to a mean IGA score of 2.39 after 12-15 months of treatment. At the final visit before each patient stopped methotrexate, the mean IGA score was 2.71. Approximately 50% of patients experienced minor side effects with gastrointestinal side effects the most common. CONCLUSIONS: In a diverse patient population, safety and efficacy of methotrexate was demonstrated. Significant improvement in IGA was noted for the majority after 6-9 months of therapy with further improvement when continuing treatment to 12-15 months. Methotrexate remains an important option for long-term symptom control with a favorable side effect profile and low cost.
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Dermatitis Atópica/tratamiento farmacológico , Inmunosupresores/uso terapéutico , Metotrexato/uso terapéutico , Adolescente , Niño , Preescolar , Esquema de Medicación , Femenino , Humanos , Masculino , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
AIMS: Iron deficiency anaemia frequently complicates inflammatory bowel disease (IBD) in children and adults. Oral iron may exacerbate gastrointestinal symptoms and absorption may be insufficient in intestinal inflammation. Even where oral iron is successful, repletion of iron stores can be unacceptably slow. Intravenous iron compounds were in the past associated with serious adverse reactions and historically were considered a last resort in children. New generation preparations have a safer profile in adults, although reluctance to use them in children may persist, where safety data are lacking. We investigate the safety and efficacy of ferric carboxymaltose and iron sucrose in children. METHODS: We retrospectively identified all children with IBD who received parenteral iron over a 38-month period in a single regional referral centre. Safety, tolerability and adverse events were established by case note review. Efficacy was assessed by change in haematinic indices pre- and post-treatment. RESULTS: Forty-one children (18 male; median age 14 years, range 3-17) received a total of 104 iron infusions. Of these, 44% (18) had Crohn's disease; 56% (23) ulcerative colitis. Thirty-five received ferric carboxymaltose, seven iron sucrose and one both. Three children developed mild rash post infusion which resolved quickly with chlorphenamine. Mean increase in haemoglobin was 2.5 g dl-1 (0.3-5.8). Iron levels increased by a mean of 8.4 g dl-1 (1-25), transferrin saturation by 16.2% (2-47). Transferrin decreased by 0.84 g dl-1 (0.3-3.4). CONCLUSIONS: New generation parenteral iron preparations are safe, well tolerated and efficacious in children with iron deficiency anaemia and IBD.
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Anemia Ferropénica/tratamiento farmacológico , Colitis Ulcerosa/complicaciones , Enfermedad de Crohn/complicaciones , Compuestos Férricos/administración & dosificación , Sacarato de Óxido Férrico/administración & dosificación , Maltosa/análogos & derivados , Adolescente , Anemia Ferropénica/etiología , Niño , Preescolar , Femenino , Compuestos Férricos/efectos adversos , Sacarato de Óxido Férrico/efectos adversos , Hemoglobinas/metabolismo , Humanos , Infusiones Intravenosas , Masculino , Maltosa/administración & dosificación , Maltosa/efectos adversos , Estudios Retrospectivos , Transferrina/metabolismoRESUMEN
Specific clinical features of aplasia cutis congenita may indicate the presence of underlying cranial or cerebrovascular defects, allowing for early recognition and intervention. Most information about aplasia cutis congenita exists as individual case reports, with few large-scale studies. We conducted a 7-year retrospective chart review of 90 cases of aplasia cutis congenita and identified clinical characteristics including morphology, number of lesions, anatomic location, presence of hair collar sign, associated cutaneous features, histology, and imaging results. The anatomic location of the lesion (vertex, midline) (P = .01), presence of hair collar sign (P < .001), vascular stains (P < .001), and nodules (P = .007) were found to be strong clinical indicators of skull or cerebrovascular involvement.
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Displasia Ectodérmica/diagnóstico , Adolescente , Niño , Preescolar , Displasia Ectodérmica/complicaciones , Femenino , Cabello/patología , Humanos , Lactante , Recién Nacido , Masculino , Estudios Retrospectivos , Cráneo/patologíaRESUMEN
Acne is one of the most common skin conditions seen by dermatologists. As with many other cutaneous diseases, due to its visibility, acne often produces a large psychosocial impact on patients who suffer from the disease. Such psychosocial burdens are exacerbated by the variation in acne presentation that can lead to the usage of multiple different treatments before visible improvements are appreciated. Although many scales have been established to determine severity from the clinician standpoint, patient-oriented scales are lacking. Clinicians use these severity tools to guide management and judge patient improvement from visit to visit. Creation of such a severity scale from a patient's perspective would allow patients to not only assess their perception of their acne independent of a physician but could also be used to determine patient satisfaction with treatment that would then help to more effectively guide management. Therefore the goal of this study is to create and validate a patient-centered acne severity scale using a visual analogue scale format.
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Acné Vulgar/psicología , Calidad de Vida/psicología , Índice de Severidad de la Enfermedad , Escala Visual Analógica , Adolescente , Niño , Femenino , Humanos , Masculino , Proyectos Piloto , Adulto JovenRESUMEN
Bacterial toxin or viral entry into the cell often requires cell surface binding and endocytosis. The endosomal acidification induces a limited unfolding/refolding and membrane insertion reaction of the soluble toxins or viral proteins into their translocation competent or membrane inserted states. At the molecular level, the specific orientation and immobilization of the pre-transitioned toxin on the cell surface is often an important prerequisite prior to cell entry. We propose that structures of some toxin membrane insertion complexes may be observed through procedures where one rationally immobilizes the soluble toxin so that potential unfolding â refolding transitions that occur prior to membrane insertion orientate away from the immobilization surface in the presence of lipid micelle pre-nanodisc structures. As a specific example, the immobilized prepore form of the anthrax toxin pore translocon or protective antigen can be transitioned, inserted into a model lipid membrane (nanodiscs), and released from the immobilized support in its membrane solubilized form. This particular strategy, although unconventional, is a useful procedure for generating pure membrane-inserted toxins in nanodiscs for electron microscopy structural analysis. In addition, generating a similar immobilized platform on label-free biosensor surfaces allows one to observe the kinetics of these acid-induced membrane insertion transitions. These platforms can facilitate the rational design of inhibitors that specifically target the toxin membrane insertion transitions that occur during endosomal acidification. This approach may lead to a new class of direct anti-toxin inhibitors.
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Membrana Dobles de Lípidos/química , Antígenos Bacterianos/ultraestructura , Toxinas Bacterianas , Técnicas Biosensibles , Membrana Celular/química , Membrana Celular/ultraestructura , Chaperonina 60/ultraestructura , Microscopía por Crioelectrón , Endosomas/química , Modelos Moleculares , Nanoestructuras/química , Nanoestructuras/ultraestructura , Estructura Terciaria de ProteínaRESUMEN
The radical species underlying the activity of the bioreductive anticancer prodrug, SN30000, have been identified by electron paramagnetic resonance and pulse radiolysis techniques. Spin-trapping experiments indicate both an aryl-type radical and an oxidising radical, trapped as a carbon-centred radical, are formed from the protonated radical anion of SN30000. The carbon-centred radical, produced upon the one-electron oxidation of the 2-electron reduced metabolite of SN30000, oxidises 2-deoxyribose, a model for the site of damage on DNA which leads to double strand breaks. Calculations using density functional theory support the assignments made.
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Óxidos N-Cíclicos/química , Radicales Libres/química , Profármacos/química , Triazinas/química , Hipoxia de la Célula , Roturas del ADN de Doble Cadena , Espectroscopía de Resonancia por Spin del Electrón , Humanos , Concentración de Iones de Hidrógeno , Cinética , Radiólisis de Impulso , Teoría Cuántica , Temperatura , TirapazaminaAsunto(s)
Dolor Abdominal/etiología , Dolor de Espalda/etiología , Enfermedades del Esófago/diagnóstico por imagen , Mediastinitis/diagnóstico por imagen , Mediastinitis/etiología , Adulto , Aire , Enfermedades del Esófago/etiología , Humanos , Masculino , Rotura Espontánea/diagnóstico por imagen , Rotura Espontánea/etiología , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVES: To evaluate a new triage workflow aimed at improving time to intravenous antibiotics in open fractures to under 60 minutes of arrival to the Pediatric Emergency Department. METHODS: Design: A prospective, multi-disciplinary, quality improvement project. SETTING: A tertiary care, Level 1 Pediatric Trauma hospital in New York. PATIENT SELECTION CRITERIA: Patients aged 17 and under with long bone open fractures between June 1, 2020 and May 31, 2021, excluding those transferred from an outside hospital, with non-long bone fractures and non-fractured, injured extremities.Outcome Measures and Comparisons: The new workflow involved splint removal and skin assessment during triage to identify open fractures. Serial Plan-Do-Study-Act (PDSA) cycles aimed to refine this workflow and reduce antibiotic administration time. Primary outcome: Percentage of open fracture patients receiving intravenous (IV) antibiotics within 60 minutes. Secondary outcome: Assessment of triage documentation regarding splint presence and removal. An exact Wilcoxon two-sample test compared time from patient arrival (quick-registration) to antibiotic administration before, during and after workflow implementation on 6/1/2020. RESULTS: A total of 51 patients (33 male) aged 17 and under, with open fractures were reviewed: 25 during the pre-intervention phase 1/1/18-5/31/20, 14 during the intervention phase 6/1/20-5/31/21, and 12 during the post-intervention phase 6/1/21-11/30/21. Continuous improvement efforts via PDSA cycles focusing on education, reinforcement, recognition, and barrier identification increased the percentage of patients receiving antibiotics within 60 minutes from 36% to 87.5%. Median time and Interquartile range (IQR: 25th percentile-75th percentile) from quick-registration to administration was 86 minutes (IQR: 51-147) before 6/1/2020, and 34 minutes (IQR: 16- 42) thereafter. CONCLUSION: The implemented triage workflow led to improved time to antibiotics to within 60 minutes for patients with long bone open fractures in the Pediatric Emergency Department. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.
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Glioblastoma multiforme (GBM) is the most aggressive malignant primary brain tumor in adults. It is a highly vascularized tumor, and the advent of angiogenic inhibitors, in particular bevacizumab, is thought to be promising for the treatment of these tumors. However, bevacizumab has been associated with an increased risk of arterial and venous thromboembolism and hemorrhage. We report a case of superior vena cava syndrome developing in a glioblastoma patient treated with bevacizumab. Superior vena cava thrombosis in the setting of treatment with vascular endothelial growth factor has not been well-described. The issue arises as how to best manage the hemostatic complications of antiangiogenic agents in patients who have an established risk of bleeding and thrombosis with their GBM. This report discusses the individual risk of bleeding and thrombosis associated with GBM and the use of bevacizumab. Studies suggest that GBM patients who require therapeutic anticoagulation for venous thromboembolic complications while on bevacizumab therapy can be anticoagulated with the risk of bleeding being comparable to that expected from therapeutic anticoagulation alone. However, the potential risks and benefits should be thoroughly discussed with each patient before starting anticoagulation therapy for thrombotic complications.
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Regional Australian masculinities are typified by 'traditional' values (e.g., stoicism, self-reliance) known to restrict social connectedness. Thus, these masculinities have been implicated in worsening men's mental health. What remains unclear, however, is how men living in inner-regional communities (i.e., townships on the fringes of major cities) might uniquely experience masculinity, social connectedness, and mental health. We interviewed 29 boys/men and one non-binary participant (M age = 43.77 years) living in the Macedon Ranges (an inner-regional Australian community). Using reflexive thematic analysis, we generated three themes. Participants described inner-regional masculinities as traditional and rigid, and attributed the Macedon Ranges' comparatively high suicide rate to these masculinities. Conversely, migration from the neighbouring city of Melbourne was implicated in introducing more inclusive masculinities to the area that conflicted with existing masculine norms. Thus, Macedon Ranges men were framed as ultimately lacking a cohesive community identity. Proximity to Melbourne was described as encouraging local men to commute daily for work instead of working locally, thereby further weakening community identity. Overall, these phenomena were implicated in damaging the psychosocial wellbeing of local men via reducing social connectedness. Because men's mental illness is so pervasive within regional Australian communities, these findings have direct implications for policymakers. Namely, policies need to acknowledge that masculinities directly influence mental health and that inner-regional masculinities are impacted by unique place-based considerations distinct from men living in other regional communities.