Scoring Tool to Predict Need for Early Video-Assisted Thoracoscopic Surgery (VATS) After Pediatric Trauma.

BACKGROUND: No widely used stratification tool exists to predict which pediatric trauma patients may require a video-assisted thoracoscopic surgery (VATS). We sought to develop a novel VATS-In-Pediatrics (VIP) score to predict the need for early VATS (within 72 h of admission) for pediatric trauma patients. METHODS: The pediatric 2017-2020 Trauma Quality Improvement Program database was used and divided into two sets (derivation set using 2017-2019 data and validation set using 2020 data). First, multiple logistic regression models were created to determine the risk of early VATS for patients ≤ 17 years old. Second, the weighted average and relative impact of each independent predictor were used to derive a VIP score. We then validated the score using the area under the receiver operating characteristic (AROC) curve. RESULTS: From 218,628 patients in the derivation set, 2183 (1.0%) underwent early VATS. A total of 8 independent predictors of VATS were identified, and the VIP score was derived with scores ranging from 0 to 9. The AROC for this was 0.91. The VATS rate increased steadily from 12.5 to 32% then 60.5% at scores of 3, 4, and 6, respectively. In the validation set, from 70,316 patients, 887 (1.3%) underwent VATS, and the AROC was 0.91. CONCLUSIONS: VIP is a novel and validated scoring tool to predict the need for early VATS in pediatric trauma. This tool can potentially help hospital systems prepare for pediatric patients at high risk for requiring VATS during their first 72 h of admission. Future prospective research is needed to evaluate VIP as a tool that can improve clinical outcomes.

Repeated mild traumatic brain injuries in mice cause age- and sex-specific alterations in dendritic spine density.

Mild traumatic brain injuries (mTBI) plague the human population and their prevalence is increasing annually. More so, repeated mTBIs (RmTBI) are known to manifest and compound neurological deficits in vulnerable populations. Age at injury and sex are two important factors influencing RmTBI pathophysiology, but we continue to know little about the specific effects of RmTBI in youth and females. In this study, we directly quantified the effects of RmTBI on adolescent and adult, male and female mice, with a closed-head lateral impact model. We report age- and sex-specific neurobehavioural deficits in motor function and working memory, microglia responses to injury, and the subsequent changes in dendritic spine density in select brain regions. Specifically, RmTBI caused increased footslips in adult male mice as assessed in a beam walk assay and significantly reduced the time spent with a novel object in adolescent male and female mice. RmTBIs caused a significant reduction in microglia density in male mice in the motor cortex, but not female mice. Finally, RmTBI significantly reduced dendritic spine density in the agranular insular cortex (a region of the prefrontal cortex in mice) and increased dendritic spine density in the adolescent male motor cortex. Together, the data provided in this study sheds new light on the heterogeneity in RmTBI-induced behavioural, glial, and neuronal architecture changes dependent on age and sex.

Multimodal Pain Management Protocol to Decrease Opioid Use and to Improve Pain Control After Thoracic Surgery.

BACKGROUND: Opioid addiction continues to be a devastating problem in our communities, and up to 40% of patients begin their addiction with legally prescribed opioids after injury or surgical procedure. An opioid-free multimodal pain regimen was developed with the goal of decreasing opioid exposure while maintaining adequate pain control. METHODS: A retrospective single-institution study was conducted of 313 consecutive patients undergoing minimally invasive lobectomy before (n = 211) and after (n = 102) implementation of an opioid-free protocol from 2016 to 2020. Data analysis was conducted on preoperative characteristics, postoperative opioid use at set time points (postoperative day 0, postoperative days 1 to 7, and total stay), pain scores, discharge with opioid prescription, and postoperative outcomes. RESULTS: Patients on the opioid-free protocol had significantly lower average total morphine milligram equivalents at all time points. In addition, 56% of patients in the opioid-free group received no oral opioids at all, and 91% did not receive a patient-controlled analgesia pump. Average pain scores were significantly lower in the opioid-free protocol patients along with percentage of time spent with pain scores <3 and <6. With implementation of the protocol, 62% of patients are discharged without an opioid prescription compared with only 7% previously. CONCLUSIONS: Implementation of an opioid-free protocol led to a significant decrease in the use of postoperative opioids at all time points while improving overall management of pain. In addition, most patients are discharged with no home opioid prescription, decreasing a potential source of community opioid spread.

Pathways to Care: How Help-Seeking Behaviors Relate to Duration of Untreated Psychosis and Treatment Engagement.

While much research has focused on the relationship between duration of untreated psychosis (DUP) and clinical outcomes in the first episode psychosis (FEP) patient population, little is known about the individual help-seeking episodes (HSE) that patients undergo before receiving appropriate care. The purpose of this project is to better understand how early referral to FEP-specific care and support system differences affect patients' DUP and engagement with treatment. Data from 50 patients was analyzed at the Early Psychosis Intervention Clinic of New Orleans (EPIC-NOLA) using a modified version of the Pathways to Care Assessments and data captured during clinical care. Patients with their first HSE leading to a referral to EPIC-NOLA (M = 13.3, SD = 11.17) had shorter DUP compared to patients referred after two or more HSEs (M = 29.7, SD = 36. 7), t (38.6) = 2.31, p = .026, 95%CI = 2.0-30.7. One chi-square test revealed a significantly greater proportion of patients referred after one HSE stayed in treatment for 12 months or more. Cluster analysis and independent t-test analyses revealed that patients with hospital pathways (M = 35.00, SD = 39.36) had significantly longer DUP compared to those with self, other and hospital (M = 15.21, SD = 19.07) care pathways. This study supports existing literature that suggest early FEP treatment leads to shortened DUP and longer treatment engagement. Additionally, patients with support systems (people or services) assisting them with help-seeking reach EPIC-NOLA faster, have shorter DUP, and have better treatment engagement.

Financing Benefits and Barriers to Routine HIV Screening in Clinical Settings in the United States: A Scoping Review.

The Centers for Disease Control and Prevention recommends everyone between 13-64 years be tested for HIV at least once as a routine procedure. Routine HIV screening is reimbursable by Medicare, Medicaid, expanded Medicaid, and most commercial insurance plans. Yet, scaling-up HIV routine screening remains a challenge. We conducted a scoping review for studies on financial benefits and barriers associated with HIV screening in clinical settings in the U.S. to inform an evidence-based strategy to scale-up routine HIV screening. We searched Ovid MEDLINE®, Cochrane, and Scopus for studies published between 2006-2020 in English. The search identified 383 Citations; we screened 220 and excluded 163 (outside the time limit, irrelevant, or outside the U.S.). Of the 220 screened articles, we included 35 and disqualified 155 (did not meet the eligibility criteria). We organized eligible articles under two themes: financial benefits/barriers of routine HIV screening in healthcare settings (9 articles); and Cost-effectiveness of routine screening in healthcare settings (26 articles). The review concluded drawing recommendations in three areas: (1) Finance: Incentivize healthcare providers/systems for implementing HIV routine screening and/or separate its reimbursement from bundle payments; (2) Personnel: Encourage nurse-initiated HIV screening programs in primary care settings and educate providers on CDC recommendations; and (3) Approach: Use opt-out approach.

Nasal dorsal augmentation with freeze-dried allograft bone.

BACKGROUND: Properly prepared freeze-dried bone has been used with impunity by orthopedic surgeons since 1992 without a single report of disease transmission. The aim of this study was to evaluate freeze-dried cortical allograft bone for nasal dorsal augmentation. METHODS: Freeze-dried human cortical bone was obtained from DCI Donor Services, Nashville, Tennessee. Standards recommended by the American Association of Tissue Banks, the U.S. Food and Drug Administration, and the Centers for Disease Control and Prevention were followed. Objective evaluation of the persistence of graft volume was obtained by cephalometric radiography. Vascularization and incorporation of new bone elements within the grafts were demonstrated by using fluorine-18 sodium fluoride positron emission tomographic/computed tomographic scanning. RESULTS: The average persistence of projection in 18 patients was 87 percent at 6 months. Thereafter, 10 patients showed 100 percent maintenance of projection at 12 to 36 months. Vascularization and incorporation of new bone elements within the grafts were demonstrated by using fluorine-18 sodium fluoride positron emission tomographic/computed tomographic scanning in four patients. CONCLUSIONS: The initial loss of 13 percent of projection is most likely attributable to resolution of early surgical edema. The authors postulate that there are two pathways based on whether the recipient bed allows vascular access to the graft. The revascularization or inductive pathway involves stem cell conversion to eventual osteoblasts. The scar bed barrier or noninductive pathway involves the preservation of the graft as an unchanged alloimplant. This report is the first of a series that will include a 5-year and a 10-year follow-up.