Implementation of a pediatric trauma cervical spine clearance pathway.

PURPOSE: Pediatric cervical spine injuries are rare events. Missed injuries must be weighed against radiation exposure and excess resource utilization in a young population. A universal pediatric cervical spine clearance algorithm does not exist. The study objective is to determine if care improved after the implementation of a standardized cervical spine clearance pathway by evaluating imaging rates, length of stay, speciality consultation, and injury detection. METHODS: A multidisciplinary group reviewed relevant literature to develop an algorithm for cervical spine clearance in pediatric trauma patients. We reviewed patient charts 15 months before and after implementation. Categorical comparisons were tested with Chi-square. A p value less than 0.05 was considered statistically significant. RESULTS: The pre- and post-implementation groups were homogenous when comparing demographics, mechanism and severity of injury. Using the cervical spine clearance pathway, patients received fewer plain cervical spine radiographs (34% vs 16%), fewer spine speciality consults (28% vs 13%), and more patients were cleared clinically (44% vs 62%) (p < 0.05). There were 2 (1.7%) documented injuries in the pre-implementation group and 3 (3%) documented injuries in the post-implementation group. There were no missed injuries. CONCLUSIONS: Use of a standardized pathway allows more patients' cervical spines to be cleared clinically and better utilizes resources without compromising patient care. LEVEL OF EVIDENCE: Level III. TYPE OF STUDY: Care Management Study.

Benefits of a family-centered approach to pediatric induction of anesthesia.

BACKGROUND/PURPOSE: We initiated a pediatric surgical program including a caregiver for the induction of anesthesia. We measured preoperative midazolam administration, preoperative time, induction time, and program satisfaction. METHODS: Families with children undergoing surgery during the study period were included. Preoperative midazolam administration, preoperative time, and induction time were compared between participants and controls. Satisfaction surveys were given to participating caregivers and staff. RESULTS: The rate of preoperative midazolam use decreased from 41% (392/964) to 13% (16/118) among participants vs controls (p < 0.0001). After linear regression analysis, this difference persisted as an adjusted odds ratio of 0.29 (95% CI = 0.16-0.52). Preoperative and induction times (minutes) were similar between groups (76.2 vs 82.2, 13.8 vs 16.2, p = nonsignificant). Based on 5-point Likert surveys, the program was rated as "beneficial" or "very beneficial" to the patient by caregivers (99.2%) and staff (77.5%). Caregivers stated it "reduced" or "greatly reduced" anxiety for them (87.1%) and their child (93.2%). CONCLUSIONS: Opponents of similar programs suggest familial presence slows care and is disruptive. Our program decreased utilization of preoperative anxiolytics with no effect on operating room efficiency. Both hospital staff and participants felt the program was beneficial to the patient. Perceived caregiver and child anxiety was reduced. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: Level III.

Use of the STROBE Checklist to Evaluate the Reporting Quality of Observational Research in Obstetrics.

OBJECTIVE: To evaluate observational research manuscripts submitted to Obstetrics & Gynecology to determine the level of adherence to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist and highlight specific areas that could be improved. METHODS: A scoring system based on the STROBE checklist was developed and validated for consistency by volunteer medical students or doctors. Using this scoring system, we performed a cross-sectional analysis on 198 observational research manuscripts submitted to Obstetrics & Gynecology from 2008 to 2016. Each manuscript was given a score based on the STROBE checklist. Comparisons were made among acceptance status, country of origin, and study type. Descriptive statistics (means, medians, and frequencies) were calculated for each manuscript category. The t test or Wilcoxon rank-sum test was used to compare differences between two groups and analysis of variance or the Kruskal-Wallis test was used to compare differences among three or more groups. RESULTS: There was a statistically significant difference between the mean score for accepted (23.2±2.7) compared with rejected (19.7±4.1) manuscripts (P<.001). This difference was not seen when comparing country of origin and study type. Poor reporting was seen among all manuscript categories for objectives, study size, missing data, study participants, and translation of risk. Additionally, rejected manuscripts had poor reporting for eligibility criteria, variables, bias and confounding, statistical methods, unadjusted and adjusted estimates, and category boundaries. CONCLUSION: Overall, accepted manuscripts show better adherence to the STROBE checklist, but there are several critical items that are poorly reported in all manuscripts.

Subspecialty Influence on Scientific Peer Review for an Obstetrics and Gynecology Journal With a High Impact Factor.

OBJECTIVE: To evaluate whether quality of peer review and reviewer recommendation differ based on reviewer subspecialty in obstetrics and gynecology and to determine the role of experience on reviewer recommendation. METHODS: We performed a retrospective cohort study of reviews submitted to Obstetrics & Gynecology between January 2010 and December 2014. Subspecialties were determined based on classification terms selected by each reviewer and included all major obstetrics and gynecology subspecialties, general obstetrics and gynecology, and nonobstetrics and gynecology categories. Review quality (graded on a 5-point Likert scale by the journal's editors) and reviewer recommendation of "reject" were compared across subspecialties using χ, analysis of variance, and multivariate logistic regression. RESULTS: There were 20,027 reviews from 1,889 individual reviewers. Reviewers with family planning subspecialty provided higher-quality peer reviews compared with reviewers with gynecology only, reproductive endocrinology and infertility, gynecologic oncology, and general obstetrics and gynecology specialties (3.61±0.75 compared with 3.44±0.78, 3.42±0.72, 3.35±0.75, and 3.32±0.81, respectively, P<.05). Reviewers with gynecology-only subspecialty recommended rejection more often compared with reviewers with a nonobstetrics and gynecology subspecialty (57.7% compared with 38.7%, P<.05). Editorial Board members recommended rejection more often than new reviewers (68.0% compared with 41.5%, P<.05). Increased adjusted odds of manuscript rejection recommendation were associated with reproductive endocrinology, female pelvic medicine and reconstructive surgery, and gynecology-only reviewer subspecialty (adjusted odds ratio [OR] 1.23 [1.07-1.41], 1.21 [1.05-1.39], and 1.11 [1.02-1.20]). Manuscript rejection recommendation rate was also increased for reviewers who had completed the highest quintile of peer reviews (greater than 195) compared with the lowest quintile (one to seven) (adjusted OR 2.85 [2.60-3.12]). CONCLUSION: Peer review quality differs based on obstetrics and gynecology subspecialty. Obstetrics and gynecology subspecialty and reviewer experience have implications for manuscript rejection recommendation. Reviewer assignment is pivotal to maintaining a rigorous manuscript selection process.

Risk factors for anastomotic leak and mortality in diabetic patients undergoing colectomy: analysis from a statewide surgical quality collaborative.

OBJECTIVES: To determine the risk factors in diabetic patients that are associated with increased postcolectomy mortality and anastomotic leak. DESIGN: A prospectively acquired statewide database of patients who underwent colectomy was reviewed. Primary risk factors were diabetes mellitus, hyperglycemia (glucose level ≥ 140 mg/dL), steroid use, and emergency surgery. Categorical analysis, univariate logistic regression, and multivariate regression were used to evaluate the effects of these risk factors on outcomes. SETTING: Participating hospitals within the Michigan Surgical Quality Collaborative. PATIENTS: Database review of patients from hospitals within the Michigan Surgical Quality Collaborative. MAIN OUTCOME MEASURES: Anastomotic leak and 30- day mortality rate. RESULTS: Of 5123 patients, 153 (3.0%) had leaks and 153 (3.0%) died. Preoperative hyperglycemia occurred in 15.6% of patients, only 54% of whom were known to have diabetes. Multivariate analysis showed that the risk of leak for patients with and without diabetes increased only by preoperative steroid use (P<.05). Mortality among diabetic patients was associated with emergency surgery (P<.01) and anastomotic leak (P<.05); it was not associated with hyperglycemia. Mortality among nondiabetic patients was associated with hyperglycemia (P<.005). The presence of an anastomotic leak was associated with increased mortality among diabetic patients (26.3% vs 4.5%; P<.001) compared with nondiabetic patients (6.0% vs 2.5%; P<.05). CONCLUSIONS: The presence of diabetes did not have an effect on the presence of an anastomotic leak, but diabetic patients who had a leak had more than a 4-fold higher mortality compared with nondiabetic patients. Preoperative steroid use led to increased rates of anastomotic leak in diabetic patients. Mortality was associated with hyperglycemia for nondiabetic patients only. Improved screening may identify high-risk patients who would benefit from perioperative intervention.

Toward a multiscale model of antigen presentation in immunity.

A functioning immune system and the process of antigen presentation in particular encompass events that occur at multiple length and time scales. Despite a wealth of information in the biological literature regarding each of these scales, no single representation synthesizing this information into a model of the overall immune response as it depends on antigen presentation is available. In this article, we outline an approach for integrating information over relevant biological and temporal scales to generate such a representation for major histocompatibility complex class II-mediated antigen presentation. In addition, we begin to address how such models can be used to answer questions about mechanisms of infection and new strategies for treatment and vaccines.