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BACKGROUND: Historically, the treatment of iliac artery occlusive disease required a surgical bypass usually consisting of an aortobifemoral bypass or an iliofemoral bypass. With the advent of balloon angioplasty and stenting, these procedures are frequently replaced with endovascular options. However, the treatment of diffuse occlusive disease of the external iliac artery (EIA) using balloon angioplasty and/or stenting does not carry a favorable long-term patency rate. Remote endarterectomy of the EIA using ring dissectors with balloon assistance provides a novel, controlled, safe, and durable treatment of the diseased and/or occluded EIA. METHODS: A retrospective review over the past 6 years was performed at our institution identifying patients treated with balloon-assisted remote endarterectomy of the EIA by the current five practicing vascular surgeons. The technique involves exposure of the ipsilateral common femoral artery. With nonocclusive disease, direct access into the common femoral artery is performed, a wire is traversed through the diseased EIA, and a balloon is inflated at the origin of the vessel providing hemostasis and control. A femoral endarterectomy is performed, and a ring dissector is passed over the endarterectomized material including the wire and balloon catheter and advanced remotely through the EIA up to the balloon. The balloon is briefly deflated, repositioned within the ring dissector, and reinflated, thus cutting the plaque. This allows for retraction of the inflated balloon and cutter, removing the endarterectomized core plaque. The procedure is similar for the treatment of an occluded EIA, but wire access across the occluded vessel is normally achieved with contralateral access. In both cases, the balloon provides control and hemostasis and is critically important in the rare treatment of vessel rupture. RESULTS: A total of 101 vessels were treated in 97 patients. The procedure was successful in 98 vessels (97%) with failure related to vessel rupture requiring conversion to an iliofemoral bypass. The estimated patency rate at three years was 94% with a median follow-up of 20 months. Restenosis/occlusion in four patients seemed to be related to a severe sclerotic response. The EIA was occluded 32% of the time. The common iliac artery (CIA) was diseased requiring angioplasty and stenting 29% of the time and a stent was placed at the transition zone between endarterectomized vessel and nontreated proximal most EIA or distal most CIA 58% of the time. There were no perioperative deaths. CONCLUSIONS: Balloon-assisted remote endarterectomy of the diffusely diseased and/or occluded EIA is a safe and durable option. It precludes the need for a prosthetic conduit and the risk of associated infection. It also involves a single groin incision and negates the need for retroperitoneal exposure of the CIA.
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Angioplastia com Balão , Arteriopatias Oclusivas/terapia , Endarterectomia , Artéria Ilíaca/cirurgia , Idoso , Angioplastia com Balão/efeitos adversos , Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/fisiopatologia , Terapia Combinada , Endarterectomia/efeitos adversos , Feminino , Humanos , Artéria Ilíaca/diagnóstico por imagem , Artéria Ilíaca/fisiopatologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/cirurgia , Recidiva , Reoperação , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
Objectives. To examine the impact of North Carolina's 2017 Strengthening Opioid Misuse Prevention (STOP) Act on opioid overdose deaths.Methods. We used quarterly data from the North Carolina Opioid Dashboard to conduct an interrupted time series analysis ranging from 2010 to 2018. Results were stratified by heroin-fentanyl deaths and other opioid deaths.Results. After the STOP Act, there was an initial rate increase of 0.60 opioid deaths per 100 000 population (95% confidence interval [CI] = 0.04, 1.15) and a decrease of 0.42 (95% CI = -0.56, -0.29) every quarter thereafter. Results differed by stratification.Conclusions. Our results suggest that North Carolina's STOP Act was associated with a reduction in opioid deaths in the year following enactment. The changes in opioid overdose death trends coinciding with the STOP Act were similar to outcomes seen with previous opioid policies.Public Health Implications. Future policies designed to reduce the availability of opioids may benefit from encouraging and increasing the availability of evidence-based treatment of opioid use disorder.
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Analgésicos Opioides/efeitos adversos , Overdose de Drogas/epidemiologia , Regulamentação Governamental , Mortalidade Prematura/tendências , Fentanila/intoxicação , Heroína/intoxicação , Humanos , North Carolina/epidemiologiaRESUMO
BACKGROUND: Medication management during transitions of care (TOC) impacts clinical outcomes. Published literature on TOC implementation is increasing, but data remains limited regarding the optimal role for the inpatient pharmacist, particularly in the community health setting. OBJECTIVE: To evaluate the impact of a dedicated inpatient TOC pharmacist on re-presentations following discharge. METHODS: This is a prospective study with historical control. All adult patients discharging home from study units were eligible. The TOC pharmacist (1) reviewed medication history and admission reconciliation, (2) met the patient/caregiver to assess barriers, (3) reviewed discharge reconciliation, (4) performed discharge education, and (5) communicated with next level of care. The primary outcome was 30 day re-presentation rate. Secondary outcomes included 60, 90, and 365 day re-presentation rates. IRB approval was obtained. RESULTS: Three hundred and eighty four patients met inclusion criteria. When compared to 1,221 control patients, the intervention had an 11% absolute and 50.2% relative reduction in 30 day re-presentation rate (OR 0.43, 95% CI 0.30-0.61, NNT 9). Reductions in re-presentations at 60, 90 and 365 days remained statistically significant. Utilization avoidance was $786,347. For every $1 invested in pharmacist time, $12 was saved. The TOC pharmacist made a total of 904 interventions (mean 2.4 per patient). CONCLUSION: This study provides new information from previous studies and represents the largest study with significant and sustained reductions in re-presentations. Integrating a pharmacist into an interdisciplinary team for medication management during TOC in a community health system is beneficial for patients and financially favorable for the institution.
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Hospitais Comunitários/organização & administração , Comunicação Interdisciplinar , Reconciliação de Medicamentos/organização & administração , Farmacêuticos/organização & administração , Serviço de Farmácia Hospitalar/organização & administração , Adulto , Idoso , Feminino , Hospitais Comunitários/normas , Humanos , Masculino , Reconciliação de Medicamentos/normas , Pessoa de Meia-Idade , North Carolina , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Farmacêuticos/normas , Serviço de Farmácia Hospitalar/normas , Estudos ProspectivosRESUMO
BACKGROUND: Recent randomized controlled studies have shown improvement in recanalization outcomes when physicians use the latest intra-arterial therapy devices in patients with acute, large-vessel, intracranial occlusions. The goal of this study was to explore how new procedures affected degree of and time to recanalization at a single center over the past 12 years as technology has improved. METHODS: Patients were included in the study if they had a large or medium intracranial vessel occlusion and had undergone intra-arterial therapy for acute stroke during the period 2002-2013. Therapies were categorized as intra-arterial thrombolysis with tissue plasminogen activator (IA tPA), mechanical thrombectomy using 1st-generation devices (Merci and Penumbra), or mechanical thrombectomy using 2nd-generation devices (stent-trievers). Recanalization was defined using a modified Thrombolysis in Cerebral Infarction (TICI) scale. RESULTS: Primary treatment was IA tPA in 24 (12.4%) patients, 1st-generation devices in 128 (66.0%) patients, and 2nd-generation devices in 42 (21.6%) patients. TICI 2b was achieved in 7 (29.2%) patients treated with IA tPA, in 79 (61.7%) patients treated with 1st-generation devices, and in 38 (90.5%) patients treated with 2nd-generation devices. Compared to patients treated with IA tPA, patients treated with 2nd-generation devices were more likely to reach TICI 2b recanalization (odds ratio, 11.66; 95% CI, 1.56-87.01), and they did so in shorter times. CONCLUSION: Technological advances over 12 years in endovascular stroke treatments significantly improved the chance of and reduced time to achieving TICI 2b recanalization in our community hospital. This shows the importance of adopting new technologies in a rapidly evolving field in order to provide the best-practice standard of care for the people of our region.
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Revascularização Cerebral/métodos , Procedimentos Endovasculares/métodos , Trombólise Mecânica/métodos , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Arteriosclerose Intracraniana/complicações , Invenções , Masculino , North Carolina , Avaliação de Resultados em Cuidados de Saúde , Melhoria de Qualidade , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/terapiaRESUMO
OBJECTIVE: Research on tumor size (TS) and intracavitary tumor location in endometrial cancer has focused primarily on low-grade tumors. Data in patients with high-grade histology are limited. Our goal is to determine if TS or lower uterine segment (LUS) involvement, is associated with nodal disease and recurrence in women with high-grade endometrial cancer. METHODS: This is an IRB-approved, multi-institutional cohort study of patients with clinically early-stage, high-grade endometrial cancer who underwent comprehensive surgical staging. Records were reviewed for demographic, pathologic, and treatment data. Nodal involvement and recurrence as a function of TS and location were estimated with odds ratios and hazard ratios. RESULTS: From 2005 to 2012, 208 patients were identified. Of these, 188 patients had tumor location and 183 had TS reported. There were 75 endometrioid (36.1%), 35 serous (16.8%), 12 clear cell (5.8%), and 26 carcinosarcoma (12.5%) cases, and 60 (28.8%) undifferentiated or mixed histologies. There were 55 recurrences (median follow up 17.2 mo). LUS tumors were associated with pelvic and para-aortic nodal disease (OR 3.83, 95% CI 1.70-8.60, p<0.01, OR 5.13, 95% CI 1.96-13.45, p<0.01). TS ≥ 2 cm was associated with pelvic nodal disease (27.4% vs. 0%, p=0.01; OR 10.00, p=0.01). Neither TS nor LUS location was independently associated with recurrence. CONCLUSIONS: In high-grade endometrial cancers, tumor involvement of the LUS and TS>2 cm was associated with pelvic nodal disease, and LUS involvement was also significantly associated with para-aortic nodal disease. There was no association between LUS involvement or TS>2 cm and recurrence.
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Neoplasias do Endométrio/patologia , Idoso , Feminino , Humanos , Metástase Linfática , Pessoa de Meia-Idade , Gradação de Tumores , Recidiva Local de Neoplasia/patologia , Estudos RetrospectivosRESUMO
Patients on warfarin therapy need to achieve and maintain anticoagulation control in order to experience the benefits of treatment while minimizing bleeding risk. Low health literacy skills may hinder patients' ability to use and adhere to warfarin in a safe and effective manner. The authors conducted this study to evaluate the relationship between health literacy and anticoagulation control among patients on chronic warfarin therapy. Participants were recruited from 2 diverse anticoagulation clinics in North Carolina. Time in therapeutic range (TTR) for warfarin therapy was used as a measure of anticoagulation control. Health literacy was assessed using the short form of the Test of Functional Health Literacy in Adults (S-TOFHLA). Of the 198 study participants, 51% had limited health literacy (S-TOFHLA score of 0-90) and 33% had poor anticoagulation control (TTR<50%). Participants with limited health literacy were less likely to correctly answer warfarin-related knowledge questions. Limited health literacy was significantly associated with TTR<50% (adjusted odds ratio=2.34, 95% CI [1.01, 5.46]). Findings indicate that limited health literacy is associated with poor anticoagulation control for patients on warfarin therapy. Lack of medication understanding may hinder the safe and effective use of this narrow therapeutic index drug.
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Anticoagulantes/uso terapêutico , Conhecimentos, Atitudes e Prática em Saúde , Letramento em Saúde/estatística & dados numéricos , Adesão à Medicação/estatística & dados numéricos , Varfarina/uso terapêutico , Idoso , Anticoagulantes/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Resultado do Tratamento , Varfarina/efeitos adversosRESUMO
OBJECTIVE: Fibroids are hormonally dependent uterine tumors. The literature on adiposity and fibroid prevalence is inconsistent. Previous work usually combined all those with body mass indexes (BMIs) ≥30kg/m2 into a single category and relied on clinically diagnosed fibroids which misclassifies the many women with undiagnosed fibroids. We used a prospective cohort design with periodic ultrasound screening to investigate associations between repeated measures of BMI and fibroid incidence and growth assessed at each follow-up ultrasound. METHODS: The Study of Environment, Lifestyle & Fibroids (SELF) followed 1,693 Black/African American women, ages 23-35 from Detroit, Michigan with ultrasound every 20 months for 5 years. Measured height and repeated weight measures were used to calculate BMI. Fibroid incidence was modeled using Cox models among those who were fibroid-free at the enrollment ultrasound. Fibroid growth was estimated for individual fibroids matched across visits as the difference in log-volume between visits and was modeled using linear mixed models. All models used time-varying BMI and adjusted for time-varying covariates. RESULTS: Compared to BMI <25kg/m2 those with BMI 30-<35kg/m2 had increased fibroid incidence (adjusted hazard ratio (aHR) 1.37, (95% Confidence Interval (CI): 0.96-1.94)), those with BMI ≥40kg/m2 had reduced incidence (aHR 0.61, (95% CI: 0.41-0.90)). Fibroid growth had mostly small magnitude associations with BMI. CONCLUSION: BMI has a non-linear association with fibroid incidence that could be driven by effects of BMI on inflammation and reproductive hormones. More detailed measures of visceral and subcutaneous adiposity and their effects on hormones, DNA damage, and cell death are needed.
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INTRODUCTION: Studies demonstrate that patient factors such as race, body composition, medical co-morbidities, and medications may be associated with cancer related outcomes independent of the patient's malignancy and related therapies for the cancer. The goal of this study is to determine demographic and prognostic factors affecting disease recurrence in women with early stage ovarian granulosa cell tumors (GCT). MATERIALS AND METHODS: This study used a dual-institution retrospective analysis of women diagnosed with GCT between 1995 and 2010. Demographics including age, race, body mass index (BMI), stage, diabetes (DM), adjuvant treatment, and progression-free survival (PFS) were extracted. Hazard ratios for recurrence were estimated by univariate and multivariate Cox regression models. RESULTS: One hundred and four women were identified with a median age of 50 years (range 12-87 years). Fifty-five (58.5%) were Caucasian, 29 (30.9%) African American, and 10 (10.2%) others. Median BMI was 29 kg/m(2) (range 12-57 kg/m(2)). Twenty-one patients had DM. The majority of women had clinical stage I disease (95.0%), 5 (6.4%) had stage II/III disease, and 5 were unstaged. In univariate analysis among early stage disease, DM showed the strongest association with recurrence (HR=3.37, 95% CI=1.38-8.20). In multivariate analysis, DM was associated with an HR of 3.19 for recurrence (95% CI=1.08-9.44). CONCLUSIONS: Our results emphasize that diabetes is one of the strongest predictors of recurrent disease in patients with ovarian GCTs. As this disease is characterized by long disease-free intervals prior to recurrence, this may serve as a potential chemopreventive strategy in patients felt to be at higher risk for recurrence.
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Tumor de Células da Granulosa/epidemiologia , Tumor de Células da Granulosa/patologia , Recidiva Local de Neoplasia/epidemiologia , Recidiva Local de Neoplasia/patologia , Neoplasias Ovarianas/epidemiologia , Neoplasias Ovarianas/patologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Criança , Feminino , Humanos , Massachusetts/epidemiologia , Pessoa de Meia-Idade , North Carolina/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Adulto JovemRESUMO
Background: The Mountain Area Health Education Center (MAHEC) Dental Health Center sought to learn how COVID-19 affected dental care attainment and patient perceptions of appropriate safety measures, as well as their acceptance of the dental office as a site for COVID-19 vaccinations. Methods: A cross-sectional online survey of dental patients was performed to inquire about barriers to care, safety precautions, including COVID-19 testing, and the acceptability of vaccination for COVID-19 in the dental office. All adult patients of the MAHEC Dental Health Center with an email address on file and a clinic visit in the past year were randomized for inclusion. Results: We sampled 261 adult patients; the majority were White (83.1%), female (70.1%), and over 60 years of age (60.1%). Patients who were included had visited the clinic for routine cleanings (67.2%) and dental emergency care (77.4%) in the past year. Respondents supported safety precautions at the clinic; however, there was little support for mandatory COVID-19 testing prior to a visit (14.7%). Just under half (47.3%) of respondents believed it would be appropriate for a dental office to give COVID-19 vaccinations. Conclusions: Overall, patients experienced concerns during the pandemic but still sought dental care for routine treatments and emergencies. Patients supported the use of precautionary COVID-19 safety measures at the clinic, though they did not support mandatory COVID-19 testing prior to a visit. Respondents were split on the acceptability of COVID-19 vaccination in the dental clinic.
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PURPOSE: Rural areas throughout the US continue to see closures of maternity wards and decreasing access to prenatal and intrapartum care. Studies examining closure's impacts have demonstrated both positive and negative effects on maternal and neonatal outcomes of mortality and morbidity. Our study aims to build on growing evidence from Canada and Scandinavia that suggests increased travel time to give birth is associated with increased emotional and financial stress for rural pregnant women. METHODS: Pregnant patients at 7 clinic sites in western North Carolina were invited to complete the Rural Pregnancy Experience Scale (RPES) while waiting for their prenatal appointments. Results were analyzed using adjusted linear regressions to examine the correlation between RPES scores and self-reported distance to anticipated birth location as well as RPES scores with recent local labor and delivery closure. FINDINGS: A total of 174 participants completed the survey and met inclusion criteria. For every 10 min increase in travel distance to the patient's anticipated place of delivery, RPES scores increased by an average of 0.72 points. Participants who reported a recent labor and delivery unit closure near them saw average increases of 2.52 on the RPES. CONCLUSIONS: Our findings are consistent with the growing body of literature internationally that demonstrates the distance required to travel to delivery location is associated with increased stress among rural pregnant women.
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Trabalho de Parto , Gestantes , Recém-Nascido , Gravidez , Feminino , Humanos , Gestantes/psicologia , North Carolina , Parto , Canadá , Cuidado Pré-NatalRESUMO
OBJECTIVE: Cervical cancer causes over 4000 deaths yearly in the United States, although highly preventable through vaccination, screening, and early treatment. We aimed to determine demographic correlates for cervical cancer in North Carolina to identify target populations for interventions and to create a framework for state-level analyses. METHOD: Data on all reported invasive cervical cancer cases from 1998 to 2007 were obtained from the North Carolina Central Cancer Registry. Age-adjusted incidence and mortality rates were estimated using population data from the National Center for Health Statistics. RESULTS: Cervical cancer incidence and mortality rates varied greatly by county and were inversely associated with county prosperity. Hispanic women had the highest incidence rate, black women the highest mortality rate, although white women accounted for most cases. Incidence rates remained fairly steady above age 35 and mortality rates steadily increased with age. A later stage at diagnosis was more common for older women and for women without private insurance. CONCLUSION: Registry-based assessment illustrates the economic, racial, and age disparities associated with cervical cancer. This localized focus on demographic correlates is an important step toward eliminating this preventable disease and offers a template for cervical cancer prevention programs in other states.
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Efeitos Psicossociais da Doença , Neoplasias do Colo do Útero/epidemiologia , Adenocarcinoma/epidemiologia , Adenocarcinoma/mortalidade , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Escamosas/epidemiologia , Carcinoma de Células Escamosas/mortalidade , Feminino , Humanos , Incidência , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , North Carolina , Grupos Raciais/estatística & dados numéricos , Sistema de Registros , Fatores de Risco , Fatores Socioeconômicos , Neoplasias do Colo do Útero/mortalidade , Adulto JovemRESUMO
OBJECTIVE: Fibroid treatments that have few side-effects and can preserve fertility are a clinical priority. We studied the association between serum vitamin D and uterine fibroid growth, incidence, and loss. DESIGN: A prospective community cohort study (enrollment 2010-2012) with 4 study visits over 5 years to conduct standardized ultrasounds, measure 25-hydroxyvitamin D (25(OH)D), and update covariates. SETTING: Detroit, Michigan area. PATIENTS: Self-identified African American or Black women aged 23-35 at enrollment without previous clinical diagnosis of fibroids. INTERVENTION(S): Serum 25(OH)D measured using immunoassay or liquid chromatography-tandem mass spectrometry. MAIN OUTCOME MEASURE(S): The primary outcomes were fibroid growth, as measured by change in log volume per 18 months, and fibroid incidence (first detection of fibroid in previously fibroid-free uterus). Adjusted growth estimates from linear mixed models were converted to estimated difference in volume for high vs. low 25(OH)D. Incidence differences were estimated as hazard ratios from age-specific Cox regression. A secondary outcome fibroid loss (reduction in fibroid number between visits), was modeled using Poisson regression. Covariates (reproductive and hormonal variables, demographics, body mass index, current smoking) and 25(OH)D were modeled as time-varying factors. RESULT(S): At enrollment among 1,610 participants with ≥1 follow-up ultrasound, mean age was 29.2 years, 73% had deficient vitamin D (<20ng/mL), and only 7% had sufficient vitamin D (≥30ng/mL). Serum 25(OH)D ≥20ng/mL compared with <20ng/mL was associated with an estimated 9.7% reduction in fibroid growth (95% confidence interval [CI]: -17.3%, -1.3%), similar to the minimally adjusted estimate -8.4% (95% CI: -16.4, 0.3). Serum 25(OH)D ≥30ng/mL compared with <30ng/mL was associated with an imprecise 22% reduction in incidence (adjusted hazard ratio=0.78; 95% CI: 0.47, 1.30), similar to the unadjusted estimate of 0.84 (95% CI: 0.51, 1.39). The >30ng/mL group also had a 32% increase in fibroid loss (adjusted risk ratio=1.32; 95% CI: 0.95, 1.83). CONCLUSION(S): Our data support the hypothesis that high concentrations of vitamin D decrease fibroid development but are limited by the few participants with serum 25(OH)D ≥30ng/mL. Interventional trials that raise and maintain 25(OH)D concentrations >30ng/mL and then prospectively monitor fibroid development are needed to further assess supplemental vitamin D efficacy and determine optimal treatment protocols.
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Leiomioma , Neoplasias Uterinas , Humanos , Feminino , Adulto , Neoplasias Uterinas/diagnóstico por imagem , Neoplasias Uterinas/epidemiologia , Estudos Prospectivos , Estudos de Coortes , Leiomioma/diagnóstico por imagem , Leiomioma/epidemiologia , Leiomioma/tratamento farmacológico , Vitamina D , VitaminasRESUMO
Significance: Vaping is an epidemic among young people, but there is little guidance on how medical providers should counsel young adults about vaping. To address this gap, we examined how electronic health record (EHR) systems prompt providers to collect vaping data and interviewed young adults about vaping communications with providers and preferred information sources. Methods: In this mixed methods study, we used survey research methods to explore if prompts exist in EHR systems to guide discussions about vaping with youth seen in primary care. We collected primary care practice information about EHR prompts regarding e-cigarette use from 10 rural North Carolina practices from August 2020 through November 2020 and interviewed 17 young adults (age 18-21 years) who reviewed resources and provided their opinion on the resource's relevance for their age group. Interviews were stratified by vaping status, transcribed, coded, and thematically analyzed. Results: Only 5 of 10 EHR systems included prompts to capture information about vaping and data capture was optional in all 5 cases. Of the 17 interviewees, 10 were female, 14 were White, 3 were non-White and the mean age was 19.6 years. Two central themes emerged. Young adults: 1) were open to confidential, non-confrontational interactions with trusted providers and supported the use of a 2-page resource/discussion guide, questionnaires about vaping, and other waiting room resources, and 2) wanted prevention and cessation resources to be age-appropriate, including medical facts from a trusted source, and to be disseminated via social media platforms used by young adults. Conclusions: We found a lack of EHR functionalities in screening for vaping status hindered patients from receiving counseling on use. Young adults report a willingness to communicate with and learn from trusted providers and to gain understanding from information accessed via social media.
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People living in rural regions in the United States face more health challenges than their non-rural counterparts which could put them at additional risks during the COVID-19 pandemic. Few studies have examined if rurality is associated with additional mortality risk among those hospitalized for COVID-19. We studied a retrospective cohort of 3,991 people hospitalized with SARS-CoV-2 infections discharged between March 1 and September 30, 2020 in one of 17 hospitals in North Carolina that collaborate as a clinical data research network. Patient demographics, comorbidities, symptoms and laboratory data were examined. Logistic regression was used to evaluate associations of rurality with a composite outcome of death/hospice discharge. Comorbidities were more common in the rural patient population as were the number of comorbidities per patient. Overall, 505 patients died prior to discharge and 63 patients were discharged to hospice. Among rural patients, 16.5% died or were discharged to hospice vs. 13.3% in the urban cohort resulting in greater odds of death/hospice discharge (OR 1.3, 95% CI 1.1, 1.6). This estimate decreased minimally when adjusted for age, sex, race/ethnicity, payer, disease comorbidities, presenting oxygen levels and cytokine levels (adjusted model OR 1.2, 95% CI 1.0, 1.5). This analysis demonstrated a higher COVID-19 mortality risk among rural residents of NC. Implementing policy changes may mitigate such disparities going forward.
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COVID-19 , COVID-19/epidemiologia , Hospitalização , Humanos , North Carolina/epidemiologia , Pandemias , Estudos Retrospectivos , SARS-CoV-2 , Estados UnidosRESUMO
OBJECTIVE: Preterm infants often require caffeine for the treatment of apnea. While the maintenance dose of caffeine citrate is usually administered once daily per FDA labeling, many providers administer the maintenance dose in two divided doses. This study evaluated the effectiveness of a twice daily dosing regimen of caffeine for apnea of prematurity. METHODS: This was a retrospective analysis conducted from 2013-2018 that included preterm infants who received caffeine that was dosed both once and twice daily respectively. The primary outcome of our study was a composite of the number of apneic and bradycardic events for five 24-hour periods prior to switching to twice daily dosing of caffeine and five 24-hour periods after switching to twice daily dosing of caffeine. RESULTS: The median five-day average incidence of apnea and bradycardia during the once and twice daily dosing periods was 6.2 events and 6.4 events respectively (p=0.09). CONCLUSIONS: There is little benefit of twice daily dosing of caffeine for apnea of prematurity.
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Introduction: The COVID-19 pandemic has created unique challenges for primary care practices while also highlighting their importance in the pandemic response. To understand primary care practice needs, a survey was conducted of practices in Western North Carolina. Methods: Phase 2 of a primary care needs assessment was administered to 63 practices in Western North Carolina over the course of six weeks, from July 23 to August 31, 2021. Results: Most practices were operating with normal hours, though some still operated with reduced hours. Many practices reported insufficient personal protective equipment (PPE) supplies. While most practices provided at least some care via telehealth, practices cited different barriers to providing telehealth, with patient technology challenges being the most frequently cited. Discussion: Practices have adapted to the restrictions of the pandemic, but many are still vulnerable, and the patients they serve may face reduced access to care due to practice limitations or barriers to telehealth. Practices play a critical role in providing care to patients throughout the pandemic and continue to assist in pandemic response by providing COVID-19 testing and other services. Conclusion: Primary care practices in Western North Carolina continue to provide care to patients and support the overall pandemic response. The pandemic has highlighted the need to include primary care in emergency response efforts. Ongoing work will allow North Carolina to reach practices more effectively in future crises via the newly created NC Responds system, which allows primary care practices to be contacted in the event of a public health emergency.
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PURPOSE: Closures of rural labor and delivery (L/D) units have prompted national and state-based efforts to assess the impact on birth outcomes. This study explores local effects of L/D closures in rural areas of North Carolina (NC). METHODS: This is a retrospective cohort study of birth outcomes of 4,065 women in 5 rural areas of NC with L/D unit closures between 2013 and 2017. Outcomes were abstracted from birth certificate data from the NC Vital Statistics Reporting System. Localized outcomes 1 year prior to L/D unit closure were compared with outcomes 1 and 2 years post closure, including: (1) birth location and demographics, (2) change in travel patterns for birth, and (3) birth outcomes, including rates of labor induction, cesarean deliveries, maternal morbidity, and neonatal outcomes. FINDINGS: Before closures, 25%-56% of deliveries occurred outside county of residence. Commercially insured and college-educated women were more likely to deliver out-of-area. Closures increased travel distance to delivery hospital an average of 7-27 miles. In 2 areas, cesarean delivery rates decreased despite an increase in labor inductions. There was also variability between areas in prenatal care adequacy and breastfeeding. CONCLUSIONS: We found that L/D unit closures in rural NC disproportionately affected women on Medicaid. The impact showed area-specific variability, highlighting effects potentially masked by statewide or national analyses. Implications for future L/D closures would be eased by regional coordination and planning to mitigate negative effects, and state and national policies should address the excess burden placed on vulnerable populations.
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Cesárea , População Rural , Feminino , Humanos , Recém-Nascido , Trabalho de Parto Induzido , North Carolina/epidemiologia , Gravidez , Estudos RetrospectivosRESUMO
BACKGROUND: The isolated northern region of Nicaragua has one of the highest rates of diarrheal disease in Central America. Political and environmental hardships faced by inhabitants of this region are contributing factors to this health inequity. The aim of this study was to assess the relationship between water and latrine infrastructure and the prevalence of diarrhea in this region. METHODS: A population-based, cross-sectional survey of women of reproductive age was conducted in the Sahsa region of northern Nicaragua in July, 2009. Households were selected by two stage cluster sampling methodology. A questionnaire was administered in Spanish and Miskito with assessment of household and socioeconomic conditions, sanitation practices, and health care access. Diarrhea prevalence differences at the household level over a two week reporting period were estimated with a standardized instrument which included assessment of water treatment and latrine use and maintenance. RESULTS: There were 189 women enrolled in the current study. The use of water purification methods, such as chlorine and filters, and latrine ownership were not associated with reduced prevalence of household diarrhea in the two week reporting period. Latrine overflow, however, was associated with an increased prevalence of diarrhea during the same two week period [adjusted prevalence difference and 95% CI: 0.19 (0.03, 0.36)]. CONCLUSIONS: Simple, low cost interventions that improve water and latrine infrastructure may reduce the prevalence of diarrheal disease in the isolated regions of Nicaragua and Central America.
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The incidence of postoperative nausea and vomiting (PONV) is unknown in neuraxial anesthesia for orthopedic surgery. The effect on PONV of adding gabapentin to an evidence-based antiemetic regimen as part of an opioid-sparing analgesic protocol is also unknown in this population. A retrospective analysis of all adults undergoing hip and knee arthroplasty and receiving neuraxial anesthesia in 2017 was conducted. The overall incidence of PONV was assessed. Additionally, PONV incidence was assessed for all combinations of gabapentin, dexamethasone, and/or ondansetron (in addition to propofol infusion) and compared with propofol alone. The PONV risk ratios were estimated, adjusting for age and PONV risk score. The overall incidence of PONV was 14.0%. The addition of gabapentin to propofol was associated with reduced PONV (multivariable risk ratio [mRR], 0.6; 95% CI, 0.4-1.0) vs propofol alone. Dexamethasone with propofol was associated with reduced PONV (mRR 0.6; 95% CI, 0.4-1.1) vs propofol alone, although not statistically significant. The addition of both gabapentin and dexamethasone to propofol was associated with stronger reduction in PONV (mRR 0.3; 95% CI, 0.1-0.7) vs propofol alone. Adding ondansetron to propofol showed little benefit. Gabapentin and dexamethasone are effective in reducing PONV in patients undergoing knee and hip arthroplasty with neuraxial anesthesia.
Assuntos
Analgésicos/administração & dosagem , Raquianestesia/efeitos adversos , Artroplastia de Quadril , Artroplastia do Joelho , Gabapentina/administração & dosagem , Náusea e Vômito Pós-Operatórios/prevenção & controle , Idoso , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , North Carolina/epidemiologia , Enfermeiros Anestesistas , Náusea e Vômito Pós-Operatórios/epidemiologiaRESUMO
BACKGROUND: Several studies have described the population of adult trauma patients who undergo withdrawal of life-sustaining treatments (WLST); however, no study has looked specifically at trauma patients who undergo WLST following surgery. METHODS: This was a retrospective chart review of all trauma patients who underwent surgery at our trauma center between January 1 and December 31, 2017. Demographics were collected along with injury patterns and advance directives. Charts of all patients who died or who were discharged to hospice were analyzed to determine whether WLST occurred. Statistics included Fisher's exact test and Mann-Whitney U test. RESULTS: Three thousand and twenty-five adult trauma patients received care and 1495 (49.4%) had operations. Thirty (2.0%) patients underwent WLST, 15 (50.0%) of whom died in the hospital and 15 (50.0%) of whom were discharged to hospice. Twenty-six (86.7%) patients had a palliative care consult and 12 (40.0%) had prior advance directives. The most common injuries were femur fractures and subdural hematomas. Adjusting for age, white race, and age-adjusted CCI, femur fracture patients had, on average, 8.8 more hours between presentation and surgery (95% CI 2.1-15.4, P = .01) and 39 fewer hours between surgery and WLST (95% CI -107-29, P = .26) than traumatic brain injury patients. DISCUSSION: The short time between surgery and WLST in this cohort of patients may demonstrate that surgery was not aligned with patients' goals of care. A patient-centered approach that includes surgeon-driven palliative care discussions may help avoid nonbeneficial surgery in the last few days of life.