Topical Anesthetics for Analgesia in Acute Corneal Abrasion: Eye Care Providers Survey.

STUDY OBJECTIVES: To evaluate the current attitudes of ophthalmologists and optometrists regarding topical anesthetic (TA) use in the emergency department (ED) for analgesia in corneal abrasions. METHODS: A survey was distributed through email to ophthalmologists and optometrists, and their responses were deidentified. Three scenarios were presented involving the addition of tetracaine in addition to usual care in the setting of uncomplicated corneal abrasion. A 250-character space for comments and demographic questionnaire followed. A chi-square test, Fisher exact test, or sign test, at a significance level of 0.05, was used. RESULTS: Of the 978 individuals surveyed, 486 responded (MD/DOs: 47.1% and ODs: 52.9%). Topical anesthetic favorability significantly decreased with shorter practice length when the patient was only examined by an ED provider. Topical anesthetic favorability was significantly impacted by respondents' degree type. When respondents were posed with using TAs if the respondents were the patient, the respondents were 22.6% more likely to use TA when compared with their answers in the scenario where the ED provider examined the patient and 20.0% more likely when compared with the scenario where a MD/OD examined the patient. Most did not support tetracaine use. CONCLUSIONS: Although treating pain is associated with improved quality of life, most respondents did not support TA use in the ED. Practice length and degree type significantly impacted responses. Respondents were more inclined to use TAs when the respondents were the patient. Results suggest that eye care providers need additional research data supporting safety before routine use in the ED, given the potential for adverse events with TAs.

Nationwide analysis of unplanned conversion during minimally invasive distal pancreatectomy for pancreatic adenocarcinoma.

BACKGROUND: Utilization of minimally-invasive distal pancreatectomy (MIDP) for pancreatic adenocarcinoma has increased. While unplanned conversion to an open procedure during MIDP is associated with inferior short-term outcomes, the long-term consequences of conversion have not been adequately examined. METHODS: Patients with pancreatic adenocarcinoma undergoing MIDP were selected from the National Cancer Database (2010-2015) and subdivided based on the occurrence of unplanned conversion. Post-operative outcomes and overall survival (OS) were examined. Conversion was additionally compared to a matched group of planned open resections. RESULTS: Among 592 patients undergoing attempted MIDP, unplanned conversion occurred in 23.1%. Despite increased 90-day mortality among patients experiencing conversion, there was no difference in median OS between groups (25.0 vs 27.8 months, p = 0.095). For patients undergoing conversion, post-operative outcomes and long-term survival were similar when compared to a propensity-matched group of patients undergoing planned open resection. On multivariable analysis, treatment at an academic facility (OR 0.63) and a robotic approach (OR 0.50) were both significantly associated with completed MIDP. CONCLUSION: Despite inferior post-operative outcomes compared to successful MIDP, unplanned conversion did not result in significantly reduced long term survival. MIDP can be attempted selectively but treatment at experienced centers via a robotic approach should be considered.

Health Disparities in the Appropriate Management of Cryptorchidism.

OBJECTIVE: To assess regional practices in management of cryptorchidism with regard to timely fixation by the current recommended age of 18 months. STUDY DESIGN: A retrospective study was performed. Charts of all patients who underwent surgical correction for cryptorchidism by a pediatric general surgeon or urologist within a tertiary pediatric hospital in an urban setting were systematically reviewed. RESULTS: We identified 1209 patients with cryptorchidism. The median age of surgical correction was 3.7 years (IQR: 1.4, 7.7); only 27% of patients had surgical correction before 18 months of age. Forty-six percent of our patients were white, 40% were African American, and 8% were Hispanic. African American and Hispanic patients were less likely to undergo timely repair (P?=?.01), as were those with public or no insurance (P?

Cardiovascular mortality among liver transplant recipients with nonalcoholic steatohepatitis in the United States-a retrospective study.

Nonalcoholic steatohepatitis (NASH) has become an increasingly important indication for liver transplantation (LT), and there has been a particular concern of excessive cardiovascular-related mortality in this group. Using the United Network for Organ Sharing-Standard Transplant Analysis and Research (UNOS STAR) dataset, we reviewed data on 56,995 adult transplants (January 2002 through June 2013). A total of 3,170 NASH liver-only recipients were identified and were matched with 3,012 non-NASH HCV+ and 3,159 non-NASH HCV- controls [matched 1:1 based on gender, age at LT (±3 years), and MELD score (±3)]. Cox regression analysis revealed significantly lower hazard of all-cause (HR 0.669; P < 0.0001) and cardiovascular-related mortality (HR 0.648; P < 0.0001) in the NASH compared to the non-NASH group after adjusting for diabetes, BMI, and race. Relative to the non-NASH HCV-positive group, NASH group has lower hazard of all-cause (HR 0.539; P < 0.0001) and cardiovascular-related mortality (HR 0.491; P < 0001). A lower hazard of all-cause mortality (HR 0.844; P = 0.0094) was also observed in NASH patients compared to non-NASH HCV-negative group, but cardiovascular mortality was similar (HR 0.892; P = 0.3276). LT recipients with NASH have either lower or similar risk of all-cause and cardiovascular-related mortality compared to its non-NASH counterparts after adjusting for diabetes, BMI, and race.

Role of Transbronchial Needle Aspiration (Conventional and EBUS Guided) in the Diagnosis of Histoplasmosis in Patients Presenting with Mediastinal Lymphadenopathy.

OBJECTIVES: The superior performance of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the diagnosis and staging of malignancy has been demonstrated, with some investigators suggesting the same for sarcoidosis. The role of EBUS-TBNA in the diagnosis of histoplasmosis is not clear, however. In this study we estimate the diagnostic yield of conventional TBNA (cTBNA) and EBUS-TBNA for the diagnosis of histoplasmosis in patients with mediastinal lymphadenopathy. METHODS: Retrospective chart review was conducted on 452 consecutive patients who underwent cTBNA or EBUS-TBNA for mediastinal lymphadenopathy from January 1, 2005 to December 31, 2014 at Methodist Le Bonheur Healthcare-affiliated hospitals in Memphis, Tennessee. Data collection included demographic information, reason for the procedure, size of the lymph nodes, procedures performed, and the final diagnosis. RESULTS: Among 452 cases reviewed, 146 underwent cTBNA and 306 underwent EBUS-TBNA. Final diagnoses include malignancy (41.5%), sarcoidosis (11.2%), and histoplasmosis (8.1%). Among 146 patients who underwent cTBNA, a final diagnosis was obtained by this modality in 58 patients (39.7%). The diagnostic rate for cTBNA for malignancy was 68% (40/59), 30% (4/13) for sarcoidosis, and 43% (6/14) for histoplasmosis. In 306 patients who underwent EBUS-TBNA, 188 had a final diagnosis (61.4%) obtained by this modality. For EBUS-TBNA, the diagnostic rates were 79.5% (101/127) for malignancy, 74% (28/38) for sarcoidosis, and 78% (18/23) for histoplasmosis. CONCLUSIONS: EBUS-TBNA had a higher yield than cTBNA for the diagnosis of histoplasmosis. Clinicians practicing in areas with a high prevalence of histoplasmosis and sarcoidosis should use EBUS-TBNA, whenever available, for this reason.

Male Caregivers of Persons with End Stage Renal Disease: A Qualitative Study.

This study explored experiences associated with burden, depressive symptoms, and perceived health in six male caregivers of persons with end stage renal disease (ESRD) using qualitative interviews. Analysis employed open coding and analysis to generate codes and categories. Eighty-three percent of the participants reported significant subjective and objective burden. Linkages occurred between sociodemographic characteristics, care recipient attributes, and caregiver-care recipient relationship, and caregivers' experience of burden and depressive symptoms. Findings suggest the need for intervention trials targeting new coping strategies to help improve the well-being of this population.

Underutilization of Aldosterone Antagonists in Heart Failure.

Background: Treatment with an aldosterone antagonist (AA) has been shown in multiple trials to reduce heart failure (HF)-related morbidity, mortality, and hospital readmission. American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) treatment guidelines recommend the use of an AA in all HF patients with an ejection fraction ≤35% and no known contraindication. Several studies have documented underuse of AA. Objectives: To determine the proportion of patients who received AA therapy consistent with the ACCF/AHA guidelines. Secondary objectives included determining the proportion of patients who received an AA inconsistent with guidelines and 30- and 90-day readmission rates. Methods: A retrospective chart review was conducted of patients admitted to an inner city academic medical center with a diagnosis of HF between August 16, 2011, and June 5, 2013. Results: A total of 346 HF admissions (87.6% African American) were evaluated. Use of an AA at discharge was consistent with guidelines in 31% of patients. A total of 121 patients (35%) were discharged on an AA. Among the remaining 225 patients who were not discharged on an AA, 170 (75.6%) had no contraindication to therapy. Sixty-one patients were readmitted within 30 days, and a total of 108 patients were readmitted within 90 days. There were no significant differences in readmission rates between patients who were discharged on AA therapy and those who were not. Conclusion: AAs are still underutilized in the treatment of HF.

Male Caregivers of Persons with End Stage Renal Disease: A Literature Review.

This literature review examined burden, depressive symptoms, and perceived health reported by male caregivers of persons with end stage renal disease. These studies suggest that male caregivers often experience negative outcomes. Compared to non-caregivers, male caregivers had higher levels of anxiety and depressive symptoms. Qualitative studies suggest depression is common and associated with conflict between caregiving responsibilities and work, poor caregiver health, and fears about the future outcomes of relatives for whom they provide care. Future research will assist healthcare providers to identify at-risk male caregivers and develop effective interventions to support this understudied caregiver population.

Mortality and Ankylosing Spondylitis in the US population: leading causes and associated factors.

OBJECTIVE: Ankylosing Spondylitis (AS) is a chronic inflammatory condition that affects the axial skeleton. Recent studies have shown that mortality risk is higher in AS patients and that it is possibly related to disease activity and duration. Our aim was to investigate the leading causes and factors associated with mortality in hospitalized AS patients in the USA. METHODS: This is a case-control study using the Cerner Health Facts® database between 2015 and 2017. The search was done using ICD codes and administrative claims. Cases were hospitalized AS patients who died during that hospitalization, while controls were patients who survived. In addition to demographics, we collected data on the inpatient use of medications such as NSAIDs, as well as different comorbidities and systemic disease manifestations. The discharge diagnoses for deceased patients were collected to infer causes of mortality. Analysis of association was performed using chi-square tests, t-tests, Wilcoxon rank-sum tests, and logistic regression methods. RESULTS: The leading causes of death were cardiovascular, infectious, respiratory, and traumatic. The Elixhauser comorbidity index was the factor most associated with mortality (p-value < 0.0001), with congestive heart failure and renal disease the most contributing. Drug use disorder was associated with mortality (adjusted OR = 10.9; p = 0.001). Inpatient NSAIDs use was not associated with increased odds for mortality (p-value 0.33). CONCLUSION: Cardiovascular and renal comorbidities are associated with mortality and need to be targeted early on to lower the odds of mortality as patients age. Strategies to prevent opioid and drug abuse should be strengthened in the AS population. Key Points • Cardiovascular and renal comorbidities are associated with mortality and need to be screened for and targeted early on to lower the odds of mortality as patients age. • Drug use disorder including opioid dependence is associated with mortality, and strategies to prevent opioid and drug abuse should be strengthened in the AS population.

Evaluation of a Novel Battery-Operated Tumbler Device for Use in the Detection of Mouse Pathogens for Rodent Health Monitoring.

The search for alternatives to live animal sentinels in rodent health monitoring programs is fundamental to the 3Rs (Reduction, Replacement, and Refinement) of animal research. We evaluated the efficacy of a novel battery-operated tumbler device that rotates soiled bedding in direct contact with sample media against the use of exhaust sample media and soiled bedding sentinel (SBS) mice. Four rodent racks were used, each with 3 test cages: a cage with a tumbler device that rotated for 10min twice a week (TUM10), a cage with a tumbler device that rotated for 60min twice a week (TUM60), and a cage housing 2 female Crl:CD1(ICR) mice. Every 2 wk, each test cage received soiled bedding collected from all cages on each respective rack. In addition to soiled bedding, the tumbler device contained various sample collection media: a contact Reemay filter (3mo-cRF) that remained in the tumbler for the duration of the study, a contact Reemay filter (1mo-cRF) that was replaced monthly, adhesive swabs (AS) that were added at every biweekly cage change, and an exhaust Reemay filter located at the exhaust outlet of the cage. All analyses were performed by direct PCR for both sample media in the animal-free methods, and fecal pellet, body swab, and oral swabs were collected from sentinel mice. Out of 16 total pathogens detected, assessment of 1mo-Crf from both TUM10 and TUM60 cages detected 84% and 79% of pathogens, respectively, while SBS samples detected only 47% of pathogens. AS in TUM60 and TUM10 cages detected the fewest pathogens (24% and 13%, respectively). These results indicate that the novel tumbler device is an effective and reliable tool for rodent health monitoring programs and a suitable replacement for live animal sentinels. In this study, 1mo-cRF in TUM10 cages detected the highest number of pathogens.

Changes in hospital utilization and management of Hirschsprung disease: analysis using the kids' inpatient database.

OBJECTIVE: This study investigates how the epidemiology, hospital utilization, and surgical management of Hirschsprung disease (HD) have changed over the last decade in the United States, using a statistically valid national sample. BACKGROUND: HD is a congenital gastrointestinal disorder that requires surgical resection for correction. Some patients experience long-term bowel dysfunction requiring hospital care. Historically, patients had multiple staged operations, whereas more recently, single-stage laparoscopic resection and pull-through operations are more common. Assessment of possible changes over time in HD-associated complications requiring hospitalization and length of hospital stay has not been quantified epidemiologically. METHODS: The Kids' Inpatient Database was queried for all discharges with an International Classification of Disease, Ninth Revision, Clinical Modification code for HD in the years 1997, 2000, 2003, and 2006. The HD cohorts from these 4 time points were compared, specifically analyzing differences in demographic data, associated diagnoses, in-hospital mortality and length of stay, procedures performed during hospitalization, and frequency of hospitalizations for HD-associated complications. Results reported included estimated frequencies and means with 95% confidence intervals. RESULTS: The estimated numbers of HD discharges, associated demographic data, and numbers of pull-through procedures have remained stable over the decade. The mean age (years) at the time of pull-through has decreased from 1.45 to 1.16 to 1.18 to 0.97 (P = 0.01). The mean length of stay (days) for these procedures has increased from 8.40 to 8.46 to 9.25 to 10.55 (P = 0.002). The estimated numbers of hospital admissions for HD-related constipation increased in recent years from 395 to 340 to 536 to 566 (P = 0.001). The estimated numbers of admissions for enterocolitis suggest an increasing trend from 466 to 402 to 584 to 556 (P = 0.11). CONCLUSIONS: HD pull-through procedures are being performed at younger ages over time, and post-pull-through lengths of stay have increased. Admissions for some HD-related complications have increased over the decade. Prospective cohort studies are needed to determine whether causal relationships exist among these trends.

Comparison of initial warfarin response in obese patients versus non-obese patients.

Achieving therapeutic anticoagulation with warfarin is complicated by substantial inter-patient and intra-patient variability with numerous factors known to influence dose requirements. Obesity is one factor for which there remains no study to date investigating its initial effect on warfarin response assessed by INR, stratified by BMI category in hospitalized patients. To compare initial warfarin response between obese and non-obese patients by evaluating average daily dose (ADD), time required to attain therapeutic INR, and mean discharge dose (MDD), stratified by BMI category. A retrospective review was conducted to evaluate initial warfarin response in hospitalized patients of different BMI categories initiated on warfarin with ≥4 consecutive days of therapy and managed by pharmacy dosing service. 211 patients were included (10 underweight, 45 normal weight, 48 overweight, 71 obese, 37 morbidly obese). Across BMI categories, the percentage of patients attaining therapeutic INR prior to discharge differed (p = 0.0004) with 71.1 % of normal weight therapeutic compared to 42.3 % of obese and 38 % of morbidly obese. Within BMI categories, when comparing ADD between patients therapeutic and subtherapeutic at discharge, no differences were observed, except among overweight patients (5.6 ± 0.3 vs. 7 ± 0.4 mg, p = 0.0143). Compared to normal weight, obese and morbidly obese required a significantly longer median time to achieve therapeutic INR (8 and 10 days vs. 6 days) and a higher ADD (6.6 ± 0.3 and 7.6 ± 0.5 vs. 5 ± 0.3 mg) and MDD (6.7 ± 0.5 and 6.7 ± 0.7 vs. 4.4 ± 0.5 mg). Compared to normal weight, obese and morbidly obese patients had a decreased initial response to warfarin.

Preliminary findings of the relationship of lower heart rate variability with military sexual trauma and presumed posttraumatic stress disorder.

Decreased heart rate variability (HRV) occurs with physical and psychological disorders and is a predictor of cardiac and all-cause mortality. This study was the first of which we are aware to examine and report the relationship between military sexual trauma (MST) and HRV measures. In a historical cohort study of female veterans with (n = 27) and without (n = 99) MST who received Holter and electrocardiogram evaluation at a Veteran Affairs medical center during 2007-2010, we examined the relationship between MST and the standard deviation of all R-R intervals (SDNN) and the square root of the mean of the sum of the squares of differences between adjacent R-R intervals (RMSSD). Female veterans with MST were younger, p = .002, frequently had a probable posttraumatic stress disorder diagnosis, 80% versus 15%, p = < .0001, and had lower SDNN, p = .0001, and RMSSD, p = .001, than those without MST. The SDNN and RMSSD of a 25-year-old female veteran with MST were comparable to that of female veterans aged 69 to 81 years without MST. Further research is needed to evaluate relationships between MST and HRV measures.

Plant-based dietary patterns and fasting insulin: a cross-sectional study from NHANES 2017-2018.

BACKGROUND: Previous studies have created plant-based diet indices to assess the health effects of specific dietary patterns. OBJECTIVE: To examine the association between the plant-based content of diet and fasting insulin in adults from the NHANES 2017-2018 database. METHODS: Demographic, dietary, lab and clinical data and fasting insulin were obtained from the NHANES 2017-2018 database. From two 24-h dietary recalls, we created a plant-based diet index (PDI) and a healthy plant-based diet index (hPDI). A high PDI score indicated more plants were consumed versus animal foods. A high hPDI score indicated healthier, plant materials (whole grains, whole fruits, vegetables, legumes, vegetable oils, seeds and nuts) were consumed. The relationships between the natural log of fasting insulin, PDI, and hPDI were analyzed using multiple linear regression adjusting for body mass index (BMI) and alanine aminotransferase (ALT). RESULTS: Analyses were based on 1,714 participants, 897 women and 817 men with a median age of 52 years. In this sample, 610 (35.6%) were white, 407 (23.8%) were black, 231 (13.5%) were Mexican, 207 (12.1%) were Asian, 157 (9.2%) were other Hispanic, and 102 (6%) were other or mixed race. Median fasting insulin was 9.74 µU/mL (IQR: 6.2, 15.56). For every 1 unit increase in PDI, the natural log of fasting insulin decreased 0.0068 ± 0.003 µU/mL (CI: -0.00097, -0.013) (p = 0.02). After adjusting for BMI and ALT, the PDI did not significantly predict fasting insulin as the association was not robust due to multicollinearity. The hPDI was inversely and significantly associated with the natural log of fasting insulin (-0.0027 ± 0.00134, CI: -0.000087, -0.0053) (p = 0.043) in a multivariable model including BMI and ALT. CONCLUSION: A healthy plant-based diet is associated with a decrease in fasting insulin levels. Healthfulness of the diet is an important factor when considering the benefit of a plant-based diet.

Opinion: Common Errors, Omissions, and Presentation Problems in the Conduct and Reporting of Animal-based Research.

As experienced authors, statisticians, editors, and scientists, we present the following comments to highlight some usages or omissions that are common in research manuscripts. Consideration of these comments will improve practices of data analysis and reporting.

Predictors of early neurologic deterioration (END) following stroke thrombectomy.

BACKGROUND: Early neurologic deterioration (END) following ischemic stroke is a serious event and is associated with poor outcomes. However, the incidence and predictors of END after stroke thrombectomy for emergent large vessel occlusion are largely unknown. METHODS: The baseline characteristics of patients enrolled in the COMPASS trial (NCT02466893) were analyzed. The primary outcome was worsening of ≥4 National Institutes of Health Stroke Scale (NIHSS) points 24 hours post thrombectomy (4+ END24) and the secondary outcome was deterioration of ≥2 points (2+ END24). RESULTS: Among 270 patients, 27 (10%) developed 4+ END24 and 42 (16%) had 2+ END24. Those with 4+ END24 were older (76.4±12.9 vs 70.9±12.9 years; p=0.04), had a higher prevalence of hypertension (96% vs 69%; p=0.003), diabetes (41% vs 27%; p=0.13) and higher pretreatment systolic blood pressure (SBP) (170.4±32.6 vs 157.6±28.1 mmHg; p=0.03). More 4+ END24 patients had failed reperfusion: Thrombolysis in Cerebral Infarction ≤2a (26% vs 8%; p=0.003). In unadjusted analysis, older patients and those with hypertension, diabetes, elevated SBP and failed reperfusion had higher odds of 4+ END24. In adjusted analysis, age increase by 5 years led to an increase in 4+ END24 of 28%, diabetes increased odds of 2.6 and failed reperfusion increased odds of 4.5. In the multivariable analysis for the secondary outcome, age (OR 1.33; 95% CI 1.109 to 1.593), diabetes (OR 2.7; 95% CI 1.247 to 5.764) and failed reperfusion (OR 7.2; 95% CI 0.055 to 0.349) were also significant predictors of 2+ END24. CONCLUSIONS: Older patients with acute ischemic stroke who have a history of diabetes or hypertension, with elevated pretreatment SBP and failed reperfusion are at a higher risk of END following stroke thrombectomy for emergent large vessel occlusion.

Oral Health and Behavior Patterns of Women with Eating Disorders-A Clinical Pilot Study.

BACKGROUND: Chronic stomach regurgitation associated with eating disorders (EDs) poses a high risk for tooth erosion. This study investigated oral health conditions, behavioral patterns, and tooth erosion in women with EDs. METHODS: 16 ED and 13 healthy women were enrolled; 14 ED and 10 healthy control subjects completed the study. Subjects completed demographic, medical, oral, and behavioral health history questionnaires. Dental caries status was recorded as Decayed, Missing and Filled Teeth (DMFT)index and the severity of tooth erosion as Basic Erosive Wear Examination (BEWE) scores. Saliva was collected for flow rate, pH, and buffering capacity analysis. RESULTS: The ED group had a lower stimulated saliva flow rate and higher DMFT index but no significant difference in BEWE scores compared to the controls (t-test, significance level 0.05). Five of the fourteen ED subjects exhibited extensive tooth erosion, which may have been exacerbated by their tooth-brushing behavior. CONCLUSIONS: Although some ED subjects showed extensive tooth erosion in this pilot study, the average BEWE score of the ED group was not significantly different from the controls. Extensive tooth erosion in ED may relate to the low stimulated salivary flow. A larger-scale clinical study is necessary to validate these results.

Feasibility of a Brief Intervention to Increase Rapid Primary Care Follow-Up Among African American Patients With Uncontrolled Diabetes.

The management of diabetes, like many other chronic conditions, depends on effective primary care engagement. Patients with diabetes without a usual source of care have a higher risk of uncontrolled disease, hospitalizations, and early death. Our objective was to study the effect of a brief intervention to help patients in medically underserved areas obtain rapid primary care follow-up appointments following hospitalization. We performed a pilot pragmatic randomized controlled trial of adult patients with uncontrolled diabetes who had been admitted to one of three hospitals in the Memphis, TN, area. The enhanced usual care arm received a list of primary care clinics, whereas the intervention group had an appointment made for them preceding their index discharge. Patients in both groups were evaluated for primary care appointment attendance within seven and fourteen days of index discharge. In addition, we examined barriers patients encounter to receiving rapid primary care follow-up using a secret shopper approach to assess wait times when calling primary care offices. Twelve patients were enrolled with six in each trial arm. Baseline demographics, access to medical care, and health literacy were similar across the groups. Primary care follow-up was also similar across the groups; no improvements in follow-up rates were seen in the group receiving assistance with making appointments. Identified barriers to making primary care follow-up appointments included inability to schedule an urgent appointment, long hold times when calling doctor's offices and lack of transportation. Additionally, hold times when calling primary care offices were found to be excessively long in the medically underserved areas studied. The study demonstrates the feasibility of providing patient assistance with scheduling rapid primary care follow-up appointments at the time of discharge and the potential to improve care transitions and access to primary care among patients living in medically underserved areas. Larger pragmatic trials are needed to further test alternative approaches for insuring rapid primary care follow-up in vulnerable patients with ambulatory care-sensitive chronic conditions.

Intensive sick day rules to prevent recurrent diabetic ketoacidosis- An intervention that exemplifies health disparities.

OBJECTIVE: Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes (T1D). In established T1D patients, DKA is frequently a result of insulin omission or inadequate insulin administration during illness or stress. Ethnic minorities and patients with lower socioeconomic status are affected disproportionately. We hypothesized that implementation of intensive sick day rules with frequent reinforcement would reduce hospitalizations secondary to DKA in T1D youth irrespective of their demographics. METHODS: Intensive sick day rules were implemented beginning January 2016. All T1D patients seen in the pediatric endocrinology clinic or hospital between January 1st 2015 through December 31st 2017 were included for chart review. Categorical variables were analyzed with Chi-square test. For the continuous variables, t test was used. Episodes of DKA per 100 patients were compared using the trends test over the three-year period. Patients who had DKA in 2015 were analyzed as a subgroup. RESULTS: The frequency of DKA episodes per 100 patient years for 2015 was 19.1, for 2016 was 15.2 and was 12.4 for 2017. This decrease was statistically significant (p=0.006). The decline was also statistically significant for the subgroup of patients who developed DKA in 2015 and followed longitudinally. The decline was not uniform across all patient groups and DKA episodes remained associated with African- American race, Medicaid insurance status and higher HbA1c throughout the years. CONCLUSION: Implementation of intensive sick day rules led to a decrease in total number of DKA admissions in our population with T1D youth. However, this intervention did not reduce the health disparity in this population and African-Americans on Medicaid insurance continued to form the disproportionate majority of admissions with DKA. This study highlights the need for further research into interventions that can improve outcomes across racial and socio-economic barriers.

Long-term functional outcomes after traumatic spine fractures.

BACKGROUND: Traumatic spine fractures can result in chronic pain, disability, and prolonged rehabilitation. The purpose of this study is to determine the long-term effects of traumatic spine fractures on patients' functional outcomes after nonoperative and operative management. METHODS: Patients with traumatic spine fractures over a 5-year period were identified and stratified by management strategy (nonoperative and operative) and compared. Functional outcomes were measured using the Boston Activity Measure for PostAcute Care to assess basic mobility and daily activity. Multiple linear regression was used to identify predictors of functional outcome after traumatic spine fractures. RESULTS: In total, 488 patients were identified: 271 nonoperative and 217 operative. Follow-up was obtained in 168 (34%) patients: 95 nonoperative and 73 operative. Mean follow-up was 5.7 years (range 3-8 years). Mean Activity Measure for PostAcute Care scores in patients managed nonoperatively for basic mobility (68 vs 64, P = .09) and daily activity (69 vs 66, P = .26) were clinically similar to those managed operatively. Multiple linear regression identified increasing age as a predictor of decreased basic mobility (ß = -0.50, P < .0001, ß = -0.17, P = .022) and daily activity (ß = -0.58, P < .0001, ß = -0.35, P = .003) in nonoperative and operative groups, respectively. In nonoperative patients, thoracic spine fracture was predictive of both decreased basic mobility (ß = -5.88, P = .041) and daily activity (ß = -8.62, P = .043). In operative patients, lower extremity fractures (ß = -8.86, P = .012), discharge location (ß = -6.91, P = .003), and time to operative fixation (ß = -0.77, P = .040) were associated with decreased basic mobility. CONCLUSION: All patients with traumatic spine fractures displayed mild to moderate functional impairment. Age, thoracic fractures, lower extremity fractures, discharge location, and time to operative fixation were associated with poor functional outcomes.