Burnout and well-being of medical and surgical residents in relation to emotional intelligence: A 3-year study.

BACKGROUND: This study aims to examine the relationship of emotional intelligence to physician burnout and well-being and compare these changes between medical and surgical residents during training. METHODS: The longitudinal study used survey data, collecting measures on burnout and emotional intelligence in residents. Postgraduate year 1 residents at a community-based Michigan hospital completed the following surveys: Maslach Burnout Inventory, Physician Wellness Inventory, and Trait Emotional Intelligence Questionnaire-Short Form survey. These measures were given quarterly in postgraduate year 1 and once during subsequent years. RESULTS: Seventy-seven residents completed measurements during their first 3 years. Forty-two (54.5%) were in the medical resident group; the remaining 35 (45.5%) were in the surgical resident group. Significant increases in measured burnout during the first year improved in subsequent years but did not return to baseline (P < .01). Emotional exhaustion (Maslach Burnout Inventory-Emotional Exhaustion) increased a relative 44% the first year (P = .000) and decreased 23% by the third year (P < .01). The Physician Wellness Inventory subscales also had significant decreases (P = .01) but less than the Maslach Burnout Inventory subscales (improvement ≤25%). Both medical and surgical groups had similar decreases in the Physician Wellness Inventory subscales (-25%) in their first year. The emotional intelligence score significantly correlated with exhaustion (Maslach Burnout Inventory-Emotional Exhaustion: r = -0.243; P = .002) and distress (Physician Wellness Inventory-Distress: r = -0.197; P = .014). CONCLUSION: The risk for burnout increased sharply at the beginning of training for this hospital resident participant group and remained high throughout residency. Emotional intelligence is an important factor associated with less emotional exhaustion during residency.

Rib Plating Outcomes in Elderly Trauma Patients With Multiple Rib Fractures: A Community Hospital Experience.

Rib fractures in the elderly are one of the most common injuries in trauma patients admitted to the hospital, accounting for over 350,000 patients annually in the United States. Rib plating has been shown to be most beneficial among certain populations. Early surgical intervention is important to utilize approaches that limit the use of pain medications. This is a retrospective data analysis to determine the efficacy of rib plating in elderly trauma patients with rib fractures. A total of 253 patients were seen with rib fractures, 63% were male and 37% were female. The mean age is 64 ± 18.5 years. Of these patients analyzed, 76% had an associated comorbid condition. A majority of patients (95%) presented to the emergency department (ED) with mild GCS range (13-15). Moderate GCS range (9-12) was 4%, and 3% of patients were with severe GCS (3-8.) The mean ISS was 10. The overall mortality rate was 4.5%. Patients were divided into 2 groups: group I consisted of patients who received open reduction and fixation of the fractured ribs, and group II was patients managed conservatively without surgery. Statistical analyses using Student's t-test and Chi-square test were performed. Institutional Review Board approval was obtained for this study. Rib plating in elderly trauma patients with multiple rib fractures has shown to be beneficial in terms of mortality. Furthermore, geriatric patients with comorbidities will benefit from early open reduction and fixation of rib fractures, though a larger study is needed to establish clearer criteria for rib plating.

Value of Thoracic CT in Blunt Trauma Patients With High Glasgow Coma Scale and Low Injury Severity Scale.

OBJECTIVE: To determine the value of ordering a routine chest CT (CCT) in patients with blunt trauma presenting to the emergency department with a high GCS and low ISS, we retrospectively collected patient data including CT scan results, when physical examination and initial chest X-ray were normal in the trauma bay area. METHODS: A retrospective data collection of 901 consecutive blunt trauma patients seen in the ED between 2017 and 2019 was analyzed. Data included physical examination, age, gender, current use of anticoagulation therapy, comorbid conditions, as well as the result of radiologic images, hospital length of stay, surgical intervention, and mortality. The patients were divided into two groups: group one (patients with negative physical examination; chest x-ray and CT) and group 2 (negative physical examination, positive or negative chest x-ray, and positive CT). Statistical analysis was performed using student's t-test and chi-square test. RESULTS: Of the 901 patients there were 489 (54%) males and 412 (46%) females with a mean age of 56 years. There were 461 patients who had a physical examination, chest x-ray, abdominal and CCT done. Group one included 442 (96%) patients, with negative physical examination, negative chest X-ray and CT scan. In group 2, 19 (4%) patients who had positive CT and or chest x-ray. Both groups were similar in GCS and ISS. Of the 19 patients, sixteen patients had a positive CCT, and thirteen of those had a positive chest x-ray. In the three patients who had negative physical examination and chest x-ray, the CT findings included one with a nondisplaced 10th rib fracture and two patients with osteoporotic compression fractures of dorsal vertebrae. The rate of both chest x-ray and CCT being positive among a group of screened patients was 16% (3/19) and the rate of a negative chest x-ray but positive CT was 16% (3/19). The odds ratio between the two outcomes was one. CONCLUSION: In blunt trauma patients presenting to the ED with a high GCS and low ISS score, when initial physical examination and chest x-ray are negative, routine CCT is of little value.

Rib Plating Outcomes in Elderly Trauma Patients with Multiple Rib Fractures: A Community Hospital Experience.

Rib plating has been shown to be beneficial among certain populations, such as patients with flail chest and failure to wean from the ventilator in patients without primary pulmonary pathology. Surgical intervention has been shown to decrease ventilatory requirements, decrease pain management modalities, and lower costs. A retrospective data analysis was done to determine the efficacy of rib plating in elderly trauma patients with rib fractures on a total of 244 patients, 63% male and 37% female, mean age is 64 ± 18.5 years, 76% had an associated comorbid condition, such as Diabetes Mellitus (DM), Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), Chronic Kidney Disease (CKD), or any combination, with 111 (46%) on anticoagulant therapy. 95% patients presented to the emergency department (ED) with Mild GCS range (13-15). Moderate GCS (9-12) was 4% and 3% of patients Severe GCS (3-8). The overall mortality rate was 4.5%.

Development and Evaluation of a Health Behavior Change Clinic in Primary Care: An Interdisciplinary Partnership.

Providing effective healthy behavior change interventions within primary care presents numerous challenges. Obesity, tobacco use, and sedentary lifestyle negatively impact the health quality of numerous medical patients, particularly in underserved patient populations with limited resources. Primary Care Behavioral Health (PCBH) models, which incorporate a Behavioral Health Consultant (BHC), can offer point-of-contact psychological consultation, treatment, and also provide opportunities for interdisciplinary psychologist-physician clinical partnerships to pair a BHC's health behavior change expertise with the physician's medical care. Such models can also enhance medical training programs by providing resident physicians with live, case-based learning opportunities when partnered with a BHC to address patient health behaviors. We will describe the development, implementation, and preliminary outcomes of a PCBH psychologist-physician interdisciplinary health behavior change clinic within a Family Medicine residency program. Patient outcomes revealed significant reductions (p < .01) in weight, BMI, and tobacco use. Implications and future directions are discussed.

Validation of Brain Injury Guidelines in the Elderly Trauma Patient Presenting at a Level Two Trauma Center.

Retrospective analysis, validating the brain injury guideline (BIG) in the management of traumatic head injury in our level II trauma center after implementation of the protocol, and compare the outcomes to those seen before the protocol, of 542 patients seen in the Emergency Department (ED), with head injury between 2017 and 2021 was completed. Those patients were divided into two groups: Group 1 (pre BIG protocol implementation) and Group 2 (post BIG protocol implementation). Data included age, race, length of stay (hospital and ICU), comorbid conditions, anticoagulant therapy, surgical intervention, GCS, ISS, findings of head CT and any subsequent progression, mortality, and readmission within one month. Student's t-test and Chi-square test were used for statistical analysis. There were 314 patients in group 1 and 228 patients in group 2. Mean age of group 2 was significantly higher than group 1 (67 vs 59 years, p=0.0001), however their gender was similar. Data available on 526 patients were classified as BIG 1=122, BIG 2=73, and BIG 3=331 patients. Post-implementation group were older (70 vs 44 years, P=0.0001) with more females (67% vs 45%, P=0.05) and had significantly more than 4 comorbid conditions (29% vs 8%, P=0.004), with the majority presented with a size of 4 mm or less of acute subdural or subarachnoid hematoma. No patient in either group had progression of their neurological examination, neurosurgical intervention, or readmission.. Elderly trauma patients may benefit from implementation of BIG criteria protocol, thus reducing cost of patient care, however a larger sample size is needed.

Can Time to Treatment Reduce In-Hospital Mortality and Morbidity Among Surgical and Nonsurgical Elderly Patients With Sepsis.

Sepsis mortality remains high and efforts to reduce it are continuing. We collected data from our patients presented to the emergency department (ED) with sepsis and performed a retrospective analysis of 1079 patients seen in the ED with sepsis during 2018 and 2020, before and after implementation of the new CDC protocol. Statistical analysis was performed using Student's t-test and chi square test as well as Cox regression analysis. The patients were divided into pre-protocol (group 1) and post-protocol (group 2). A total of 1079 patients were included in the study. The mean age was 65 + 16.86 years, divided equally between gender (male 49%, female 51%). Patients with certain comorbidities showed statistically significant survival rate in the protocol group. The current protocol for sepsis when implemented will improve patients' survival, in both surgical and medical patients and significantly in those with comorbid conditions.

Longitudinal Study of Emotional Intelligence, Well-being, and Burnout of Surgical and Medical Residents.

INTRODUCTION: Emotional intelligence (EI) as a concept is becoming increasingly relevant in the healthcare industry. In order to examine the relationship between EI, burnout, and wellness, we administered these measures quarterly in resident physicians and analyzed the variables in each subset to gain insights and understanding of their relationship. METHODS: In 2017 and 2018, all residents entering the training programs in year one (PGY-1) were administered The Emotional Intelligence Questionnaire - Short Form (TEIQue-SF), The Maslach Burnout Inventory (MBI), and The Physician Wellness Inventory (PWI). The questionnaires were completed quarterly. Statistical analysis included ANOVA and ANCOVA. RESULTS: The overall combined PGY-1 resident year (n = 80) had an EI global trait mean score of 5.47 (SD: 0.59) at the beginning of their first year. The domains of burnout and physician wellness were examined across four different time points during the resident's first year. Domain scores changed significantly over the four time points during the first year. There was a relative 46% increase in exhaustion (P < .001), 48% increase in depersonalization (P < .001), and an 11% decrease in personal achievement (P < .001). Physician wellness domains also changed significantly between time 1 and the end of the year (time 4). There was a relative 12% decrease in career purpose (P < .001), a 30% increase in distress (P < .001), and 6% decrease in cognitive flexibility (P < .001). Each burnout domain and physician wellness domain were highly correlated with emotional quotient (EQ). Emotional quotient was independently assessed with each domain at baseline and with changes overtime. The lowest EQ group reported their distress increased significantly over time (P = .003) and a decline in career purpose (P < .001) and cognitive flexibility (P = .04). The response rate was 100%. CONCLUSION: Emotional intelligence is associated with well-being and burnout in individual residents; therefore, it is important to identify those who require increased support during residency in order to succeed.

Acute Traumatic Subdural Hematoma in the Elderly and Associated Factors that May Influence Chronicity.

Traumatic acute subdural hematomas (TASDH) is by far the most common traumatic brain injury in adult patients with blunt trauma, who presented to the Emergency Department (ED). One of the serious sequale of TASDH is the development of Chronic Subdural Hematomas (CSD) with associated deterioration in mental status and convulsion.1,2 Studies to identify the risk factors that favors development of chronicity of TASDH are few and inconclusive. As seen in our prior initial study, there were few factors which were common in those who developed chronicity of their TASDH, and we elected to expand our pool of patients to include those admitted between the years of 2015 and 2021 with ATSDH and identify the common factors associated with development of CSD.

The Impact of Alcohol Level on Elderly Trauma Patients Presenting to the Emergency Department.

Alcohol is a chemical substance that alters cognitive ability and judgment. We looked at our elderly patients that arrived at the Emergency Department (ED) following trauma and evaluated the factors that may influence outcome. Retrospective analysis of patients seen in ED with positive alcohol was performed. Statistical analysis was performed to identify the confounding factors for outcomes. Records collected on 449 patients with a mean age of 42 ± 16.9 years. There were 314 males (70%) and 135 females (30%). Average GCS was 14, and average ISS was 7.0. Mean alcohol level was 176 g/dL ± 91.6. There were 48 patients aged 65 years and older with significantly higher hospital stay (4.1 and 2.8 days, P = .019) and ICU stay (2.4 and 1.2 days, P = .003) compared to the 64 and younger group. Elderly trauma patients had a higher mortality and length of stay due to a higher number of comorbidities.

The Value of Abdominal and Pelvic CT Scan in Trauma Patients With Low Injury Severity Score and High Glasgow Coma Scale.

INTRODUCTION: Computed tomography scans became the mainstay of emergency department (ED) evaluation of trauma patients including those with a high Glasgow Coma Scale (GCS) and a low Injury Severity Score (ISS). We elected to find the value of abdominal and pelvic CT in patients with negative physical examination and Focused Assessment of Sonography for Trauma (FAST) on arrival to the ED. METHODS: This study is a retrospective analysis of 901 consecutive patients from 2017 to 2019 who presented to the ED with level 2 and 3 activation criteria. Each patient received a physical examination, CT abdomen and pelvis, and FAST exam. Data were collected on external factor including GCS, ISS, age, sex, comorbidities, anticoagulation use, and surgical intervention. The patients were divided into 2 groups, Group A and B. Group A consisted of patients with a negative physical exam, FAST, and CT result. Group B included patients with a negative physical exam and FAST exam with positive CT findings. Statistical analysis was done using a Student's t-test and chi-square test for significance value of P < .05. Institutional Review Board approval was obtained for this study. RESULTS: A total of 901 patients were analyzed which included 489 (54.3%) male and 412 (45.7%) female with a mean age of 56.2 (SD = 22.62) years. Out of the 901 patients, 461 patients received a physical, FAST, and CT exam. Group A consisted of 442 (95.9%) patients and Group B had 19 (4.1%) patients. Both groups were similar in GCS and ISS scoring with no significance difference in age, sex, comorbidities, and anticoagulation use. There was a significant difference in the ICU and hospital mean length of stay when CT scan was positive [2 (SD = 4.23) days vs. .6 (SD = 1.33) days with P < .0001 and 4.57 (SD ± 4.17) days vs. 2.5 (SD = 2.00) days with P < .0001, respectively]. The CT findings of the 19 patients in group B consisted of 6 incidentalomas, 5 vertebral compression fractures, 4 pelvic bone fractures, 1 minor liver contusion, 1 non-specific bowel thickening, 1 non-displaced rib fracture, and 1 case of small amount of free fluid in the pelvis. None of the CT findings required surgical intervention. CONCLUSION: Computed tomography of the abdomen and pelvis in trauma patients with high GCS and low ISS with initial negative physical and FAST examination did not provide additional critical information.

Emotional Intelligence, Burnout, and Wellbeing Among Residents as a Result of the COVID-19 Pandemic.

BACKGROUND: We previously reported the correlation between emotional intelligence (EI) with burnout/wellbeing in our PGY-1 residents, finding that EI moderated the development of burnout in the PGY-1 year. When COVID-19 arrived in early 2020, we were already collecting EI and burnout data for the 2019-2020 year. We elected to follow those residents throughout the year and compare them to the subsequent cohort to study the effect of the pandemic on their burnout and wellbeing and the influence of EI on this pattern. MATERIALS AND METHODS: All residents entering the training program (PGY-1) 2019-2020 (SURGE) & 2020-2021 (POST-SURGE) were administered the emotional intelligence questionnaire short form (TEIQue-SF), the Maslach burnout inventory, and the physician's wellness inventory. The questionnaires were completed quarterly. Statistical analysis included ANOVA. Institutional Review Board approval was obtained prior to the study. RESULTS: The overall combined PGY-1 residents year (n = 73) mean EI was 3.9 with no differences between academic year groups. The domains of burnout and physician wellbeing were examined across four different time points during the resident's first year. Domain scores changed over the four time periods during the first year. There was a relative decrease in achievement by 3.4 points, decrease in career purpose by 1.8 points, decrease in cognitive flexibility by .6 points and increase in distress by 4.1 points. Emotional exhaustion increased significantly more for the SURGE 2019-2020 group compared to the POST-SURGE 2020-2021 group (a relative 77% change). Emotional intelligence was independently assessed within each domain at baseline and for changes over time. DISCUSSION: Patterns of burnout and wellbeing were different with the COVID-19 SURGE group compared to the COVID-19 POST-SURGE group, perhaps because of differing expectations of the PGY-1 year participants but also perhaps due to the destabilizing effect of the first COVID-19 surge.

Role of Abdominal Ultrasound and Magnetic Resonance Imaging in Pregnant Women Presenting With Acute Abdominal Pain.

Background and Purpose: Abdominal pain during pregnancy is quite common; however, surgical pathology such as acute appendicitis as a cause of such pain is not. Diagnostic tests used in addition to history and physical examination (PE) are ultrasound (US) and magnetic resonance imaging (MRI). We elected to find the role of these tests in pregnant patients who presented to our emergency department with acute abdominal pain.Materials And Methods: Retrospective analysis of 136 pregnant women with acute abdominal pain presented to the emergency department (ED). We reviewed PE, US, MRI, gestational age, comorbid conditions, and length of stay. Statistical analysis was done using student's t-test and chi-square test. Institutional review board approval was obtained.Results: Mean age was 26 (±4.6) and the mean gestational age was 24 (±9.9) weeks. Of those patients, there were 81 patients who had an US and MRI performed. The US was positive in 16 patients, while the MRI was positive in 25 patients. Three patients went for appendectomy. The US sensitivity was 0% and specificity 79%. Positive predictive value for US was 0% and negative predictive value was 95%, which was less than 100%. The MRI likelihood ratios were calculated for each test's clinical application and demonstrated that the US test result was indeterminate for ruling in and for ruling out appendicitis while the MRI allowed for high ability to rule out the disease.Conclusion: In pregnant women with acute abdominal pain and a positive PE highly suggestive of surgical pathology, US had limited value and patients should proceed to MRI.

Effect of Implementation of an Early Treatment of Sepsis Protocol on Surgical Outcomes.

Sepsis outcomes remain high regarding mortality and morbidity, despite efforts to reduce them. We retrospectively evaluated a protocol in the first 6 months of implementation to measure outcomes. Retrospective data collection and analysis was performed of 200 consecutive patients seen in the ED during the first 4 months of 2020 after implementation of the sepsis protocol (group 1) and compared to another 200 consecutive patients during the same time frame in 2019 before the sepsis protocol (group 2). The collected parameters included age, gender, race, length of stay comorbid conditions, mortality, and therapy received. Statistical significance was determined at a p-value ≤.05. Mean age and gender of the groups were similar, 64 vs 66 years for group 1 and 2, respectively. Each group was 45% male. Mean length of stay were 8.9 and 8.6 days in group 1 and 2, respectively. Group 1 had a mortality rate of 13% vs 18% in group 2 (p = .21). Comorbid conditions including cardiovascular disease, diabetes, renal failure, and COPD were analyzed regarding mortality that influenced outcomes using Cox regression analysis. COPD and diabetic patient mortality were significantly lower in the protocol group. Surgical patients had a survival rate of 92.4%. Therefore, the current protocol for sepsis management did improve mortality. Further studies with a larger number of patients are in progress.

Factors Favoring the Development of Chronic Subdural Hematoma After Traumatic Acute Subdural Hematoma in the Elderly.

INTRODUCTION: Traumatic acute subdural hematoma (TASDH) is by far the most common traumatic brain injury in elderly patients presented to the emergency department, and a number of those treated conservatively will develop chronic subdural hematoma (CSDH). The factors contributing to chronicity were not well studied in the elderly; therefore, we retrospectively analyzed our elderly patients with acute subdural hematomas to identify the risk factors which might contribute to the development of subsequent CSDH. METHODS: A retrospective analysis of 254 patients with TASDH admitted between 2012 and 2016 to our level 2 trauma department in a community hospital was collected. Data include age, sex, comorbid conditions, CT findings, anticoagulant therapy, surgical interventions, disposition after discharge, and mortality. Data on those readmitted within the first 2 months with the diagnosis of CSDH were also studied (group A), and compared to those not readmitted (group B). Multiple logistic regression was used to determine the risk factors associated with readmission at P ≤ .05. Institutional review board approval was obtained for this study. RESULTS: There were 254 patients who were admitted with TASDH, 144 male (56.7%) and 110 female (43.3%), with the mean age of 71.4 (SD ± 19.38) years. Only 37 patients (14.6%) went for surgery in their initial admission. A total of 14 patients (5.6%) were readmitted subsequently with the diagnosis of CSDH within two months of initial discharge (group A). Only four patients (28.5%) were on anticoagulant therapy and these patients went for emergency craniotomy for evacuation of hematoma. All 14 patients had a history of coronary artery disease and hypertension and only 5 (35.7%) were diabetic. Review of head CT on initial admission of those patients revealed 4 patients (28.5%) had multiple lesions and 4 (28.5%) had tentorial/falax bleeding and 4 (28.5%) had a shift. The initial size and thickness of the bleeding was 1.4-5 mm. The adjusted model identified diabetes, race, and initial disposition as significant risk factors (P < .05). CONCLUSION: Risk associated with the transformation of TASDH to CSDH is difficult to assess in those group of elderly patients because of the small number; however, diabetes, race, and initial disposition to home pointed toward a risk for future development of CSDH and those patients should be followed clinically and radiographically over the next few months after discharge, particularly those on anticoagulant therapy.

Traumatic brain injury in the elderly with high Glasgow coma scale and low injury severity scores: Factors influencing outcomes.

BACKGROUND: Current trauma activation guidelines do not clearly address age as a risk factor when leveling trauma patients. Glasgow coma scale (GCS) and mode of injury play a major role in leveling trauma patients. We studied the above relationship in our elderly patients presenting with traumatic head injury. METHODS: This study was a retrospective analysis of patients who presented to the emergency department with traumatic brain injuries. We classified the 270 patients into two groups. Group A was 64 years and younger, and group B was 65 years and older. Their GCS, ISS, age, sex, comorbidities, and anticoagulant use were abstracted. The primary outcome was mortality and length of stay. The groups were compared using an independent student's t-test and Chi-square analysis. The Cox regression analysis was used to analyze differences in the outcome while adjusting for the above factors. RESULTS: There were 140 patients in group A, and 130 patients in group B who presented to the ED with a GCS of 14-15 and an ISS of below 15. The mean ISS significantly differed between group A (6.2 ± 6.8) vs (7.9 ± 3.2) in group B (p < 0.0001). The most common diagnosis in group A was concussion (57.3%), while in group B was subdural and subarachnoid hemorrhage (55%). In group B, 13.8% presented as a level one or level two trauma activation. The mean hospital and intensive care stay for group A was 2.1 (±1.9) days and 0.9 (±1.32) days, respectively, versus 4.2 (±3.04) days and 2.4 (±2.02 days) for the elderly group B. Mortality in group A was zero and in group B was 3.8%. Cox regression analysis showed age as an independent predictor of death as well as length of stay. CONCLUSION: Elderly traumatic brain injury patients presenting to the ED with minor trauma and high GCS should be triaged at a higher level in most cases.

Implementing a sleep technician-supervised and personalized APAP interface fitting session prior to initiation of home APAP therapy improves adherence in patients with obstructive sleep apnea.

STUDY OBJECTIVES: Home automatic positive airway pressure (APAP) therapy is becoming a mainstay treatment of obstructive sleep apnea. It is typically prescribed without any prior supervised titration. Initial experience of APAP treatment dictates subsequent use. Discomfort related to the APAP interface contributes to poor APAP adherence. METHODS: After obtaining institutional review board approval, 156 adult patients newly diagnosed with obstructive sleep apnea were prospectively randomized into 2 groups (group A and group B). Group A received a 30-minute personalized interface/mask fitting session supervised by a certified sleep technician, during which APAP therapy was simulated and patients were educated on proper use. Patients sampled different interfaces to address any issues with comfort. Group B received usual care where patients obtained an interface through durable medical equipment suppliers. Primary endpoints included percent APAP usage (number of days APAP was used for ≥ 4 hours divided by 30 days) and APAP usage (number of days APAP was used for any duration) during the initial 30 days of home APAP therapy. Interface-associated air leak served as the secondary endpoint. RESULTS: Mean percent APAP usage was higher in group A compared to group B (78.4% vs 67.8%; P = .04). On average, group A utilized the APAP machine on more days compared to group B (27 vs 24 days; P = .01). APAP interface associated air leak was lower in group A compared to group B (14.9 vs 21.1 l/min; P = .03). CONCLUSIONS: Our findings demonstrate that implementing a personalized interface fitting session supervised by a sleep technician improves APAP adherence. CITATION: Syed Z, Mehta I, Hella JR, Barber K, Khorfan F. Implementing a sleep technician-supervised and personalized APAP interface fitting session prior to initiation of home APAP therapy improves adherence in patients with obstructive sleep apnea. J Clin Sleep Med. 2021;17(10):2057-2065.

Efficacy of Preoperative Usage of Dexamethasone in Diabetic Patients Undergoing Total Hip or Knee Arthroplasty for Control of Nausea and Vomiting.

BACKGROUND: Dexamethasone has been used in surgical patients to decrease nausea, vomiting, and postoperative pain. However, it is not well studied how much dexamethasone complicates glucose control in diabetic patients and whether this leads to poor surgical outcomes. METHODS: We analyzed 256 diabetic patients who underwent elective hip and knee arthroplasty and evaluated the groups that received dexamethasone intraoperatively (201 patients), those who received dexamethasone postoperatively (237 patients), and those who did not receive the steroid intraoperatively (55 patients) and postoperatively (19 patients). RESULTS: 256 diabetic patients were included in the study. The mean age of the group was 68.7 (SD ± 9-10) years. Patients were divided into 123 males (48%) and 133 females (52%). 174 (78%) patients had a total knee replacement operation, and 82 (32%) patients had total hip replacement operation. The mean hemoglobin A1c was 6.728 (SD ± 0.99). The mean ASA score was 2.86 (SD ± 0.38). 201 (78.5%) patients received preoperative or intraoperative dexamethasone, and 237 (92.6%) patients received it postoperatively. The mean blood glucose for all patients raised from 131.9 to 172.2 mg/dL (P = .012) postoperatively, 206.1 mg/dL in the first 24 hours, and 146.2 mg/dL (P = .39) in the second postoperative day. The change was significant in patients who had poorly controlled diabetes (P < .01) preoperatively. There was no significant difference in our study regarding dexamethasone use and effect on postoperative nausea (P = 1.0) and vomiting (P = .52). There was an improvement in pain scores in the patients who received dexamethasone postoperatively which was statistically significant (P = .054). CONCLUSION: Dexamethasone use in diabetic patients for control of postoperative nausea and vomiting in those undergoing elective total knee and hip arthroplasty had a negative impact on glycemic control specifically in those with poorly controlled diabetes and should be avoided.

Fragility Vertebral Compression Fractures in Postmenopausal Women: The Role of a Fracture Liaison Service Program.

BACKGROUND: As the aging population increases in the United States, so has the prevalence of osteoporosis (10.2 million adults aged 50 years and older in 2010). Programs to manage the increased incidence of fragility fractures in such patients particularly the postmenopausal women are the priority. Programs such as the Fracture Liaison Service (FLS) might be the answer. METHODS: Data of 256 postmenopausal women with vertebral compression fractures treated with vertebroplasty between 2012 and 2017 were divided into 2 groups. Group A were patients seen between 2012 and 2014 before the establishment of the FLS program at the clinic. Group B were patients seen between 2015 and 2017 who presented to the FLS program in our clinic. Data collected included demographics, refracture rates, dual-energy X-ray absorptiometry (DEXA) scan T-scores, fracture risk score (FRAX), serum calcium and vitamin D levels, and comorbid conditions. RESULTS: There were 103 female patients with a mean age of 79.75 years (standard deviation [SD] ± 10.86) in group A, while group B had 153 patients with a mean age of 75.66 years (SD ± 10.78). There was no significant difference in the DEXA scan T-scores, FRAX scores, and mean serum calcium and vitamin D levels; however, there was a significant reduction in the refracture rate for vertebral compression fractures (P = .003). CONCLUSION: FLS programs, when implemented, will have a beneficial effect in reducing refracture rates of postmenopausal women with osteoporotic fragility fractures.

The Use of Paravertebral Analgesia in the Management of Pain in the Elderly Patient With Rib Fractures.

BACKGROUND: Elderly patients with rib fractures carry a high morbidity rate, particularly due to pulmonary complications as decreased respiratory efforts ensue secondary to pain. Risk of bleeds in the elderly on anticoagulant therapy is high. The effort to reduce narcotic use in patients is now a health care priority. We propose that the use of paravertebral analgesia (PVA) pumps is an alternative pain control method with less risk and easy placement. METHODS: Two hundred and seventy-nine patients were admitted with multiple fractured ribs to the Trauma Center of Community Hospital and treated with the application of continuous PVA via a pump (72 patients). Pain scores were recorded before and after the initiation of the pump. These patients were compared with a group of the remaining 207 patients who received intravenous narcotics only. RESULTS: The mean change from baseline in pain scores for all patients was 1.43 (SD = 2.75). The mean change in pain for the treatment group was 1.93 (SD = 2.60), and the change in pain for the control group was 1.24 (SD = 2.79). Change in pain differed between groups (1.3 vs 1.8; P = .01) although it was a small difference. After adjusting for age, gender, Injury Severity Score, Glasgow Coma Scale, number of fractures, and comorbid conditions, there was no significant difference in pain post-procedure (odds ratio = 0.75; P = 0.39) with an effect size of 30% and total sample size of 279. CONCLUSION: The PVA pump using bupivacaine is an effective safe and alternative method for managing elderly patients with rib fractures eliminating the serious side effects associated with narcotics.