Predictive factors for operative intervention and ideal length of non-operative trial in adhesive small bowel obstruction.

BACKGROUND: Small bowel obstruction (SBO) is responsible for 350,000 U.S. hospitalizations and costs ~ $2.3 billion annually. The current standard of care for SBO is to trial 3 to 5 days of non-operative management. This study evaluated the factors associated with operative management. METHODS: This retrospective cohort study included adult patients admitted with adhesive SBO. Exclusions were for operative intervention within 24 h or death. RESULTS: At baseline (N = 360), mean age was 65.9 years, 57.8% female, 72.3% white, mean BMI 26.1, 38.7% with history of SBO and 98.1% had history of abdominal surgery. Symptom onset prior to hospitalization was 1-2 days. 55.6% had successful non-operative management at discharge (median length of stay 3 days) vs. 44.4% operative conversion. In univariate analyses, BMI, SBO history, surgical history, days symptom onset, vitals, abdominal pain, obstipation, acute kidney injury, and lack of small bowel feces sign on CT scan were significantly associated with operative management. In a multivariable logistic regression, after controlling all other variables, a lack of small bowel feces sign (adjusted odds ratio, aOR = 2.25, 95% CI 1.06-4.77, p = 0.04) and history of exploratory laparotomy (aOR = 0.44, 95% CI 0.21-0.90, p = 0.03) were significantly associated with operative management. Time from admission to surgery averaged 3.89 days: small bowel resection (55/160) was 4.9 days (median = 4), compared to patients without resection (3.4 days, median = 2; p = 0.00; OR = 1.2, 95% CI 1.07-1.35). CONCLUSIONS: A lack of small bowel feces sign can be a potential indicator for operative management and should be further explored. Since the median resolution of symptoms in the non-operative management group was ~ 2 days and a 20% higher odds for bowel resection each day surgery is delayed, the conservative trial period for adhesive SBO should not exceed 3 days.

Potential of Mobile Health Technology to Reduce Health Disparities in Underserved Communities.

INTRODUCTION: Mobile health (mHealth) has the potential to change how patients make healthcare decisions. We sought to determine the readiness to use mHealth technology in underserved communities. METHODS: We conducted a cross-sectional survey of patients presenting with low-acuity complaints to an urban emergency department (ED) with an underserved population. Patients over the age of two who presented with low-acuity complaints were included. We conducted structured interview with each patient or parent (for minors) about willingness to use mHealth tools for guidance. Analysis included descriptive statistics and univariate analysis based on age and gender. RESULTS: Of 560 patients included in the survey, 80% were adults, 64% female, and 90% Black. The mean age was 28 ± 9 years for adults and 9 ± 5 years for children. One-third of patients reported no primary care physician, and 55% reported no access to a nurse or clinician for medical advice. Adults were less likely to have access to phone consultation than parents of children (odds ratio [OR] 0.49, 95% confidence interval [CI], 0.32 - 0.74), as were males compared to females (OR 0.52, 95% CI, 0.37-0.74). Most patients (96%) reported cellular internet access. Two-thirds of patients reported using online references. When asked how they would behave if an mHealth tool advised them that their current health problem was low risk, 69% of patients responded that they would seek care in an outpatient clinic instead of the ED (30%), stay home and not seek urgent medical care (28%), or use telehealth (11%). CONCLUSION: In this urban community we found a large capacity and willingness to use mHealth technology in medical triage.

A High Preoperative Pain and Symptom Profile Predicts Worse Pain Outcomes for Children After Spine Fusion Surgery.

BACKGROUND: Preoperative pain predicts persistent pain after spine fusion, yet little is understood about the nature of that pain, related symptoms, and how these symptoms relate to postoperative pain outcomes. This prospective study examined children's baseline pain and symptom profiles and the association between a high symptom profile and postoperative outcomes. METHODS: Seventy children (aged 10-17 years) scheduled for correction of idiopathic scoliosis completed pain and symptom surveys during their preoperative visit (ie, pain intensity [0-10 numeric rating scores], a pediatric version of the 2011 fibromyalgia survey criteria [including pain locations and symptom severity scale], neuropathic pain symptoms [painDETECT], and Patient-Reported Outcome Measurement System measures of fatigue, depression, function, pain interference, and pain catastrophizing). Pain intensity and total analgesic use were recorded daily postoperatively and for 2 weeks after discharge. A 2-step cluster analysis differentiated a high and low pain and symptom profile at baseline, and a multivariate main effects regression model examined the association between pain profile and posthospital discharge pain and analgesic outcomes. RESULTS: The cluster analysis differentiated 2 groups of children well characterized by their baseline symptom reporting. Thirty percent (95% confidence interval [CI], 20.2%-41.8%) had a high symptom profile with higher depression, fatigue, pain interference, a pediatric version of the fibromyalgia survey criteria symptoms, neuropathic pain, and catastrophizing. Girls were more likely than boys to be clustered in the high symptom profile (odds ratio [OR], 5.76 [95% CI, 1.20-27.58]; P = .022) as were those with preoperative pain lasting >3 months (OR, 3.42 [95% CI, 1.21-9.70]; P = .018). Adjusting for sex, age, and total in-hospital opioid consumption, high cluster membership was independently associated with higher self-reported pain after discharge (mean difference +1.13 point [97.5% CI, 0.09-2.17]; P = .015). Children in the high symptom cluster were more likely to report ongoing opioid use at 2 weeks compared with the low symptom group (87% vs 50%; OR, 6.5 [95% CI, 1.30-33.03]; P = .015). At 6 months, high symptom cluster membership was associated with higher pain intensity, higher pain interference, and ongoing analgesic use (P ≤ .018). CONCLUSIONS: A behavioral pain vulnerable profile was present preoperatively in 30% of children with idiopathic scoliosis and was independently associated with poorer and potentially long-lasting pain outcomes after spine fusion in this setting. This high symptom profile is similar to that described in children and adults with chronic and centralized pain disorders and was more prevalent in girls and those with long-standing pain. Further study is needed to elucidate the potential mechanisms behind our observations.

Evaluation of emergency pediatric tracheal intubation by pediatric anesthesiologists on inpatient units and the emergency department.

BACKGROUND AND OBJECTIVES: There are limited data on pediatric emergency tracheal intubation on inpatient units and in the emergency department by anesthesiologists. This retrospective cohort study was designed to describe the frequency of difficult intubation and adverse events associated with emergency tracheal intubation performed by pediatric anesthesiologists in a large children's hospital. METHODS: All emergency tracheal intubation on inpatient units and the emergency department performed by pediatric anesthesiologists over a 7-year period in children <18 years were identified by querying our perioperative clinical information system. Medical records were comprehensively reviewed to describe the emergency intubation process and outcomes. RESULTS: One hundred and thirty-two intubations from 120 children (median age 3.3 years) were eligible. The majority of emergency tracheal intubations were successful with 1-2 laryngoscopy attempts, while 14 (10.6%) were difficult. Despite grade 3 view in 3/14 cases, the airway was secured after multiple direct laryngoscopy attempts. Eleven required use of an alternative airway device to secure the airway. A preexisting airway abnormality or craniofacial abnormality was present in 57% of cases with difficult intubation including half with micrognathia or retrognathia. Major intubation-related adverse events such as aspiration, occurred in 5 (3.8%) emergency tracheal intubations. Mild-to-moderate intubation-related adverse events occurred in 23 (17.4%) emergency tracheal intubations including mainstem bronchus intubation (13.6%). CONCLUSION: A significant rate of difficult intubation and mild-to-moderate intubation-related adverse events were found in emergency tracheal intubations on inpatient units and the emergency department in children performed by a pediatric anesthesiology emergency airway team. Difficult intubation was observed frequently in children with preexisting airway and craniofacial abnormalities and often required the use of an alternative airway device to successfully secure the airway.