Assessing the feasibility of using the ketogenic diet in autism spectrum disorder.

BACKGROUND: Evidence demonstrating efficacy of dietary interventions for autism spectrum disorder (ASD) remains inconsistent. Recent research on the ketogenic diet (KD) for the treatment of ASD has suggested a benefit. Children with ASD often demonstrate ritualised food-specific behaviours, taste and texture aversions, and an increased prevalence of food restrictions and allergies. There is a need to investigate how these features contribute to initiation and adherence of the KD. Two surveys were administered to assess the feasibility of utilising the KD for ASD. METHODS: First, paper surveys were given to caregivers of children presenting to outpatient neurology clinics. Next, experienced clinicians were recruited and surveyed online using Qualtrics. Chi-squared analysis was used to compare ASD and non-ASD caregiver responses. Descriptive metrics were used to present clinician responses. Responses to each question were evaluated individually. RESULTS: One hundred and fourteen surveys were collected from caregivers. There were no significant differences in (1) stated feasibility of adopting a new diet, (2) a carbohydrate restricted diet, (3) diet restrictions, (4) documented allergies or (5) personal/cultural restrictions between groups with and without ASD. Seventy clinician responses were collected. The majority (67.4%) indicated that feasibility for a child with ASD to adopt a KD for any reason depends on ASD severity. Some respondents 73% rated adherence to the KD as more difficult compared to age-matched controls, whereas 26% considered it similar. Multiple familial and child characteristics were rated as increasing the difficulty of successful KD. CONCLUSIONS: The results of the present study suggest that it is feasible for children with ASD to adopt a KD, and success is highly individualised to child and family.

A Measure of the Impact on Real-Time Patient Care of Evidence-based Medicine Logs.

Introduction: Evidence-based medicine (EBM) is a critical skill for physicians, and EBM competency has been shown to increase implementation of best medical practices, reduce medical errors, and increase patient-centered care. Like any skill, EBM must be practiced, receiving iterative feedback to improve learners' comprehension. Having residents document patient interactions in logbooks to allow for residency program review, feedback, and documentation of competency has been previously described as a best practice within emergency medicine (EM) to document practice-based learning (PBL) competency. Quantifying how residents use the information they query, locate, evaluate, and apply while providing direct patient care can measure the efficacy of EBM education and provide insight into more efficient ways of providing medical care. Methods: Practice-based learning logs were surveys created to record resident EBM activity on-shift and were placed into our residency management software program. Residents were required to submit 3-5 surveys of EBM activity performed during a 28-day rotation during which additional information was sought. This study included all PBL logs completed by EM residents from June 1, 2013-May 11, 2020. Using qualitative methodology, a codebook was created to analyze residents' free-text responses to the prompt: "Based on your research, would you have done anything differently?" The codebook was designed to generate a three-digit code conveying the effect of the researched information on the patient about whom the log was written, as well as whether the information would affect future patient care and whether these decisions were based on scientific evidence. Results: A total of 10,574 logs were included for primary analysis. In total, 1,977 (18.7%) logs indicated that the evidence acquired through research would affect future patient care. Of these, 392 (3.7%) explicitly stated that the EBM activity conducted as part of our project led to real-time changes in patient care in the ED and would change future management of patients as well. Conclusion: We present a proof of concept that PBL log activity can lead to integration of evidence-based medicine into real-time patient care. While a convenience sample, our cohort recorded evidence of both lifelong learning and application to patient care.

Hospitalizations Are Increasing in Distal Upper Extremity Fractures.

Introduction Distal upper extremity (DUE) fractures are common and include bony fractures of the wrist, hand, and finger. DUE fractures can require hospital admission for clinical observation or surgical fixation. The trend of hospitalization rate for these injuries may more accurately predict future staffing needs, required resources, and expected revenue for orthopedic surgery hand services. The purpose of this study is to determine the trend of hospitalization percentage from 2009 to 2018 for patients presenting to the United States (US) emergency departments (EDs) with DUE fractures. Methods The National Electronic Injury Surveillance System (NEISS) was utilized to collect data from 138,700 patients with wrist, hand, or finger fractures presenting to the US EDs between 2009 and 2018. A total of 752 patients were excluded for ages less than two years old or no sex entry. The unadjusted and adjusted (age, sex, race, and fracture location) hospitalization rates across years were evaluated using binary logistic regression. Results From 2009 to 2018, 137,948 DUE fractures were reported, of which 4749 (3.4%) were hospitalized. Wrist fractures accounted for the highest amount (2953) and the highest proportion of hospitalized patients (62.2%). Higher hospitalization rates were seen among patients 40 years and older (p < 0.05). Together, the DUE fracture hospitalization rate increased significantly (p < 0.05) in 2016 (OR = 1.215, 95% CI = 1.070-1.380), 2017 (OR = 1.154, 95% CI = 1.016-1.311), and 2018 (OR = 1.154, 95% CI = 1.279-1.638) from 2009. The adjusted results showed hospitalization rate statistically increased (p < 0.05) in 2016 (OR = 1.184, 95% CI = 1.040-1.346) and 2018 (OR = 1.389, 95% CI = 1.225-1.575) compared to 2009. An inconsistent increase in hospitalization rate was seen across locations of fracture: wrist (2012, 2013, 2018), hand (2018), and finger (2016, 2018). Conclusions The hospitalization rate of patients with DUE fractures increased in 2016 and 2018 from 2009. These data may predict a need to increase future staffing and resources for orthopedic surgery hand services as hospitals resume pre-pandemic practices.

Comparative Benefits and Risks Associated with Currently Authorized COVID-19 Vaccines.

This article provides a systematic assessment of the efficacy, risks, and methodological quality of evidence from five major publicly available vaccine trials. Results from Pfizer-BioNTech mRNA, Moderna-US NIH mRN-1273, AstraZeneca-Oxford ChAdOx1 nCov-19, Gamaleya GamCovidVac (Sputnik V), and Ad26.COV2.S Johnson & Johnson vaccines were included. Extracted benefits and risks data from each trial were summarized using the GRADE approach denoting the overall certainty of evidence along with relative and absolute effects. Relative risk reduction across all five vaccine trials ranged from 45% to 96%. Absolute risk reduction in symptomatic COVID-19 ranged from 6 to 17 per 1000 across trials. None of the vaccines were associated with a significant increase in serious adverse events compared to placebo. The overall certainty of evidence varied from low to moderate. All five vaccines are effective and safe, but suggest room for improvement in the conduct of large-scale vaccine trials. Certainty of evidence was downrated due to risk of bias, which can be mitigated by improving transparency and thoroughness in conduct and reporting of outcomes.

Morphologic analysis of the sublime tubercle: considerations in the approach to ulnar collateral ligament reconstruction.

Background: Given the increased incidence of ulnar collateral ligament (UCL) injuries and the projected increase in reconstruction procedures, a robust understanding of the morphologic location of the sublime tubercle is paramount to anatomic reconstruction. There is limited research evaluating the morphology of the sublime tubercle of the proximal ulna in an anterior-to-posterior plane. Methods: Twenty-five computed tomography (CT) scans of intact proximal elbow joints for patients were selected using a de-identified database. Cases with history of fracture or surgical intervention to the elbow joint were excluded. These CT scans were then imported into the Mimics Innovation Suite 24.0 software to analyze the sublime tubercle angle from the midpoint of the trochlear notch. All left elbow angle and clock-face values were converted to right elbow values for analysis. Results: The average sublime tubercle angle from the midpoint of the trochlear notch was 282.53 degrees. The angle was converted to a clock face descriptor which located the sublime tubercle at 9.42. Our findings demonstrate that, in the non-throwing population, the morphology of the sublime tubercle can be expected to have a consistent medial location between 9 and 10 o'clock or 2 and 3 o'clock on the contralateral elbow. Conclusions: In relation to the proximal ulnar landmarks, the sublime tubercle, in the non-throwing population, has a consistent relative location.