Assessment of Ventilation Using Adult and Pediatric Manual Resuscitators in a Simulated Adult Patient

BACKGROUND

The bag-valve-mask (BVM) or manual resuscitator bag is used as a first-line technique to ventilate patients with respiratory failure. Volume-restricted manual resuscitator bags (eg, pediatric bags) have been suggested to minimize overventilation and associated complications. There are studies that both support and caution against the use of a pediatric resuscitator bag to ventilate an adult patient. In this study, we evaluated the ability of pre-hospital clinicians to adequately ventilate an adult manikin with both an adult- and pediatric-size manual resuscitator bag without the assistance of an advanced airway or airway adjunct device.

METHODS

This study was conducted at an international conference in 2022. Conference attendees with pre-hospital health care experience were recruited to ventilate an adult manikin using a BVM for 1 min with both an adult and pediatric resuscitator bag, without the use of adjunct airway devices, while 6 ventilatory variables were collected or calculated: tidal volume (VT), breathing frequency, adequate breaths (VT > 150 mL), proportion of adequate breaths, peak inspiratory pressure (PIP), and estimated alveolar ventilation (EAV).

RESULTS

A total of 208 participants completed the study. Ventilation with the adult-sized BVM delivered an average VT of 290.4 mL compared to 197.1 mL (P < .001) when using the pediatric BVM. PIP with the adult BVM was higher than with the pediatric BVM (10.6 cm H2O vs 8.6 cm H2O, P < .001). The median EAV with the adult bag (1,138.1 [interquartile range [IQR] 194.0-2,869.9] mL/min) was markedly greater than with the pediatric BVM (67.7 [IQR 0-467.3] mL/min, P < .001).

CONCLUSIONS

Both pediatric- and adult-sized BVM provided lower ventilation volumes than those recommended by professional guidelines for an adult. Ventilation with the pediatric BVM was significantly worse than with the adult bag when ventilating a simulated adult subject.

Provider perspectives of community-acquired pressure injury prevention in veterans with spinal cord injury

CONTEXT/OBJECTIVE

Community-acquired pressure injuries (CAPrI) are a common and costly complication of spinal cord injury (SCI). Most studies and interventions focus on the prevention of pressure injuries acquired in the hospital. The goal of this study is to better understand SCI provider perspectives of the risks, actions and resources needed to prevent CAPrIs.

DESIGN

Qualitative descriptive, semi-structured interviews of SCI providers analyzed using a deductive-inductive approach.

SETTING

Three geographically different veteran health administration spinal cord injury/disorder centers.

PARTICIPANTS

30 interprofessional SCI providers.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

Provider perspective of risks, actions and resources for CAPrI prevention in veterans with SCI.

RESULTS

30 interviews revealed a model of provider perspectives of CAPrI prevention including veteran risk characteristics, veteran preventive activities and provider, family, community caregiving resources.

CONCLUSION

Understanding provider perspectives of Veteran CAPrI preventive risks, actions and resources guides more appropriate interventions to prevent CAPrIs in individuals living with SCI.

Veteran model of preventing community-acquired pressure injuries associated with spinal cord injury: A qualitative descriptive study

CONTEXT/OBJECTIVE

Pressure injuries (PrIs) are the second leading cause of hospitalization in people with spinal cord injury (SCI). The majority of PrIs occur in the community, but there is little known about prevention of community acquired PrI (CAPrI). The purpose of this study was to better understand risks, resources, and actions associated with CAPrI prevention from the perspective of veterans living with SCI in the community.

METHODS

A qualitative descriptive design using photovoice (n = 30) with or without guided tours (n = 15) was conducted with Veterans living with SCI at 3 sites across the United States to determine environmental/lifestyle risks at home, prevention activities, resources used, and challenges in CAPrI prevention. Interviews were audio-recorded, transcribed and analyzed using thematic analysis, followed by inductive thematic synthesis.

RESULTS

Qualitative analyses revealed a model describing veteran's perspective of preventing CAPrIs associated with SCI. The model included 3 themes and 9 subthemes: Factors that Lead to Risk for Pressure Injury (Challenges and Barriers), Factors that Affect Chosen Actions (Veteran Motivators, Veteran Values, Veteran Satisfaction with Provider Relationships, and Veteran Supports), and Preventive Activities within Context of Life (Physical Care, Coping, Advocacy).

CONCLUSION

Incorporating the veteran model of prevention within the context of life into clinical care could support provider-veteran collaboration to identify and integrate successful strategies that prevent CAPrIs while also improving veteran quality of life.

Development of a decision support tool to prevent community acquired pressure injuries for use in the spinal cord injury clinic using the delphi technique

STUDY DESIGN

Delphi Technique.

OBJECTIVES

Describe the development of a decision support tool to prevent community-acquired pressure injuries (CAPrIs) in individuals with spinal cord injury (SCI) for use in SCI clinics, called the Community-Acquired Pressure Injury Prevention-Field Implementation Tool (CAPP-FIT).

SETTING

Veteran Health Administration Hospital, Chicago, Illinois, USA.

METHODS

Concept mapping of current pressure injury (PrI) guidelines and qualitative research describing risks, actions, and resources needed to prevent CAPrIs associated with SCI were used to develop 40 veteran checklist items (Items) along with 37 associated provider actions (Actions) for the tool. The Delphi technique was used to refine Items and Actions with a panel of interprofessional SCI providers (n = 15), veterans with SCI (n = 4), and caregivers (n = 3) to determine consensus on a 4-point Likert scale (strongly agree-strongly disagree) for each Item and Action. A 75% agreement was set for responses rated as strongly agree or agree.

RESULTS

Panelists were 60% female, 62% White, 33% veterans with SCI or caregivers, 33% wound care certified with a mean age of 59 years. Two survey rounds were required for consensus for 41 Item and 38 Action CAPP-FIT. Response rate was 95% for both rounds. Delphi round 1 showed all but two Actions affirming agreement above 75%. Substantive comments from panelists required revision to 5 Items and 9 Actions and one additional Item/Actions related to coping, meeting threshold percent agreement in Round 2.

CONCLUSIONS

The CAPP-FIT could become a useful tool for Veterans living with SCI, caregivers, and SCI providers.

The relationship of sinus opacification, olfaction and dupilumab efficacy in patients with CRSwNP

BACKGROUND

Loss of sense of smell is one of the most burdensome symptoms of chronic rhinosinusitis with nasal polyps (CRSwNP) but its relationship to sinus disease on imaging is unclear. Dupilumab improves sense of smell and radiographic severity of sinus disease in patients with CRSwNP. We investigated the relationship of sinus opacification severity and loci to olfactory impairment and dupilumab efficacy in patients with CRSwNP from the SINUS-24/SINUS-52 (NCT02912468/NCT02898454) studies.

METHODS

Sinus opacification was evaluated using the Lund-Mackay computed tomography (LMK-CT) score and sense of smell using patient-reported loss of smell (LoS) score, University of Pennsylvania Smell Identification Test (UPSIT) score and the 22-item Sino-Nasal Outcome Test (SNOT-22) smell/taste item.

RESULTS

At baseline, 95% of patients (688/724) had impaired sense of smell and opacification was extensive across all sinuses. Greater olfactory impairment was associated with greater opacification, especially in the ethmoid, sphenoid and frontal sinuses. At Week 24, reductions in LMK-CT total score and ethmoid and sphenoid sinus scores with dupilumab were weakly correlated with improvements in sense of smell assessed by LoS, UPSIT and SNOT-22 smell/taste item. More dupilumab than placebo patients achieved clinically meaningful improvement in LMK-CT total score at Week 24 and Week 52.

CONCLUSION

Radiographic disease severity on imaging was associated with smell outcomes in this cohort. Opacification of the ethmoid, sphenoid and frontal sinuses was associated with severe smell loss. These data suggest that dupilumab effects on smell may be partly mediated through reduced sinus inflammation.

Use of the Veterans Health Administration online patient portal among Veterans with spinal cord injuries and disorders

CONTEXT/OBJECTIVE

Online patient portals like the Veteran Health Administration's (VA) My HealtheVet (MHV) may be particularly useful for Veterans with spinal cord injuries/disorders (SCI/D), many of whom experience barriers to care. The objective of this analysis was to examine MHV use among Veterans with SCI/D.

DESIGN

Retrospective database analysis.

SETTING

VA SCI/D System of Care.

PARTICIPANTS

Veterans with SCI/D who utilize VA care.

INTERVENTIONS

N/A.

OUTCOME MEASURES

MHV registration and use of key portal features among Veterans who newly registered for MHV. Veteran characteristics associated with registration and use of portal features using multiple logistic regression.

RESULTS

14.6% of Veterans with SCI/D in our sample registered to use MHV. 48.7% used the medication refill feature, 28.7% used the appointment view feature, 25.0% sent or read at least one secure message and 10.8% used the Blue Button feature. Adjusted analyses indicate that having a C5-8 (OR: 1.36, CI95%: 1.06-1.76, P < 0.05) or T1-S5 (OR: 1.41, CI95%: 1.13-1.78, P < 0.01) (vs. C1-C4), having (vs. not having) neurogenic bladder (OR: 1.45, CI95%: 1.18-1.77, P < 0.01), being married (vs. not married) (OR: 2.00, CI95%: 1.67-2.39, P < 0.01), and increased healthcare utilization in the third (OR: 1.71, CI95%: 1.31-2.24, P < 0.01) and fourth (OR: 1.73, CI95%: 1.27-2.34, P < 0.01) quartiles (vs. first quartile) were associated with increased odds of MHV registration. We also identified factors associated with use of key MHV features.

CONCLUSIONS

Our results suggest that MHV registration and use of key portal features was limited among Veterans with SCI/D. Effort to increase portal use in this population are warranted.

Medical Student Mentorship in the COVID-19 Era

Background

The Covid-19 pandemic led to a reduction of in-person, guided mentorship due to social distancing and an emphasis on virtual meetings. The effect of these changes on medical students' experiences and specialty choice has yet to be studied in a large-scale manner.

Objective

To determine the perspective of third- and fourth-year medical students regarding the impact of the COVID-19 pandemic on mentorship.

Design

The authors distributed a modified Likert scale questionnaire (score: 1-10) to assess responses.

Participants

Third- and fourth-year medical students at two large US allopathic medical schools.

Main Measures

Responses to each survey item were analyzed to characterize the impact of the COVID-19 pandemic on mentorship relationships in medical school. A score of 1-5 was considered "disagree" and a score of 6-10 was considered "agree."

Key Results

A total of 144 responses were collected with a response rate of 16.2%. Overall, 80.6% (n = 116) of respondents agree that the COVID-19 pandemic has had a negative impact on their medical school experience. Nearly half (41.0%, n = 59) expressed concern over the lack of mentorship opportunities, and 66.0% (n = 95) reported that the pandemic has made it more difficult to form or maintain connections with their mentors. Importantly, 43.6% (n = 61) of respondents reported that having close mentoring relationships reduced the impact of the pandemic on their medical training. While many respondents (79.9%, n = 114) did not change career plans due to the pandemic, most students are concerned about evaluating prospective residency programs (88.9%, n = 128). Notably, M3s have much lower confidence than M4s in their ability to choose a specialty (5.9 vs. 8.2, p = 6.43e - 08).

Conclusions

This investigation illustrates the concerns that medical students have regarding access to mentorship opportunities due to the COVID-19 pandemic. We hope that these findings encourage medical schools to evaluate and expand their current mentorship programs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01838-4.

Dual utilization of Medicare and VA outpatient care among Veterans with spinal cord injuries and disorders

OBJECTIVE

Veterans with spinal cord injuries and disorders (SCI/D) utilizing Veterans Affairs healthcare facilities are also Medicare eligible. Use of multiple health care systems potentially duplicates or fragments care in this population; yet little is known about those using multiple systems. This study describes dual use of services paid for by VA and Medicare among Veterans with SCI/D.

DESIGN

Retrospective, cross-sectional, observational study.

PARTICIPANTS

Veterans with SCI/D (n = 13,902) who received healthcare services within the VA SCI System of Care and were eligible for or enrolled in Medicare in 2011.

INTERVENTIONS

N/A.

OUTCOME MEASURES

Patient characteristics, average number of visits and patient level frequencies of reasons for visits were determined for individuals within healthcare utilization (VA only, Medicare only, or dual VA/Medicare) groups. Multinomial logistic regression analyses were used to investigate associations of patient variables on dual use.

RESULTS

65.3% of Veterans with SCI/D were VA only users for outpatient encounters, 4.4% had encounters paid for by Medicare only, and 30.3% were dual users. Veterans were less likely to be VA only users if they were older than 69 and if they had been injured for greater than ten years. African American Veterans with SCI (compared to white) were more likely to be VA only users.

CONCLUSION

A substantial number (∼30%) of Veterans with SCI/D are dual users. These numbers highlight the importance of improved strategies to coordinate care and increase health information sharing across systems.

The influence of the COVID-19 pandemic on the psychological well-being of college students: a cross-sectional study

OBJECTIVE

Even before the outbreak of the COVID-19 pandemic, concerns regarding college students' mental health were on the rise due to the increasing number of students afflicted with mental health issues. Exposure to numerous pandemic-related measures exacerbated existing issues with anxiety, depression, and stress. This study aimed to assess depression, anxiety, and stress levels among university students in the Aseer region in Saudi Arabia.

SUBJECTS AND METHODS

Data were collected from eligible individuals using a web-based, self-administered DASS-21 questionnaire. This questionnaire consists of 21 questions with a rating scale of 0-3. Each of the psychological factors of depression, anxiety, and stress was categorized as normal, mild, moderate, severe, and extremely severe. Results were expressed using descriptive statistics as proportions, and the Mann-Whitney/Kruskal-Wallis' test was used to evaluate the presence of a significant difference between each of the socio-demographic factors of the respondents and the psychological outcomes.

RESULTS

Respondents aged between 18-24 years reported higher rates of extremely severe depression than other age groups. Females had higher rates of depression, especially severe and extremely severe forms. Extremely severe anxiety had a relatively high prevalence across all age groups. Extremely severe stress was more common among respondents aged between 18-24 years, while respondents older than 34 years reported the highest prevalence of severe stress. The Mann-Whitney/Kruskal-Wallis' tests showed statistically significant differences between participants in the different groups.

CONCLUSIONS

The COVID-19 pandemic had a high psychological impact on university students, which indicates that a psychological support program should be implemented to reduce this impact.

Traumatic blunt urethral injuries in females: A retrospective study of the National Trauma Data Bank

INTRODUCTION

Female blunt urethral injury (FBUI) is much less common than in males. Due to this rarity, studies of FBUI are largely confined to smaller case series. This study analyzes circumstances associated with FBUI and its contribution to mortality in greater detail.

METHODS

Using the National Trauma Data Bank, we analyzed predictors of FBUI, and tested FBUI as a predictor of mortality. Univariate analysis used Chi-squared for categorical data and T-test for continuous data. Multivariate analysis used multiple logistic regression.

RESULTS

A total of 245 (0.021%) of 1 185 904 female blunt trauma patients sustained FBUI, vs. 2242 (0.145%) for males (p<0.001). Eighty-seven FBUIs (0.097%) occurred under age 16 vs. 153 (0.016%) in older patients (p<0.001). FBUI was more common with motorcycle (n=14, 0.203%), bicycle (n=11, 0.110%), and automobile vs. pedestrian accidents (n=47, 0.146%) than falls (n=72, 0.011%) or automobile accidents (n=61, 0.029%) (p<0.001). FBUI occurred in 114 (0.011%) patients with Injury Severity Score (ISS) <15 vs. 131 (0.091%) with ISS >15 (p<0.001). Slightly more than half (56.7%) of FBUI occurred with pelvic fractures. Age (odds ratio [OR] 0.95, p<0.001), injury severity (OR 1.05, p<0.001), auto vs. pedestrian (OR 4.1, p<0.001), motorcycle crashes (OR 6.9, p<0.001), and bicycle crashes (OR 3.9, p<0.001) independently predicted FBUI. A total of 9.4% of FBUI patients died vs. 2.5% without FBUI (p<0.001). The association of FBUI with death was not significant on multivariate analysis.

CONCLUSIONS

FBUI is more prevalent in young patients with high-force direct trauma. FBUI is not an independent predictor of mortality, suggesting that it is a marker of severe injury rather than a direct cause of death.

Telemedicine Use Among Physiatrists During the Early Phase of the COVID-19 Pandemic and Potential for Future Use

Introduction: With the coronavirus disease 2019 (COVID-19) pandemic causing the need for social distancing, telemedicine saw a significant increase in use to provide routine medical care. As a field, physiatry had already been implementing telemedicine prior to the pandemic. In this study, we characterized the use of telemedicine among physiatrists during the early phase of the COVID-19 pandemic to understand the barriers and facilitators to implementing telemedicine use in the field of physiatry in the future. Methods: Online survey of a cross-sectional sample of physiatrists. Analysis was conducted using logistic regression. Results: One hundred seventy one (n = 171) participants completed the survey. Before the pandemic, only 17.5% of respondents used telemedicine. In the logistic regression, physicians who used a hospital-provided platform were more likely to use telemedicine in the future compared with those who used their own secure platform, conducted a phone visit, and used a non-secure platform or other platforms. The three most popular barriers identified were "inability to complete the physical examination," "patients lack of access to technology," and "patients lack of familiarity with the technology." Discussion: Focus on education on telemedicine functional examination strategies and technology strategies for patients and providers (including addressing the digital divide and hospital-provided secure platforms) are potential targets of implementation strategies for greater telemedicine uptake for physiatrists in the future.

Triangulation of veteran and provider models of preventing community-acquired pressure injuries in spinal cord injury to reveal convergence and divergence of perspectives

CONTEXT/OBJECTIVE

Community-acquired pressure injuries (CAPrI) are a common and costly complication of spinal cord injury (SCI). The majority of PrIs occur in the community, but there is little guidance in CAPrI prevention. This study describes how provider and veteran perspectives of CAPrI prevention converge and diverge.

DESIGN

The Farmer triangulation method was used to compare two models from previous qualitative research describing provider and veteran perspectives of CAPrI prevention based on the framework of CAPrI risks, resources, and preventive activities. The previous qualitative research revealed the provider model of CAPrI prevention using semi-structured interviews with interprofessional SCI providers at the Veteran Health Administration (VA) (n = 30). A qualitative descriptive design using photovoice (n = 30) with or without guided tours (n = 15) revealed the Veteran model of CAPrI prevention.

SETTING

The previous qualitative research was conducted at three geographically different VA spinal cord injury/disorder centers in the United States (north, south, west).

PARTICIPANTS

30 interprofessional SCI providers; 30 Veterans living with SCI at three VA SCI Centers in the United States.

INTERVENTIONS

n/a.

OUTCOME MEASURES

Provider-Veteran perspectives of CAPrI prevention that demonstrated agreement, partial agreement, divergence, and silence.

RESULTS

Providers and veterans agreed on what is basic care, and the importance of family, caregiver and health provider/system supports, but they viewed motivation, veteran role, informal supports, and adequacy of supports differently.

CONCLUSION

Understanding how SCI providers and veterans living with SCI view prevention in the community informs how to promote preventive care in the context of veterans' lives.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Young age is associated with decreased recurrence for renal cell carcinoma

INTRODUCTION

We aimed to examine stage-specific oncologic outcomes for young versus conventional-age patients with localized disease in a modern cohort.

MATERIALS AND METHODS

The Surveillance, Epidemiology and End Results database was queried for patients with T1-T2N0M0 kidney cancer from 1975-2016, including clear cell, papillary, and chromophobe renal cell carcinoma. Patients were stratified into ≤ 40 years-old or > 40 years-old cohorts and underwent definitive treatment via percutaneous ablation, partial nephrectomy, or radical nephrectomy. Primary outcome was cancer-specific survival. Cox regression and Kaplan-Meier analysis were performed.

RESULTS

A total of 44,673 patients were identified with 41,812 patients in the conventional-age and 2,861 patients in the young cohort with mean ages of 62.1 and 34.7 years old, respectively. The young cohort had a higher proportion of T1a disease compared to the conventional-age cohort (65.2% vs. 58.6%) and a lower proportion of the cT1b (24.4% vs. 29.3%), cT2a (6.8% vs. 8.4%), and cT2b (3.6% vs. 3.7%) disease. Chromophobe histology was more prevalent in the younger population (10.5% vs. 6.6%). Nuclear grade 3 or 4 were more prominent in the conventional-age population (24.8% vs. 19.1%). Cancer-specific death was significantly higher in the conventional-age cohort (2.4% vs. 0.7%). Cox regression analysis demonstrated patients > 40 years old, increasing stage, and higher grade were at independently increased risk of cancer-specific death. Kaplan-Meier analysis showed significantly improved 5-year cancer-specific survival for the young versus conventional-age cohorts when sub-stratified by stage.

CONCLUSION

When stratified by stage, young patients with localized kidney cancer experience improved cancer-specific survival.

Internalization, reduced growth, and behavioral effects following exposure to micro and nano tire particles in two estuarine indicator species

Synthetic rubber emissions from automobile tires are common in aquatic ecosystems. To assess potential impacts on exposed organisms, early life stages of the estuarine indicator species Inland Silverside (Menidia beryllina) and mysid shrimp (Americamysis bahia) were exposed to three tire particle (TP) concentrations at micro and nano size fractions (0.0038, 0.0378 and 3.778 mg/L in mass concentrations for micro size particles), and separately to leachate, across a 5-25 PSU salinity gradient. Following exposure, M. beryllina and A. bahia had significantly altered swimming behaviors, such as increased freezing, changes in positioning, and total distance moved, which could lead to an increased risk of predation and foraging challenges in the wild. Growth for both A. bahia and M. beryllina was reduced in a concentration-dependent manner when exposed to micro-TP, whereas M. beryllina also demonstrated reduced growth when exposed to nano-TP (except lowest concentration). TP internalization was dependent on the exposure salinity in both taxa. The presence of adverse effects in M. beryllina and A. bahia indicate that even at current environmental levels of tire-related pollution, which are expected to continue to increase, aquatic ecosystems may be experiencing negative impacts.

Increasing rate of pathologic upgrading in low risk prostate cancer patients in the active surveillance era

INTRODUCTION

Management of prostate cancer has seen an increasing predilection for active surveillance in low risk (LR) patients. We aimed to evaluate the rate of pathologic upgrading in patients with very low (VLR) or LR prostate cancer after prostatectomy.

MATERIALS AND METHODS

The National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) Database were queried for patients diagnosed with Gleason 6 prostate cancer and prostate specific antigen (PSA) < 10 ng/mL from 2010 to 2016. All patients underwent 12-core biopsy and a subsequent prostatectomy for final pathologic staging. Our primary outcome was rate of pathologic upgrading over the study period.

RESULTS

A total of 35,332 patients from the NCDB and 7,186 patients from the SEER database were collected. Patient population had an average age of about 59 years old and was over 80% white. Mean pre-biopsy PSA was higher for the upgraded cohorts in the NCDB and SEER populations (5.3 versus 4.9 and 5.5 versus 5.1 respectively, p < 0.001). Upgraded cohorts were more likely to have a higher percentage of positive cores at biopsy (p < 0.001). Multivariable analysis demonstrated that increasing age, increasing PSA and year of diagnosis were all predictors of upgrading (p < 0.05) in both databases. African American race was significantly associated with upgrading in the NCDB database only (p = 0.001). Over the studied time period, the rate of upgrading at prostatectomy increased from 41.2% to 56.7% in the NCDB population and from 41.9% to 45.4% in the SEER population.

CONCLUSIONS

The rate of pathologic upgrading of VLR and LR prostate cancer at prostatectomy has been increasing in recent years. Increasing age, pre-biopsy PSA and an increasing percentage of positive cores at biopsy are predictors of this outcome. This may relate to improved patient selection for active surveillance and definitive treatment.

Promoting informed prostate cancer screening decision-making for African American men in a community-based setting

PURPOSE

Current screening guidelines for prostate cancer (PCa) encourage men to make individual screening decisions after consulting with their primary care provider to weigh the risks and benefits of undergoing prostate specific antigen (PSA) testing, but many men at high risk of PCa diagnosis (notably African American men) are more likely to be uninsured and lack a primary care provider. An academic-community partnership redesigned its community-based screening program to ensure access to services for African American men, incorporating a session with a trained clinical educator in community settings, designed to increase knowledge and promote informed decision-making regarding PSA testing. This study evaluated effects of the intervention on decision-making outcomes.

METHODS

To evaluate program efficacy, 88 men completed pre- and post-test surveys assessing outcomes of interest.

RESULTS

Participants' knowledge, beliefs, attitudes, anxiety levels, and self-efficacy all improved from pre- to post-test at a statistically significant level. Most notably participants' awareness that PCa is often not life-threatening, and watchful waiting is a reasonable treatment option increased after the encounter. More than half of the study sample felt they had received enough knowledge to make an informed decision about whether the PSA test was right for them.

CONCLUSION

Our findings show the program had positive effects on men's ability to make informed decisions about PCa screening and demonstrate that educational outreach programs with an emphasis on informed decision-making can effectively balance screening guidelines with the needs of underserved populations in community settings to improve outcomes.

An estimation of optimum dietary concentration of soy bean meal for carps (Catla catla, Labeo rohita and Cirhinus mrigala)

Soybean meal is an inexpensive plant origin protein which has been used in practical diets as a replacement of animal protein such as fish meal or chicken meal, due to the uneconomical price of animal protein diets. Consequently, a research study was conducted on some commercial species of Indian major carps i.e. Catla (Cattla cattla), Rohu (Labeo rohita) and Mrigala (Cirhinus mrigala) (Hamilton, 1822) to estimate optimum dietary protein requirement of soy bean meal in diet in an intensive polyculture. Three different diets (SBM I, SBM II and SBM III) were formulated by 80%, 50% and 20% replacement of fish meal with soybean meal from a 45% fish meal diet (control).Highest monthly mean weight gain was obtained by SBM II (with 35% CP and about 50% substitution of fish meal), while SBM III (45% Crude Protein and about 20% substitution of fish meal) was stood second. All tested diets respond enormously by producing high yield as compare to control diet, though SBM II generated highest yield among all. On the bases of the following research, it was revealed that the SBM can surrogate even50% fish meal without any augmentation of other amino acids in the diet of Indian major carps.

737 Supporting Surgeons in Their Return to Training

Aim

t any one time, approximately 10% of the junior doctor workforce (∼5000 doctors) take time out of training. Following the Bawa Gaba case, and with trainees shielding during the COVID pandemic, there is greater scrutiny and demand to support trainees returning to the frontline. Supported Return to Training (SuppoRTT) is a Health Education England Program designed to improve the Return-To-Training (RTT) experience. For surgical specialties there are additional challenges of reintroducing trainees to practical skills.

Method

e designed and facilitated the first regional SuppoRTT course for Orthopaedic Specialist Registrars, which consisted of peer and consultant-led clinical updates, forum discussions and externally commissioned professional coaching. A pre-course survey established participants’ concerns and expectations about RTT and formed the basis of discussions. A post-course survey assessed value of the course and impact on participants.

Results

Eight participants (6 female) attended. Grade of training on return ranged from ST3 to ST8. Main areas of concern related to colleague perception, reduced confidence with decision-making, operative skill fade, and frustrations with organisational elements of managing work-life balance. There was an overwhelmingly positive response to the support offered on our course, particularly to the discussions around RTT concerns and returning to on-calls. All respondents strongly agreed that sharing their concerns and hearing about peer experience was valuable.

Conclusions

High numbers of trainees take approved time out of training. RTT is associated with anxiety around performance and safety. Surgical trainees can be supported with a targeted course that offers clinical update, peer support and professional coaching.

Minimally invasive management versus open surgery in the treatment of penetrating bladder injuries: a retrospective cohort study

Background

While blunt extra-peritoneal bladder injury is typically treated non-operatively or with minimally invasive management, the treatment for penetrating bladder injury is generally open surgery. We identify a group of patients with penetrating bladder injury who were treated with minimally invasive management and compare the results with those who underwent traditional open surgical treatment.

Methods

This retrospective cohort study analyzes penetrating bladder injuries from a single trauma center from 2012 through 2019, and from the National Trauma Data Bank for 2016 and 2017. Mortality, complications, and length of stay were compared for minimally invasive management versus open surgery. We used Chi square to test significance for categorical variables, Mann–Whitney U test for ordinal variables, and T-test for continuous variables. Multivariate analysis was performed with multiple logistic, ordinal, and linear regression.

Results

Local: 117 (0.63%) had a bladder injury; 30 (25.6%) were penetrating. 6 (20.0%) were successfully treated with minimally invasive management with no complication versus 24 complications in 11 patients (45.8%) for open surgery (p = 0.047). Open surgical management was not a significant independent predictor of mortality or hospital length of stay. National Trauma Data Bank: 5330 (0.27%) had a bladder injury; 963 (19.5%) were penetrating. 97 (10.1%) were treated with minimally invasive management. The minimally invasive management group had 12 complications in 5 patients (4.9%) versus 280 complications in 169 patients (19.7%) for open surgery (p =  < 0.001). Open surgery was a significant independent predictor of complications (OR 1.57, p = 0.003) and longer hospital length of stay (B = 5.31, p < 0.001).

Conclusions

Most penetrating bladder injury requires open surgery, however a small proportion can safely be managed with minimally invasive management. Minimally invasive management is associated with lower total complications and shorter hospital length of stay in select patients.

Short-term outcomes of anterior approach sacrospinous ligament fixation for apical vaginal prolapse - A retrospective study

Introduction

Vaginal sacrospinous fixation and sacrospinous hysteropexy (SSF/SSHP) are highly effective procedures for apical compartment prolapse. The established technique is the posterior vaginal approach. The alternative anterior approach through an anterior vaginal incision, although occasionally mentioned in the literature, is less well established. However, this approach is a more appropriate route if posterior vaginal surgery is not indicated. The aim of this paper is to review surgical outcomes of anterior approach in our centre and to compare outcomes of SSF vs SSHP.

Methods

Retrospective case note review of 60 patients who underwent anterior SSF for prolapse between 2009-2017 was performed. Preoperative and postoperative symptoms and findings were recorded. Anterior SSF involved an anterior vaginal incision and paravaginal access to the ligament for dissection and fixation to either the cervix or vault.

Results

SSF was performed in 39 patients, out of which 8 underwent vaginal hysterectomy concomitantly. SSHP for uterine prolapse was performed in 21 patients. There were no cases of recurrent apical prolapse in the cohort at mean follow-up of 1 year. No intra-operative visceral injuries were observed. Recurrence of anterior wall prolapse and postoperative voiding dysfunction was observed in 8.3% and short-term buttock pain in 6.6% of patients.

Conclusion

Anterior approach SSF and SSHP is a safe and effective technique for apical prolapse and is the recommended route when posterior vaginal surgery is not required.

Should COVID-19 patients >75 years be Ventilated? An Outcome Study

BACKGROUND

Elderly patients with COVID-19 disease are at increased risk for adverse outcomes. Current data regarding disease characteristics and outcomes in this population are limited.

AIM

To delineate the adverse factors associated with outcomes of COVID-19 patients ≥75 years of age.

DESIGN

Retrospective cohort study.

METHODS

Patients were classified into mild/moderate, severe/very severe and critical disease (intubated) based on oxygen requirements. The primary outcome was in-hospital mortality.

RESULTS

A total of 355 patients aged ≥75 years hospitalized with COVID-19 between 19 March and 25 April 2020 were included.Mean age was 84.3 years. One-third of the patients developed critical disease. Mean length of stay was 7.10 days. Vasopressors were required in 27%, with the highest frequency in the critical disease group (74.1%). Overall mortality was 57.2%, with a significant difference between severity groups (mild/moderate disease: 17.4%, severe/very severe disease: 71.3%, critical disease: 94.9%, P < 0.001).Increased age, dementia, and severe/very severe and critical disease groups were independently associated with increased odds for mortality while diarrhea was associated with decreased odds for mortality (OR: 0.12, 95% CI: 0.02-0.60, P < 0.05). None of the cardiovascular comorbidities were significantly associated with mortality.

CONCLUSION

Age and dementia are associated with increased odds for mortality in patients ≥75 years of age hospitalized with COVID-19. Those who require intubation have the greatest odds for mortality. Diarrhea as a presenting symptom was associated with lower odds for mortality.

147 A Meta-Analysis Comparing the Diagnostic Accuracy of Initial RT-PCR And CT Scan in Suspected COVID-19 Patients

Introduction

Reverse transcriptase Polymerase chain reaction(RT-PCR) is considered as the gold standard diagnostic test for COVID-19 infection. It’s accuracy has been doubted and subsequently had effects on planning, performing operations causing. Research has suggested the use of Computed Tomography Scan instead. In this study we performed a meta-analysis comparing the diagnostic accuracy of CT compared to RTPCR.

Method

Our systematic review and meta-analysis were undertaken as per PRISMA guidelines. The methodological quality of each included study was assessed using the QUADAS-2 tool on RevMan 5.3. We performed data analyses using Stata version 12.

Results

Sensitivity estimates for CT scan ranged from 0.69 to 1.00 and for RT-PCR varied ranging from 0.47 to 1.00. The pooled estimate of sensitivity for CT was 0.95 (95% CI – 0.88-0.98) and specificity was 0.31 (95% CI – 0.035-0.84). It was found that specificity of initial RT-PCR(100%) was higher than CT(31%). With respect to sensitivity, CT(95%) was superior to RT-PCR(91%) p (0.000)

Conclusions

Sensitivity of CT is significantly higher than RT-PCR for detecting COVID-19 infection, however as CT findings are not specific. Since CT scans are readily available, protocols can be developed to utilise it to minimalize delay in planning surgery.

Fluorescein diacetate and rapid molecular testing for the early identification of rifampicin resistance in Mali

BACKGROUND: Non-conversion on auramine smear microscopy indicates a lack of treatment response, possibly associated with initial rifampicin-resistant tuberculosis (RR-TB). However, dead bacteria still stain positive and may be detected. Fluorescein diacetate smear microscopy (FDA) shows live mycobacteria only. Therefore, we studied the potential of 2-month (2M) FDA for the identification of initial RR-TB.METHODS: Between 2015 and 2018, we enrolled new smear-positive pulmonary TB patients from five local centres in Bamako, Mali. After baseline screening, sputum samples were collected at 1M, 2M, 5M and 18M. We used rpoB sequencing to identify initial RR-TB.RESULTS: Of 1359 patients enrolled, 1019 (75%) had rpoB sequencing results. Twenty-six (2.6%, 95%CI: 1.7-3.7) had mutations conferring rifampicin resistance. Most frequent rpoB mutations were located at the codons Asp435Val (42.4%) and Ser450Leu (34.7%). Among patients with initial RR-TB, 72.2% were FDA-negative at 2M (P = 0.2). The positive and negative predictive value of 5M FDA for culture-based failure was respectively 20.0% and 94.7%.CONCLUSION: FDA did not identify the majority of patients with initial RR-TB or culture-based failure. As the full spectrum of mutations identified on sequencing was identified using Xpert, our data support its rapid universal implementation in Mali.

Capture rates of comorbidity measures at inpatient rehabilitation facilities after a stroke or brain injury

BACKGROUND

Comorbidity indices have been used to represent the overall medical complexity of patient populations in clinical research; however, it is not known how well they capture the comorbidities of patients with a stroke or brain injury admitted to inpatient rehabilitation facilities (IRFs).

OBJECTIVE

To determine how well commonly used comorbidity indices capture the comorbidities of patients admitted to IRFs after a stroke or brain injury.

DESIGN

Cross-sectional, retrospective study.

SETTING

IRFs nationwide.

PARTICIPANTS

Adults from four impairment groups: (1) hemorrhagic stroke, (2) ischemic stroke, (3) nontraumatic brain injury (NTBI), and (4) traumatic brain injury (TBI).

MAIN OUTCOME MEASURES

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes were extracted from the Uniform Data System for Medical Rehabilitation (UDSMR) for IRF discharges from October 1, 2015 to December 31, 2017. The percentage of discharges captured by Deyo-Charlson, Elixhauser, and Centers for Medicare and Medicaid Services (CMS) tiers was determined, as was the percentage of comorbidities captured. These measures were also compared with respect to their ability to capture chronic medical complexity by examining the percentage of codes captured after removal of codes deemed to represent hospital complications or sequela of the admission diagnosis.

RESULTS

The percentage of discharges without at least one ICD-10-CM code captured by any index ranged from 0.3%-3.8%. The percentage of comorbidities with a prevalence exceeding 1% captured by at least one index ranged from 37.1%-43.6%. Chronic comorbidities were most likely to be captured by Elixhauser (40.7%-44.4%), followed by Deyo-Charlson (7.8%-9.6%), then CMS tiers (4.5%-6.9%). Existing comorbidity measures capture most IRF discharges related to a brain injury or stroke, whereas most medical comorbidities escape representation. Several common, functionally relevant diagnoses were not captured.

CONCLUSION

The use of comorbidity indices in the IRF neurologic injury population should account for the fact that these measures miss several common, important comorbidities.

Contemporary analysis of epididymal tumors using a national database

Introduction

Epididymal tumors are rare malignancies with sparse research available to guide recommendations. We sought to characterize malignant epididymal tumors in the United States using population level data.

Material and methods

The Surveillance, Epidemiology, and End-Results database was queried for patients diagnosed with malignant epididymal tumors between 1975–2016. International classification of disease for oncology code C63.0 was used to identify population with disease of interest. Primary objective was to characterize patient demographics, disease characteristics, and management. Secondary objectives included overall and cancer-specific survival (CSS) utilizing Kaplan-Meier (KM) analysis.

Results

A total of 66 cases of malignant epididymal tumors were identified during the study period. The cohort was largely white (84.8%), with a mean age of diagnosis of 46.9 years old. The predominant histology consisted of rhabdomyosarcoma 26%, leiomyosarcoma 23%, liposarcoma 17%, adenocarcinoma 9%, and malignant fibrous histiocytoma 5%. During histopathological assessment, 21.1% of tumors were classified as high-grade while 71.2% exhibited sarcomatoid elements. Majority of patients presented with localized disease (68.2%), whereas regional (18.2%) and distant (13.2%) disease was less frequently discovered. All patients were diagnosed by surgical therapy consisting of radical epididymectomy (39.4%), partial epididymectomy (27.3%) or ‘unknown surgery’ (33.3%). Meanwhile, 15.2% and 34.8% received radiation and chemotherapy, respectively. KM analysis revealed an 84.9% CSS at 5-years. Over 60% of documented cases have arisen since 2000, with 3.0% of the cohort diagnosed in 2016, increased from 1.5% of the diagnoses in 1975.

Conclusions

Malignant epididymal tumors are exceedingly rare and typically present with localized disease. Surgical excision is associated with an estimated 85% CSS at 5-years.

Developing a decision support tool to prevent community-acquired pressure injuries in spinal cord injury in ambulatory care: A nurse-led protocol for mix methods research

BACKGROUND

There is a lack of formal guidelines and decision support tools to prevent community-acquired pressure injuries (CAPrIs) in Veterans with spinal cord injury (SCI).

PURPOSE

In this article we present our research protocol that describes our plans to create and test a decision support tool to prevent CAPrIs in SCI.

METHODS

In Aim 1, we identified mental-models of CAPrI prevention from the perspectives of Veterans (using photovoice, guided tours), and Veterans Health Administration SCI providers (using interviews), and triangulation to compare the two mental-models. This led to a decision support tool developed and validated using Delphi approaches in Aim 2 and will be followed by tool automation and system redesign for pilot implementation in Aim 3.

FINDINGS

The nurse-led research protocol provides a map to systematically explore, address and translate research into evidence-based practice.

DISCUSSION

Refinement of the protocol will guide future research and implementation.

Infectious complications associated with perioperative blood transfusion in partial or radical nephrectomy

INTRODUCTION/BACKGROUND

Perioperative allogeneic blood transfusion (PBT) is associated with increased infectious risk for many surgical procedures, although this has not been thoroughly explored for extirpative renal surgery. Underlying mechanisms may be related to an alteration of the patient immune response. We aimed to assess the infectious complications associated with PBT after radical or partial nephrectomy.

METHODS/MATERIALS

The Nationwide Inpatient Sample (1996-2015) was queried for patients undergoing radical or partial nephrectomy. We assessed rates of infectious complications in patients who did and did not receive PBT. Infections were index complications and included sepsis, abscess, pneumonia, urinary tract infection, and wound infection. Multivariable logistic regression was used to examine the risk of infectious complications accounting for age, gender, race, insurance, income, surgery type and approach, length of stay, comorbidity, and PBT.

RESULTS

We identified 140,183 patients undergoing partial or radical nephrectomy during the study period with 17,874 (12.7%) receiving PBT. The rate of PBT was stable throughout the study period (Cochran-Armitage, P= 0.97). Patients receiving PBT compared to those without were relatively older (proportion of age >70, 42.6% vs. 30.5%), non-white (25.4% vs. 21.1%), who underwent radical nephrectomy (84.3% vs. 77.4%), and with longer hospital stay (9.1 vs. 5.1 days; all P< 0.001). On multivariable analysis, PBT was associated with higher odds of any infectious complication (OR 1.56, 95% CI 1.5-1.68, P< 0.001). During the study period, the risk of infectious complications was persistently increased in those receiving PBT.

CONCLUSION

PBT is independently associated with an increased risk of postoperative infections for patients undergoing partial or radical nephrectomy. This may be due to underlying transfusion-related immunomodulatory mechanisms. While PBT is necessary in many instances to promote patient survival, providers should remain cautious when providing PBT after extirpative renal surgery.

Robustness of the EWMA Sampling Plan to Non-Normality

The effect of non-normality on the OC function of the sampling plan under EWMA is studied by deriving the OC function for a non-normal population represented by the first four terms of an Edgeworth series.

Trends in utilization of neoadjuvant and adjuvant chemotherapy for muscle invasive bladder cancer

Purpose

Previous studies have noted increased utilization of perioperative chemotherapy over time. The goal of this study was to determine trends in perioperative chemotherapy use within a contemporary population.

Materials and Methods

The National Cancer Database was queried for patients diagnosed with cT2-4N0M0 urothelial muscle invasive bladder cancer from 2011 to 2015 and underwent subsequent radical cystectomy. We retrospectively analyzed factors associated with perioperative chemotherapy and evaluated overall treatment trends in the use of neoadjuvant and adjuvant chemotherapy. Linear regression, logistic regression, Cox regression, and Kaplan–Meier analysis were performed.

Results

In total, 7,101 patients met inclusion criteria for analysis. The use of perioperative chemotherapy increased from 46.4% in 2011 to 57.2% in 2015 (p=0.003). Neoadjuvant chemotherapy use increased from 22.9% to 32.3% (p=0.007) over the time period analyzed, while adjuvant chemotherapy use experienced no significant change (23.5% to 24.9%, p=0.182). Logistic regression demonstrated that increased age and Charlson Comorbidity Index were predictors of not receiving chemotherapy (p<0.05), while those with increasing T stage, income above $48,000, and insurance other than Medicaid or Medicare were more likely to receive perioperative chemotherapy (p<0.05). Kaplan–Meier analysis revealed patients receiving neoadjuvant chemotherapy had the best 5-year overall survival at 48.3% compared to adjuvant chemotherapy (42.6%) or no chemotherapy (37.8%) (p<0.001).

Conclusions

The increasing use of perioperative chemotherapy noted in prior studies has continued through 2015. Neoadjuvant chemotherapy appears to drive this increase while adjuvant chemotherapy utilization remains unchanged. Clinical and socioeconomic factors affect utilization of perioperative chemotherapy.

Outcomes in patients with severe COVID-19 disease treated with tocilizumab: a case-controlled study

BACKGROUND

COVID-19 is an ongoing threat to society. Patients who develop the most severe forms of the disease have high mortality. The interleukin-6 inhibitor tocilizumab has the potential to improve outcomes in these patients by preventing the development of cytokine release storm.

AIMS

To evaluate the outcomes of patients with severe COVID-19 disease treated with the interleukin-6 inhibitor tocilizumab.

METHODS

We conducted a retrospective, case-control, single-center study in patients with severe to critical COVID-19 disease treated with tocilizumab. Disease severity was defined based on the amount of oxygen supplementation required. The primary endpoint was the overall mortality. Secondary endpoints were mortality in non-intubated patients and mortality in intubated patients.

RESULTS

A total of 193 patients were included in the study. Ninety-six patients received tocilizumab, while 97 served as the control group. The mean age was 60 years. Patients over 65 years represented 43% of the population. More patients in the tocilizumab group reported fever, cough and shortness of breath (83%, 80% and 96% vs. 73%, 69% and 71%, respectively). There was a non-statistically significant lower mortality in the treatment group (52% vs. 62.1%, P = 0.09). When excluding intubated patients, there was statistically significant lower mortality in patients treated with tocilizumab (6% vs. 27%, P = 0.024). Bacteremia was more common in the control group (24% vs. 13%, P = 0.43), while fungemia was similar for both (3% vs. 4%, P = 0.72).

CONCLUSION

Our study showed a non-statistically significant lower mortality in patients with severe to critical COVID-19 disease who received tocilizumab. When intubated patients were excluded, the use of tocilizumab was associated with lower mortality.

Assessing the Ability of Comorbidity Indexes to Capture Comorbid Disease in the Inpatient Rehabilitation Spinal Cord Injury Population

OBJECTIVE

To examine whether commonly used comorbidity indexes (Deyo-Charlson comorbidity index, Elixhauser comorbidity index, the Centers for Medicare and Medicaid Services [CMS] comorbidity tiers) capture comorbidities in the acute traumatic and nontraumatic SCI inpatient rehabilitation population.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

Data were obtained from the Uniform Data System for Medical Rehabilitation from October 1, 2015 to December 31, 2017 for adults with spinal cord injury (SCI) (Medicare-established Impairment Group Codes 04.110-04.230, 14.1, 14.3). This study included SCI discharges (N=66,235) from 833 inpatient rehabilitation facilities.

MAIN OUTCOME MEASURES

International Classification of Diseases-10th Revision-Clinical Modifications (ICD-10-CM) codes were used to assess 3 comorbidity indexes (Deyo-Charlson comorbidity index, Elixhauser comorbidity index, CMS comorbidity tiers). The comorbidity codes that occurred with >1% frequency were reported. The percentages of discharges for which no comorbidities were captured by each comorbidity index were calculated.

RESULTS

Of the total study population, 39,285 (59.3%) were men and 11,476 (17.3%) were tetraplegic. The mean number of comorbidities was 14.7. There were 13,939 distinct ICD-10-CM comorbidity codes. There were 237 comorbidities that occurred with >1% frequency. The Deyo-Charlson comorbidity index, Elixhauser comorbidity index, and the CMS tiers did not capture comorbidities of 58.4% (95% confidence interval, 58.08%-58.84%), 29.4% (29.07%-29.76%), and 66.1% (65.73%-66.46%) of the discharges in our study, respectively, and 28.8% (28.42%-29.11%) of the discharges did not have any comorbidities captured by any of the comorbidity indexes.

CONCLUSION

Commonly used comorbidity indexes do not reflect the extent of comorbid disease in the SCI rehabilitation population. This work suggests that alternative measures may be needed to capture the complexity of this population.

Trends in treatment of cT1 penile cancer: Analysis of the National Cancer Database

OBJECTIVE

To characterize the treatment trends and outcomes in clinical stage T1 penile cancer using the National Cancer Database (NCDB).

METHODS

The National Cancer Database was queried for all men with cT1 penile cancer from 2004 to 2015. Patients were categorized as cT1a or cT1b. Treatment was categorized as no treatment, local therapy (including penile sparing therapies), partial penectomy, or radical penectomy. Trends in treatment were analyzed over time and in correlation with stage and demographic variables. Stage and treatment type were evaluated in respect to pathological outcomes and survival.

RESULTS

A total of 2,484 men were identified with cT1 penile cancer, 90.1% of which had cT1a disease. The most common treatments were local therapy for cT1a and partial penectomy for cT1b. Over the time period studied, use of local therapy decreased while use of partial or radical penectomy increased. Patients treated at low volume facilities were more likely to undergo no treatment (8.0% vs. 6.5% in high volume) or local therapy (49.9% vs. 41.5% in high volume, P < 0.001). Local therapy was associated with increased risk of positive margin (odds ratio 4.7, P < 0.001) and positive margin was associated with a trend toward decreased overall survival (P = 0.07).

CONCLUSIONS

In the past decade, there has been decreased use of local therapy and increased use of partial or radical penectomy in cT1 penile cancer. Men treated at low volume facilities are more likely to be treated with local therapy which is associated with increased rates of positive margins and may also be associated with a trend toward decreased overall survival. Centralization of care in T1 penile cancer may lead to improved outcomes.

Diabetes Mellitus among new tuberculosis patients in Bamako, Mali

Introduction

Diabetes Mellitus (DM) increases worldwide, mostly in low- and middle-income countries. In Mali, the prevalence in the adult population is estimated at 1.8%, but tuberculosis (TB) patients are not systematically screened. The goal of our study was to determine the prevalence of DM among newly diagnosed TB patients.

Methods

We conducted a cross sectional study and a pilot prospective cohort study in four health centers in Bamako. All patients underwent fasting capillary-blood glucose (FCBG) test at Day 0, and repeated after one-week of TB treatment. Venous FBG test was performed for discrepancies between the two FCBG results. Thereafter, FCBG was performed for pilot study at month-2 (M2) and M5 of TB treatment.

Results

Two hundred and one patients were enrolled in this study. Impaired fasting blood glucose was identified in 17 (8.5%), of whom 11 (5.5%) had DM (VFBG >7 mmol/L). Among patients with DM, seven (63.6%) had successful TB treatment outcome, versus 142 (74.7%) of those without DM (p = 0.64), and (OR: 1.69, 95%CI 0.47–6.02).

Conclusion

The prevalence of DM among TB patients in Bamako exceeds that of the general population and screening at TB diagnosis suffices to identify those with DM. Systematic screening of both diseases will allow better treatment.

Chemotherapy increases survival and downstaging of upper tract urothelial cancer

INTRODUCTION

To evaluate the overall survival and pathologic downstaging effect of neoadjuvant chemotherapy for upper tract urothelial cell carcinoma.

MATERIALS AND METHODS

The National Cancer Database (NCDB) was queried for patients with stage II-IV upper tract urothelial cell carcinoma undergoing definitive surgical resection (nephroureterectomy) from 2004-2015. Patients with metastatic disease were excluded. Cohorts were stratified by receipt of neoadjuvant chemotherapy (NAC). Kaplan-Meier analysis and Cox regression were used to evaluate overall survival. Logistic regression was used to predict the odds of pathologic downstaging to non-invasive disease (< pT2). Propensity score matched analysis was performed between groups.

RESULTS

A total of 3634 patients were identified with non-metastatic stage II-IV disease undergoing surgical resection; 3364 received no chemotherapy and 270 received NAC. Patients undergoing NAC had a 10.9% rate of downstaging to non-invasive disease (OR 6.35, p < 0.001). Moreover, on Kaplan-Meier analysis, median survival was 27.3 months and 44.8 months for no chemotherapy versus NAC, respectively (log-rank, p = 0.001). Cox regression for death also revealed benefits for receiving NAC (HR 0.67, p < 0.001). Findings were confirmed on propensity score matching (532 matched patients). After matching, Cox regression for death noted improvement with neoadjuvant as compared to no chemotherapy (HR 0.61, p < 0.001).

CONCLUSION

Neoadjuvant chemotherapy increases likelihood of downstaging to non-invasive disease in patients with upper tract urothelial cell carcinoma. Chemotherapy also provides an overall survival benefit in patients undergoing nephroureterectomy.

Improving childhood tuberculosis detection and treatment through facility-based screening in rural Pakistan

SETTING

Many children with tuberculosis (TB) remain undiagnosed due to the absence of services, lack of child-friendly diagnostics and underappreciation of TB as a common cause of childhood illness.

OBJECTIVE

To show the impact of systematic verbal screening and contact tracing with appropriate management services on TB case finding in pediatric populations.

DESIGN

Between October 2014 and March 2016, children were verbally screened at the pediatric out-patient departments of four public hospitals in Jamshoro District, Pakistan. Children with symptoms or risk of TB were referred for clinical evaluation and free chest X-ray and bacteriological tests. Children with TB were started on treatment and their care givers asked to bring household members to the hospital for screening.

RESULTS

Over 105 000 children were verbally screened and 5880 presumptive childhood TB patients were identified; 1417 children (prevalence 1.3%) were diagnosed with TB; 43% were female. The median age was 5 years; 82% had pulmonary TB. An additional 390 children with TB were diagnosed through contact tracing. These activities resulted in a three-fold increase in pediatric TB case notifications.

CONCLUSION

Systematic verbal screening with clinical evaluation and free diagnostics can identify children with TB who may otherwise be missed in rural health settings.