Determinants of pressure injury development in patients with COVID-19

OBJECTIVE

Pressure injuries (PIs) often develop in critically ill patients due to immobility, and underlying comorbidities that decrease tissue perfusion and wound healing capacity. This study sought to provide epidemiological data on determinants and current managements practices of PI in patients with COVID-19.

METHOD

A US national insurance-based database consisting of patients with coronavirus or COVID-19 diagnoses was used for data collection. Patients were filtered by International Classification of Diseases (ICD) codes corresponding to coronavirus or COVID-19 diagnosis between 2019-2020. Diagnosis of PI following COVID-19 diagnosis was queried. Demographic data and comorbidity information was compared. Logistic regression analysis was used to determine predictors for both PI development and likelihood of operative debridement.

RESULTS

A total of 1,477,851 patients with COVID-19 were identified. Of these, 15,613 (1.06%) subsequently developed a PI, and 8074 (51.7%) of these patients had an intensive care unit (ICU) admission. The average and median time between diagnosis of COVID-19 and PI was 39.4 and 26 days, respectively. PI was more likely to occur in patients with COVID-19 with: diabetes (odds ratio (OR): 1.39, 95% confidence interval (CI): 1.29-1.49; p<0.001); coronary artery disease (OR: 1.11, 95% CI: 1.04-1.18, p=0.002), hypertension (OR: 1.43, 95% CI: 1.26-1.64; p<0.001); chronic kidney disease (OR: 1.18, 95% CI: 1.10-1.26; p<0.001); depression (OR: 1.45, 95% CI 1.36-1.54; p<0.001); and long-term non-steroidal anti-inflammatory drug use (OR: 1.21, 95% CI: 1.05-1.40; p=0.007). They were also more likely in critically ill patients admitted to the ICU (OR: 1.40, 95% CI: 1.31-1.48; p<0.001); and patients requiring vasopressors (OR:1.25, 95% CI: 1.13-1.38; p<0.001), intubation (OR: 1.21, 95% CI 1.07-1.39; p=0.004), or with a diagnosis of sepsis (OR: 2.38, 95% CI 2.22-2.55; p<0.001). ICU admission, sepsis, buttock and lower back PI along with increasing Charlson Comorbidity Index (CCI) (OR: 1.04, 95% CI 1.00-1.08; p=0.043) was associated with surgical debridement. The vast majority of patients with COVID-19 did not undergo operative debridement or wound coverage.

CONCLUSION

PIs are widely prevalent in patients with COVID-19, especially in those who are critically ill, yet the vast majority do not undergo operative procedures.

DECLARATION OF INTEREST

The authors have no conflicts of interest to declare.

Gender-Affirming Surgery Improves Mental Health Outcomes and Decreases Anti-Depressant Use in Patients with Gender Dysphoria

BACKGROUND

Patients with gender dysphoria face significant health disparities and barriers to care. Transition-related care includes hormonal therapy, mental healthcare, and gender-affirming surgeries. Studies have described favorable surgical outcomes and patient satisfaction, however, the degree to which these procedures impact mental health conditions is not fully understood. The purpose of this study was to evaluate the effect of gender-affirming plastic surgery on mental health and substance abuse in the transgender population.

METHODS

A national insurance claims-based database was used for data collection. Patients with a diagnosis of gender dysphoria were propensity score-matched for the likelihood of undergoing gender-affirming surgery (no surgery being the control cohort), based on comorbidities, age, and sex. Primary outcomes included post-operative antidepressant use and the prevalence of mental health conditions.

RESULTS

A total of 3,134 patients with gender dysphoria were included in each cohort. Patients in the surgery group had overall lower rates of mental health conditions, substance abuse, and SSRI/SNRI use. There was an absolute decrease of 8.8% in SSRI or SNRI prescription after gender-affirming plastic surgery (p<0.001), and significant decreases in post-operative depression (7.7%), anxiety (1.6%), suicidal ideation (5.2%) and attempts (2.3%), alcohol abuse (2.1%), and drug abuse (1.9%).

CONCLUSION

Gender-affirming surgery in appropriately selected gender dysphoric patients is associated with decreased postoperative rates of SSRI or SNRI use and improved mental health.

Oncoplastic breast reduction surgery decreases rates of reoperation with no increased medical risk

The purpose of this study is to compare the oncologic, medical, and surgical outcomes of lumpectomy versus oncoplastic breast reduction surgery (OBRS) on a national scale. A national insurance-based database was queried for patients who had a lumpectomy with or without a same-day breast reduction by Current Procedural Terminology (CPT) codes. Patients were then matched by obesity, body mass index range, age, region, neoadjuvant chemotherapy, and outcomes were compared. There were 421,455 patients in the lumpectomy group and 15,909 patients in the OBRS group. After matching, 15,134 patients were identified in each group. Repeat lumpectomy or subsequent mastectomy was more common in the lumpectomy group (15.2% vs. 12.2%, p < 0.001). OBRS patients had higher rates of 90-day surgical complications including dehiscence, infection, fat necrosis, breast abscesses, and antibiotic prescription (p < 0.001). Meanwhile, any medical complication was less common in the OBRS group (3.7% vs. 4.5%, p = 0.001). Logistic regression revealed that OBRS was associated with decreased odds of repeat lumpectomy (OR = 0.71, 95% CI 0.66-0.77, p < 0.001) with no significant increased odds of subsequent mastectomy (OR = 1.01, 95% CI 0.91-1.11, p = 0.914). OBRS was found to be associated with decreased risk for reoperation in the form of lumpectomy without increased likelihood of subsequent mastectomy. Although OBRS was associated with increased wound complications, medical complications were found to occur less frequently. This study endorses increased consideration of OBRS when lumpectomy or OBRS is appropriate.

Addition of sodium bicarbonate to rations of postpartum dairy cows: physiological and metabolic effects

Sodium bicarbonate was added to complete mixed rations to characterize physiological, metabolic, and ruminal changes immediately postpartum when dairy cows are switched abruptly from a low energy ration prepartum to a high energy ration postpartum. Twelve Holstein cows were paired and assigned randomly to either a control or buffered ration containing .8% sodium bicarbonate. Rations consisted of 50% corn silage:50% concentrate. All All cows were fed a similar dry cow ration for a minimum of 7 days prepartum and experimental rations for 2 wk beginning at parturition. Blood, feces, and urine were sampled on days 1, 2, 4, 7, 10, and 14 postpartum. Rumen fluid was sampled on days 7 and 14. Dry matter intake and milk production were 2.75% of body weight and 30.3 kg/day for cows fed buffer and 2.49% and 27.6 kg/day for cows fed control. Higher partial pressure of carbon dioxide and base excess in blood in cows fed buffer existed on days 2 and 4 postpartum than for cows fed the control ration. Cows fed buffer had higher concentrations of ruminal ammonia than cows fed control. This difference was less pronounced in blood urea nitrogen and urinary ammonia. Urine pH was higher for cows fed buffer than for control. Addition of sodium bicarbonate improved the acid-base status after abrupt change of ration and may be associated with increased dry matter intake and improved ration adaptation. Concentrations of most minerals and metabolites in blood serum did not differ between rations.

Acid insoluble ash as a marker of digestibility for sheep fed corn plants or hay and for lactating dairy cattle fed hay

Research has shown acid insoluble ash (AIA) in feeds to be an acceptable natural marker for the determination of dry matter digestibility in sheep and steers fed diets of hay plus grain. However, in previous studies, animals were fed diets designed to ensure little or no orts. The purpose of this study was to determine the adequacy of AIA as an indicator of dry matter digestibility when sheep or dairy cows were fed ad libitum. Fecal, feed and ort samples from wethers and lactating Holstein cows from previous digestibility studies were used to determine the usefulness of AIA as an indicator of digestibility. Thirty-two wethers were fed whole corn plants or corn stover frozen and stored fresh or ensiled. Diets were fed ad libitum to ensure between 5 and 10% orts. In a second study, seven wethers and 10 lactating cows fed fed ad libitum alfalfa or orchard grass hay diets with 23% grain to ensure at least 10% orts. Correlation coefficients for digestibility determined by total collection versus AIA for wethers fed corn plants, cows fed hay diets and wethers fed hay diets were .96, .95 and .40, respectively. The low correlation for wethers fed hay was apparently due to a high quantity of orts with a variable AIA content. The range of total recovery of AIA from all animals was of total recovery of AIA from all animals was 98 to 102% when ort AIA was taken into account, and 91 to 121% when ort AIA was not taken into account. The use of AIA as a natural marker for the estimation of digestibility when diets are fed ad libitum has potential, provided that a sufficient number of animals is used and diets are adequately mixed to limit feed selection and sorting, or intake is determined and feed and orts are sampled.

Addition of sodium bicarbonate to rations of pre- and postpartum dairy cows

Sodium bicarbonate was added to complete mixed rations to evaluate the effect of buffer addition on adaptation to high-energy rations by dairy cows in elderly lactation. Forty-five Holstein cows were assigned to one of three treatment groups: control pre- and postpartum; control prepartum, buffer postpartum; and buffer pre- and postpartum. Rations consisted of 85% chopped grass hay: 15% concentrate prepartum and 60% corn silage:40% concentrate postpartum. On day 4 postpartum, cows were switched abruptly to the postpartum ration for 9 wk. Buffered rations contained .6% sodium bicarbonate prepartum and .7% postpartum. Daily dry matter intake as a percent of body weight for cows fed buffer postpartum (3.51%) was greater than for cows fed no buffer (3.04%) of buffer pre- and postpartum (3.14%). Average production of 4% fat-corrected milk was greater for cows fed buffer postpartum and buffer pre- and postpartum (31.9 kg/day and 31.7 kg/day) than for cows fed no buffer (28.9 kg/day). Milk fat tests were not different. Cows fed the buffered rations lost body weight between wk 1 and 9 as compared to a net gain for cows fed no buffer. Cows fed buffers consumed more dry matter during wk 1 than did cows fed no buffer. Samples of rumen fluid, feces, and serum showed few differences that could be attributed to treatments. Compared to controls, cows fed sodium bicarbonate adapted to rations more rapidly postpartum as indicated by increased feed intake during the first 2 wk and by increased milk production during the first 4 wk of the trial.