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Acta Orthopaedica Jul 2023Premature physeal closure (PPC) is a common and concerning complication to distal femoral fractures as the distal growth plate accounts for 70% of the growth of the...
BACKGROUND AND PURPOSE
Premature physeal closure (PPC) is a common and concerning complication to distal femoral fractures as the distal growth plate accounts for 70% of the growth of the femur. The literature is not unanimous in determining the risk factors of PPC, and the epidemiological characterization of these fractures is limited. Our aim was to calculate the population-based incidence and investigate risk factors for PPC in these fractures.
PATIENTS AND METHODS
In this register-based study, between 2014 and 2021, 70 children with distal femoral physeal fractures presented to our hospital. Demographic data, and fracture- and treatment-related details were collected using the Kids' Fracture Tool. A directed acyclic graph (DAG) was constructed to determine confounding factors used in the risk analysis.
RESULTS
Physeal fractures of the distal femur occurred with an annual incidence of 6/105 children, and a resulting PPC occurred in 16/70 (23%) with an annual incidence of 1.3/105 children. In multivariable analysis, dislocation exceeding 10 mm was a risk factor for PPC (OR 6.3, CI 1.4-22).
CONCLUSION
One-fourth of distal femoral physeal fractures developed PPC. Greater dislocation and higher injury energy were significant risk factors, whereas choice of fracture treatment was not an independent risk factor. All patients with PPC belonged in the age group 11-16 years.
Topics: Child; Humans; Adolescent; Growth Plate; Femoral Fractures, Distal; Tibial Fractures; Epiphyses; Risk Factors; Femur; Retrospective Studies; Femoral Fractures; Salter-Harris Fractures
PubMed: 37449728
DOI: 10.2340/17453674.2023.13654 -
Revista Paulista de Pediatria : Orgao... 2023To describe the incidence and to analyze risk factors associated with cholestasis in neonates with gastroschisis.
OBJECTIVE
To describe the incidence and to analyze risk factors associated with cholestasis in neonates with gastroschisis.
METHODS
This is a retrospective cohort study in a tertiary single center analyzing 181 newborns with gastroschisis between 2009 and 2020. The following risk factors associated with cholestasis were analyzed: gestational age, birth weight, type of gastroschisis, silo closure or immediate closure, days of parenteral nutrition, type of lipid emulsion, days of fasting, days to reach a full diet, days with central venous catheter, presence of infections, and outcomes.
RESULTS
Among the 176 patients evaluated, 41 (23.3%) evolved with cholestasis. In the univariate analysis, low birth weight (p=0.023), prematurity (p<0.001), lipid emulsion with medium-chain triglycerides and long-chain triglycerides (p=0.001) and death (p<0.001) were associated with cholestasis. In the multivariate analysis, patients who received lipid emulsion with fish oil instead of medium chain triglycerides/long chain triglycerides (MCT/LCT) emulsion had a lower risk of cholestasis.
CONCLUSIONS
Our study shows that lipid emulsion with fish oil is associated with a lower risk of cholestasis in neonates with gastroschisis. However, this is a retrospective study and a prospective study should be performed to confirm the results.
Topics: Humans; Infant, Newborn; Birth Weight; Retrospective Studies; Emulsions; Gastroschisis; Prospective Studies; Soybean Oil; Fish Oils; Cholestasis; Triglycerides
PubMed: 37436246
DOI: 10.1590/1984-0462/2024/42/2022152 -
Best Practice & Research. Clinical... Aug 2023The increase in caesarean sections (CS) has resulted in an increase in women with a uterine niche. The exact aetiology of niche development has yet to be elucidated but... (Review)
Review
The increase in caesarean sections (CS) has resulted in an increase in women with a uterine niche. The exact aetiology of niche development has yet to be elucidated but is likely multifactorial. This study aimed to give a systematic overview of the available literature on histopathological features, risk factors and results of preventive strategies on niche development to gain more insight into the underlying mechanisms. Based on current published data histopathological findings associated with niche development were necrosis, fibrosis, inflammation, adenomyosis and insufficient approximation. Patient-related risk factors included multiple CS, BMI and smoking. Labour-related factors were CS before onset of labour, extended cervical dilatation, premature rupture of membranes and presenting part of the fetus at CS below the pelvic inlet. Preventive strategies should focus on the optimal level of incision, training of surgeons and full-thickness closure of the myometrium (single or double-layer) using non-locking sutures. Conflicting data exist concerning the effect of endometrial inclusion. Future studies without heterogeneity in population, using standardized performance of the CS after proper training and using standardized niche evaluation with a relevant core outcome set are required to allow meta-analyses and to develop evidence-based preventive strategies. These studies are needed to reduce the prevalence of niches and prevent complications in subsequent pregnancies such as caesarean scar pregnancies.
Topics: Pregnancy; Female; Humans; Cicatrix; Uterus; Cesarean Section; Myometrium; Risk Factors
PubMed: 37385157
DOI: 10.1016/j.bpobgyn.2023.102363 -
Economic Analysis and Policy Sep 2023This paper examines the effectiveness of four major COVID-19 social distancing policies, (i) shelter-in-place orders (SIPO), (ii) non-essential business closures, (iii)...
This paper examines the effectiveness of four major COVID-19 social distancing policies, (i) shelter-in-place orders (SIPO), (ii) non-essential business closures, (iii) mandatory quarantine for travelers, and (iv) bans on large gatherings, on both COVID cases and COVID deaths. Results indicate that states are highly ineffective in producing the fraction of the population that does not have COVID-19 or the fraction of the population that does not die from COVID-19. We find that having any form of social distancing policies increases the fraction of the population not considered a positive COVID-19 case by 23.5 percentage points. Results also show that having any of the four major social distancing policies reduces the fraction of the population who has died of COVID-19 by 1.3 percentage points between March 1, 2020 and September 1, 2020; during the first 100 days, effectiveness would improve by 2.1 percentage points. Evidence suggests that there is no effective uniform national COVID-19 social distancing policy. Furthermore, conditional efficiency regressions after 100 days suggest that behavioral noncompliance and premature expiration of social distancing policies both negatively impact effectiveness. Partial regression plots suggest that bans on large gatherings and the closure of non-essential businesses were the two most impactful COVID-19 social distancing policies.
PubMed: 37363405
DOI: 10.1016/j.eap.2023.06.026 -
PharmacoEconomics Aug 2023Atrial fibrillation (AF) remains the most common form of cardiac arrhythmia. Management of AF aims to reduce the risk of stroke, heart failure and premature mortality...
BACKGROUND
Atrial fibrillation (AF) remains the most common form of cardiac arrhythmia. Management of AF aims to reduce the risk of stroke, heart failure and premature mortality via rate or rhythm control. This study aimed to review the literature on the cost effectiveness of treatment strategies to manage AF among adults living in low-, middle- and high-income countries.
METHODS
We searched MEDLINE (OvidSp), Embase, Web of Science, Cochrane Library, EconLit and Google Scholar for relevant studies between September 2022 and November 2022. The search strategy involved medical subject headings or related text words. Data management and selection was performed using EndNote library. The titles and abstracts were screened followed by eligibility assessment of full texts. Selection, assessment of the risk of bias within the studies, and data extraction were conducted by two independent reviewers. The cost-effectiveness results were synthesised narratively. The analysis was performed using Microsoft Excel 365. The incremental cost effectiveness ratio for each study was adjusted to 2021 USD values.
RESULTS
Fifty studies were included in the analysis after selection and risk of bias assessment. In high-income countries, apixaban was predominantly cost effective for stroke prevention in patients at low and moderate risk of stroke, while left atrial appendage closure (LAAC) was cost effective in patients at high risk of stroke. Propranolol was the cost-effective choice for rate control, while catheter ablation and the convergent procedure were cost-effective strategies in patients with paroxysmal and persistent AF, respectively. Among the anti-arrhythmic drugs, sotalol was the cost-effective strategy for rhythm control. In middle-income countries, apixaban was the cost-effective choice for stroke prevention in patients at low and moderate risk of stroke while high-dose edoxaban was cost effective in patients at high risk of stroke. Radiofrequency catheter ablation was the cost-effective option in rhythm control. No data were available for low-income countries.
CONCLUSION
This systematic review has shown that there are several cost-effective strategies to manage AF in different resource settings. However, the decision to use any strategy should be guided by objective clinical and economic evidence supported by sound clinical judgement.
REGISTRATION
CRD42022360590.
Topics: Adult; Humans; Atrial Fibrillation; Cost-Effectiveness Analysis; Developed Countries; Cost-Benefit Analysis; Stroke
PubMed: 37204698
DOI: 10.1007/s40273-023-01276-5 -
Journal of Perinatology : Official... Oct 2023Patent ductus arteriosus (PDA) is the most common cardiovascular condition diagnosed in premature infants. Acetaminophen was first proposed as a potential treatment for... (Review)
Review
Patent ductus arteriosus (PDA) is the most common cardiovascular condition diagnosed in premature infants. Acetaminophen was first proposed as a potential treatment for PDA in 2011. Since that time acetaminophen use among extremely preterm neonates has increased substantially. The limited available data demonstrate that acetaminophen reduces PDA without evident hepatotoxicity. These findings have led some to suggest that acetaminophen is a safe and effective therapy for PDA closure. However, the lack of apparent hepatoxicity is predictable. Acetaminophen induced cellular injury is due to CYP2E1 derived metabolites; and hepatocyte CYP2E1 expression is low in the fetal and neonatal period. Here, we review preclinical and clinical data that support the hypothesis that the lung, which expresses high levels of CYP2E1 during fetal and early postnatal development, may be particularly susceptible to acetaminophen induced toxicity. Despite these emerging data, the true potential pulmonary risks and benefits of acetaminophen for PDA closure are largely unknown. The available clinical studies in are marked by significant weakness including low sample sizes and minimal evaluation of extremely preterm infants who are typically at highest risk of pulmonary morbidity. We propose that studies interrogating mechanisms linking developmentally regulated, cell-specific CYP2E1 expression and acetaminophen-induced toxicity as well as robust assessment of pulmonary outcomes in large trials that evaluate the safety and efficacy of acetaminophen in extremely preterm infants are needed.
Topics: Infant, Newborn; Humans; Ductus Arteriosus, Patent; Acetaminophen; Indomethacin; Infant, Low Birth Weight; Ibuprofen; Cytochrome P-450 CYP2E1; Infant, Extremely Premature
PubMed: 37169914
DOI: 10.1038/s41372-023-01697-2 -
The Journal of Maternal-fetal &... Dec 2023To identify risk factors, maternal and neonatal adverse outcomes related to unintended lower segment uterine extension during cesarean delivery (CD).
OBJECTIVE
To identify risk factors, maternal and neonatal adverse outcomes related to unintended lower segment uterine extension during cesarean delivery (CD).
METHODS
A retrospective cohort analysis in a single, university-affiliated medical center between 1 January 2018 and 31 December 2019. All singleton pregnancies delivered by CD were included. Univariate and multivariate analyses were performed to identify maternal and obstetrical predictors for uterine extension during CD. For secondary outcomes, we assessed the correlation between uterine extension and any adverse maternal or neonatal outcome. Risk factors were analyzed using ROC statistics to measure their prediction performance for a uterine extension.
RESULTS
Overall, 1746 (19.3%) CDs were performed during the study period. Of them, 121 (6.9%) CDs were complicated by unintended uterine extension. There was no difference in maternal demographics and clinical data stratified by uterine extension at CD. Uterine extensions were significantly more common following induction of labor, intrapartum fever, premature rupture of membranes, a trial of labor after cesarean, advanced gestational age, emergent CD, and in particular CD during the second stage of labor (37.2% vs. 6.5%) and after failed vacuum extraction (6.6% vs. 1.1%), < .05 for all. The incidence of postpartum hemorrhage and re-laparotomy did not differ between the groups. Most of the extensions were caudal-directed (40.4%), and were closed by a two-layer closure (92%). Mean extension size was 4.5 ± 1.7 cm. Using multivariable analysis, the only factor that remained significant was CD at the second stage of labor (adjusted odds ratio (aOR) 54.2, 95% CI 4.5-648.9, = .002), with an area under the ROC curve 0.653 (95% CI 0.595-0.712, < .001). Emergent CD, body mass index, birth weight, failed vacuum attempt, and trial of labor after cesarean were not significant. For secondary outcomes, an unintended uterine extension was associated with longer operation time, higher estimated blood loss, greater pre- to post-CD hemoglobin difference, increased blood products transfusion, puerperal fever, and longer hospital stay. No clinically significant neonatal adverse outcomes were observed.
CONCLUSIONS
In our cohort, second-stage CD was the strongest predictor for an unintended uterine extension. Following uterine extension, women had increased infectious and blood-loss morbidity.
Topics: Pregnancy; Infant, Newborn; Female; Humans; Retrospective Studies; Cesarean Section; Trial of Labor; Postpartum Hemorrhage; Risk Factors
PubMed: 37127602
DOI: 10.1080/14767058.2023.2204997 -
Current Problems in Cardiology Sep 2023This was a first-time evaluation that sought to analyze the cost-effectiveness of oral paracetamol and intravenous (IV) indomethacin as alternatives to ibuprofen for PDA...
This was a first-time evaluation that sought to analyze the cost-effectiveness of oral paracetamol and intravenous (IV) indomethacin as alternatives to ibuprofen for PDA in neonates. Decision-analytic, literature-based, economic simulation models were constructed, to follow up the use and consequences of oral/IV ibuprofen versus IV indomethacin, and oral/IV ibuprofen versus oral paracetamol, as first-line therapies for PDA closure. Model outcomes of interest were "success", defined as PDA closure with/without adverse events, or "failure" due to no response to the first course of treatment, death or premature discontinuation of therapy due to adverse events. Oral ibuprofen is dominant/cost-effective over IV indomethacin in 97.9% of simulated cases, but oral paracetamol was 75.2% dominant/cost-effective over oral ibuprofen. Against IV ibuprofen, IV indomethacin was 55.3% dominant/cost-effective, whereas oral paracetamol was dominant/cost-effective in 98.5% of the cases. Sensitivity analyses confirmed the robustness of the study results. For PDA closure, while IV indomethacin was cost-effective against IV ibuprofen, oral paracetamol was cost-effective against both oral and IV ibuprofen.
Topics: Infant, Newborn; Humans; Indomethacin; Ibuprofen; Ductus Arteriosus, Patent; Acetaminophen; Infant, Premature; Cyclooxygenase Inhibitors; Infant, Low Birth Weight; Cost-Effectiveness Analysis
PubMed: 37088173
DOI: 10.1016/j.cpcardiol.2023.101751 -
Pediatrics and Neonatology Sep 2023Very preterm infants are at risk for neurodevelopmental impairment because of postnatal morbidities. This study aims to (1) compare the outcomes of very-low-birth-weight...
BACKGROUND
Very preterm infants are at risk for neurodevelopmental impairment because of postnatal morbidities. This study aims to (1) compare the outcomes of very-low-birth-weight (VLBW) infants in Singapore during two time periods over a decade; 2) compare performances among Singaporean neonatal intensive care units (NICUs); and 3) compare a Singapore national cohort with one from the Australian and New Zealand Neonatal Network (ANZNN).
METHODS
Singapore national data on VLBW infants born during two periods, 2007-2008 (SG2007, n = 286) and 2015-2017 (SG2017, n = 905) were extracted from patient medical records. The care practices and clinical outcomes among three Singapore NICUs were compared using SG2017 data. Third, using data from the ANZNN2017 annual report, infants with gestational age (GA) ≤29 weeks in SG2017 were compared with their Oceania counterparts.
RESULTS
SG2017 had 9.9% higher usage of antenatal steroids (p < 0.001), 8% better survival for infants ≤26 weeks (p = 0.174), and used 12.7% lesser nonsteroidal anti-inflammatory drugs for patent ductus arteriosus closure (p < 0.001) than those of SG2007 cohort. Rate of late-onset sepsis (LOS) was almost halved (7.4% vs. 14.0%, p < 0.001), and exclusive human milk feeding after discharge increased threefold (p < 0.001). SG2017, in contrast, had a higher rate of chronic lung disease (CLD) (20.0% vs. 15.1%, p = 0.098). Within SG2017, the rates of LOS, CLD, and human milk feeding varied significantly between the three NICUs. When compared with ANZNN2017, SG2017 had significantly lower rates of LOS for infants ≤25 weeks (p = 0.001), less necrotizing enterocolitis for infants ≤27 weeks (p = 0.002), and less CLD across all GA groups.
CONCLUSION
Postnatal morbidities and survival rates for VLBW infants in Singapore have improved over a decade. Outcomes for VLBW infants varied among three Singapore NICUs, which provide a rationale for collaboration to improve clinical quality. The outcomes of Singaporean VLBW infants were comparable to those of their ANZNN counterparts.
Topics: Infant, Newborn; Infant; Humans; Female; Pregnancy; Cohort Studies; Infant, Premature; Singapore; Australia; Infant, Very Low Birth Weight; Infant Mortality; Morbidity; Sepsis
PubMed: 36967293
DOI: 10.1016/j.pedneo.2022.12.016 -
Medical Education Online Dec 2023Most medical students entering clerkships have limited understanding of clinical reasoning concepts. The value of teaching theories of clinical reasoning and cognitive...
BACKGROUND
Most medical students entering clerkships have limited understanding of clinical reasoning concepts. The value of teaching theories of clinical reasoning and cognitive biases to first-year medical students is unknown. This study aimed to evaluate the value of explicitly teaching clinical reasoning theory and cognitive bias to first-year medical students.
METHODS
Using Kolb's experiential learning model, we introduced dual process theory, script theory, and cognitive biases in teaching clinical reasoning to first-year medical students at an academic medical center in New York City between January and June 2020. Due to the COVID-19 pandemic, instruction was transitioned to a distance learning format in March 2020. The curriculum included a series of written clinical reasoning examinations with facilitated small group discussions. Written self-assessments prompted each student to reflect on the experience, draw conclusions about their clinical reasoning, and plan for future encounters involving clinical reasoning. We evaluated the value of the curriculum using mixed-methods to analyze faculty assessments, student self-assessment questionnaires, and an end-of-curriculum anonymous questionnaire eliciting student feedback.
RESULTS
Among 318 total examinations of 106 students, 254 (80%) had a complete problem representation, while 199 (63%) of problem representations were considered concise. The most common cognitive biases described by students in their clinical reasoning were anchoring bias, availability bias, and premature closure. Four major themes emerged as valuable outcomes of the CREs as identified by students: (1) synthesis of medical knowledge; (2) enhanced ability to generate differential diagnoses; (3) development of self-efficacy related to clinical reasoning; (4) raised awareness of personal cognitive biases.
CONCLUSIONS
We found that explicitly teaching clinical reasoning theory and cognitive biases using an experiential learning model provides first-year medical students with valuable opportunities for developing knowledge, skills, and self-efficacy related to clinical reasoning.
Topics: Humans; Problem-Based Learning; Clinical Reasoning; Students, Medical; Pandemics; COVID-19; Curriculum; Bias; Cognition
PubMed: 36454201
DOI: 10.1080/10872981.2022.2153782