High Acuity Research Articles

Preserving the Midwifery Model of Care on a High Acuity Labor and Delivery Unit: Midwives' Perspectives Working in a US Tribal Health System.

Today nearly 9 out of 10 certified nurse-midwives/certified midwives (CNMs/CMs) attend births in hospitals. As the demand for hospital midwifery care has increased over the last quarter century, CNM/CMs' scope of practice has expanded to include care for high-risk patients. Hospital CNMs/CMs are faced with the challenge of balancing support for physiologic birth with an increasingly complex pregnant population cared for in a medicalized ecosystem. Varied perceptions of patient risk and unique philosophies of care can lead to complex discussions between midwives and physicians on the most appropriate care plan for patients. This article shares the experiences and successes of a hospital midwifery practice in the Alaska Native Tribal Health System and explores strategies for promoting the midwifery model of care (MMOC). Midwives in this Tribal Health System experience robust interprofessional collaboration and an organizational focus on patient-centered relationship-based care. Interprofessional collaboration is noted to be among the most critical elements for protecting a MMOC in a hospital setting. Although distinct from one another, the medical and midwifery models can be complementary in the care of high-risk patients, and the Indigenous concept of Two-Eyed Seeing is offered as an approach to integrating the 2 models of care to achieve optimal care for birthing people and their families.

Optimising risk stratification in diabetic ketoacidosis: a re-evaluation of acid-base status and hyperosmolarity using observational data.

Accurate assessment of severity in diabetic ketoacidosis (DKA) can optimise early management and facilitate prioritisation for high acuity care. The primary aim was to evaluate the relationship between severity of acidosis (considering pH, bicarbonate, and anion gap) and hyperosmolarity with hospital mortality. Secondary outcomes included intensive care mortality, mechanical ventilation, vasopressor/inotrope use, and dialysis. A retrospective cohort study was conducted of adults (≥ 16yr) with DKA admitted to US intensive care units. Data were extracted from the Medical Information Mart for Intensive Care (MIMIC)-IV dataset and eICU Collaborative Research Database. Univariable and multivariable logistic regression analyses were used to evaluate biochemistry obtained within 4h of admission and the primary and secondary outcomes. We identified 4071 eligible admissions. There was no clear relationship between serum bicarbonate or anion gap and any outcome. Almost half the population did not have blood gas analysis within 4h of admission; for 2292 patients with blood gases available, pH < 7 and inappropriately high PCO2 were associated with significant increases in mortality and all secondary outcomes. Osmolarity ≥ 320mosm/L was associated with fourfold increased mortality and higher rates of mechanical ventilation, use of vasopressors/inotropes, and dialysis. Failure of adaptive mechanisms (thirst and hyperventilation) indicating physiological decompensation may be more important for risk stratification in DKA than the degree of acidosis, which was only associated with outcome when severely abnormal. Blood gas analysis is essential to adequately assess disease severity as bicarbonate and anion gap were not predictive of outcome.

Multiple loci for foveolar vision in macaque monkey visual cortex.

In humans and nonhuman primates, the central 1° of vision is processed by the foveola, a retinal structure that comprises a high density of photoreceptors and is crucial for primate-specific high-acuity vision, color vision and gaze-directed visual attention. Here, we developed high-spatial-resolution ultrahigh-field 7T functional magnetic resonance imaging methods for functional mapping of the foveolar visual cortex in awake monkeys. In the ventral pathway (visual areas V1-V4 and the posterior inferior temporal cortex), viewing of a small foveolar spot elicits a ring of multiple (eight) foveolar representations per hemisphere. This ring surrounds an area called the 'foveolar core', which is populated by millimeter-scale functional domains sensitive to fine stimuli and high spatial frequencies, consistent with foveolar visual acuity, color and achromatic information and motion. Thus, this elaborate rerepresentation of central vision coupled with a previously unknown foveolar core area signifies a cortical specialization for primate foveation behaviors.

Utilizing Lactation Acuity to Improve Lactation Services in a U.S. Hospital.

National staffing guidelines for hospital lactation services do not account for the lactation acuity of breastfeeding patients. Higher acuity breastfeeding couplets require a higher level of knowledge and skill from lactation care providers. In these cases, a referral to an International Board Certified Lactation Consultant (IBCLC) is recommended for appropriate management. Use of a lactation acuity classification system as a clinical practice innovation was implemented at Oklahoma University Medical Center to improve the distribution of staff resources for optimal care of breastfeeding patients. Lactation service reports from this facility, a tertiary care teaching hospital, were reviewed to evaluate staffing, number of lactation consults, reason for and acuity of consults, and time spent. The review included over 10,000 lactation consults completed over a 1-year period. Once the lactation acuity system for IBCLC staff was in place, there was an increased mean direct consult time and acuity level with 85% of IBCLC time allocated to high acuity consults. Trained bedside nurses handled most low-acuity patients. The percentage of patients needing a lactation consult who received one increased along with the number of consults per patient. Data on time spent per consult were stratified by acuity, location, and reason for consult, including details on priority consults for neonatal intensive care unit patients. The productivity of the lactation team was higher with the use of a lactation acuity system compared to without it. The data reported support the use of lactation acuity in making recommendations for staffing of hospital lactation services.

Unveiling dust, molecular gas, and high star-formation efficiency in extremely UV bright star-forming galaxies at z ~ 2.1-3.6

We analysed the Atacama Large Millimetre/submillimetre Array (ALMA) far-infrared (FIR), 1.3 mm, dust continuum and CO emission of 12 starburst galaxies at $z 2.1-3.6$ selected for their extreme brightness in the rest-frame UV, with absolute magnitudes of $-23.4$ to $-24.7$. We also analysed their Very Large Telescope (VLT) High Acuity Wide field $K$-band Imager (HAWK-I) $H$- and s $-band images. The targeted galaxies are characterised by negligible dust attenuations with blue UV spectral slopes ($-2.62$ to $-1.84$), very young stellar populations of $ 10$ Myr, and powerful starbursts with a high mean specific star-formation rate of $ $, placing them $ 1.5$ dex above the main sequence at similar redshifts and stellar masses stars odot $). The FIR dust continuum emission revealed in nine galaxies gives IR luminosities of $(5.9-28.3) L_ odot $, with six galaxies remaining dominated by unobscured UV star-formation rates, and high dust masses barely produced by supernovae within the 10 Myr timescale. The CO emission detected in eight galaxies leads to molecular gas masses higher than stellar masses, with the mean molecular gas mass fraction as high as $82&lt;!PCT!&gt;$. The corresponding star-formation efficiencies reach $ 40$&lt;!PCT!&gt;, with amazingly short molecular gas depletion timescales between less than 13 Myr and 71 Myr. These unique properties never reported in previously studied galaxies highlight that these galaxies are likely caught at the very beginning of their stellar mass build-up and undergo a very efficient and fast conversion of gas into stars that can only result from the gas collapse within a very short free-fall time. We find that the feedback-free starburst model seems to be able to explain the formation of these galaxies. To reconcile the co-spatial FIR dust emission with the UV-bright unattenuated emission, we speculate about the presence of radiation-driven outflows that can temporarily remove dust at the location of the starburst and expel it at large distances in line with the measured high FIR effective radii (1.7 kpc to 5 kpc) in comparison to the very compact stellar radii that are a few hundreds of parsecs).

POSSIBILITIES OF AUTOREFKERATOMETRY

In modern ophthalmology, autorefkeratometry has long become a routine diagnostic study, without which it is impossible to imagine any examination. Computerized autorefkeratometers allow you to obtain a huge amount of information about the condition of the patient’s eye in a short time. At the same time, the information obtained is not always subjected to in-depth analysis.Refractometry data should be compared with keratometry data, compared with the indicators of the paired eye, and evaluate, if possible, the dynamics of changes and their tendency. Comparison of the obtained parameters with the average statistical indicators and the age norm make it possible to establish the presence of pathology that does not belong to the field of refractive errors. Thus, the occurrence of anisometropia with similar keratometry parameters suggests opacity of the lens or vitreous pathology. Direct astigmatism is typical for young people, and oblique or reverse astigmatism is typical for patients 65+. A shift in the irido-lens diaphragm is always accompanied by a change in refraction and its instability. Keratectasias are characterized by high variability in refraction and keratometry data, while sometimes maintaining high visual acuity that does not correspond to changes in optical power. Diopter syndrome is manifested by refractive transformations in accordance with changes in the anterior-posterior axis of the eye due to retinal edema. Dry eye syndrome can be manifested by noticeable refractive instability and errors in determining keratometric parameters.High-quality performance of autorefkeratometry, taking into account the nuances, and an in-depth analysis of the data obtained are necessary for making a diagnosis and assessing the dynamics of treatment of ocular pathology.

Case Report: Front surface eccentricity of scleral lens: Its impact on visual quality in eyes with higher-order aberrations induced by refractive surgery

Purpose To report the impact of front surface eccentricity (FSE) of scleral lenses (SCLs) on the visual performance of eyes exhibiting refractive surgery-induced higher-order aberrations (HOAs) Method A female teenager presented to the clinic with blurring of vision and dependency on spectacles even after undergoing Small Incision Lenticule Extraction (SMILE) in both eyes (BE). Her presenting uncorrected high contrast distance visual acuity (HCDVA) was 20/60 in the right eye (RE) and 20/40 in the left eye (LE). On examination, the cornea showed a ring-shaped area of ablation with faint scarring and a well-apposed lenticule-extraction site. Subjective refraction improved the HCDVA to 20/20p in RE and 20/25 in LE but the patient was not happy with the quality of vision. Ocular aberrometry revealed an increase in total HOAs as the underlying cause of unsatisfactory vision. Result A contact lens trial was recommended for BE to enhance visual quality. Rigid corneal lenses (RCLs) were tried, but the patient was intolerant to them. Large diameter SCLs of different FSEs (0, 0.6, and 0.8) were tried to reduce these aberrations. SCL with FSE 0 yielded the most favourable visual outcome, which was confirmed subjectively on ocular aberrometry. Conclusion With this case report, we hypothesize that the eccentricity of SCL can be selected according to the asphericity (at 6 mm) of the posterior corneal surface. This case also re-emphasizes the impact of SCL with varying FSEs on reducing HOAs and enhancing visual quality in eyes where conventional RCLs yield suboptimal results.

Analysis of emergency centre recidivism for interpersonal violence in a district-level hospital in Cape Town, South Africa.

Interpersonal violence is a major cause of morbidity and mortality in low- and upper-middle-income countries. It is postulated that a significant portion of these patients have repeated presentations to an already overburdened healthcare system. Data describing the burden of interpersonal violence recidivism are poor. To determine and describe the burden of emergency centre recidivism for interpersonal violent injury presenting to Khayelitsha Hospital, Cape Town, over a 2-year period. An analysis of a prospectively collected observational database combined with a retrospective chart review was conducted of all trauma patients who presented to Khayelitsha Hospital from 1 October 2020 to 30 September 2022. All patients (aged ≥14 years) with ≥2 presentations for interpersonal violence-related injuries were included. Cases were limited to the inclusion of mechanisms of injury attributable to stab wounds, blunt assault, firearm injury and gender-based violence. Recidivist cases were identified by repeat hospital number on the electronic hospital patient system. Repeat cases were manually reviewed for inclusion. Summary statistics are used to describe all variables. In total, 10 218 interpersonal violence presentations were identified over the study period, and 1 125 (11.0%) were attributed to recidivists (522 patients). The mean (standard deviation) age was 30 (7.7) years, and most were male (n=463, 88.7%). Stab wounds (n=583, 51.8%) and blunt assault injuries (n=456, 40.5%) were the main mechanisms of injury. Repeat presentation occurred within a median of 198 (25th - 75th percentile, 81.5 - 373.9) days. A total of 337 (64.6%) patients presented with higher acuity at one of their subsequent visits. Recidivist presentations represent a significant proportion of interpersonally violently injured patients, and are likely to be under-documented. Recidivism poses a measurable burden, and further research is needed to facilitate the identification of at-risk individuals, and specific secondary prevention strategies should be developed to prevent or reduce escalating patterns of injury associated with interpersonal violence.

Retinal Damage and Visual Network Reconfiguration Defines Visual Function Recovery in Optic Neuritis.

Recovery of vision after acute optic neuritis (AON) is critical to improving the quality of life of people with demyelinating diseases. The objective of the study was to prospectively assess the changes in visual acuity, retinal layer thickness, and cortical visual network in patients with AON to identify the predictors of permanent visual disability. We studied a prospective cohort of 88 consecutive patients with AON with 6-month follow-up using high and low-contrast (2.5%) visual acuity, color vision, retinal thickness from optical coherence tomography, latencies and amplitudes of multifocal visual evoked potentials, mean deviation of visual fields, and diffusion-based structural (n = 53) and functional (n = 19) brain MRI to analyze the cortical visual network. The primary outcome was 2.5% low-contrast vision, and data were analyzed with mixed-effects and multivariate regression models. We found that after 6 months, low-contrast vision and quality of vision remained moderately impaired. The thickness of the ganglion cell layer at baseline was a predictor of low-contrast vision 6 months later (ß = 0.49 [CI 0.11-0.88], p = 0.012). The structural cortical visual network at baseline predicted low-contrast vision, the best predictors being the betweenness of the right parahippocampal cortex (ß = -036 [CI -0.66 to 0.06], p = 0.021), the node strength of the right V3 (ß = 1.72 [CI 0.29-3.15], p = 0.02), and the clustering coefficient of the left intraparietal sulcus (ß = 57.8 [CI 12.3-103.4], p = 0.015). The functional cortical visual network at baseline also predicted low-contrast vision, the best predictors being the betweenness of the left ventral occipital cortex (ß = 8.6 [CI: 4.03-13.3], p = 0.009), the node strength of the right intraparietal sulcus (ß = -2.79 [CI: -5.1-0.4], p = 0.03), and the clustering coefficient of the left superior parietal lobule (ß = 501.5 [CI 50.8-952.2], p = 0.03). The assessment of the visual pathway at baseline predicts permanent vision disability after AON, indicating that damage is produced early after disease onset and that it can be used for defining vision impairment and guiding therapy.

Randomised controlled trial of HOYA one-day multifocal contact lenses: The HOMCL trial

Trial designDouble-masked crossover RCT (Research Registry: #8136) comparison of a new HOYA one-day disposable multifocal contact lens (HOMCL) with Alcon DAILIES TOTAL1® Multifocal (ADT1). MethodsSixty presbyopic participants from three countries attended for baseline measurements and fitting of both lens types and then for a fortnight completed daily diaries of symptoms with habitual optical correction, and VF-14 questionnaire. Participants collected either HOMCL or ADT1, when the vision was measured again, and they wore this product for a fortnight, completing daily diaries and VF-14. Participants then collected the other type and had vision and symptoms recorded in the same way. ResultsThere were no serious adverse events. Primary outcomes were no significant differences between the lens types in willingness to purchase nor stated preference; no significant differences in the daily symptom ratings of comfort; statistically significant findings with the daily symptom ratings and VF-14 of better near vision with HOMCL and better distance vision with ADT1. Secondary outcomes were better high contrast distance visual acuity with ADT1 (<1 line), better low contrast distance visual acuity with ADT1; faster Wilkins rate of reading test with HOMCL; no significant differences in near visual acuity, wearing time, or number of lenses required during fitting process. Exploratory analyses were better handling scores with ADT1; and some, but not all of the dry eye data indicating better acceptance of HOMCL by patients with relatively dry eyes. For all measures, there were some participants who preferred/performed better with each lens type. ConclusionsThe differences between the performance of the two products were small. There was a trend in some clinical measurements and the daily diary data and VF-14 questionnaire, for HOMCL to outperform ADT1 for near vision and vice versa for distance vision.

The impact of reduced pediatric emergency care hours on the patterns of emergency department utilization

Purpose: The declining recruitment rate of pediatric residents in Korea has led to a decrease in the number of emergency departments (EDs) offering a 24/7 pediatric emergency care (PEC). This study evaluated the impact of reduced PEC hours on the utilization patterns of a single ED.Methods: We reviewed medical records of pediatric patients who were defined as individuals aged 14 years or younger undergoing pediatricians’ practices in a tertiary hospital ED in Korea. Given the reduction of PEC hours from full-time to 08:00-24:00 on September 27, 2022, the patients were grouped as those who visited during March 27, 2022-September 26, 2022 (“control”), and those who visited during September 27, 2022-March 26, 2023 (“reduction”). The following variables were analyzed between the 2 periods: the number of patients, age, sex, visits via ambulances, severity by the Korean Triage and Acuity Scale with high acuity (a level 1-2 of the scale), disease-related visits, time of visit, ED length of stay (EDLOS), disposition, chief complaints, and diagnoses.Results: Among 3,577 pediatric patients, 1,315 visited the ED during the reduction period, down by 41.9% in numbers from the control period. From the control to reduction periods, we observed an increase in the median age (from 3.0 years [interquartile range, 1.0-7.0] to 4.0 years [1.0-8.0]; P = 0.005) and decreases in the median EDLOS (from 140.0 minutes [80.0-217.0] to 104.0 minutes [54.0-169.8]; P &lt; 0.001) and proportion of hospitalization (from 22.1% to 12.6%; P &lt; 0.001). No change was observed in the proportions of highacuity cases or chief complaints. We noted decreases in infection-related diagnoses during the reduction.Conclusion: Reducing PEC hours was associated with shorter EDLOS, fewer hospitalizations, and older age, with no difference in the severity. Even with reduced PEC hours, relevant resources should be redistributed to ensure the accessibility to PEC.

Multilevel analysis of factors affecting the interhospital transfer of high-acuity pediatric patients: a focus on severe pediatric emergency patients

Purpose: The authors aimed to identify the factors affecting interhospital transfer (“transfer”) of severe pediatric patients who visited to an emergency department (ED).Methods: Using the Korean National ED Information System, we analyzed high-acuity patients aged 18 years or younger who visited EDs of local or regional emergency centers nationwide. The high acuity was defined as a Korean Triage and Acuity Scale 1-2. To investigate the factors associated with transfer, a multilevel modeling was selected, examining independent variables at both individual- and hospital-levels with transfer as a dependent variable.Results: A model consisting of variables at individual- and hospital-levels showed the factors as follows: mode of arrival(self-transport: odds ratio, 0.48 [95% confidence interval, 0.38-0.61]; other ambulances: 0.41 [0.24-0.71]; compared with firehouse ambulance), visit at 18:00-07:59 (0.75 [0.64-0.88]), intentional injury (1.59 [1.03-2.47]; compared with non-injury), decreased level of consciousness (drowsy: 1.94 [1.33-2.84]; stupor: 4.08 [2.99-5.57]; coma: 1.81 [1.26-2.60]; compared with alert), severe illness diagnosis (1.49 [1.12-1.98]), the number of all beds in EDs (1.02 [1.01-1.04]), and acceptance for treatment (0.92 [0.87-0.98]; with increment of 1%).Conclusion: This study confirms that both individual-level and hospital-level factors affect the transfer risk of severe pediatric patients in EDs. The study suggests the needs for direct transportation to specialized pediatric treatment facilities, and concentrated support for the pediatric emergency medical centers and pediatric trauma centers.

The experiences of newly qualified nurses in intensive care unit: a qualitative meta-synthesis.

Clinical rotation practicum provides NQNs with more opportunities to learn their professional knowledge and develop basic nursing skills. ICU is often used as one of the clinical practicum departments for NQNs. Nursing shortages have been particularly felt in ICU. Due to the characteristic fast-paced working environments, high acuity of patient care, and technical complexities of an ICU. The experience of NQNs is highly stressful and challenging in these settings, which hinders their professional development and impacts patient care. The study aimed to systematically review and synthesis the findings of qualitative studies exploring experience of NQNs in ICU rotation, to provide a basis for enhancing the quality of clinical nursing. Nine databases were systematically searched for relevant publications from inception until February 2024. All qualitative studies in English and Chinese that explored the experience of NQNs in ICU rotation were collected. Two independent reviewers selected the studies and used The Joanna Briggs Institute Critical Appraisal Tool to evaluate the quality of the studies. Meta-synthesis was performed to integrate the results. A total of 13 studies revealed five descriptive themes and 14 sub-themes: ICU readiness, physical and psychological stress, positive self-perception, developing relationships, and ICU reflections. Standardized training in ICU, the working ability of NQNs is exercised and their professional quality is improved. However, it is also adversely affected by various stressors. The appropriate guidance and monitoring should be given by hospital managers, so as to promote the development of NQNs and enhance the quality of clinical nursing. https://www.crd.york.ac.uk/PROSPERO/, CRD42023475257.

Efficacy of enhanced monofocal intraocular lens in combined phacovitrectomy for patients with photoreceptor-preserving epiretinal membrane

The aim of this study is to evaluate the visual outcomes and quality of an enhanced monofocal intraocular lens (IOL), compared to a conventional monofocal IOL in patients with epiretinal membrane (ERM). This retrospective comparative study reviewed medical records of 110 eyes of 110 patients with photoreceptor-preserving ERM (55 patients in each group) who underwent phacovitrectomy and received either a conventional monofocal IOL (Tecnis PCB00) or an enhanced monofocal IOL (Tecnis Eyhance ICB00) from March 2021 to October 2021. Baseline examination included corrected (CDVA) and uncorrected (UDVA) distance visual acuity, and measurement of pupil size. Postoperative evaluation included uncorrected intermediate (UIVA) and near (UNVA) visual acuity, and defocus curve. Contrast sensitivity was assessed using CGT-2000 (Takagi, Seiko, Japan). The baseline parameters showed no difference between PCB00 and ICB00 groups. At 3 months, there was no difference of UDVA and CDVA, but UIVA (0.27 vs. 0.39 LogMAR; p = 0.001) and UNVA (0.35 vs. 0.45 LogMAR; p = 0.014) were better in ICB00 group. On the defocus curve, the ICB00 group demonstrated a slower slope decrease, with higher visual acuity from − 1.5 to -3.0 diopters when compared to the PCB00 group. The distant contrast sensitivity showed no significant difference between two groups. In conclusion, the enhanced monofocal IOL improved intermediate visual outcomes, achieving equivalent distance visual acuity and similar contrast sensitivity to the conventional monofocal IOL. It could be an alternative option to conventional monofocal IOL when planning combined phacovitrectomy for patients with photoreceptor-preserving ERM.

From Theory to Practice: Utilizing Simulation for High Acuity, Low Occurrence Trauma Events

From Theory to Practice: Utilizing Simulation for High Acuity, Low Occurrence Trauma Events

Hidden in red: evidence for and against red camouflage in a jumping spider (Saitis barbipes)

Investigating the conspicuousness of animal color patterns to different observers is crucial for understanding their function. This study examines the peculiar case of a jumping spider (Saitis barbipes) whose males display red and black ornaments during courtship despite an apparent inability to distinguish these colors. We propose that, through predator eyes, red may actually be a better match than black to the spiders’ leaf litter background, and that the black fringe of hairs surrounding red ornaments may blur with red at natural predator acuities and viewing distances to produce a background-matching desaturated red. In a field experiment, we test whether red ornaments reduce predation relative to red ornaments painted black, and find that, unexpectedly, spiders with red ornaments are more heavily predated upon. Having established birds as the spiders’ primary predators, we image the spiders in their natural habitat using an avian-vision camera. We find their red coloration to have similar color contrast, but lower achromatic contrast, with the background than black coloration. We also find that red and black elements blur together at typical avian acuities and viewing distances to produce lower chromatic and achromatic contrasts with the background than would be seen by animals with higher acuities and/or closer viewing distances. Interestingly, red ornaments appear orange or yellow when viewed obliquely, which reduces their achromatic, but not chromatic, contrast with the background. Our imaging results provide support for our hypothesis that red is camouflaging, whereas the results of our predation experiment do not. Any functional significance of the spiders’ red coloration therefore remains unresolved.

Posttraumatic Stress Disorder and Substance Use Disorder Screening, Assessment, and Treatment.

We review prevalence, etiology, impact on treatment, and best practices for treatment of posttraumatic stress disorder (PTSD) in a substance use disorder (SUD) treatment setting. Recommendations are given related to screening, assessment, and symptom monitoring. PTSD and SUDs are highly comorbid. This comorbidity is associated with higher acuity, more difficulty completing treatment, and worse prognosis. Integrated treatment is recommended, and trauma-focused psychotherapies combined with pharmacotherapy show particular promise. PTSD is highly prevalent in substance using samples, negatively impacting treatment course and worsening prognosis. This comorbidity has been explained by a variety of models, with self-medication having garnered the most support. Trauma-focused psychotherapies combined with pharmacotherapy demonstrate the most efficacy and are recommended when treating co-occurring SUDs and PTSD. Specifically, prolonged exposure (PE), concurrent treatment of PTSD and SUDs using PE (COPE), and cognitive processing therapy (CPT) have been seen as promising trauma-focused treatments. Investigations into ways to best augment therapy are also underway, both through treatment format and neuromodulation. Several recommendations are given.

FEATURES OF FUNCTIONAL DIAGNOSTICS OF OPTIC NERVE DAMAGE IN CASE OF HEAD INJURY

Introduction. Traumatic optic nerve damage is a rare complication of a head injury. Symptoms of primary damage appear at the time of first diagnostic in the early period and mask TON’s signs. Understanding of visual disturbances for the patient comes in a later period, when recovery is limited due to the irreversibility of the received injuries. Difficulties of early diagnosis of optic nerve damage in case of head trauma encourage the search for new, more informative methods. The aim of the study was to analyze the functional manifestations of the optic nerve damage in case of head injuries with different localization. Materials and methods. 366 cases (732 eyes) of patients with traumatic optic neuropathy (TON) were studied according to archival data in the period from 2014 to 2019. The control group consisted of 58 practically healthy persons (116 eyes). All patients were divided into three groups: A group - patients with traumatic brain injury (TBI) was 120 persons, B group - patients with craniofacial injury (CFI) - 118 persons and C group - with combined injuries - 128 injured. The degree of optic nerve damage was assessed using visometry, pupillometry, and perimetry. Results. In case of craniocerebral injury, decrease of visual acuity with an average value of 0.92±0.06 corresponded to degrees 0 (93%) and I (7%). In the case of craniofacial trauma, according to the research, visual acuity decreased to 0.76±0.13 (by 0.24, 24% compared to the control group, p&lt;0.05). The first degree (23%) and the second degree (7%) were determined. With a combined primary head injury, visual acuity decreased to 0.42±0.21 (by 0.58, 58%, compared to the control group, p&lt;0.05). One third were patients with I, II and III degrees of visual impairment. The use of static perimetry made it possible to detect damage to the optic nerve in patients with 0 degrees of reduced visual acuity. At the same time, 88% of patients of A group (n=120) had 0A class, 23% of B group (n=118) had 0B class, and in C group (n=122) there was almost no. The relative afferent pupillary defect’s test was negative at 0A group of vision loss, but the pupil cycle speed (PSC) was reduced in all patients. This confirms damage to the optic nerve in patients with high visual acuity This study showed that patients with TBI had high visual acuity in 93% of cases, The visual acuity was around 0.5-1.0, but sensitivity in the central part of the visual field decreased by 12 times, and the pupil reaction rate decreased by 55% compared to the control group. In case of craniofacial trauma (B group), visual acuity decreased to 0.76±0.13 (by 0.24, 24% compared to the control group, p&lt;0.05). I degree (23%) and II degree (7%) decrease of visual acuity was determined. As for the sensitivity in the central part of the visual field, it was 46.59% lower than in the A group. In patients with a combined injury of the head and face, a third of the injured had visual acuity less than 0.1, which is not found in other variants of injury. Conclusions. Analysis showed that severity of optic nerve damage depends on localization of the head injury. The use of static perimetry and pupillometry is important for the early diagnosis of TON in conditions with high visual acuity when other symptoms are weak or not amenable to examination.

Evaluation of unplanned reattendances to the pediatric emergency department – a five-year study

BackgroundUnplanned reattendances (UR) are an important quality indicator in the emergency department (ED). Understanding the risk factors associated with UR can aid clinicians in optimizing the allocation of time and resources, as well as targeted counselling for this specific group of patients. In this study, we aimed to compare patient characteristics between children who attended a pediatric emergency department (ED) with unplanned reattendances (UR) and those without UR. We also aimed to study the association between healthcare delivery factors such as timing of the attendance, patient load, changeover months for rotating junior doctors, presence of supervision, and rate of UR.Study designWe performed a retrospective, single-center cohort study of patients < 18 years old who visited the ED between January 2018 and March 2023. UR was defined as a revisit within 72 h of the index ED visit. We collected data on demographics, attendance data and clinical characteristics. Logistic regression was performed for factors independently associated with UR, after adjusting for age, patient acuity, timing of attendance, presence of senior doctor supervision, rotation months for junior doctors, and diagnostic category.ResultsOut of the 544,699 eligible children, 24,733 (4.5%) reattended the ED within 72 h, of which 10,915 (44.1%) of them were hospitalized on their reattendance visit. The independent factors associated with UR were young age (age < 3 years old: aOR 1.585 95%CI 1.481–1.698, p < 0.001), high acuity P2+ (aOR 1.398 95%CI 1.354–1.444, p < 0.001), attendance in the evening (aOR 1.086 95%CI 1.055–1.117, p < 0.001) and night (aOR 1.365 95%CI 1.314–1.417, p < 0.001), gastrointestinal diagnosis (aOR 1.528, CI 1.469–1.588; p < 0.001) and respiratory diagnosis (aOR 1.155, CI 1.121–1.189, p < 0.001).ConclusionsWe identified independent risk factors for UR that could guide resource allocation. Future studies should investigate if targeted interventions may reduce UR in these at-risk populations.

Determinants of Outcomes for Acute Myeloid Leukemia Patients Treated in a Community-Based Specialized Versus Non-Specialized Hospital Setting.

The treatment setting influences acute myeloid leukemia (AML) outcomes. Most cancer patients receive care in the community, yet few studies have evaluated the effectiveness of clinical programs outside of academic or National Cancer Institute (NCI)-designated cancer centers. This was a multi-level, case-controlled study of real-world outcomes for initial AML treatment in a community-based network for 1,391 patients with AML between 2011 and 2018. We benchmarked survival within our network against the Surveillance, Epidemiology, and End Results (SEER) database. Coarsened exact matching was performed against 17,186 chemotherapy-treated patients in the SEER database. Cox proportional and accelerated failure time multivariable modeling were performed to identify patient, disease, therapy and center characteristics associated with the risk of AML mortality. Within the network, 799 patients were treated at six specialized blood cancer centers and 592 at 63 other hospitals. Patients receiving high-intensity induction at specialized centers had improved median survivals of 31 months versus 18 months [P<0.001] at non-specialized centers. Median survivals were 13 for non-specialized centers versus 10 months for SEER [P<0.001], and 18 for the entire network versus 10 months for SEER [P<0.001]. Multivariable modeling showed significant impacts from age (HR = 1.025), high-intensity induction therapy (HR= .695), diagnosis year (HR= .937), neighborhood income (HR = .997; P<0.01), higher acuity (HR = 1.002) and Charlson comorbidity score (HR = 1.117). AML treatment may be effectively delivered in the community hospital setting, with specialized centers producing better outcomes for higher intensity treatments.