Need For Further Intervention Research Articles

Impact of national drug price negotiation policy on the accessibility and utilization of PCSK9 inhibitors in China: an interrupted time series analysis

BackgroundPCSK9 inhibitors are a novel class of lipid-lowering drugs that have demonstrated favorable efficacy and safety. Evolocumab and alirocumab have been added to China’s National Reimbursement Drug List through the National Drug Price Negotiation (NDPN) policy. This study aims to evaluate the impact of the NDPN policy on the utilization and accessibility of these two PCSK9 inhibitors.MethodsThe procurement data of evolocumab and alirocumab were collected from 1,519 hospitals between January 2021 and December 2022. We determined the monthly availability, utilization, cost per daily defined dose (DDDc), and affordability of the two medicines. Single-group interrupted time series (ITS) analysis was performed to assess the impact of the NDPN policy on each drug, and multiple-group ITS analysis was performed to compare the differences between them.ResultsThe NDPN policy led to a significant and sudden increase in the availability and utilization of PCSK9 inhibitors, along with a decrease in their DDDc. In the year following the policy implementation, there was an increase in the availability, utilization, and spending, and the DDDc remained stable. The affordability of PCSK9 inhibitors in China have been significantly improved, with a 92.97% reduction in out-of-pocket costs. The availability of both PCSK9 inhibitors was similar, and the DDDc of alirocumab was only $0.23 higher after the intervention. The market share of evolocumab consistently exceeded that of alirocumab. Regional disparities in utilization were observed, with higher utilization in the eastern region and a correlation with per capita disposable income.ConclusionsThe NDPN policy has successfully improved the accessibility and utilization of PCSK9 inhibitors in China. However, regional disparities in utilization indicate the need for further interventions to ensure equitable medicine access.

Association of HbA1C and comfort with diabetes self-management among adolescents and young adults with type 1 diabetes.

Adolescents and young adults (AYA) living with type 1 diabetes (T1D) are a vulnerable demographic at risk for sub-optimal glycemic outcomes at a time when they are taking over their diabetes management. The purposes of this study were to examine levels of self-reported comfort with diabetes management tasks among AYA living with T1D and to describe the relationships among comfort levels, sociodemographic factors, and HbA1c. During a routine diabetes care visit, AYA aged 15-23 years old living with T1D received a transition survey to self-assess their comfort level with different diabetesmanagement tasks. Among 161 participants who completed the survey (median age 17 years, median diabetes duration 7 years, 82.3% White, 40.9% female, 66.5% with private insurance, and median HbA1c 8.8%), comfort with diabetes management tasks was generally rated highly (median overall comfort level of 4.5 out of 5), irrespective of race or insurance type. Regression analysis revealed that higher self-reported comfort level with diabetes management tasks was associated with a higher HbA1c (p = 0.006), after controlling for age, sex, race, insurance type, and diabetes duration. These findings suggest that self-reported comfort with independently managing T1D may not be a sufficient metric in assessing AYA patients' need for further intervention to optimize glycemic outcomes as they transition from pediatric to adult diabetes care, and highlights the importance of continuity of care to support diabetes management during this transitional period.

Interventions on gender equity in the workplace: a scoping review

BackgroundVarious studies have demonstrated gender disparities in workplace settings and the need for further intervention. This study identifies and examines evidence from randomized controlled trials (RCTs) on interventions examining gender equity in workplace or volunteer settings. An additional aim was to determine whether interventions considered intersection of gender and other variables, including PROGRESS-Plus equity variables (e.g., race/ethnicity).MethodsScoping review conducted using the JBI guide. Literature was searched in MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, ERIC, Index to Legal Periodicals and Books, PAIS Index, Policy Index File, and the Canadian Business & Current Affairs Database from inception to May 9, 2022, with an updated search on October 17, 2022. Results were reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension to scoping reviews (PRISMA-ScR), Sex and Gender Equity in Research (SAGER) guidance, Strengthening the Integration of Intersectionality Theory in Health Inequality Analysis (SIITHIA) checklist, and Guidance for Reporting Involvement of Patients and the Public (GRIPP) version 2 checklist.All employment or volunteer sectors settings were included. Included interventions were designed to promote workplace gender equity that targeted: (a) individuals, (b) organizations, or (c) systems. Any comparator was eligible. Outcomes measures included any gender equity related outcome, whether it was measuring intervention effectiveness (as defined by included studies) or implementation. Data analyses were descriptive in nature. As recommended in the JBI guide to scoping reviews, only high-level content analysis was conducted to categorize the interventions, which were reported using a previously published framework.ResultsWe screened 8855 citations, 803 grey literature sources, and 663 full-text articles, resulting in 24 unique RCTs and one companion report that met inclusion criteria. Most studies (91.7%) failed to report how they established sex or gender. Twenty-three of 24 (95.8%) studies reported at least one PROGRESS-Plus variable: typically sex or gender or occupation. Two RCTs (8.3%) identified a non-binary gender identity. None of the RCTs reported on relationships between gender and other characteristics (e.g., disability, age, etc.). We identified 24 gender equity promoting interventions in the workplace that were evaluated and categorized into one or more of the following themes: (i) quantifying gender impacts; (ii) behavioural or systemic changes; (iii) career flexibility; (iv) increased visibility, recognition, and representation; (v) creating opportunities for development, mentorship, and sponsorship; and (vi) financial support. Of these interventions, 20/24 (83.3%) had positive conclusion statements for their primary outcomes (e.g., improved academic productivity, increased self-esteem) across heterogeneous outcomes.ConclusionsThere is a paucity of literature on interventions to promote workplace gender equity. While some interventions elicited positive conclusions across a variety of outcomes, standardized outcome measures considering specific contexts and cultures are required. Few PROGRESS-Plus items were reported. Non-binary gender identities and issues related to intersectionality were not adequately considered. Future research should provide consistent and contemporary definitions of gender and sex.Trial registrationOpen Science Framework https://osf.io/x8yae.

A comparative analysis of opioid-free and opioid-sparing anaesthesia techniques for laparoscopic ovariectomy in healthy dogs

ObjectiveTo compare the perioperative analgesic effects of an opioid-free (OFA) and an opioid-sparing (OSA) anaesthetic protocol in dogs undergoing laparoscopic ovariectomy. Study designProspective, randomized, blinded, clinical trial. AnimalsA group of 28 client-owned dogs. MethodsDogs were allocated to one of two groups. The OFA group was administered intramuscular (IM) dexmedetomidine 5 μg kg–1 and ketamine 1 mg kg–1, followed by two intraoperative constant rate infusions (CRIs) of dexmedetomidine (3 μg kg–1 hour–1) and lidocaine (1 mg kg–1 loading dose, 2 mg kg–1 hour–1). The OSA group was administered IM dexmedetomidine 5 μg kg–1, ketamine 1 mg kg–1 and methadone 0.2 mg kg–1, followed by two intraoperative saline CRIs. In both groups, anaesthesia was induced with intravenous (IV) propofol 2 mg kg–1 and diazepam 0.2 mg kg–1 and maintained with isoflurane. Rescue dexmedetomidine (0.5 μg kg–1) was administered IV if there was a 20% increase in cardiovascular variables compared with pre-stimulation values. Ketorolac (0.5 mg kg–1) was administered IV when the surgery ended. Postoperative analgesia was evaluated using the Short Form-Glasgow Composite Measure Pain Scale and methadone (0.2 mg kg–1) was administered IM if the pain score was ≥ 6/24. Statistical analysis included mixed analysis of variance, Chi-square test and Mann–Whitney U test. ResultsThere were no significant differences in the intraoperative monitored variables between groups. The OFA group showed a significantly lower intraoperative rescue analgesia requirement (p = 0.016) and lower postoperative pain scores at 3 (p =0.001) and 6 (p < 0.001) hours. No dogs were administered rescue methadone postoperatively. Conclusions and clinical relevanceAlthough both groups achieved acceptable postoperative pain scores with no need for further intervention, the analgesic efficacy of the OFA protocol was significantly superior to that of the OSA protocol presented and was associated with a lower intraoperative rescue analgesia requirement and early postoperative pain scores.

The effect of chimney fitted improved stove on kitchen fine particulate matter (PM2.5) concentrations in rural Ethiopia: Evidence from a randomized controlled trial

BackgroundMillions of Ethiopian people cook with biomass fuels using traditional stoves, releasing harmful pollutants and contributing to a significant public health crisis. Improved stoves offer a potential escape route, but their effectiveness needs close scrutiny. This study delves into the impact of chimney-fitted stoves on kitchen PM2.5 concentrations in rural Ethiopian households. MethodWe conducted a randomized controlled trial with 86 households equally divided (1:1 ratio) between intervention and control groups. The 24-h average kitchen PM2.5 concentrations was measured using Particle and Temperature Sensor (PATS+) at baseline and after intervention. All relevant sociodemographic and cooking related characteristics were collected at baseline and dynamic characteristics were updated during air monitoring visits. Three distinct statistical models, including independent sample t-tests, paired sample t-tests and one-way analysis of variance were used to analyze the data using Statistical Package for the Social Sciences (SPSS) software for Windows (v 24.0). ResultAt baseline, the average 24-h kitchen PM2.5 concentrations were 482 μg/m3 (95% CI: 408, 557) for the control and 405 μg/m3 (95% CI: 318, 492) for the intervention groups. Despite remaining elevated at 449 μg/m3 (95% CI: 401, 496) in the control group, PM2.5 concentrations reduced to 104 μg/m3 (95% CI: 90,118) in the intervention group, indicating a statistically significant difference (t = 6.97, p < 0.001). All three statistical analyses delivered remarkably consistent results, estimating a PM2.5 reductions of 74% with the before-and-after approach, 76% when comparing groups, and 74% for difference in difference analysis. Beyond the overall reduction, homes with primary school completed women, larger kitchens, smaller family size, and those specifically baking Injera (the traditional energy-intensive staple food), witnessed even greater drops in PM2.5 levels. ConclusionPregnant women in our study encountered dangerously high PM2.5 exposures in their kitchens. While the intervention achieved a significant PM2.5 reductions, unfortunately remained above the WHO's safe limit, highlighting the need for further interventions.

Effect of chronic heavy tobacco smoking on ankle fracture healing

IntroductionTobacco smoking is linked to an elevated risk of osteomyelitis and delayed healing in long bone fractures. However, the impact of smoking on bone union and soft tissue recovery following ankle fractures remains unclear. This study presents a retrospective comparative analysis evaluating the effects of chronic heavy tobacco smoking on the healing process and outcomes of ankle fractures after surgical interventions. Materials and MethodsWe examined 220 consecutive cases of chronic heavy smokers (CHS) with closed ankle fractures who were referred to our unit for further treatment. A control group, consisting of 220 age- and sex-matched individuals (non-smokers with closed ankle fractures), was identified for comparative analysis. We collected clinical data, including pre-existing comorbidities, Lauge-Hansen fracture classification, necessity for surgery, and the surgical procedures performed.The primary outcomes investigated were the time required for fracture union and wound healing. Secondary outcomes included postoperative complications such as prolonged pain, bleeding, swelling, infection, compartment syndrome, and neurovascular impairment, as well as the incidence of delayed union, non-union, and the need for further intervention. Both cohorts were monitored for a minimum of 24 months. ResultsOur analysis revealed that the surgical cohort of chronic heavy smokers exhibited a statistically significant delay in fracture union compared to both the conservatively managed smokers and the control group.Further scrutiny of the surgical cohort of chronic smokers indicated a significant correlation between smoking and extended postoperative pain duration, persistent swelling at the fracture site, and both superficial and deep wound infections. Additionally, these patients experienced delays in both fracture union and wound healing when compared to the control group.Similarly, the conservatively managed chronic smokers showed a marginal increase in the incidence of post-injury pain duration, extended swelling at the fracture site, and delayed union compared to the control group. ConclusionPatients who are chronic heavy smokers and require surgical intervention for ankle fractures should be made aware of their increased risk for delayed fracture union and poor wound healing. Orthopedic surgeons should proactively encourage these patients to participate in smoking cessation programs.

Trends in Stroke Thrombolysis Care Metrics and Outcomes by Race and Ethnicity, 2003-2021

Understanding is needed of racial and ethnic-specific trends in care quality and outcomes associated with the US nationwide quality initiative Target: Stroke (TS) in targeting thrombolysis treatment for acute ischemic stroke. To examine whether the TS quality initiative was associated with improvement in thrombolysis metrics and outcomes across racial and ethnic groups. This retrospective cohort study included patients who presented within 4.5 hours of ischemic stroke onset at hospitals participating in the Get With The Guidelines-Stroke initiative from January 1, 2003, to December 31, 2021. The data analysis was performed between December 15, 2022, and November 27, 2023. TS phases I (2010-2013), II (2014-2018), and III (2019-2021). The primary outcomes were thrombolysis rates and time metrics. Patient function and mortality were secondary outcomes. Analyses included 1 189 234 patients, of whom 1 053 539 arrived to the hospital within 4.5 hours. The cohort included 50.4% female and 49.6% male patients and 2.8% Asian [median (IQR) age, 72 (61-82) years], 15.2% Black [median (IQR) age, 64 (54-75) years], 7.3% Hispanic [median (IQR) age, 68 (56-79) years], and 74.1% White [median (IQR) age, 75 (63-84) years] patients). Unadjusted thrombolysis rates increased in both the pre-TS (2003-2009) and TS periods in all racial and ethnic groups from 10% to 15% in 2003 to 43% to 46% in 2021, but disparities were observed in adjusted analyses and persisted in TS phase III, with Asian, Black, and Hispanic patients having significantly lower odds of receiving thrombolysis than White patients (adjusted odds ratio, 0.85 [95% CI, 0.81-0.90], 0.76 [95% CI, 0.74-0.78], and 0.86 [95% CI, 0.83-0.89], respectively). Door-to-needle (DTN) times improved in all racial and ethnic groups during TS, with DTN times of 60 minutes or less increasing from 26% to 28% in 2009 to 66% to 72% in 2021. However, in adjusted analyses, racial and ethnic disparities emerged. During TS phase III, compared with White patients, Asian, Black, and Hispanic patients had significantly lower odds of receiving thrombolysis with a DTN time of 60 minutes or less compared with White patients (risk-adjusted odds ratios, 0.91 [95% CI, 0.84-0.98], 0.78 [95% CI, 0.75-0.81], and 0.87 [95% CI, 0.83-0.92], respectively). During TS, clinical outcomes improved for all racial and ethnic groups from pre-TS, with TS phase III showing higher odds of ambulation at discharge among Asian, Black, Hispanic, and White patients. Asian, Black, and Hispanic patients were less likely to present within 4.5 hours. In this cohort study of patients with ischemic stroke, the TS quality initiative was associated with improvement in thrombolysis frequency, timeliness, and outcomes for all racial and ethnic groups. However, disparities persisted, indicating a need for further interventions.

Long-term investigation of minimally invasive alcohol-based therapy as the treatment of odontogenic keratocyst:A retrospective cohort study

The aim of this study was to evaluate the clinical efficacy of alcohol-based therapy for patients with large odontogenic keratocysts (OKCs).The study was implemented as a retrospective, single-center study. Patients treated with ethanol-based therapy for odontogenic keratocyst were retrospectively evaluated for baseline and postoperative data. The pre- and postoperative clinical situation and the extent of radiographic shrinkage were compared. The event is defined as the achievement of >50% reduction in cyst volume.The cyst reduction rate calculated on panoramic radiographs ranged from 7.4% to 99.9% (mean [standard deviation] 55.3% [27.9%]) and was statistically significant (P < 0.05). Specifically, it has been found that, radiographically, 47.6% of patients achieved >50% reduction in cyst volume within 12 months. The continuous cortical bone was rebuilt, and the cyst cavity was filled with regenerated trabecular bone. The 22 included patients presented with nonclinical problems, had no need for further intervention, and exhibited persistent impaction of the teeth.The results of this study demonstrated that ethanol-based therapy triggered marked radiographic reductions of large OKC, indicating that using this technique is efficient.

A novel technique for contained aspiration and irrigation of priapism

Abstract Background Ischemic priapism is a urological emergency requiring prompt corporal aspiration and irrigation, with risk of blood spillage that can place a significant biological hazard to the urologist and rest of emergency room staff. Aim The study sought to develop and validate a method for contained corporal aspiration that minimizes exposure to sharps and occupational hazards. Methods We used one large bore needle connected to a vacuum aspiration device and blood draw tubes for corporal aspiration and irrigation of ischemic priapism. Outcomes Feasibility of this method was assessed in 18 consecutive patients presenting to the emergency room with ischemic priapism. Clinical characteristics, resolution of priapism, and need for further interventions were documented. Results A total of 18 patients were treated using this technique. The mean time from onset to presentation was 12 hours. The etiology in all patients was recreational intracavernosal drug abuse, and 72% were HIV positive. Priapism completely resolved in all 18 patients. No patients required shunt procedures or further interventions to achieve detumescence. Clinical Implications This system can be used for safe management of ischemic priapism in any clinical scenario but is particularly beneficial to minimize exposure risk in the setting of increased risk of blood-borne infections. Strengths and Limitations This initial trial shows that this technique is safe and effective for cavernosal aspiration of ischemic priapism. Larger trials are required to validate this method. Conclusion Contained aspiration and irrigation of priapism can be used for effective management of ischemic priapism while minimizing health risks to urologists and emergency room staff.

Mid-Term Results of an Italian Multicentric Experience with the RoadsaverTM Dual-Layer Carotid Stent System.

Carotid artery stenting (CAS) using first-generation single-layer stents is widely accepted as a good alternative to standard carotid endarterectomy (CEA) but it is associated with worse outcomes in terms of both plaque prolapse and cerebral embolization. To evaluate the perioperative and midterm outcomes of CAS using the new-generation RoadsaverTM dual-layer micromesh-covered carotid stent. Herein, we present the results of an observational, retrospective, multicentric study on non-consecutive patients who underwent the CAS procedure between January 2017 and December 2022 at three Italian, high-volume vascular surgery centers. The inclusion criteria were the patients' eligibility for the CAS procedure in accordance with the current Italian guidelines, and the implantation of a Roadsaver stent. Both symptomatic and asymptomatic patients were included in the study. The patients requiring reintervention for carotid restenosis following CEA were also included. Perioperative data regarding procedural success was defined as the successful implantation of the device in the desired position, less than 30% residual stenosis, and the absence of intraoperative neurological complications. The primary outcome was any adverse cerebrovascular event such as stroke or transient ischemic attack (TIA) during the procedure and/or after discharge. The secondary outcomes were the need for further intervention, and all-cause death following procedure. Three-hundred-fifty-three (353) patients were included in our study; the mean age was 74.3 years. A total of 5.9% of the patients were symptomatic on their operated side, while 7.3% had contralateral carotid occlusion. A cerebral embolic protection device (CPD) was employed in all patients. A total of 13.3% of the patients were operated on for restenosis after CEA Technical success was achieved in 96.9% of the cases with an intraoperative report of six TIAs (1.7%) and six ipsilateral strokes (1.7%). The mean hospital stay was 1.8 days. The thirty-day follow up showed one TIA and one more stroke. At the mean 35-month follow-up time, the primary outcome was present in six patients (1.7%), where four TIAs (1.1%) and two strokes (0.5%) were reported. Restenosis occurred in five patients (1.4%). Death for any cause was reported in 11 patients (3.1%). As most recent, high-quality studies show, the CAS procedure with second-generation devices such as the Roadsaver stent is safe and effective in preventing carotid-related cerebrovascular events in both symptomatic and asymptomatic patients. The intraoperative and postoperative cerebrovascular complication rate in high volume centers is very low, ensuring confidence in its employment for the CAS procedure along with a CPD as a valid alternative to CEA.

Case Report: Optical Pumped Magnetometer Magnetocardiography as a Potential Method of Therapy Monitoring in Fulminant Myocarditis

Background: Fulminant myocarditis (FM) is associated with high mortality and an unfavorable long-term prognosis. However, noninvasive, rapid diagnostic and monitoring methods for FM are lacking. Case summary: This report details the case of a patient diagnosed with FM through a comprehensive assessment involving typical clinical symptoms, laboratory analyses, echocardiographic evidence, and cardiac magnetic resonance (CMR) findings. Before the patient underwent CMR, optical pumped magnetometer magnetocardiography (OPM-MCG) revealed abnormalities characteristic of substantial myocardial injury. After invasive coronary angiography, the patient’s coronary arteries were determined not to exhibit significant stenosis. Additionally, a myocardial bridge was observed in the middle segment of the anterior descending branch of the left coronary artery. Over a 7-month follow-up, the patient’s symptoms showed marked improvement, and the OPM-MCG eventually normalized, aligning with the findings indicated by the CMR. Conclusion: OPM-MCG is a valuable tool for therapy monitoring in FMs, offering a safe, non-invasive, and highly effective test for ancillary diagnostics and long-term prognostic follow-up. Additionally, MCG may potentially assist in clinical decision-making regarding the need for further interventions in patients with myocardial bridge.

A Novel Diagnostic and Treatment Algorithm for Acute Mastoiditis in Children Based on 109 Cases.

Acute mastoiditis (AM) is a potentially life-threatening condition primarily affecting children. To date, there are no consistent criteria or valid guidelines for the diagnosis and treatment of pediatric AM. Therefore, this study evaluates the clinical course of AM in terms of clinical signs and treatment. In addition, a novel classification scheme for the disease and a treatment algorithm is being proposed. Patient records over a 12-year period from a single center were reviewed to identify confirmed cases of AM in children. Data collected included clinical signs, body temperature, and infection parameters during the disease, as well as radiological imaging, antibiotics, and surgical as well as conservative treatment. In addition, a classification of the AM stages was established in accordance with the findings described and practical experience, consisting of four stages (1, mastoidal irritation; 2, mild AM; 3, advanced AM; 4, advanced AM and additional complications) with corresponding treatment recommendations. In the retrospective cohort, those AM cases that were treated alongside the classification were compared with the rest concerning clinical course and outcome. A total of 109 patients (mean age, 3.8 ± 3.8 years) were included. The main symptoms at hospital admission were auricular protrusion (n = 73; 67.0%), fever (n = 56; 51.4%) with a mean temperature of 38.3 ± 1.1°C, and otalgia (n = 28; 25.7%). The mean laboratory-tested levels of leukocytes and C-reactive protein at the time of hospital admission were 15.96 ± 8.7/nl and 59.6 ± 54.0 mg/L, respectively. During winter, there was a higher prevalence of AM, with peak hospital admissions in April (n = 22). The most common pathogen was Streptococcus pyogenes (32 cases). Treatment was purely conservative in four cases, whereas the remaining cases underwent surgery (41× grommet insertion, 64× plus mastoidectomy). The outcome was generally good, but in eight patients a second surgical procedure had to be performed as they showed signs of clinical deterioration. A total of 101 patients were treated according to the proposed algorithm, and all of which had a good outcome without the need for further interventions. Based on clinical experience in a large cohort of pediatric AM patients, a novel diagnostic and treatment algorithm has been developed and successfully tested in a retrospective cohort for AM in children to prevent further complications and to ease its management by pediatricians and otorhinolaryngologists in the emergency setting.

Stereotactic Radiosurgery and Radiotherapy for Vestibular Schwannoma in NF2-Related Schwannomatosis.

To determine the long-term control rates and hearing outcomes for growing vestibular schwannoma in NF2-related schwannomatosis (NF2) treated with stereotactic radiosurgery (SRS) and fractionated radiotherapy (FRT). Retrospective review of all patients treated with SRS/FRT between 1986 and2021 from a tertiary NF2 unit. Overall tumor control was defined as: (1) growth control (growth failure was defined as growth in any dimension of 3 millimetres or more from baseline post-SRS/FRT), and (2) treatment control (no need for further intervention). Loss of serviceable hearing was defined as a drop in speech discrimination score below 50% after SRS/FRT. There were 81 cases, with a mean duration of follow-up of 125 months. Overall control rate was 72% (58/81), with 80% (65/81) growth control and 74% (60/81) treatment control. There was a 5-year actuarial survival of 77% and 10-year survival of 71%. Forty-three percent (30/69) of cases did not have serviceable hearing at baseline. Of those remaining, 49% (19/39) preserved serviceable hearing during follow-up at a mean of 106 months. Actuarial survival for preservation of serviceable hearing at 5 and 10 years was 69% and 53%. There were poorer outcomes with increasing genetic severity, and with baseline tumor size >3 cm. No cases of SRS/FRT-related malignancy were identified at a mean follow-up of 10 years. Stereotactic radiosurgery/fractionated radiotherapy are an effective option to treat growing vestibular schwannoma in patients with NF2 with the potential for hearing preservation in a proportion of patients. 4-Case Series Laryngoscope, 134:2364-2371, 2024.

OGBN P27 Outcome of specialist-led urgent laparoscopic cholecystectomy for gallstone disease at a London District General Hospital

Abstract Background Laparoscopic cholecystectomy is the mainstay for treatment of symptomatic gallstones and its associated complications. Emergency cholecystectomy rates in the United Kingdom (UK) remain low despite NICE guidelines recommendations to offer surgery within 7 days for acute cholecystitis and index cholecystectomy for mild gallstone pancreatitis. We analysed our data over last 10 years to assess the safety and feasibility of providing an emergency cholecystectomy service in a London District general Hospital with a specialist Upper Gastrointestinal / hepatobiliary consultant workforce in line with NICE guidelines. Methods Data of 663 consecutive patients undergoing index admission emergency cholecystectomy during 2013-2023 from a prospectively maintained database was reviewed. Patient demographics, duration of hospital stay, complications, need for further interventions and re-admission rates were collected and analysed. Results Six hundred and sixty-three consecutive patients underwent emergency cholecystectomy gallstone disease and associated complications. The conversion rate was 5.2% (n=35). The median time from presentation to surgery was 2 days (Range 0-63), overall length of stay was 6 days (Range 1-91), and post-procedure stay was 2 days (Range 1-89). Overall complication rate was 7% (n=45), bile leak was observed in 8 patients (1.2%) with no evidence of major biliary injury. One patient had postoperative haemorrhage requiring laparotomy (No bleeder identified) (grade IVa) and 1 patient died within 90 days for reasons unrelated to the operation. The re-admission rate was 10.2%. Conclusions Index admission emergency laparoscopic cholecystectomy in district general hospitals is feasible and safe when performed by a specialist consultant workforce, leading to compliance to guidelines and a low rate of complications and readmissions to hospital.

Bone marrow aspirate concentrate chondroplasty to delaying need for total knee arthroplasty: a retrospective review of a veteran cohort.

Aim: Osteoarthritis (OA) is a highly prevalent and costly condition, rooted in cartilaginous defects. Despite various causes, the inability for chondrocytes to regenerate prohibits these lesions from self-healing. Debridement commonly provides symptomatic relief but does not target the underlying disease process, necessitating investigation into possible treatments. Intraosseous and intraarticular bone marrow aspirate concentrate (BMAC) injection is a new promising therapy aimed at repairing these cartilage defects. Methods/materials: We retrospectively reviewed patients who underwent BMAC chondroplasty and examined the efficacy in delaying need for further intervention. Results: Only 5 of 23 procedures (21.7%) required postoperative intervention within the2-year follow-up period. Only one request for total knee arthroplasty was made, but the procedure has not been done. Conclusion: This study demonstrates that BMAC chondroplasty may be an efficacious method to delay need for total knee arthroplasty.

Impact evaluation of KOICA MNCH project in Jimma Ethiopia using a difference in differences analysis

Abstract Background The maternal mortality ratio in Ethiopia is 412, which is higher than its neighboring countries. To address this issue and improve the health of women of childbearing age, the Maternal Neonatal and Child Health (MNCH) project was implemented in Jimma zone, Oromia, Ethiopia with support from the Korea International Cooperation Agency (KOICA). The objective of this study is to measure the impact of the project on maternal health in Jimma, Ethiopia. Methods The study employed DID analysis to measure the impact of the project on five key variables, including ANC 4, institutional delivery, satisfaction with MCH-related services, pregnancy-related knowledge, and delivery-related knowledge. A total of 789 participants were randomly selected for the baseline survey from both the intervention and control groups in 2017. The same groups were surveyed again one year later using the same study design for the endline survey. Results The study found that the trends in ANC4 and the level of satisfaction with the MCH service provided were similar in both the intervention and control groups. However, significant impacts were observed in terms of institutional delivery, pregnancy-related knowledge, and delivery-related knowledge. The odds ratio for institutional delivery was 2.83 (p &amp;lt; 0.01) for women in the intervention group compared to the control group. Similarly, the odds ratio for pregnancy-related knowledge was 0.67 (p &amp;lt; 0.01), and the odds ratio for delivery-related knowledge was 1.70 (p &amp;lt; 0.01) for women in the intervention group compared to the control group. Conclusions The study concludes that the KOICA MNCH project partially achieved its objective, as the intervention had a positive impact on institutional delivery and maternal knowledge levels. However, the insignificant impact on ANC4 and the level of satisfaction with MCH services suggest the need for further intervention to fully address maternal health issues in Ethiopia. Key messages • This study is significant because it has provided empirical evidence that maternal health projects implemented in the Jimma Zone of Ethiopia can positively impact various aspects of maternal health. • The results of this study can serve as a valuable reference for policymakers and healthcare professionals involved in designing and implementing maternal health interventions.

Stricturing Crohn's disease: what is the role of endoscopic stenting? A systematic review.

Endoscopic stenting for stricturing Crohn's disease (CD) is an emerging treatment that achieves more persistent dilatation of the stricture over time than endoscopic balloon dilatation (EBD). We aimed to explore the efficacy and safety of stenting for the treatment of CD strictures. A systematic electronic literature search was performed (PROSPERO; no. CRD42022308033). The primary outcomes were technical success, efficacy, complication rate, and the need for further interventions due to reobstruction. The outcomes of partially covered self-expanding metal stents (PCSEMS) with scheduled retrieval after seven days were also analyzed. Eleven eligible studies were included in the review. Overall, 173 patients with CD were included in this study. Mean percentage of technical success was 95% (range, 80%-100%), short-term efficacy was 100% in all studies, and long-term efficacy was 56% (range, 25%-90%). In patients with a scheduled PCSEMS retrieval, the long-term efficacy was 76% (range, 59%-90%), the mean complication rate was 35% (range, 15%-57%), and the major complication rate was 11% (range, 0%-29%). Endoscopic stenting with scheduled PCSEMS retrieval may be considered a feasible second-line treatment for short CD strictures to postpone surgery. However, larger head-to-head prospective studies are needed to understand the role of stenting as an alternative or additional treatment to EBD in CD.

Prevalence of Dental Caries among School Going Children in Dolakha, Nepal

IntroductionThere is a significant prevalence and morbidity of dental caries due to a lack of health education and insufficient preventive measures and the health status of students is not satisfactory. A number oforal disorders are linked to chronic diseases, and poor oral health has a major negative impact on overall health. People's everyday lives and general well-being are significantly impacted by pain, issues with eating, chewing, smiling, and communication brought on by missing, discolored, and damaged teeth. The aim of the study was to assess dental caries status among age groups, 3-14 years based on government and private schools.MethodsA cross-sectional comparative study done among 377 school going students age 3-15 years. Children from both private and public schools were included in the study. Dental caries status was assessed using the WHO oral health assessment form for children 2013.ResultsThe overall caries prevalence among the study participants was 341 (90.2%). Dental caries varied among age groups. Males scored higher dental caries levels than females. The private school students (5.78 ± 4.69) showed significantly higher levels of dental caries than the government school students (5.01 ±4.61).ConclusionsThe caries prevalence is very high in the school children of Dolakha with the highest burden among middle childhood age group with high number of untreated caries which emphasizes the need for further intervention.

Early versus late endoscopic treatment of pancreatic necrotic collections: A systematic review and meta-analysis.

Background and study aims Recently studies have compared early (<4 weeks) vs. late or standard (>4 weeks) endoscopic treatment of pancreatic necrotic collections (PNC) and have reported favorable results for early treatment. In this meta-analysis, we compared the efficacy and safety of early vs. late endoscopic treatment of PNC. Patients and methods We reviewed several databases from inception to September 30, 2021 to identify studies that compared early with late endoscopic treatment of PNC. Our outcomes of interest were adverse events (AEs), resolution of PNC, performance of direct endoscopic necrosectomy, need for further interventions, and mean number of endoscopic necrosectomy sessions. We calculated pooled risk ratios (RRs) with 95% confidence intervals (CIs) for categorical variables and mean differences (MDs) with 95% CIs for continuous variables. Data were analyzed by random effect model. Heterogeneity was assessed by I 2 statistic. Results We included four studies with 427 patients. We found no significant difference in rates of AEs, RR (95% CI) 1.70 (range, 0.56-5.20), resolution of necrotic or fluid collections, RR (95% CI) 0.89 (range, 0.71-1.11), need for further interventions, RR (95% CI) 1.47 (range, 0.70-3.08), direct necrosectomy, RR (95% CI) 1.39 (range, 0.22-8.80), mortality, RR (95% CI) 2.37 (range, 0.26-21.72) and mean number of endoscopic necrosectomy sessions, MD (95% CI) 1.58 (range,-0.20-3.36) between groups. Conclusions Early endoscopic treatment of PNC can be considered for indications such as infected necrosis or sterile necrosis with symptoms or complications; however, future large multicenter studies are required to further evaluate its safety.

The Volar Cortical Hinge: An Independent Risk Factor for Distal Radius Fracture Displacement.

Background Displaced distal radius fractures are prone to redisplacement after manipulation. This can result in the need for delayed surgery. Several criteria have been studied to predict the likelihood of redisplacement. We hypothesized that reduction in the volar cortex would be an additional predictive factor. Purpose The aim of this study was to assess whether the quality of the volar cortex reduction predicts the subsequent need for further intervention (surgery or remanipulation). As a secondary outcome, we assessed whether the quality of the reduction predicts the rate of malunion. Methods A retrospective review was performed of displaced adult distal radius fractures over a 2-year period that had undergone closed reduction at presentation. We identified 105 patients and a review of their electronic notes and radiographs was then performed. The volar cortex reduction was defined as "anatomical," "opposed," or "displaced." We assessed the radial height, radial inclination, radial/ulnar translation, volar/dorsal angulation, teardrop angle, presence of dorsal comminution, quality of the cast (molding, cast index), and volar cortex reduction. These measurements were taken at five time points (prereduction, postreduction, 1 week, 2 weeks, and 6 weeks). All patients that subsequently required surgical fixation or repeat reduction were identified as the primary outcome measure. The 6-week radiographs were assessed for radiographic malunion as our secondary outcome measure. A statistical analysis was then performed to assess the factors that influenced a loss of position and the need for delayed surgical intervention. Results Of the 105 patients, 22 patients required delayed surgery, 3 patients underwent a repeat manipulation, and 12 patients had a radiographic malunion at 6 weeks. During the study period, the proportion of patients requiring surgery or repeat manipulation in the displaced group was 10/21 (47.6%), in the opposed group it was 11/50 (23.4%), and in the anatomic group it was 4/36 (11.1%; p = 0.008). We then included the patients with a radiographic malunion and found the proportion of patients with an adverse outcome in the displaced group was 14/21 (66.7%), in the opposed group it was 17/47 (36.2%), and in the anatomic group it was 6/36 (16.7%; p = 0.001). At the 1-week time point, this association was equally significant, as the proportion in the displaced group was 17/33 (51.5%), in the opposed group it was 15/45 (33.3%) and in the anatomic group it was 1/22 (4.5%; p = 0.001). The patients' age, quality of cast, presence of dorsal comminution, and degree of initial displacement did not predict the subsequent need for surgery or remanipulation. Conclusion The most important factor in our study for significant redisplacement of an initially dorsally displaced distal radius fracture is the association of the volar cortex. This parameter maintains significance at the 1-week time point. This data shows that volar cortex reduction is a useful clinical measurement in assessing which distal radius fractures will undergo delayed displacement requiring intervention. Level of evidence Level 3-Retrospective comparative study.