Standard Management Protocol Research Articles

404 ERAS protocol to improve racial and ethnic disparities in pain management following cesarean delivery

To assess efficacy of an enhanced recovery after surgery (ERAS) protocol on racial/ ethnic disparities in pain management after cesarean. We performed a retrospective cohort study of all scheduled cesarean deliveries 6 months before and after ERAS implementation at our institution. Pre-ERAS, only sodium citrate was given preoperatively, and all postoperative medications were given as needed. The ERAS protocol included preoperative acetaminophen, celecoxib, ondansetron, and sodium citrate. Postoperatively, patients received scheduled nonsteroidal anti-inflammatory drugs and acetaminophen. Oral oxycodone was used as needed. The primary outcome was total opioid use in the first 48 hours post-cesarean before and after ERAS, reported in equivalents of 5mg Oxycodone tablets. Data were also analyzed by racial/ethnic groups; non-Hispanic Black (NHB), non-Hispanic White (NHW), Asian (A), and Hispanic (H). Analysis was by chi squared, independent t-tests, ANOVA, Mann Whitney U, and Kruskal-Wallis tests depending on variable and data normality. Pre-ERAS and post-ERAS groups included 50 and 99 women. There were more women and a higher percentage of Hispanic women in the post-ERAS group due to closure of another city hospital. Post-ERAS, total opioid use in 48 hours was less (13.6 vs 3.0 5mg Oxycodone tablets, p<0.001) and pain scores were lower on postoperative day 1 (POD1) and 2 (POD2) (POD1 max rest- 6.7 vs 5.3, p= 0.001; POD2 max rest 6.9 vs 6.0, p = 0.041). Pre-ERAS pain scores differed by race with NHB and Hispanic patients reporting the highest mean and max VAS pain scores POD1 and POD2 (POD1, max VAS rest: NHB-7.5, NHW-6.3, A-3.8 H-8.0, p=0.007). Pre-ERAS there were also differences in acetaminophen use and number of pain assessments by group on POD1. Post-ERAS, analgesic use, number of pain assessments and max VAS pain scores on POD1 were similar in all racial/ ethnic groups. A standardized ERAS protocol for post-cesarean pain management may improve disparities in post-cesarean pain control. More research is needed to continue addressing this important topic.

327 Implementation of an antepartum anemia protocol: a prospective cohort study

In randomized trials, antepartum intravenous iron sucrose (IVFe) is effective at improving pre-delivery Hemoglobin (Hb). Yet, there is a gap between this knowledge and implementation into care. We aimed to determine if implementation of a standardized protocol for management of antepartum anemia in the real-world improves IVFe utilization, as well as clinical outcomes. We performed a prospective cohort study evaluating incorporation of an anemia protocol into care. Our protocol, developed with multidisciplinary stakeholders, included (1) serial 3rd trimester Hb assessment (2) oral iron supplementation for antepartum Hb 9.5-11g/dL and (3) IVFe use (300mg weekly/3 weeks) for persistent Hb<9.5g/dL. We compared a 6-months Pre-implementation (1/2018-6/2018) to 6-months Post-implementation (1/2019-6/2019). Women with an antepartum Hb <11.0g/dL were included in this analysis. Outcomes evaluated: IVFe utilization, number of IVFe doses, pre-delivery Hb, and blood transfusion. 1455 women were included (Pre=792;Post=663) without significant baseline differences. Antepartum Hb nadir was no different between groups (Pre:10.2[9.6-10.6] vs. Post:10.2[9.6-10.6], p=0.67; Table). IVFe was administered to 23.6% of women with antepartum Hb<9.5g/dL in the Pre-implementation group compared to 41.7% Post-implementation (OR 1.79 95%CI [1.17-2.75]). Of the patients who received IVFe, more women in the Post-implementation received at least 3 IVFe doses (Pre:23.7% vs. Post:47.3%, p=0.02). Pre-delivery Hb significantly increased from Pre- to Post-implementation (Pre:10.9[10.1-11.6] vs. Post:11.0[10.3-11.7] p=0.03). There was a non-significant difference in blood transfusion between groups (Pre:7.1% vs. Post:5.0%, p=0.10). Implementation of a standardized antepartum anemia protocol is associated with increased IVFe utilization and an improvement in pre-delivery hemoglobin. Implementation strategies are needed to increase protocol adherence with the goal of a clinically significant reduction in blood product administration and morbidity at delivery.

Reducing revision rates following Pedicle Subtraction Osteotomy surgery: a single-center experience of trends over 7years in patients with Adult Spinal Deformity.

This is a single-center, retrospective study. To assess if implemented changes to clinical practice have reduced mechanical complications following pedicle subtraction osteotomy (PSO) surgery. Adult spinal deformity (ASD) is increasing in prevalence with concurrent increasing demands for surgical treatment. The most extensive technique, PSO, allows for major correction of rigid deformities. However, surgery-related complications have been reported in rates up to 77% and especially mechanical complications occur at unsatisfactory frequencies. We retrospectively included all patients undergoing PSO for ASD between 2010 and 2016. Changes to clinical practice were introduced continuously in the study period, including rigorous patient selection; inter-disciplinary conferences; implant-material; number of surgeons; surgeon experience; and perioperative standardized protocols for pain, neuromonitoring and blood-loss management. Postoperative complications were recorded in the 2-year follow-up period. Competing risk survival analysis was used to assess cumulative incidence of revision surgery due to mechanical complications. The Mann-Kendall test was used for analysis of trends. We included 185 patients undergoing PSO. The level of PSO changed over the study period (P < 0.01) with L3 being the most common level in 2010 compared to L4 in 2016. Both preoperative and surgical corrections of sagittal vertical axis were larger towards the end of the study period. The 2-year revision rate due to mechanical failure steadily declined over the study period from 52% in 2010 to 14% for patients treated in 2016, although without statistically significant trend (P = 0.072). In addition, rates of mechanical complications steadily declined over the study period and significant decreasing trends were observed in time trend analyses of overall complications, major complications and rod breakage. We observed decreased risks of revision surgery due to mechanical complications following PSO in patients with ASD over a 7-year period. We attribute these improvements to advancements in patient selection, surgical planning and techniques, surgeon experience and more standardized perioperative care. III.

The Outcome of Operated Neonates with an Isolated Congenital Diaphragmatic Hernia in a Limited Resource Scenario: A Critical Analysis.

Introduction:Congenital diaphragmatic hernia (CDH) is one of the most common neonatal emergencies, and the ideal current therapy requires high standards of neonatal care and advanced facilities. However, majority of neonates born with CDH are treated in public sector hospitals, with limitations in resources and workforce.Objectives:The aim of the study was to review and analyze the outcome of operated neonates with isolated CDH in a public sector hospital and medical college where a standard protocol of management was followed, considering the need for optimization of therapy in view of the resource constraints.Materials and Methods:A retrospective chart review and analysis of the antenatal, preoperative, operative, and postoperative records of all neonates with operated CDH during the 3-year period from June 2015 to June 2018 at the hospital was done. The standard institutional protocol being followed included preoperative stabilization, risk stratification for patient selection, early decision regarding operative intervention, and continued postoperative ventilation.Results:During the 3-year period, 78 children were admitted with CDH, of which 40 newborns with operated CDH were studied. The mean age at surgery was 72 h. Thirty-five of these 40 cases (87.5%) made an uneventful recovery, while mortality was 5/40 (12.5%). All mortalities (5/40) occurred during the postoperative period after 3 days due to respiratory failure while being ventilated.Conclusion:The strategy of a uniform protocol in the management of CDH adapted to the practical constraints of the institution yielded good results in the low-to-moderate risk group of neonatal CDH. The approach also facilitated the segregation of high-risk cases and optimal utilization of available facilities in a limited resources scenario.

Supplementation of Selenium Nanoparticles-Loaded Chitosan Improves Production Performance, Intestinal Morphology, and Gut Microflora in Broiler Chickens.

The current study aimed to evaluate the efficacy of selenium nanoparticles (SeNPs), combined or loaded with chitosan (COS), in broiler chickens reared under standard management protocols. The parameters under investigation were production performance, organ development, components of the intestinal barrier, and ileal microbial count. Two hundred and forty day-old chicks were raised in five groups, with each group containing eight replicates (n=6/replicate). The control group received a basal diet whereas the other four groups received basal diets supplemented with SeNPs (0.5 mg/kg), COS (200 mg/kg), SeNPs+COS (0.5 mg/kg SeNPs + 200 mg/kg COS), and SeNPs-loaded COS (SeNPs-L-COS) (200 mg/kg) respectively. On day 35, two birds/replicate were sampled to collect the viscera under investigation. The results revealed that dietary inclusion of SeNPs-L-COS increased (p<0.05) the body weight gain and improved (p<0.05) feed conversion ratio. Similarly, SeNPs-L-COS supplementation increased (p<0.05) the small intestinal villus surface area as well as the count of acidic goblet cells and intraepithelial lymphocytes when compared with the control group. Whereas the total goblet cell count was higher (p<0.05) in the small intestines of both the SeNPs+COS and SeNPs-L-COS groups. Microbial analysis of ileal contents also revealed an increase (p<0.05) in Lactobacilli species count with a concurrent decrease (p<0.05) in Escherichia coli count in the SeNPs-L-COS group when compared with the COS and control groups. Based on the results of the current trial, we can conclude that supplementation with SeNPs-L-COS is a superior combination for promoting the gut health and performance of broilers.

Lumen-Apposing Metal Stents for Walled-Off Pancreatic Necrosis: A Practice Pattern Survey of Gastroenterologists

<h2>ABSTRACT</h2><h3>Background & Aims</h3> Endoscopic ultrasound-guided placement of LAMS has emerged as an effective treatment for WON following acute necrotizing pancreatitis, but a standardized management protocol has not yet emerged. We sought to characterize practice variations in the use of lumen-apposing metal stents (LAMS) for the treatment of walled-off pancreatic necrosis (WON). <h3>Methods</h3> A 30-question survey was sent to 341 endoscopists in the United States to collect information on practitioner demographics, procedural practices, necrosectomy practices, and LAMS-related adverse events. <h3>Results</h3> A total of 69 of the 341 surveys were completed for a response rate of 20.2%. Almost all reported using LAMS placement as the primary method of WON treatment (92.5%). At the time of LAMS placement, almost half of respondents perform balloon dilation (45.2%), and a minority place pigtail stents through the LAMS channel (15.0%). Necrosectomy is performed by less than half during index LAMS placement procedure (46.8%). Approximately half never use hydrogen peroxide lavage (52.4%). Most respondents reported experiencing adverse events at some point. About half reported a stent indwell time of the greater than 1 month. <h3>Conclusion</h3> A convergence of practice patterns when using LAMS to treat WON has not been demonstrated. Considerable variability exists in certain aspects of LAMS use including placement technique, necrosectomy practices, follow-up treatment, and stent removal. Further investigation is necessary to standardize this procedure to effectively and safely treat WON.

The Expanding Spectrum of Dystrophinopathies: HyperCKemia to Manifest Female Carriers.

ABSTRACTBackground:X-linked dystrophinopathies have a wide spectrum of manifestation. The most common forms are severe Duchenne muscular dystrophy (DMD) and Becker’s muscular dystrophy (BMD). However, less common manifestations are isolated cardiomyopathy, myalgia, cramps, rhabdomyolysis, hyperCKemia, and manifest female carriers. Materials and Methods:This case series is a part of an ongoing long-term prospective cohort of children with DMD and BMD from the year 2013. The clinical details are maintained in the clinic files and standard management protocols are followed. For this case series, clinical details were collected from the clinic files and recorded on a case record proforma. Details of cardiology, radiology, and genetic investigations were collected. Results:We report cases of classical DMD, BMD, manifest female carrier with proximal pelvic girdle weakness, a female carrier with isolated dilated cardiomyopathy, and infantile-onset asymptomatic hyperCKemia. We also report less common but notable clinical presentations of DMD, autism, intellectual disability, epilepsy, and asymptomatic transaminitis. Conclusions:It is important for clinicians to be aware of these less common clinical presentations for prompt diagnosis, and to avoid unnecessary investigations. Here, we report the clinical spectrum of dystrophinopathies seen in pediatric neuromuscular clinic and emphasize the variability and expanding knowledge about different manifestations of dystrophinopathies.

The importance of general practitioners in emergency and pre-hospital first aid

The purpose of this study is to determine the critical role and managerial impact of general practitioners in pre-hospital first aid and emergency work. The study subjects were 100 emergency patients treated in a hospital between May 2020 and November 2021. They were randomly assigned to an observation group and a control group, each having 50 cases. The control group followed a standard management protocol, but the observation group included emergency care. Management, compare the management effectiveness of the two patient groups. The observation group's arrival and rescue times were much shorter than those in the control group. Patient satisfaction was much greater in the observation group than in the control group. Conclusion: General practitioners have a broader range of medical expertise and are better equipped to give complete medical care to their patients. Emergency management can enhance general practitioners' productivity, further reduce emergency response time, prioritize patient treatment time, and raise the success rate of rescue. Additionally, patient satisfaction.

Perioperative nutrition care and dietetic practices in the scope of bariatric surgery in Saudi Arabia using adapted protocols for evaluation.

Objectives:This study evaluates the availability of perioperative nutritional care protocols and the practices of bariatric registered dietitians in Saudi Arabia. The primary outcomes of the study were conducted using an adapted American survey “with permission.”Methods:A cross-sectional survey of a selected 32 dietitians providing bariatric services completed a self-administered online questionnaire from 12 hospitals in Jeddah, Saudi Arabia.Results:All surveyed dietitians were females, mainly Saudi nationals (93.9%, n = 30), and accredited by the Saudi Commission for Health Specialties (93.8%, n = 30). Only 37.5% (n = 6) of the dietitians were specialized in bariatric surgery. Perioperative common practices of dietitians included a conduct of screening for nutrition risk before (44%, n = 14) and after surgery (62.5%, n = 20) and applied a nutrition management protocol that is mainly based on the application of nutrition care process (62.5%, n = 20). Dietitians (81%, n = 26) reported the importance of having standardized protocols for nutritional management of patients undoing bariatric surgery, where 69% (n = 22) confirmed the availability of pre-operative written protocols in hospitals and 75% (n = 24) confirmed the existence of post-operative protocols. Pre-operative practices included using approaches for weight loss before surgery, for example, very low and low-calorie diet. Dietitians (25%, n = 8) see two to ten patients per month. The sleeve gastrectomy procedure is the most often performed surgery.Conclusion:This is the first study to evaluate the perioperative nutrition care protocols and practices related to bariatric surgery in Saudi Arabia. Perioperative bariatric protocols are available, but some dietitians are not aware of their availability and contents. Researchers emphasize the importance of creating national protocols by the Saudi Credentials Body to standardize practices within the field.

Improving Management of Adult Ankle Fractures in Malawi: An Assessment of Providers' Knowledge and Treatment Strategies.

The burden of musculoskeletal trauma is increasing worldwide, especially in low-income countries such as Malawi. Ankle fractures are common in Malawi and may receive suboptimal treatment due to inadequate surgical capacity and limited provider knowledge of evidence-based treatment guidelines. This study was conducted in 3 phases. First, we assessed Malawian orthopaedic providers' understanding of anatomy, injury identification, and treatment methods. Second, we observed Malawian providers' treatment strategies for adults with ankle fractures presenting to a central hospital. These patients' radiographs underwent blinded, post hoc review by 3 U.S.-based orthopaedic surgeons and a Malawian orthopaedic surgeon, whose treatment recommendations were compared with actual treatments rendered by Malawian providers. Third, an educational course addressing knowledge deficits was implemented. We assessed post-course knowledge and introduced a standardized management protocol, specific to the Malawian context. In Phase 1, deficits in injury identification, ideal treatment practices, and treatment standardization were identified. In Phase 2, 17 (35%) of 49 patients met operative criteria but did not undergo a surgical procedure, mainly because of resource limitations and provider failure to recognize unstable injuries. In Phase 3, 51 (84%) of 61 participants improved their overall performance between the pre-course and post-course assessments. Participants answered a mean of 32.4 (66%) of 49 questions correctly pre-course and 37.7 (77%) of 49 questions correctly post-course, a significant improvement of 5.2 more questions (95% confidence interval [CI], 3.8 to 6.6 questions; p < 0.001) answered correctly. Providers were able to identify 1 more injury correctly of 8 injuries (mean, 1.1 questions [95% CI, 0.6 to 1.6 questions]; p < 0.001) and to identify 1 more ideal treatment of the 7 that were tested (mean, 1.0 question [95% CI, 0.5 to 1.4 questions]; p < 0.001). Adult ankle fractures in Malawi were predominantly treated nonoperatively despite often meeting evidence-based criteria for surgery. This was due to resource limitations, knowledge deficits, and lack of treatment standardization. We demonstrated a comprehensive approach to examining the challenges of providing adequate orthopaedic care in a resource-limited setting and the successful implementation of an educational intervention to improve care delivery. This approach can be adapted for other conditions to improve orthopaedic care in low-resource settings.

Analysis of primary cesarean sections in NTSV (Nulliparous, Term, Single, Vertex) in a tertiary care hospital in South India

Introduction and Aim: Globally, rising caesarean section rates have become public health concern. Cesarean section analysis and audits using Robson ten group classification system have identified the main drivers of Cesarean section rates (CSR) are the gravidas with previous CS and the nulliparous with term singleton foetus with vertex presentation (NTSV).1-10 Given the low rates of vaginal birth after a cesarean section, once a woman undergoes her first CS, she is extremely likely to have repeat CS in subsequent pregnancies. This increases the burden of high risk pregnancies and increased CS rates subsequently. Reducing primary cesarean sections in NTSV is the key for improving overall health statistics of the institutions. Hence, this one year prospective study was conducted to know the factors contributing to CS in NTSV population in a tertiary care hospital in South India. Materials and Methods: The study is prospective observational study which is conducted in labour wards of department of Obstetrics & Gynaecology at teaching hospital attached to KLE Academy of Higher Education’s Jawaharlal Nehru Medical College, Belagavi, from January 2016 to December 2016. Results: Total number of gravidas who delivered during study period, were 6236, out of which 2494 (40%) were NTSVs. The CS among NTSVs were found to be 849(34.01%). The main indications for emergency cesarean sections in NTSV were fetal distress, non-progress of labour, failed induction i.e. 44.76%, 16.65% and 15.31%, respectively. Conclusion: The primary cesarean sections among the NSTV is an important contributor to the overall cesarean sections of the health institute. The main indications of CS were fetal distress, non-progress of labour and failed induction. There is a need to develop standard clinical protocols for management of these conditions and emphasise vaginal delivery in NTSVs. Also strategies like training the obstetricians in interpretation and management of suspicious and non-reactive

Perspectives of health workers on the referral of women with obstetric complications: a qualitative study in rural Sierra Leone

ObjectivesSierra Leone has one of the highest maternal mortality ratios in the world. Timely and well-coordinated referrals are necessary to reduce delays in providing adequate care for women with obstetric...

Management of Atrial Fibrillation Following Cardiac Surgery: Observational Study and Development of a Standardized Protocol.

Postoperative atrial fibrillation (POAF) is the most common complication occurring after cardiac surgery. Guidelines for the management of this complication are scarce, often resulting in differences in treatment strategy use among patients. To evaluate the management of POAF in a cardiac surgery department, characterize the extent of its variability, and develop a standardized protocol. This was an observational retrospective study with data from patients who underwent cardiac surgeries with subsequent POAF between January 1, 2017, and June 1, 2018. We assessed the difference in the proportions of patients whose first POAF episodes were treated with a rate control (RaC) strategy, a rhythm control (RhC) strategy, and both among different hospital units. We also assessed the mean duration of POAF episodes, POAF recurrences, and the management of anticoagulation. Data from 97 patients were included in this study. The POAF management strategy differed significantly among the 3 types of hospital units (P = 0.001). Considering all POAF episodes (including all recurrences), 83 of the 97 patients (85.6%) received amiodarone as part of the RhC strategy. Anticoagulation was used in 58 (59.8%) patients and was suboptimal according to the study criteria in 29.5% of the patients included. Based on these results, a hospital working group developed a standardized protocol for POAF management. POAF management was heterogeneous at our institution. This article highlights the need for clear practice guidelines based on large prospective studies to provide care according to best practices.

Standard management protocol to improve the short-term outcome of biliary atresia.

This study compared the outcomes of patients with biliary atresia (BA) treated according to a standardised protocol with historical patients. This is a single-centred retrospective study of BA patients treated from 1980 to 2016. A standardised treatment protocol was established since 2008 regarding peri-operative management. The outcomes being compared between the two groups (Groups I and II = before and after 2008, respectively) were jaundice clearance (JC), incidence of recurrent cholangitis, hospital admission and native liver survival (NLS). A total of 128 patients were included (Group I = 100, Group II = 28). The overall median follow-up period was 15.3 years (I vs. II = 20.6 years vs. 5.1 years, respectively). There was no significant difference in the JC at the sixth month between the two groups (I vs. II = 60.0 vs. 82.1%, respectively, P = 0.07). The incidence of recurrent cholangitis was similar between the two groups (I vs. II = 39 vs. 35.7%, respectively, P = 0.45), but the median hospital admission episode per patient was non-significantly higher in Group I (I vs. II = 4.2 vs. 2.7, respectively, P = 0.08). There was an improvement in the 1-year NLS rate in Group II (I vs. II = 69.0 vs. 85.7%, respectively, P = 0.05). The introduction of a standardised management protocol has improved the short-term outcome of BA patients, with a better 1-year NLS observed.

Effectiveness of Multi-Modal Blood Management in Bernese Periacetabular Osteotomy and Periacetabular Osteotomy with Proximal Femoral Osteotomy.

ObjectiveBernese periacetabular osteotomy (PAO), an effective treatment for patients with developmental dysplasia of the hip (DDH), is characterized by wide exposure, cancellous bone surgery, and difficult techniques. In addition, the hip joint is deep and of rich muscles and neurovascular supply, which significantly increases bleeding. For patients who had combined proximal femoral osteotomy (PFO), the blood loss may be tremendous. The blood management for PAO is still challenging. We aimed to evaluate the effectiveness of multi‐modal blood management for PAO and PAO combined with PFO.Patients and MethodsWe retrospectively evaluated patients who had PAO with or without combined procedures from June 2010 to December 2018 in our department. The multi‐modal blood management protocol included three parts: (i) pre‐operation – autologous component blood donation and iron supplement/erythropoietin; (ii) during operation – controlled hypotension anesthesia, intraoperative auto‐blood transfusion, tranexamic acid (20 mg/kg, IV / 0.5 g local), and standardized surgical procedure to shorten surgical time; and (iii) post‐operation – no drainage used, selective allo‐blood transfusion, and ice packing technique. As the lacking of the above standard blood management protocol during PAO or PAO + PFO initially, we divided all the patients into three groups: Group A (PAO) – before protocol started, 74 hips; Group B (PAO) – after protocol finalized, 178 hips; Group C (PAO + PFO) – after protocol finalized, 55 hips. The intraoperative blood loss, surgical time, allo‐transfusion rate, pre‐ and postoperative hemoglobin were compared among groups.ResultsBoth the general characteristics and preoperative hemoglobin were comparable among the three groups (P < 0.001). The intraoperative blood loss was 797.1 ± 312.2, 381.7 ± 144.0 and 544.1 ± 249.1 mL, respectively. The surgical time was 109.6 ± 18.5, 80.2 ± 20.0 and 154.3 ± 44.7 min, respectively. The allo‐transfusion rate was 86.5%, 0%, and 2%, respectively. The mean decreased value of hemoglobin on the first postoperative day of group B and group C was greater than that of group A, which was associated with the higher allo‐transfusion rate of group A. However, on the third postoperative day, the mean decreased value of hemoglobin of group B was less than that of group A and group C.ConclusionPerioperative multi‐modal blood management for PAO or PAO + PFO can significantly decrease intraoperative blood loss, reduce allo‐transfusion rate from over 80% to 0%, and ensure the rapid recovery of postoperative hemoglobin level.

Outcomes following adoption of a standardized protocol for abscess drain management in pediatric appendicitis

Background/purposeThough evidence-based clinical pathways for the diagnosis and treatment of pediatric appendicitis have been established, protocols guiding management of percutaneous abscess drains are lacking. We hypothesized a drain management protocol utilizing drain output and clinical factors instead of fluoroscopic drain studies would reduce interventional radiologic procedures without adversely impacting clinical outcomes. MethodsA standardized protocol was uniformly adopted at a tertiary-care children's hospital in April 2016. A retrospective chart review included all cases of appendicitis requiring abscess drainage by interventional radiology three years pre- and postprotocol implementation. ResultsFifty-eight patients (preprotocol = 39, postprotocol = 19) underwent percutaneous abscess drainage, of whom 52 (preprotocol = 34, postprotocol = 18) required a drain. Baseline demographics and clinical presentation were similar across groups. Following protocol implementation, total number of IR procedures decreased from 2.4 to 1.3 per patient (p = 0.004). There was no significant difference in the number of postprocedure diagnostic imaging studies, readmissions, or inpatient days, and there was a trend towards a decrease in number of drain days (10.7 to 5.7, p = 0.067). ConclusionA standardized protocol for management of abscess drains for complicated appendicitis reduced the number of IR procedures without a negative impact on clinical outcomes or increase in alternative imaging studies. This approach may decrease radiation exposure, anesthetic administration, and resource utilization. Type of studyTreatment study (retrospective comparative study). Level of evidenceLevel III.

Improving the Management of Adult Patients with Acute Ankle Fractures in Malawi: An Examination of Providers’ Knowledge and Treatment Strategies

Category:Trauma; Ankle; OtherIntroduction/Purpose:The burden of trauma is growing worldwide, especially in low-income countries. In Malawi, ankle fractures are common and may receive inadequate treatment due to limited surgical capacity and provider knowledge of evidence- based treatment guidelines. We sought to examine ankle fracture management in Malawi, identify providers’ knowledge gaps, and address these knowledge gaps in ways that were relevant to the Malawian context.Methods:This study had three phases. First, we performed a baseline assessment of orthopaedic providers’ knowledge of anatomy, injury identification, and ideal treatment methods. Second, we observed providers’ treatment strategies while they cared for adult patients with ankle fractures over a five-week period at a large central hospital. We performed blinded, post-hoc reviews of patient x-rays and compared our treatment recommendations to the plans and rationales of Malawian providers. Third, we implemented an educational course addressing the knowledge gaps we identified, performed pre- and post-course knowledge assessments, and launched a standardized protocol for ankle fracture management in Malawi.Results:In our baseline assessment, we identified significant knowledge gaps in identification of common injuries on x-ray and ideal treatment practices. In our observations of treatment practices, 17/49 patients (35%) met operative criteria based on evidence-based guidelines but did not receive operative treatment by Malawian providers. For 7/17 (41%) of these patients, Malawian providers believed nonoperative treatment was ideal. In our educational course, 51/61 participants (84%) performed better between the pre- and post-course assessments. Overall scores improved from a mean of 66% to 77%, an improvement of 5.2/49 questions (95% CI 3.8-6.6, p<0.001). Providers could identify one more injury correctly out of 6 that were tested (95% CI 0.6-1.6, p<0.001), and identify one more ideal treatment out of 7 (95% CI 0.5-1.4, p<0.001).Conclusion:In Malawi, ankle fractures are common, and most are treated non-operatively. This is partly due to resource limitations, but also due to gaps in provider knowledge and lack of treatment standardization. Here we demonstrated a comprehensive approach to examining the challenges to providing adequate care, as well as the successful implementation of an intervention to improve care capacity nationwide.

Management of Ankle Fractures with Syndesmotic Disruption: A Survey of Orthopaedic Surgeons

Category:Ankle; TraumaIntroduction/Purpose:With an increasing frequency of syndesmotic fixation during ankle fracture ORIF and no current gold standard management protocol, it is important for surgeons to understand the frequency and usage patterns of the various techniques among other orthopaedic surgeons. The purposes of this study are to determine how orthopaedic surgeons currently manage ankle fractures with concomitant syndesmotic disruption and to identify surgeon demographics predictive of syndesmotic management.Methods:An 18-question survey, including 10 specific syndesmotic management questions was sent to the Orthopaedic Trauma Association (OTA) and Canadian Orthopaedic Association (COA), as well as sent to email addresses of foot and ankle-fellowship trained surgeons. Surgeon demographic questions included years, country, and type of practice, fellowship(s) completed, setting of ankle fracture surgery, and number of ankle fractures operated on per year. Multinomial regression analysis was performed to determine if surgeon demographics were predictive of syndesmotic management.Results:One-hundred ten orthopaedic surgeons completed our survey. Selected predictors of syndesmotic management included: private practice with academic appointments (0.077 [0.007, 0.834]; p=0.035) being predictive of not using screws through an ORIF plate; foot & ankle fellowship (9.981 [1.787, 55.764]; p=0.009) and trauma fellowship (6.644 [1.302, 33.916]; p=0.023) predictive of utilizing screws through a plate; no fellowship (14.886 [1.226, 180.695]; p=0.034) predictive of only using 1 screw; and surgeons practicing in the U.S. were more likely to not use screws across just 3 cortices (0.031 [0.810, 3.660]; p=0.009). Additionally, among those utilizing suture-button devices, foot & ankle fellowship-trained surgeons were more likely to implement suture-button through plate (7.676 [1.286, 45.806]; p=0.025).Conclusion:Several surgeon factors influence decision making in the management of ankle fractures with syndesmotic disruption. This study raises awareness of differences in management strategies that should be used for further discussion when determining a potential gold standard for management of these complex injuries.

Reducing post-operative opioids in children undergoing outpatient urologic surgery: A quality improvement initiative

Opioid prescriptions have been implicated as one of the proximate causes of the national opioid epidemic. Children and adolescents and their families are at risk for increased opioid exposure through prescriptions after surgery. In pediatric urologic surgery, indications for postoperative opioids can vary widely and a focus on opioid stewardship is important to reduce potential harms. To measure the efficacy of a quality improvement initiative aimed to reduce post-operative opioids for pain management in a large pediatric surgical cohort. Patients undergoing ambulatory pediatric urologic surgery at a tertiary children's hospital between July 2016 to June 2019 were analyzed. Structured physician peer-to-peer comparisons, electronic health record redesign and a standardized pain management protocol were implemented. Rate of opioid prescriptions per month, utilization of non-opioid analgesia, unplanned encounters in the emergency department and/or office during implementation were aggregated. Opioid doses and prescribed opioid days before and after protocol implementation were analyzed. A subcohort, from October-December 2018 was administered a patient-reported outcome questionnaire focused on pain management and return to baseline activity. A total of 6684 consecutive outpatient urologic cases were included (median age=3.3 years old (IQR 0.9-9.2) and 92.3% male). Comparing 6 months pre-intervention and the post-intervention latest 6 month intervals, opioid prescription rate decreased from 43.9% to 2.3% (p<0.001). Additionally, non-opioid analgesia with ketorolac increased from 30.7% to 50.6% (p<0.001). Concurrently, no differences in the rate of office visits within 5 days, overall ED visits, ED visits for pain or for bleeding within 30 days after implementation were identified. Between October to December 2018, 373 cases were performed and a Patient-Reported Outcome (PRO) questionnaire was completed for 128 of those patients (34%). Families reported a low patient pain score of 3.7 (SD 2.4) and a rapid postoperative recovery time of a median 2 (IQR 1-4) days to full resumption of pre-operative level of activity. High satisfaction with opioid reduction in post-operative pain management was reported (median score of 10 (IQR 8-10)). Opioid prescriptions and utilization may be minimized without increasing unplanned encounters or adversely affecting quality of life. The QI framework utilized in this process can be implemented to reduce opioid exposure in other surgical patient populations.

Clinical and laboratory predictors of 30-day mortality in severe acute malnourished children with severe pneumonia.

To determine the predictors of mortality within 30days of hospital admission in a diarrhoeal disease hospital in Bangladesh. Cohort study of hospitalised children aged 0-59months with severe acute malnutrition (SAM) and severe pneumonia in Dhaka Hospital, icddr,b, Bangladesh from April 2015 to March 2017. Those discharged were followed up, and survival status at 30days from admission was determined. Children who died were compared with the survivors in terms of clinical and laboratory biomarkers. Multivariable logistic regression analysis was used for calculating adjusted odds ratio for death within 30days of hospital admission. We enrolled 191 children. Mortality within 30days of admission was 6% (14/191). After adjusting for potential confounders (hypoxia, CRP and haematocrit) in logistic regression analysis, independent factors associated with death were female sex (aOR=5.80, 95% CI: 1.34-25.19), LAZ <-4 (aOR=6.51, 95% CI: 1.49-28.44) and Polymorphonuclear Leucocytes (PMNL) (>6.0×109 /L) (aOR=1.06, 95% CI: 1.01-1.11). Using sex, Z-score for length for age (LAZ), and PMNL percentage, we used random forest and linear regression models to achieve a cross-validated AUC of 0.83 (95% CI: 0.82, 0.84) for prediction of 30-day mortality. The results of our data suggest that female sex, severe malnutrition (<-4 LAZ) and higher PMNL percentage were prone to be associated with 30-day mortality in children with severe pneumonia. Association of these factors may be used in clinical decision support for prompt identification and appropriate management for prevention of mortality in this population.