Academic Tertiary Care Hospital Research Articles

8506 Surgical Management of Late 1st Trimester Cesarean Scar Ectopic Pregnancy

<h3>Study Objective</h3> To describe the safe surgical management of late 1^st trimester cesarean scar ectopic pregnancy. <h3>Design</h3> A case report. <h3>Setting</h3> Academic tertiary care hospital. Patient placed in dorsal lithotomy in Trendelenburg position with sponge on ring forceps placed in the vagina. <h3>Patients or Participants</h3> 33-year-old G8P4044 presenting with foul smelling discharge and an LMP 10 weeks prior. Her surgical history is notable for 3 prior cesarean sections and laparoscopic right salpingectomy for ectopic pregnancy. Pelvic ultrasound notable for live intrauterine pregnancy measuring 10 weeks 6 days with complete posterior placenta previa and thin myometrium in lower uterine segment concerning for cesarean scar ectopic pregnancy. <h3>Interventions</h3> Patient was diagnosed with cesarean scar ectopic pregnancy by Maternal Fetal Medicine. She underwent preoperative bilateral uterine artery embolization by Interventional Radiology. She underwent total laparoscopic gravid hysterectomy and left salpingectomy with lysis of adhesions by Benign Gynecology. <h3>Measurements and Main Results</h3> Diagnosis and management of cesarean scar ectopic pregnancy requires multidisciplinary collaboration for safe management. Here, we present a case of a late 1^st trimester cesarean scar ectopic pregnancy managed safely with input from Maternal Fetal Medicine, Family Planning, Interventional Radiology and Benign Gynecology teams. We show the diagnosis of cesarean scar ectopic pregnancythrough transvaginal ultrasound and discuss management options in the late 1^st trimester. We show preoperative bilateral uterine artery embolization. Finally, we show technique for safe lysis of adhesions with low estimated blood loss during laparoscopic total gravid hysterectomy. Final pathology was consistent with intrauterine fetus with placenta accreta. The patient was discharged home on day of surgery without any postoperative complications. <h3>Conclusion</h3> A detailed 1^st TM ultrasound should be considered inpatients who are high risk for cesarean scar ectopic pregnancy. Embolization of bilateral uterine arteries prior to gravid hysterectomy can decrease intraoperative blood loss. A multidisciplinary approach is preferred for management of late 1^st trimester cesarean scar ectopic pregnancies.

Laparoscopic Repair of Post-Coital Vaginal Perforation Communicating with the Abdominal Cavity

<h3>Study Objective</h3> The objective of this video is to describe an approach to the work-up and surgical management of postcoital vaginal laceration communicating with the abdominal cavity. <h3>Design</h3> N/A. <h3>Setting</h3> An academic tertiary care hospital. <h3>Patients or Participants</h3> The patient is an 18 y/o G0 who presented 12 hours after intercourse with heavy vaginal bleeding, diffuse abdominal pain, and multiple syncopal episodes. Initial exam was notable for hypotension, diffuse abdominal pain with involuntary guarding, and copious vaginal bleeding from the vagina of unclear origin. <h3>Interventions</h3> A bedside FAST scan demonstrated free fluid in Morrison's pouch. CT scan demonstrated multiple foci of air in the pelvis consistent with vaginal perforation. The patient was taken to the OR for laparoscopic repair of a 4cm full-thickness vaginal perforation communicating with the abdominal cavity, where 300cc of hemoperitoneum was evacuated from the abdominal cavity. An air leak test was performed at the end of the case to ensure no injury to the sigmoid colon. <h3>Measurements and Main Results</h3> The patient received was discharged on POD#1 in stable condition. <h3>Conclusion</h3> Vaginal perforation communicating with the abdominal cavity is a rare complication of intercourse that can have a delayed presentation and occur with hemorrhagic shock. FAST scan can be employed at the bedside to rapidly identify massive hemoperitoneum. Though prior case reports have mainly reported an open repair, a laparoscopic approach is a safe and effective method to repair vaginal defects communicating with the abdominal cavity. Finally, given the high rate of traumatic rectovaginal fistula reported in this population, surgeons should consider the use of an intraoperative air-leak test to confirm colorectal integrity after the repair.

Optimizing Surgeon Longevity: Ergonomics in Robotic Surgery

<h3>Study Objective</h3> To describe the risk of physical injury to robotic surgeons and review optimal set up of the robotic console, bedside assistant, and uterine manipulator that decrease risk of a work-related injury. <h3>Design</h3> Video demonstration with narrated description. <h3>Setting</h3> Tertiary care academic teaching hospital. <h3>Patients or Participants</h3> Surgeons trained in robotic surgery. <h3>Interventions</h3> Ergonomically favorable operating room set up for the robotic console, bedside assistant, and uterine manipulator. <h3>Measurements and Main Results</h3> Per the US Labor Department, the highest incidence of work-related injuries is in healthcare. Prior research suggests robotic surgery is more ergonomically favorable in the upper back, shoulders, arms and wrists and mentally less stressful than conventional laparoscopy. However, over 50% of robotic surgeons have work related pain with less than 20% of all robotic surgeons having received formalized ergonomic training. This video reviews appropriate operating room set up for the robotic console, bedside assistant, and uterine manipulator along with common positioning and postural errors that may lead to physical strain. <h3>Conclusion</h3> In order to maximize career longevity and minimize work-related injuries, surgeons must understand the ergonomically correct set up that is recommended for the robotic console, bedside assistant, and uterine manipulator. Early adoption of these recommendations can help prevent physical injuries and should be an essential foundation of trainees' operative skills.

8418 Fascial Closure Technique after Gynecologic Laparoscopic Surgery and Postoperative Pain: A Randomized Controlled Trial

<h3>Study Objective</h3> To compare postoperative pain between closing port site fascia > 10 mm via traditional direct method versus fascial closure device (FCD) in patients undergoing minimally invasive gynecologic surgery. <h3>Design</h3> Prospective, singled-blinded, randomized controlled trial. Primary outcome was pain on postoperative days (POD) 1, 2, 7, and 14. <h3>Setting</h3> Tertiary care academic affiliated hospital. <h3>Patients or Participants</h3> Patients 18 years undergoing laparoscopic or robotic gynecologic procedure with one port site > 10 mm for any indication (benign and malignant) were eligible. Patients were identified in preoperative holding and consented. 123 participants were enrolled from March 2021 to March 2022. <h3>Interventions</h3> Participants were randomized to fascial closure with FCD or traditional direct closure on the day of surgery. Postoperative pain scores were assessed using digital 100-point Visual Analog Scale. Fascial closure was timed, and narcotics utilized while admitted were converted into morphine equivalents per hour. <h3>Measurements and Main Results</h3> Descriptive statistics were run on all variables and group comparisons made using independent sample t-tests, chi-squares, or Mann Whitney U. 60 patients (48.8%) were randomized to FCD group and 63 patients (51.2%) to traditional direct closure. There was no statistical difference in pain scores between FCD (POD1: 60.27±22.90, POD2: 48.61±23.01, POD7: 33.60±24.12, POD14: 23.00±24.99) and traditional closure (POD1: 53.60±29.33, POD2: 26.94±28.59, POD7: 29.31±24.05, POD14: 18.57±24.62) groups or narcotic use in morphine equivalents per hour (1.54±1.11 vs 1.98±1.23, FCD and traditional closure, respectively). Length of fascial closure was statistically significantly lower using the FCD (<i>Mdn</i> = 77.0) compared to traditional closure (<i>Mdn</i> = 137.0), <i>p</i> = .001. <h3>Conclusion</h3> This study demonstrates no significant difference in postoperative pain scores at multiple time points or narcotic use between use of FCD versus traditional direct closure, but it does show a statistically significant lower fascial closure time using the FCD.

Systematic Approach to Using Magnetic Resonance Imaging for the Patient with Deep Infiltrating Endometriosis

<h3>Study Objective</h3> To demonstrate systematically how to identify deep infiltrative endometriosis (DIE) on MRI and compare preoperative MRI imaging to intraoperative laparoscopic findings. <h3>Design</h3> Video demonstration of MRI images and surgical footage with narrated description. <h3>Setting</h3> Tertiary care academic teaching hospital. <h3>Patients or Participants</h3> Patients with deep infiltrative endometriosis in the anterior, middle, and posterior compartments. <h3>Interventions</h3> Preoperative MRI was completed for patients with suspected DIE due to reported symptoms or examination findings to confirm DIE presence and extension. <h3>Measurements and Main Results</h3> The diagnosis and evaluation of DIE is difficult with physical examination and laparoscopic exploration alone. MRI is easily reproducible and surveys the anterior, middle, and posterior compartments of the pelvis in single study even if lesions are obscured by adhesions. This video reviews how to systematically identify DIE on preoperative MRI and provides specific tips for each pelvic compartment. This video shows how appropriate preoperative planning allows for one step laparoscopy with subspecialty surgeons (e.g.: case 1 with General Surgery, case 3 with Colorectal Surgery). <h3>Conclusion</h3> Because successful treatment of DIE requires surgical excision, preoperative confirmation of DIE presence and extension is extremely important. Surgeons should understand how to evaluate MRI images for DIE and use these findings to guide preoperative surgical planning and intraoperative exploration.

Microbial Pattern and their Sensitivity of Ventilator Associated Pneumonia in an Intensive Care Unit of a Ter-tiary Care Hospital in Dhaka

Background: ICU admission imposes great risk of nosocomial infections on the patients due to various invasive interventions. Patients treated in these units receive invasive procedures such as endotracheal intubation and mechanical ventilation which predispose to a nosocomial pneumonia of a special entity named as ‘Ventilator Associated Pneumonia’. Almost half of all the cases of hospital acquired pneumonia are due to VAP and about half of all antibiotics administration in ICU are for treatment of Ventilator Associated Pneumonia. Objectives: objective of the current study was to study the local microbiological profile of ventilator associated pneumonia and their sensitivity pattern in the Critical Care department of BIRDEM general hospital. Design: Cross-sectional study. Setting: ICU of an academic tertiary care hospital in the period of July 2017 to June 2018. Methods: All consecutive patients who were intubated and mechanically ventilated for a period of at least 48 hours within the study period were evaluated for the selection criteria of the study. The included study participants were followed up daily for signs of development of VAP. Once VAP was suspected pertinent investigations were sent to confirm the diagnosis. Tracheal aspirate was collected using conventional specimen trap and aseptic endotracheal suctioning technique and sent for Gram staining and culture and sensitivity testing. Results: In this study total 92 patients out of 625 intubated patients during the study period after fulfilling the inclusion criteria were selected as study participants. 35 participants out of 92developed VAP. Only 1 (2.9 %) patient did not yield any microbial growth in the tracheal aspirate sample and 34 (97.2 %) participants had growth of organisms in their tracheal aspirate samples. Total growths of 45 organisms were found in respiratory secretions of 34 VAP patients. The commonest organism was Acinetobacter which was grown in 21 (46.7%) samples followed by Pseudomonas in 10 (22.2%) samples; Klebsiella in 8 (17.8%) samples; Staphylococcus aureus in 3 (6.7%) samples; Candida in 2 (4.4%) and Enterococcus in 1 sample (2.2%). Most of the bacteria grown in the tracheal aspirates of VAP positive participants were sensitive to less than three antibiotic classes. Conclusion: Multidrug resistant organisms are mostly responsible for both early and late onset VAP in ICU. Bangladesh Crit Care J September 2022; 10(2): 122-126

A study to evaluate the change in management plan of chronic otitis media (mucosal) after cone beam computed tomography

: Imaging of temporal bone helps the Otologists in preoperative surgical planning in ear surgery. Cone Beam Computed Tomography (CBCT) has much higher spatial resolution and clarity as compared to conventional X-Ray and much lower radiation exposure as compared to HRCT Temporal Bones. : To evaluate the change in management plan of Chronic Otitis Media (Mucosal) after CBCT. Also to determine the sensitivity and specificity of the CBCT findings by comparing with intra operative findings in the study participants. We conducted an observational descriptive study in the ENT Department of an academic Tertiary care hospital from October 2017 to October 2019. We included 95 patients whose management plan before CBCT was compared with the plan after CBCT and the percentage of cases undergoing a change in the management after CBCT was determined. The correlation of CBCT findings and intra operative findings in terms of specificity and sensitivity was also statistically calculated. : Subsequent to imaging, the management plan was changed in only 4 patients which was statistically non-significant. CBCT showed a 100% sensitivity, specificity, positive predictive value and negative predictive value to detect pneumatisation of the Mastoid, high jugular bulb and low-lying dura. The sensitivity to detect ossicular erosion was 98.9%. : Thorough clinical examination is the most important factor in decision making in patients with Chronic Otitis Media (Mucosal) and management plan remains unchanged after imaging. Though thorough clinical examination remains the gold standard in making a management plan of patients with Chronic Otitis Media (Mucosal), CBCT with its available details and minimal radiation helped to minimise intraoperative inadvertent injuries which might result due to normal anatomic variations like low lying dura, forward lying sinus, contracted mastoid cavity etc.

Retention of discharge instructions using an interdisciplinary model for at-risk children with cancer: A quality improvement initiative.

We sought to improve caregiver retention of critical initial hospital discharge instructions using a multidisciplinary, team-based intervention for newly diagnosed pediatric cancer patients at high risk for unfavorable outcomes. A multidisciplinary team of pediatric residents, nurses, social workers, pharmacists and hematology/oncology faculty implemented practices to optimize teaching of key discharge material as part of four Plan-Do-Study-Act intervention cycles. An 11-question survey distributed at the first post-discharge clinic visit assessed the efficacy of the intervention, as defined by caregiver retention of critical home instructions. Thirty-nine caregivers of pediatric cancer patients in an urban academic tertiary-care children's hospital took part in this project. Overall retention of key discharge information was greater in the post-intervention cohort compared to the baseline cohort (median total scores: 89 and 63, respectively; p=.001). Improvements in the proportions of correct responses post-intervention were also observed across all subject matters: from 0.57 to 0.88 for fever guidelines (p=.059), from 0.71 to 0.78 for signs of sepsis (p=.65), from 0.57 to 1.00 for accurate choice of on-call number (p=.004), and from 0.71 to 0.94 for antiemetic management (p=.14). Initiation of our comprehensive cancer-specific program to improve caregiver retention of discharge instructions at the first post-hospitalization clinic visit has been successful and sustainable. This project demonstrated that a multi-disciplinary collaborative team effort increases caregiver retention of critical health information, and this has potential to lead to improved outcomes for patients.

Geometric Indices for Predicting Ischemic Mitral Regurgitation: Correlation of Mitral Valve Coaptation Area With Tenting Height, Tenting Area and Tenting Volume

Ischemic remodeling of the left ventricle in patients with coronary artery disease (CAD) results in geometric changes of the mitral valve (MV) apparatus, leading to reduced MV leaflet coaptation. Although the calculation of the coaptation area has value in assessing the effects of left ventricular remodeling on the MV, it is difficult and time-consuming to measure. In this study the authors hypothesized that the tenting volume (TV) would have a greater association with coaptation area than tenting height (TH) or tenting area (TA). A retrospective review. A single tertiary-care academic hospital. There were 145 adult patients who underwent coronary artery bypass graft surgery between April 2018 and July 2020. Intraoperative 2- and 3-dimensional transesophageal echocardiographic studies were obtained in the precardiopulmonary bypass period. Offline analysis was used to obtain TH, TA, TV and coaptation area for each patient. Correlation between the coaptation area and the TH, TA, and TV was conducted using Pearson's correlation. The median age of the population was 68.0 years (61.0-73.3), the body mass index was 29.0 kg/m2 (25.7-33.5), and 17.8% were females. Increases in TV were the most reliable predictor of decreases in coaptation area (R2=0.75) followed by TA (R2=0.48) and TH (R2=0.47). As a representative of the complete topography of the MV, the authors' study demonstrated that in patients with CAD, TV has a greater negative correlation with coaptation area as compared to TH or TA.

A NURSE-DRIVEN, FAMILY-ENGAGED EARLY MOBILITY PROGRAM IN THE CARDIAC INTENSIVE CARE UNIT

A NURSE-DRIVEN, FAMILY-ENGAGED EARLY MOBILITY PROGRAM IN THE CARDIAC INTENSIVE CARE UNIT

Measuring the Effectiveness of Choosing Wisely Campaign on Laboratory Testing for Hospitalized Patients.

Since the start of the Choosing Wisely Campaign (CWC) in 2012, there have been multiple interventions to curb unnecessary laboratory testing. However, no study has examined the impact of the CWC on laboratory tests in an inpatient setting. The objective of this study was to determine if the CWC is associated with a decrease in the number of laboratory tests performed during hospitalization. A retrospective study was conducted at a tertiary care academic hospital using data from January 2008 through September 2018. Data on age, gender, race, length of stay, and the date of common laboratory tests were collected. Data were categorized into pre-campaign (2008-2010), early-campaign (2013-2015), and late-campaign (2016-2018) periods. Of the 10,510,491 labs, 4,637,250 (44.1%) were performed on females, and 5,005,847 (47.6%) on African Americans. The mean (standard deviation [SD]) age of the total population was 51.7 (17.9) years, and the length of hospitalization was 6.3 (9.1) days. Using generalized linear models, the researchers found that overall laboratory tests increased by 8.6% in the late-campaign compared with the pre-campaign period (adjusted p < 0.0001). The percentage changes translate into the following number of additional tests per 100 patient-days during the late-campaign period compared with the pre-campaign period: sodium 8.6, potassium 7.9, hemoglobin 7.1, creatinine 7.1, magnesium 3.9, and alanine transferase 2.4. The findings of this study, if validated by data from other institutions, will suggest the need for better implementation strategies for high-value care. Future research exploring an effective strategy for delivering high-value care is needed.

Association of dysglycemia with post-operative outcomes in pediatric surgery

BackgroundPerioperative dysglycemia is associated with adverse surgical outcomes in adults. We sought to determine the association between perioperative dysglycemia and 30-day adverse surgical events in pediatric patients undergoing non-cardiac surgery. MethodsWe analyzed records from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACS-NSQIP-P) database from 2016 to 2021 at two academic tertiary care hospitals. The primary outcomes were individual 30-day adverse events, composite serious adverse events, composite hospital acquired infections and composite morbidity. ResultsA total of 5410 records were analyzed: the cohort was 52.6% male and 52.6% non-Hispanic White, and 1472 (27.2%) had dysglycemia. Children undergoing procedures in general surgery (48.4%), neurosurgery (25.4%), and orthopedic surgery (16.0%) had higher rates of dysglycemia compared to other surgical specialties. Patients with dysglycemia were more likely to have surgical site infection (4.3% dysglycemic vs. 3.1% normoglycemic, p = 0.028), cardiac arrest (2.6% vs. 0.1%, p < 0.001), and sepsis (3.7% vs. 1.3%, p < 0.001); more likely to undergo reoperation (11.3% vs. 5.8%, p < 0.001); and more likely to remain hospitalized after 30 days (33.0% vs. 6.1%, p < 0.001). After controlling for patient and case demographics, perioperative dysglycemia was associated with more composite serious adverse events (OR 1.85, 95% CI 1.49–2.29, p = 0.000), composite hospital acquired infections (OR 1.42, 95% CI 1.04–1.93, p = 0.026), and composite morbidity (OR 2.52, 95% CI 2.13–2.97, p = 0.000). ConclusionsPerioperative dysglycemia in children undergoing non-cardiac surgery is associated with increased risk of adverse events and outcomes. Interventions that screen and normalize blood glucose in the perioperative period may mitigate risk and improve quality of care.

Prevalence and factors associated with COVID-19 among healthcare workers at a university hospital in Thailand.

Globally, healthcare workers (HCWs) have a high risk of SARS-CoV-2 infection, but less is known about healthcare workers in Thailand. We estimated the prevalence and risk factors for COVID-19 among HCWs in Bangkok, Thailand. A retrospective cohort study was conducted at a large tertiary care academic hospital in Thailand from May 2020 to May 2021. HCWs that presented with fever and/or acute respiratory tract symptoms who tested with RT-PCR were identified, and their clinical data were collected. There were 1432 HCWs with fever and/or acute respiratory tract symptoms during May 2020 and May 2021. A total of 167 patients were front-line HCWs and 1265 were non-front-line HCWs. Sixty HCWs (4.2%) developed COVID-19; 2 were front-line and 58 were non-front-line HCWs. The prevalence of COVID-19 in front-line HCWs was 1.7% (2/167), and 4.6% (58/1265) in non-front-line HCWs (P = .04). In addition, non-front-line HCWs, non-medical staffs, history of contact with a confirmed COVID-19 case at home/family, unvaccinated status, fair compliance to personal protective equipment (PPE) standard, and initial presentation with pneumonia were significantly more common in HCWs with COVID-19 than those without COVID-19 (P < .05). Front-line HCWs, history of contact with a confirmed COVID-19 case at the clinical care areas in the hospital, vaccinated status, good compliance to PPE standards, and initial presentation with upper respiratory infection were significantly more common in HCWs without COVID-19 than those with COVID-19 (P < .05). Multivariate analysis revealed history of exposure with confirmed COVID-19 case at home or in family, unvaccinated status, non-frontline-HCWs, non-medical staffs, and fair compliance to PPE standard to be independent factors associated with COVID-19 in HCWs. COVID-19 was more common in non-front-line HCWs at this tertiary hospital. Thai guidelines on infection prevention and control for COVID-19 seem to be effective in preventing SARS-CoV-2 transmission. Therefore, the adherence to these recommendations should be encouraged.

The Prevalence of Cognitive Frailty and Its Association with Sleep duration and Depression Among Older Adults with Heart Failure

ABSTRACT Objectives The prevalence of cognitive frailty and its associated factors in older population with heart failure have not been extensively studied. We investigated the prevalence of cognitive frailty and its association with sleep duration and depression among older adults with heart failure. Methods This secondary analysis used a cross-sectional sample with 168 older adults with heart failure from an academic tertiary care hospital in South Korea. Results Cognitive frailty was found in 58 (34.5%) older adults with heart failure. Our main finding revealed that longer sleep durations of ≥ 8 h (adjusted odds ratio (OR) = 2.62, 95% confidence interval (CI) = 1.04–6.59) and depression (adjusted OR = 2.84, 95% CI = 1.22–6.61) predicted an increased risk of cognitive frailty. Conclusions Early detection on changes in sleep patterns and depression can play a crucial role in reducing the risk of cognitive frailty in patients with heart failure. Longitudinal studies are needed to explore that sleep patterns and depression are both linked to greater risk of developing cognitive frailty among older adults with heart failure. Clinical Implications Development of a validated instrument for cognitive frailty screening may be beneficial for older adults with heart failure to prevent adverse outcomes.

Investigating Healthcare Provider Bias Toward Patients Who Use Drugs Using a Survey-based Implicit Association Test: Pilot Study.

Negative bias against people who use illicit drugs adversely affects the care that they receive throughout the hospital. We hypothesized that emergency providers would display stronger negative bias toward these patients due to life-threatening contexts in which they treat this population. We also hypothesized that negative implicit bias would be associated with negative explicit bias. Faculty, nurses, and trainees at a midwestern tertiary care academic hospital were invited (June 26, 2019-September 5, 2019) to complete an online implicit association test and explicit bias survey. Mean implicit association test results did not vary across demographics (n = 79). There were significant differences in explicit bias scores between departments regarding whether patients who use drugs deserve quality healthcare access (P = 0.017). We saw no significant associations between implicit and explicit bias scores. Though limited by sample size, the results indicate that emergency and obstetrics/gynecology providers display more negative explicit bias toward this patient population than other providers.

Prioritizing Hormone Therapy Over Vigabatrin as the First Treatment for Infantile Spasms: A Quality Improvement Initiative.

Infantile spasms (IS) are early childhood seizures with potentially devastating consequences. Standard therapies (adrenocorticotropic hormone [ACTH], high-dose prednisolone, and vigabatrin) are strongly recommended as the first treatment for IS. Although this recommendation comes without preference for one standard therapy over another, early remission rates are higher with hormone therapy (ACTH and high-dose prednisolone) when compared with vigabatrin. Using quality improvement (QI) methodology that included hormone therapy as the first treatment, we sought to increase the percentage of children with new-onset nontuberous sclerosis complex (TSC)-associated IS achieving 3-month electroclinical remission from a mean of 53.8% to ≥70%. This was an observational consecutive sample cohort study at a single academic tertiary care hospital that compared a prospective intervention cohort (May 2019-January 2022, N = 57) with a retrospective baseline cohort (November 2015-April 2019, N = 67). Our initiative addressed key drivers such as the routine use of vigabatrin over hormone therapy as first treatment and the common initiation of a second treatment after 14 days for initial nonresponders. We included consecutive children without TSC presenting with new-onset IS diagnosed and treated between ages 2 and 24 months. We displayed our primary outcome and process measures as control charts in which the centerline is the quarterly (previous 3 months) mean based on statistical process control methodology. QI interventions that included the standardization of hormone therapy as the first treatment resulted in higher rates of 3-month remission, rising from 53.8% (baseline cohort) to 75.9% (intervention cohort). Process measure results included an increased rate of children receiving hormone therapy as first treatment (mean, 44.6%-100%) and a decreased number of days to both clinical follow-up after first treatment (mean, of 16.3-12.6 days) and starting a second treatment within 14 days for initial nonresponders (mean, 36.3-17.2 days). For children with IS, improved rates of 3-month electroclinical remission can be achieved with QI methodology. Implementation of similar QI initiatives at other centers may likewise improve local remission rates.

Lichen Sclerosus throughout Childhood and Adolescence: Not Only a Premenarchal Disease

To determine the frequency of persistence of vulvar lichen sclerosus (LS) through the pubertal transition and assess if the symptomatology and exam findings differ by menarchal status at onset of symptoms DESIGN: A retrospective cohort study SETTING: Academic tertiary care hospital PARTICIPANTS: Females aged 21 years or younger with a diagnosis of vulvar LS INTERVENTION: None MAIN OUTCOME MEASURES: Menarchal status at symptom onset, presenting symptoms, exam findings, persistence after menarche RESULTS AND CONCLUSIONS: Of the 196 patients who met criteria, 141 were premenarchal and 55 postmenarchal. Of these 55, 36 had postmenarchal symptom onset, and the others had premenarchal symptom onset or LS diagnosis. Over the data review period, 26 patients were followed through the pubertal transition, and 10 (38.5%) had continued symptoms of LS. The premenarchal group (n=141) was significantly more likely than the symptom-onset postmenarchal group (n=36) to present with vulvar itching (70.2% vs 52.8%; P=.048), vulvar bleeding (26.2% vs 5.6%; P=.008), and bowel symptoms (16.3% vs 0%; P=.009). The premenarchal group was significantly more likely on exam to have subepithelial hemorrhages (24.8% vs 5.6%; P=.01). The postmenarchal group had more clitoral adhesions (25.0% vs 4.3%; P < .0001) and loss of labia minora (47.2% vs 2.1%; P < .0001). Thirteen postmenarchal patients presented with dyspareunia. This study suggests that premenarchal LS can persist after menarche in about 40% of adolescents and can initially develop in postmenarchal adolescents. Initial symptoms and exam findings differ on the basis of menarchal status. Continued surveillance is recommended.

Posterior Glottic Injury Following Prolonged Intubation in COVID-19 Patients.

The objective of this study was to characterize the risk factors for posterior glottic injury (PGI) in patients with coronavirus disease 2019 (COVID-19) who underwent prolonged intubation. This was a case-control study designed to assess the risk factors associated with development of PGI in COVID-19 patients who underwent prolonged intubation. This single-center study was conducted at a tertiary care academic hospital in a metropolitan area. We retrospectively reviewed patients who underwent prolonged intubation (≥7 days) for COVID-19 and compared those with PGI to those without. Patient demographics, comorbidities, and intubation characteristics were compared. Factors associated with PGI development among COVID-19 patients were assessed using multivariate regression. We identified 56 patients who presented with PGI following prolonged intubation for COVID-19 and 60 control patients who underwent prolonged intubation for COVID-19 but did not develop PGI. On univariate analyses, the number of reintubations due to failed extubation efforts was significantly associated with development of PGI (odds ratio [OR], 2.9; 95% CI, 1.4-6.2). On multivariate analyses, patients with cardiovascular disease (OR, 3.3; 95% CI, 1.2-9.0); non-COVID-19 respiratory illnesses, which included obstructive sleep apnea and asthma (OR, 5.9; 95% CI, 2.0-17.8); and diabetes mellitus (OR, 11.6; 95% CI, 3.7-36.6) were more likely to develop PGI. Our results represent the largest case-control study investigating risk factors for PGI in the setting of prolonged intubation specific to COVID-19. Our study suggests a significant role of comorbidities associated with poor wound healing with development of PGI.

Code Status Blues: Do Legal Nudges Discourage Doctors From Ordering Do-Not-Resuscitate?

BackgroundLaws influence human behavior, including practitioners' behavior, and legal nudges may affect bedside patient care practices. Do-not-resuscitate (DNR) practices are one such example. Ensuring that practitioners order DNR for patients who request it is a crucial part of providing quality end-of-life care. On April 1, 2018, in the state of Texas, Senate Bill 11 (SB 11) took effect. This law did not make DNR orders illegal, but it constrained and complicated the process for issuing them. This study aimed to determine if DNR order utilization decreased after the law's implementation. MethodsThe authors conducted a retrospective cohort chart review of all adult patients admitted to a single academic urban tertiary care hospital in Texas before and after the state's DNR law went into effect. The authors reviewed code status orders for the 5426 sickest patients. The primary outcome is the proportion of patients who had DNR orders in effect at the end of their hospitalizations. ResultsImplementation of the DNR law's cumbersome documentation and witnessing requirements correlated with a substantial decline in DNR orders for patients at the highest risk of dying from chronic or severe illness. ConclusionThis is the first study the authors know of that examines whether DNR usage declined after implementation of a DNR law. A troubling implication of this study is that the Texas law has had a chilling effect on doctors' willingness and ability to place medically and ethically appropriate DNR orders and has threatened the right of patients with serious illness to forgo cardiopulmonary resuscitation.

Redesigning Care of Hospitalized Young Adults With Chronic Childhood-Onset Disease.

BackgroundYoung adults with chronic childhood-onset disease (CCOD) are routinely admitted to internal medicine hospitalist services, yet most lack transition preparation to adult care. Providers and patients feel the strain of admissions to adult services in part due to their medical and social complexity.MethodsWe performed a descriptive study of a care redesign project for young adults with CCOD hospitalized at a large, tertiary care academic hospital. We describe the process of implementation of the Med-Peds (MP) service line and characterize patients cared for by the service. We measured and analyzed patient demographics, process implementation, healthcare screening, and healthcare utilization data.ResultsDuring the 16 months of the study period, 254 patients were cared for by the MP service line, accounting for 385 hospitalizations. The most common CCODs were sickle cell disease (22.4%) and type 1 diabetes (14.6%). The majority (76%) of patients completed transition readiness assessment, and 38.6% completed social determinant of health (SDH) screening during their admission. Patients had high prevalence of SDH with 66.7% having an unmet social need. The average length of stay was 6.6 days and the average 30-day readmission rate was 20.0%.ConclusionsThere is opportunity to redesign the inpatient care of young adult patients with CCOD. The MP service line is a care model that can be integrated into existing hospital medicine teams with MP physicians. Hospitals should consider redesigning care for young adults with CCOD to meet the transitional and social needs unique to this patient population.