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Primary palliative care in acute care surgery: an American Association for the Surgery of Trauma Critical Care Committee and Palliative Care Committee clinical consensus document.
No full textAdherence to Perinatal Asphyxia or Sepsis Management Guidelines in Low- and Middle-Income Countries.
No full textIMPORTANCE: Most of the 2.3 million annual neonatal deaths occur in sub-Saharan Africa and South Asia, with perinatal asphyxia and neonatal sepsis being the leading causes of neonatal mortality. Most neonatal deaths are considered preventable through high-quality clinical care, which includes adherence to clinical care guidelines.
OBJECTIVE: To assess adherence to World Health Organization clinical care guidelines for management of perinatal asphyxia and neonatal sepsis and to identify patient-level factors in adherence among neonates who died from these conditions.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study obtained data from December 2015 through October 2023 from the Child Health and Mortality Prevention Surveillance (CHAMPS) catchment areas in 7 low- and middle-income countries in sub-Saharan Africa (Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa) and South Asia (Bangladesh). Participants were neonates who were born alive and were aged 0 to 28 days at the time of death and had either perinatal asphyxia or neonatal sepsis.
EXPOSURE: Medical records of neonates who died from perinatal asphyxia or neonatal sepsis determined by postmortem diagnostics.
MAIN OUTCOMES AND MEASURES: The main outcome was the proportion of deceased neonates who received guideline-adherent treatments before they died. Mixed-effect multivariable logistic regression analyses were performed to identify factors associated with administration of at least bag-valve-mask (BVM) ventilation for perinatal asphyxia.
RESULTS: Of the 1194 neonates (median [IQR] age at the time of death, 2 [1-6] days; 692 males [58.0%]) who died and were enrolled in CHAMPS with available clinical data, 476 (39.9%) died from perinatal asphyxia, 562 (47.0%) died from neonatal sepsis, and 156 (13.1%) from both conditions. These neonates had a median (IQR) birth weight of 2130 (1266-2988) g. For cases with perinatal asphyxia, guideline adherence ranged from 12.2% (n = 77) for adrenaline administration to 85.4% (540) for supplemental oxygen administration. Only 4.4% of neonates (28) with perinatal asphyxia received all recommended treatments. Among cases with neonatal sepsis, antibiotics were administered to 86.8% (623), although the recommended treatment was administered to only 61.0% (438). In multivariable analyses, neonates in whom clinicians accurately identified perinatal asphyxia were more likely to receive BVM ventilation than those who had received discordant antemortem and postmortem diagnoses (adjusted odds ratio, 2.00; 95% CI, 1.29-3.12).
CONCLUSIONS AND RELEVANCE: In this cross-sectional study, clinical care guideline adherence was suboptimal among neonates who died from perinatal asphyxia or neonatal sepsis. This finding underscores the critical need to increase adherence in regions with high rates of neonatal mortality and may inform strategies for strengthening health systems to support compliance with clinical care guidelines
Benchmarking clinical reasoning and accuracy of large language models on breast oncology multiple-choice questions
No full textCommunicating neurological prognosis in the prenatal period: a narrative review and practice guidelines.
No full textClinicians may face an array of challenges in conducting fetal neurological consultations including prognostic uncertainty, a lack of training in fetal counseling, and limited opportunity to build rapport with families. In this setting, it is critical to employ high-quality, family-centered care to allow expectant parents to make informed decisions. Despite the challenges and gravity of these consultations, there remains limited data outlining best conduct and communication practices. This narrative review aims to summarize relevant literature around counseling within fetal neurology, focusing on three key themes: (1) discussing neurological prognosis and uncertainty, (2) navigating evolving decision making, (3) recognizing bias and understanding patient context. We provide practical recommendations to clinicians conducting fetal neurological counseling and outline future research priorities. IMPACT: Fetal neurological conditions can have a significant impact on child short- and long-term health outcomes. Prenatal consultations are an important venue to discuss information regarding fetal prognosis and decision making with expectant parents. However, there is limited evidence supporting best communication practices within this setting. This review summarizes current literature around expectant parent prognostic communication preferences and outlines practical recommendations and priorities for future research
Assessing the Impact of the COVID-19 Pandemic on Childhood Arterial Ischemic Stroke: An Unanticipated Natural Experiment.
No full textBACKGROUND: The VIPS (Vascular Effects of Infection in Pediatric Stroke) II prospective cohort study aimed to better understand published findings that common acute infections, particularly respiratory viruses, can trigger childhood arterial ischemic stroke (AIS). The COVID-19 pandemic developed midway through enrollment, creating an opportunity to assess its impact.
METHODS: Twenty-two sites (North America, Australia) prospectively enrolled 205 children (aged 28 days to 18 years) with AIS from December 2016 to January 2022, including 100 cases during the COVID-19 pandemic epoch, defined here as January 2020 to January 2022. To assess background rates of subclinical infection, we enrolled 100 stroke-free well children, including 39 during the pandemic. We measured serum SARS-CoV-2 nucleocapsid total antibodies (present after infection, not vaccination; half-life of 3-6 months). We assessed clinical infection via parental interview.
RESULTS: The monthly rate of eligible AIS cases declined from spring through fall 2020, recovering in early 2021 and peaking in the spring. The prepandemic and pandemic cases were similar except pandemic cases had fewer clinical infections in the prior month (17% versus 30%;
CONCLUSIONS: The COVID-19 pandemic may have had dual effects on childhood AIS: an indirect protective effect related to public health measures reducing infectious exposure in general, and a deleterious effect as COVID-19 emerged as another respiratory virus that can trigger childhood AIS
Maternal Body Mass Index as a Risk Factor for Perinatal Ischemic Stroke: A Step Toward Prevention?
No full textAtrasentan in Patients with IgA Nephropathy.
No full textBACKGROUND: Patients with IgA nephropathy and severe proteinuria have a high lifetime risk of kidney failure. The efficacy and safety of the selective endothelin type A receptor antagonist atrasentan in reducing proteinuria in patients with IgA nephropathy are incompletely understood.
METHODS: We are conducting a phase 3, multinational, double-blind, randomized, controlled trial involving adults with biopsy-proven IgA nephropathy, a total urinary protein excretion of at least 1 g per day, and an estimated glomerular filtration rate of at least 30 ml per minute per 1.73 m
RESULTS: A total of 340 patients were recruited into the main stratum. Among the first 270 patients in the main stratum (135 per trial group) who completed the week 36 visit, the geometric mean percentage change in the urinary protein-to-creatinine ratio relative to baseline was significantly greater with atrasentan (-38.1%) than with placebo (-3.1%), with a geometric mean between-group difference of -36.1 percentage points (95% confidence interval, -44.6 to -26.4; P\u3c 0.001). The percentage of patients with adverse events did not differ substantially between the two groups. Fluid retention was reported by 19 of 169 patients (11.2%) in the atrasentan group and in 14 of 170 (8.2%) in the placebo group but did not lead to discontinuation of the trial regimen. No apparent cases of cardiac failure or severe edema occurred.
CONCLUSIONS: In this prespecified interim analysis, atrasentan resulted in a significant and clinically meaningful reduction in proteinuria as compared with placebo in patients with IgA nephropathy. (Funded by Novartis; ALIGN ClinicalTrials.gov number, NCT04573478.)
Prophylactic cardiac denervation to prevent post-operative atrial fibrillation after coronary artery bypass grafting: a systematic review and meta-analysis.
No full textBACKGROUND: Despite revolutionary advances in the field of percutaneous coronary intervention (PCI), a significant number of patients with coronary artery disease (CAD) require coronary artery bypass grafting (CABG), which is associated with postoperative atrial fibrillation (POAF) risk. This meta-analysis evaluates the efficacy and safety of prophylactic cardiac denervation (PCD) during CABG to prevent POAF.
METHODS: A systematic search was conducted across PubMed, CENTRAL, Web of Science, Scopus, and Embase until December 2024. Pooled data were reported using risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, with a 95% confidence interval (CI). This systematic review and meta-analysis is registered with PROSPERO ID: CRD42025631310.
RESULTS: Five studies with 1266 patients were included in the final analysis. Compared to CABG alone, CABG plus PCD did not show any significant difference in the incidence of POAF (RR 0.77, [95% CI 0.38, 1.56], p = 0.47, I
CONCLUSION: CABG with adjuvant PCD did not show significant efficacy in preventing the incidence of POAF compared to CABG alone. This calls for further research focusing on investigating combined preventive strategies, rather than relying solely on PCD, and developing risk stratification tools to identify patients most likely to benefit from autonomic modulation
Ethnic Variations and Surgical Outcomes in Rhinoplasty: A Systematic Review.
No full textBACKGROUND: Rhinoplasty, especially among diverse ethnic groups, requires specialized techniques to address anatomical differences and patient preferences. This systematic review focuses on the surgical outcomes and patient satisfaction in rhinoplasty, highlighting methods tailored to specific populations, particularly Asian and Hispanic individuals, who often seek subtle alterations that preserve ethnic identity.
OBJECTIVE: To systematically review surgical approaches and outcomes in rhinoplasty for non-Caucasian patients, assessing efficacy, patient satisfaction, complication rates, and psychosocial impacts to guide practice improvements and enhance culturally sensitive care.
METHODS: A comprehensive literature search was conducted across major databases, including PubMed, Embase, and Scopus, covering publications from 2000 to 2023. Studies were included based on their focus on ethnic rhinoplasty outcomes, patient satisfaction, or unique surgical techniques. The methodological quality was assessed using the MINORS scale for non-randomized studies.
RESULTS: Of the 558 studies initially identified, 14 met the inclusion criteria. Analysis revealed that for Asian rhinoplasty, grafting techniques and minimally invasive approaches were commonly employed to achieve refined yet natural results. Hispanic rhinoplasty often addressed specific structural and aesthetic concerns, such as managing the nasolabial angle. Across studies, patients reported high satisfaction with outcomes, with lower complication rates associated with graft-supported techniques.
CONCLUSION: This review emphasizes the need for culturally attuned approaches in rhinoplasty. Tailoring surgical techniques to the unique anatomical and aesthetic needs of different ethnic groups enhances both patient satisfaction and clinical outcomes. Addressing patient expectations and promoting techniques that preserve ethnic characteristics is essential for successful rhinoplasty outcomes in diverse populations.
LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266