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Reducing Intubations and Related Risks in Neonates with Retinopathy of Prematurity Undergoing Laser Photocoagulation.
No full textINTRODUCTION: Although associated with respiratory morbidity, elective endotracheal intubation (ETI) for laser photocoagulation for retinopathy of prematurity (ROP) is the standard practice at our institution, with 100% of patients undergoing preoperation ETI. To mitigate this risk, we strove to reduce the percentage of infants intubated for laser photocoagulation by 30% by June 2022.
METHODS: We assembled a multidisciplinary team and implemented a deep sedation guideline utilizing dexmedetomidine, fentanyl, and midazolam with noninvasive ventilation support for laser photocoagulation in January 2020. Outcome, process, and balancing measures tracked the efficacy and safety of the quality improvement project.
RESULTS: We reduced the percentage of infants requiring intubation for laser photocoagulation from 100% (8/8) to 10% (1/10). We reduced the average time to return to baseline respiratory status from 224.1 to 33.8 hours (9.3d to1.4 d). Cardiorespiratory index scores slightly increased (1 to 1.2), and pain scores remained unchanged after interventions.
CONCLUSIONS: A multidisciplinary team approach using a deep sedation guideline and noninvasive ventilation can safely reduce the requirement for intubation during laser photocoagulation with a faster return to baseline respiratory status
EMS Bypass to Endovascular Stroke Centers is Associated with Shorter Time to Thrombolysis and Thrombectomy for LVO Stroke.
No full textOBJECTIVES: Large vessel occlusion (LVO) strokes may be eligible for treatment with intravenous thrombolysis (IVT) and endovascular therapy (EVT). Patients selected for treatment have better neurologic outcomes with EVT, and delays in this therapy lead to worse outcomes. However, EVT is offered at a limited number of hospitals, referred to as endovascular stroke centers (ESC). This poses a difficult decision for EMS: to take potential stroke patients to the closest primary stroke center (PSC) or longer transport time to a more distant ESC. We hypothesized that patients with LVO stroke undergoing EVT transported directly to an ESC would have more favorable outcomes as measured by the modified Rankin scale (mRS) at 90 days, compared to transport to a PSC followed by transfer to an ESC.
METHODS: The OPUS-REACH consortium examined transportation patterns and outcomes in patients with LVO stroke who received endovascular treatment. This cohort includes 2400 patients with LVO stroke throughout eight endovascular centers in the Northeast U.S. from 2015 to 2020. All patients enrolled in the OPUS-REACH database were eligible for inclusion. Patients were excluded if they were missing the pickup address, had an in-hospital stroke, or arrived
RESULTS: The primary outcome did not reach significance with 40% of the bypass group as compared with the 33.1% of the non-bypass group having a good outcome. However, the bypass group underwent shorter times from last-known-well to both thrombolysis (120.9 vs 153.3 min,
CONCLUSIONS: In patients with LVO stroke who undergo thrombectomy, EMS transport directly to an ESC results in shorter time thrombectomy, although we did not observe a difference in 90-day functional outcomes. Additionally, bypass to reach a more capable endovascular stroke center does not delay administration of IVT from time of LKW
Impact of early term labor induction on maternal and fetal outcomes in patients with obesity
Full text linkMind and Muscle: Managing Psychiatric Comorbidities in Fibromyalgia Patients Treated with Pregabalin versus Milnacipran
No full textManagement of perianal abscesses in infants: A systematic review from the APSA outcomes and evidence-based practice committee.
No full textBACKGROUND: Management of infant perianal disease, including perianal abscess and fistula-in- ano (FIA), remains controversial. There is lack of consensus regarding the risks and benefits of operative and non-operative approaches.
METHODS: The American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee created a priori consensus-based questions regarding the various approaches to management of perianal abscess and FIA in infants. A comprehensive search strategy was created, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to identify and review relevant articles and answer the established questions.
RESULTS: Over 2460 titles and abstracts were screened to identify 31 manuscripts describing the expected course of perianal disease when managed with nonoperative management (NOM) strategies (such as hygiene, sitz baths, and systemic antibiotics), operative intervention for abscess only (incision and drainage (I&D)) or direct surgical management of the FIA (e.g. upfront fistulotomy). Initial failure of NOM is approximately 37.5 %. Recurrence rate after initial success with NOM or I&D is approximately 21 % and 24 %, respectively. The rate of FIA development is approximately 21 % after NOM and 20 % after I&D. Recurrence after operative management of FIA, regardless of approach, is 7 %. Time to complete resolution varies widely and does not appear to differ based on treatment strategy.
CONCLUSIONS: Both operative and non-operative approaches can be safely used in the management of perianal abscess and FIA but recurrence is common regardless of approach. Risks and benefits of each approach should be considered on a case-by-case basis.
TYPE OF STUDY: Systematic Review of level 3-4 studies.
LEVEL OF EVIDENCE: Level 4
TCT-1017 Percutaneous PFO Closure Versus Medical Therapy for Prevention of Recurrent Stroke in Patients With Cryptogenic Stroke: A Comparative Clinical Outcomes Analysis
No full textBackground: Cryptogenic stroke accounts for nearly 25% of ischemic strokes, with PFO being implicated as a possible embolic source. The optimal strategy for secondary prevention remains debated—between medical therapy and transcatheter PFO closure. Our study objective was compare long-term clinical outcomes between PFO closure and medical therapy in patients with cryptogenic stroke. Methods: Data were analyzed from major randomized trials including RESPECT, CLOSE, and REDUCE. The primary outcome was recurrent ischemic stroke. Secondary outcomes included transient ischemic attack (TIA), major bleeding, atrial fibrillation, and all-cause mortality. Patient-level data were extracted, and pooled estimates were analyzed. Results: PFO closure significantly reduced the risk of recurrent stroke compared to medical therapy (HR 0.41, p\u3c 0.001). However, the incidence of new-onset atrial fibrillation was significantly higher in the closure group (p\u3c 0.001). No significant difference was found in major bleeding or mortality. Conclusion: In patients with cryptogenic stroke and PFO, percutaneous closure significantly reduces the risk of recurrent stroke compared to medical therapy alone (p\u3c 0.001), with a modest increase in atrial fibrillation risk. Clinical decision-making should weigh this benefit against the arrhythmic risk and be guided by patient anatomy and preferences. Categories: STRUCTURAL: Congenital and Other Structural Heart Diseas
TCT-488 Sex-Based Differences in Cardiovascular Outcomes With Achieved LDL-C \u3c55 mg/dL: A Comparative Cohort Analysis
No full textBackground: Aggressive lowering of low-density lipoprotein cholesterol (LDL-C) is a cornerstone of atherosclerotic cardiovascular disease (ASCVD) prevention. Guidelines recommend an LDL-C target of \u3c 55 mg/dL for very high-risk individuals, but evidence regarding sex-specific benefits at this ultra-low LDL threshold is limited. Women have historically been underrepresented in lipid-lowering trials and may experience different plaque biology and risk profiles. This study evaluates long-term cardiovascular outcomes in women versus men who achieved LDL-C \u3c 55 mg/dL, focusing on major adverse cardiovascular events (MACE) and secondary endpoints. Methods: We analyzed 9,420 patients (3,920 women; 5,500 men) from a multi-center prospective ASCVD registry treated with high-intensity statin ± ezetimibe or PCSK9 inhibitors between 2016–2021. Patients were stratified by achieved LDL-C \u3c 55 mg/dL versus ≥55 mg/dL and by sex. The primary endpoint was 5-year incidence of MACE (composite of cardiovascular death, MI, and stroke). Results: At 5-year follow-up, women who achieved LDL-C \u3c 55 mg/dL had numerically lower rates of MACE compared to men (9.2% vs. 10.5%, p=0.12), though not statistically significant. However, women had significantly lower rates of myocardial infarction (3.8% vs. 5.4%, p=0.01), revascularization (6.8% vs. 9.1%, p=0.004), hospitalization for angina (5.1% vs. 7.8%, p=0.001), and all-cause mortality (4.3% vs. 5.5%, p=0.03) compared to men with similarly low LDL levels. Cardiovascular death and stroke rates were similar across sexes. These findings suggest women may derive relatively greater benefit from achieving LDL-C \u3c 55 mg/dL, particularly in reducing ischemic events and need for interventions. Conclusion: In patients with established ASCVD, achieving an LDL-C target \u3c 55 mg/dL is associated with favorable long-term cardiovascular outcomes in both sexes. Women may experience greater relative reductions in MI, revascularization, and mortality compared to men at this LDL threshold. These findings support aggressive lipid-lowering strategies in high-risk women and highlight the importance of sex-specific cardiovascular risk management. Categories: CORONARY: Womens Health Issues: Coronar
Task-shifting and system readiness: a narrative review of strategies for pediatric emergency care in low-resource settings.
No full textBACKGROUND: In various low- and middle-income countries (LMICs), non-specialist healthcare providers (HCPs), such as general practitioners, nurses, and community health workers (CHWs), often manage acute pediatric emergencies. HCPs in these settings may face challenges due to limited training in emergency care and a lack of ongoing educational opportunities. Additionally, they often operate in clinical environments that lack dedicated emergency departments (EDs), child-specific care protocols, or the necessary pediatric equipment required for managing critically ill children. This is concerning, considering that acute illnesses and injuries are significant contributors to the high rates of preventable childhood deaths in low-and middle-income countries.
OBJECTIVE: This review synthesizes evidence on pediatric emergency care strategies to improve fidelity to evidence-based practice that can be utilized and scaled beyond the conventional ED framework, without relying on Pediatric Emergency Medicine (PEM)-trained personnel, who may be unavailable in these regions. This includes task shifting, where community and non-physician HCPs learn how to provide emergency triage and acute lifesaving interventions for children in preventing morbidity and mortality, and other strategies, framed within the established concept of pediatric readiness , which is a systems-based approach encompassing staff competencies, protocols, equipment, and quality improvement. Additionally, this review explores practical examples from international real-world applications of such strategies.
METHODS: A narrative review of literature from 2000 to 2024 covering task-shifting, protocols, simulation training, and system approaches for pediatric emergency care in low-resource settings.
RESULTS: Our synthesis of the literature suggests that low-dose, low-fidelity simulation-based training can effectively enhance confidence and competence in pediatric resuscitation. By recognizing the roles of community-based and non-specialist providers within a pediatric readiness framework, standardizing relevant protocols, and providing appropriate tools and education, we can substantially improve pediatric emergency care systems on a broader scale.
CONCLUSION: This review offers valuable insights for clinicians and policymakers dedicated to reducing preventable pediatric mortality in low-resource settings