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Nebulized Tranexamic Acid for the Control of Pediatric Post-tonsillectomy Hemorrhage
No full textObjective: The aim of this study is to determine whether nebulized tranexamic acid (TXA) is effective and safe in controlling post-tonsillectomy hemorrhage (PTH) and to analyze factors that are associated with surgical hemostatic control.
Methods: A retrospective chart review was performed of all patients younger than 18 years of age presenting with PTH from January 2019 until October 2023. Demographic and clinical data was collected and included indication for tonsillectomy, pharyngeal exam at presentation, hematologic work-up, American Society of Anesthesiologists physical status classification, treatment modalities including nebulized TXA use and surgical control of bleeding, length of stay and readmission rate.
Results: A total of 287 patients with a median age of 6.3 years were included. The TXA group included 100 (34.8 %) patients and the no TXA group included 187 (65.2 %) patients. A lower percentage of patients required surgical control of bleeding in the TXA group compared to the no TXA group (26.0 % vs 41.7 %, p-value = 0.010). While controlling for active bleeding and clot on exam, TXA showed a reduction of 75 % in the odds of surgical intervention for PTH (OR = 0.25 [95 % CI: 0.13, 0.48, p-value=\u3c0.001]). The median length of hospital stay was one night for both groups. Readmission rates for rebleeding were also similar in both groups (TXA group 9.0 % vs no TXA group 7.0 %, p-value = 0.518). No complications attributable to nebulized TXA administration were noted.
Conclusion: Nebulized TXA holds promise to be an effective and safe modality for the management of post-tonsillectomy hemorrhage
Racial and Ethnic Factors and Opioid Use Disorder Treatment After an Emergency Department Visit
Get PDFImportance: There are racial and ethnic disparities in opioid use disorder (OUD) treatment engagement during and after emergency department (ED) encounters.
Objective: To identify patterns of barriers and facilitators to treatment engagement after an ED visit among Black, Hispanic, and White individuals with OUD.
Design, setting, and participants: This qualitative study was conducted from June 2023 to May 2024 using in-depth semistructured individual telephone interviews. Participants with OUD were previously enrolled in a multisite study comparing 2 formulations of buprenorphine in ED patients with untreated OUD on treatment engagement.
Exposures: A diagnosis of moderate-to-severe OUD and a visit to an ED.
Main outcomes and measures: The primary outcome was identification of key themes at both the behavioral and health system levels associated with treatment engagement, identified through thematic analysis of interview data.
Results: A total of 57 individuals (20 female [35.1%]; mean [SD] age, 41.7 [12.8] years; 20 Black [35.1%]; 17 Hispanic [29.8%]; 20 White [35.1%]) participated in the study. Although racial and ethnic group-specific factors existed, common barriers to treatment engagement included stigma, structural factors (eg, transportation and insurance), uncertainty navigating the health system, and mental health issues. Black participants specifically described how previous trauma and daily stress contributed to a lack of treatment engagement. Black and Hispanic participants expressed experiences of racism and mistrust within the health system. Hispanic and White participants expressed concerns about the adverse effects and taste of sublingual buprenorphine. Common facilitators included positive attitudes toward treatment and patient experiences with ED staff and stable health care access. Hispanic participants described family support as a crucial factor toward treatment engagement. Black participants expressed the importance of connecting with individuals who were abstinent.
Conclusions and relevance: In this qualitative study of 57 individuals with OUD previously treated in the ED, common themes emerged across racial and ethnic groups. However, Black, Hispanic, and White individuals with OUD encountered distinct barriers and facilitators to treatment engagement after an ED visit, such as the importance of family support among Hispanic individuals as a facilitator and experiences of racism within the health system among both Black and Hispanic individuals as a barrier. Future ED-based interventions should address disparities by reducing barriers and enhancing facilitators to improve equitable treatment access
Blood Transfusion Guidelines in Skull Base Surgery: A Scoping Review
No full textObjective: Consensus guidelines are lacking for the administration of blood product transfusions in adult skull base neurosurgery. This study aims to synthesize the current literature and provide preliminary evidence-based considerations for blood product transfusions in skull base surgery.
Methods: A scoping review was conducted using PubMed, Web of Science, and SCOPUS databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines.
Results: Eleven articles were included. Of the three studies reporting skull base surgery outcomes, greater mean age was correlated with a higher likelihood of transfusion. Pre-admission diagnoses of cardiovascular disease, diabetes, coagulopathy, anticoagulation, liver disease, stroke, and seizure were the most common comorbid diseases of transfused patients. Transfused patients had a greater range of hospital length of stay (15.5-19.9 days versus 4.9-8 days). One study comparing anemic versus non-anemic patients found a marked difference in the mean length of stay (4.6 versus 1.4 days, respectively) between their two patient groups. Additionally, this study found anemic patients to have a 3.4 % mortality rate while the non-anemic cohort had a 0.8 % mortality rate. The average volume of transfused blood in standard and transglabellar/subcranial approaches was 545 mL and 194 mL, respectively. Only one study proposed a hemoglobin threshold specific to skull base surgery for blood transfusion at 7-8 g/dL.
Conclusion: Based on our scoping review, a hemoglobin level of 7 g/dL (Level B, Class IIa) may represent a reasonable starting point to guide transfusions in skull base surgery, though prospective validation is warranted
Social Skills and Academic Performance in College Students With ADHD
No full textAttention-Deficit/ Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that affects up to 5% of children worldwide. The deficits characteristic of this disorder often result in significant functional impairment to academic, occupational, and social domains that start in early childhood and often persist into adulthood. Experiencing these difficulties from an early age often results in the development of poor self-efficacy for these individuals, further compounding deficits to functioning. While many individuals with ADHD struggle with social functioning, research has also found that individuals who report having better social skills, also reported having better self-efficacy. It has yet to be established if this relationship contributes to better functional outcomes in individuals with ADHD. The purpose of this study is to explore the cross section social skills, self-efficacy, and academic performance in university students with ADHD. It was hypothesized that social skills are positively associated with academic functioning. It was also hypothesized that the relationship between social skills and academic functioning will be mediated by self-efficacy. This was explored by posting an anonymous Formester survey on relevant reddit forums that contained a demographic survey, the generalized self-efficacy scale, and the social skills inventory. There were 69 respondents who met criteria for inclusion. It was found that social skills were significantly correlated with grade point average. However, self-efficacy was not found to act as a mediator for this relationship. While more work will be needed to explore the intersection of these variables, this finding holds implications regarding the role of social skills in academic outcomes and self-beliefs for individuals with ADHD and could inform the development of novel interventions aimed at improving functional outcomes for these individuals
Pneumonia and Hypokalemia Outcomes Investigated in a Rural, Midwestern Population
No full textBackground
Pneumonia is a broad term encompassing lung infections with varying causes, presentations, and prognoses. The objective of this study was to determine if the presence of hypokalemia in subjects admitted to the hospital for pneumonia was associated with an increased mortality rate compared to subjects admitted with pneumonia without hypokalemia. Finding comorbidities associated with worse outcomes in subjects with pneumonia could improve treatment and subsequently improve morbidity and mortality rates.
Methods
This retrospective study used data from the Freeman Health System (FHS) electronic medical record in Joplin and Neosho, MO, from January 1, 2019, to December 31, 2021. Hospital admissions of subjects ≥18 years old with pneumonia, hypokalemia, or both were identified through the International Classification of Diseases, Tenth Revision (ICD-10) codes related to pneumonia and hypokalemia. Of the 4,414 subjects with pneumonia, 1,045 concurrently had hypokalemia, and 3,369 did not. Additionally, 3,594 subjects had hypokalemia without pneumonia. Mortality rates of sample groups were assessed and compared.
Results
Of the sample groups identified, the mortality rate for subjects with pneumonia and hypokalemia was the highest at 218 (20.86%), followed by pneumonia without hypokalemia at 567 (16.83%), and hypokalemia but no pneumonia at 195 (5.43%). The two-sample comparison tests showed the differences in mortality rates in the three sample groups, which were all statistically significant.
Conclusions
The group with pneumonia and hypokalemia had a higher mortality rate than the group with pneumonia without hypokalemia or hypokalemia without pneumonia. This data suggests that hypokalemia was associated with increased mortality in subjects with pneumonia. This finding opens up discussion for identifying other comorbidities that may be present in subjects with pneumonia and could help decision-making in the care of subjects with pneumonia prior to hospitalization, upon admission, or during hospitalization
COVID-19 Microangiopathy: Insights into Plasma Exchange as a Therapeutic Strategy
No full textCOVID-19-associated thrombotic microangiopathy has emerged as a severe complication that exacerbates morbidity and mortality in critical cases. Thrombotic microangiopathy, characterized by microvascular thrombosis and endothelial injury, includes conditions like thrombotic thrombocytopenic purpura and atypical hemolytic uremic syndrome. This review investigates therapeutic plasma exchange as a potential strategy to mitigate COVID-19-induced thrombotic microangiopathy, examining its role in removing pro-inflammatory cytokines, immune complexes, and pro-thrombotic factors. Additionally, it highlights the synergistic effects when therapeutic plasma exchange is combined with treatments such as complement inhibitors and immunosuppressants. Preliminary evidence, drawn from case reports and early trials, supports the efficacy of therapeutic plasma exchange in improving outcomes for COVID-19-associated thrombotic microangiopathy. However, larger randomized controlled trials are necessary to definitively establish its place in COVID-19 management, particularly for high-risk and transplant patients with underlying immunological vulnerabilities