Mitochondria oxidize substrates to generate the ATP that fuels muscle contraction and locomotion. This review focuses on three steps in oxidative phosphorylation that have independent roles in ...setting the overall mitochondrial ATP flux and thereby have direct impact on locomotion. The first is the electron transport chain, which sets the pace for oxidation. New studies indicate that the electron transport chain capacity per mitochondria declines with age and disease, but can be revived by both acute and chronic treatments. The resulting higher ATP production is reflected in improved muscle power output and locomotory performance. The second step is the coupling of ATP supply from O2 uptake (mitochondrial coupling efficiency). Treatments that elevate mitochondrial coupling raise both exercise efficiency and the capacity for sustained exercise in both young and old muscle. The final step is ATP synthesis itself, which is under dynamic control at multiple sites to provide the 50-fold range of ATP flux between resting muscle and exercise at the mitochondrial capacity. Thus, malleability at sites in these subsystems of oxidative phosphorylation has an impact on ATP flux, with direct effects on exercise performance. Interventions are emerging that target these three independent subsystems to provide many paths to improve ATP flux and elevate the muscle performance lost to inactivity, age or disease.
Anterior cruciate ligament (ACL) injury leads to a sustained increase in synovial fluid concentrations of inflammatory cytokines and biomarkers of cartilage breakdown. While this has been documented ...post‐injury, it remains unclear whether ACL reconstruction surgery contributes to the inflammatory process and/or cartilage breakdown. This study is a secondary analysis of 14 patients (nine males/five females, mean age = 9, mean BMI = 28) enrolled in an IRB‐approved randomized clinical trial. Arthrocentesis was performed at initial presentation (mean = 6 days post‐injury), immediately prior to surgery (mean = 23 days post‐injury), 1‐week post‐surgery, and 1‐month post‐surgery. Enzyme‐linked immunosorbant assay kits were used to determine concentrations of carboxy‐terminal telopeptides of type II collagen (CTXII), interleukin‐6 (IL‐6), and IL‐1β in the synovial fluid. The log‐transformed IL‐1β was not normally distributed; therefore, changes between time points were evaluated using a non‐parametric Kruskal‐Wallis one‐way ANOVA. IL‐1β concentrations significantly increased from the day of surgery to the first postoperative time point (P ≤ .001) and significantly decreased at the 4‐week postoperative visit (P = .03). IL‐1β concentrations at the 4‐week postoperative visit remained significantly greater than both preoperative time points (P > .05). IL‐6 concentrations at 1‐week post‐surgery were significantly higher than at initial presentation (P = .013), the day of surgery (P < .001), and 4 weeks after surgery (P = .002). CTX‐II concentrations did not differ between the first three‐time points (P > .99) but significantly increased at 4 weeks post‐surgery (P < .01). ACL reconstruction appears to reinitiate an inflammatory response followed by an increase in markers for cartilage degradation. ACL reconstruction appears to initiate a second “inflammatory hit” resulting in increased chondral breakdown suggesting that post‐operative chondroprotection may be needed.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
PURPOSEElevated synovial fluid (SF) concentrations of proinflammatory cytokines, degradative enzymes, and cartilage breakdown markers at the time of anterior cruciate ligament (ACL) reconstruction ...are associated with worse postoperative patient-reported outcomes and cartilage quality. However, it remains unclear if this is due to a more robust or dysregulated inflammatory response or is a function of a more severe injury. The objective of this study was to evaluate the association of the molecular composition of the SF, patient demographics, and injury characteristics to cartilage degradation after acute ACL injury.
METHODSWe performed a cluster analysis of SF concentrations of proinflammatory and anti-inflammatory cytokines, and biomarkers of cartilage degradation, bony remodeling, and hemarthrosis. We evaluated the association of biomarker clusters with patient demographics, days between injury, Visual Analogue Scale pain, SF aspirate volumes, and bone bruise volumes measured on magnetic resonance imaging.
RESULTSTwo clusters were identified from the 35 patients included in this analysis, dysregulated inflammation and low inflammation. The dysregulated inflammation cluster consisted of 10 patients and demonstrated significantly greater concentrations of biomarkers of cartilage degradation (P < 0.05) as well as a lower ratio of anti-inflammatory to proinflammatory cytokines (P = 0.053) when compared with the low inflammation cluster. Patient demographics, bone bruise volumes, SF aspirate volumes, pain, and concomitant injuries did not differ between clusters.
CONCLUSIONSA subset of patients exhibited dysregulation of the inflammatory response after acute ACL injury which may increase the risk of posttraumatic osteoarthritis. This response does not appear to be a function of injury severity.
BACKGROUND
Observation status could improve efficiency of healthcare resource use but also might shift financial burdens to patients and hospitals. Although the use of observation stays has increased ...for adult patient populations, the trends are unknown among hospitalized children.
OBJECTIVE
The goal of this study was to describe recent trends in observation stays for pediatric populations at children's hospitals.
DESIGN, SETTING, AND PARTICIPANTS
Both observation and inpatient stays for all conditions were retrospectively studied using the Pediatric Health Information System database (2010 to 2019).
EXPOSURE, MAIN OUTCOMES, AND MEASURES
Patient type was classified as inpatient or observation status. Main outcomes included annual percentage of observation stays, annual percentage of observation stays having prolonged length of stay (>2 days), and growth rates of observation stays for the 20 most common conditions. Risk adjusted hospital‐level use of observation stays was estimated using generalized linear mixed‐effects models.
RESULTS
The percentage of observation stays increased from 23.6% in 2010 to 34.3% in 2019 (P < .001), and the percentage of observation stays with prolonged length of stay rose from 1.1% to 4.6% (P < .001). Observation status was expanded among a diverse group of clinical conditions; diabetes mellitus and surgical procedures showed the highest growth rates. Adjusted hospital‐level use ranged from 0% to 67% in 2019, indicating considerable variation among hospitals.
CONCLUSION
Based on the increase in observation stays, future studies should explore the appropriateness of observation care related to efficient use of healthcare resources and financial implications for hospitals and patients.
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•Pediatric thyroidectomy has been identified as a surgical procedure that may benefit from concentrating cases to high-volume surgeons.•Despite significant variation in caseloads to define surgeon ...volume, pediatric thyroid patients have generally better outcomes when operated on by higher volume surgeons.
Pediatric thyroidectomy has been identified as a surgical procedure that may benefit from concentrating cases to high-volume surgeons. This systematic review aimed to address the definition of “high-volume surgeon” for pediatric thyroidectomy and to examine the relationship between surgeon volume and outcomes.
PubMed, Embase, Cochrane Library, Scopus, Web of Science, ClinicalTrials.gov, and OpenGrey databases were searched for through February 2020 for studies which reported on pediatric thyroidectomy and specified surgeon volume and surgical outcomes.
Ten studies, encompassing 6430 patients, were included in the review. Five single-center retrospective studies reported only on high-volume surgeons, one single center retrospective study reported on only low-volume surgeons, and four national database studies (2 cross sectional, 2 retrospective reviews) reported outcomes for both high-volume and low-volume surgeons. Majority of patients underwent total thyroidectomy (54.9%); common indications for surgery were malignancy (41.7%) and hyperthyroidism/thyroiditis (40.5%). Rates of transient hypocalcemia (11.4% - 74.2%), transient recurrent laryngeal nerve injury (0% - 9.7%), and bleeding (0.5% - 4.3%) varied across studies. Definitions for high-volume pediatric thyroid surgeons ranged from ≥9 annual pediatric thyroid operations to >200 annual thyroid operations (with >30 pediatric cases). Four studies reported significantly better outcomes, including lower post-operative complications and shorter length of hospital stay, for patients treated by high-volume surgeons.
Despite significant variation in caseloads to define volume, pediatric thyroid patients have generally better outcomes when operated on by higher volume surgeons. Concentration thyroidectomy cases to a smaller cohort of surgeons within pediatric practices may confer improved outcomes.
Systematic Reviews and Meta-Analyses; Level IV
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
General equivalence mappings (GEMs) were developed to facilitate a transition from International Classification of Diseases, Ninth Revision (ICD-9) to ICD, Tenth Revision (ICD-10). Validation of GEMs ...is suggested as coding errors have been reported for adult populations. The purpose of this study was to illustrate limitations of the GEMs for pediatric surgical procedures.
Using the 2014 to 2016 National Inpatient Sample, we evaluated all patients undergoing inguinal hernia repair. ICD-9 codes for the repair were independently classified as laparoscopic or open approach by two surgeons. Conversions of the ICD-9 to ICD-10 codes were compared between the GEMs strategy and surgeons' manual mapping. National trends were compared for overall, adult, and pediatric populations.
We found significant inconsistencies in the proportion of laparoscopic inguinal hernia repair based on mapping strategies employed. For adults, the comparison of the proportions in 2016 was 17.79% (GEMs) versus 21.44% (Manual). In pediatric population, the contrast was 0.45% (GEMs) versus 17.75% (Manual), and no laparoscopic repair cases were found using GEMs in the last quarter of 2015.
Some conversions of ICD-9 and ICD-10 using the current GEMs are not valid for certain populations and procedures. Clinical validation of coding conversions is essential.
Level V.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
This study sought to evaluate the influence of International Classification of Diseases, Tenth Revision (ICD-10) transition on Perforated Appendix Admission Rate (PAAR), which is a commonly used ...indicator representing access to care developed by Agency for Healthcare Research and Quality (AHRQ).
In this interrupted time series study of Pediatric Health Information System database from 2013 to 2018, we employed three study phases (pre-implementation, washout, and initial implementation) to evaluate the influence of ICD-10 transition on trends in PAAR. ICD-10 diagnosis codes suggested by AHRQ's specifications were used to identify perforated and simple appendicitis, and PAAR was estimated accordingly. Generalized linear mixed models were used to examine the association of ICD-10 initial implementation and being documented as perforated appendicitis on encounter level.
We identified a total of 94,810 encounters diagnosed with appendicitis, and almost all patients’ characteristics were similar over the three study phases, except for PAAR. The pre-implementation PAAR in October 2013 was 33.1%, and the immediate influence of ICD-10 transition on PAAR was 3.2% (P = 0.002), with a 0.38% per quarter increase over time (P = 0.02). After adjusting for age, gender, race/ethnicity, payer, and year, the likelihood of being documented as having perforated appendicitis in 2016 was 1.5 times higher than the estimated likelihood before the implementation (adjusted Odds Ratio: 1.51; 95% Confidence Interval: 1.40-1.63; P < 0.001).
The 2015-2018 ICD-10 transition may be erroneously associated with an increasing trend of PAAR. Care should be taken when interpreting the metric during this period.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
IMPORTANCE: Differences in time to diagnostic and therapeutic measures can contribute to disparities in outcomes. However, whether there is an association of timeliness by sex for trauma patients is ...unknown. OBJECTIVE: To investigate whether sex-based differences in time to definitive interventions exist for trauma patients in the US and whether these differences are associated with outcomes. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study conducted from July 2020 to July 2021, using the 2013 to 2016 Trauma Quality Improvement Program (TQIP) databases from level I to III trauma centers in the US. Patients 18 years or older with an Injury Severity Score (ISS) greater than 15 and who carried diagnoses of traumatic brain injury, intra-abdominal injury, pelvic fracture, femur fracture, and spinal injury as a result of their trauma were included in the study. Data were analyzed from July 2020 to July 2021. MAIN OUTCOMES AND MEASURES: Primary outcomes assessed timeliness to interventions, using Wilcoxon signed rank and χ2 tests. Secondary outcomes included location of discharge after injury, using propensity score–matched generalized estimating equations modeling. RESULTS: Of the 28 332 patients included, 20 002 (70.6%) were male patients (mean SD age, 43.3 18.2 years) and 8330 (29.4%) were female patients (mean SD age, 48.5 21.1 years), with significantly different distributions of ISS scores (ISS score 16-24: male patient, 10 622 53.1%; female patient, 4684 56.2%; ISS score 41-74: male patient, 2052 10.3%; female patient, 852 10.2%). Male patients more frequently had abdominal (4257 21.3% vs 1268 15.2%) and spinal cord (3989 20.0% vs 1274 15.3%) injuries, whereas female patients experienced greater proportions of femur (3670 44.0% vs 8422 42.1%) and pelvic (3970 47.6% vs 6963 34.8%) fractures. Female patients experienced significantly longer emergency department length of stay (median IQR, 184 92-314 minutes vs 172 86-289 minutes; P < .001), longer time in pretriage (median IQR, 52 36-80 minutes vs 49 34-77 minutes; P < .001), and increased likelihood of discharge to nursing or long-term care facilities instead of home after matching by age, ISS, mechanism, and injury type (male patient:female patient, odds ratio, 0.72; 95% CI, 0.67-0.78). CONCLUSIONS AND RELEVANCE: Results of this cohort study suggest that female trauma patients experienced slightly longer delays in trauma care and had a higher likelihood of discharge to long-term care facilities than their male counterparts.
The impact of COVID-19 pandemic on pediatric surgical care systems is unknown. We present an initial evaluation of self-reported pediatric surgical policy changes from hospitals across North America.
...On March 30, 2020, an online open access, data gathering spreadsheet was made available to pediatric surgeons through the American Pediatric Surgical Association (APSA) website, which captured information surrounding COVID-19 related policy changes. Responses from the first month of the pandemic were collected. Open-ended responses were evaluated and categorized into themes and descriptive statistics were performed to identify areas of consensus.
Responses from 38 hospitals were evaluated. Policy changes relating to three domains of program structure and care processes were identified: internal structure, clinical workflow, and COVID-19 safety/prevention. Interhospital consensus was high for reducing in-hospital staffing, limiting clinical fellow exposure, implementing telehealth for conducting outpatient clinical visits, and using universal precautions for trauma. Heterogeneity in practices existed for scheduling procedures, implementing testing protocols, and regulating use of personal protective equipment.
The COVID-19 pandemic has induced significant upheaval in the usual processes of pediatric surgical care. While policies evolve, additional research is needed to determine the effect of these changes on patient and healthcare delivery outcomes.
III
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Application of Quality Improvement methodology to nuanced clinical scenarios may be useful to ensure consistent delivery of equitable and comprehensive care. The purpose of this article is to inform ...the pediatric surgical readership of opportunities where quality improvement methodology may aid in navigating ethical nuances of complex surgical care. We present three case scenarios and discuss how quality improvement methodology could be utilized to address issues of provider autonomy, patient autonomy, and justice.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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