Objective
The objective was to compare first‐attempt intubation success using direct laryngoscopy augmented by laryngeal manipulation, ramped patient positioning, and use of a bougie (A‐DL) with ...unaided video laryngoscopy (VL) in adult emergency department (ED) intubations.
Methods
This study was a secondary analysis of a multicenter prospective observational database of ED intubations from the National Emergency Airway Registry (NEAR). We compared all VL procedures to seven exploratory permutations of A‐DL using multivariable regression models. We further stratified by blade shape into hyperangulated VL (HA‐VL) and standard‐geometry VL (SG‐VL). We report differences in first‐attempt intubation success and peri‐intubation adverse events with cluster‐adjusted odds ratios (ORs) with 95% confidence intervals (CIs). We report univariate comparisons in patient characteristics, difficult airway attributes, and intubation methods using descriptive statistics and OR with 95% CI.
Results
We analyzed 11,714 intubations performed from January 1, 2016, through December 31, 2017. Of these encounters, 6,938 underwent orotracheal intubation with either A‐DL or unaided VL on first attempt. A‐DL was used first in 3,936 (56.7%, 95% CI = 46.9 to 66.5) versus unaided VL in 3,002 (43.3%, 95% CI = 33.5 to 53.1). Of the A‐DL first intubations 1,787 (45.4%) employed ramped positioning alone, 1,472 (37.4%) had external laryngeal manipulation (ELM), and 365 (9.3%) used a bougie. Rapid sequence intubation (RSI) was the most common method used in 5,602 (80.8%, 95% CI = 77.0 to 84.5) cases. First‐attempt success was significantly higher with all VL (90.9%, 95% CI = 88.7 to 93.1) versus all A‐DL (81.1%, 95% CI = 78.7 to 83.5) despite the VL group having more patients with reduced mouth opening, neck immobility, and an initial impression of airway difficult. Multivariable regression analyses controlling for indication, method, operator specialty and year of training, center clustering, and all registry‐recorded difficult airway predictors revealed first‐attempt success was higher with all unaided VL compared with any A‐DL (adjusted OR AOR = 2.8, 95% CI = 2.4 to 3.3), DL with bougie (AOR = 2.7, 95% CI = 2.1 to 3.5), DL with ELM (AOR = 1.8, 95% CI = 1.5 to 2.2), DL with ramped positioning (AOR = 2.8, 95% CI = 2.3 to 3.3), or DL with ELM plus bougie (AOR = 2.8, 95% CI = 2.3 to 3.3). Subgroup analyses of HA‐VL and SG‐VL compared with any A‐DL yielded similar results (AOR = 3.2, 95% CI = 2.6 to 3.0; and AOR = 2.4, 95% CI = 1.9 to 3.0, respectively). The propensity score–adjusted odds for first‐attempt success with VL was also 2.8 (95% CI = 2.4 to 3.3). Fewer esophageal intubations were observed in the VL cohort (0.4% vs. 1.3%, AOR = 0.2, 95% CI = 0.1 to 0.5).
Conclusions
Video laryngoscopy used without any augmenting maneuver, device, or technique results in higher first‐attempt success than does DL that is augmented by use of a bougie, ELM, ramping, or combinations thereof.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Abstract Background The ability to predict whether a child has complicated appendicitis at initial presentation may influence clinical management. However, whether complicated appendicitis is ...associated with pre-hospital or in-hospital factors are not clear. We also investigate whether hyponatremia may be a novel pre-hospital factor associated with complicated appendicitis. Materials and methods A retrospective review of all pediatric patients ( < 12 years) with appendicitis treated with appendectomy from 2000-2013 was performed. The main outcome measure was intraoperative confirmation of gangrenous or perforated appendicitis. A multivariable analysis was performed and the main predictors of interest were age <5 years, symptom duration >24 hours, leukocytosis (WBC count >12 x103 /ml), hyponatremia (sodium < 135 mEq/L), and time from admission to appendectomy. Results Of 392 patients, 179 (46%) had complicated appendicitis at the time of operation. Univariate analysis demonstrated that patients with complicated appendicitis were younger, had a longer duration of symptoms, higher WBC count, and lower sodium levels than patients with non-complicated appendicitis. Multivariable analysis confirmed that symptom duration >24 hours (OR = 5.5, 95% CI = 3.5-8.9, P <.01), hyponatremia (OR = 3.1, 95% CI = 2.0-4.9, P <.01), age <5 years (OR = 2.3, 95% CI = 1.3-4.0, P <.01), and leukocytosis (OR = 1.9, 95% CI = 1.0-3.5, P = .04) were independent predictors of complicated appendicitis. Increased time from admission to appendectomy was not a predictor of complicated appendicitis (OR = 0.8, 95% CI = 0.5-1.2, P = 0.2). Conclusions Pre-hospital factors can predict complicated appendicitis in children with suspected appendicitis. Hyponatremia is a novel marker associated with complicated appendicitis. Delaying appendectomy does not increase the risk of complicated appendicitis once intravenous antibiotics are administered. This information may help guide resource/personnel allocation, timing of appendectomy, and decision for non-operative management of appendicitis in children.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
BACKGROUND:Ligation of intersphincteric fistula tract is a novel surgical technique in the treatment of transsphincteric fistula-in-ano that has been shown to be successful in the short term. Median ...follow-up in current literature ranges from 5 to 9 months. However, the long-term success rate is unknown.
OBJECTIVE:This study describes our long-term results in performing the ligation of intersphincteric fistula tract procedure.
DESIGN:This study is a retrospective review.
PATIENTS:Thirty-eight patients from August 2008 to October 2011 were evaluated.
INTERVENTIONS:All patients underwent the ligation of intersphincteric fistula tract for fistula-in-ano.
MAIN OUTCOME MEASURES:Patient and fistula characteristics, primary healing rate, secondary healing rate, previous treatments, and failures were reviewed.
RESULTS:The median follow-up was 26 months (range, 3–44 months), and 26 patients (68%) were followed for greater than 12 months. The overall primary healing rate was 61% (23 of 38), and it was 62% (16 of 26) in patients followed for over 12 months. Eighty percent (12/15) of the failures are early failures (persistent symptoms or failure at ≤6 months), and 20% are late failures (>6 months) with 1 failure occurring 12 months postprocedure. Increase in length of fistula tract was associated with decreased healing (OR 0.55, 95% CI 0.34–0.88, p = 0.01). There were no intraoperative complications and no reported incontinence.
CONCLUSION:Our study demonstrates favorable long-term results for the ligation of intersphincteric fistula tract procedure. It appears that long tracts negatively affect healing, and late failures can occur up to 12 months postoperatively. Understanding the type of failure can help guide subsequent treatment to maximize healing success.
To engineer tissue-like structures, cells must organize themselves into three-dimensional (3D) networks that mimic the native tissue microarchitecture. Microfabricated hydrogel substrates provide a ...potentially useful platform for directing cells into biomimetic tissue architecture in vitro. Here, we present microgrooved methacrylated gelatin hydrogels as a suitable platform to build muscle-like fibrous structures in a facile and highly reproducible fashion. Microgrooved hydrogel substrates with two different ridge sizes (50 and 100 μm) were fabricated to assess the effect of the distance between engineered myofibers on the orientation of the bridging C2C12 myoblasts and the formation of the resulting multinucleated myotubes. It was shown that although the ridge size did not significantly affect the C2C12 myoblast alignment, the wider-ridged micropatterned hydrogels generated more myotubes that were not aligned to the groove direction as compared to those on the smaller-ridge micropatterns. We also demonstrated that electrical stimulation improved the myoblast alignment and increased the diameter of the resulting myotubes. By using the microstructured methacrylated gelatin substrates, we built free-standing 3D muscle sheets, which contracted when electrically stimulated. Given their robust contractility and biomimetic microarchitecture, engineered tissues may find use in tissue engineering, biological studies, high-throughput drug screening, and biorobotics.
Pediatric Readiness and Facility Verification Remick, Katherine, MD; Kaji, Amy H., MD, PhD; Olson, Lenora, PhD, MA ...
Annals of emergency medicine,
03/2016, Volume:
67, Issue:
3
Journal Article
Peer reviewed
Study objective We perform a needs assessment of pediatric readiness, using a novel scoring system in California emergency departments (EDs), and determine the effect of pediatric verification ...processes on pediatric readiness. Methods ED nurse managers from all 335 acute care hospital EDs in California were sent a 60-question Web-based assessment. A weighted pediatric readiness score (WPRS), using a 100-point scale, and gap analysis were calculated for each participating ED. Results Nurse managers from 90% (300/335) of EDs completed the Web-based assessment, including 51 pediatric verified EDs, 67 designated trauma centers, and 31 EDs assessed for pediatric capabilities. Most pediatric visits (87%) occurred in nonchildren’s hospitals. The overall median WPRS was 69 (interquartile ratio IQR 57.7, 85.9). Pediatric verified EDs had a higher WPRS (89.6; IQR 84.1, 94.1) compared with nonverified EDs (65.5; IQR 55.5, 76.3) and EDs assessed for pediatric capabilities (70.7; IQR 57.4, 88.9). When verification status and ED volume were controlled for, trauma center designation was not predictive of an increase in the WPRS. Forty-three percent of EDs reported the presence of a quality improvement plan that included pediatric elements, and 53% reported a pediatric emergency care coordinator. When coordinator and quality improvement plan were controlled for, the presence of at least 1 pediatric emergency care coordinator was associated with a higher WPRS (85; IQR 75, 93.1) versus EDs without a coordinator (58; IQR 50.1, 66.9), and the presence of a quality improvement plan was associated with a higher WPRS (88; IQR 76.7, 95) compared with that of hospitals without a plan (62; IQR 51.2, 68.7). Of pediatric verified EDs, 92% had a quality improvement plan for pediatric emergency care and 96% had a pediatric emergency care coordinator. Conclusion We report on the first comprehensive statewide assessment of “pediatric readiness” in EDs according to the 2009 “Guidelines for Care of Children in the Emergency Department.” The presence of a pediatric readiness verification process, pediatric emergency care coordinator, and quality improvement plan for pediatric emergency care was associated with higher levels of pediatric readiness.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
PURPOSE:The ligation of the intersphincteric fistula tract is a new surgical procedure without any use of biologic material. The purpose of this study is to present our early results with this novel ...technique.
METHODS:A retrospective review of patients who underwent the procedure for high transsphincteric fistulas was analyzed. The procedure was performed by a single surgeon. Patient and fistula characteristics, complications, and recurrences were reviewed.
RESULTS:Twenty-five patients underwent the ligation of intersphincteric fistula tract procedure. All the patients had transsphincteric fistulas that were not suitable for fistulotomy. All patients underwent the procedure on an outpatient basis with a median follow-up of 24 weeks (range, 8–52 wk). Of the 25 patients, 17 (68%) healed completely and did not require any further surgical treatment. Eight of the 25 patients had persistent symptoms5 patients had a clear tract with an internal opening, 2 patients had a draining sinus without an identifiable internal opening, and 1 patient presented with an intersphincteric fistula, which was at the site of the intersphincteric groove incision. There were no statistically significant differences in recurrence rates with regard to the presence of a seton at the time of surgery, history of previous operations such as mucosal advancement flap, or seton placement.
CONCLUSION:The ligation of intersphincteric fistula is a promising sphincter-preserving procedure that is simple and safe, and it does not require expensive biologic material. Our early data confirm a low recurrence rate with a primary healing rate of 68%.
Study objective Apnea is a known complication of pediatric seizures, but patient factors that predispose children are unclear. We seek to quantify the risk of apnea attributable to midazolam and ...identify additional risk factors for apnea in children transported by paramedics for out-of-hospital seizure. Methods This is a 2-year retrospective study of pediatric patients transported by paramedics to 2 tertiary care centers. Patients were younger than 15 years and transported by paramedics to the pediatric emergency department (ED) for seizure. Patients with trauma and those with another pediatric ED diagnosis were excluded. Investigators abstracted charts for patient characteristics and predefined risk factors: developmental delay, treatment with antiepileptic medications, and seizure on pediatric ED arrival. Primary outcome was apnea defined as bag-mask ventilation or intubation for apnea by paramedics or by pediatric ED staff within 30 minutes of arrival. Results There were 1,584 patients who met inclusion criteria, with a median age of 2.3 years (Interquartile range 1.4 to 5.2 years). Paramedics treated 214 patients (13%) with midazolam. Seventy-one patients had apnea (4.5%): 44 patients were treated with midazolam and 27 patients were not treated with midazolam. After simultaneous evaluation of midazolam administration, age, fever, developmental delay, antiepileptic medication use, and seizure on pediatric ED arrival, 2 independent risk factors for apnea were identified: persistent seizure on arrival (odds ratio OR=15; 95% confidence interval CI 8 to 27) and administration of field midazolam (OR=4; 95% CI 2 to 7). Conclusion We identified 2 risk factors for apnea in children transported for seizure: seizure on arrival to the pediatric ED and out-of-hospital administration of midazolam.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Resistive random access memory (ReRAM) properties in which the resistance of the insulating material drastically changes by voltage application have recently attracted much attention. In this work, ...molybdenum oxide prepared by thermal oxidation of Mo films was studied to investigate its potential as a material exhibiting ReRAM switching. The samples oxidized between 400 and 600°C were composed of MoO3 and were switchable. Current-to-voltage curves, which were measured in air at room temperature by using a Pt–Ir probe as the top electrode, indicated the yielding of both the monopolar and bipolar switching properties. The resistance on-off ratio was between 10 and 102.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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