Pelvic obliquity (PO), or pelvic alignment in the coronal plane, is an important radiographic parameter to indicate fusion levels and judge success of scoliosis correction in patients with ...neuromuscular scoliosis. There are multiple commonly used techniques to measure PO that have good to excellent interrater and intrarater reliability, but these different methods yield inconsistent values when used on the same radiograph. This study evaluates the inconsistency in the magnitude of PO measurements for patients with neuromuscular scoliosis among 5 common measurement techniques.
Radiographs of 63 patients with neuromuscular scoliosis were evaluated by 5 raters. Each rater measured PO on each radiograph using the Osebold, O'Brien, Allen and Ferguson, Lindseth, and Maloney techniques. Patients were divided into 2 cohorts based on coronal balance or imbalance. Interrater and intrarater analyses were performed using a 2-way random effects model to calculate absolute agreement. The mean difference in PO between all possible pairs of the techniques was compared using a 2-tailed t test.
The Maloney and Osebold techniques demonstrated excellent interrater reliability, and the Maloney, Osebold, and O'Brien techniques demonstrated excellent intrarater reliability. Significant differences in PO measurement were found in 6 of the 10 comparisons for the balanced spines and 8 of the 10 comparisons for the unbalanced spines. Variability in measurement was captured by best-fit lines, which demonstrated greater dispersion between the means for the Osebold and Maloney techniques in the unbalanced spines than in the balanced spines.
To our knowledge, this study is the first to evaluate mean differences in magnitude of PO among common measurement techniques while accounting for coronal imbalance. Although there is no gold standard for measuring PO, the Maloney and Osebold techniques are the most consistent. This study suggests that those 2 techniques can be used interchangeably when the spine is coronally balanced, but the Osebold technique becomes more inconsistent than the Maloney technique when coronal imbalance exceeds 2 cm.
This information is relevant to surgeons using PO to plan fusion levels and striving for objective ways to judge correction intraoperatively as well as for researchers compiling PO data from multiple centers or studies.
DKA and HHS represent two extremes in the spectrum of decompensated diabetes mellitus. Their pathogenesis is related to absolute or relative deficiency in insulin levels and elevations in insulin ...counterregulatory hormones that lead to altered metabolism of carbohydrate, protein, and fat and varying degrees of osmotic diuresis and dehydration, ketosis, and acidosis. In DKA, insulin deficiency and ketoacidosis are the prominent features of the clinical presentation, and insulin therapy is the cornerstone of therapy. In HHS, hyperglycemia, osmotic diuresis, and dehydration are the prominent features, and fluid replacement is the cornerstone of therapy. As many as one-third of patients may have mixed features of both DKA and HHS. Because the three-pronged approach to therapy for either DKA or HHS consists of fluid administration, intravenous insulin infusion, and electrolyte replacement, mixed cases are managed using the same approach. The therapeutic regimen is tailored according to the prominent clinical features present. In adult patients with mixed features, fluids may be administered more rapidly than they would be in younger patients, or in patients with DKA alone, because the risk for fatal cerebral edema in adults is low and the consequences of undertreatment include vascular occlusion and increased mortality. In younger patients with mixed features, rapid correction of metabolic abnormalities and, consequently, of hyperosmolarity by administration of hypotonic fluids and insulin should be avoided to decrease the risk for precipitating cerebral edema. In addition, if ketoacidosis has been a prominent feature in a mixed case, the patient may have type 1 diabetes with no residual pancreatic islet beta cell secretion and may subsequently need ongoing, life-long insulin therapy after resolution of the acute episode of decompensated diabetes. ICU admission is indicated in the management of DKA, HHS, and mixed cases in the presence of cardiovascular instability, inability to protect the airway, obtundation, the presence of acute abdominal signs or symptoms suggestive of acute gastric dilatation, or if there is not adequate capacity on the floor unit to administer the intravenous insulin infusion and to provide the frequent and necessary monitoring that must accompany its use.
The outpatient clinical note documents the clinician's information collection, problem assessment, and patient management, yet there is currently no validated instrument to measure the quality of the ...electronic clinical note. This study evaluated the validity of the QNOTE instrument, which assesses 12 elements in the clinical note, for measuring the quality of clinical notes. It also compared its performance with a global instrument that assesses the clinical note as a whole.
Retrospective multicenter blinded study of the clinical notes of 100 outpatients with type 2 diabetes mellitus who had been seen in clinic on at least three occasions. The 300 notes were rated by eight general internal medicine and eight family medicine practicing physicians. The QNOTE instrument scored the quality of the note as the sum of a set of 12 note element scores, and its inter-rater agreement was measured by the intraclass correlation coefficient. The Global instrument scored the note in its entirety, and its inter-rater agreement was measured by the Fleiss κ.
The overall QNOTE inter-rater agreement was 0.82 (CI 0.80 to 0.84), and its note quality score was 65 (CI 64 to 66). The Global inter-rater agreement was 0.24 (CI 0.19 to 0.29), and its note quality score was 52 (CI 49 to 55). The QNOTE quality scores were consistent, and the overall QNOTE score was significantly higher than the overall Global score (p=0.04).
We found the QNOTE to be a valid instrument for evaluating the quality of electronic clinical notes, and its performance was superior to that of the Global instrument.
Cleft lip and palate (CLP) comprise over 90% of the world's congenital anomalies and cause significant disability worldwide, while disproportionally burdening low- and middle-income countries ...(LMICs). Research can help inform strategies that reduce disparities in accessing CLP care. We performed a scientometric analysis of CLP research in LMICs to identify influential contributors and themes.
The authors searched seven citation databases accessed via Web of Science, from inception to March 2, 2021. Social network analysis was done using VOSviewer. The Kruskal-Wallis test and linear regression were used.
In total, 1561 articles authored by 6414 researchers affiliated with 2113 organizations in 119 countries were included. Most authors (n = 6387, 99.6%) had published two or more articles. The USA (454 articles), Brazil (211 articles), China (175 articles), and India (127 articles) published the most. The most prolific institutions were the University of Sao Paulo (94 articles), the University of Pittsburgh (57 articles), and the University of Iowa (55 articles). Marazita ML (33 articles), Shi B (27 articles), and Murray JC (22 articles) had the highest number of publications. An estimated 510 articles (32.7%) were focused on epidemiology, 240 (15.4%) on management, and 54 (3.5%) on global plastic surgery for CLP.
LMICs are disproportionally burdened by CLP, but research is limited and often produced by high-income countries. This study elucidates partnership and health system strengthening opportunities to improve LMIC research capacity and ultimately informs the management and outcomes for patients with CLP.
Children with cleft lip and/or palate (CL/P) are highly susceptible to malnutrition, which can restrict their ability to receive safe surgery. Ready-to-use therapeutic foods (RUTF) are an effective ...treatment for children with malnutrition; however, the effectiveness of short-term nutritional supplementation in preparing patients for cleft surgery has not been demonstrated. We studied the effectiveness of RUTF in transitioning malnourished patients with CL/P, who were initially ineligible for surgery, into surgical candidates.
A cohort of patients with CL/P who were initially deemed ineligible for surgery due to malnutrition from Ghana, Honduras, Malawi, Madagascar, Nicaragua, and Venezuela was followed by Operation Smile. Patients were enrolled in a nutrition program that provided RUTF packets and tracked age, weight, and height at each visit. A WHO Z score was calculated for each patient to longitudinally track malnutrition status. Patients were considered eligible for surgery when their Z scores were in the normal range (Z>–1). The study was part of a collaborative programme between Operation Smile (NGO), Birdsong Peanuts (peanut shellers and distributors), and MANA Nutrition (RUTF producer).
556 patients were recruited between June, 2017, and January, 2020. Initially, 28·2% (n=157) were diagnosed with severe malnutrition, 21·0% (n=117) with moderate malnutrition, and 50·7% (n=282) with mild malnutrition. Most patients (325 66·4%) presented for at least one return visit. Of patients who returned, 207 (56·1%) became eligible for surgery; 32 (15·5%) initially with severe malnutrition, 30 (14·5%) with moderate malnutrition, and 145 (70·0%) with mild malnutrition. By the second visit, the mean Z score increased significantly from −2·5 (moderate malnutrition) to −1·7 (mild malnutrition) (p<0·001). Mean time to attain surgical eligibility from enrolment was 6 weeks (range 1–103 weeks). There was a significant difference in the proportion of patients who became eligible by country (p<0·001).
Malnutrition prevents many children with CL/P in low-income and middle-income countries from receiving surgical care, even when provided for free, creating a larger disparity in access to surgery. In an average of 6 weeks with an approximate cost of US $30 per patient, RUTF transitioned over half of these patients into safe surgical candidates, making it an effective short-term preoperative nutritional intervention. Through unique partnerships, the expansion of cost-effective, large-scale nutrition programmes can play a pivotal role in ensuring those at the highest risk of living with unrepaired CL/P receive timely and safe surgical care.
Birdsong Peanuts.
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