Ochsner Journal最新文献

Background: Chest pain in the emergency department requires swift diagnosis to distinguish between acute coronary syndrome and noncardiac causes. The use of the HEART score, which risk-stratifies patients based on history, electrocardiogram, age, risk factors, and troponin, reduces unnecessary admissions and costs. However, evaluations by resident physicians supervised by attending physicians can delay treatment and increase costs.

Methods: We assessed interrater reliability between attending physician and resident physician HEART scores in 2 study phases. In phase 1, participants were not provided with a standardized form, but in phase 2, participants used a standardized form to calculate HEART scores. Differences in scores were compared by years of experience and by study phase.

Results: A total of 75 HEART score comparisons were analyzed. Fifty comparisons between attending physicians and resident physicians were completed in phase 1, and 25 comparisons were completed in phase 2. Discrepancies between attending and resident physician scores ≤3 vs >3 decreased from 24% in phase 1 to 8% in phase 2. Attending physician years of experience did not affect discrepancies in HEART scores ≤3 vs >3 between attending and resident physicians (odds ratio [OR] 1.18 [95% CI 0.78 to 1.81]). Similarly, resident physician years of experience did not affect differences in HEART scores ≤3 vs >3 between attending and resident physicians (OR 0.77 [95% CI 0.38 to 1.53]).

Conclusion: The study found good agreement between attending physician and resident physician HEART scores, with experience level not significantly affecting discrepancies. The standardized scoring form improved consistency, although not significantly.

Background: Newer analgesic techniques to reduce opioid use and pain after total knee arthroplasty (TKA) include preoperative cryoneurolysis, adductor canal block (ACB), and local anesthetic infiltration between the popliteal artery and capsule of the knee (iPACK) block. The purpose of this study was to evaluate whether changing the regional analgesic from ropivacaine to liposomal bupivacaine would provide superior pain relief and reduce opioid requirements at 2 and 12 weeks following TKA.

Methods: We conducted a retrospective medical records review of 140 consecutive patients who underwent primary TKA at a single site and received ACB with ropivacaine (multimodal-ropivacaine [MM-R] group, n=70) or ACB/iPACK with liposomal bupivacaine (multimodal-liposomal bupivacaine [MM-LB] group, n=70). The primary outcomes were the morphine milligram equivalent (MME) of filled opioid prescriptions at discharge and during the first 12 weeks after TKA, as well as the Knee injury and Osteoarthritis Outcome Score and the Patient-Reported Outcomes Measurement Information System pain intensity and pain interference scores at 2 and 12 weeks postsurgery.

Results: The median MMEs for discharge opioid prescriptions and all opioid prescriptions were, respectively, 65% (P<0.0001) and 48% (P<0.0001) lower for patients in the MM-LB group vs the MM-R group. The MM-LB group had significantly better patient-reported outcomes 2 weeks after TKA compared to the MM-R group.

Conclusion: Compared with ropivacaine-based regional analgesia, liposomal bupivacaine-based regional analgesia in the context of a modern multimodal pain regimen may reduce opioid requirements and improve patient-reported outcomes during acute and short-term recovery after TKA.

Background: Weekend vs weekday hospital admission has been associated with poorer mortality rates for many conditions. Studies evaluating weekend admission for hip fractures have resulted in contradictory conclusions regarding outcomes.

Methods: We conducted a retrospective analysis of all patients who underwent surgery for a fragility hip fracture at a quaternary level teaching hospital during a 6-year period. A total of 1,164 patients were included: 796 weekday admissions (Monday through Friday) vs 368 weekend admissions (Saturday and Sunday). Patients were subdivided based on surgeon experience level (473 consultants vs 690 nonconsultants). Statistical tests included chi-square tests and logistic regression. Demographic data included age, sex, prior hip fracture, fracture type, operation, and American Society of Anesthesiologists grade. The primary outcome was 1-year mortality. Secondary outcomes were acute mortality (<24 hours), subacute mortality (1 to 30 days), change in mobility from baseline at 1 year, preoperative delay (>48 hours), and surgical duration.

Results: The weekend admission cohort had a higher 1-year mortality rate than the weekday admission cohort (30.4% vs 23.2%; P=0.029), while subacute mortality trended toward significance (P=0.083). No significant difference was seen in acute mortality (P=0.5). Hemiarthroplasty was associated with increased mortality at 12 months (P=0.012) compared to the other operative interventions. The median duration of surgery was lower in the weekend cohort vs the weekday cohort (1.15 hours [69 minutes] vs 1.23 hours [73.8 minutes]; P<0.001). Consultants performed surgeries 16.2 minutes faster than nonconsultants (P<0.001) and trended toward a lower 1-year mortality rate (22.1% vs 27.9%; P=0.058). No significant difference was seen in mobility change at 1 year in both the consultant vs nonconsultant analysis (P>0.9) and in the weekday vs weekend analysis (P>0.12).

Conclusion: A significantly increased 1-year mortality rate and a shorter surgical duration were observed among patients admitted on the weekends.

Background: More than 16,000 Virginians die of cardiovascular disease each year, with increased morbidity among Black and low-income adults. Hypertension (HTN) is the most modifiable cardiovascular disease risk factor. A community-based health intervention administered in partnership with schools may increase HTN awareness and reduce the development of unhealthy practices.

Methods: Elementary school students (n=52) attending a majority Black and low-income school participated in an educational intervention program called Teach BP that is designed to increase HTN awareness across 4 topics: knowledge of blood pressure (BP) and HTN, organ systems impacted by HTN, habits to maintain a healthy BP, and competency in operating a BP monitor.

Results: Students' ability to define and recognize HTN increased by an average of 62.7%. Their awareness of how HTN affects the body increased by an average of 92.1%. Additionally, students demonstrated competency in operating a BP monitor.

Conclusion: The Teach BP program was effective at increasing students' awareness of HTN.

[This corrects the article DOI: 10.31486/toj.24.0101.].

Background: The occurrence of central venous catheter infections is a metric that hospital systems track. We determined that central line-associated bloodstream infections (CLABSIs) at our institution occurred in a delayed fashion, prompting us to raise the question of whether the infections were related to insertion or to catheter care and then to design a training simulation focused on how to change the dressing for central venous catheters.

Methods: Using low-cost equipment, such as refrigerator magnets and tape, we constructed a reusable SorbaView SHIELD Contour (Centurion Medical Products Corporation) sterile central line dressing for use in training.

Results: This cost-effective simulation innovation gives staff who care for central venous catheters the opportunity to practice the manual skills involved in dressing changes and eliminates the problem of expending a single-use dressing with each learner experience. The magnetic dressings can be reused as long as the integrity of the SorbaView SHIELD Contour is preserved.

Conclusion: We hope that ongoing training with this simulation model, along with demonstration of competency, will result in standardized central line care and a decrease in CLABSI rates at our institution.

Background: Cerebellar ataxia with neuropathy and bilateral vestibular areflexia syndrome (CANVAS) is a rare, progressive, neurodegenerative disorder characterized by late-onset ataxia, bilateral vestibular impairment, and sensory neuropathy.

Case report: A 51-year-old male presented to the hospital with worsening dizziness, tremulousness of limbs, and falls during the preceding year. The patient experienced gradually progressive sensorimotor lower motor neuron quadriparesis, asymmetric ataxia, chronic pancerebellar dysfunction, oscillopsia, and impaired vestibulo-ocular reflex. His comorbidities included poorly controlled type 2 diabetes mellitus, chronic alcohol use, and thalidomide therapy for polycythemia vera with myelofibrosis. Diagnostic workup revealed sensory axonal neuropathy, hypercellular bone marrow with myelofibrosis, and utriculo-saccular dysfunction. Diabetes and thalidomide- and alcohol-related complications were presumed to be the reason for the patient's symptoms, but investigations revealed a diagnosis of CANVAS coexisting with polycythemia vera. The patient was treated with rehabilitation exercises and medications that slightly improved but did not resolve his symptoms. More than 1 year after the patient's last follow-up, a physician at another hospital discontinued the thalidomide prescription because of the patient's neuropathy. Two months later, the patient developed febrile neutropenia and died of pneumonia and sepsis.

Conclusion: To our knowledge, CANVAS coexisting with polycythemia vera has only been reported once in the literature. The significance of this coexistence is not clear. Future case studies may help elucidate a link between these two entities.

Background: Endotracheal intubation is commonly associated with postoperative sore throat. We evaluated the effect of the jaw thrust maneuver on the incidence and severity of sore throat.

Methods: A total of 110 female patients undergoing laparoscopic abdominal procedures were enrolled in the study, and 99 patients were included in the final analysis. The patients were randomized into 2 groups: the jaw thrust group (n=49) and the non-jaw thrust group (n=50). Sore throat monitoring and grading were performed at 0, 2, 4, 8, 12, and 24 hours postextubation.

Results: The overall incidence of sore throat was higher in the non-jaw thrust group than in the jaw thrust group, with a maximum incidence at 4 hours, and the difference in incidence between the 2 groups was significant at the 4-, 8-, 12-, and 24-hour time points postextubation. However, no significant difference in sore throat severity was found between the non-jaw thrust and jaw thrust groups. The time of laryngoscopy was significantly less for patients in the jaw thrust group.

Conclusion: In our population, the jaw thrust maneuver lowered the incidence but not the severity of sore throat during the initial 24 hours after extubation. The jaw thrust maneuver also significantly lowered laryngoscopy time.