Ventilator-associated pneumonia and intubation location in adults with traumatic injuries: Systematic review and meta-analysis

alexandrossfakianakis shared this article with you from Inoreader Ventilator-associated pneumonia and intubation location in adults with traumatic injuries: Systematic review and meta-analysis via Journal of Trauma and Acute Care Surgery - Current Issue BACKGROUND Ventilator-associated pneumonia (VAP) is an important cause of morbidity and mortality among critically ill patients, particularly those who present with traumatic injuries. This review aims to determine whether patients with traumatic injuries who are intubated in the prehospital setting are at higher risk of developing VAP compared with those intubated in the hospital. METHODS A systematic review of Medline, Scopus, and Cochrane electronic databases was conducted from inception to January 2021. Inclusion criteria were patients with traumatic injuries who were intubated in the prehospital or hospital settings with VAP as an outcome. Using a random-effects model, the risk of VAP across study arms was compared by calculating a summary relative risk with 95% confidence intervals. The results of individual studies were also summarized qualitatively. RESULTS The search identified 754 articles of which 6 studies (N = 2,990) met the inclusion criteria. All studies were good quality based on assessment with the Newcastle Ottawa scale. Prehospital intubation demonstrated an increased risk of VAP development in two of the six studies. Among the six studies, the overall quality weighted risk ratio was 1.09 (95% confidence interval, 0.90–1.31). CONCLUSION Traumatically injured patients who are intubated in the prehospital setting have a similar risk of developing VAP compared with those that are intubated in the hospital setting. LEVEL OF EVIDENCE Systematic review and meta-analysis; Level IV. View on Web

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Tracheostomy decreases continuous analgesia and sedation requirements

alexandrossfakianakis shared this article with you from Inoreader Tracheostomy decreases continuous analgesia and sedation requirements via Journal of Trauma and Acute Care Surgery - Current Issue BACKGROUND The goals of sedation in the critically ill surgical patient are to minimize pain, anxiety, and agitation without hindering cardiopulmonary function. One potential benefit of tracheostomy during endotracheal intubation is the reduction of sedation and analgesia; however, there are little data to support this supposition. We hypothesized that patients undergoing tracheostomy would have a rapid reduction in sedation and analgesia following tracheostomy. METHODS A retrospective review of tracheostomies performed at a single Level I trauma center from January 2013 to June 2018 was completed. An evaluation of Glasgow Coma Scale, Richmond Agitation-Sedation Scale, and Confusion Assessment Method for the intensive care unit 72 hours pretracheostomy to 72 hours posttracheostomy was performed. The total daily dose of sedation, anxiolytic, and analgesic medications administered were recorded. Mixed-effects models were used to evaluate longitudinal drug does over time (hours). RESULTS Four hundred sixty-eight patients included for analysis with a mean age of 58.8 ± 18.3 years. There was a significant decrease in propofol and fentanyl utilization from 24 hours pretracheostomy to 24 hours posttracheostomy in both dose and number of patients receiving these continuous intravenous medications. Similarly, total morphine milligram equivalents (MME) use and continuous midazolam significantly decreased from 24 hours pretracheostomy to 24 hours posttracheostomy. By contrast, intermittent enteral quetiapine and methadone administration increased after tracheostomy. Importantly, Richmond Agitation-Sedation Scale, Glasgow Coma Scale, and Confusion Assessment Method scoring were also significantly improved as early as 24 hours posttracheostomy. Total MME use was significantly elevated in patients younger than 65 years and in male patients pretracheostomy compared with female patients. Patients admitted to the medical intensive care unit had significantly higher MME use compar ed with those in the surgical intensive care unit pretracheostomy. CONCLUSION Tracheostomy allows for a rapid and significant reduction in intravenous sedation and analgesia medication utilization. Posttracheostomy sedation can transition to intermittent enteral medications, potentially contributing to the observed improvements in postoperative mental status and agitation. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III. View on Web

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Scalable deep learning algorithm to compute percent pulmonary contusion among patients with rib fractures

alexandrossfakianakis shared this article with you from Inoreader Scalable deep learning algorithm to compute percent pulmonary contusion among patients with rib fractures via Journal of Trauma and Acute Care Surgery - Current Issue BACKGROUND Pulmonary contusion exists along a spectrum of severity, yet is commonly binarily classified as present or absent. We aimed to develop a deep learning algorithm to automate percent pulmonary contusion computation and exemplify how transfer learning could facilitate large-scale validation. We hypothesized that our deep learning algorithm could automate percent pulmonary contusion computation and that greater percent contusion would be associated with higher odds of adverse inpatient outcomes among patients with rib fractures. METHODS We evaluated admission-day chest computed tomography scans of adults 18 years or older admitted to our institution with multiple rib fractures and pulmonary contusions (2010–2020). We adapted a pretrained convolutional neural network that segments three-dimensional lung volumes and segmented contused lung parenchyma, pulmonary blood vessels, and computed percent pulmonary contusion. Exploratory analysis evaluated associations between percent pulmonary contusion (quartiles) and odds of mechanical ventilation, mortality, and prolonged hospital length of stay using multivariable logistic regression. Sensitivity analysis included pulmonary blood vessel volumes during percent contusion computation. RESULTS A total of 332 patients met inclusion criteria (median, 5 rib fractures), among whom 28% underwent mechanical ventilation and 6% died. The study population's median (interquartile range) percent pulmonary contusion was 4% (2%–8%). Compared to the lowest quartile of percent pulmonary contusion, each increasing quartile was associated with higher adjusted odds of undergoing mechanical ventilation (odds ratio [OR], 1.5; 95% confidence interval [95% CI], 1.1–2.1) and prolonged hospitalization (OR, 1.6; 95% CI, 1.1–2.2), but not with mortality (OR, 1.1; 95% CI, 0.6–2.0). Findings were similar on sensitivity analysis. CONCLUSION We developed a scalable deep learning algorithm to automate percent pulmonary contusion calculating using chest computed tomography scans of adults admitted with rib fractures. Open code sharing and collaborative research are needed to validate our algorithm and exploratory analysis at a large scale. Transfer learning can help harness the full potential of big data and high-performing algorithms to bring precision medicine to the bedside. LEVEL OF EVIDENCE Prognostic and epidemiological, Level III. View on Web

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Environmental exposures and anti-Müllerian hormone: a mixture analysis in the Nurses’ Health Study II

alexandrossfakianakis shared this article with you from Inoreader Environmental exposures and anti-Müllerian hormone: a mixture analysis in the Nurses' Health Study II via Epidemiology - Published Ahead-of-Print Background: Previous studies have linked environmental exposures with anti-Müllerian hormone (AMH), a marker of ovarian reserve. However, associations with multiple environment factors has to our knowledge not been addressed. Methods We included a total of 2,447 premenopausal women in the Nurses' Health Study II (NHSII) who provided blood samples during 1996-1999. We selected environmental exposures linked previously with reproductive outcomes that had measurement data available in NHSII, including greenness, particulate matter, noise, outdoor light at night, ultraviolet radiation, and six hazardous air pollutants (1,3-butadiene, benzene, diesel particulate matter, formaldehyde, methylene chloride, and tetrachloroethylene). For these we calculated cumulative averages from enrollment (1989) to blood draw and estimated associations with AMH in adjusted single exposure models, principal component analysis (PCA), and hierarchical Bayesian kernel machine regression (BKMR). Results Single exposure models showed negative associations of AMH with benzene (percentage reduction in AMH per interquartile range (IQR) increase = 5.5%, 95%CI=1.0, 9.8) and formaldehyde (6.1%, 95%CI=1.6, 10). PCA identified four major exposure patterns but only one with high exposure to air pollutants and light at night was associated with lower AMH. Hierarchical BKMR pointed to benzene, formaldehyde, and greenness, and suggested an inverse joint association with AMH (percentage reduction comparing all exposures at the 75th percentile to median= 8.2%, 95%CI=0.7, 15.1. Observed associations were mainly among women above age 40. Conclusions We found exposure to benzene and formaldehyde to be consistently associated with lower AMH levels. The associations among older women are consistent with the hypothesis that environmental exposures accelerate reproductive aging. Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved. View on Web

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Recall of Acyclovir Sodium Injection 500 mg per 10 mL (50 mg/mL), Due to the Presence of Particulate Matter

alexandrossfakianakis shared this article with you from Inoreader Eugia US LLC Issues Voluntary Nationwide Recall of Acyclovir Sodium Injection 500 mg per 10 mL (50 mg/mL), Due to the Presence of Particulate Matter via Food and Drug Administration--Recalls/Safety Alerts East Windsor, New Jersey, Eugia US LLC (formerly AuroMedics Pharma LLC) has initiated a voluntary recall of lot number AC22006 of AuroMedics Acyclovir Sodium Injection 500 mg per 10 mL (50 mg/mL), 10 mL single dose vial to the consumer level from the U.S. market due to a product complaint for the pr View on Web

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Long-Term Exposure to Oxidant Gases and Mortality: Effect Modification by PM2.5Transition Metals and Oxidative Potential

alexandrossfakianakis shared this article with you from Inoreader Long-Term Exposure to Oxidant Gases and Mortality: Effect Modification by PM2.5Transition Metals and Oxidative Potential via Epidemiology - Published Ahead-of-Print Background: Populations are simultaneously exposed to outdoor concentrations of oxidant gases (i.e., O3 and NO2) and fine particulate air pollution (PM2.5). Since oxidative stress is thought to be an important mechanism explaining air pollution health effects, the adverse health impacts of oxidant gases may be greater in locations where PM2.5 is more capable of causing oxidative stress. Methods: We conducted a cohort study of 2 million adults in Canada between 2001-2016 living within 10-km of ground-level monitoring sites for outdoor PM2.5 components and oxidative potential. Ox exposures (i.e., the redox weighted average of O3 and NO2) were estimated using a combination of chemical transport models, land use regression models, and ground level data. Cox proportional hazards models were used to estimate associations between 3-year moving average Ox and mortality outcomes across strata of transition metals and sulfur in PM2.5 and three measures of PM2.5 oxidative potential adjusting for possible confounding factors. Results: Associations between Ox and mortality were consistently stronger in regions with elevated PM2.5 transition metal/sulfur content and oxidative potential. For example, each interquartile increase (6.27 ppb) in Ox was associated with a 14.9% (95% CI: 13.0, 16.9) increased risk of nonaccidental mortality in locations with glutathione-related oxidative potential (OPGSH) above the median whereas a 2.50% (95% CI: 0.600, 4.40) increase was observed in regions with OPGSH levels below the median (interaction p-value View on Web

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Using Latent Profile Analysis to Identify Associations Between Gestational Chemical Mixtures and Child Neurodevelopment

alexandrossfakianakis shared this article with you from Inoreader Using Latent Profile Analysis to Identify Associations Between Gestational Chemical Mixtures and Child Neurodevelopment via Epidemiology - Published Ahead-of-Print Background: Unsupervised machine learning techniques have become increasingly popular for studying associations between gestational exposure mixtures and human health. Latent profile analysis is one method that has not been fully explored. Methods: We estimated associations between gestational chemical mixtures and child neurodevelopment using latent profile analysis. Using data from the Maternal-Infant Research on Environmental Chemicals (MIREC) research platform, a longitudinal cohort of pregnant Canadian women and their children, we generated latent profiles from 27 gestational exposure biomarkers. We then examined the associations between these profiles and child Verbal IQ, Performance IQ, and Full-Scale IQ, measured with the Wechsler Preschool and Primary Scale of Intelligence (WPPSI-III). We validated our findings using k-means clustering. Results: Latent profile analysis detected five latent profiles of exposure: a reference profile containing 61% of the study participants, a high Mono-ethyl Phthalate (MEP) profile with moderately low persistent organic pollutants (POPs) containing 26%, a high POP profile containing 6%, a low POP profile containing 4%, and a smoking chemicals profile containing 3%. We observed negative associations between both the smoking chemicals and high MEP profiles and all IQ scores, and between the high POP profile and Full-Scale and Verbal IQ scores. We also found a positive association between the low POP profile and Full-Scale and Performance IQ scores. All associations had wide 95% confidence intervals. Conclusion: Latent profile analysis is a promising technique for identifying patterns of chemical exposure, and is worthy of further study for its use in examining complicated exposure mixtures. Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved. View on Web

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Are detailed behavioral, psychosocial, and environmental variables necessary to control for confounding in pregnancy weight gain research?

alexandrossfakianakis shared this article with you from Inoreader Are detailed behavioral, psychosocial, and environmental variables necessary to control for confounding in pregnancy weight gain research? via Epidemiology - Published Ahead-of-Print Background: Associations between pregnancy weight gain and adverse outcomes may be spurious due to confounding by factors not typically measured in cohort studies. We determined the extent to which the addition of detailed behavioral, psychosocial, and environmental measurements to commonly available covariates improved control of confounding. Methods: We used data from a prospective U.S. pregnancy cohort study (2010‒2013, n=8978). We calculated two propensity scores for low and high pregnancy weight gain (vs. adequate gain) using 11 standard confounders (e.g., age, education). We examined the balance of characteristics between weight gain groups before and after propensity score matching. We used negative binomial regression to estimate the association between weight gain and small- and large-for-gestational-age birth, preterm birth, and unplanned Cesarean delivery, controlling for propensity score. To this model we then added 17 detailed behavioral, psychosocial, and environmental measurements ('fully adjusted'). We calculated the risk ratio due to confounding as the ratio of the standard confounder-adjusted risk ratio to the fully adjusted risk ratio. Results: There were minimal imbalances between weight gain groups in detailed measures after matching for a propensity score of standard covariates. Accordingly, the inclusion of detailed covariates had minimal impact on estimated associations between low or high pregnancy weight gain and adverse pregnancy outcomes: risk ratios due to confounding were null for all outcomes (e.g., 1.1 [95% CI: 1.0, 1.1] for low weight gain and preterm birth). Conclusions: Adjustment for detailed behavioral, psychosocial, and environmental measurements had minimal impact on estimated associations between pregnancy weight gain and adverse perinatal outcomes. Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved. View on Web

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Accounting for misclassification and selection bias in estimating effectiveness of self-managed medication abortion

alexandrossfakianakis shared this article with you from Inoreader Accounting for misclassification and selection bias in estimating effectiveness of self-managed medication abortion via Epidemiology - Published Ahead-of-Print Background: Studies on the effectiveness of self-managed medication abortion may suffer from misclassification and selection bias due to self-reported outcomes and loss to follow-up. Monte Carlo sensitivity analysis can estimate self-managed abortion effectiveness accounting for these potential biases. Methods: We conducted a Monte Carlo sensitivity analysis based on data from the Studying Accompaniment model Feasibility and Effectiveness Study (the SAFE Study), to generate bias-adjusted estimates of effectiveness of self-managed abortion with accompaniment group support. Between July 2019 and April 2020, we enrolled a total of 1051 callers who contacted accompaniment groups in Argentina and Nigeria for self-managed abortion information; 961 took abortion medications and completed at least one follow-up. Using these data, we calculated measures of effectiveness adjusted for ineligibility, misclassification, and selection bias across 50,000 simulations with bias parameters drawn from pre-specified Beta distributions in R. Results: After accounting for potential influence of various sources of bias, bias-adjusted estimates of effectiveness were similar to observed estimates, conditional on chosen bias parameters: 92.68% (95% simulation interval: 87.80%, 95.74%) for mifepristone in combination with misoprostol (versus 93.7% in the observed data) and 98.47% (95% simulation interval: 96.79%, 99.39%) for misoprostol alone (versus 99.3% in the observed data). Conclusions: After adjustment for multiple potential sources of bias, estimates of self-managed medication abortion effectiveness remain high. Monte Carlo sensitivity analysis may be useful in studies measuring an epidemiologic proportion (i.e., effectiveness, prevalence, cumulative incidence), while accounting for possible selection or misclassification bias. Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved. View on Web

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