Utility of amylase and lipase as predictors of grade of injury or outcomes in pediatric patients with pancreatic trauma.

INTRODUCTION: Grade of injury, serum amylase, and lipase are markers used to assess pancreatic injury. It is unclear how amylase and lipase relate to grade of injury or predict outcome. We hypothesize that serum amylase and lipase are good predictors of grade of injury and outcomes in patients with pancreatic trauma. METHODS: This study is a multicenter review from 9 pediatric trauma centers of all children admitted to their institution over 5 years with a pancreatic injury. Initial as well as peak amylase and lipase values were analyzed with relation to pancreatic grade, length of stay, and outcomes. RESULTS: One hundred thirty-one records were analyzed. There were 44 girls and 85 boys with an average age of 9.0 ± 0.4 years. The mean injury severity score (ISS) score was 15.5 ± 1.2 SE. The average length of stay (in days) was analyzed by grades 0 (3.93), 1 (7.73), 2 (13.4), 3 (18.4), 4 (31), and 5 (13.5). Neither initial nor peak amylase/lipase correlated with grade of injury. Neither amylase nor lipase predicted length of stay or mortality. Maximal amylase was highly predictive of developing a pseudocyst. CONCLUSION: There seems to be limited value for repetitive routine amylase and lipase levels in the management of pediatric trauma patients with pancreatic injury.

Differences in continence system between community-dwelling black and white women with and without urinary incontinence in the EPI study.

OBJECTIVE: We sought to compare continence system function of black and white women in a population-based sample. STUDY DESIGN: As part of a cross-sectional population-based study, black and white women ages 35-64 years were invited to have pelvic floor testing to achieve prespecified groups of women with and without urinary incontinence. We analyzed data collected from 335 women classified as continent (n = 137) and stress (n = 102) and urge (n = 96) incontinent based on full bladder stress test and symptoms. Continence system functions were compared across racial and continence groups. RESULTS: Comparing black to white women, maximal urethral closure pressure (MUCP) was 22% higher in blacks than whites (68.0 vs 55.8 cm H(2)O, P < .0001). White and black women with stress incontinence had MUCP 19% and 23% lower than continent women. MUCP in urge incontinent white women was as low as stress incontinent whites, but blacks with urge had normal urethral function. CONCLUSION: Black women have higher urethral closure pressures than white women. White women with urge incontinence, but not black women, have reduced MUCP.

Provider knowledge, attitudes, and treatment preferences for early pregnancy failure.

OBJECTIVE: We sought to describe health care provider knowledge, attitudes, and treatment preferences for early pregnancy failure (EPF). STUDY DESIGN: We surveyed 976 obstetrician/gynecologists, midwives, and family medicine practitioners on their knowledge and attitudes toward treatment options for EPF, and barriers to adopting misoprostol and office uterine evacuations. We used descriptive statistics to compare practices by provider specialty and logistic regression to identify associations between provider factors and treatment practices. RESULTS: Seventy percent of providers have not used misoprostol and 91% have not used an office uterine evacuation to treat EPF in the past 6 months. Beliefs about safety and patient preferences, and prior induced abortion training were significantly associated with use of both of these treatments. CONCLUSION: Increasing education and training on the use of misoprostol and office uterine evacuation, and clarifying patient treatment preferences may increase the willingness of providers to adopt new practices for EPF treatment.

Treatment patterns for early pregnancy failure in Michigan.

AIMS: We describe current treatment patterns for early pregnancy failure (EPF) among women enrolled in two Michigan health plans. METHODS: We conducted a retrospective review of EPF treatment among Michigan Medicaid enrollees between January 1, 2001, and December 31, 2004, and enrollees of a university-affiliated health plan between January 1, 2001, and December 31, 2005. Episodes were identified by the presence of a diagnostic code for EPF. Surgical treatment was distinguished from nonsurgical management using procedure codes. Facility charges, procedure, and place of service codes were used to determine whether a procedure was done in an office as opposed to an operating room. Cases without a claim for surgical uterine evacuation were examined for a misoprostol pharmacy claim and, if present, were classified as medical management. Cases without a procedure or pharmacy claim were classified as expectant management. RESULTS: Respectively, we identified 21,311 and 1,493 episodes of EPF in the Medicaid and university-affiliated health plan databases, respectively. Women enrolled in Medicaid were more likely to be treated with surgery than were enrollees of the university-affiliated health plan (35.3 vs. 18.0%, respectively, p < 0.000). Among Medicaid enrollees, only 0.5% of surgical evacuations occurred in the office, but office procedures were common among enrollees of the university-affiliated health plan (30.5%, p < 0.000). The proportion of cases managed with misoprostol was <1% in both groups. Caucasian race and age were both associated with having a surgical uterine evacuation (p < 0.001). CONCLUSIONS: EPF is primarily being treated with expectant management or surgical evacuation in an operating room and may not reflect evidence-based practices or patient preferences.

Patient preferences, satisfaction, and resource use in office evacuation of early pregnancy failure.

OBJECTIVE: To examine patient treatment preferences and satisfaction with an office-based procedure for early pregnancy failure and to compare resource use and cost between office and operating room management of early pregnancy failure. METHODS: This study was a prospective observational study of 165 women presenting for surgical management of early pregnancy failure. Participants completed a preoperative questionnaire addressing treatment preferences and expectations and a postoperative questionnaire measuring level of pain experienced and satisfaction with care. Resource use was determined by measuring the time patients spent at the health care facility and the actual procedure time. Cost was estimated using an institutional database. RESULTS: One hundred fifteen women from the office and 50 from the operating room were enrolled. Patients selecting outpatient management scored "privacy," "avoiding going to sleep," and "previous experience" higher than the operating room group (P < .05). Patients who perceived that their physicians preferred one procedure over the other were more likely to select that procedure (P < .001). Satisfaction was high in both groups, and underestimating the procedure's discomfort was negatively associated with satisfaction (P < .002). Costs were greater than two-fold higher in the operating room group compared with the office group (P < .01). Complications were uncommon, but hemorrhage-related complications were four times more common in the operating room group than in the office group (P < .01). CONCLUSION: Office-based surgical management of early pregnancy failure is an acceptable option for many women and offers substantial resource and cost savings. LEVEL OF EVIDENCE: II-2.

Age differences in timed accurate stepping with increasing cognitive and visual demand: a walking trail making test.

BACKGROUND: Impaired vision, cognition, and divided attention performance predict falls. Requiring both visual and cognitive input, the ability to step accurately is necessary to safely traverse challenging terrain conditions such as uneven or slippery surfaces. We compared healthy young and older adults in the time taken to step accurately under conditions of increasing cognitive and visual demand. METHODS: Healthy Young (n = 42, mean age 21) and Older (n = 37, mean age 70) participants were required to step accurately on an instrumented walkway under conditions of increasing visual and cognitive demand. Based on the paper-and-pencil neuropsychological test, the Trail Making Test (P-TMT) A and B, participants stepped on instrumented targets with increasing sequential numbers (Walking Trail Making Test A [W-TMT A]) and increasing sequential numbers and letters (Walking Trail Making Test B [W-TMT B]), under conditions of Low as well as Normal lighting. RESULTS: W-TMT performance time increased with increased age (Older vs Young), decreased light (Low vs Normal), and increased cognitive demand (Trails B vs Trails A). W-TMT performance time was disproportionately increased in Low light and in the Older group under the highest cognitive demand (W-TMT B) conditions. Paired W-TMT A-B differences were three times higher in the Older group than in the Young group. In the Older group, the correlation between W-TMT results and P-TMT B was particularly strong (p <.001). CONCLUSIONS: The time to perform a stepping accuracy task, such as may be required to avoid environmental hazards, increases under reduced lighting and with increased cognitive demand, the latter disproportionately so in older adults.