Can critical care transport be safely reduced in children intubated during emergency management of status epilepticus in the United Kingdom: a national audit with case-control analysis.

OBJECTIVE: This study describes the baseline clinical characteristics, predictors of successful extubation at referring hospitals and short-term outcomes of children intubated for status epilepticus and referred to United Kingdom (UK) paediatric critical care transport teams (PCCTs). DESIGN: Multicentre audit with case-control analysis, conducted between 1 September 2018 and 1 September 2020. SETTING: This study involved 10 UK PCCTs. PATIENTS: Children over 1 month of age intubated during emergency management for status epilepticus (SE), referred to UK PCCTs. Patients with trauma, requiring time-critical neurosurgical intervention or those with a tracheostomy were excluded. INTERVENTIONS: No interventions were implemented. MEASUREMENTS AND MAIN RESULTS: Out of the 1622 referrals for SE, 1136 (70%) were intubated at referral. The median age was 3 years (IQR 1.25-6.54 years). Among the intubated children, 396 (34.8%) were extubated locally by the referring team, with 19 (4.8%) requiring reintubation. Therefore, the overall rate of successful extubation was 33% (377/1136). There was significant variation between PCCTs, with local extubation rates ranging from 2% to 74%. Multivariable analyses showed region/PCCT, contributing diagnosis, acute changes on CT, preceding encephalopathy and type of continuous sedation (midazolam) used postintubation were significantly associated with transfer to a critical care unit. CONCLUSION: This study highlights wide regional variation in early extubation practices. Regions with high successful extubation rates have established extubation guidelines from PCCTs. Successful extubation represents critical care transports that have been avoided.

"We are everyone's ASHAs but who's there for us?" a qualitative exploration of perceptions of work stress and coping among rural frontline workers in Madhya Pradesh, India.

OBJECTIVE: More than a million female village-level lay providers called 'Accredited Social Health Activists (ASHAs)', who deliver primary care, face high levels of stress due to work demands and low compensation, within the context of poverty and gender inequality. Evidence on ASHAs has focused on workplace challenges from a system perspective, without sufficient probing into individual-level stress. This study aims to gain perspectives into the experiences of work stress, the related health symptoms, and the responses to stress among ASHAs in India. METHODS: Focus group discussions (FGDs) conducted with ASHAs in Sehore district, Madhya Pradesh, were audio-recorded and transcribed. Grounded theory was used to generate themes under the various domains of ASHAs' work and domestic life. We identified pathways between the conditions that trigger stressful events, experiences of these events, resulting perceptions, effects on health and wellbeing, and approaches used by ASHAs to respond to stress. RESULTS: Six FGDs with 59 ASHAs generated the following themes: (a) Facility: Workload, undue pressures, unstructured work; ASHAs' relationships with seniors (e.g., feelings of being disrespected, blamed, or targeted), and low access to physical and administrative resources; (b) Home: Feelings of guilt for putting less time for family/child care; disrespect by the elderly for a poorly incentivised job; (c) Community: Low acceptance by the villagers; caste- and gender-bias; difficult community-level relationships (emotional labour, fear/stigma towards her services); (d) Somatic and psychological symptoms: headache, exhaustion, depressive symptoms (to cite a few); and (e) Responses to stress: Motivation (support from peers, family, a sense of identity/pride, incentives), Individual strengths (e.g., social responsibility), and spiritual recourse mechanisms. CONCLUSIONS: This study will inform the development of a strengths-based coaching intervention to address work stress among ASHAs. The findings are relevant to building the evidence on alleviation of work stress among female frontline cadres in low-resource settings globally.

Trends and Factors Associated With Ventilator-Associated Pneumonia: A National Perspective.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a hospital-acquired pneumonia that occurs more than 48 hours after mechanical ventilation. Studies showing temporal trends, predictors, and outcomes of VAP are very limited. OBJECTIVE: We used the National database to delineate the trends and predictors of VAP from 2009 to 2017. METHODS: We analyzed data from the Nationwide Inpatient Sample (NIS) for adult hospitalizations who received mechanical ventilation (MV) by using ICD-9/10-CM procedures codes. We excluded hospitalizations with length of stay (LOS) less than two days. VAP and other diagnoses of interest were identified by ICD-9/10-CM diagnosis codes. We then utilized the Cochran Armitage trend test and multivariate survey logistic regression models to analyze the data. RESULTS: Out of a total of 5,155,068 hospitalizations who received mechanical ventilation, 93,432 (1.81%) developed VAP. Incidence of VAP decreased from 20/1000 in 2008 to 17/1000 in 2017 with a 5% decrease. Patients who developed VAP had lower mean age (59 vs 61; p<0.001) and higher LOS (25 days vs. 12 days; p<0.001). In multivariable regression analysis, we identified that males, African Americans, teaching hospitals and co-morbidities like neurological disorders, pulmonary circulation disorders and electrolyte disorders are associated with the increased odds of developing VAP. VAP was also associated with higher rates of discharge to facilities and increased LOS. CONCLUSION: Our study identified the trends along with the risk predictors of VAP in MV patients. Our goal is to lay the foundation for further in-depth analysis of this trend for better risk stratification and development of preventive strategies to reduce the incidence of VAP among MV patients.

Comparative Evaluation of Efficacy of Conventional Arch Bar, Intermaxillary Fixation Screws, and Modified Arch Bar for Intermaxillary Fixation.

AIM: Comparative evaluation of efficacy of conventional arch bar, intermaxillary fixation screws, and modified arch bar with respect to plaque accumulation, time required for procedure, postoperative stability after achieving the intermaxillary fixation, mucosal growth, and complication encountered for intermaxillary fixation. MATERIALS AND METHODS: This study is a randomized clinical trial in which participants were divided into three groups of 10 each, and designated as Group A, Group B, and Group C. In Group A, intermaxillary fixation was achieved by the conventional method using Erich arch bar, fastened with 26-gauge stainless-steel wires. In Group B, intermaxillary fixation was achieved by the use of 2 mm × 8 mm 4-6 stainless-steel intermaxillary fixation screws. In Group C, intermaxillary fixation was achieved by modified screw arch bar. A conventional arch bar was modified by making perforations in the spaces between the winglets along the entire extension of the bar which was then adapted to the vestibular surface of the maxilla and mandible, close to the cervical portion of the teeth, and perforations were made in the inter-radicular spaces with a 1.1-mm bur, and after this, 1.5-mm screws were placed to fix the bar. RESULTS: In the present study, a total of 30 patients were analyzed. The average working time for Group A, Group B, and Group C were 110, 16, and 29 min respectively. Oral hygiene scores through modified Turskey Gilmore plaque index which was taken at immediate postoperative, 15, 30, and at 45 days. Maximum hygiene was maintained in intermaxillary fixation screw group followed by modified arch bar group and conventional arch bar group. Maximum stability was seen in the conventional arch bar group followed by modified arch bar group and intermaxillary fixation screw group. With respect to mucosal coverage, maximum mucosal growth was seen in intermaxillary fixation screws group. When complications were taken into consideration, maximum complications were reported in Group A followed by Group B and Group C. CONCLUSION: This study emphasizes that the use of modified arch bar is quick and easy method than conventional arch bar with least chances of glove puncture and needle stick injury to the operator. Oral hygiene maintenance is comparatively better in patients with modified arch bar than with conventional arch bars. Modified arch bar was significantly stable when compared with IMF screws, and therefore, for the patients who require long-term intermaxillary fixation, modified arch bars can be a viable option.

Mast cell corticotropin-releasing factor subtype 2 suppresses mast cell degranulation and limits the severity of anaphylaxis and stress-induced intestinal permeability.

BACKGROUND: Psychological stress and heightened mast cell (MC) activation are linked with important immunologic disorders, including allergy, anaphylaxis, asthma, and functional bowel diseases, but the mechanisms remain poorly defined. We have previously demonstrated that activation of the corticotropin-releasing factor (CRF) system potentiates MC degranulation responses during IgE-mediated anaphylaxis and psychological stress through corticotropin-releasing factor receptor subtype 1 (CRF1) expressed on MCs. OBJECTIVE: In this study we investigated the role of corticotropin-releasing factor receptor subtype 2 (CRF2) as a modulator of stress-induced MC degranulation and associated disease pathophysiology. METHODS: In vitro MC degranulation assays were performed with bone marrow-derived mast cells (BMMCs) derived from wild-type (WT) and CRF2-deficient (CRF2-/-) mice and RBL-2H3 MCs transfected with CRF2-overexpressing plasmid or CRF2 small interfering RNA. In vivo MC responses and associated pathophysiology in IgE-mediated passive systemic anaphylaxis and acute psychological restraint stress were measured in WT, CRF2-/-, and MC-deficient KitW-sh/W-sh knock-in mice. RESULTS: Compared with WT mice, CRF2-/- mice exhibited greater serum histamine levels and exacerbated IgE-mediated anaphylaxis and colonic permeability. In addition, CRF2-/- mice exhibited increased serum histamine levels and colonic permeability after acute restraint stress. Experiments with BMMCs and RBL-2H3 MCs demonstrated that CRF2 expressed on MCs suppresses store-operated Ca2+ entry signaling and MC degranulation induced by diverse MC stimuli. Experiments with MC-deficient KitW-sh/W-sh mice systemically engrafted with WT and CRF2-/- BMMCs demonstrated the functional importance of MC CRF2 in modulating stress-induced pathophysiology. CONCLUSIONS: MC CRF2 is a negative global modulator of stimuli-induced MC degranulation and limits the severity of IgE-mediated anaphylaxis and stress-related disease pathogenesis.

Evaluation of efficacy of intermaxillary fixation screws versus modified arch bar for intermaxillary fixation.

AIM: This study aimed to evaluate the efficacy of intermaxillary fixation (IMF) screws and modified arch bar. MATERIALS AND METHODS: This study is a randomized clinical trial in which all participants were divided into two groups of ten in each group and designated as Group A and Group B. In Group A, IMF was achieved by the use of four to six 2×8mm stainless steel IMF screws. In Group B, IMF was achieved by modified screw arch bar. RESULTS: In the present study, a total of twenty patients were analyzed. The average working time for Group A and Group B was 16 min and 29 min, respectively. Oral hygiene scores through modified Turesky Gilmore plaque index were calculated at immediate postoperative period and after 15 days, 30 days, and 45 days. Maximum hygiene was maintained in IMF screw group than modified arch bar group, but maximum stability was observed in the modified arch bar group than IMF screw group. CONCLUSION: This study emphasizes the use of IMF screws as a quick and easy method than modified arch bar. Oral hygiene maintenance was comparatively better in patients with IMF screws than those with modified arch bar. Modified arch bar was significantly stable when compared with IMF screws; therefore, for patients who require long-term IMF, modified arch bars can be a viable option, but the perforation in the original arch bar may lead to the weakening of the arch bar, and therefore the prefabricated modified arch bar would be a better option.

Is hypertension associated with job strain? A meta-analysis of observational studies.

Job strain results from a combination of high workload and few decision-making opportunities in the workplace. There is inconsistent evidence regarding the association between job strain and hypertension, and methodological shortcomings preclude firm conclusions. Thus, a meta-analysis of observational studies on hypertension among occupational groups was conducted to determine whether job strain was associated with hypertension. In January 2012, we carried out a comprehensive, topic-specific electronic literature search of the Ovid MEDLINE, EMBASE and PsychoINFO databases complemented by individual help from non-communicable disease experts. Experimental/interventional studies and studies on personality disorders were excluded. Nine of 894 identified studies met the eligibility criteria and were included in the meta-analysis. The pooled OR of the nine studies was 1.3 (95% CI 1.14 to 1.48; p<0.001), of case-control studies 3.17 (95% CI 1.79 to 5.60; p<0.001) and of cohort studies 1.24 (95% CI 1.09 to 1.41; p<0.001), all of which indicated statistically significant positive associations between job strain and hypertension. In a subgroup analysis, cohort studies of good methodological quality showed significant associations between job strain and hypertension, while those of poor methodological quality showed no association or subgroup differences. We conclude that despite methodological differences, case-control and cohort studies of good methodological quality showed positive associations between hypertension and job strain.

Is hypertension associated with job strain? A meta-analysis of observational studies.

Job strain results from a combination of high workload and few decision-making opportunities in the workplace. There is inconsistent evidence regarding the association between job strain and hypertension, and methodological shortcomings preclude firm conclusions. Thus, a meta-analysis of observational studies on hypertension among occupational groups was conducted to determine whether job strain was associated with hypertension. In January 2012, we carried out a comprehensive, topic-specific electronic literature search of the Ovid MEDLINE, EMBASE and PsychoINFO databases complemented by individual help from non-communicable disease experts. Experimental/interventional studies and studies on personality disorders were excluded. Nine of 894 identified studies met the eligibility criteria and were included in the meta-analysis. The pooled OR of the nine studies was 1.29 (95% CI 1.14 to 1.47; p<0.001), of case­control studies 2.88 (95% CI 1.63 to 5.09; p<0.001) and of cohort studies 1.24 (95% CI1.09 to 1.41; p<0.001), all of which indicated statistically significant positive associations between job strain and hypertension [corrected]. In a subgroup analysis, cohort studies of good methodological quality showed significant associations between job strain and hypertension, while those of poor methodological quality showed no association or subgroup differences. We conclude that despite methodological differences, case-control and cohort studies of good methodological quality showed positive associations between hypertension and job strain.

Dandy Walker Syndrome with Tessier 7 Cleft-a Rare Case Report and a Surgical Note on the Use of Vermilion Flap and Lazy W-Plasty.

The Dandy-Walker syndrome is a malformation of the brain that involves the mal-development of the cerebellum, associated with a cystic enlargement of this area, and frequently hydrocephalus. This malformation occurs in ~1 in 30,000 babies. It is seen mostly in females. Developmental anomalies like cleft lip, cleft palate, and cardiac malformation, orthopaedic and urinary structural abnormalities may also occur in 30% of the individuals. We report a case of Dandy Walker syndrome with Tessier 7 facial cleft with paramedian cleft palate in a 6 month old child. Surgical methods used to correct this anomaly include commissuroplasty, myoplasty of the orbicularis oris, and closure of the cleft cheek. Authors report a vermilion square flap technique that combines a lower lip mucocutaneous vermilion border flap with a lazy W-plasty to ensure a natural commissure and skin closure.