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Chronic kidney disease (CKD) is a progressively worsening condition that is often overlooked in its early stages. In Brazil, factors such as population aging and rising comorbidities are expected to shift CKD prevalence toward more advanced stages, leading to greater socioeconomic and environmental impacts. The significant burden of renal replacement therapy (RRT) suggests the need to prioritize preventive and early detection strategies.
Methods
We developed a patient-level simulation model to estimate the impact of CKD in Brazil over 10 years (from 2023 to 2032) on clinical, patient, health system, environmental, productivity, and societal outcomes. Validation was conducted against Brazilian demographic data and cross-validated with the Inside CKD model. We estimated productivity losses by multiplying CKD-related workdays missed by daily costs for patients and caregivers.
Results
The number of Brazilians with CKD was projected to increase by 7.2 percent (approximately 27.7 million) over the next 10 years, mainly among patients with late-stage disease, while the number of patients undergoing dialysis was projected to increase by 170.8 percent (approximately 233,000) over the same period. CKD was projected to result in BRL198 billion (USD 38 billion) of lost income. From an environmental standpoint, freshwater consumption, fossil fuel depletion, and carbon dioxide emissions due to patients with CKD were projected to increase by 40 percent by 2032. RRT was projected to require the equivalent annual water usage of approximately 370,000 households and the annual power of approximately 11 million lightbulbs and will produce annual carbon dioxide emissions equivalent to approximately 1.5 million cars.
Conclusions
While the overall number of patients with CKD will increase by 7 percent (from 25.8 million in 2022 to 27.7 million in 2032), the distribution toward later stages of CKD will cause significant impacts in terms of the healthcare system (resource use and costs), patients and caregivers, society, and the environment.
The growing burden of chronic kidney disease (CKD) in Brazil is increasingly evident, marked by its significant contributions to mortality rates and healthcare costs. Managing CKD, especially through renal replacement therapy (RRT), demands substantial resources. To enhance healthcare decision-making, a thorough examination of the relationship between the rising prevalence of CKD and its clinical and economic impacts is crucial.
Methods
We developed a patient-level simulation model to project the natural history of CKD, defined as the IMPACT CKD. This model integrated factors such as acute kidney injury, cardiovascular events, and comorbidities, and aimed to assess CKD’s clinical, humanistic, and economic impact on the healthcare system. It forecasted the burden of CKD over the next decade (2023 to 2032). This projection is pivotal to derive the burden of CKD for health technology assessment (HTA) evaluations. Validation was conducted against Brazil’s demographic data and cross-validated with the Inside CKD model.
Results
The IMPACT CKD forecast a rapid increase of CKD population in Brazil, outpacing the growth of the general population. Specifically, there is an expected 6.9 percent increase in stages 3 to 5 CKD, leading to a higher demand for dialysis (projected 370,000 cases in 2032) and transplants (projected 115,000 cases in 2032). A significant increase in cardiovascular CKD-related events (+100.6%) and mortality (+67.8%) is expected. In 2032, it is projected 15 million CKD patients will be in stages 1 to 2, and 12.7 million in stages 3 to 5. CKD-related healthcare costs will represent 25.7 percent of Brazil’s healthcare budget, and dialysis will reach USD2.7 billion in annual costs.
Conclusions
IMPACT CKD predicts an increasing CKD prevalence and an alarming rise in stages 3 to 5 and RRT, including thousands of premature deaths, and a substantial economic burden on the Brazilian healthcare system. This data could be informative for healthcare decision-makers when choosing strategy to reduce the impact of CKD in Brazil.
Post-procedural antimicrobial prophylaxis is not recommended by professional guidelines but is commonly prescribed. We sought to reduce use of post-procedural antimicrobials after common endoscopic urologic procedures.
Design:
A before-after, quasi-experimental trial with a baseline (July 2020–June 2022), an implementation (July 2022), and an intervention period (August 2022–July 2023).
Setting:
Three participating medical centers.
Intervention:
We assessed the effect of a bundled intervention on excess post-procedural antimicrobial use (ie, antimicrobial use on post-procedural day 1) after three types of endoscopic urologic procedures: ureteroscopy and transurethral resection of bladder tumor or prostate. The intervention consisted of education, local champion(s), and audit-and-feedback of data on the frequency of post-procedural antimicrobial-prescribing.
Results:
1,272 procedures were performed across all 3 sites at baseline compared to 525 during the intervention period; 644 (50.6%) patients received excess post-procedural antimicrobials during the baseline period compared to 216 (41.1%) during the intervention period. There was no change in the use of post-procedural antimicrobials at sites 1 and 2 between the baseline and intervention periods. At site 3, the odds of prescribing a post-procedural antimicrobial significantly decreased during the intervention period relative to the baseline time trend (0.09; 95% CI 0.02–0.45). There was no significant increase in post-procedural unplanned visits at any of the sites.
Conclusions:
Implementation of a bundled intervention was associated with reduced post-procedural antimicrobial use at one of three sites, with no increase in complications. These findings demonstrate both the safety and challenge of guideline implementation for optimal perioperative antimicrobial prophylaxis.
This trial was registered on clinicaltrials.gov, NCT04196777.
Interpersonal psychotherapy (IPT) and antidepressant medications are both first-line interventions for adult depression, but their relative efficacy in the long term and on outcome measures other than depressive symptomatology is unknown. Individual participant data (IPD) meta-analyses can provide more precise effect estimates than conventional meta-analyses. This IPD meta-analysis compared the efficacy of IPT and antidepressants on various outcomes at post-treatment and follow-up (PROSPERO: CRD42020219891). A systematic literature search conducted May 1st, 2023 identified randomized trials comparing IPT and antidepressants in acute-phase treatment of adults with depression. Anonymized IPD were requested and analyzed using mixed-effects models. The prespecified primary outcome was post-treatment depression symptom severity. Secondary outcomes were all post-treatment and follow-up measures assessed in at least two studies. IPD were obtained from 9 of 15 studies identified (N = 1536/1948, 78.9%). No significant comparative treatment effects were found on post-treatment measures of depression (d = 0.088, p = 0.103, N = 1530) and social functioning (d = 0.026, p = 0.624, N = 1213). In smaller samples, antidepressants performed slightly better than IPT on post-treatment measures of general psychopathology (d = 0.276, p = 0.023, N = 307) and dysfunctional attitudes (d = 0.249, p = 0.029, N = 231), but not on any other secondary outcomes, nor at follow-up. This IPD meta-analysis is the first to examine the acute and longer-term efficacy of IPT v. antidepressants on a broad range of outcomes. Depression treatment trials should routinely include multiple outcome measures and follow-up assessments.
Children with left aortic arch and aberrant right subclavian artery may present with either respiratory or swallowing symptoms beyond the classically described solid-food dysphagia. We describe the clinical features and outcomes of children undergoing surgical repair of an aberrant right subclavian artery.
Materials and methods:
This was a retrospective review of children undergoing repair of an aberrant right subclavian artery between 2017 and 2022. Primary outcome was symptom improvement. Pre- and post-operative questionnaires were used to assess dysphagia (PEDI-EAT-10) and respiratory symptoms (PEDI-TBM-7). Paired t-test and Fisher’s exact test were used to analyse symptom resolution. Secondary outcomes included perioperative outcomes, complications, and length of stay.
Results:
Twenty children, median age 2 years (IQR 1–11), were included. All presented with swallowing symptoms, and 14 (70%) also experienced respiratory symptoms. Statistically significant improvements in symptoms were reported for both respiratory and swallowing symptoms. Paired (pre- and post-op) PEDI-EAT-10 and PEDI-TBM-7 scores were obtained for nine patients, resulting in mean (± SD) scores decreasing (improvement in symptoms) from 19.9 (± 9.3) to 2.4 (± 2.5) p = 0.001, and 8.7 (± 4.7) to 2.8 (± 4.0) p = 0.006, respectively. Reoperation was required in one patient due to persistent dysphagia from an oesophageal stricture. Other complications included lymphatic drainage (n = 4) and transient left vocal cord hypomobility (n = 1).
Conclusion:
Children with a left aortic arch with aberrant right subclavian artery can present with oesophageal and respiratory symptoms beyond solid food dysphagia. A thorough multidisciplinary evaluation is imperative to identify patients who can benefit from surgical repair, which appears to be safe and effective.
OBJECTIVES/GOALS: The Community Research Liaison Model (CRLM) is a novel model to facilitate community engaged research (CEnR) and community–academic research partnerships focused on health priorities identified by the community. We describe the CRLM development process and how it is operationalized today. METHODS/STUDY POPULATION: The CRLM, informed by the Principles of Community Engagement, builds trust among rural communities and expands capacity for community and investigator-initiated research. We followed a multi-phase process to design and implement a community engagement model that could be replicated. The resulting CRLM moves community–academic research collaborations from objectives to outputs using a conceptual framework that specifies our guiding principles, objectives, and actions to facilitate the objectives (i.e., capacity, motivations, and partners), and outputs. RESULTS/ANTICIPATED RESULTS: The CRLM has been fully implemented across Oregon. Six Community Research Liaisons collectively support 18 predominantly rural Oregon counties. Since 2017, the liaison team has engaged with communities on nearly 300 community projects. The CRLM has been successful in facilitating CEnR and community–academic research partnerships. The model has always existed on a dynamic foundation and continues to be responsive to the lessons learned by the community and researchers. The model is expanding across Oregon as an equitable approach to addressing health disparities across the state. DISCUSSION/SIGNIFICANCE: Our CRLM is based on the idea that community partnerships build research capacity at the community level and are the backbone for pursuing equitable solutions and better health for communities we serve. Our model is unique in its use of CRLs to facilitate community–academic partnerships; this model has brought successes and challenges over the years.
Social Determinants of Health (SDOH) greatly influence health outcomes. SDOH surveys, such as the Assessing Circumstances & Offering Resources for Needs (ACORN) survey, have been developed to screen for SDOH in Veterans. The purpose of this study is to determine the terminological representation of the ACORN survey, to aid in natural language processing (NLP).
Methods:
Each ACORN survey question was read to determine its concepts. Next, Solor was searched for each of the concepts and for the appropriate attributes. If no attributes or concepts existed, they were proposed. Then, each question’s concepts and attributes were arranged into subject-relation-object triples.
Results:
Eleven unique attributes and 18 unique concepts were proposed. These results demonstrate a gap in representing SDOH with terminologies. We believe that using these new concepts and relations will improve NLP, and thus, the care provided to Veterans.
Memory is the connective tissue that makes lives meaningful. A connection to the past enables sense making in the present and renders possible futures as thinkable. In the case of traumatic or difficult pasts, this connection becomes intensely important. At personal, collective and national levels, past harms and injustices need to be made visible and subject to commemorative exploration in order for victims to ‘go on’ in the present. In this context, repair is usually considered to be a memorial work of putting the past in order to meet ongoing moral and epistemic demands (Margalit, 2002; Blustein, 2008; Campbell, 2014). Through this work it becomes possible to envisage a reconstruction or ‘healing’ of personal and social ecologies of thought and feeling.
This understanding of memorial work as repair is complicated by issues around mental health. For example, while some approaches to trauma (for example Johnstone and Boyle, 2018) emphasize the need to understand personal histories – ‘what happened to you’ – as a way of addressing current feelings and experiences – ‘what’s wrong with you’ – there is also a counter-discourse around the inherently unrepresentable nature of traumatic pasts (Caruth, 1996). Pain and suffering incurred through extraordinary and horrific violations of social and personal relations may be simply incomprehensible and hence difficult to both recollect and to narrate. Mental health issues may also call into question the reliability of memory. Victims – and in some cases perpetrators – may have their recollected experiences problematized or discounted (see Haaken and Reavey, 2010). They may also be accused of focusing unduly and unhelpfully upon the past rather than facing up to problems in the present. Here, repair can take the form of an injunction to disconnect from a difficult past in order to ‘move on’ with living.
In this chapter, we want to explore the tensions in memorial repair work around mental health. We will be concerned with the question of when and how the past comes to matter for persons managing severe and enduring mental health issues. Crucially, we look at the practices which are enacted to manage these tensions, and how they are collectively performed within an institutional setting. Our argument is informed by work we have conducted in a medium-secure forensic pathway in a large inpatient psychiatric unit.
The quenching of cluster satellite galaxies is inextricably linked to the suppression of their cold interstellar medium (ISM) by environmental mechanisms. While the removal of neutral atomic hydrogen (H i) at large radii is well studied, how the environment impacts the remaining gas in the centres of galaxies, which are dominated by molecular gas, is less clear. Using new observations from the Virgo Environment traced in CO survey (VERTICO) and archival H i data, we study the H i and molecular gas within the optical discs of Virgo cluster galaxies on 1.2-kpc scales with spatially resolved scaling relations between stellar ($\Sigma_{\star}$), H i ($\Sigma_{\text{H}\,{\small\text{I}}}$), and molecular gas ($\Sigma_{\text{mol}}$) surface densities. Adopting H i deficiency as a measure of environmental impact, we find evidence that, in addition to removing the H i at large radii, the cluster processes also lower the average $\Sigma_{\text{H}\,{\small\text{I}}}$ of the remaining gas even in the central $1.2\,$kpc. The impact on molecular gas is comparatively weaker than on the H i, and we show that the lower $\Sigma_{\text{mol}}$ gas is removed first. In the most H i-deficient galaxies, however, we find evidence that environmental processes reduce the typical $\Sigma_{\text{mol}}$ of the remaining gas by nearly a factor of 3. We find no evidence for environment-driven elevation of $\Sigma_{\text{H}\,{\small\text{I}}}$ or $\Sigma_{\text{mol}}$ in H i-deficient galaxies. Using the ratio of $\Sigma_{\text{mol}}$-to-$\Sigma_{\text{H}\,{\small\text{I}}}$ in individual regions, we show that changes in the ISM physical conditions, estimated using the total gas surface density and midplane hydrostatic pressure, cannot explain the observed reduction in molecular gas content. Instead, we suggest that direct stripping of the molecular gas is required to explain our results.
OBJECTIVES/GOALS: To determine the signs, symptoms, and diagnoses that are significantly upregulated in cases of long COVID while identifying risk factors and demographics that increase one’s likelihood of developing long COVID. METHODS/STUDY POPULATION: This is a retrospective, big data science study. Data from Veterans Affairs (VA) medical centers across the United States between the start of 2020 and the end of 2022 were utilized. Our cohort consists of 316,782 individuals with positive COVID-19 tests recorded in the VA EHR with a history of ICD10-CM diagnosis codes in the record for case-control comparison. We looked at all new diagnoses that were not present in the six months before COVID diagnosis but were present in the time period from one month after COVID through seven months after. We determined which were significantly enriched and calculated odds ratios for each, organized by long COVID subtypes by medical specialty / affected organ system. Demographic analyses were also performed for long COVID patients and patients without any new long COVID ICD10-CM codes. RESULTS/ANTICIPATED RESULTS: This profile shows disorders that are highly upregulated in the post-COVID population and provides strong evidence for a broad definition of long COVID. By breaking this into subtypes by medical specialty, we define cardiac long COVID, neurological long COVID, pulmonary long COVID, and eight others. The long COVID cohort was older with more comorbidities than their non-long COVID counterparts. We also noted any differences regarding sex, race, ethnicity, severity of acute COVID-19 symptoms, vaccination status, as well as some analysis regarding medications taken. DISCUSSION/SIGNIFICANCE: This profile can be utilized to decisively define long COVID as a clinical diagnosis and will lead to consistence in future research. Elucidating an actionable model for long COVID will help clinicians identify those in their care that may be experiencing long COVID, allowing them to be admitted into more intensive monitoring and treatment programs.
The Community Research Liaison Model (CRLM) is a novel model to facilitate community-engaged research (CEnR) and community–academic research partnerships focused on health priorities identified by the community. This model, informed by the Principles of Community Engagement, builds trust among rural communities and expands capacity for community and investigator-initiated research. We describe the CRLM development process and how it is operationalized today. We followed a multi-phase process to design and implement a community engagement model that could be replicated. The resulting CRLM moves community–academic research collaborations from objectives to outputs using a conceptual framework that specifies our guiding principles, objectives, and actions to facilitate the objectives (i.e., capacity, motivations, and partners), and outputs. The CRLM has been fully implemented across Oregon. Six Community Research Liaisons collectively support 18 predominantly rural Oregon counties. Since 2017, the liaison team has engaged with communities on nearly 300 community projects. The CRLM has been successful in facilitating CEnR and community–academic research partnerships. The model has always existed on a dynamic foundation and continues to be responsive to the lessons learned by the community and researchers. The model is expanding across Oregon as an equitable approach to addressing health disparities across the state.
It is important for SARS-CoV-2 vaccine providers, vaccine recipients, and those not yet vaccinated to be well informed about vaccine side effects. We sought to estimate the risk of post-vaccination venous thromboembolism (VTE) to meet this need.
Methods
We conducted a retrospective cohort study to quantify excess VTE risk associated with SARS-CoV-2 vaccination in US veterans age 45 and older using data from the Department of Veterans Affairs (VA) National Surveillance Tool. The vaccinated cohort received at least one dose of a SARS-CoV-2 vaccine at least 60 days prior to 3/06/22 (N = 855,686). The control group was those not vaccinated (N = 321,676). All patients were COVID-19 tested at least once before vaccination with a negative test. The main outcome was VTE documented by ICD10-CM codes.
Results
Vaccinated persons had a VTE rate of 1.3755 (CI: 1.3752–1.3758) per thousand, which was 0.1 percent over the baseline rate of 1.3741 (CI: 1.3738–1.3744) per thousand in the unvaccinated patients, or 1.4 excess cases per 1,000,000. All vaccine types showed a minimal increased rate of VTE (rate of VTE per 1000 was 1.3761 (CI: 1.3754–1.3768) for Janssen; 1.3757 (CI: 1.3754–1.3761) for Pfizer, and for Moderna, the rate was 1.3757 (CI: 1.3748–1.3877)). The tiny differences in rates comparing either Janssen or Pfizer vaccine to Moderna were statistically significant (p < 0.001). Adjusting for age, sex, BMI, 2-year Elixhauser score, and race, the vaccinated group had a minimally higher relative risk of VTE as compared to controls (1.0009927 CI: 1.007673–1.0012181; p < 0.001).
Conclusion
The results provide reassurance that there is only a trivial increased risk of VTE with the current US SARS-CoV-2 vaccines used in veterans older than age 45. This risk is significantly less than VTE risk among hospitalized COVID-19 patients. The risk-benefit ratio favors vaccination, given the VTE rate, mortality, and morbidity associated with COVID-19 infection.
To determine whether primary school children’s weight status and dietary behaviours vary by remoteness as defined by the Australian Modified Monash Model (MMM).
Design:
A cross-sectional study design was used to conduct secondary analysis of baseline data from primary school students participating in a community-based childhood obesity trial. Logistic mixed models estimated associations between remoteness, measured weight status and self-reported dietary intake.
Setting:
Twelve regional and rural Local Government Areas in North-East Victoria, Australia.
Participants:
Data were collected from 2456 grade 4 (approximately 9–10 years) and grade 6 (approximately 11–12 years) students.
Results:
The final sample included students living in regional centres (17·4 %), large rural towns (25·6 %), medium rural towns (15·1 %) and small rural towns (41·9 %). Weight status did not vary by remoteness. Compared to children in regional centres, those in small rural towns were more likely to meet fruit consumption guidelines (OR: 1·75, 95 % CI (1·24, 2·47)) and had higher odds of consuming fewer takeaway meals (OR: 1·37, 95 % CI (1·08, 1·74)) and unhealthy snacks (OR = 1·58, 95 % CI (1·15, 2·16)).
Conclusions:
Living further from regional centres was associated with some healthier self-reported dietary behaviours. This study improves understanding of how dietary behaviours may differ across remoteness levels and highlights that public health initiatives may need to take into account heterogeneity across communities.
Childhood obesity prevention is critical to reducing the health and economic burden currently experienced by the Australian economy. System science has emerged as an approach to manage the complexity of childhood obesity and the ever-changing risk factors, resources and priorities of government and funders. Anecdotally, our experience suggests that inflexibility of traditional research methods and dense academic terminology created issues with those working in prevention practice. Therefore, this paper provides a refined description of research-specific terminology of scale-up, fidelity, adaptation and context, drawing from community-based system dynamics and our experience in designing, implementing and evaluating non-linear, community-led system approaches to childhood obesity prevention.
Design:
We acknowledge the importance of using a practice lens, rather than purely a research design lens, and provide a narrative on our experience and perspectives on scale-up, fidelity, context and adaptation through a practice lens.
Setting:
Communities.
Participants:
Practice-based researcher experience and perspectives.
Results:
Practice-based researchers highlighted the key finding that community should be placed at the centre of the intervention logic. This allowed communities to self-organise with regard to stakeholder involvement, capacity, boundary identification, and co-creation of actions implemented to address childhood obesity will ensure scale-up, fidelity, context and adaptation are embedded.
Conclusions:
We need to measure beyond primary anthropometric outcomes and focus on evaluating more about implementation, process and sustainability. We need to learn more from practitioners on the ground and use an implementation science lens to further understand how actions work. This is where solutions to sustained childhood obesity prevention will be found.
Patients with Fontan physiology require non-cardiac surgery. Our objectives were to characterise perioperative outcomes of patients with Fontan physiology undergoing non-cardiac surgery and to identify characteristics which predict discharge on the same day.
Materials and Method:
Children and young adults with Fontan physiology who underwent a non-cardiac surgery or an imaging study under anaesthesia between 2013 and 2019 at a single-centre academic children’s hospital were reviewed in a retrospective observational study. Continuous variables were compared using the Wilcoxon rank sum test, and categorical variables were analysed using the Chi-square test or Fisher’s exact test. Multivariable logistic regression analysis results are presented by adjusted odds ratios with 95% confidence intervals and p values.
Results:
182 patients underwent 344 non-cardiac procedures with anaesthesia. The median age was 11 years (IQR 5.2–18), 56.4% were male. General anaesthesia was administered in 289 (84%). 125 patients (36.3%) were discharged on the same day. On multivariable analysis, independent predictors that reduced the odds of same-day discharge included the chronic condition index (OR 0.91 per additional chronic condition, 95% CI 0.76–0.98, p = 0.022), undergoing a major surgical procedure (OR 0.17, 95% CI 0.05–0.64, p = 0.009), the use of intraoperative inotropes (OR 0.48, 95% CI 0.25–0.94, p = 0.031), and preoperative admission (OR = 0.24, 95% CI: 0.1–0.57, p = 0.001).
Discussion:
In a contemporary cohort of paediatric and young adults with Fontan physiology, 36.3% were able to be discharged on the same day of their non-cardiac procedure. Well selected patients with Fontan physiology can undergo anaesthesia without complications and be discharged same day.
Stigma negatively shapes the lives of people who use substances through criminalization processes and criminal justice involvement. This chapter draws from the authors’ lived experiences to explore the harms created by stigma at the intersection of substance use and criminal justice. Stigma produces a social context contributing to high rates of criminal justice involvement among people who use substances through inequitable social conditions, criminalization of substances, and under-resourcing of substance use services. Substance use stigma is reinforced by harmful police practices, painful imprisonment experiences, and insufficient support offered to formerly incarcerated people living in the community. Approaches for reducing substance use stigma involve reforming drug policy to decriminalize substances, improving access to substance use treatment and harm reduction services, and involving people with lived and living experiences of substance use and criminal justice involvement in policymaking and service delivery.
COVID-19 is a major health threat around the world causing hundreds of millions of infections and millions of deaths. There is a pressing global need for effective therapies. We hypothesized that leukotriene inhibitors (LTIs), that have been shown to lower IL6 and IL8 levels, may have a protective effect in patients with COVID-19.
Methods:
In this retrospective controlled cohort study, we compared death rates in COVID-19 patients who were taking a LTI with those who were not taking an LTI. We used the Department of Veterans Affairs (VA) Corporate Data Warehouse (CDW) to create a cohort of COVID-19-positive patients and tracked their use of LTIs between November 1, 2019 and November 11, 2021.
Results:
Of the 1,677,595 cohort of patients tested for COVID-19, 189,195 patients tested positive for COVID-19. Forty thousand seven hundred one were admitted. 38,184 had an oxygen requirement and 1214 were taking an LTI. The use of dexamethasone plus a LTI in hospital showed a survival advantage of 13.5% (CI: 0.23%–26.7%; p < 0.01) in patients presenting with a minimal O2Sat of 50% or less. For patients with an O2Sat of <60 and <50% if they were on LTIs as outpatients, continuing the LTI led to a 14.4% and 22.25 survival advantage if they were continued on the medication as inpatients.
Conclusions:
When combined dexamethasone and LTIs provided a mortality benefit in COVID-19 patients presenting with an O2 saturations <50%. The LTI cohort had lower markers of inflammation and cytokine storm.
Post-operative nausea and vomiting is frequent after congenital cardiac surgery.
Aims:
We sought to determine factors associated to severe post-operative vomiting after congenital cardiac surgery and the effect on post-operative outcomes.
Methods:
Patients > 30 days of age who underwent elective cardiac surgical repair as part of an enhanced recovery after congenital cardiac surgery programme were retrospectively reviewed. Patient characteristics and perioperative factors were compared by univariate analysis for patients with severe post-operative vomiting, defined as three events or more, and for patients with no-or-mild post-operative vomiting. All variables with a p-value < 0.1 were included in a multivariable model, and major post-operative outcomes were compared using regression analysis.
Results:
From 1 October, 2018 to 30 September, 2019, 430 consecutive patients were included. The median age was 4.8 years (interquartile range 1.2–12.6). Twenty-one per cent of patients (91/430) experienced severe post-operative vomiting. Total intraoperative opioids > 5.0 mg/kg of oral morphine equivalent (adjusted odds ratio 1.72) and post-operative inotropes infusion(s) (adjusted odds ratio 1.64) were identified as independent predictors of severe post-operative vomiting after surgery. Patients suffering from severe post-operative vomiting had increased pulmonary complications (adjusted odds ratio 5.18) and longer post-operative hospitalisation (adjusted coefficient, 0.89).
Conclusions:
Greater cumulative intraoperative opioids are associated with severe post-operative vomiting after congenital cardiac surgery. Multimodal pain strategies targeting the reduction of intraoperative opioids should be considered during congenital cardiac surgery to enhance recovery after surgery.
In this paper, we consider changes to memorial practices for mental health service users during the asylum period of the mid-nineteenth up to the end of the twentieth century and into the twenty-first century. The closing of large asylums in the UK has been largely welcomed by professionals and service-users alike, but their closure has led to a decrease in continuous and consistent care for those with enduring mental health challenges. Temporary and time-limited mental health services, largely dedicated to crisis management and risk reduction have failed to enable memory practices outside the therapy room. This is an unusual case of privatised memories being favoured over collective memorial activity. We argue that the collectivisation of service user memories, especially in institutions containing large numbers of long-stay patients, would benefit both staff and patients. The benefit would be in the development of awareness of how service users make sense of their past in relation to their present stay in hospital, how they might connect with others in similar positions and how they may connect with the world and others upon future release. This seems to us central to a project of recovery and yet is rarely practised in any mental health institution in the UK, despite being central to other forms of care provision, such as elderly and children's care services. We offer some suggestions on how collective models of memory in mental health might assist in this project of recovery and create greater visibility between past, present and future imaginings.
Savage et al. do an excellent job of making the case for social bonding in general, but do a less good job of distinguishing the manners by which dance and music achieve this. It is important to see dance and music as two parallel and interactive mechanisms that employ the “group body” and “group voice,” respectively, in engendering social cohesion.