Effect of admission fascia iliaca compartment blocks on post-operative abbreviated mental test scores in elderly fractured neck of femur patients: a retrospective cohort study

Background: Post-operative cognitive impairment is common in elderly patients following surgery for hip fracture, with undertreated pain being an important etiological factor. Non-opioid based analgesic techniques, such as nerve blocks, may help reduce the risk of cognitive complications. The aim of this study was to investigate whether receiving a fascia iliaca compartment block (FICB) as part of a pre-operative analgesic regime increased the odds of high post-operative abbreviated mental test scores (AMTS) when compared with conventional analgesia without a nerve block. Methods: A retrospective data analysis of a cohort of 959 patients, aged ≥ 65 years with a diagnosis of hip fracture and admitted to a single hospital over a two-year period was performed. A standardized analgesic regime was used on all patients, and 541/959 (56.4%) of included patients received a FICB. Provision of the FICB was primarily determined by availability of an anesthetist, rather than by patient status and condition. Post-operative cognitive ordinal outcomes were defined by AMTS severity as high (score of ≥ 9/10), moderate, (score of 7 – 8) and low (score of ≤ 6). A multivariable ordinal logistic regression analysis was performed on patient status and clinical care factors, including admission AMTS, age, gender, source of admission, time to surgery, type of anesthesia and ASA score. Results: Admission FICB was associated with higher adjusted odds for a high AMTS (score of ≥ 9) relative to lower AMTS (score of ≤ 8) than conventional analgesia only (OR = 1.80, 95% CI 1.27 – 2.54; p = 0.001). Increasing age, lower AMTS on admission to hospital, and being admitted from a residential or nursing home were associated with worse cognitive outcomes. Mode of anesthesia or surgery did not significantly influence post-operative AMTS. Conclusion: Post-operative AMTS is influenced by pre-operative analgesic regimes in elderly patients with hip fracture. Provision of a FICB to patients on arrival to hospital may improve early post-operative cognitive performance in this population

High on-clopidogrel platelet reactivity in ischaemic stroke or transient ischaemic attack: Systematic review and meta-analysis

Objectives To assess the prevalence of high on-clopidogrel platelet reactivity (HCPR) in patients with ischaemic stroke or transient ischaemic attack (IS/TIA), their outcome and genetic basis of on-treatment response variability in IS/TIA patients. Methods We conducted a comprehensive search of PubMed and EMBASE from their inceptions to March 9, 2019. Studies that reported absolute numbers/percentages of HCRP at any time point after IS/TIA onset evaluated with any type of platelet function tests, clinical outcomes and genotyping data were included. Results Among 21 studies of 4312 IS/TIA patients treated with clopidogrel, the pooled prevalence of HCPR was 28% (95%CI: 24–32%; high heterogeneity: I2 = 88.2%, p < 0.001). Heterogeneity degree diminished across groups defined by the HCPR testing method. Clopidogrel non-responder IS/TIA patients had poorer outcome compared to responders (RR = 2.09, 95%CI: 1.61–2.70; p = 0.036; low heterogeneity across studies: I2 = 27.4%, p = 0.210). IS/TIA carriers of CYP2C19*2 or CYP2C19*3 loss of function alleles had a higher risk of HCPR compared to wild type (RR = 1.69, 95%CI: 1.47–1.95; p < 0.001; I2 = 0.01%, p = 0.475). Conclusions This systematic review shows a high prevalence of clopidogrel resistance in IS/TIA and poor outcome in these patients. CYP2C19 polymorphisms may potentially influence clopidogrel resistance

Age-dependent seroprevalence of dengue and chikungunya: inference from a cross-sectional analysis in Esmeraldas Province in coastal Ecuador

Objectives There are few population-based estimates for prevalence of past exposure to dengue and chikungunya viruses despite common epidemiological features. Here, we have developed a novel statistical method to study patterns of age-dependent prevalence of immunity in a population following exposures to two viruses which share similar epidemiological features including mode of transmission and induction of long-lasting immunity. This statistical technique accounted for sociodemographic characteristics associated with individuals and households. Settings The data consist of a representative sample from an ongoing longitudinal birth cohort set-up in a tropical district in coastal Ecuador (Esmeraldas). Participants We collected data and blood samples from 319 individuals belonging to 152 households following epidemics of the infections in 2015 in Latin America. Primary outcome Plasma was tested for the presence of specific IgG antibodies to dengue and chikungunya viruses by commercial ELISA and defined a bivariate binary outcome indicating individuals’ past exposure status to dengue and chikungunya (ie, presence/absence of IgG antibodies to dengue or chikungunya or both). Results Dengue seroprevalence increased rapidly with age reaching 97% (95% credible interval (CrI): 93%–99%) by 60 years. Chikungunya seroprevalence peaked at 42% (95% CrI: 18%–66%) around 9 years of age and averaged 27% (95% CrI: 8.7%–51.6%) for all ages. Rural areas were more likely to be associated with dengue-only exposure while urban areas and shorter distance to the nearest household were associated with exposures to both. Women living in urban settings were more likely to be chikungunya seropositive while rural men were more likely to be dengue seropositive. Conclusion Dengue seroprevalence was strongly age dependent consistent with endemic exposure while that of chikungunya peaked in childhood consistent with the recent emergence of the virus in the study area. Our findings will inform control strategies for the two arboviruses in Ecuador including recommendations by the WHO on dengue vaccination

Prospective study of factors associated with asthma attack recurrence (ATTACK) in children from three Ecuadorian cities during COVID-19: a study protocol

Introduction Asthma is a growing health problem in children in marginalised urban settings in low-income and middle-income countries. Asthma attacks are an important cause of emergency care attendance and long-term morbidity. We designed a prospective study, the Asthma Attacks study, to identify factors associated with recurrence of asthma attacks (or exacerbations) among children and adolescents attending emergency care in three Ecuadorian cities. Methods and analysis Prospective cohort study designed to identify risk factors associated with recurrence of asthma attacks in 450 children and adolescents aged 5–17 years attending emergency care in public hospitals in three Ecuadorian cities (Quito, Cuenca and Portoviejo). The primary outcome will be rate of asthma attack recurrence during up to 12 months of follow-up. Data are being collected at baseline and during follow-up by questionnaire: sociodemographic data, asthma history and management (baseline only); recurrence of asthma symptoms and attacks (monthly); economic costs of asthma to family; Asthma Control Test; Pediatric Asthma Quality of life Questionnaire; and Newcastle Asthma Knowledge Questionnaire (baseline only). In addition, the following are being measured at baseline and during follow-up: lung function and reversibility by spirometry before and after salbutamol; fractional exhaled nitric oxide (FeNO); and presence of IgG antibodies to SARS-CoV-2 in blood. Recruitment started in 2019 but because of severe disruption to emergency services caused by the COVID-19 pandemic, eligibility criteria were modified to include asthmatic children with uncontrolled symptoms and registered with collaborating hospitals. Data will be analysed using logistic regression and survival analyses. Ethics and dissemination Ethical approval was obtained from the Hospital General Docente de Calderon (CEISH-HGDC 2019-001) and Ecuadorian Ministry of Public Health (MSP-CGDES-2021-0041-O N° 096-2021). The study results will be disseminated through presentations at conferences and to key stakeholder groups including policy-makers, postgraduate theses, peer-review publications and a study website. Participants gave informed consent to participate in the study before taking part

Adoption of Lung Protective ventilation IN patients undergoing Emergency laparotomy: the ALPINE study. A prospective multicentre observational study

Background Emergency abdominal surgery is associated with a high risk of postoperative pulmonary complications (PPCs). The primary aim of this study was to determine whether patients undergoing emergency laparotomy surgery are ventilated using a lung-protective ventilation strategy comprising of tidal volume ≤8 ml kg−1 ideal body weight−1, PEEP >5 cm H2O, and recruitment manoeuvres. The secondary aim was to investigate the association between ventilation factors (lung-protective ventilation strategy, intraoperative FiO2, and peak inspiratory pressure) and the occurrence of PPCs. Methods Data were collected prospectively in 28 hospitals across London as part of routine National Emergency Laparotomy Audit. Patients were followed up for 7 days. Complications were defined according to the European Perioperative Clinical Outcome definition. Results Data were collected from 568 patients. The median [inter-quartile range (IQR)] tidal volume observed was 500 ml (450–540 ml), corresponding to a median tidal volume of 8 ml kg−1 ideal body weight−1 (IQR: 7.2–9.1 ml). An lung-protective ventilation strategy was employed in 4.9% (28/568) of patients and was not protective against the occurrence of PPCs in the multivariable analysis (hazard ratio=1.06; P=0.69). A peak inspiratory pressure of <30 cm H2O was protective against the development of PPC (hazard ratio=0.46; confidence interval: 0.30–0.72; P=0.001). The median FiO2 was 0.5 (IQR: 0.44–0.53) and an increase in FiO2 by 5% increased the risk of developing a PPC by 8% (2.6–14.1%; P=0.008). Conclusions Both intraoperative peak inspiratory pressure and FiO2 are independent factors significantly associated with the development of a postoperative pulmonary complication in emergency laparotomy patients. Further studies are required to identify their causality effect and to demonstrate if their manipulation could lead to better clinical outcomes

Evaluating the role of transthoracic echocardiography in hospitalised patients with COVID-19 infection

Objective To identify the most common transthoracic echocardiogram (TTE) parameters in patients hospitalised with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2/COVID-19) and their association with myocardial injury and outcomes. Methods A retrospective, single-centre, observational, exploratory cohort study was performed at the height of the COVID-19 pandemic. All SARS-CoV-2 polymerase chain reaction (PCR) positive patients who underwent a TTE during their inpatient admission between 1st March 2020 and 31st October 2020 were analysed. The most frequent cardiovascular risk factor profile and echocardiographic features were investigated. Results A total of 87 patients met the eligibility criteria. A salient 41.4% (n=36) of our cohort succumbed to this devastating virus. More than half of our hospital population (58.6%) were admitted to the intensive care unit (ITU) and this was significantly associated with inpatient mortality (OR 7.14, CI 2.53 – 20.19, p < 0.001). Hypertension was the most common cardiovascular risk factor (51.7%) with no additional prominence in non survivors (OR 2.33, CI 0.97 – 5.61, p = 0.059). Remarkably, 90.8% of our cohort demonstrated a preserved left ventricular ejection fraction although 69.1% had elevated troponin levels. Only 1 patient (1.1%) were given a diagnostic label of myocarditis. A raised pulmonary artery systolic pressure (36.8%) and right ventricular (RV) dysfunction (26.4%) were the most common echocardiographic features. In particular, the presence of RV dysfunction was significantly related to adverse outcomes (OR 2.97, CI 1.11 – 7.94, p < 0.03). Conclusions In this cohort of extremely unwell patients hospitalised with COVID pneumonitis, the presence of RV dysfunction or admission to ITU was significantly associated with inpatient case fatality ratio. Moreover, COVID-19 induced myocarditis remains extremely rare