Research Spotlight

Wen, J., X. Qi, K. A. Lyon, B. Liang, X. Wang, D. Feng and J. H. Huang (2020). “Lessons from China when Performing Neurosurgical Procedures During the COVID-19 Pandemic.” World Neurosurg Apr 25. pii: S1878-8750(20)30847-0. [Epub ahead of print].

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OBJECTIVE: The novel coronavirus disease 2019 (COVID-19) pandemic poses a substantial threat to the health of health care personnel on the front line of caring for patients with COVID-19. The Centers for Medicare and Medicaid Services have announced that all nonessential planned surgeries and procedures should be postponed until further notice and only urgent procedures should proceed. Neurologic surgeries and procedures should not be delayed under the circumstance in which it is essential at saving a life or preserving functioning of the central nervous system. METHODS: With the intent to advise the neurosurgery team on how to adequately prepare and safely perform neurosurgical procedures on confirmed and suspected patients with COVID-19, we discuss considerations and recommendations based on the lessons and experience shared by neurosurgeons in China. RESULTS: Perioperative and intraoperative strategies, considerations, as well as challenges arisen under the specific circumstance have been discussed. In addition, a case of a ruptured aneurysm in a suspected patient with COVID-19 is reported. It is advised that all health care personnel who immediately participate in neurosurgical surgeries and procedures for confirmed and suspected patients with COVID-19 should take airborne precautions and wear enhanced personal protective equipment. CONCLUSIONS: Following the proposed guidance, urgent neurosurgical surgeries and procedures can be safely performed for the benefit of critical patients with or suspected for COVID-19.

Wang, C. H., A. F. Lee, W. T. Chang, C. H. Huang, M. S. Tsai, E. Chou, C. C. Lee, S. C. Chen and W. J. Chen (2020). “Comparing Effectiveness of Initial Airway Interventions for Out-of-Hospital Cardiac Arrest: A Systematic Review and Network Meta-analysis of Clinical Controlled Trials.” Ann Emerg Med 75(5): 627-636.

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STUDY OBJECTIVE: We compare effectiveness of different airway interventions during cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest. METHODS: We systematically searched the PubMed and EMBASE databases from their inception through August 2018 and selected randomized controlled trials or quasi randomized controlled trials comparing intubation, supraglottic airways, or bag-valve-mask ventilation for treating adult out-of-hospital cardiac arrest patients. We performed a network meta-analysis along with sensitivity analyses to investigate the influence of high intubation success rate on meta-analytic results. RESULTS: A total of 8 randomized controlled trials and 3 quasi randomized controlled trials were included in the network meta-analysis: 7,361 patients received intubation, 7,475 received supraglottic airway, and 1,201 received bag-valve-mask ventilation. The network meta-analysis indicated no differences among these interventions for survival or neurologic outcomes at hospital discharge. Rather, network meta-analysis suggested that supraglottic airway improved the rate of return of spontaneous circulation compared with intubation (odds ratio 1.11; 95% confidence interval 1.03 to 1.20) or bag-valve-mask ventilation (odds ratio 1.35; 95% confidence interval 1.11 to 1.63). Furthermore, intubation improved the rate of return of spontaneous circulation compared with bag-valve-mask ventilation (odds ratio 1.21; 95% confidence interval 1.01 to 1.44). The sensitivity analyses revealed that the meta-analytic results were sensitive to the intubation success rates across different out-of-hospital care systems. CONCLUSION: Although there were no differences in long-term survival or neurologic outcome among these airway interventions, these system-based comparisons demonstrated that supraglottic airway was better than intubation or bag-valve-mask ventilation and intubation was better than bag-valve-mask ventilation in improving return of spontaneous circulation. The intubation success rate greatly influenced the meta-analytic results, and therefore these comparison results should be interpreted with these system differences in mind.

Wall, A. E., T. Pruett, P. Stock and G. Testa (2020). “Coronavirus disease 2019: Utilizing an ethical framework for rationing absolutely scarce health-care resources in transplant allocation decisions.” Am J Transplant Apr 13. [Epub ahead of print].

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The novel Coronavirus disease 2019 (COVID-19) is impacting transplant programs around the world, and, as the center of the pandemic shifts to the United States, we have to prepare to make decisions about which patients to transplant during times of constrained resources. In this paper, we discuss how to transition from the traditional justice vs utility consideration in organ allocation to a more nuanced allocation scheme based on ethical values that drive decisions in times of absolute scarcity. We recognize that many decisions are made based on the practical limitations that transplant programs face, especially at the extremes. As programs make the transition from a standard approach to a resource-constrained approach to transplantation, we utilize a framework for ethical decisions in settings of absolutely scarce resources to help guide programs in deciding which patients to transplant, which donors to accept, how to minimize risk, and how to ensure the best utilization of transplant team members.

Thomas, J. W. and C. J. Buckley, 2nd (2020). “Traumatic Pneumoperitoneum After Vaginal Intercourse.” Pediatr Emerg Care 36(5): e301-e303.

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OBJECTIVES: Pneumoperitoneum with peritonitis, although uncommon, is a serious injury encountered in the pediatric emergency department. Although the patients may often appear ill or toxic, they can have normal vital signs at initial presentation. Patients with such injury can present with a variety of complaints because of the nature of referred pain. As a result, some patients may be more or less straightforward, thus illustrating the importance of obtaining a detailed history and performing a thorough physical examination. METHODS: We discuss an uncommon case report of pneumoperitoneum with peritonitis in an adolescent patient presenting with vaginal bleeding and abdominal pain hours after vigorous coitus. RESULTS: Examination under anesthesia, flexible sigmoidoscopy, and exploratory laparoscopy revealed a vaginal laceration and a 2- to 3-cm perforated area at the left edge of the vaginal laceration that involved the rectovaginal septum entering the peritoneal cavity. CONCLUSIONS: Pneumoperitoneum resulting from vaginal intercourse in an otherwise healthy adolescent female is a rare cause of peritonitis. Although it has been described in the adult literature, this case illustrates the importance of considering sexual history as a contributory factor in pediatric patients presenting with an acute abdomen.

Tenforde, M. W., J. Chung, E. R. Smith, H. K. Talbot, C. H. Trabue, R. K. Zimmerman, F. P. Silveira, M. Gaglani, K. Murthy, A. S. Monto, E. T. Martin, H. Q. McLean, E. A. Belongia, L. A. Jackson, M. L. Jackson, J. M. Ferdinands, B. Flannery and M. M. Patel (2020). “Influenza vaccine effectiveness in inpatient and outpatient settings in the United States, 2015 – 2018.” Clin Infect Dis Apr 9. pii: ciaa407. [Epub ahead of print].

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BACKGROUND: Demonstration of influenza vaccine effectiveness (VE) against hospitalization for severe illness in addition to milder outpatient illness may strengthen vaccination messaging and improve suboptimal uptake in the U.S. Our objective was to compare patient characteristics and VE between U.S. inpatient and outpatient VE networks. METHODS: We tested adults >/=18-years with acute respiratory illness (ARI) for influenza within two VE networks, one outpatient- and the other hospital-based, from 2015-2018. We compared age, sex, and chronic high-risk conditions between populations. The test-negative design was used to compare vaccination odds in influenza-positive cases versus influenza-negative controls. We estimated VE using logistic regression adjusting for site, age, sex, race/ethnicity, peak influenza activity, time-to-testing from symptom-onset, season (overall VE) and underlying conditions. VE differences (DeltaVE) were assessed with 95% confidence intervals (CI) determined through bootstrapping with significance defined as excluding the null. RESULTS: The VE networks enrolled 14,573 (4144 influenza-positive) outpatients and 6769 (1452 influenza-positive) inpatients. Inpatients were older (median 62-years vs. 49-years) and had more high-risk conditions (median 4 vs. 1). Overall influenza VE across seasons was 31% (95%CI:26%-37%) among outpatients and 36% (27%-44%) among inpatients. Strain-specific VE among outpatients versus inpatients was 37% (25%-47%) vs. 53% (37%-64%) against H1N1pdm09, 19% (9%-27%) vs. 23% (8%-35%) against H3N2, and 46% (38%-53%) vs. 46% (31%-58%) against B-viruses. DeltaVE was not significant for any comparison across all sites. CONCLUSIONS: Inpatients and outpatients with ARI represent distinct populations. Despite comparatively poor health status among inpatients, influenza vaccination was effective in preventing hospitalizations associated with influenza.