Surgeons have hesitated early cholecystectomy because of cardiovascular comorbidities during adoption of guidelines

The introduction of the guidelines has resulted in an increase of laparoscopic surgeries performed, but the rate of early surgery was still low. Here, the initial effect of the introduction of the guideline was confirmed in single center, and factors disturbing early cholecystectomy were analyzed. This study included 141 patients who were treated for acute cholecystitis from January 2010 to October 2014 at Kanazawa Medical Center. Each patient was assigned into a group according to when they received treatment. Patients in Group A were treated before the Tokyo Guidelines were introduced (n = 48 cases), those in Group B were treated after the introduction of the guidelines (93 cases). After the introduction of the guidelines, early laparoscopic cholecystectomy was significantly increased (P < 0.001), however, the rate of early operations was still 38.7% only. There are many cases with cardiovascular disease in delayed group, the prevalence had reached 50% as compared with early group of 24% (P < 0.01). Approximately 25% of patients continued antiplatelet or anticoagulant therapy. In the early days of guidelines introduction, the factor which most disturbed early surgery was the coexistence of cardiovascular disease. These contents could be described in the next revision of the guidelines.

Impact of time to intubation on mortality and pulmonary sequelae in critically ill patients with COVID-19: a prospective cohort study

Question We evaluated whether the time between first respiratory support and intubation of patients receiving invasive mechanical ventilation (IMV) due to COVID-19 was associated with mortality or pulmonary sequelae. Materials and methods Prospective cohort of critical COVID-19 patients on IMV. Patients were classified as early intubation if they were intubated within the first 48 h from the first respiratory support or delayed intubation if they were intubated later. Surviving patients were evaluated after hospital discharge. Results We included 205 patients (140 with early IMV and 65 with delayed IMV). The median [p25;p75] age was 63 [56.0; 70.0] years, and 74.1% were male. The survival analysis showed a significant increase in the risk of mortality in the delayed group with an adjusted hazard ratio (HR) of 2.45 (95% CI 1.29–4.65). The continuous predictor time to IMV showed a nonlinear association with the risk of in-hospital mortality. A multivariate mortality model showed that delay of IMV was a factor associated with mortality (HR of 2.40; 95% CI 1.42–4.1). During follow-up, patients in the delayed group showed a worse DLCO (mean difference of − 10.77 (95% CI − 18.40 to − 3.15), with a greater number of affected lobes (+ 1.51 [95% CI 0.89–2.13]) and a greater TSS (+ 4.35 [95% CI 2.41–6.27]) in the chest CT scan. Conclusions Among critically ill patients with COVID-19 who required IMV, the delay in intubation from the first respiratory support was associated with an increase in hospital mortality and worse pulmonary sequelae during follow-up.

Feasibility, Acceptability, and Preliminary Efficacy of Dignity Therapy in Patients With Early Stage Dementia and Their Family. A Pilot Randomized Controlled Trial

Purpose: Dementia is the major cause for disability and dependence in older people and associated with considerable psychological burden. The aim of this study was to determine the feasibility, acceptability and preliminary efficacy of Dignity Therapy, a brief psychotherapeutic intervention to enhance dignity and reduce psychological burden, in patients with early stage dementia and in their families or close friends.Materials and methods: In this randomized, waitinglist-controlled clinical trial a total of 54 patients with new diagnosis of early stage dementia and 54 study partners (spouses: n = 37; relatives: n = 14; close friends: n = 3) were randomly assigned to immediate treatment (n = 28) or delayed treatment (n = 26) after 3 months waiting. The main outcomes were feasibility: proportion of screened and invited patients who consented participation; Acceptability: number of drop-outs, and satisfaction with treatment; Efficacy: psychological burden (Hospital Anxiety and Depression Scale—HADS), quality of life (WHOQOL-Bref), and sense of dignity (Patient Dignity Inventory—PDI).Results: In total 38.6% of all eligible patients (n = 140) consented and were enrolled. Along the study six participants (11.1%) dropped out. Patients' satisfaction with the treatment was high and with no significant difference between the groups. HADS scores were significantly lower in both groups at the 3-months follow-up (immediate group: mean difference = −2.69, SE = 0.85, P = 0.003; delayed group: mean difference = −1.97, SE = 0.89, P = 0.031). There was no significant group by time interaction effect (F = 0.71; df = 2, 70.3; P = 0.50). PDI scores only decreased significantly (i.e., improvement of dignity) in the immediate group (mean difference = −6.56, SE = 1.63, P &lt; 0.001; delayed group: mean difference = −3.01, SE = 1.69, P = 0.081), but the group by time interaction effect was not statistically significant (F = 2.29; df = 1, 46.8; P = 0.14). Quality of life improved in some respects by the treatment, but the immediate and the delayed group did not differ significantly over time. After pooling patients' data of both groups, Dignity Therapy resulted in significant improvements in almost all outcome measures. Patients' family members/close friends reported high satisfaction with the intervention.Conclusions: Our findings suggest that Dignity Therapy is feasible and highly accepted in patients with early stage dementia. Patients reported significant improvements, however, there was no significant effect of the intervention in the immediate treatment group compared to the delayed group.

Concurrent decompression and resection versus decompression with delayed resection of acutely ruptured brain arteriovenous malformations

OBJECTIVE Brain arteriovenous malformations (bAVMs) most commonly present with rupture and intraparenchymal hemorrhage. In rare cases, the hemorrhage is large enough to cause clinical herniation or intractable intracranial hypertension. Patients in these cases require emergent surgical decompression as a life-saving measure. The surgeon must decide whether to perform concurrent or delayed resection of the bAVM. Theoretical benefits to concurrent resection include a favorable operative corridor created by the hematoma, avoiding a second surgery, and more rapid recovery and rehabilitation. The objective of this study was to compare the clinical and surgical outcomes of patients who had undergone concurrent emergent decompression and bAVM resection with those of patients who had undergone delayed bAVM resection. METHODS The authors conducted a 15-year retrospective review of consecutive patients who had undergone microsurgical resection of a ruptured bAVM at their institution. Patients presenting in clinical herniation or with intractable intracranial hypertension were included and grouped according to the timing of bAVM resection: concurrent with decompression (hyperacute group) or separate resection surgery after decompression (delayed group). Demographic and clinical characteristics were recorded. Groups were compared in terms of the primary outcomes of hospital and intensive care unit (ICU) lengths of stay (LOSs). Secondary outcomes included complete obliteration (CO), Glasgow Coma Scale score, and modified Rankin Scale score at discharge and at the most recent follow-up. RESULTS A total of 35/269 reviewed patients met study inclusion criteria; 18 underwent concurrent decompression and resection (hyperacute group) and 17 patients underwent emergent decompression only with later resection of the bAVM (delayed group). Hyperacute and delayed groups differed only in the proportion that underwent preresection endovascular embolization (16.7% vs 76.5%, respectively; p < 0.05). There was no significant difference between the hyperacute and delayed groups in hospital LOS (26.1 vs 33.2 days, respectively; p = 0.93) or ICU LOS (10.6 vs 16.1 days, respectively; p = 0.69). Rates of CO were also comparable (78% vs 88%, respectively; p > 0.99). Medical complications were similar in the two groups (33% hyperacute vs 41% delayed, p > 0.99). Short-term clinical outcomes were better for the delayed group based on mRS score at discharge (4.2 vs 3.2, p < 0.05); however, long-term outcomes were similar between the groups. CONCLUSIONS Ruptured bAVM rarely presents in clinical herniation requiring surgical decompression and hematoma evacuation. Concurrent surgical decompression and resection of a ruptured bAVM can be performed on low-grade lesions without compromising LOS or long-term functional outcome; however, the surgeon may encounter a more challenging surgical environment.

Early versus delayed hip reduction in the surgical treatment of femoral head fracture combined with posterior hip dislocation: a comparative study

Background Few studies focus on the treatment of femoral head fracture combined with posterior hip dislocation, and the safe interval time between injury and hip reduction remains controversial. The purpose of this study was to evaluate and compare the outcome of early and delayed hip reduction in the surgical treatment of femoral head fracture combined with posterior hip dislocation. Methods A total of 71 patients were evaluated in this retrospective study. Based on the time to hip reduction, they were divided into early group (within 6 h after injury) and delayed group (between 6 and 12 h after injury). The two groups were compared in reference to hospital day, fracture healing time, the occurrence of complications and final functional outcome. The Thompson-Epstein criteria, modified Merle D’Aubigné and Postel scores, visual analog scale (VAS) and Medical Outcomes Short Form 12-item questionnaire score (SF-12) were used for final functional evaluation. Results The mean hospital stay and fracture healing time in the early group were significantly lower than those in the delayed group. The incidence of infection, post-traumatic osteoarthritis, and avascular necrosis of the femoral head (ANFH) in the delayed group were higher than that in the early group. The early group had better functional outcomes in terms of Thompson-Epstein criteria, modified Merle D’Aubigné and Postel scores and physical component scale (PCS) than the delayed group. Conclusions For the treatment of femoral head fracture combined with posterior hip dislocation, the early and prompt hip reduction can effectively facilitate the fracture healing and patient rehabilitation, and obtain a better functional outcome.

Effect of Health Literacy on Decision Delay in Patients With Acute Myocardial Infarction

Background: Health literacy (HL) is a risk factor for adverse outcomes in patients with cardiovascular disease, and shorter pre-hospital delay time is crucial for successful treatment of acute myocardial infraction (AMI) patients. Most previous studies focused on the influencing factors of pre-hospital delay but ignore the essential contribution of decision delay.Aims: Therefore, the purpose of this study was to explore the effect of HL on decision delay.Methods: Continuously included AMI patients admitted to a grade A class three hospital in Chongqing. HL level was assessed using Brief Health Literacy Screen and categorized as adequate or inadequate. Mann-Whitney U-test and Chi-square test were used to compare the differences between groups, and binary logistic regression was used to analyze the association between HL and decision delay.Results: A total of 217 AMI patients were enrolled in this study, including 166 males (76.5%) and 51 females (23.5%), with the median age was 68 years old; 135 (62.2%) patients had delayed decision-making while 82 (37.8%) did not; 157 (72.7%) patients had inadequate HL and 59 (27.3%) had adequate HL. The total HL score of non-delayed group was higher than that in delayed group (9.22 vs. 7.02, P &lt; 0.000).Conclusion: After adjusting for covariates, HL was significantly negatively associated with decision time. AMI patients with inadequate HL were more likely to delay seeking timely medical care.

The Impact of the Time Interval Between Cycles on Pregnancy Outcome of Ovulation Induction Cycle Intrauterine Artificial Insemination

ObjectiveThe objective of this study was to estimate whether the time interval between two intrauterine inseminations (IUI) treatments needs to be extended by one menstrual cycle or more in patients undergoing successive cycles of ovulation stimulation, and whether this will have an impact on the clinical pregnancy rate (CPR).Study DesignRetrospective cohort study.Study siteThe study site was the reproductive medicine center of a teaching hospital.Patient(s)The subjects were women and their husbands who received two or more intrauterine insemination in our reproductive medicine center due to mild infertility in the period from January 2017 to December 2019. Patients were divided into 2 groups according to the number of days between the last menstrual day(LMD)and the previous IUI operation day(POD), continuous group (the time from the LMD to POD ≤ 34 days) and delayed group (the time from the LMD to POD ≥ 35 days). We excluded cycles with intervals of more than 180 days.In order to avoid the inclusion of multiple repeat cycles for the same couple, only the first two cycles of IUI treatment in the same couple were allowed to be included in this study. That is, when they failed the first IUI cycle, they were given a second IUI treatment.Intervention(s)No intervention.Main Outcome Measure(s)A total of 550 cycles met the inclusion criteria, and 374 (68.0%) cycles met the inclusion criteria for the continuous group,the remaining 176 (32.0%) cycles with at least one or more menstruations between two IUI cycles were included in the delayed group.The primary outcome measure was clinical pregnancy rate (CPR), with secondary outcomes including abortion rate. Differences in clinical pregnancy rate (CPR)、abortion rate were compared between the two groups.ResultThere was no significant difference between the continuous group and the delayed group in female age, male age, infertility duration, infertility type, female BMI, endometrial classification, endometrial thickness, semen volume before treatment, sperm density before treatment, percentage of forward motile sperm before treatment, sperm density after treatment, and percentage of forward motile sperm after treatment. There were no statistical differences between the delayed group vs continuous group regarding the clinical pregnancy rate (20.5 % vs 21.9 %) and abortion rate (27.8% vs 22.0%)（P>0.05）. The above factors were included for binary logistic regression analysis. It was found that the increase of endometrial thickness promoted the clinical pregnancy rate, which was statistically significant (OR=1.205, 95% CI 1.05-1.384,P=0.008). Compared with primary infertility, secondary infertility can promote the improvement of clinical pregnancy rate, which is statistically significant (OR=2.637,95%CI 1.313-5.298,P=0.006). The effect of time interval between IUI on clinical pregnancy was not statistically significant (OR=1.007,95% CI 0.513-1.974,P=0.985).ConclusionsOverall, prolonging the interval between two IUI did not significantly improve pregnancy outcomes. Unless there are clear clinical indications, it is not necessary to deliberately prolong the interval between two treatments.

Peer group-based online intervention program to empower families of those raising children with disabilities: Study protocol for a non-randomized waitlist-controlled trial

BackgroundFamilies raising children with disabilities assume risks to their health and lives. Therefore, it is necessary to support these families to improve family empowerment, which is the ability of these families to control their own lives and to promote the collaborative raising of children with disabilities. This is the first online program development and interventional study focusing on the empowerment of families raising children with disabilities who live at home in Japan.MethodThe program consisted of four online peer-based group sessions. Moreover, the families engage in several activities in stages wherein they discover their own issues, find measures to resolve them, and take action, while visualizing interfamily relationships, including social resources, and the status of their family life, with facilitators and other peer members. This study was a non-randomized, waitlist-controlled trial. It compared the results of the intervention group (early group) and the waitlist-controlled group (delayed group). The participants were allocated to the early or delayed group in the order of their applications. The main outcome was family empowerment. Other outcomes are the caregiver burden, awareness of the use of social resources, self-compassion, and the quality of life (QOL) of primary caregivers. The timing of the online surveys was as follows: the initial evaluation (Time 1 [T1]) was conducted before the start of the first early group program, and post-intervention evaluation (Time 2 [T2]) was conducted immediately (within one week) after the early group had completed all four sessions (four weeks) of the program. Follow-up evaluation (Time 3 [T3]) was conducted four weeks after the post-intervention evaluation. This timing was the same in the delayed group, but the delayed group attended the program after a four-week waiting period, compared to the early group.DiscussionThe intention is to evaluate whether the provision of the program developed in this study and the evaluation test design are feasible and to verify the efficacy of this program.Clinical trial registrationThe UMIN Clinical Trials Registry (UMIN000044172), registration date: May 19, 2021. https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000050422

The Impact of the Time Interval Between Cycles on Pregnancy Outcome of Intrauterine Insemination

Objective: The objective of this study was to estimate whether the time interval between two intrauterine inseminations (IUI) treatments needs to be extended by one menstrual cycle or more, and whether this will have an impact on the clinical pregnancy rate (CPR).Study Design: Retrospective cohort study.Study site: The study site was the reproductive medicine center of a teaching hospital.Patient(s): The subjects were women and their husbands who received two or more intrauterine insemination in our reproductive medicine center due to mild infertility in the period from January 2014 to December 2020. Patients were divided into 2 groups according to the number of days between the last menstrual day(LMD)and the previous IUI operation day(POD), continuous group (the time from the LMD to POD ≤ 34 days) and delayed group (the time from the LMD to POD ≥ 35 days). If the previous cycle was a pregnancy or abortion cycle, the next cycle immediately adjacent to it was defined as a new cycle, and the days between the two cycles were not included in the study.Intervention(s):No intervention.Main Outcome Measure(s): A total of 1491 cycles were finally included in the study.990 cycles followed by the second IUI cycle after the previous failure,501 cycles at least one menstrual cycle was separated between two IUI treatments. The primary outcome measure was clinical pregnancy rate (CPR), with secondary outcomes including abortion rate and live birth rate. Differences in clinical pregnancy rate (CPR)、abortion rate and live birth rate were compared between the two groups.Result: No significant differences with regard to baseline demographic and the number of treatment cycles, the duration of infertility, the type of infertility, the mode of treatment, and the cause of infertility were observed between the two groups.There were no statistical differences between the delayed group vs continuous group regarding the clinical pregnancy rate(15.0% vs 13.7%), live birth rate(78.7% vs 74.3%), and abortion rate(17.3% vs 18.4%)（P＞0.05）.The above factors were included for binary logistic regression analysis. The observed difference in clinical pregnancy rate between the groups was not statistically significant after adjustment(OR = 1.101,95%CI 0.807-1.499, P=0.546）.The all cycles were divided into four groups based on female age. results showed that when the female's age was ≤ 25 years old, the pregnancy rate in the continuous group was 16.5%, which was significantly higher than that in the delayed group by 5.8% (difference 0.107, 95% CI 0.016-0.198, P = 0.055), approached, but did not reach, statistical significance. When the female was 30-35 years old, the pregnancy rate in the delayed group was 19.4%, which was significantly higher than 10.9% in the continuous group (difference 0.085, 95% CI 0.016-0.154, P = 0.011). The difference between the two groups was statistically significant. The all cycles were divided into three groups based on years of infertility. Our results show that when the number of years of infertility was≤2 years, the clinical pregnancy rate was 20.7% in the delayed group and 12.5% in the continuous group (difference 0.107, 95% CI 0.150-0.014, P = 0.013), statistical significance was maintained. Based on the number of treatment cycles, it is divided into 2 cycles, 3 cycles, and≥4 cycles. The results showed that when≥4 cycles, the pregnancy rate in the continuous group were 19.4%, which was significantly higher than 6.1% in the delayed group (difference 0.133, 95% CI 0.246-0.020, P = 0.038). Statistical significance was maintained at P < 0.05.Conclusions: Overall, prolonging the interval between two IUI did not significantly improve pregnancy outcomes. Yet, for different age stages, duration of infertility, and the number of treatment cycles, we suggest that more flexible treatment strategies can be tried to improve the clinical pregnancy rate.

Delayed interval BNT162b2 mRNA COVID-19 vaccination provides robust immunity

Shortages of COVID-19 vaccines have results in delayed dosing intervals as a strategy to immunize a greater proportion of the population. The effect of this strategy on vaccine immunogenicity is not well studied. Humoral (anti-RBD levels and neutralization) and cellular immune responses were compared in health care workers receiving two doses of BNT162b2 (Pfizer-BioNTech) vaccines at standard (3-6 week) and delayed (8-12 week) intervals. In the delayed group, anti-RBD antibody titres were significantly enhanced compared to the standard interval group. Neutralizing antibody responses were excellent and comparable in both groups. A slight decrease in Spike-specific polyfunctional CD4+ T-cells expressing interferon-γ and IL-2 as well as monofunctional CD4+ T-cells was seen in the delayed group. Both polyfunctional and monofunctional CD8+ T-cell responses were comparable. Our data suggest that the strategy of delayed second dose mRNA vaccination is not overtly detrimental, and specifically may lead to an enhanced humoral immune response.