Santa Clara Valley Medical Center, commonly known as Valley Medical Center or simply Valley Medical, is a prominent 731-bed public tertiary, teaching, and research hospital in San Jose, California. Located in the Fruitdale neighborhood of West San Jose, Valley Medical Center is the anchor facility of the Santa Clara County Health System, serving Santa Clara County. Valley Medical is home to numerous innovative research and care centers, such as the Rehabilitation Trauma Center, the only federally-designated spinal cord injury center in Northern California.
OBJECTIVE:To investigate the effects of anesthesia type and deferred umbilical cord clamping (DCC) on short-term maternal and neonatal outcomes at Cesarean section (CS). METHODS:This single-center retrospective study of all CS ≥35 weeks from January 2018-December 2023 compared maternal and neonatal outcomes between deliveries with and without DCC ≥60 seconds (s) under general anesthesia (GA) versus regional anesthesia (RA). The cord was clamped earlier for maternal hemorrhage, placental separation, cord avulsion, or infant apnea after 30-60s. Multivariable generalized estimating equations were used to assess the independent and joint effects of anesthesia type and DCC on outcomes, adjusting for emergent CS, chorioamnionitis, and severe preeclampsia/eclampsia. RESULTS:4341 mothers and 4463 infants were studied. DCC was performed in 62% (121/195) of GA and 87% (3728/4268) of RA infants. Interaction analyses demonstrated that the association between DCC and postpartum hemorrhage (PPH) differed by anesthesia type. Among mothers receiving GA, DCC ≥60s was not associated with PPH ≥1000 mL (50% vs 42%, p=.3) or transfusion (15% vs 16%, p=.8), whereas among RA mothers, DCC ≥60s was associated with lower adjusted probabilities of PPH (25% vs 48%, p<.001) and transfusion (5% vs 15%, p<.001). There was no significant interaction between DCC ≥60s and anesthesia type for neonatal outcomes. DCC ≥60s was associated with lower adjusted odds of 5-min APGAR <7 (OR 0.2 (0.2-0.4), p<.001), delivery room (DR) intubation (OR 0.0 (0.0-0.2), p<.001), umbilical artery pH < 7 (OR 0.5 (0.3-0.8), p=.007) and NICU admission (OR 0.5 (0.4-0.6), p<.001). CONCLUSION:Regardless of anesthesia type, DCC ≥60s was not associated with higher risks of PPH or transfusion among mothers; and was not associated with any detriment in short term neonatal outcomes. We suggest that GA deliveries can be safely considered eligible for DCC under a standardized institutional protocol with predefined exit criteria.
BACKGROUND:Although pulmonary artery (PA) enlargement on computed tomography (CT) has been linked to adverse cardiopulmonary outcomes, its prognostic significance in asymptomatic individuals undergoing low-dose lung cancer screening CT's remains unclear. PURPOSE:To evaluate the prognostic value of PA enlargement for predicting mortality in asymptomatic patients undergoing low-dose CT lung cancer screenings. MATERIALS AND METHODS:A total of 777 patients undergoing low-dose screening CT's at a tertiary academic center (2014-2018) were retrospectively identified. PA diameter and PA:AA ratio were measured. The primary endpoint was overall survival (OS), calculated from the date of reference CT to death or censoring at last follow-up. For survival analysis, patients with ≥3 years follow-up were included. Clinical and imaging variables were analyzed using univariate Cox proportional hazard model and statistically significant variables (P < 0.05) were entered into multivariable analysis to identify independent predictors of mortality. All statistical analyses were performed using Python (pandas, seaborn, lifelines). RESULTS:Sex-specific PA diameter thresholds (90th percentile: 29 mm men, 27 mm women) were applied. PA dilation was present in 179 patients (23%). On univariate analysis, age, underweight BMI, smoking status, diabetes, hypertension, coronary artery disease, PA dilation (absolute and PA:AA ratio), and emphysema severity (Goddard score) were associated with decreased survival. On multivariate analysis, PA dilation remained independently associated with increased mortality (HR = 1.83; 95% CI: 1.20-2.79; P = 0.005), along with age, underweight BMI, smoking status, hypertension, and higher Goddard scores. CONCLUSION:PA enlargement on low-dose CT independently predicts worse survival and may help risk-stratify asymptomatic patients undergoing lung cancer screening.
OBJECTIVES:The transition to electric vehicles (EVs) represents a potential strategy for reducing carbon emissions from the health care sector. Ambulances, however, have unique operational demands, including rapid response times, variable call volumes, and prolonged periods at hospitals. Using data from the National Emergency Medical Services Information System (NEMSIS) in 2024, we modeled the feasibility for implementing EV ambulances in multiple response environments, as well as the possible benefits of providing at-hospital charging at various speeds. METHODS:We used an observational study design and retrospective analysis to assess the average time on task and estimated driving distances for EMS 9-1-1 calls stratified by urbanicity. These ranges were tested against two hypothetical operating profiles of electric ambulances to assess practicality, assuming a 25% remaining battery capacity at hospital arrival. Potential models for at-hospital charging were evaluated using different charging rates. RESULTS:Estimated mileage fell within range requirements for most cases, ranging from 99.9% of dispatches for urban settings with a higher-capacity vehicle to 97.6% of dispatches in frontier settings for a lower-capacity vehicle type. Assuming charging time to span from ambulance arrival at hospital to return to service, both Level-2 and Level-3 charging stations restored significant fractions of total energy used during transport. CONCLUSIONS:Electric ambulance battery capacity ranges cover the majority of distances required by single dispatches across multiple urbanicity settings, but higher-capacity battery vehicles may be more consistently reliable in rural or frontier settings. Incorporating at-hospital charging stations may offset a significant portion of charging time requirements. Benefits of reductions in vehicle emissions likely differ according to local power grid composition.
Objectives:To identify demographic and medical factors associated with changing bladder management method and document the reason for changing bladder management method among adults with spinal cord injury (SCI). Methods:This cohort study included 20 Spinal Cord Injury Model Systems (SCIMS) centers. Participants were individuals injured between 1972 and 2019 who completed 2 consecutive assessments of bladder management method within 5 years and identified the reason for changing bladder management method at the second assessment. Main outcome measures were change in bladder management method since first assessment (changed/not changed) and, if change occurred, reason for changing. Results:Of 10,769 persons included in the analysis, 10.6% reported change in bladder management at the second assessment. After adjusting for covariates, higher odds of changing bladder management was observed among people who completed first assessment at discharge from initial rehabilitation and those who (a) used nonvolitional voiding for bladder management, (b) were older than 44 years of age, (c) had less than high school education, and (d) resided in a hospital or nursing home. The most reported reason for changing bladder management was medical-related factors (48.2%), followed by functional improvement (28.5%) and personal factors (19.6%). Conclusion:Understanding the patterns and predictors of bladder management transitions can help clinicians anticipate potential changes, provide proactive education and support, and implement strategies to minimize secondary complications.
Patients with severe burn injuries endure intense pain, which is amplified by serial operations, daily dressing changes, and regular physical therapy. While peripheral nerve blocks have become increasingly popular in the management of isolated burns to the extremities, there have been few reports on the use of neuraxial anesthesia to treat burn pain. Here, we describe the inclusion of epidural anesthesia in our algorithm for management of burns to the lower trunk, bilateral lower extremities, buttocks, and perineum. We hypothesized that epidural anesthesia would be associated with reduced opioid use and improved pain scores. We performed a retrospective review of all patients admitted to a verified burn center who underwent epidural catheter placement between 2018 and 2024. Visual analog scale pain scores and opioid consumption (standardized in morphine milligram equivalents [MMEs]) were extracted for several days before and after placement of each patient's first epidural catheter. During the study period, 11 patients underwent epidural catheterization in our burn unit. An average of 1.8 (SD 1.3) catheters were placed per patient, for a total of 20 catheters. All patients experienced significant reductions in daily opioid consumption (92.5 MMEs/day pre-epidural to 58.1 MMEs/day postepidural, P = .008) and average pain scores (6.25 pre-epidural to 2.45 postepidural; P = .008). Minor complications including nausea/vomiting and pruritus occurred in 4 patients. There were no major complications or infections. We conclude that epidural anesthesia is safe and effective for relieving pain and decreasing opioid consumption in patients with burn injuries.
