Monthly Archives: October 2018

Violence Against Women: A Case Report of Violence Perpetrated By a Couple on a Single Lady

DOI: 10.31038/AWHC.2018113

Abstract

Introduction: Violence against women (VAW) is a menace that is increasing all over the world. It is one of the most widespread human rights abuses and a public health problem. Most victims of violence against women know their perpetrators.

Case Presentation: A 28 year old single lady had a quarrel with her female neigbour. The neigbour’s husband held the single lady’s hands behind her and ordered his wife tit beat up the single lady. The female neigbour then bit the left upper eye lid of the single lady resulting in haemorrhage and pain. The injury was sutured.

Conclusion: Men are not the only perpetrators of such violence. Single women are at risk of being victims of violence. To end violence against women, everyone is involved because in some societies such issues are never discussed in public.

Key Words

Violence, Single Lady, Human Bite, Eye

Introduction

Violence against women is a menace that is increasing worldwide. It takes the form of sexual abuse and rape, physical injury comprising of cuts, bruises, human bite and burns and sexual harassment at the workplace. The perpetrators are usually male partners or colleagues. Violence against women is wide spread around the world [1]. It is a term used to collectively refer to violent acts that are primarily or exclusively committed against women and physical abuse is one of the commonest forms of abuse [2]. It is a form of gender based violence which can be described as any harm that is perpetrated against a person as a result of inequalities that are based on gender roles [3]. The united nations declaration on the elimination of violence against women in 1993 defines violence against women as any act of gender based violence that results in or is likely to result in physical, sexual or psychological harm of suffering of women including threats of such acts, coercion or arbitrary deprivation of liberty whether occurring in private or public life [4]. Violence against women is a major public health and human rights concern [5]. For this reason the United Nations has designated November 25 as the international day for the elimination of violence against women 2. Violence against women is a burning issue of human rights often swept under the carpet as if it does not matter especially in Africa and particularly in Nigeria [1]. Worldwide governments and various organizations are actively working to combat this menace through a variety of programmes [2]. Women are crucial to the growth and development of any nation2 therefore violence against women is a major threat to social and economic development [1].

Case Presentation

A twenty eight year old single Nigerian lady had a quarrel with her female neigbour. The neigbour’s husband overpowered the single lady by holding the single lady’s hands behind her and commanded his wife to beat up the single lady. The single lady was bitten on the left upper eye lid by her neigbour. There was haemorrhage and pain.

On examination, there was a 4cm laceration on the upper left eye lid with rough edges bleeding palpebral conjunctiva and eyeball were intact. Visual acuity could not be properly assessed because the patient was uncooperative because the left eye was very tender. Irrigation was done. The patient was to pay out of pocket, so she refused treatment and presented three days later by which time there was profuse foul smelling pussy discharge from the injury. Irrigation was done and the discharge sent for microbiological studies. Analgesics and antibiotics were administered. The laceration was sutured when the eye discharge had subsided.

AWHC-18-104-DabotaYvonneBuowari-Nigeria_F1

AWHC-18-104-DabotaYvonneBuowari-Nigeria_F2

Discussion

Violence against women is a serious issue and can render a woman disabled in extreme as in this case if there was no prompt treatment, the single lady may have lost one eye. It is not only men that physically abuse women as in this case the violence was perpetrated by a couple. There is a stigma of being single in some societies as the woman is seen as being unable to defend herself because she has no body to speak for her. Sometimes single ladies are even abused and violated by their own relatives’ and friends. In this case the victim’s neigbour overpowered her physically and authorized his wife to beat her up because the victim had no male partner at that time to fight for her. Not being able to assess health insurance led to a delay in the management as the victim had to pay out of pocket and she did not have the money at the time the injury occurred. Further delay in the management may have led to blindness or poor vision in the affected eye. The discomfort from the injury led to some loss of work days. There some non-governmental organizations in Nigeria that helps to fight violence against women. Single women which include women that have never married, those divorce and widows are usually the victims of violence and discrimination in the society.

Conclusion

Men are not the only perpetrators of violence against women. Single women that include the never married, divorced and widowed are at risk of being violated physically, socially and financially (that is economically). Health insurance is important in the management of injuries resulting from violence against women. Ending violence against women involves everyone.

References

  1. Haaga PT, Elechi FA, Okoye AC (2015) Violence against Women and Its Implications for Peace and Security in Nigeria. International Journal of Peace and Conflict Studies 2: 27–40.
  2. Alokan FB (2013) Domestic Violence against Women: A Family Menace, 1st Annual International Interdisciplinary Conference, AIIC, Book of Proceedings, 100–107.
  3. Ashimolowo OR, Otufale GA (2012) Assessment of domestic violence among women in Ogun State, Nigeria. Greener Journal of Social Sciences 2: 102–114.
  4. General Assembly Resolution 48/08 of 28 December 1993.
  5. Mbadugha EI (2016) Intimate Partner Violence and Sexual Violence against Women: Any End in Sight. International Journal of Medicine and Biomedical Research 5: 9–18.

Aqueduct-100, A New Device and Method for Controllable Cervical Dilation

DOI: 10.31038/JCRM.2018134

Abstract

Objective

The aim of this investigation was to evaluate the effectiveness of the Aqueduct-100 for cervical dilation to a predetermined diameter in patients meeting eligibility criteria.

Materials and Methods

This modified cervical dilator (Aqueduct-100) is a triple balloon catheter with a diameter of 2.3 mm enabling a one-time insertion of the device into the cervical canal. After insertion through the vagina and into the endometrial cavity, the device was fixed in place and inflated. The dilating balloons remained inflated inside the cervix for one minute until dilation reliably reached the desired 5.0–5.5mm diameter. This study was conducted at the Obstetrics and Gynecology department at the principle investigator’s surgical suite and Baptist Medical Arts Surgical Center, Miami, FL, USA from November 2016 through July 2017. The study included 30 patients ages 18 or older who were undergoing a diagnostic or operative hysteroscopy that required dilation.

Results

There were no reported problems operating the Aqueduct-100 mechanical dilator during the 29 reported procedures. In addition, the final diameter of the cervix after dilation was sufficient to perform the desired diagnostic/operative procedure without the need for further dilation by another method. Finally, the device was found to be user-friendly and adjustable to a patient’s cervical anatomy through a gentle, radial force.

Conclusion

The results of the study suggest that Aqueduct-100 device can be used as an alternative for mechanical dilators to prevent uterine and cervical injuries during cervical dilation prior to diagnostic or operative hysteroscopy procedures.

Keywords

cervical incompetency; hysteroscopy; mechanical dilators; uterine perforation

Introduction

Cervical dilation allows sufficient access to the endometrial cavity when surgical instruments are required during an intrauterine procedure. Current dilation methods include hygroscopic or mechanical dilators, sometimes preceded by a pharmacological agent to ripen the cervix for dilation.[1,2] These methods can be slow to work or involve multiple visits with the physician.[3] Moreover, if multiple insertions of the mechanical instruments are necessary during a single procedure, patients may require anesthesia for pain management, in addition to having an increased risk of infection, cervical or uterine lacerations, and intraperitoneal hemorrhages.[3, 4,5] Studies demonstrate the most frequently reported complications occurring during the dilation of the cervix prior to hysteroscopy are perforation and cervical trauma, with uterine perforation rates of approximately 0.7–0.8%.[6] Risk factors associated with uterine perforation include cervical stenosis, severe uterine anteflexion or retroflexion, infection, myomas of lower uterine segments, and synechiae.[7] Furthermore, reports associate cervical trauma as a contributing factor for cervical insufficiency.[8]

Limitations associated with the methodology of current dilators include the inability to tailor the device to a patient’s cervical anatomy or the unique requirements of each intrauterine procedure.[9] The functional inflexibility of current dilators may also exacerbate patient discomfort and increase the potential for injury endangering cervical integrity for future pregnancies, ie cervical incompetence.[4,5] To facilitate the mechanical methods for cervical dilation, we propose a cervical dilator based on a single act of insertion through the cervix, providing gradual and uniform dilation to a predetermined diameter within one minute, thereby reducing the risk of potential complications.

Material and Methods

Device Characteristics and Study Organization

The modified cervical dilator (Aqueduct-100) used in this study is a triple-balloon catheter that dilates the cervix during a single act of insertion. The dimensions of the two dilating balloons (diameter and length) were selected to enable efficient dilation to all cervices ranging between 1 to 7cm. The outer diameter of the semi-rigid catheter is 7 French (2.3mm), enabling easy insertion and manipulation of the catheter along the cervical canal. The consistency and endurance of the dilating balloons were tested previously to determine the breaching point for the Aqueduct-100. In vitro studies of the device revealed there was no detection of risk or breakage at a pressure of 14 bars. The reliability of these results was corroborated by an in vivo and ex vivo study reporting the ex-vivo mechanical response of the uterine cervix tissue did not differ considerably from what was observed in vivo.9 The study was conducted at the Obstetrics and Gynecology department at the principle investigator’s surgical suite and Baptist Medical Arts Surgical Center, Miami, FL, USA from November 2016 through July 2017. The data were collected by the study coordinators in the operating room. An independent data and safety monitoring board monitored the study and reviewed the protocol compliance and outcome data. The protocol was approved by the institutional review board of Baptist Hospital, Miami, FL

Study Patients

Thirty patients were enrolled using the following inclusion criteria: (1) subjects were age 18 or older and (2) undergoing a diagnostic or operative hysteroscopy that required dilation. All patients enrolled signed an informed consent form. Each procedure was performed by the principle investigator and began with measurements of the cervix, uterine cavity, and diameter of the internal ostium (os). All patients underwent operative hysteroscopy under local anesthesia with conscious sedation. In all the patients where the cervix could be cannulated, the dilating balloons were inflated for exactly one minute.

Procedure

The initial diameter of the cervix was measured prior to the dilation procedure with the use of Hegar’s rods. The catheter, with its balloons deflated (Fig. 1), was inserted through the vagina and the cervix into the endometrial cavity under sterile conditions. An anchoring balloon was inflated through the “Anchor channel”
(Fig. 2) using a 2.5ml syringe with 1.5ml of bacteriostatic saline solution to fix the catheter in place. Two elongated dilating balloons were then inflated simultaneously at each end of the cervical canal (internal ostium and external ostium) by performing 3 consecutive injections of 2.5ml bacteriostatic saline solution through the “Dilation channel” (total volume of 7.5ml reaching an internal balloon pressure of 6 bars) (Fig. 2–3). The surgeon controlled the inflation rate, dilating the cervix gradually according to the resistance created by the cervix. The inflation of the dilating balloon required approximately 10 seconds, and the inflated balloons remained in the cervical canal for 1 minute. After the balloons were completely dilated, a bacteriostatic saline solution was injected into the cervical canal between the 2 dilating balloons through the “Infusion channel” to wash and lubricate the cervix. For catheter removal, all 3 balloons were deflated, and the catheter was removed in preparation for the intrauterine procedure. A final cervical diameter assessment was determined by measuring the dilation of the cervix prior to the intrauterine procedure. This measurement was confirmed by Hegar’s rods.

JCRM 2018-117-LarrySpiegelmanUSA_F1

JCRM 2018-117-LarrySpiegelmanUSA_F2

JCRM 2018-117-LarrySpiegelmanUSA_F3

Results

The age of the 30 patients ranged from 29 to 59, mean (SD) = 44.97 ± 8.08. In one patient, the dilation could not be performed due to severe cervical stenosis after a previous LEEP cone biopsy. Although not excluded from the study, it was impossible to safely proceed with the procedure to any dilation without surgical intervention. For the remaining 29 patients, the initial diameter of the internal os was measured prior to each cervical dilation, and the final diameter of the internal os was measured at the end of the dilation procedure and prior to the intrauterine procedure as described in the methods (Table 1). In all patients, the final diameter of the cervix after dilation met the necessary diameter required to perform the diagnostic/operative procedure without the need for further dilation by another method.

Table 1. Initial and final diameter (mm) of the cervices

Number of Patients (N)

Mean Diameter (mm)

Standard Deviation (SD)

Initial Measurement

29

2.98

0.76

Final Measurement

29

5.60

0.51

The overall satisfaction of the physician was evaluated based on three categories: a) general ease of use, b) ease of insertion of the catheter along the cervix, and c) confidence with the procedure. The physician who carried out the dilation procedure recorded a score ranging between 1 to 4 for each category – 1 = Unacceptable, 2 = Difficult, 3 = Acceptable, and 4 = Good. In all the 29 procedures performed, the doctor did not encounter problems operating the device and assigned the maximum score of 4 in all categories.

Discussion

Based on our results, the Aqueduct-100 may be a replacement for traditional mechanical cervical dilators when considering the prevention of uterine and/or cervical injury. Advantages of this cervical dilator include: a demonstrated single act of insertion of the device through the cervix and adjustability of the device to fit the needs of the surgeon during a variety of diagnostic or operative hysteroscopies requiring dilation. The advantages of Aqueduct-100 compared to traditional mechanical dilators are summarized in Table 2.

Understanding cervical resistance is central to ensuring patient safety when dilating a cervix through mechanical instruments. Excessive force can lead to cervical or uterine injury, including bleeding, lacerations, and perforations.[3,4,5] According to a recent study, Arsenijevic et al. reported cervical resistance was depressed after 23 seconds with a pressure of 3.8 bars when using a continuous controllable balloon dilator.[2] In comparison, the two dilating balloons of the Aqueduct-100 generated a pressure of 6 bars during 10 seconds of dilation to overcome the resistance of the cervix. By inflating the dilating balloons through three consecutive injections of 2.5 ml of saline, the cervix was dilated radially and gradually. The inflated balloons remained inside the cervix for one minute, to allow the cervical walls time to adjust to the radial forces. Moreover, during the dilation period saline was injected between the dilating balloons to wash and lubricate the cervical canal. Injecting saline between the dilating balloons washes and cleans the cervix from bloody mucus thus providing a clean cervix prior to insertion of the hysteroscope and reducing the risk of infection.

Table 2. Comparison of Aqueduct-100 to mechanical dilators

Feature

Mechanical dilators1–5

Aqueduct-100

Duration of dilation procedure

Approximately one minute

One minute

Number of insertions required

Multiple

One

Forcefulness of dilation procedure

High direct force

Gentle radial force

Ability to adapt to unique cervical anatomies

Highly dependent on the skill of the physician

Adaptation to cervical anatomies built into the product design (semi-rigid shaft)

Risk of injury due to false route, perforation

Highly dependent on the skill of the physician

Very low

Risk of cervical incompetence

Present

Very low

1. Gupta JK, Johnson N. Should we use prostaglandins, tents or progesterone antagonists for cervical ripening before first trimester abortion? Contraception. 1992; 46(5): 489–497.
2. Biron-Shental T, Fishman A, Fejgin MD. Medical and mechanical methods for cervical ripening. Int J Gynaecol Obstet. 2004; 85(2): 159–160.
3. Lichtenberg ES, Paul M, Jones H. First trimester surgical abortion practices: a survey of national abortion federation members. Contraception. 2001; 64(5): 385–392.
4. Gelber S, Sciscione A: Mechanical methods of cervical ripening and labor induction. Clin Obstet Gynecol 2006, 49: 642–657.
5. Iams J D. Philadelphia, PA: Elsevier Inc; 2009. Cervical insufficiency; p. 586.

A previous study with the Aqueduct-100 cervical dilator was conducted in the department of Gynecology, Hospital General Santa María del Puerto, Cádiz, Spain.[10] Fifty patients were divided into 2 groups. Group A (n = 38) underwent cervical dilation while the dilating balloons remained inflated inside the cervix for five minutes and Group B (n = 12) underwent cervical dilation while the dilating balloons remained inflated inside the cervix for 3 minutes. The average initial diameter of the cervix of Group A was 3.0 ± 1.0mm and in Group B, 2.2 ± 0.6mm (P = 0.0220). The final diameter was 8.1 ± 1.1mm and 6.4 ± 0.8mm respectively (P < 0.0001). The results demonstrated the correlation between the duration of the dilation process and the final diameter of the dilated cervix, ie the ability to dilate the cervix to a pre-determined diameter by controlling the duration of the process. This finding has practical significance. The 3-minute dilation process can be implemented in procedures that require a cervical diameter approximately 6.5mm and the 5-minute dilation process can be implemented in procedures that require approximately an 8–9mm cervical dilation, such as in hysteroscopic myomectomy and dilation and evacuation (D&E) procedures.

Conclusion

In our present study, the dilating balloons remained inflated inside the cervix for 1 minute to dilate the cervix to the desired 5.0–5.5mm in diameter required to successfully perform each of the hysteroscopy procedures. In all cases that the cervix could be cannulated, the cervix was successfully dilated to the minimal diameter required to at least perform the hysteroscopic procedures using a 5mm operative hysteroscope. Moreover, there was no difficulty reported upon inserting a 6mm operative device for a bipolar ablation procedure.

Current dilators do not have the ability to adjust to meet the needs of the unique cervical anatomy/physiology and procedural requirements of each patient. Because of this, patient discomfort and the risk of injury is increased, endangering cervical integrity for future pregnancies. Considering our findings, the Aqueduct-100 device may be used as an alternative to mechanical dilators with decreased risk of uterine and cervical injuries during cervical dilations. It is important to emphasize that due to the limited number of participants enrolled in this study, a further prospective study may be required to achieve the power to validate the effectiveness of Aqueduct-100 cervical dilator.

Acknowledgements

The authors would like to thank Andrew O. Idowu, MD, MBA for his assistance with analgesia during the surgical procedures.

Disclosure Statements

Larry Spiegelman declares no conflict of interest.

Ramon Sanchez-Rauder declares no conflict of interest.

Cristina Travieso declares no conflict of interest.

References

  1. Allen RH, Goldberg AB (2016) Cervical dilation before first-trimester surgical abortion (< 14 weeks’ gestation). Contraception. 93(4): 277–291. [Crossref]
  2. Arsenijevic S, Vukcevic-Globarevic G, Volarevic V, Macuzic I, Todorovic P, Tanaskovic I, et al. (2012) Continuous controllable balloon dilation: a novel approach for cervix dilation. Trials. 13: 196. [Crossref]
  3. Gupta JK, Johnson N (1992) Should we use prostaglandins, tents or progesterone antagonists for cervical ripening before first trimester abortion? Contraception. 46(5): 489–497. [Crossref]
  4. Gelber S (2006) Sciscione A: Mechanical methods of cervical ripening and labor induction. Clin Obstet Gynecol. 49: 642–657. [Crossref]
  5. Jansen FW, Vredevoogd CB, van Ulzen K, Hermans J, Trimbos JB, Trimbos-Kemper TC. (2006) Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol. 49: 642–657. [Crossref]
  6. Loffer FD (1995) Contraindications and complications of hysteroscopy. Obstet Gynecol Clin North Am. 22(3): 445–455. [Crossref]
  7. Iams J D (2009) Philadelphia, PA: Elsevier Inc; Cervical insufficiency; p. 586.
  8. Leppert PC (1995) Anatomy and physiology of cervical ripening. Clin Obstet Gynecol. 38(2): 267–279. [Crossref]
  9. Mazza E, Nava A, Bauer M, Winter R, Bajka M, Holzapfel GA (2006) Mechanical properties of the human uterine cervix: an in vivo study. Med Image Anal. 10(2): 125–36. [Crossref]
  10. Vico de Miguel FJ, Pantoja-Garrido M, Frias-Sanchez Z, Pantoja-Rosso FJ, Martins E, Weichselbaum A (2017) Experience with a device for controlled cervical dilation. Ginecol Obstet Mex. 85(3): 125–133.

Observational Study to Assess the Safety and Clinical Effectiveness of the Hospital Universitario de Canarias Massive Transfusion Protocol

DOI: 10.31038/JCRM.2018133

Abstract

Introduction: Massive haemorrhage (MH) is a frequent entity and leads to high mortality rates.The early administration of blood products with high ratios following massive haemorrhage protocols (MHP) has proven to reduce mortality and transfusion of blood components.

Objectives: evaluate the safety and effectiveness of newly implemented MHP for surgical patients with MH and study mortality at 30 day of the haemorrhagic process.

Methods: a new massive haemorrhage protocol was developed and it was based on the early administration of blood products with a 3: 3: 1 ratio (red-blood cells, fresh frozen plasma, platelet). It was a prospective study in which 34 patients with massive haemorrhage were included. The patients were divided in two groups (implementation or non-implementation of the new protocol).

Results: the application of the protocol has not led to a decrease in the mortality rate or in the administration of red blood products and hemostatic drugs. Though there was an increase in the administration of procoagulant factors, but it was not associated with a higher incidence of adverse effects and complications related to mass transfusion.

Key words

massive haemorrhage, transfusion, protocol

Introduction

Massive transfusion refers to the infusion of a large volume of blood products over a relatively short period of time, in response to a clinical situation of massive haemorrhage (MH). Massive bleeding leads to high mortality rates, partly as a result of the “lethal triad” (hypothermia, acidosis and coagulopathy) [1–2].

MH can occur from a variety of causes, both traumatic and non-traumatic (rupture of an aortic aneurysm, perioperative complications of several surgeries, gastrointestinal bleeding, uterine atony, etc.) [3].

The implementation of massive haemorrhage protocols (MHPs) has proven to reduce mortality and transfusion of blood components. The administration of high plasma and platelet proportions in relation to red blood cell concentrates, together with the rapid onset of transfusion, enables coagulopathy to be prevented or treated early [4–5]. The HEMOMAS consensus document suggests that transfusion protocols in MH should work with an alarm system established in the haemotherapy commissions of each hospital, as a multidisciplinary consensual protocol, regularly analyzing its efficacy and safety [6].

 The MHPs were designed to focus primarily on the polytraumatized patient, without considering another type of cause of MH [7–8]. It is not yet clear whether the same protocol can be used in patients with HM regardless of the cause.

In an effort to standardise the care of patients with perioperative haemorrhage, in our hospital we have developed the “Massive haemorrhage protocol of the Hospital Universitario Canarias” which was approved by the Hospital Transfusions Committee. This is based above all on the recommendations of the HEMOMAS document and the European Guide for the management of severe haemorrhages and coagulopathy in trauma patients.

This protocol is based on the early administration of blood products with a 3: 3: 1 ratio (red-blood cells, fresh frozen plasma, and platelet), damage control, restrictive fluid resuscitation and coagulation monitoring [9]. Its objectives are to reduce variability in clinical practice, try to prevent and treat coagulopathy associated with massive bleeding and ensure a safe supply of blood products.

Methods

Study Population

Patients were recruited between January 2015 and January 2017.

A prospective observational descriptive study was conducted to evaluate the safety and effectiveness of the implementation of an MHP in a third level, hospital. This protocol was approved by the Ethics and Clinical Research Committee of the Hospital Universitario de Canarias.

 The study was conducted following the standards of good clinical practice for trials with medical products in the European Community and the Declaration of Helsinki on medical research involving human subjects. Registration was completed at ClinicalTrials.gov (NCT03074890).

All MH patients undergoing any elective or emergency surgical procedure were included, 34 in total. Exclusion criteria were patients under 18 years of age, patients with congenital or acquired coagulation factor deficiencies and congenital platelet aggregation disorders. All patients received information from the study and gave their written consent.

Patients were intervened and treated by the specialist physicians in charge at the time of the MH. The study population was divided into 2 groups based on whether or not the MHP was implemented. MHP group: patients on whom the protocol was activated. Non-MHP group: patients who were transfused with no protocol guidance.

Massive haemorrhage protocol

Massive haemorrhage was identified with one or more of the following criteria: (1) replacement of whole blood volume in a 24-h period (7% of ideal body weight in adults); (2) replacement of 50% of blood volume in a 3-h period or (3) blood loss ≥ 150 mL/min for 10 consecutive minutes.

HP is summarized in Figure 1.

JCRM 2018-115 - Venesa Gonzalez Spain_F1

The activation of MHP was the responsibility of the anaesthesiologist or the emergency team.

Once the protocol was activated, 3 packed red-blood cells (RBC), 3 packed fresh frozen plasma (FFP) and one packed unit of platelet (PLT) were administered. At the same time, factors related to lethal triad (hypothermia and acidosis), hydroelectrolytic alterations were corrected and the cause of bleeding was treated while the appropriate complementary tests were performed. In addition, 2 g of tranexamic acid was administered to stabilise the clot, and 2 g of fibrinogen was added to give it quality. Prothrombin complexes were administered to generate thrombin. Laboratory results were not awaited to begin transfusion. If after all this the bleeding continued, more RBC, FFP and other packed PLT were transfused and an ampoule of calcium plus cryoprecipitates was added. If the bleeding persisted, activated Factor VII was administered at a dose of 60–90 mcg/kg.

In our hospital we do not have viscolastic tests (thromboelastometry/thromboelastography) for clinical decision making within MHP.

The implementation of MHP required the multidisciplinary cooperation of several Hospital Services (Anaesthesiology, Haematology and Intensive Care).

Doppler echocardiography of supra-aortic trunks and central venous accesses was performed to assess thrombotic phenomena in patients who received a massive transfusion in the first 48–72 hours.

Study end points

The primary objective of the study was to evaluate the safety and effectiveness of newly implemented MHP for surgical patients with traumatic and non-traumatic MH.

Secondary objectives included determining mortality at 30 days, comparing outcomes between patients who received transfusion of blood products according to MHP and those who did not, and assessing the incidence of adverse reactions with high rates of blood products.

Statistical Analyses

A descriptive statistic was performed for all variables included in the data collection notebook.

Qualitative variables were expressed with absolute frequencies and percentages and quantitative and ordinal variables with means and standard deviations. Proportion comparisons were made with Fisher’s chi-square or exact tests, as appropriate. Comparisons of two groups in quantitative and ordinal variables were made with Mann-Whitney tests; comparisons of groups controlling for confounding variables were made with ANOVA, as appropriate. Probability values below 0.05 were considered significant. Analyses were performed with the SPSS statistical package version 17.0 (IBM SPSS, Chicago, IL, USA).

Data were expressed in frequencies and percentages for categorical variables, and in means with their 95% confidence intervals for numerical variables.

Demographic data (age, sex, weight, height, and ASA) were compared among the target groups to confirm their homogeneity.

Results

Patient characteristics

We recruited a total of 34 patients with MH who underwent surgical procedures. 20 of them (59%) received blood products according to the MHP and the remaining 14 (41%) according to the criteria of the anestheologist in charge.

The mean age of the MHP group was 55 ± 19 years, while in the non-MHP group 57 ± 18 years. No statistically significant differences were observed in the demographic and clinical data, nor in the laboratory results carried out prior to the intervention, being both groups homogeneous and comparable to each other.

Table 1 describes the basic characteristics of the patients.

Table 1. Baseline characteristics of patients with massive hemorrhage. (n = 34).

Variable

MHP Group
(n = 20)

Non-MHP Group
(n = 14)

P

Age (years)

55 ± 19

57 ± 18

0,83

Sex (males)— n (%)

12(60)

9(64)

1,0

BMI (kg/m2)

26 ± 4

28 ± 5

0,57

ASA— n (%)

3,0 ± 1

2,67 ± 1

0,42

APACHE II

13 ± 6

13 ± 7

0,93

Antiplatelet Agents— n (%)

4(20)

4(26,7)

0,43

OAC— n (%)

5(25)

1(6,7)

0,2

Hepatopathology — n (%)

2(10)

0(0)

0,5

Haemoglobin (g/dL)

12,3 ± 2,2

10,8 ± 2,6

0,09

Platelet 103/mm3

120 ± 52

266 ± 163

0,98

pH

7,33 ± 0,12

7,37 ± 0,12

0,42

Lactic acid (mmol/L)

2,87 ± 4,6

1,42 ± 0,79

0,47

Base deficit (mmol/L)

-3,46 ± 4,74

-1,3 ± 3

0,4

PT (%)

87,8 ± 21,11

91 ± 13

0,9

INR

1,12 ± 0,32

1 ± 0,15

0,78

aPTT (seg)

35,74 ± 7,28

37,8 ± 3

0,72

Fibrinogen (mg/dL)

474 ± 162

515,8 ± 219

0,73

Variable values are denoted as mean ± standard deviation. aPTT = activated partial thromboplastin time: ASA: American Society of Anesthesiologists; BMI: body mass index; INR = international normalized ratio; OAC: oral anticoagulants; PT = prothrombin time.

Ninety-four percent of patients had non-traumatic MH and only 6% of patients had MH secondary to trauma (Table 2).

Cardiovascular surgery was the main cause of HM (35 and 13.3%), followed by abdominal surgery (20%).

Massive bleeding occurred during emergency surgery in 60% of subjects in the MHP group and 40% in the non-MHP group.

The estimated intraoperative bleeding was similar in both groups. In the MHP group there was an estimated mean bleeding of 2640 ± 1467 mL, and in the non-MHP group of 2090 ± 866 mL.

Table 2. Intraoperative period variables

MHP Group
(n = 20)

Non-MHP Group
 (n = 14)

 P

Patient type— n (%)

0,1

Trauma surgery

0(0)

2(13,3)

Orthopedics surgery

1(5)

1(6,7)

Abdominal surgery

4(20)

3(20)

Vascular surgery

4(20)

0(0)

Cardiovascular surgery

7(35)

2(13,3)

Other surgeries

4(20)

7(46,7)

Type of intervention — n (%)

0,24

 Elective surgery

8(40)

9(60)

 Urgent surgery

12(60)

6(40)

Intraoperative estimated bleeding (mL)

2640 ± 1467

2090 ± 866

0,24

pRBC (units)

4 ± 2

3 ± 1

0,18

pFPP (units)

3 ± 2

1 ± 1

0,1

pPLT (units)

0,7 ± 0,6

0,3 ± 0,6

0,18

Fibrinogen (g)

1,5 ± 0,9

0,9 ± 1,2

0,07

TXA (g)

2,5 ± 1

1,6 ± 1

0,03

PCC (UI)

900 ± 911

333 ± 523

0,07

Cryoprecipitate (UI)

0

0

1,0

rFVII (µg)

0

0

1,0

pH

7,25 ± 0,13

7,32 ± 0,04

0,07

Lactic acid (mmol/L)

5,24 ± 6

4,27 ± 8,62

0,25

Variable values are denoted as mean ± standard deviation. pRBC: packed red-blood cells; pFFP: packed fresh frozen plasma; pPLT: packed platelets; rFVII: recom- binant factor VII; PCC: prothrombin complex concentrate; Lactic acid (mmol/L); TXA: tranexamic acid.

The ratio of RBC: FPP transfused was higher in the MHP group than in the non-MHP group with a ratio of approximately 3: 3. vs. 3: 1 respectively.

Compared to the non-MHP group, the MHP group received more RBC (4 vs. 3 units, p = 0.18) more FPP (3 vs. 1 units, p = 0.1) and more platelets (0.7 ± 0.6 vs. 0.3 ± 0.6, p = 0.18). However, the differences in the 3 parameters were not statistically significant.

The MHP group received more TXA (2.5 ± 1 vs 1.6 ± 1 grams, p = 0.03), more fibrinogen (1.45 ± 0.88 vs 0.87 ± 1.2 p = 0.07) and more PCC (900 ± 911 vs 333 ± 523, p = 0.07), being statistically significant with TXA. Cryoprecipitates and activated factor VII were not administered in any of the groups.

Lactic acid increased to similar numbers in the intraoperative period in both groups (5.2 ± 6 vs 4.2 ± 8, p = 0.25).

During the immediate postoperative period, bleeding stopped in 85% of patients in the MHP group and in 86% in the non-MHP group. Bleeding measured in the first 24 hours was higher in the MHP group than in the non-MHP group, almost doubling in the latter group.

In terms of the amount of blood products and haemostatic drugs administered in the 48 post-operative hours, more tranexamic, fibrinogen and CCP were administered in the MHP group with statistical significance (p<0.05). More FPP, cryoprecipitate, rFVII and blood retrieval processes were also administered, but without reaching statistical significance. The number of RBC and PLT units was similar in both groups. This data is shown in table 3.

Three patients had to be re-operated in the postoperative period, all of them belonging to the MHP group. But only one of them was caused by bleeding, specifically pericardial tamponade. The other reasons for reintervention were a compartment syndrome and a left

Table 3. Haemoderivatives and hemostatic drugs administered postoperatively at 48 h.

MHP Group

(n = 20)

Non-MHP Group

(n = 14)

 P

pRBC (units)

5,5 ± 4,3

5,7 ± 2,2

0,29

pFPP (units)

4,6 ± 4,3

2,4 ± 2,9

0,1

PLT (units)

1,0 ± 1,0

0,9 ± 1,8

0,25

TXA (g)

2,7 ± 1,0

0,9 ± 1,2

0,007

Fibrinogen (g)

2,0 ± 0,5

0,9 ± 1,3

0,006

PCC (UI)

2,6 ± 1,9

0,7 ± 1,0

0,004

Cryoprecipitate (UI)

1,0 ± 3,2

0

0,6

rFVII (µg)

526 ± 1611

0

0,6

Stop bleeding — n (%)

17(85)

12 (86)

0,36

Blood recuperator for autotransfusion (ml)

3,3 ± 6,4

0

0,2

Estimated bleeding
24 h (mL)

541 ± 550

286 ± 181

0,18

Need for reintervention due to bleeding — n (%)

1(5,3)

0(0)

1,0

Variable values are denoted as mean ± standard deviation. pRBC: packed red-blood cells; pFFP: packed fresh frozen plasma; pPLT: packed platelets; TXA: tranexamic acid; PCC: prothrombin complex concéntrate; rFVII: recombinant factor VII.

Postoperative analytical variables at 24 and 48 hours are shown in table 4. Haemoglobin in the 24-hour postoperative was quite similar in both groups (9.5 ± 2 g/dL in the MPH group, and 10 ± 1 g/dL in the non-MHP group), as well as haematocrit (28% ± 5 for the first and 30% ± 4 for the second) and platelets (132 ± 114 103/mm3 and 162 ± 76 103/mm3 respectively). The same happened with some variables that measured coagulation (PT, INR, aPTT), while fibrinogen was lower in the MHP group (296 ± 170 mg/dL in relation to 401 ± 214 mg/dL) and the highest D-dimer (10316 ± 22311 ng/dL in relation to 7760 ± 11368ng/dL). The pH value was similar in both groups (MHP: 7.29 ± 0.11; non-MPH: 7.28 ± 0.07).

In the post-operative period at 48 hours, the numbers of platelets, fibrinogen, PT, INR and aPTT were quite similar in terms of mean and standard deviation.

Haemoglobin at 48 hours in the MHP group was significantly higher than in the non-MHP group, with an average of 9.61 and 8.46 g/dL respectively (p = 0.04). Hematocrit figures were also higher in the MHP group (28.85 vs 25.47%, p = 0.03).

However, the lactic acid figures were higher in the MHP group, with a mean of 4 ± 4 being approximately 3 ± 2 in the non-MHP group; and the base deficit was lower in the MHP group (–6 ± 4) compared to the non-MHP group (–5 ± 4). However, these figures were not statistically significant either.

Table 4. Postoperative analyzes at 24 and 48 hours.

24 h

48 h

MHP Group

(n = 20)

Non-MHP Group

(n = 14)

P

MHP Group

(n = 20)

Non-MHP Group

(n = 14)

P

Haemoglobin (g/dL)

9,5 ± 2,0

10 ± 1,5

0,2

9,6 ± 1,4

8,5 ± 0,8

0,04

Hematocrit (%)

28,3 ± 5,6

30,5 ± 4,6

0,18

28,8 ± 4,4

25,5 ± 2,7

0,03

PLT (103/mm3)

132 ± 114

162 ± 76

0,1

128 ± 56

142 ± 76

0,7

PT (%)

77 ± 20

84 ± 13

0,36

83 ± 24

93 ± 11

0,3

INR

1,25 ± 0,4

1,1 ± 1,6

0,36

1,22 ± 0,5

1,0 ± 1,3

0,2

aPTT (secs)

44,2 ± 22,5

33,8 ± 9,1

0,14

32,4 ± 4,8

31,0 ± 4,8

0,3

Fibrinogen (mg/dL)

296 ± 170

400 ± 214

0,08

603 ± 178

663 ± 183

0,5

D dimer (ng/dL)

10316 ± 22311

7759 ± 11368

1,0

1741 ± 1589

3088 ± 3836

0,9

pH

7,29 ± 0,11

7,28 ± 0,07

0,61

7,37 ± 0,06

7,35 ± 0,08

0,7

Lactic acid (mmol/L)

4,4 ± 3,9

2,7 ± 1,8

0,11

2,3 ± 2,2

2,3 ± 4,1

0,2

Base Deficit (mmol/L)

-5,2 ± 3,9

-6 ± 3,9

0,4

-1,65 ± 3,66

-3,4 ± 3,33

0,1

CPK-NAC (U/L)

359 ± 361

645 ± 468

0,09

3233 ± 7554

1944 ± 2183

0,7

Variable values are denoted as mean ± standard deviation. aPTT = activated partial thromboplastin time; CPK-NAC = creatine kinase INR = international normalized ratiol; PLT: Platelets; PT = prothrombin time.

Once the protocol was implemented only 15% of patients reached phase 2, 75% reached phase 3 , and 10% reached phase 5 (Graph 1).

JCRM 2018-115 - Venesa Gonzalez Spain_F2

Figure 1. Adherence to MHP

Table 5 describes minor and major bleeding events (decrease in Hb > 2 g/dL or requiring reintervention for bleeding). Major (26% vs 7%; p = 0.2) and minor (32% vs 13%, p = 0.2) bleeding events were more frequent in the MHP group without statistical significance.

The presence of thrombotic episodes was assessed by clinical and doppler ultrasound. Doppler ultrasound was only possible for 11 patients (55%) in the MPH group and 9 (64%) in the non-MHP group. In the MPH group, none of the patients showed thrombosis, while in the non-MHP group, 5 (35%) showed thrombotic symptoms (supra-aortic trunk thrombosis in one patient, and central venous access thrombosis in 3). However, despite these percentage differences, there were no significant differences.

Table 6 describes adverse effects and complications that may be related to mass transfusion (Table 6).

Non-immunological reactions occurred in 100% of patients in the non-MHP group and in 95% of patients in the MHP group. Among these the most frequent were thrombocytopenia (80% in the MHP group versus 47% in the non-MHP group; p = <0.04), hypocalcemia (85% and 93% respectively), and acidosis (65% and 73%).

Infectious complications occurred in 2 patients in the MHP group (pneumonia) and in a single patient in the non-MHP group (tracheobronchitis after 10 days).

Immunological reactions occurred in 10% of patients in the MHP group and in 20% of patients in the non-MHP group. And in all cases the reaction was lung injury, specifically transfusion-related acute lung injury or TRALI.

Table 5. Haemorrhage and thrombotic events

MHP Group
(n = 20)

Non-MHP Group
(n = 14)

P

Minor hemorrhagic — n (%)

6(32)

2(13)

0,2

Major hemorrhagic — n (%)

5(26)

1(7)

0,2

Doppler echocardiography— n (%)

11(55)

9(60)

0,76

Thrombosis SAT— n (%)

0(0)

2(14)

0,2

Central venous access thrombosis — n (%)

0(0)

3(21)

0,74

TVP— n (%)

0(0)

0(0)

Pulmonary embolism — n (%)

0(0)

0(0)

TIA— n (%)

0(0)

0(0)

AMI— n (%)

0(0)

0(0)

Variable values are denoted as mean ± standard deviation. AMI = acute myocardial infarction; SAT = supraaortic trunk thrombosis ; TIA: transient ischemic attak; TVP = Deep venous thrombosis.

Table 6. Complications and adverse effects of the patients with massive haemorrhage

MHP Group

(n = 20)

Non-MHP Group

(n = 20)

 P

Non-immunological reactions — n (%)

19(95)

14(100)

1,0

Hypothermia — n (%)

6 (30)

5(33)

1,0

Coagulopathy— n (%)

7(35)

1(6,7)

0,1

Thrombocytopenia — n (%)

16(80)

7(47)

0,04

Acidosis— n (%)

13(65)

11(73)

0,72

Hypocalcemia— n (%)

17(85)

14(93)

0,62

Hyperkalemia— n (%)

2(10)

0(0)

0,5

TACO— n (%)

10(50)

5(33)

0,32

Infections— n (%)

2(10)

1(6,7)

1,0

Immunological reactions— n (%)

2(10)

3(20)

0,63

Hemolytic reactions— n (%)

0(0)

0(0)

1

Allergic reactions— n (%)

0(0)

0(0)

1

Pulmonary injury— n (%)

2(10)

3(20)

0,63

TRALI— n (%)

2(10)

3(20)

0,63

TACO: Transfusion Associated Circulatory Overload; TRALI: Transfusion Related Acute Lung Injury).

Table 7 shows mortality at 30 days and its etiology in both groups. In the MHP group there were more deaths, 40% (n = 8) of patients, while in the non-MHP group 21% (n = 3) of patients died (p = 0.3). Only 10% (n = 2) of patients in the MHP group died from haemorrhagic causes, compared to 7% (n = 1) in the non-MHP group. The main cause of mortality in the MHP group was multiorgan failure in 20% (n = 4) of patients, and septic shock of abdominal origin secondary to dehiscence of anastomosis in 10% (n = 2). While in the non-MHP group the causes of non-hemorrhagic mortality (14%) were heart failure and massive cerebral infarction.

Table 7. Overall mortality at 30 days of patients with massive haemorrhage

Variable

MHP Group
(n = 20)

Non-MHP Group
(n = 14)

P

Mortality at 30 days — n (%)

8 (40)

3 (21)

0,3

Cause of death — n (%)

0,6

 Haemorrhage

2(10)

1(7)

 Organ failure

4(20)

0 (0)

 Other

2(10)

2(14)

Hospital lenght of stay (days)

16 ± 16

22 ± 22

0,3

Variable values are denoted as mean ± standard deviation.

Discussion

The implementation of MHP in our hospital did not imply a consumption decrease of blood products. Moreover, there was a non-significant increase in the use of FFP in the MPH patients (3 units vs 1 units); there was no difference in the number of units administered of pRBC (4 units vs 3 units) and pPLT (0.7 units vs 0.3 units) between the two groups.

The average number of pRBC transfusions administered during the 48 post-operative hours was similar in both groups (5.5 units vs. 5.7 units), as was the amount of pPLT (1 units vs. 0.9 units); while the number of FFP was higher in the MHP group (4.6 units vs. 2.9 units).

An increase in haemostatic drug administration was observed in the MHP group. The amount of TXA administered was significantly higher in the MPH group (2.5 grams vs 1.6 grams), as well as the administration of fibrinogen (1.5 grams vs 0.9 grams) and PCC (2.6 IU vs 0.7).

Regarding the use of activated FVII, there was an increase in its use in the postoperative period with the implementation of the protocol, but it was only administered to 2 patients in the MHP group.

The application of the protocol was not associated with a higher incidence of adverse effects or complications related to massive transfusion, or even the eventual appearance of thrombotic phenomena associated with the increased administration of haemostatic drugs in the MHP group. However, and contrary to expectations, our results show an increase in the appearance of these phenomena in patients in the non-MHP group.

There was no decrease in postoperative bleeding after implementation of MHP. There was also no decrease in haemorrhagic events, both minor (32% vs 13%) and major (26% vs 7%).

There was no higher incidence of immunological reactions in the MHP group, but lower. There was also no increase in non-immunological reactions, which occurred as well in a lower percentage in the MHP group.

We did not find a decrease in mortality in MHP patients (40% vs. 21%). The publications on this subject are very variable, but there is agreement with other authors [10–13].

Adherence to the MHP as a whole was poor, largely due to difficulties in modifying “traditional” empirical therapeutic strategies. There was greater compliance in the initial phases of the protocol (including haemoderivatives, fibrinogen and prothrombinic complex) than in the final phases (cryoprecipitate and FVIIa). However, there were no significant differences in the cessation of bleeding in the first 24 hours between the groups.

In this study we observed a non-significant decrease in hospital stay in patients who followed MHP (16 days vs. 22 days), which has also been seen in other studies [14–15].

The main limitations of this study include the relatively small sample size, and the relatively low protocol adherence rate. In addition, the study was not randomised, so there is a possibility that the MHP tended to be activated for more severe patients.

Given the limitation of sample size and heterogeneity in the etiology and development of bleeding, we cannot conclude that there are significant differences in mortality between the two groups

Conclusions

Although the application of the protocol has not led to a decrease in the mortality rate, this does not differ from that reported in the literature and given the limitation of sample size and heterogeneity in the etiology and development of bleeding, we cannot conclude that there are significant differences in mortality between the two groups.

We could also consider it safe even though there was an increase in the administration of procoagulant factors since it was not associated with a higher incidence of adverse effects and complications related to mass transfusion.

The absence of viscoelastic tests could have influenced this increased consumption of procoagulant factor.

References

  1. Hardy JF, de Moerloose P, Samama CM (2005) The coagulopathy of massive transfusion. Vox Sang. 89: 123–7 [Crossref]
  2. Ferrara A, MacArthur JD, Wright HK, Modlin IM, McMillen MA (1990) Hypothermia and acidosis worsen coagulopathy in the patient requiring massive transfusion. Am J Surg. 160: 515–8. [Crossref]
  3. Fernández-Hinojosa, F. Murillo-Cabezas, A. Puppo-Moreno, S.R. Leal-Noval (2012) “Treatment alternatives in massive hemorrhage”, Med Intensiva 36: 496–503. [Crossref]
  4. Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, Sebesta J, Jenkins D, Wade CE, Holcomb JB (2007) “The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital”. J Trauma 63: 805–813. [Crossref]
  5. Holcomb JB, Jenkins D, Rhee P, et al. (2007) “Damage control resuscitation: directly addressing the early coagulopathy of trauma”. J Trauma. 62: 307–310. [Crossref]
  6. Llau JV, Acosta FJ, Escolar G, Fernández-Mondéjar E, Guasch E, Marco P et al. (2015)  Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document). Med Intensiva 39: 483–504. [Crossref]
  7. National Blood Authority (NBA). (2011) “Patient Blood Management Guidelines: Module 1”. Critical Bleeding /Massive Transfusion. Canberra, Australia: NBA;
  8. Goodnough LT, Levy JH, Murphy MF (2013) Concepts of blood transfusion in adults. Lancet. 381 (9880): 1845–1854. [Crossref]
  9. Holcomb JB, Fox EE, Zhang X, et al. (2013) PROMMTT Study Group. “Cryoprecipitate use in the PROMMTT study”. J Trauma Acute Care Surg 75(Suppl 1): S31- [Crossref]
  10. Greer SE, Rhynhart KK, Gupta R, Corwin HL (2010) “New developments in massive transfusion in trauma”. Current opinion in anaesthesiology 23: 2 246–50. [Crossref]
  11. O’Keeffe T, Refaai M, Tchorz K, Forestner JE, Sarode R (2008) “A massive transfusion protocol to decrease blood component use and costs”. Arch Surg. 143: 686–90, discussion: 90–1. [Crossref]
  12. Snyder CW, Weinberg JA, McGwin G, et al. (2009) “The relationship of blood product ratio to mortality: Survival benefit or survival bias?” J Trauma. 66: 358–362. [Crossref]
  13. Magnotti LJ, Zarzaur BL, Fischer PE, Williams RF, Myers AL, Bradburn EH, Fabian TC, Croce MA (2011) “Improved survival after hemostatic resuscitation: does the emperor have no clothes?”. J Trauma 70: 97–102. [Crossref]
  14. Sirat Khan, Shubha Allard, Anne Weaver, Colin Barber, Ross Davenport, Karim Brohi (2013) “A major haemorrhage protocol improves the delivery of blood component therapy and reduces waste in trauma massive transfusion”. Mayo vol 44, Issue 5,pages 587–592. [Crossref]
  15. Cotton BA, Au BK, Nunez TC, et al. (2009) “Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications”. J Trauma 66: 41–9. [Crossref]

Does flooring-type change the gait characteristics of the older adult? Analysis of balance and temporal-spatial gait parameters and ground reaction force

DOI: 10.31038/ASMHS.2018234

Abstract

Introduction: Slips, trips and loss of balance were the major causes of fall in older adult. The study aimed to compare the balance, temporal-spatial gait parameters and ground reaction forces of compliant, rubber and standard flooring.

Materials and Methods: Sixty-four healthy, elderly people were assessed between July 2016 and December 2017. Eight optoelectronic cameras were used to measure the centers of mass (COM) of the body during gait: the velocity, the lowest position, and medio-lateral and vertical COM displacements. We also compared the temporal-spatial gait parameters, vertical ground reaction force (GRF), and anterior-posterior GRF of the three flooring types.

Results: The step widths of the gait on the compliant and rubber floorings were significantly narrower than that of the standard flooring (p = 0.005 and 0.032, respectively). The COM velocity of the compliant flooring was higher than that of the rubber flooring (p = 0.03). There were no differences in the lowest COM positions, or in the medio-lateral and vertical COM displacements. There were significant increases in the peak posterior and anterior GRFs for the standard flooring with comparison to the compliant and rubber floorings (p < 0.001).

Conclusion: Compared with the rubber and standard flooring, the compliant flooring displayed no differences in balance and stability for older adult people in both the vertical and antero-posterior planes. For both legs, there was less vertical GRF at the toe-off phase and less anterior-posterior GRF with the compliant flooring. The selected compliant flooring may be a safe instrument that can be used to adjust the environmental factor in order to prevent falls.

Trial registration number TCTR2018–0211001, approved for registration at TCTR since 2018-02-06; and retrospectively registered.

Keywords

Flooring type, gait characteristics, balance, temporal-spatial gait parameters, ground reaction force, elderly

Introduction

A fall is an unintentional loss of balance, causing unprepared contact with the ground or the floor. Approximately 28%–35% of people aged 65 or over fall each year [1–3], with the figure increasing to 32%–42% for those over 70 [4–6]. The frequency of falls increases with age and frailty level. Assantachai et al. found that the overall prevalence of falls among elderly Thais in urban areas was 19.8% over a six-month period [7]. Falls and their consequential injuries are major public health problems that often require medical attention. The fall fatality rate varies, depending on the country or the culture of the population.

Many factors are considered to increase the risk of falls. Environmental factors are one of the four major risks of falls (biological, behavioral, socioeconomic, and environmental) identified in a WHO global report [8]. Compliant flooring was introduced with the aim of reducing the risk of falls among the older adult. A recent scoping review protocol suggested that compliant flooring would reduce the incidence of fallrelated injuries [9, 10]. Although some studies have demonstrated that compliant flooring may increase the risk of falls by older adults [11], other studies did not find evidence in support of that finding [12, 13]. From biomechanical efficacy records, compliant flooring may reduce the fallrelated impact forces with a minimal effect on standing and walking balance [10]. However, the safety and balance effects when walking on compliant flooring compared with on rubber or standard flooring have not yet been documented. For this reason, it was decided to study the dynamics of balance, temporalspatial gait parameters, and ground reaction forces of specific compliant flooring compared with rubber and standard flooring for healthy, older adult people.

Materials and methods

Study design

An experimental design was conducted with the approval of the Institutional Review Board of our hospital. It was approved for registration at the Thai Clinical Trials Registry (http://www.clinicaltrials.in.th; registration number TCTR20180211001). This experimental design followed the TIDieR checklist (Additional file 1) [14].

Participants

Sixty-four older adult people were recruited for this study. Prior to its commencement, all participants read an information sheet and signed an informed consent form that had been approved by the Human Research Protection Unit of our hospital. Patients who refused to participate or who had any discomfort during the study were able to withdraw. The inclusion criteria were participants aged 60 years or older between July 2016 and December 2017. The study included healthy, the older adult people who had not had any falls in the year preceding the study, and who did not have any walking problems. Excluded were patients who had bone disease, muscular disease, pain anywhere on their body that exceeded a score of 4 on a 10-point VAS (visual analogue scale) pain scale and affected their walking pattern, or a history of lower extremity surgery in the 6 months prior to the study. The results of this study will be released to the healthcare community. Datasets or statistical codes will not be made public. The results of the study will be disseminated to study participants by means of lectures given by the investigators.

Intervention

Compliant flooring

This study used a multilayered flooring (10 m long, 2 m wide, and 0.003 m deep), with a stiffness of 19.17 kN/m. After studying the test methods used to measure the shock absorption properties of indoor-sports flooring materials, we designed our own protocol (the “ball bounce method”) to compare the relative shock absorption of the tested materials. With that method, a solid metal ball (stainless steel; 5 cm diameter) weighing 258 g is dropped from a height of 200 cm onto a 20 cm × 20 cm piece of tested material that has been securely installed on a concrete floor. The rebound height is simultaneously recorded using a video camera (10 MP, 60 fps), and 3 repetitions are averaged.

The selected compliant flooring (Figure 1), the Unix Ultimate Oak (SCG Cement-Building Materials, BK, THA), http://www.sjsourcing.com/products?id=4, can absorb a force of around 30% with a coefficient of restitution (COR) of 0.83 [15, 16]. The comparison flooring in this study was rubber flooring (Figure 1) with a COR of 0.92 and standard flooring (a rigid force plate) (Figure 2).

ASMHS 2018-105 - Phob Ganokroj Thailand_F6

Figure 1. (A) Front view of the 29 reflective markers that were applied on the body. Patients was standing on the compliant flooring. (B) Back view of the patients with the reflective markers. Patients was standing on the rubber flooring.

ASMHS 2018-105 - Phob Ganokroj Thailand_F7

Figure 2. The rigid force plate and the standard flooring type

Protocol

Eight optoelectronic cameras (Motion Analysis Corp., Santa Rosa, CA, USA) were used to record three-dimensional kinematic data at a sampling rate of 200 Hz. Twenty-nine reflective markers were placed bilaterally on anatomical landmarks, as illustrated at Figure 1. This enabled the construction of 12 segments to fully estimate the body center of mass (COM) [17]. Two force platforms (ATMI, Watertown, MA, USA), used to measure the ground reaction force at a sampling rate of 1600 Hz, were synchronized with the motion analysis cameras. Data relating to the participants walking on the three types of flooring were collected. All participants were conducted at our motion analysis laboratory facility.

Participants walked on a 10-meter walkway of each flooring at a self-comfortable speed; the walk was repeated 5 times for each flooring type. A successful trial was defined as one in which all parts of the foot contacted the force platform surface during each step, and in which no marker fell off during data collection. The study measurement was conducted by PG who was the sports medicine orthopedics doctor and PK who was specialized in motion gait analysis.

Data analysis

Kinematic data were filtered using a Butterworth low-pass filter with a cut-off frequency of 6 Hz [18]. Orthotrak software, version 6.6 (Motion Analysis Corp., Santa Rosa, CA, USA) was used to analyze the temporal-spatial gait parameters of gait velocity, step width, and step length. The gait velocity was defined as the speed of the center of mass in a forward direction. Step width was determined by the distance between the ankles’ joint centers in a medio-lateral line. Step length was defined as the heel-marker distance between one foot as it contacted the ground, and the other foot as it touched the ground at the same instant of time.

Cortex software, version 3.1 (Motion Analysis Corp., Santa Rosa, CA, USA) was used to analyze the dynamic balance while walking, as indicated by the displacement of the COM in the vertical and medio-lateral directions. The vertical COM displacement was represented by the difference between the maximum COM position and the minimum, or lowest, COM position in the vertical direction. The mediolateral COM displacement was the maximum COM position minus the minimum COM position in the medio-lateral direction [19].

The ground reaction forces (GRF) in the vertical and antero-posterior directions were analyzed using the Orthotrak software. The characteristics of the following gait events were examined: 1) when the foot contacted the ground in the loading response phase (vertical GRF exceeded 30 N); 2) when the vertical GRF was at its first peak in the loading response phase; 3) when the vertical GRF was at its second peak in the terminal stance phase; and 4) at the toe-off phase. Leg dominance was determined using this self-reported question: “If you kicked a ball at a target, which leg would you use to kick the ball?” [20].

Sample size estimation

G* Power, version 3.1, [21] was used to determine the adequate sample size. The estimated sample size was calculated based on the primary outcome, the COM displacement, using a one-way repeated measures ANOVA. It was decided to arbitrarily select a moderate treatment effect. To detect the effect size (Cohen f = 0.175) with an 0.7 correlation among 3 repeated measures, 90% power of test and a 5% type I error, a minimum of 42 participants were needed for this study.

Statistical analysis

All Statistical analysis were performed using SPSS Statistics for Windows, version 18.0 (SPSS Inc., Chicago, IL, USA). Firstly, data were evaluated for normality using Shapiro–Wilk’s test and a histogram plot with a normal curve. Descriptive statistics were used to summarize the demographic data and motion analysis measurements, including the temporal-spatial gait parameters. The mean and standard deviation (mean ± SD) were calculated for the quantitative variables, while absolute frequency and percentage were determined for the categorical variables. One-way repeated measures ANOVA was used to establish the differences in the gait characteristics and GRFs of the three flooring conditions. Bonferroni’s test was employed for a post-hoc analysis. The dominant and non-dominant legs were analyzed separately to avoid producing a bimodal distribution influencing normality. The statistically significant level was set at 0.05.

Results

There were 64 elderly people (38 females and 26 males), with a mean age of 67.2 ± 4.4 years, a mean weight of 56.0 ± 9.6 kg, and a mean height of 158.0 ± 8.0 cm.

Temporal-spatial parameters

The temporal-spatial parameters during walking on the three flooring types are in Table 1. The step width of the compliant and rubber flooring were significantly narrower than that of the standard flooring (p = 0.005 and 0.032, respectively; Figure 3A). The step length (non-dominant leg) while walking on the rubber flooring was significantly shorter than that for the compliant and standard flooring (p < 0.001 and 0.035, respectively; Figure. 3B). The gait velocity and step length of the dominant leg were not significantly different for the three flooring types.

ASMHS 2018-105 - Phob Ganokroj Thailand_F1

Figure 3. Comparison between flooring types of step width and length (non-dominant leg):
Comparison between flooring types using Bonferroni’s test. (A) for step width and (B) for step length of the non-dominant leg (error bar = 95% CI for mean). (cm) The blue bar is for compliant flooring, the red bar for rubber flooring and the green bar for standard flooring. The statistically significant level was set at 0.05.

Table 1. Temporalspatial parameters of walking on the compliant, rubber and standard flooring.

Variable

Compliant flooring
(Mean ± SD)

Rubber flooring
(Mean ± SD)

Standard flooring
(Mean ± SD)

P-value

Step width (cm)

9.65 ± 3.09#1

9.89 ± 2.98#2

10.22 ± 3.09#1,#2

0.002

Velocity of dominant leg (cm/s)

108.74 ± 11.78

107.18 ± 12.72

108.68 ± 14.31

0.207

Velocity of non-dominant leg (cm/s)

108.63 ± 11.61

106.93 ± 12.61

108.51 ± 14.38

0.145

Step length of dominant leg (cm)

57.82 ± 4.96

57.16 ± 5.12

56.99 ± 5.29

0.100

Step length of non-dominant leg (cm)

58.54 ± 5.14#3

57.47 ± 5.41#2

58.32 ± 5.65#2, #3

<0.001

#1 Standard flooring VS Compliant flooring
#2 Standard flooring VS Rubber flooring
#3 Compliant flooring VS Rubber flooring

Center of mass movement

The center of mass movement defined the dynamic balance of the patients. The movement of the COM variables during walking on the three flooring types are in Table 2. Although the COM velocity of the compliant flooring was significantly higher than that for the rubber flooring, with 108.64 and 106.74 cm/s, respectively (p = 0.03;
Figure 4), it was not significantly different to that for the standard flooring. There were no differences in the minimum positions of the COM, the medio-lateral displacements, and the COM vertical displacements of the three flooring types.

Table 2. Movement of the center of mass variables.

Variable

Compliant flooring
(Mean ± SD)

Rubber flooring
(Mean ± SD)

Standard flooring
(Mean ± SD)

P-value

COM velocity (cm/s)

108.64 ± 11.65 #3

106.74 ± 12.65 #3

108.36 ± 14.33

0.040

COM minimum position (cm)

79.76 ± 11.30

79.97 ± 11.14

74.74 ± 22.34

0.066

COM medio–lateral displacement (cm)

3.38 ± 1.30

3.43 ± 1.23

3.18 ± 1.68

0.132

COM vertical displacement (cm)

2.45 ± 0.59

2.37 ± 0.57

2.34 ± 0.89

0.212

COM = center of mass
#1 Standard flooring VS Compliant flooring
#2 Standard flooring VS Rubber flooring
#3 Compliant flooring VS Rubber flooring

ASMHS 2018-105 - Phob Ganokroj Thailand_F2

Figure 4. Comparison between flooring types of COM velocity.
Comparison between flooring types using Bonferroni’s test for center of mass (COM) velocity (error bar = 95% CI for mean). (cm/s) The blue bar is for compliant flooring, the red bar for rubber flooring and the green bar for standard flooring. The statistically significant level was set at 0.05.

Vertical ground reaction force

The vertical ground reaction force (VGRF) of both the dominant and non-dominant legs walking on the three flooring types are in Table 3. There was a reduction in the VGRF at the toe-off phase to the compliant and rubber flooring compared to the standard flooring for both the dominant and non-dominant legs (p = 0.005 and < 0.001, respectively; Figure 5). There were no differences in the VGRFs at the initial contact, loading response (first peak) and the second peak VGRF while walking on the three flooring types (Figure 6).

ASMHS 2018-105 - Phob Ganokroj Thailand_F3

Figure 5.
Comparison between flooring types of VGRF (toe-off phase).
Comparison between flooring types using Bonferroni’s test for vertical ground reaction force (GRF) at toe-off phase (error bar = 95% CI for mean). (N/kg) The blue bar is for compliant flooring, the red bar for rubber flooring and the green bar for standard flooring. The statistically significant level was set at 0.05.

ASMHS 2018-105 - Phob Ganokroj Thailand_F5

Figure 6. VGRF of the three flooring types:
Vertical ground reaction force (GRF) of the gait cycle for the three flooring types for the non-dominant leg (A) and the dominant leg (B). (N/kg) The blue line is for compliant flooring, the red line for rubber flooring and the green line for standard flooring.

Anterior-posterior ground reaction force

The anterior-posterior ground reaction force (APGRF) of both legs while walking on the three flooring types are in Table 4. There was a significant increase in the peak posterior GRF for the standard flooring compared with the compliant and the rubber flooring, with p < 0.001 for both the dominant and non-dominant legs. As for the peak anterior GRF, there was also a significant increase for the standard flooring compared with that for the rubber and compliant flooring (Figure 7).

ASMHS 2018-105 - Phob Ganokroj Thailand_F4

Figure 7. Anterior and posterior GRFs of the three flooring types:
Anterior and posterior ground reaction forces (GRFs) of the gait cycle for the three flooring types for the non-dominant leg (A) and the dominant leg (B). (N/kg) The blue line is for compliant flooring, the red line for rubber flooring and the green line for standard flooring.

Table 3. Vertical ground reaction force of both legs.

Leg side

Event

Compliant flooring
(Mean ± SD)

Rubber flooring
(Mean ± SD)

Standard flooring
(Mean ± SD)

P-value

Nondominant leg

Initial contact (N/kg)

0.033 ± 0.008

0.034 ± 0.008

0.033 ± 0.009

0.339

Loading response (N/kg)

(First peak VGRF)

1.079 ± 0.075

1.070 ± 0.075

1.077 ± 0.081

0.091

Terminal stance (N/kg)

(Second peak VGRF)

1.100 ± 0.062

1.098 ± 0.067

1.103 ± 0.066

0.546

Toe off (N/kg)

0.083 ± 0.036 #1

0.080 ± 0.039

0.114 ± 0.059 #1

<0.001

Dominant leg

Initial contact (N/kg)

0.033 ± 0.008

0.034 ± 0.008

0.034 ± 0.008

0.802

Loading response (N/kg)

(First peak VGRF)

1.064 ± 0.066

1.058 ± 0.066

1.065 ± 0.067

0.237

Terminal stance (N/kg)

(Second peak VGRF)

1.102 ± 0.058

1.101 ± 0.062

1.102 ± 0.062

0.774

Toe off (N/kg)

0.085 ± 0.047 #1

0.092 ± 0.051 #1

0.108 ± 0.055 #1,#2

0.005

VGRF = vertical ground reaction force
#1 Standard flooring VS Compliant flooring
#2 Standard flooring VS Rubber flooring
#3 Compliant flooring VS Rubber flooring

Table 4. Anteriorposterior ground reaction force of both legs.

Leg side

Event

Compliant flooring
(Mean ± SD)

Rubber flooring
(Mean ± SD)

Standard flooring
(Mean ± SD)

P-value

Nondominant leg

Peak posterior (N/kg)
(Loading response)

-0.13 ± 0.02 #1,#3

-0.12 ± 0.02 #2,#3

-0.15 ± 0.03 #1,#2,#3

<0.001

Peak anterior (N/kg)
(Terminal stance)

0.17 ± 0.02 #1

0.16 ± 0.02 #2

0.17 ± 0.02 #1,#2

<0.001

Dominant leg

Peak posterior (N/kg)
(Loading response)

-0.13 ± 0.02 #1

-0.12 ± 0.02 #2

-0.16 ± 0.03 #1,#2

<0.001

Peak anterior (N/kg) (Terminal stance)

0.16 ± 0.02 #3

0.16 ± 0.02 #2,#3

0.17 ± 0.03 #2

<0.001

#1 Standard flooring VS Compliant flooring
#2 Standard flooring VS Rubber flooring
#3 Compliant flooring VS Rubber flooring

Discussion

Dynamic stability can be threatened by various travel surface changes, especially in the case of compliant surfaces. Adapting locomotor movements to the different types of surface encountered in daily life is essential. Many elderly people experience balance impairment, which is one of the major risks of falls [22–24]. With advancing age, there is a generalized reduction in visual function, which has been associated with impaired postural stability and an increased risk of falls.

Lord and Menz demonstrated that walking on a compliant surface increases the risk of falls by the elderly [25]. The vertical COM is decreased when stepping onto a compliant surface [26]. This adaptation of lowering the vertical COM peak provides a more stable posture. The lowering of the COM can also be seen in response to locomotion on a slippery surface in order to prevent a threat to instability [27]. However, the medio-lateral COM does not change when walking on a compliant surface [28]. The dynamic stability margin in the anterior–posterior direction demonstrates a constant overcompensation and subsequent correction of COM control. A scoping review of biomechanical efficacy found that the overall participants were able to maintain static and dynamic balance on carpet and on purpose-designed, novel compliant flooring (NCF) [10]. The present study also showed no statistically significant differences in the COM minimum positions, COM medio-lateral displacements, and COM vertical displacements of the three flooring types (p > 0.05). This may suggest good active regulation of the COM in both the frontal and sagittal plane while walking on both the compliant and the rubber flooring. Thus, the selected compliant flooring may not influence the balance and stability of elderly people in the vertical and horizontal planes.

There are 4 categories of compliant flooring: 1) thick vinyl; 2) carpet with no underlay; 3) NCF with no underlay or overlay; and 4) combination flooring [10]. In our study, the selected compliant flooring was categorized as a combination flooring with some shock-absorption properties. The rubber flooring was categorized as an NCF with no underlay or overlay. Consequently, the authors chose a rigid force for the standard flooring as the control group and aimed to compare it with different compliant flooring categories (categories 3 and 4). The authors found that there was more COM velocity with the compliant flooring than with the rubber flooring, but those velocities were not significantly different to that of the standard flooring. The results of this study indicate that there were no differences in the COM medio-lateral and vertical displacements of the three flooring types.

With increasing age, adults typically take shorter and wider steps [29]. Older people usually have more difficulty than younger adults maintaining balance while walking on irregular or uneven surfaces. Older people tend to adopt a more conservative walking pattern, characterized by a slower walking velocity and shorter steps to ensure trunk stability and maintain a stable gaze [30–32]. MacLellan and Patla found that step width and length increased on a medium-density foam surface [28]. These adaptations increase the base of support and provide better control of the COM. The results of the present study demonstrated that the step widths on the compliant and rubber flooring were significantly narrower than that on the standard flooring. However, there were no statistically significant differences in the step lengths of the dominant leg on the three flooring types. The step length of the non-dominant leg on the rubber flooring was shorter than that on the selected compliant flooring and the standard flooring. The gait velocity and the COM velocity of the compliant flooring were also not significantly different to those of the standard flooring. It can therefore be concluded that no conservative walking pattern was demonstrated on the rubber flooring and the compliant flooring.

Walking on an uneven terrain is more energetically costly than walking on smooth ground. Voloshina et al. found an increase in the hip- and knee-joint muscle activities and work performance on an uneven surface relative to a smooth surface [33]. MacLellan and Patla also found an increase in gastrocnemius and soleus activity during push-off, accounting for the increases in step length seen on the compliant surface in the current study [28]. The present study found that the vertical GRFs for the three flooring types were not statistically different for both legs for the three events of initial contact, loading response and terminal stance. However, in the toe off phase, there were lower vertical GRFs on the compliant flooring and rubber flooring than on the standard flooring, which may be the result of their superior shock-absorption properties. The horizontal force had a negative phase during the first half of the stance, indicating the presence of a backward, horizontal, frictional force acting between the ground and the foot. This force may prevent an individual from slipping while walking on a slippery floor [34]. In addition, this study found that there were higher peak posterior and anterior GRFs on the standard flooring than on the compliant and rubber flooring for both legs. The lower the posterior GRF, the more slippery an event may be. However, the differences in the values were very small (0.01–0.04 N/kg), which would not have a significant clinical impact.

The major strength of this study is that it included a large number of participants to detect statistically significant levels of difference. The authors studied the selected compliant flooring and compared the results with those of the rubber and the standard flooring (the rigid force plate, which represented the common residential flooring type).

However, the study also had several limitations. Firstly, the gait speed was not controlled as we considered that doing so might influence gait parameters such as step width, step length, or velocity. However, with a self-comfortable speed, patients could walk with a more natural pattern without needing to be concerned about their pace. Secondly, all participants were healthy, older people who did not have any walking problems. Therefore, we do not know the effect of the compliant or the rubber flooring on the balance and other gait parameters of younger people or on patients who have some walking difficulties. There was some gender difference of the data (38 females and 26 males). A gender population controlled should be considered in our future study. Thirdly, there was a limitation in the arrangement of the force plate during the walking tests. Having a number of force plates placed consecutively over the full length of the walking route instead of having only 2 plates placed centrally would have allowed us to collect force data during consecutive steps and therefore to analyze simultaneous work. Finally, we selected one popular compliant flooring, however, it may not represent all other compliant floorings.

Conclusion

In conclusion, the compliant flooring demonstrated no differences from the rubber and standard flooring in terms of balance and stability for elderly people in both the vertical and anteroposterior axes. For both legs, there were lower vertical GRFs at the toe-off phase and lower anterior-posterior GRFs for the compliant and rubber flooring than for the standard flooring. The selected compliant flooring may be a safe flooring that can be used to adjust the environmental factor in order to reduce the risk of falls by the elderly.

Acknowledgements

This work was supported by SCG Cement-Building Materials Co., Ltd. The authors gratefully acknowledge Miss Suchitphon Chanchoo for data collection and statistical analysis, Miss Waraporn Chalermsuk for manuscript preparation, and Mr. David Park for thoroughly proofreading the manuscript.

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Serum 25-hydroxyvitamin D and Osteocalcin Levels and Insulin Sensitivity in Young Women

DOI: 10.31038/EDMJ.2018241

Abstract

Introduction

Vitamin D and osteocalcin have been reported to affect insulin secretion and sensitivity in the elderly. This study aimed to investigate whether the levels of 25-hydroxyvitamin D [25(OH)D] and osteocalcin were associated with insulin sensitivity in young Korean women.

Methods

One hundred and twenty-eight healthy women (16–38 yrs) were recruited and divided into obese (BMI ≥ 25 kg/m2) and non-obese (BMI < 25 kg/m2) groups according to their body mass index (BMI). The serum 25(OH)D level was measured by radioimmunoassay, total osteocalcin was measured by electrochemiluminescence immunoassay, and carboxylated osteocalcin was measured by enzyme immunoassay. The standard 75-g oral glucose tolerance test was performed, and the metabolic clearance rate was calculated as an index of insulin sensitivity: [MCR = 18.8 – (0.271 × BMI) – (0.0052 × Insulin120) – (0.27 × Glucose90)].

Results

The median levels of 25(OH)D were below 20 ng/ml in both obese and non-obese subjects. Obese women had higher serum 25(OH)D (P < 0.01) levels, but the total and carboxylated osteocalcin levels did not differ between the two groups (P > 0.05). Multiple linear regression analysis showed that 25(OH)D was significantly negatively associated with the MCR after adjustment for age, total osteocalcin, and carboxylated osteocalcin (β = -0.333, P < 0.01).

Conclusion

Most of the participants had vitamin D deficiency. A low vitamin D level interferes with conclusions regarding the relationship between osteocalcin and metabolic parameters. Further prospective studies will be needed to confirm the different effects of vitamin D/osteocalcin on insulin sensitivity according to age.

Keywords

25-hydroxyvitamin D; Osteocalcin; Insulin sensitivity

Introduction

Most Koreans have low levels of 25-hydroxyvitamin D [25(OH)D] and a high prevalence of vitamin D insufficiency. The prevalence of vitamin D insufficiency is higher in young adults than in elderly people [1]. Additionally, the prevalence of type 2 diabetes mellitus is rapidly rising. Low insulin sensitivity is associated with type 2 diabetes mellitus [2]. Vitamin D and osteocalcin have been reported to affect insulin secretion and insulin sensitivity [3,4]. Vitamin D deficiency has been associated with impaired insulin secretion in humans and in animal models [5]. The concentration of 25(OH)D was lower in patients with type 2 diabetes mellitus than in nondiabetic controls [6].

Total osteocalcin is synthesized by osteoblasts and undergoes a posttranslational vitamin K-dependent modification in which 3 glutamic acid residues are carboxylated. Total osteocalcin and carboxylated osteocalcin synthesis are directly regulated by 1, 25-dihydroxyvitamin D and parathyroid hormone [7]. In animal models, osteocalcin-deficient mice have obesity, hyperglycemia, glucose intolerance, and insulin sensitivity [4,8]. In humans, serum total osteocalcin is inversely associated with measures of insulin sensitivity and fat mass [3]. In a cross-sectional study of nondiabetic older adults, elevated carboxylated osteocalcin is associated with lower insulin sensitivity [7].

However, increasing numbers of studies have suggested that there is ambiguity and inconsistency between the rodent studies and results in humans. Few studies have confirmed a link between energy metabolism of the adipose tissue and skeleton. There have been multiple studies in young and normoglycemic populations, even in Asians reporting the lack of a relationship or ambiguity between vitamin D/osteocalcin and insulin sensitivity [9–13]. Furthermore, the interaction between vitamin D and insulin sensitivity in the general population has not been adequately determined. Many previous studies on the association of vitamin D/osteocalcin and insulin sensitivity were performed in older adults [6,7]. Therefore, we aimed to evaluate whether a low vitamin D status was associated with insulin sensitivity in young Korean women.

Methods

We performed a survey to identify genetic markers for polycystic ovary syndrome in the Korean population [14]. Subjects were excluded if they had been on medication which had effect on calcium metabolism and vitamin D levels, such as calcium, vitamin D, and anticonvulsant drugs or if they had a condition causing malabsorption of nutrients such as inflammatory bowel disease. Subjects who had been diagnosed with type 2 diabetes mellitus or who had any missing data due to the inadequate sample volume were excluded. Finally, of 2000 women under 40 years of age who voluntarily participated in the survey between 2008 and 2010, we enrolled 128 healthy young women. Throughout the year, we invited volunteers to visit our hospital on the morning after an overnight fast of at least 8 h. Based on their Body Mass Index (BMI), subjects were divided into two groups. The BMI was categorized as < 25 kg/m2 or ≥ 25 kg/m2, which was suggested as the cut-off point for obesity in Asian populations [15]. Written informed consent was obtained from all participants or their parents if the participants were younger than 18 years of age. The institutional review board of Ewha Womans University Mokdong Hospital approved this study.

Height, weight, and waist circumference were measured. The waist circumference was measured on bare skin at the narrowest indentation between the 10th rib and iliac crest at midrespiration. BMI, defined as body weight in kilograms divided by the square of height in meters (kg/m2), was used as an index of obesity. The blood pressure was calculated as the mean of two manual sphygmomanometer readings with the patient in the seated position.

We stored the frozen serum samples, which were drawn after overnight fasting, at −80°C until analysis and instantly kept the frozen serum sample at -20°C for measurement. The serum 25(OH)D was measured by radioimmunoassay (Parkard, CA, USA), and the mean inter- and intraassay coefficients of variation (CV) were 7.3% and 8.1%, respectively. Total osteocalcin was measured using an electrochemiluminescence immunoassay (Roche, MA, USA), and the mean inter- and intraassay CVs were 1.5% and 0.7%, respectively. Carboxylated osteocalcin was measured by enzyme immunoassay (Takara Bio, Shiga, Japan), and the mean inter- and intraassay CVs were 1.4% and 3.7%, respectively. The 75-g oral glucose tolerance test (OGTT) was performed in the morning after an 8-hr overnight fast. Blood for measuring the insulin and glucose levels was collected at 0, 30, 60, 90, 120 minutes. Glucose levels were measured by the glucose oxidase method (Beckman Model Glucose Analyzer 2, CA, USA), and insulin levels were measured by radioimmunoassay (BioSource, Nivelles, Belgium). The homeostasis model assessment-estimated insulin resistance (HOMA-IR) index was calculated as the product of the fasting insulin level (mIU/L) and fasting glucose level (mg/dL) divided by 405. The metabolic clearance rate (MCR) was calculated as an index of insulin sensitivity by the Stumvoll Method: [MCR (mL/kg·min) = 18.8 – (0.271 × BMI) – (0.0052 × Insulin120) – (0.27 × Glucose90)] [16].

The statistical analyses were performed using SPSS 18.0 software package for Windows (IBM Corporation, Chicago, IL, USA). Because 25(OH)D, total osteocalcin, carboxylated osteocalcin, and MCR had a markedly skewed distribution, logarithmic transformation of these values was performed before regression analysis. Quantitative variables were reported as the means ± standard deviations. Variables with a skewed deviation were reported with medians and interquartile ranges. Two groups with different parameters were compared using Student’s t test or Mann-Whitney U test, depending on the data distribution. To investigate the association of the serum 25(OH)D, total osteocalcin, and carboxylated osteocalcin with insulin sensitivity, multiple linear regression analyses were performed. The considered covariates were age, total osteocalcin, and carboxylated osteocalcin. Statistical significance was defined as P < 0.05.

Results

Table 1 shows the clinical characteristics of the subjects. Age was comparable between obese and non-obese women. The mean BMI (P < 0.01), waist circumference (P < 0.01), systolic blood pressure (P < 0.01), diastolic blood pressure (P < 0.01), and 2-hour post-load glucose (P < 0.01) were higher in obese women than in non-obese women. The MCR was significantly lower, and fasting plasma insulin and HOMA-IR were higher in obese women than in non-obese women (Ps < 0.01, Table 1).

Table 2 shows the bone metabolism parameters of subjects according to BMI. Obese women had higher serum 25(OH)D (P < 0.01) levels; however, the total and carboxylated osteocalcin levels did not differ between the two groups (P > 0.05). The median 25(OH)D levels were below 20 ng/ml in both obese and non-obese subjects (Table 2).

Multiple linear regression analysis showed that 25(OH)D was negatively associated with MCR (β = -0.333, P < 0.01) and positively associated with the 2-hour post-load glucose (β = 0.254, P < 0.01) after adjusting for age, total osteocalcin, and carboxylated osteocalcin (Table 3).

Discussion

In this study, the 25(OH)D levels were low in both obese and non-obese subjects. Most of the participants had vitamin D deficiency. Obese women had higher serum 25(OH)D levels. The total and carboxylated osteocalcin levels did not differ between the two groups. Additionally, a higher 25(OH)D level was negatively associated with insulin sensitivity.

Vitamin D is acquired through diet and cutaneous synthesis in sunlight. It is called vitamin D3 (cholecalciferol) after its formation in the skin and vitamin D2 or D3 when obtained from dietary sources that undergo hydroxylation in the liver, resulting in formation of 25(OH)D, the chief circulating form of vitamin D [17].

In contrast to previous reports [6,18], a higher 25(OH)D level was negatively associated with insulin sensitivity in this study. Hypovitaminosis D has long been suspected as a risk factor for glucose intolerance [19]. Vitamin D status has been inversely associated with diabetes mellitus in epidemiological studies [5,20]. Several clinical intervention studies support that vitamin D supplementation may affect glucose homeostasis or insulin sensitivity [21,22]. Significant improvements in the FPG, insulin, and homeostasis model assessment-insulin sensitivity after treatment with vitamin D were reported in a study of 100 patients with type 2 diabetes mellitus who were between 30 to 70 years old [22]. A potential explanation for the association between a low 25(OH)D level and impaired glucose tolerance has focused on the direct effects of vitamin D on pancreatic ß-cell insulin secretion. Vitamin-D receptors and vitamin D-binding proteins are known to exist in pancreatic tissues. In in vitro studies, 1, 25-dihydroxyvitamin D3, the active form of vitamin D, induced increased transcription and protein expression of insulin receptors [23].

Table 1. Clinical characteristics of the subjects

Total subjects
(n = 128)

Non-obese
(n = 74)

Obese
(n = 54)

P value

Age (years)

25 ± 4

25 ± 3

25 ± 5

0.620

BMI (kg/m2)

22.6 ± 4.3

19.2 ± 0.7

27.3 ± 2.3

<0.001

Waist circumference (cm)

76.4 ± 11.2

68.3 ± 4.7

87.4 ± 7.4

<0.001

Systolic BP (mmHg)

109 ± 11

104 ± 9

115 ± 11

<0.001

Diastolic BP (mmHg)

71 ± 9

68 ± 8

75 ± 9

<0.001

FPG (mg/dl)

84 ± 8

84 ± 9

85 ± 7

0.240

2-h PPG (mg/dl)

102 ± 23

96 ± 22

111 ± 21

<0.001

FPI (U/ml)

7.6 (5.8, 10.2)

7.3 (6.0, 9.0)

9.6 (5.4, 15.3)

0.005a

2-h PPI (U/ml)

36.6 (19.5, 68.1)

35.8 (22.3, 66.7)

38.0 (13.4, 92.4)

0.948a

MCR (mL/kg∙min)

9.6 (8.3, 10.7)

10.6 (9.6, 11.3)

8.3 (5.4, 9.2)

<0.001a

HOMA-IR

1.5 (1.2, 2.2)

1.4 (1.2, 1.8)

2.1 (1.1, 3.2)

0.004a

Plus-minus values indicate the means ± SD.
Values before parentheses are medians, and values in parentheses are interquartile ranges.
P values were calculated with the Mann-Whitney U test.
P values, non-obese subjects vs obese subjects.
Non-obese: BMI < 25 kg/m2
Obese: BMI ≧ 25 kg/m2
BMI: Body Mass Index
BP: Blood Pressure
FPG: Fasting Plasma Glucose;
2-h PPG: 2-hour Post-Load Glucose
FPI: Fasting Plasma Insulin
2-h PPI: 2-hour Post-Load Insulin
MCR: Metabolic Clearance Rate
HOMA-IR: Homeostasis Model Assessment-Estimated Insulin Resistance

Table 2. Bone metabolism parameters of the subjects

Total subjects

(n = 128)

Non-obese

(n = 74)

Obese

(n = 54)

P value

25(OH)D (ng/ml)

16.1 (13.6, 19.0)

15.5 (12.4, 18.0)

17.0 (14.9, 22.6)

0.002

Carboxylated osteocalcin (ng/ml)

6.4 (3.7, 9.3)

5.9 (3.3, 8.5)

6.9 (4.2, 9.9)

0.186

Total osteocalcin (ng/ml)

15.9 (13.4, 18.9)

16.3 (14.0, 19.7)

15.2 (12.5, 18.5)

0.189

Values before parentheses are medians, and values in parentheses are interquartile ranges.
P values were calculated with the Mann-Whitney U test
P values, non-obese subjects vs obese subjects
Non-obese: BMI < 25 kg/m2
Obese: BMI ≧ 25 kg/m2
25(OH)D: 25-hydroxyvitamin D

Table 3. Association of bone metabolism parameters and insulin sensitivity indices

FPG

2-h PPG

HOMA-IR

MCR

Standardized coefficients

(beta)

P value

Standardized coefficients

(beta)

P value

Standardized coefficients

(beta)

P value

Standardized coefficients

(beta)

P value

Age

0.160

0.097

0.160

0.086

-0.038

0.697

0.247

0.007

25(OH)D

-0.046

0.607

0.254

0.004

-0.005

0.952

-0.333

<0.001

Total osteocalcin

-0.081

0.410

-0.002

0.987

-0.096

0.331

-0.043

0.640

Carboxylated osteocalcin

0.020

0.847

0.165

0.101

0.131

0.212

0.061

0.533

FPG: Fasting Plasma Glucose
2-h PPG: 2-hour post-load glucose
HOMA-IR: The Homeostasis Model Assessment-Estimated Insulin Resistance
MCR: Metabolic Clearance Rate
25(OH)D: 25-hydroxyvitamin D

The MCR, 25(OH)D, total osteocalcin, and carboxylated osteocalcin were analyzed after log transformation.

In this study, obese women had higher levels of serum 25(OH)D. This is not consistent with the associations reported in previous studies. In the Korea Third National Health and Nutrition Examination Survey of 8,421 men and women, an inverse association between the 25(OH)D level and metabolic syndrome risk, particularly for abdominal obesity, was reported [24]. Obese individuals have low concentrations of 25(OH)D [25]. In a large cohort of 302 healthy adults in the USA, the serum 25(OH)D level was negatively correlated with the BMI and body fat mass [26]. Sequestration of vitamin D in body-fat stores and its consequent reduced bioavailability have been suggested as an explanation for this association [27].

Risk factors for hypovitaminosis D include older age, female sex, lower latitude, winter season, and darker skin pigmentation as well as factors that determine sunlight exposure, such as clothing, cultural practices, and dietary habits. In Canada, young women of Asian and African descent had lower levels of vitamin D than white Canadian women. Additionally, in Australia, Middle Eastern and Asian immigrants had lower vitamin D levels than white Australian and European women [28]. These studies indicate that ethnic differences play a role in the circulating level of serum vitamin D. The sunlight exposure time is different according to the time of year. When we adjusted the sampling time of year because the subjects in our study had a low vitamin D status, there was no effect of the difference of the sampling time on the results. Therefore, the difference in the sampling time may not affect the vitamin D levels in our study.

In general, older age has been suggested as a risk factor for vitamin D insufficiency because cutaneous synthesis of vitamin D3 declines with age [29]. However, in Korea and Canada, vitamin D insufficiency is more prevalent among young adults than in the older population [1]. In the Korea National Health and Nutrition Examination Survey from 2008, the serum 25(OH)D level increased with age in those between 20–29 and 60–69 years of age in both sexes, and vitamin D insufficiency was most prevalent in the 20–29 age group. These observations may be due to behavioral factors, including an indoor lifestyle, sunscreen use, outdoor activity, and dietary habits [29]. It is unclear why the associations between 25(OH)D and insulin sensitivity and between 25(OH)D and obesity in this study were different from the results of previous reports. Ethnic differences and low vitamin D status in our subjects may provide an explanation for the different relationship of 25(OH)D.

Contrary to the associations seen in previous studies, the total osteocalcin levels did not differ between the obese and non-obese women in this study. As previously described in detail [30], total osteocalcin is the most abundant noncollagenous protein of the bone matrix, and it has been used as a marker of bone formation. Carboxylated Gla residues are related to calcium and hydroxyapatite binding, allowing for deposition of total osteocalcin in mineralized bone matrix. Uncarboxylated osteocalcin is more easily released into the circulation; however, both the carboxylated and uncarboxylated forms can be detected in blood.

A study in elderly Swedish men showed that the plasma total osteocalcin was a strong negative predictor of fat mass and plasma glucose [31]. Additionally, in the investigation of postmenopausal women, the serum total osteocalcin levels were shown to have a statistically significant negative- correlation with BMI [32]. Total osteocalcin was particularly inversely related to visceral obesity in Korean obese and overweight men [33]. Additionally, the relationship between vitamin D/osteocalcin and insulin sensitivity was weak in young adults [9–12].

The serum total osteocalcin level was significantly negatively correlated with FPG and Hemoglobin A1c in both men and postmenopausal women with type 2 diabetes mellitus [34,35]. Additionally, hyperglycemia influences the response of osteoblasts to parathyroid hormone and 1, 25-dihydroxyvitamin D [36]. In animal models, chronic hyperglycemia decreased total osteocalcin [37]. Circulating levels of total osteocalcin were lower in animals on a high-fat diet, with a larger reduction in those that were under-expressing the insulin receptor [38]. In some studies, the serum total osteocalcin level had no correlation with insulin sensitivity [39,40]. Of note, the total or carboxylated osteocalcin levels were not associated with insulin sensitivity indices in our study.

In nondiabetic older adults, an elevated carboxylated osteocalcin level was associated with lower insulin sensitivity [7]. However, in the present study, carboxylated osteocalcin did not differ between the obese and non-obese groups. Levels of carboxylated and uncarboxylated osteocalcin are influenced by the vitamin K status, while the total circulating concentration of osteocalcin is independent of vitamin K [30]. Factors influencing the levels of carboxylated osteocalcin, such as the vitamin K status, should be considered in explaining the relationship of carboxylated osteocalcin with obesity and insulin sensitivity. In this study, the vitamin K status was not measured. The proportion of carboxylated osteocalcin was lower than in previous studies. The difference of the standardization of methods for measuring osteocalcin, sample stability or handling, and the biological variability may affect the levels of carboxylated osteocalcin. We used an enzyme immunoassay to measure carboxylated osteocalcin; however, a two-sited immunofluorometric assay was used in a previous study [12].

With this study population being limited to young Korean women, confounding factors affecting bone metabolism according to ethnicity and age could be controlled. However, there are some limitations in this study. First, due to the small sample size, generalization of the results is difficult. Therefore, additional research is necessary to determine the patterns in other age and ethnic groups. Second, measurements of physical activity were not made in this study. Comparison of this information between the obese and non-obese groups would be helpful to further understand the mechanism behind the differences in 25(OH)D status between the two young age groups. Finally, most subjects in this study had vitamin D deficiency [defined as 25(OH)D of less than 20 ng/ml, n = 102 (80%)] or insufficiency [25(OH)D from 20 to less than 30 ng/ml, n = 21 (16%)]. Considering that the obese group had only 9% (n = 5) with a sufficient 25(OH)D level, it was difficult to analyze the relationship between 25(OH)D and obesity. Additionally, other bone turnover markers and vitamin K statuses should be considered to confirm the status of bone turnover in these vitamin D-deficient subjects. The results may reflect overall bone formation because we did not measure other bone formation markers, especially the bone resorption markers.

Conclusion

In conclusion, the levels of 25(OH)D were low in our subjects. Unlike in previous reports, a higher 25(OH)D level was negatively associated with insulin sensitivity in young Korean women, suggesting that the low vitamin D levels interfere with conclusions on the relationship between osteocalcin and metabolic parameters. Further studies on subjects of different ages and a prospective study in young women of the same age will be needed to confirm the different effects of vitamin D/osteocalcin on insulin sensitivity according to age.

Acknowledgement

We appreciate Yoon Jeong Lee R.N. for her help in recruitment and testing of the subjects.

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Career Outcomes for STEM, Social and Behavioral Sciences and Education Doctoral Alumni

DOI: 10.31038/ASMHS.2018233

Abstract

Traditionally doctoral students are trained to pursue tenure-track positions in research-intensive institutions. However, a survey of 914 PhD alumni at a public research university in a diverse array of disciplines finds that students move across employment sectors over a 15-year period. This study used a three-tier taxonomy to classify both short- and long-term employment outcomes based on employment sector, career type and job sector for Science, Technology, Engineering and Mathematics (STEM) and Social and Behavioral Sciences and Education (SBSE) doctoral alumni. The study is unique in that demographic information such as race, gender and citizenship status and academic performance measures were examined to gain a deeper understanding of career trajectories. The findings indicate differing career paths based on demographic characteristics, but also finds there is no correlation between academic performance metrics such as GPA and GRE scores and job placements in academia or outside of academia. This has significant implications for doctoral training and suggests that graduate programs must prepare students for both academic and alternative careers, particularly as tenure-track positions and U.S. federal research dollars continue to shrink. This study also adds to a growing body of literature on the need for rigorous data collection, and transparency to help students make informed choices about PhD training and career pathways.

Keywords

Career outcomes, doctoral training, STEM, Social and Behavioral Sciences and Education

Introduction

Graduate study is a high-stress pursuit [1]. Some of this stress results from uncertainty about career outcomes. Academic institutions have traditionally trained and prepared doctoral students for a single career pathway: tenure-track faculty positions. However, today’s knowledge-based economy offers doctoral students rich and varied career options, and doctorate holders have the potential to contribute to a broad spectrum of the US workforce. In this paper, we use data from a 15-year survey of Ph.D. alumni from a comprehensive research university to document the diversity of career pathways pursued by PhD students in Science, Technology, Engineering and Mathematics (STEM) fields and in the Social and Behavioral Sciences and Education (SBSE). We separate our examination of STEM and SBSE alumni, as we suspect that the career paths of alumni in these broad disciplinary areas may differ. We also analyze how career outcomes change for different cohorts by age, and how they correlate with demographics and academic performance indicators. This study provides a better understanding of the career trajectories of doctoral alumni, which has significant implications for appropriate training and advising of Ph.D. students. This in turn may lead to higher rates of career satisfaction and well-being for individuals over the course of their careers. Institutional transparency about career outcomes can also encourage students to explore all available career tracks and mitigate some of the stress inherent in the pursuit of a doctoral degree.

New research shows that Ph.D. holders are increasingly migrating to non-academic sectors despite a persistent culture in academia that emphasizes the singular path to success as the professoriate at a research-intensive university. National data sources and the research literature underscore the shift away from academic careers in specific disciplines. For example, only 17.7% of PhDs (in science, engineering and heath disciplines) in 2015 had secured tenure-track positions within five years of receiving their degree. This compares to a 25.9% tenure track placement in 2006 and a 27% placement in 1993 [2]. Similarly, the National Science Foundation’s Survey of Earned Doctorates (SED) found that 50% of science, engineering and health discipline PhDs are engaged in careers outside of academia within 14 years of graduation [3]. Almost 75% of all biomedical doctoral alumni engage in careers beyond academia, including for-profit, government and non-profit sectors [4,5]. The shift is present, though perhaps less stark, in the Social and Behavioral Sciences. A study of 3000 Social Science graduates who earned their degrees in the United States between 1995 and 1999 found that 77% hoped to obtain tenure-track positions, but only 40% found such positions within a year of earning their degree [6].

The steady exodus away from careers in academia can be attributed in part to a declining number of faculty jobs [7]. It also reflects some students’ loss of interest in a lifetime career in academia as they progress through doctoral programs [8–11]. Students may reassess their opportunities for success in hyper-competitive environments, which place a premium on publications and grants. When students observe the life-work imbalances of their faculty advisers, long postdoctoral training periods, and meager salaries for academics at early stages of their careers, these factors may also contribute to student interest in alternative paths [8]. For these reasons, and because students move between employment sectors in the course of a career, it becomes incumbent upon graduate institutions to inform current and former students about a wide-range of career options [7, 10, 12–14].

The move towards transparency about PhD career outcomes has gained momentum in recent years [13, 15–17], yet, the use of divergent taxonomies prevented aggregation and identification of national trends [18–22]. A unified and replicable taxonomy for the biomedical sciences was developed in 2017 by several groups, including the National Institutes of Health Broadening Experiences in Scientific Training (NIH-BEST) grantee consortium, the Association of American Medical Colleges’ Graduate Research Education and Training (AAMC GREAT) group, and Rescuing Biomedical Research (RBR). The consortium proposed a common three-tier taxonomy to standardize PhD career outcomes classifications: Tier 1 includes five employment sectors; Tier 2 comprises five career types; and Tier 3 includes 26 job functions [23], as shown in S1 Appendix. This taxonomy is flexible enough to adapt to disciplines beyond biomedical sciences and was used to categorize the 914 alumni in this study.

In addition to improved data collection and transparency about Ph.D. career outcomes, new training models and professional development offerings are crucial to helping students make the transition to work environments and cultures outside academia [10, 12, 24, 25]. The research literature indicates that employers look for transferrable skills such as the ability to work in collaborative teams, strong communication and presentation skills, and project management experience. The literature calls on faculty mentors and the graduate training community to strongly encourage mentees to fully explore myriad career options during their graduate studies [26]. Some also suggest the use of professional nonacademic mentors and successful alumni to provide students with guidance throughout a graduate program [24].

Wayne State University (WSU) is a comprehensive research institution with an enrollment that includes 1,500 doctoral students in 75 doctoral programs. Our PhD alumni work as professors, lead research labs, own consulting firms, teach undergraduates and work in executive management in industry and government. Like other academic institutions, our training models have long been based on the assumption that students would pursue tenure-track faculty positions. To gain a granular understanding of career trajectories, the Graduate School launched the 2015 Alumni Census project to collect employment information of doctoral alumni who graduated over a 15-year window from 1999 to 2014 [18]. Analyzing longitudinal data provided us with a deeper understanding of how our alumnus navigate through the early and middle stages of their careers.

In addition to looking at career changes over time, our study also collected demographic information on doctoral alumni so that we could better understand how race, gender and citizenship status interact with career outcomes. We also examined key metrics associated with academic performance such as GRE scores, cumulative GPA and time-to-PhD degree completion. Traditionally, strong performance in these metrics was believed to be correlated with securing a tenure-track position at a research institution, while lower performers on these types of measures were perceived as accepting positions outside academia at a higher rate; jobs which have been traditionally viewed as less prestigious.

To provide a short- and long-term snapshot, we used the career of the alumnus at the time of the data collection and “binned” these data in aggregate for alumni based on number of years from graduation (0–5 years; 6–10 years; and 10–15 years post-graduation). These aggregated career outcomes data were then classified according to the unified three-tier taxonomy, and used to ask the following questions: (a) in which employment sectors, career types, and job functions are WSU’s alumni engaged; (b) is there a distinction between the types of careers pursued based on gender, race and U.S. citizenship status of alumni; and (c) is there a correlation of career outcomes with academic characteristics such as GRE scores, doctoral GPA, and time-to-PhD degree completion?

To our knowledge, this report is unique. It is the first published research to examine doctoral career paths along with the demographics and academic preparedness of alumni in STEM and SBSE. There exists an abundance of literature on STEM career outcomes; however there is less robust information on SBSE career trajectories. This study attempts to close some of those information gaps and shed light on what we anticipate are divergent pathways. Specifically, we assume that STEM alumni, particularly those in engineering, would pursue jobs in business and industry, while SBSE PhDs would follow more traditional paths securing teaching and research positions in academic settings.

Methods & Materials

Alumni Census Project

 In 2015 WSU’s Graduate School launched an Alumni Census Project in which the current employment information of 496 STEM and 418 SBSE doctoral alumni who graduated from 1999–2014 were collected, as previously described [18]. The departments included in this study and the numbers of alumni surveyed in each are described in Table 1. The information gathered included a direct survey of alumni to indicate their current job placement, as well as information gathered directly from graduate programs and graduate faculty. Alumni were also asked to answer a series of questions about their career trajectories, including information on their first placement, the length of time they have been with their current employer as well as their various job titles over time to provide a rich view of their career progression. The complete survey is in S2 Appendix. Self-reported employment data were validated using alumni institutional websites, federal funding agency and publication records, Google, LinkedIn, and other professional social media sites.

Table 1a. STEM Majors

Departments

College of Engineering

College of Liberal Arts & Sciences

Grand Total

Chemical Engineer & Materials Science

58

58

Civil & Environmental Engineering

24

24

Computer Science

4

74

78

Electrical & Computer Engineering

70

70

Engineering Dean

36

36

Industrial & Manufacturing Engineering

53

53

Mathematics

50

50

Mechanical Engineering

65

65

Physics & Astronomy

1

61

62

Grand Total

311

185

496

Table 1b. SBSE Majors

Departments

College of Education

College of Liberal Arts & Sciences

School of Business

School of Social Work

Grand Total

Administrative & Organizational Studies

54

54

Anthropology

12

12

Business Administration

5

5

Economics

38

38

Political Science

22

22

Psychology

197

197

Social Work

3

3

Sociology

34

34

Teacher Education

4

4

Theoretical & Behavioral Foundations

49

49

Grand Total

107

303

5

3

418

Ethical Approval

This project was conducted with approval from Wayne State University’s Institutional Review Board on the Use of Human Subjects, IRB#094013B3E.

Data Reporting and Visualization

All data are reported in aggregate or with identifiable information removed. Data in which a group is below 4% are not reported in order to maintain confidentiality and anonymity of the individual(s).

Demographic characteristics used in the study include gender (men and women); race (Asian, Black, White); and citizenship status (U.S. citizen/permanent resident or non-U.S. citizen). The 496 STEM alumni include 106 women (21.4%) and 390 men (78.6%); 291 Asian (58.7%), 188 White (37.9%) and 17 Black (3.4%) alumni; 119 U.S. citizens/permanent residents (24%) and 377 non-U.S. citizens (76%), as shown in Table 2a. The 418 SBSE alumni include 266 women (63.6%), 152 men (36.4%); 307 White (74.5%), 56 Black (13.6%), 49 Asian (11.9%); 353 U.S. citizens/permanent residents (84.4%), and 65 non-U.S. citizens (15.6%), as shown in Table 2b. Note that we report race data in only three categories because the number of alumni in other race categories falls below our 4% reporting threshold. This reduces the number of SBSE alumni included in analyses that consider race from 418 to 412.

Academic characteristics assessed were (a) GRE-Quantitative and GRE-Verbal scores submitted at the time of graduate admission; (b) cumulative GPA at doctoral graduation; and (c) time to doctoral degree completion. For our analysis, GRE Quantitative scores (GRE-Q) are shown in blocks of scores of 137–145, 146–155, 156–166. GRE-Verbal scores (GRE-V) are shown in blocks of scores of 130–145, 146–155, 156–170. Note that the GRE is not a requirement for admission to all programs at WSU, therefore the numbers in these analyses do not total 496 (for STEM) or 418 (for SBSE). Data are expressed as percent of alumni in each score/year range.

Cumulative GPA at time of doctoral graduation is grouped as blocks of 3.0–3.5 GPA, 3.51–3.75 GPA, 3.76–4.0 GPA; and Time-to-Degree completion (TTD) in blocks of 3.5–5.0, 5.1–6.0, 6.1–7, 7+ years. At WSU, average Time-to-Degree for STEM doctoral students is 6.1 years and 6.9 years for SBSE students.

As we examined our data, we realized that the distributions of alumni in each of the three tiers: Employment Sectors, Career Types and Job Functions, change over time. Since most of these changes were seen in 5 year windows, we have depicted all data in three 5 year windows to visualize employment shifts; i.e., Window 1 (0–5 years); Window 2 (6–10 years); and Window 3 (11–15 years) immediately following graduation. Note that in this manuscript, the trajectory of each alumnus over a 15-year time period is not reported. Rather, the overall alumni aggregate employment data are shown in each time window from years following graduation within each of the three tiers at the specific time of the survey.

Outcome analyses were performed using SPSS version 25 (IBM 2018). Chi-Squared (Χ2) analyses with follow-up z tests employing a Bonferroni correction were used to test for significantly different proportions of alumni in different Employment Sectors, Career Types, and Job Functions over time. Since time windows contained different sets of participants, between-subjects analyses were conducted. Multinomial logistic regression analyses were then conducted to test for significant interactions between time windows and demographic characteristics. Singularities in the Hessian matrix due to small sample sizes in some cells prevented valid multinomial analysis. Because of the Hessian matrix violations, Chi-Squared (Χ2) analyses were used to test for significantly different proportions of demographic groups within each tier. As with time windows, post hoc z tests with Bonferroni corrections were used to test for significant effects if the omnibus Chi-square test was significant. Differences among comparison groups were considered to be statistically significant at p < .05.

Table 2a. Gender, race, and citizenship status of 15-year STEM doctoral alumni (n = 496)

Women

Men

Asian

Black

White

US citizen or Permanent Resident

Non-US Citizen

Total (496)

106

390

291

17

188

119

377

Asian (291)

51

240

291

21

270

Black (17)

6

11

17

12

5

White (188)

49

139

188

86

102

US Citizen or Permanent Resident (119)

36

83

21

12

86

119

Non-US Citizen (377)

70

307

270

5

102

377

Table 2b. Gender, race, and citizenship status of 15-year SBSE doctoral alumni (n =418)

Women

Men

Asian

Black

White

US Citizen or Permanent Resident

Non-US Citizen

Total (418)*

266

152

49

56

307

353

152

Asian (49)

31

18

49

18

31

Black (56)

35

21

56

48

8

White (307)

195

112

307

281

26

US Citizen or Permanent Resident (353)

231

122

18

48

281

353

Non-US Citizen (65)

35

30

31

8

26

65

* Note that we report race data in only three categories because the number of alumni in other race categories fall below our 4% reporting threshold. This reduces the number of SBSE alumni included in analyses that consider race to 412 from 418.

In addition, we conducted multinomial logistic regression analyses to test for significant interactions between combinations of demographic characteristics (e.g., gender, race, and citizenship). However, singularities in the Hessian matrix due to small sample sizes in some cells prevented valid multinomial analysis. Chi-Squared (Χ2) analyses were also attempted to examine patterns of career outcomes in isolated subsets of alumni; however, small and n = 0 cell sizes for some categories resulted in uninterpretable results. Because the patterns of findings appear to be similar for these small groups, we decided to present analyses on each demographic variable (rather than combinations of variables) to yield robust results that could be used as a basis for future investigations. Thus, the analyses presented here focus on patterns of career outcomes within each demographic group for the entire 15-year window. Logistic regression analyses were used to test whether academic characteristics were associated with Employment Sector outcomes. Significance was determined with a p value < .05.

Results

15-year career outcomes of WSU’s STEM doctoral alumni

Figure 1 shows overall 15-year STEM doctoral alumni career outcomes. Data are presented by tier in three time windows that build from the center of the circle as follows: 0–5 years; 6–10 years; and 11–15 years. In our overall STEM alumni outcomes, not all employment sectors, career types and job functions were equally represented.

For employment sector (Tier 1), overall across the three time periods we found that STEM alumni were almost evenly split between careers in academia (47.2%) and the for profit sector (48.2%). Only a small percentage go on to work in government (4.2%) or nonprofit (.4%) sectors (Figure 1a).

Tier 2 (Career Type) shows that alumni engage in careers that are discipline related (46.2%), primarily research (23.8%), and primarily teaching (23.4%), with a small percent engaged in further training or education (4.2%) and others in careers not related to discipline (2.4%) (Figure 1b).

CST2018-117-MaryE.WoodUSA_Figure1

Figure 1. STEM Doctoral Alumni Career Outcomes by Tier

For Tier 3 we find that seven primary job functions describe the work of 87.3% of Wayne State’s STEM PhD alumni: faculty (tenured/tenure track) (31.9%), research group leader (16.9%), technical support/product development (13.3%), research staff or technical director (9.7%), and data science, analytics, and software engineering (7.3%), post-doctoral research (4.2%) business development, consulting and strategic alliances (4%) (Figure 1c). The remaining 12.7% of STEM alumni are engaged in other job functions which have fewer than 4% alumni in each.

STEM Demographic Characteristics and Employment Sector (Tier 1)

We analyzed the Tier 1-Employment Sector data as three windows of 5-years each to see if there were significant career shifts over time, or significant differences in career outcome by gender, race or U.S. citizenship status. We find that the pattern of employment sector for STEM alumni did not significantly change over time, Χ2 (6, N = 496) = 7.35, p = .29. However, there was a significant difference between men and women in terms of their sector of employment, Χ2 (3, N = 496) = 8.97, p = .03, with women more likely to hold academic jobs and men more likely to be employed in the for-profit sector, p < .05 (Figure 2).

CST2018-117-MaryE.WoodUSA_Figure2

Figure 2. Gender and Employment Sector of STEM Doctoral Alumni

There was also a significant effect of race on employment sector Χ2 (6, N = 496) = 19.91, p = .003. A higher proportion of Asians entered the for-profit sector as compared to Whites (p < .05). (Figure 3). There were no significant differences between U.S. citizen and non-U.S. citizen alumni in the STEM fields, Χ2 (3, N = 496) = 1.86, p = .60.

CST2018-117-MaryE.WoodUSA_Figure3

Figure 3.Race and Employment Sector of STEM Doctoral Alumni

STEM Demographic Characteristics and Career Type
(Tier 2)

We further analyzed the Tier 2- Career Type data as three windows of 5-years each for total alumni as well as by gender, race, and U.S. citizenship status. As with Tier 1, we find that for STEM alumni, the distribution of career types did not significantly change over time, Χ2 (, N = 496) = 12.15, p = .15. However, men and women differed in their career types, Χ2 (4, N = 496) = 11.64, p = .02. Significantly more women were in primarily teaching careers (p < .05), and more men in science-related careers (p < .05). (Figure 4). Racial group distributions were similar across Career Types, Χ2 (8, N = 496) = 6.96, p = .54. Career type was not associated with citizenship status, Χ2 (4, N = 496) = 2.3, p = .68.

CST2018-117-MaryE.WoodUSA_Figure4

Figure 4. Gender and Career Type of STEM Doctoral Alumni

STEM Demographics and Job Function (Tier 3)

We also analyzed the Tier 3- Job Function data in the same manner as described for employment sector and career type. For this Tier, we found significant changes in the proportions of alumni in different job functions across the different five-year time windows, Χ2 (8, N = 392) = 37.38, p = .0001. Specifically, the proportion of alumni in faculty jobs increased significantly from window 1 (0–5 years) to 2 (5–10 years) (p < .05). We believe this shift may reflect a transition where alumni shift from postdoctoral positions or other additional training to faculty positions. Similarly, the number of alumni in group leader (research) jobs increased significantly from window 1 (0–5 years) to 3 (10–15 years) (p < .05), whereas the proportion of STEM alumni in data science/technical support and product development jobs declined from window block 1 to 3 (p < .05). There was also a significant decrease in alumni in research staff or technical director jobs from Window 1 to 2 (p < .05) (Figure 1c). Again, these shifts can be viewed as part of the expected course of career advancement of Ph.D. holders.

A significant difference was also found between women and men with regard to job function (Figure 5). The significant Chi-square for gender, Χ2 (4, N = 392) = 17.58, p = .001 was accounted for by the fact that women were more likely to hold tenured/tenure track faculty jobs and men were more highly represented in group leader jobs (p < .05). (Figure 5). There were no significant racial group differences, Χ2 (8, N = 392) = 8.47, p = .39, or citizenship group differences Χ2 (4, N = 392) = 6.29, p = .18 in job functions.

CST2018-117-MaryE.WoodUSA_Figure5

Figure 5. Job Function of STEM Doctoral Alumni by Gender

STEM Academic performance indicators and employment sector

We also examined the association of academic characteristics with the two largest STEM employment sectors: “Academia” and “For-profit.” Participation in other sectors is too small to allow for meaningful comparisons.

There are no statistically significant differences in most of the academic performance indicators examined between alumni who end up in careers in academia as versus the for-profit sector. There is an equivalent spread of GRE-Quantitative scores, GRE-Verbal scores and cumulative GPA of alumni between these sectors (Figure 6). However, STEM alumni who took longer to complete their degrees were more likely to enter the for-profit sector, B = .165, SE = .049, Wald (df = 1) = 11.37, p = .001. A follow-up t-test showed that alumni in the academic sector completed their degrees, on average, in 5.68 years (SD = 1.68) whereas alumni in the for-profit sector completed their degrees, on average, in 6.33 years (SD = 2.30), t (471) = 14.88, p = .001.

CST2018-117-MaryE.WoodUSA_Figure6

Figure 6. STEM Doctoral Alumni Academic Performance Indicators and Employment Sector

15-year career outcomes of WSU’s SBSE doctoral alumni

SBSE alumni outcomes show not all employment sectors, career types, and job functions are equally represented. SBSE alumni data in Tiers 1, 2 and 3 across the three time windows (0–5 years; 6–10 years; and 11–15 years) is summarized (Figure 7).

In Tier 1, we found the majority of SBSE alumni are employed in academia (64.6%) and the for-profit sector (27.5%). The remaining 8.1% work in government (5.0%) and nonprofit (2.9%) sectors (Figure 7a). This is different from STEM alumni, for whom similar percentages worked in academia and the for-profit sector. Still, over a third of SBSE alumni move on to careers outside of academia. Tier-2 (Career Type) shows that alumni engage in careers that are discipline-related (39.2%) and primarily teaching (38.3%). Approximately 18.9% engage in careers that are primarily research and a small percentage in careers not related to their Ph.D. discipline (3.6%) (Figure 7b).

For Tier-3 (Job Functions), we find that seven primary job functions describe the work of 86.1% of WSU’s SBSE’s alumni: faculty tenure/tenure track (35.9%), healthcare provider (15.1%),  administration (11.2%), business development, consulting, and strategic alliances (6.7%), research staff or technical director (6.2%), full-time teaching staff/instructor (6.0%), part-time teaching staff/adjunct (5.0%) (Figure 7c). The remaining 13.9% of SBSE alumni are engaged in job functions that have fewer than 4% alumni in each.

Demographics Characteristics and Employment Sector (Tier 1)

Approximately 92.1% of SBSE alumni are engaged in either academia or for-profit sectors. For the SBSE alumni, unlike STEM graduates, the pattern of employment sector did not significantly change over time, Χ2 (6, N = 418) = 3.96, p = .68. The percentage of SBSE alumni in academic and for-profit careers appears relatively stable across the three time windows. Note that as discussed earlier, the trajectory of each alumnus over a 15-year time period is not reported. Rather, we show aggregate alumni employment data in each time window grouped by years following graduation. For example, a student who graduated in 2006 would be represented in the 6–10 year block only.

In addition, for SBSE alumni we do not see the same gender and race differences we find for STEM alumni. In SBSE fields, men and women did not significantly differ in employment sector, Χ2 (3, N = 418) = 2.11 p = .55. Racial group distributions were similar across employment sector, Χ2 (6, N = 412) = 10.85, p = .09. Also, as with STEM alumni, employment sector was not associated with citizenship status, Χ2 (3, N = 418) = 5.59, p = .13.

Demographics Characteristics and Career Type (Tier 2)

For SBSE alumni, the majority are split between careers that primarily involve teaching and other discipline-related career types. As in the case of SBSE Tier 1 employment sector, the distribution of career types did not significantly change over time, Χ2 (6, N = 418) = 5.30, p = .51. There were no significant gender differences in career types, Χ2 (3, N = 418) = 5.82, p = .12. Racial group distributions were similar across career types, Χ2 (6, N = 412) = 8.27, p = .22. Nor was career type associated with citizenship status, Χ2 (3, N = 418) = 4.62, p = .20. To summarize, career types – whether primarily teaching, primarily research, discipline-related or not related to discipline of study– did not vary for SBSE doctoral alumni with respect to gender, race, or citizenship status.

CST2018-117-MaryE.WoodUSA_Figure7

Figure 7. SBSE Doctoral Alumni Career Outcomes by Tier

Demographics Characteristics and Job Function (Tier 3)

For job function, as with employment and career type, we find no statistically significant changes in the proportions of alumni in different job functions over our three time windows, Χ2 (12, N = 360) = 13.08 p = .36. However, there was a significant Chi-square for gender, Χ2 (6, N = 360) = 13.65, p = .03 in the job function category of healthcare provider. Specifically, our data show that women are more likely to work as health care providers than men. (Figure 8).

CST2018-117-MaryE.WoodUSA_Figure8

Figure 8. SBSE Doctoral Alumni Job Function by Gender

There were also some significant racial group differences in job functions, Χ2 (12, N = 354) = 31.1, p = .002 (Figure 9). White alumni were more likely than Asian alumni to work as healthcare providers. White alumni were also more likely to hold full-time teaching staff/instructor position than Black alumni. Note that Figure 9 depicts the overall percentage of alumni within the seven top job functions with respect to racial demographics. Although White alumni held 50% of the positions reported for full-time teaching staff/instructor job functions, only 4% of White alumni were represented in this category overall.  However, 17% of black alumni are represented in these job functions. There were no significant citizenship group differences in job functions, Χ2 (6, N = 360) = 8.35, p =.21

CST2018-117-MaryE.WoodUSA_Figure9

Figure 9. SBSE Doctoral Alumni Job Function by Race

SBSE Academic Performance Indicators and Employment Sector

We examined the association of academic characteristics with career outcomes in only the two largest employment sectors of “Academia” and “For-profit”, since participation in other sectors is too small to allow for meaningful comparisons.

Interestingly, we found no statistically significant differences in any of the academic characteristics examined between alumni in academia and for-profit sectors. An equivalent spread of GRE-Quantitative scores, GRE-Verbal scores, cumulative GPA, and Time-to-Degree completion of alumni between these sectors is shown (Figure 10). Thus, we can conclude that these traditional performance metrics tell us little about what career path our alumni are likely to take.

CST2018-117-MaryE.WoodUSA_Figure10

Figure 10. SBSE Doctoral Alumni Academic Performance Indicators and Employment Sector

Discussion

In this paper, we have investigated the 15-year career trajectories of STEM and SBSE doctoral alumni of Wayne State University, a comprehensive research university in Detroit, Michigan. The findings of our study have implications for how higher education institutions approach training and advising for Ph.D. students.

First, our findings confirm exiting studies that show that today’s doctoral students pursue diverse career trajectories – not just tenured positions in the academy. This indicates that we should be advising doctoral students in STEM and SBSE fields about diverse career pathways they might pursue after the Ph.D. Universities should take steps to prepare doctoral students for success not just in academia, but in other areas, particularly the for-profit sector.

As suspected, a common theme throughout the data for STEM alumni was the different career paths for men and women. Our findings show that for employment sector and career type, women were more likely to work in academia in primarily teaching roles, while men were more likely to work in the for-profit sector and in science-related positions. This is further reflected in the job function outcomes in which women worked as faculty whereas men pursued positions such as group leader.

The finding that women in STEM fields were more likely to pursue careers in academia is interesting and encouraging.   Research has consistently shown that women and minorities are underrepresented in STEM [26]. This trend is reflected in our 15-year Ph.D. alumni data: in STEM fields, the sample included 76% men compared to 24% women (Table 2). The need to increase diversity in STEM fields is an issue that has been identified at both the national level and at Wayne State [27]. Recognizing these disparities, WSU has actively sought to increase the representation of women and minorities in STEM fields through programs such as the NIH BUILD (Building Infrastructure Leading to Diversity) program, Wayne Med Direct and the Postdoctoral to Faculty Transition (PFT) fellowship. WSU provides support and training to current students and early career scholars to produce a pipeline of underrepresented students for doctoral training and faculty positions in a range of disciplines [28].

As expected, the data does suggest that a majority of SBSE alumni follow more traditional pathways with alumni securing academic positions at greater levels than those in STEM disciplines.  Overwhelmingly, SBSE alumni are working in academia, in both tenured/ tenure-track positions and non-tenured roles (adjuncts or full-time instructors).  We found that White alumni are more likely to hold non-tenure track positions than Asians and Black alumni. The percentage of SBSE alumni in non-tenured roles can be viewed from a number of different perspectives. On one hand, part-time and adjunct teaching offer less job security and upward mobility than tenured/tenure-track positions. However, some PhDs, such as those embarking on a second career or preferring a part-time position, may view non-tenured positions as offering more flexibility.

In conclusion, both STEM and SBSE students will clearly benefit from early advising about diverse career pathways.  There are some statistically significant gender differences and a few differences by race, but, in general, our research demonstrates that Ph.D. students of diverse backgrounds seek a wide array of career pathways.  Citizens and non-citizens are equally likely to pursue a variety of career tracks and job functions.

Furthermore, any preconceived notions that graduate schools, graduate program or faculty advisors might hold about who might and might not succeed in the “traditional” tenure/tenure-track academic career based on academic performance metrics should be discarded. Students with higher and lower scores on traditional academic metrics used to evaluate applicants and evaluate student progress to degree show practically no difference in terms of the likelihood that alumni will pursue different types of careers.

For graduate schools, data on the career trajectories of doctorate holders should shape training and advising. For doctoral students and Ph.D. holders, transparency about diverse career pathways can help them to envision and explore career paths that best fit their interests and needs. We hope that attention to these matters will alleviate some of the stress inherent in the pursuit of a Ph.D. and contribute to higher rates of career satisfaction and well-being for doctoral alumni over the course of their careers.

Contributors: N/A

Acknowledgements: The authors wish to thank Drs. Mark Byrd, Christine Chow, Andrew Feig and Song Yan for their assistance in data collection; and Prassanna Viswanathan for data validation and visualization.

Units of Measurement: N/A

Abbreviations & Symbols: N/A

Competing interests: The authors declare that they have no competing interests.

Funding information: This work was supported by the National Institutes of Health; Grant number: DP7 0D01842; URL: nih.gov; and Wayne State University to AM. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Appendix S1: Three Tier Taxonomy

Tier 1: Employment Sectors

Tier 2: Career Types

Tier 3: Job Functions

Academia

Primarily Research

Administration

Government

Primarily Teaching

Business Development, Consulting, and Strategic Alliances

For-Profit

Science-related

Clinical Research Management

Nonprofit

Not-related to science

Clinical Services

Other

Further training or education

Data Science, Analytics, and Software Engineering

Entrepreneurship

Faculty: non-tenure track

Faculty: tenured/tenure track

Faculty: track unclear or not applicable

Full-time Teaching Staff/Instructor

Group Leader (research)

Healthcare Provider

Intellectual Property and Law

Part-time Teaching Staff/Adjunct

Postdoctoral Research

Regulatory Affairs

Research Staff or Technical Director

Sales and Marketing

Science Education and Outreach

Science Policy and Government Affairs

Science Writing and Communication

Technical Support and Product Development

Completing further education or training

Other

Deceased/retired

Appendix S2

CST2018-117-MaryE.WoodUSA_Figure11

CST2018-117-MaryE.WoodUSA_Figure12

CST2018-117-MaryE.WoodUSA_Figure13

CST2018-117-MaryE.WoodUSA_Figure14

CST2018-117-MaryE.WoodUSA_Figure15

CST2018-117-MaryE.WoodUSA_Figure16

CST2018-117-MaryE.WoodUSA_Figure17

CST2018-117-MaryE.WoodUSA_Figure18

CST2018-117-MaryE.WoodUSA_Figure19

CST2018-117-MaryE.WoodUSA_Figure20

CST2018-117-MaryE.WoodUSA_Figure21

CST2018-117-MaryE.WoodUSA_Figure23

CST2018-117-MaryE.WoodUSA_Figure22

CST2018-117-MaryE.WoodUSA_Figure24

CST2018-117-MaryE.WoodUSA_Figure25

CST2018-117-MaryE.WoodUSA_Figure26

CST2018-117-MaryE.WoodUSA_Figure27

Single versus Double Chest Tube Drainage after Thoracotomy for Cancer

DOI: 10.31038/CST.2018342

Abstract

Background

After pulmonary lobectomy, two chest tubes are traditionally placed: an apical tube for air evacuation and a diaphragmatic tube for fluid drainage. This study investigates whether one apical chest tube is as effective as two chest tubes after lobectomy.

Methods

Between July 2008 and November 2009, 40 consecutive patients with lung cancer underwent thoracotomy and lobectomy. The initial 20 patients had two chest tubes placed while the latter 20 patients had a single chest tube. All 40 patients had epidural catheters placed.

Results

The groups were similar in demographics, comorbidities, lobe resected, and lung pathology. Length of stay, chest tube days, and chest tube drainage were less in the single tube group; however, they did not achieve statistical significance. Similarly, post-operative airleak and residual pneumothorax after tube removal were not significantly different but were less in the single tube group. While the post-operative day to oral pain control was similar in the single and double chest tube groups, postoperative pain as assessed by the VAS pain scale was lower in the single tube group each of the first four PODs with the difference achieving significance on postoperative days 3 (3.6 ± 0.5 versus 5.9 ± 0.5) and 4 (3.2 ± 0.6 versus 5.4 ± 0.6).

Conclusion

Single apical chest tube drainage after thoracotomy for lobectomy is as effective as apical and diaphragmatic double tube drainage. Single tube drainage improves patient’s postoperative comfort and may result in less chest tube drainage, fewer chest tube days, and a shorter hospital stay.

Introduction

The classic mantra in thoracic surgery has always included the use of two chest tubes after pulmonary lobectomy. One chest tube is placed in the apex of the chest for air drainage while the other is placed along the diaphragm for fluid drainage [1]. Recently there have been reports, are randomized, substituting the double chest tube approach for a single chest tube after surgery [2–5].

The theoretical advantage of a single chest tube would be less drainage and subsequently earlier chest tube removal as well as decreased pain. Reducing post-operative pain can allow patients to ambulate earlier, which can avoid complications such as pneumonia and deep vein thrombosis. It also encourages the use of incentive spirometry and pulmonary toilet [6]. All of these advantages can lead to shorter hospital stay and decreased cost. Of course, there are potential disadvantages to using a single tube. Due to inadequate drainage of either air or fluid, there is the potential for having a residual pneumothorax or a loculated fluid collection after tube removal.

This study includes patients undergoing thoracotomy for lobectomy with mediastinal lymph node dissection who have a diagnosis of cancer. The aim of the study is to identify if single chest tube placement will result in less chest tube drainage, decreased overall pain, and subsequently shorter hospital stays.

Methods

Setting

Karmanos Cancer Institute/Detroit Medical Center is a large academic, tertiary care center affiliated with Wayne State University School of Medicine. It is located in Detroit, Michigan and has a wide referral base from southeastern Michigan.

Patients

We obtained IRB approval: HIC#035410MP4E, protocol #1003008149. In a retrospective fashion, we identified 40 consecutive patients from July 1, 2008 through November 30, 2009 who had a diagnosis of lung cancer and subsequently underwent a standard posteriolateral thoracotomy and lobectomy with mediastinal lymph node dissection by a single surgeon after IRB approval. None of these patients had preoperative chemotherapy or radiation treatment. The first 20 patients had a straight #32 French chest tube (Covidien, Mansfield, MA) as well as a curved #28 French chest tube placed after lobectomy. The second 20 patients had a single straight apical #32 French tube placed. All patients were adults. Preoperatively, all 40 patients had epidural catheters placed for post-operative pain control. These catheters remained in place for 72 hours along with a Foley catheter which was placed after the induction of anesthesia. Preoperative antibiotics were also given approximately one hour prior to skin incision.

Data Collection

Medical records including inpatient charts, electronic medical records, operative reports, laboratory data, and radiographic data and images were reviewed for all 40 patients in a retrospective manner. Data was collected on demographics, associated comorbidities, stage of lung cancer, side of tumor and pre-operative Pulmonary Function Tests (PFTs). We also collected outcome data including total chest tube output, total chest tube days, days of chest tube airleak, total hospital stay, and complications. Post-operative pain information gathered included days to oral pain control and patient reported pain based on the Visual Analogue Scale (VAS) pain scale from 1–10 as collected from a similar pool of nurses. Scores were collected every six hours prior to any bolus pain medication.

Definitions

Comorbidities were defined based on previous diagnosis by primary care physicians. Complications were defined as follows. Smoking was defined as greater than 15 pack-years with the average in our patients being 30 pack-years and the maximum 75. Prolonged airleaks were defined as airleaks lasting longer than 7 days. Residual pneumothorax was defined as a pneumothorax seen on upright chest X-ray after chest tube removal. Pneumonia was defined as either positive sputum cultures or changes on X-ray with appropriate patient symptoms and elevated WBC count. Arrhythmias were recorded when they required treatment. Chest tube management was similar in all patients. Patients were on suction until there was no evidence of airleak with cough or Valsalva. Removal was based on output of less than 200cc per day (currently we use less than 400cc per day).

Data Analysis

Data was entered into a Microsoft Excel spreadsheet for analysis. Categorical variables were compared using chi-square or Fisher’s exact test where appropriate while continuous variables were compared using the Student t-test with Bonferroni correction when using multiple comparisons. All statistical tests were 2-tailed and a p value of <0.05 was considered statistically significant.

Results

Patient demographics were identified in our 40 patients and are shown in table 1. There was a predominance of female patients (82%) and white patients (75%), though they were similar in both the single and double chest tube groups. The average age was approximately 65 in both groups with the single chest tube groups having slightly more patients greater than 70 years of age (7 vs 4). Comorbid conditions such as hypertension, diabetes mellitus, Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), and a previous diagnosis of cancer were also similar in both groups. While there were slightly more smokers in the double chest tube group (16 vs 19), this was not statistically significant.

Table 1. Preoperative Characteristics.

Single tube

Double tube

p value

Age

65.4 ± 9.8

65.0 ± 10.0

NS

Sex (M:F)

3:17

3:17

NS

Resection

Upper

10

10

NS

Middle

1

1

NS

Lower

8

8

NS

Bilobe

1

1

NS

Tumor Side

NS

Right

13

14

NS

Left

7

6

NS

Associated disease (#)

COPD

3

5

NS

CAD

7

7

NS

Smoker

16

19

NS

PFT (%)

FEV1

81.7 ± 18.0

80.3 ± 16.9

NS

FVC

87.4 ± 22.1

88.4 ± 10.5

NS

DLCO

65.6 ± 12.2

68.3 ± 19.0

NS

The pre-operative stage of the cancer showed that all patients were either stage I or II while the post-operative stage was similar except that one patient in the single group and two patients in the double group were identified as stage III due to positive mediastinal nodes that were not identified on preoperative scanning. Our lymph node dissections typically yield around 10 lymph nodes. The tumors were predominantly right-sided (65% single chest tube and 70% double chest tube) and mostly in the upper followed by lower lobes. All patients had pre-operative pulmonary function test including a FEV-1, FVC, and DLCO which were similar in both groups.

Outcomes measured are shown in Table 2. Days of chest tube airleak (2.2 ± 0.7 vs. 2.9 ± 0.7), total chest tube drainage (1971 ± 170 mL vs. 2201 ± 231 mL), and total chest tube days (5.9 ± 0.5 vs. 6.9 ± 0.6) were all less in the single chest tube group versus the double chest tube group. Still, statistical significance was not achieved. Overall patient length of stay was similar (7.8 ± 0.8 vs. 7.9 ± 0.7). In terms of complications, arrhythmias, chyle leaks, and pneumonias were similar. Though prolonged airleak and residual pneumothorax after tube removal were not significantly different, they occurred less in the single versus the double tube group (1 vs. 3 and 0 vs. 2 patients, respectively).

Table 2. Comparison of postoperative characteristics, complications, and pain scores.

Variable

Single tube

Double tube

p value

Days of airleak

2.2 ± 0.7

2.9 ± 0.7

0.450

Chest tube days

5.9 ± 0.5

6.9 ± 0.6

0.238

Total chest tube drainage (mL)

1971 ± 170

2202 ± 231

0.418

Length of stay (days)

7.8 ± 0.8

7.9 ± 0.7

0.920

Prolonged airleak

1

3

0.343

Arrythmia

4

2

0.410

Chyle leak

1

0

1.000

Pneumonia

2

3

0.663

Residual airspace

0

2

0.487

Days to oral pain control

3.9 ± 0.3

4.4 ± 0.2

0.164

VAS score

POD 1

6.2 ± 0.6

7.0 ± 0.6

0.400

POD 2

5.4 ± 0.7

6.7 ± 0.4

0.112

POD 3

3.6 ± 0.5

5.9 ± 0.5

0.009

POD 4

3.2 ± 0.6

5.4 ± 0.6

0.013

Total days to oral pain control again showed a similar pattern with fewer days in the single group (3.9 ± 0.3 vs. 4.4 ± 0.2) but again, statistical significance was not achieved. We then assessed postoperative pain using the VAS pain scale. This analysis showed that on Post-Operative Day (POD) 1 and 2 there was less pain in the single group (6.2 vs. 7.0 and 5.4 vs. 6.7) that was not significant. However, on POD 3 and 4 this pattern achieved significance with the single tube group reporting less pain than the double group (3.6 vs. 5.9 and 3.2 vs. 5.4, p<0.02 for each).

Discussion

Double chest tube placement has been the standard in thoracic surgery with one tube placed anterior and apical while the other is placed posterior and basal for fluid drainage. The timing of removing these tubes has more recently been challenged. For example, an output as high has 450 mL/day has been shown to be safe for removal of chest tubes after pulmonary resections [7]. Thus, total chest tube output may not be a useful outcome measure in light of this study. Still, it would be expected that two chest tubes would have more drainage than a single chest tube. Given the high absorptive capacity of the pleura and the lack of complications after early tube removal it is likely that a single tube will suffice in this regard. In fact, continued drainage may simply add to fluid loss that may not be beneficial.

Air leak is another factor that may keep chest tubes in longer than anticipated. We used underwater suction for the first day post-operatively and then as needed based on the presence of an airleak. Suction has the theoretical advantage of promoting lung expansion. Suction via a single tube has been shown to deliver equivalent intrapleural pressure as suction through dual chest tubes [8]. However, suction or waterseal has been shown to be equivalent in terms of post-operative airleak after thoracotomy [9]. Certainly being attached to wall suction limits your ability to ambulate.

Further study has been done looking specifically at the type of tube used. In our study, we used the standard rigid 32 French chest tubes. Others have shown that using more flexible Blake (Ethicon, Somerville, NJ) tubes are equivalent in terms of patient outcome [10] and using these tubes may further increase patient comfort. Further, small tubes such as 24 or 28 French are often used. However, 32 French tubes were used in both groups so no bias was introduced.

Alex et al. first used single chest tubes and found no difference in post-operative outcomes but reported overall less pain in the single tube group [4]. It is not clear in this study if all patients underwent mediastinal lymph node dissection. Another European group showed no difference in outcomes and reported less analgesia use in the single group 2 though this group included patients with sleeve resections and chest wall resections in addition to lobectomy. Two years later it was shown that a single chest tube reduces hospital costs due to a shorter hospital stay as compared to using two chest tubes [5]. Most recently, Okur et al. compared single and double chest tubes in terms of pain scale though their group was not limited to cancer pathologies [3]. Further, this study excluded patients if the surgeon expected increased postoperative output.

Interestingly, these studies all reported their total chest tube drainage to be less than typically seen at our institution leading us to investigate our patient population. This difference could be the result of stapling devices used or a particular sealant used in the operating room. To the author’s knowledge, this is the first North American-based study that compares single versus double chest tube placement in patient undergoing thoracotomy for lobectomy and mediastinal lymph node dissection for a diagnosis of cancer. The inclusion of a lymph node dissection has the possibility of resulting in more post-operative drainage. Further, limiting our study to patients with cancer pathologies avoids the variables patients with infectious or traumatic pathologies add.

Pain has been reported as a major issue among patients with chest tubes after surgery [11]. In fact, reduced pain is one of the advantages cited by those who advocate thoracoscopic lung resection [12]. Respiratory rehabilitation with incentive spirometry and ambulation is important in any postoperative patient including those with chest surgery [6]. This can help control sputum secretion and potentially avoid respiratory complications in the early post-operative period [13]. Therefore, keeping patients comfortable is an important part to their post-thoracotomy recovery [14]. We used epidural catheters placed prior to surgery and removed early on post-operative day three. This plus the use of a single chest tube allowed patients to experience much less pain which should lead to fewer complications.

The VAS pain scale was used in this study to assess the degree of pain experienced by each patient. Of course, pain is a very subjective finding though its importance cannot be overstated. This method is one of the most common ways to assess pain in a hospital setting [15,16]. This scale ranges from 1 (no pain) to a 10 (worst pain) and patients are asked to report a number as they see fit. This is not a perfect method to assess pain since it is subjective and does not take into account the quality of the pain 7. Still, using this method we were able to show that after epidural catheter removal, pain was reported to be less in patients with one chest tube than with two after similar operations.

Single chest tube placement after pulmonary lobectomy for cancer is as effective as double tube placement in terms of chest tube days, total chest tube output, complications after surgery, and total hospital stay. Pain, however, is reported to be less intense if a single chest tube is used which could potentially result in earlier ambulation and fewer complications. While this study only incorporates twenty patients treated similarly in each arm, a larger study may show single chest tube use to be superior. Still, perceived pain is clearly less with a single chest tube. Given these data we recommend single chest tube use on all thoracotomies for cancer unless specific circumstances dictate otherwise.

Acknowledgement

Christopher Gayer did the chart review and analyzed the data.

Frank Baciewicz was the senior author and oversaw the project.

Abbreviations

CAD: Coronary Artery Disease -Disease of coronary arteries to heart resulting from arthrosclerosis

COPD: Chronic Obstructive Pulmonary Disease – Chronic disease of lungs leading to decreased function

PFT: Pulmonary Function Test – Tests done to assess pulmonary function pre-operatively

POD: Post-Operative Day – Days after operation

VAS: Visual Analogue Scale – A patient-reported pain scale from 1–10

References

  1. Khan IH, Vaughan R (1999) A national survey of thoracic surgical practice in the UK Int J Clin Pract 53: 252–256. [crossref]
  2. Gomez-Caro A, Roca MJ, Torres J (2006) Successful use of a single chest drain postlobectomy instead of two classical drains: a randomized study. Eur J Cardiothorac Surg 29: 562–566.
  3. Okur E, Baysungur V, Tezel C, Sevilgen G, Ergene G, et al. (2009) Comparison of the single or double chest tube applications after pulmonary lobectomies. Eur J Cardiothorac Surg 35: 32–35. [crossref]
  4. Alex J, Ansari J, Bahalkar P (2003) Comparison of the immediate postoperative outcome of using the conventional two drains versus a single drain after lobectomy. Ann Thorac Surg 76: 1046–1049.
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  9. Alphonso N, Tan C, Utley M (2005) A prospective randomized controlled trial of suction versus non-suction to the under-water seal drains following lung resection. Eur J Cardiothorac Surg 27: 391–394.
  10. Icard P, Chautard J, Zhang X, Juanico M, Bichi S, et al. (2006) A single 24F Blake drain after wedge resection or lobectomy: a study on 100 consecutive cases Eur J Cardiothorac Surg 30: 649–651. [crossref]
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  12. Nicastri DG, Wisnivesky JP, Litle VR, et al. (2008) Thoracoscopic lobectomy: report on safety, discharge independence, pain, and chemotherapy tolerance. J Thorac Cardiovasc Surg 135: 642–647.
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Global Healthcare Workers Migration: A Human Resource Management Concern

DOI: 10.31038/IMROJ.2018335

Abstract

The World Health Organization estimates a deficit of approximately 2.4 million physicians, nurses, and midwives along with a need for an additional 2 million pharmacists and paramedical professionals. Compounding this crisis for the most vulnerable communities is the phenomenon healthcare worker migration. Both developed and developing nations are struggling to mitigate the immense challenges resulting from the existing shortage combined with increasing demands and diminishing supplies of healthcare providers. WHO established a Global Code of practice with the aim of addressing the growing healthcare worker crisis. United Nations General Assembly passed a resolution calling on the international community to work together towards the creation of 40 million healthcare and social workers with particular focus on the expected 18 million person deficit in healthcare workers by 2030. The WHO’s Global Code of Practice on the International Recruitment of Health Personnel has provided clear benefits in mitigating this growing problem most evident with the creation of 117 national authorities and being used to establish 65 bilateral agreements with respect to health worker development and migration. The healthcare workforce shortage is an ongoing crisis with global ramifications effecting developed and developing nations alike.

Introduction

Shortages within the healthcare workforce represent a growing problem for the Americas. This problem is but a portion of a global crisis. The World Health Organization estimates a deficit of approximately 2.4 million physicians, nurses, and midwives along with a need for an additional 2 million pharmacists and paramedical professionals [1]. Both developed and developing nations are struggling to mitigate the immense challenges resulting from the existing shortage combined with increasing demands and diminishing supplies of healthcare providers [2]. Overall issues are further complicated in that healthcare workers are most sparse in regions in which they are most desperately needed, particularly impoverished, developing nations [2].

Compounding this crisis for the most vulnerable communities is the phenomenon healthcare worker migration. A prime example of this sub-Saharan Africa, which carries 24% of the world’s disease burden, while only have 3% of the global healthcare workforce to combat it, as well as merely 1% of global financial resources to fund any and all health initiatives [1]. The reasons for this migration are multifaceted and in recent history has become increasingly complex [3, 4]. Some factors which contribute to health worker migration include: active recruitment of healthcare workers to wealthy nations at the detriment to their respective home countries or countries in which they were trained, insufficient health systems, poor working conditions, lack of recognition, overwork, low wages in these developing nations [3]. All of these factors contribute to the increasingly low health worker numbers in the most vulnerable countries [3].

In response to this ongoing crisis, the WHO established the Global Code of Practice on the International Recruitment of Health Personnel in 2010. After detailing the aims of this WHO initiative and summarizing its current progress, this review will present both the successes and obstacles to this initiative; then focusing particularly on how implementation has progressed in the Americas. Concluding with an evaluation as to which targeted initiative hold promise in mitigating the disparity in the capabilities with regard to providing healthcare when comparing developed and developing nations.

Global Code of Practice on the International Recruitment of Health Personnel

In 2010, the WHO established a Global Code of Practice with the aim of addressing the growing healthcare worker crisis. The objectives of this code are as follows: to establish and promote voluntary principles and practices for the ethical international recruitment of health personnel, with respect to both source and destination; to create a reference for nations while establishing or improving the infrastructures necessary for international recruitment of health personnel; to provide guidance where appropriate with regards to the formulation and implementation of bilateral and/or multilateral; to facilitate and promote international discussion and advance cooperation related to the ethical international recruitment of health personnel as part of strengthening health systems, with a particular focus on the situation of developing countries [5]. These objectives aim to mitigate the growing health personnel crisis across the globe. The Global Code of Practice outlines several important methods for addressing this growing concern. Overall, the aim is to improve the healthcare workforce globally. Methods for doing so include increasing healthcare education, training, efficiency. The ultimate goal with regards to training and education being to have a system of generate a healthcare workforce which is self-sustaining for each individual nation, as sourcing healthcare workers from other nations inherently places strain on the healthcare system of the source country. Another important aspect is the collection of pertinent data and the establishment oversight bodies to monitor and make recommendations from information collected, and to share this information with international agencies in order to aid with overcoming issues from a more global mindset [5]. This data gathering and international cooperation is especially important for the most vulnerable communities where resources and healthcare work-forces are under the greatest strain [5].

Finally, the Global Code of Practice established in 2010 sought to develop a means of regulating healthcare worker migration in a manner as to aid the most vulnerable nations. It is important to understand that this regulation must be undertaken with respect to any nation’s obligations to its own citizenry as well as with respect to the liberties any particular healthcare worker [5]. Essentially, the goal with respect to healthcare worker migration is to permit the free migration of healthcare workers while encouraging the bolstering of vulnerable healthcare systems and allowing decreasing the limitations of free mobility of health professionals.

Current Progress with Implementation of the Global Code of Practice

Since the establishment of the Global Code of Practice, international consensus is that it has had a positive effect on addressing the health personnel crisis. A recent meeting among high profile entities working with the World Health Organization highlighted some of these factors focusing on international health worker migration [6]. The meeting affirmed that the Global Code of Practice is working to mitigate the health personnel crisis, most effectively by elucidating various problems within the current global state of health worker migration, allowing for discussion to methods of amelioration [6].

Some countries have successfully implemented strategies to drastically increase the production of new health workers. The successes can be used to develop policies in other nations as well as a possible resource of health workers for nations without the capacity for such production [6]. Other policy measures are being implemented at both the national level and with bilateral agreements to create environments with mutually beneficial health worker migration, implementation and improvements to health worker monitoring and management information systems, recruitment health workers to rural communities [6]. The potential of appropriate utilization and integration of refugee health workers and potential training of refugees as health workers.

Challenges to implementation include: differences in populations, capacity to educate new health workers, capability to train health workers with new technologies, impediments to health worker skill recognition, lack of prioritization with regard to specializing training and employment of health worker at the national level, as well as predatory practices in recruiting health workers [6]. Other factors outside a health worker migration such as increasing burden of chronic conditions, anti-globalization sentiments, and growing refugee populations [6].

Presented during the meeting was evidence demonstrating the necessity for a more refined and evidence based approach to addressing the increasing scope and complexity of international health worker migration [6]. This approach is key towards the success of Global Code of Practice being successful. The meeting closed with calling for a third round of National Reporting to the World Health Organization regarding health personnel and health worker migration [6].

With respect to the challenges still clearly evident, the successes of World Health Organization promoted practices is deserving of recognition. Since the adoption of the Global Code of Practice, the world has seen the creation of 117 national authorities dedicated to its implementation as well as the Code being used to establish 65 bilateral agreements with respect to health worker development and migration [7]. The recommendations from information gathered regarding health personnel has also resulted in recognition from the United Nations. In 2016, the United Nations General Assembly passed a resolution calling on the international community to work together towards the creation of 40 million healthcare and social workers with particular focus on the expected 18 million person deficit in healthcare workers by 2030 [8].

National Reporting on Status of Health Personnel Workforce

As outlined in the Global Code of Practice, information gathering and national reporting are integral to implementing, monitoring, and improving efforts to address the health worker shortage. Since the inception of the Code, there have been two rounds of National Reporting. Of the 194 member states 74 submitted National Reports to the World Health Organization in 2016 [7]. This represents a 32% increase in participating nations from the first round of reporting [7]. While the Pan American Health Organization demonstrated a drastic increase between the first and second round of reporting, from 4 to 9 members submitting National reports in 2013 and 2016 respectively; this still represents only 26% of the 35 members [7]. The importance of data gathering cannot be underestimated without inhibiting global and regional efforts to increase the health workforce.

Health Personnel Workforce in the Americas

Back in 2005, experts from around the Caribbean and Latin America gather for a conference to discuss and coordinate measures to enact policies of managed migration [14]. An important reason for these efforts is to mitigate the brain drain of professionals form the regions across multiple industries and sectors [14]. Of particular importance was the retention health professionals [14]. The Pan American Health Organization has overseen successes in the implementation of the Global Code of Practice. This is exemplified by the increases in physicians per capita as depicted in Figure 1. Of all the Pan American Health Organization countries which submitted data for multiple years, the vast majority saw improvements. This indicates that monitoring these statistics provides information which can positively inform policy. It also shows which countries are not implement effective policies, which can be seen as a marker for further changes, possibly with a different approach Figure 1 [15].

IMROJ 2018-107 - Satisg Bidaisee WI_F1

Figure 1. Global Health Observatory Statistics

However, the Americas have faced a number of difficulties particularly amongst the poorer nations. To establish a holistic picture of the current state of health personnel shortages and health worker migration in the Americas analyses from three member states: the United States of America, Canada, and El Salvador will serve as examples. These three nations represent both developed and developing countries, as well as presenting health worker shortages in both socialized and privatized health systems.

United States

Prior to the creation of the World Health Organization Code of Practice, the Alliance for International Ethical Recruitment Practices was developed in the United States [9]. The Alliance Code in light of drastic increases in the number of firms actively recruiting foreign nurses. This dramatic and unregulated market created an environment which enable unfair and subversive recruitment practices which disadvantaged incoming healthcare worker migrants coming to the United States [10]. The purpose of the implementing the Alliance Code was to establish minimum standards for employers and recruiters to ensure transparent, reasonable, and ethical practices for contracting international workers in addition to setting goals of best practices respecting health worker rights to labor autonomy while mitigating the detriments encumbered by source countries’ healthcare systems [9]. While the Alliance Code is distinct from the World Health Organization Code of Practice, both share the same aspirations and goals [10]. The World Health Organization Code of Practice is a broad set of guidelines for national and international agencies, while the Alliance Code represents a more narrowed and detailed set of guidelines for a particular aspect of this issue, namely healthcare worker recruitment practices. Since the inception of the Alliance Code the following strategies have been identified as crucial for its ultimate success: a multi-stakeholder approach, realizing the potential impacts of variations in immigration policy, challenges with enforcing compliance with a voluntary set of guidelines, generating understanding of the importance of ethical practice at the level of individual recruitment employees, standardizing credential assessment and certification [10].

Canada

In contrast, Canada has a single-payer healthcare system. As such, the government has a much greater deal of control with regard to ethical recruitment practices. However, government-funded health systems face their own challenges regarding health worker shortages. Since the mid-2000’s the number of immigrating health professionals has been increasing in Canada, particularly physicians and nurses [2]. International health professionals have been vital to Canadian physician resource planning [11]. As a matter of policy, efforts to maintain these trends in order to alleviate the healthcare worker shortage persisted in spite of economic hardship during the global recession, and efforts to improve integration of international health professional are underway [2]. The major threat to continued addressing of the labor shortage in Canada is financial constraints and political climate is trending toward addressing government debts and deficits [2]. The significant and increasing numbers of health migrants to Canada suggests that the nation may be exacerbating shortages in less developed source nations, however evidence shows there is also substantial increases in health professionals trained in Canada preparing to emigrant elsewhere represents a mitigating factor in Canadian overall health worker policy [2]. While compliance with the World Health Organizations’ Code of Practice is a topic in healthcare policy discussions in Canada, current political climate indicates that efforts to address the health professional workforce within Canada, especially in underserved communities seem to be taking priority [2]. While discussions are also underway in Canada to promote the development of education system to create a self-sustaining healthcare environment, the Canadian Medical Association regards international professionals a significant component of Canadian health workforce planning [12, 13].

El Salvador

Moving from the developed countries to developing nations, El Salvador has again its own unique challenges to combatting the healthcare worker shortages. Researchers discuss the legal implications of the World Health Organization Code of Practice and how coordination between national agencies is needed to implement the guidelines [2]. Overall, the understanding with regards to El Salvador is that the Code of Practice is too broad in its scope and lacks concrete definitions which would be necessary for it to be used as a source of regulation. Recommendations propone for the Code to be technically assessed by the Ministry of Health, and for those assessments to be given to lawmakers to enact legislation as would be appropriate to best serve the people [2]. The key difference to be noted is that while El Salvador intends to use government intervention to enact these changes as in Canada, limited resources called for careful assessment prior to implementation [2]. Since El Salvador is a common source country for health workers migrating to more developed countries like Canada and the United States, there is also an emphasis on the components of the Code of Practice relating to retaining health workers with possible policy changes both encouraging health professionals to stay or creating barriers to their emigration, while maintaining respect for individual autonomy [2].

Conclusion

The healthcare workforce shortage is an ongoing crisis with global ramifications effecting developed and developing nations alike. The World Health Organization’s Global Code of Practice on the International Recruitment of Health Personnel has provided clear benefits in mitigating this growing problem most evident with the creation of 117 national authorities and being used to establish 65 bilateral agreements with respect to health worker development and migration [7]. Additionally, in 2016, the United Nations General Assembly passed a resolution calling for the creation of 40 million healthcare and social workers by 2030 [8]. It has been made clear from evidence around the world and shown here across the Americas that addressing the health professional shortage is a complex and multi-faceted endeavor. The more information we gather the better able we are to identify which particular problems are arising in particular regions. Many of the lessons learned thus far can be used to influence further policy developments at the regional, national, international level. One obvious aspect in which the Americas stand to directly benefit is by increasing participation in the next round of National reporting to the World Health Organization. Again, the Pan American Health Organization demonstrated a drastic increase between the first and second round of reporting, from 4 to 9 members submitting National reports in 2013 and 2016 respectively; this still represents only 26% of the 35 members [7]. Increasing the available data will serve both to benefit members of the Pan American Health Organization as well as nations across globe.

References

  1. WHO (2006) Health workers: a global profile. In: The World Health Report 2006 – Working together for health: World Health Organization, Geneva, Switzerland.
  2. WHO (2013) WHO policy dialogue on international health workforce mobility and recruitment challenges: technical report. Copenhagen: The WHO Regional Office for Europe.
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  4. Taylor AL, Dhillon IS (2011) The WHO Global Code of Practice on the International Recruitment of Health Personnel: The Evolution of Global Health Diplomacy. Global Health Governance Volume: 01
  5. WHO Global Code of Practice for International Recruitment of Health Personnel.
  6. High Level Dialogue.
  7. SDG3.c.1 Health Worker Density and Distribution Health Worker Labour Mobility.
  8. UNGeneral Assembly Resolution.
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  11. http://rcpsc.medical.org/publicpolicy/imwc/IMG_Task%20force-poster-FINAL-ENG.pdf
  12. ACHDHR (2009) How many are enough? Redefining self-sufficiency for the health workforce, A Discussion Paper. Canadian Federal/Provincial/Territorial, Advisory Committee on Health Delivery and Human Resources, Ottawa, ON: Health Canada.
  13. CMA and CCCPR (2008) International Medical Graduates in Canada, January 16, Ottawa, ON: Canadian Medical Association and Canadian Collaborative Centre for Physician Resources.
  14. Expert group meeting on international migration and development in Latin America and the Caribbean
  15. Global Health Observatory Statistics

Cross-sectional Study Investigating Texting and Driving in Grenada, West Indies

DOI: 10.31038/IMROJ.2018334

Abstract

Objective

Conduct a cross-sectional study to gather data regarding texting while driving behaviors, identify vulnerable populations, as well as assess public opinions about receptiveness to interventions in Grenada, West Indies. This will inform efforts to curb motor vehicle accidents (MVAs) locally.

Design and Methods

An anonymous 16-item questionnaire assessing cell phone usage while driving was answered by Grenadian drivers recruited from across Grenada. The survey assessed incidence and prevalence of texting while driving, frequency of MVAs involving texting, participant risk perception, demographic data, as well as which interventions are perceived to be effective in reducing texting while driving. Drivers were approached in public car parks and roadsides by the study researchers to obtain their participation.

Results

From 191 survey responses, mean age was 37.05 ±10.038 years. 50.3% admitted to texting while driving. Statistically significant between group differences were documented with variables of gender (females comprise 59% of never texted group vs. comprising only 40% of texting while driving group, p=0.009), mean age (Never texted group39.3 years ± 11 vs. Texted while driving group 34.9 years ± 8, 0.003), and knowing anyone involved in a MVA due to texting while driving (texted while driving group 26% vs never texted group 5%, p≤0.001).

Conclusions

Younger age, male gender, and knowing other drivers who had MVA’s involving texting while driving was associated with increased incidence of person’s texting while driving. Interventions targeting the socially reinforcing effects to these groups, safer technologies, as well as legislation may mitigate texting while driving’s consequence in Grenada.

Introduction

Distracted driving (DD) is devoting a significant amount of time or effort towards a secondary task such that they cannot maintain driving performance at an acceptable level [1]. Distractions can be categorized as visual, auditory, physical, or cognitive, all which impact driver performance. Distractions can also be categorized as internal or external. While non-technological distractions exist, newer technological distractions are more cognitively demanding and time consuming [2]. Individuals using mobile phones are reported to have delayed reaction times to braking, traffic signals, impairing lane positioning, and maintaining safe vehicular distance [1]. The World Health Organization (WHO) suggests that even hands-free devices do not completely alleviate the problem, and texting dramatically increases the risk of MVA [1]. Texting while driving is hazardous in that it requires active cognition to form a message as the driver also physically manipulates the phone. One explanation proposes attention span is limited, and complex secondary tasks force the driver to divide their attention which impedes concentration on driving; while another propones some driving conditions place higher demands on the driver, so they cannot cope with both tasks [3]. A meta-analysis of 28 studies revealed that texting while driving decreased performance relating to: eye movement, stimulus detection, reaction time, maintaining speed, lane positioning, and vehicular control; compromising the safety of everyone on the roadway [4].

Cell phone use while driving is an established major risk factor for MVAs [5]. Drivers using cell phones are four times more likely to be involved in a MVA [1,6,7]. Even more striking, deficits from cell phone use are comparable to driving under the influence of alcohol. Strayer et al. found that while drinkers tended to be more aggressive on the road, cell phone users had greater delays in reaction time [2]. Other studies demonstrate cell phone use interferes with visual and steering capabilities, suggesting a compounding effect of cognitive, visual and physical demands [8].

Who Has Been Impacted?

The WHO estimates that 1.3 million deaths result from MVAs worldwide annually [1,9] According to data from the Fatality Analysis Reporting System collected between 1999–2008, the number of fatalities due to DD decreased between 1999–2005 [5]. However, the number of DD related fatalities grew rapidly by 28% thereafter, which was attributed to increased texting post 2005. Researchers used multivariate analysis to show approximately 16,000 additional fatalities can be attributed to increases in text messaging while driving from 2001 to 2007 [5]. US Department of Transportation National Highway Traffic Safety Administration reported that DD was associated with approximately 421,000 injuries in motor vehicle collisions in 2012, with evidence that smartphone use is increasingly contributing to these incidents [10]. Coinciding with this increase in MVAs due to DD is an increased prevalence of habitual engagement in DD. Participants in surveys who drove experimental routes indicated strong willingness to engage in activities which impaired attentiveness to the task of driving, particularly cell phone use [11]. In 2013, the Center of Disease Control (CDC) compiled data from the 2011 European Styles and Health Styles surveys to compare estimates of cell phone use among drivers in the US and European nations [12]. Among drivers aged 18–64, self-reported cell phone use for making calls while driving in the past 30 days was variable, ranging from 21% in the UK to 69% in the US [12]. Additionally, drivers who admitted to reading or sending text messages while driving at least once in the past 30 days was also variable, ranging from 15% in Spain to 31% in the US [12]. This suggests that among these different countries, willingness to engage in cell phone use is variable, and likely dependent on multiple factors.

Who Texts and Drives and Why?

Many explanations for the motivations behind texting while driving have been developed. Researchers speculate the motivations vary from perceived urgency of the message to the consideration of current risks by the driver [3]. Research by Lerner et al. suggests driver decisions about cell phone use are strongly correlated with the consideration of task motivations [13]. DD is weakly related to driving considerations such as current or predicted road conditions [13]. However, Lerner et al. demonstrated a strong positive correlation between age of the driver, behaviors the driver determined risky, and when they chose to engage in such behaviors, texting being a prime example of risky behavior [13]. Additionally, teen drivers (aged 15–19) were more likely to engage in cell phone use than any other age group [13]. Cell phone use showed a strong linear relationship with the perceived risk of the task [13]. Although there was a weak relationship between willingness and road type; there was a stronger influence of driving task (merging, exits, lane change) [13]. Taken together this evidence suggests a correlation with driver’s willingness to text when the risk is perceived as minimal and their age, coupled with consideration for the driving maneuver difficulty plays an important predictive role.

Cross-sectional and observational studies demonstrate impairment due to cell phone use is particularly prevalent in younger and inexperienced drivers [14–16]. Recent work reports 71.5% of drivers surveyed ages 18 to 24 reporting reading text messages in the last 30 days [17]. This is due to multiple factors such as perceived risk and familiarity with technology. Independent of reason, multiple studies demonstrates younger drivers are more likely text and drive; therefore interventions should be targeted at this demographic.

What Has Been Done About It?

Certain nations such as the UK have curbed texting and driving by banning cell phone use while operating a vehicle [18]. The UK government demands hands-free devices only while the vehicle is in motion and even while its stopped in traffic or at a red light. Additionally, penalties include monetary and incurrence of penalty points [18]. The consequence is more severe with the threat of loss of license if the driver obtained their license two years prior to the incident [18]. In the US, texting is prohibited in 46 states, DC. Puerto Rico, Guam, and the US Virgin Islands for all drivers [7]. However, no state prohibits an “all cell phone” use [7]. It is important to note that the ability to enforce these regulations have proven to be problematic due to the difficulty of apprehending someone texting while driving as compared to other risky behaviors such as speeding and driving while intoxicated [19].

What About Low And Middle-Income Countries?

Investigations in the risks and prevalence of texting while driving has been increasing in recent years. However, relatively little research has focused on the incidence of texting while driving in low and middle-income countries [9]. This is especially surprising considering that the WHO estimates that 90% of road traffic related deaths occur in low and middle-income countries [9]. There are indications that texting while driving poses a significant risk amongst non-Western drivers presented by reports from South Africa and Kuwait [20,21].

Grenada has sparse research into the growing incidence of MVAs as it relates to DD. However, from September to December 1980, data regarding causes of death was collected from the English-speaking Caribbean, which showed MVAs as the fourth leading cause of death [22]. The study revealed MVAs were more likely to involve young males, and associated risk factors were inexperienced drivers and alcohol intoxication [22]. Today concern grows texting while driving represents a novel, growing risk factor for Caribbean MVAs.

The need for data to understand motivations behind DD is necessary to implement effective prevention campaigns and strategies. Recent research from 2015 suggests that there has been an increase in the number of non-fatal crashes in Grenada [6]. However, there has also been an increase from 4.1 to 11.9 per 100,000, in the proportion of fatalities in MVAs in Grenada from 2000–2009 [6]. Researchers speculate that a possible explanation for the increase could be DD, specifically texting while driving.

To address this growing problem in Grenada, we have begun collecting data on traffic accidents and cell phone use. Obtaining this information may be useful in understanding the current social influences on driving behavior to effectively reach and deter the public from DD [2]. This data will assist the national government by informing legislation of opportunities to deter drivers from texting. It will also aid to regional police, healthcare workers, and educators with developing awareness to this public health crisis [2].

Methods

Study Design, Oversight, Participants, and Data Management

Researchers obtained ethical and research clearance from the Institutional review board at St. George’s University in Grenada, while noting a minimal risk of discomfort associated with recollection of MVAs. Additionally, participants gained exposure to risks of texting while driving and insight regarding the risks of engaging in such behavior. No compensation was provided for participants, but it was communicated the information gathered will be provided to RGPF and to potentially inform policy, regulations and legislation.

The survey was a 16 question, anonymous, self-reporting paper questionnaire assessing cell phone usage while driving taking no more than 7 minutes to complete. The survey assesses the frequency of texting while driving and the reported frequency of MVA involving texting, as well as demographic data. The survey also assesses how informed participants are to the risks of texting while driving, current legislation, as well as which interventions they believe will reduce DD behavior. There were 191 motor vehicle drivers from all parishes across Grenada from April 1 through June 30, 2017. Drivers were approached in public car parks as well as roadsides by the study researchers to obtain informed consent for their participation in a survey. The informed consent was verbally obtained from drivers and upon receipt, drivers were presented with the survey to assess their texting and driving behavior.

Survey data was compiled to MS Excel dataset which was stored on a secured computer along with MVA data extracted from RGPF records into a separate MS Excel dataset by the principal investigators to be retained indefinitely. No personal identifiers were included in either dataset to ensure participant anonymity and confidentiality. Original paper surveys are retained in a secure location for five years, after which they will be destroyed.

Results

(Table 1) displays the compiled survey data regarding texting while regarding frequency, prevalence, circumstance, as well as receptiveness to interventions or discouraging factors.

Demographic Data and Overall Characteristics

Sample size was n=191 participants. For the variable of age, 180 valid responses recorded age, ranging from 18 to 64 years of age (mean=37.05 years, std. deviation=10.038 years). Grouping the sample by gender revealed 190 valid responses with men comprising a majority (men=97, 51.1%, women=93, 48.9%). Of 191 responses, 96 (50.3%) answered “yes” to the question “Have you ever texted while driving”, with 95 (49.7%) responding “No”. From 180 valid responses to the question “Have any of the following occurred to someone you know because of texting”, 32 (17.8%) responded that a MVA had almost occurred, 28 (15.6%) responded that a motor vehicle accident had occurred, and 2 (1.1%) had been ticketed. When asked “Are you aware of any local laws pertaining to texting while driving, 75 (41.1%) of the 181 usable responses replied “Yes” while 106 (58.6) replied “No”.

Differences between Groups

Stratifying the sample by texting behavior (Never texted while driving Vs. Ever) revealed statistically significant between group differences in variables: sex, age, and having known anyone in an MVA due to texting. Females were less likely to text while driving (females comprise 59% of never texted group vs. comprising only 40% of texting while driving group, p=0.009.) Mean age of participants who reported never texting while driving was older than those who responded texting while driving behavior (39.3 years ± 11 vs. 34.9 years ± 8, p=0.003. Having known anyone in a MVA due to texting was more strongly associated with the ever texted while driving group. 26% of people who admitted to texting while driving knew someone in texting related accident vs. 5% who never texted while driving knew someone in texting related accident (p=<0.001). No significant intergroup differences were found based on the variable of awareness of current local laws pertaining to texting while driving (43% who never texted were aware of laws vs. 40% who ever texted were aware of laws, p=0.735.)

Discussion

This study examined texting as a risk factor for MVA’s, frequency of negative outcomes from texting while driving, and knowledge and perception of these risks in the location of Grenada, West Indies. Utilizing survey responses to drive descriptive data gathering allowed for examination of risk taking behavior, as well as provided an opportunity for further investigation of possible public health interventions targeted to reduce harm caused by texting and driving.

Compared to females, male drivers were more likely to respond that they did engage in texting while driving (p=0.009), a difference reflected in prior studies examining distracted driving stratified by sex [14, 15, 9, 23–25] .Comparison of the mean ages between those who had never texted while driving versus those who did text while driving revealed that those who never texted while driving were on average 4.6 years older (39.3±11 years, 34.9±8, p=0.003). This is also supported by previous research that suggests that younger drivers are disproportionately affected by DD [14, 16, 17]. Additionally, there is a statistically significant relationship (p<0.001) between those admitting to texting and driving and knowing someone who was involved in a MVA due to texting. This provides evidence that the knowledge of MVAs involving DD, is not a strong deterrent of such behavior. In future studies, investigating the type or extent of the relationship between the texter and the victim of a MVA involving texting may be useful.

Awareness of the illegality and consequences for texting while driving was similar among those who did text and those who did not text while driving (p=0.735). This speaks to larger concerns about whether legislation alone is sufficient to deter DD since such laws cannot be regularly or strictly enforced. However, social influences seem to be connected to DD, as knowing someone who was involved in a MVA due to texting correlated with texting while driving. This may be explained by perceptions of risk while DD is in part reinforced through socialization, thus perpetuating the habit [26,24]. Since young adults are among the highest risk for DD, it is plausible to target primary driver education as a forum to teach how to drive distraction free despite social bias.

Table 1. Survey Data n=191. (Questions 4 through 12 only pertain to those who answered yes to question 1).

1. Ever texted while driving?

Yes

96 (50.3%)

No

95 (49.7%)

No Response

0

2. Are you aware of any local laws pertaining to texting and driving?

Yes

75 (41.4%)

No

106 (58.6%)

No Response

10

3. Any of the following occur to someone You know because of texting?

None

118 (61.8%)

Ticket

2 (1.0%)

Almost Accident

32 (16.8%)

Accident

28 (14.7%)

No Response

11

4. How often do you text while driving?

Rarely

57 (59.4%)

Sometimes

27 (28.10%)

Most of the Time

12 (12.50%)

No Response

0

5. Do you text while the vehicle is in Motion?

Standing Still

28 (29.2%)

In Motion

16 (16.7%)

Both

52 (54.2%)

No Response

0

6. How do you text?

Read Only

21 (22.1%)

Write Only

3 (3.2%)

Both

71 (74.7%)

No Response

0

7. Circumstances you text? Emergency

 44 (47.3)

Directions

7 (7.5%)

Can’t Wait

27 (29.0%)

Boredom

2 (2.2%)

All the Above

13 (14.0%)

No Response

3

8. Do you text when with others or alone?

Alone

57 (60.6%)

With Others

2 (2.1%)

Both

35 (37.2%)

No Response

2

9. Impact on driving ability while texting?

Negative

64 (68.1%)

Not Affected

29 (30.9%)

Positive

1 (1.1%)

No Response

2

10. Emotions about texting while driving?

Guilty

24 (25.3%)

Worried

35 (36.8%)

Neutral

34 (35.8%)

Invincible

2 (2.1%)

No Response

1

11. Is it dangerous to text and drive?

Yes

91 (95.8%)

No

4 (4.2%)

No Response

1

12. Have you ever had any of the following while texting?

None

67 (72.8%)

Ticket

1 (1.1%)

Near Accident

23 (25.0%)

Accident

1 (1.1%)

No Response

4

13. Would any of the following deter you from texting while driving?

Yes

No

No Response

Make it illegal to text and drive

43 (39.1%)

67 (60.9%)

81

Different Technology

65 (59.1%)

45 (40.9%)

81

Ticketing

23 (20.9%)

87 (79.1%)

81

Getting in an accident

32 (29.1%)

78 (70.9%)

81

Nothing

6 (5.5%)

104 (94.5%)

81

Most participants who responded “yes” to have you ever texted while driving admitted they believed it is dangerous (n=91, 95.8%), and their driving ability is negatively affected (n=64, 68.1%). One explanation of this contradictory behavior is the texters believe the frequency of texting while driving correlates with risk level, and having a relatively low texting rate reduces risk of MVA. Also, the majority of ‘texters’ tend to be alone in their vehicle (n=57, 60.6%), and have never personally encountered any negative consequences such as getting into an accident (n=1, 1.1%) or being ticketed for texting while driving (n=1, 1.1%). This suggests the perceived risk to oneself and not being responsible for other passengers may play a role in motivating texting behavior.

The subjects were asked about possible interventions to curb texting while driving to reveal what measures are perceived as effective by the population in deterring this behavior. The interventions perceived most effective were “implementation of different technology” to make texting safer (n=65, 59.1%), and “make it illegal to text and drive” (n=43, 39.1%). This suggests drivers want to continue to text and drive, and but would like to do so safely if possible. However, research suggests hands-free equipment such as headsets and vocally based texting technology still impairs a driving ability [19]. Additionally, about 40% of drivers reported making it illegal to text and drive would be a good deterrent. However as previous mentioned, ‘texters’ and ‘non-texters’ were equally aware of the legal regulations regarding texting and driving and it was determined to have no significant deterrent effects. Additionally, difficulty enforcing may compromise the efficacy of such a strategy as an independent and sole solution.

Conclusion

This study profiled DD from texting in Grenada. Survey data demonstrates the behavior is disproportionately prevalent among younger age groups and males, revealing vulnerable populations. Responses suggest interventions targeting socially reinforcing effects, safer technologies, as well as legislation may mitigate texting while driving’s consequence in Grenada, West Indies. The findings and conclusions of this study will be made available to the Royal Grenadian Police Force to inform public educational initiatives regarding attitudes surrounding DD, campaigns to reduce the behavior, and law enforcement policy to curb texting while driving.

References

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Low levels of HDL-cholesterol and endothelial dysfunction: a systematic review and meta-analysis

DOI: 10.31038/IMROJ.2018333

Abstract

Introduction

HDL-C is believed to retard the formation of atherosclerotic lesions by removing excess cholesterol from cells and preventing endothelial dysfunction. However, there are no systematic analyses or well-conducted meta-analyses to evaluate the relationship between very low HDL-C and endothelial dysfunction [1]. The aim of this study is to examine this association of very low HDL-C with endothelial dysfunction in different ages and sex.

Methods and analysis

The update systematic review and meta-analysis will be conducted using published studies that will be identified from electronic databases (i.e., PubMed, EMBASE, Web of Science, and Google Scholar. Studies that (1) examined the association between very low HDL-C and endothelial dysfunction, (2) had a longitudinal or prospective cohort design, (3) were conducted among in adults aged 34 to 70 years., (4) provided sufficient data for calculating ORs or relative risk with a 95% CI, (5) were published as original articles written in English or other languages, and (6) have been published until January 2018 will be included. Study selection, data collection, quality assessment and statistical syntheses will be conducted based on discussions among investigators.

Ethics and dissemination

Ethics approval was not required for this study because it was based on published studies. The results and findings of this study will be submitted and published in a scientific peer-reviewed journal.

Strengths and limitations of this study

This systematic review and meta-analysis will offer better understanding regarding the association between metabolic syndrome and endothelial dysfunction. The findings from this study will be useful for assessing of very low HDL-C and the risk factors in endothelial dysfunction, and determining approaches for prevention of endothelial dysfunction in the future.

An improved understanding of this relationship may help to inform public health endothelial dysfunction prevention strategies.

Included studies may have substantially different methodologies, which could limit our ability to draw reliable conclusions from the existing evidence base. Depending on the results, confounding factors that were not adjusted for the selected studies and low generalizability situations can be limitations.

To minimize these limitations we will evaluate the heterogeneity between the studies, perform sensitivity analysis and meta-regression.

Trial registration number: PROSPERO (CRD42018083467).

Abbreviations: CIs = Confidence Intervals, HDL = high-density lipoprotein, LDL = low-density lipoprotein, MD = mean difference, RR = risk ratio, WC = waist circumference

Key words

HDL-C, endothelial dysfunction, systematic review

Background

HDL is believed to retard the formation of atherosclerotic lesions by removing excess cholesterol from cells and preventing endothelial dysfunctionand a very low HDL-C increased risk of cardiovascular events [1].

It is in large part the results of unbalanced diet, low socioeconomic and cultural levels, stress and sedentary lifestyle. Although the literature on the very low HDL-C and the risk factors for endothelial dysfunction has been increasing, to our knowledge, a systematic review of the association between very low of HDL-C and risk of endothelial dysfunction has not yet been conducted [1–11].

This study aims to systematically access the association between a very low HDL-C and the endothelial dysfunction in adults aged 34 to 70 years; and to provide a framework to further understand these factors in order to better target prevention strategies.

Methods/Design

This systematic review of the literature will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The databases PubMed, Embase, Web of Science, Google Scholar, and Cochrane will be searched for articles [12]. Our search will focus on cohort, case-control and cross-sectional studies examining the association between very low HDL-C and endothelial dysfunction. The primary outcome is endothelial dysfunction. Two reviewers will independently screen articles, extract relevant data and assess the quality of the studies.

The aim of this analysis is to investigate whether there is an association between HDL-C levels and endothelial dysfunction in the adult population with cardiovascular outcomes. We plan to look at the prevalence of very low HDL-C levels in endothelial dysfunction individuals and to analyze whether low and very low HDL levels (<20; 20–30; 30–40 vs.> 40 mg/dL as ref. according to sex) in endothelial dysfunction might to be additional risk factor and predictor of CVD events, and mortality (CV-mortality, mortality and all-cause mortality) [1–2].

The study is registered with PROSPERO (CRD42018083467). This protocol conforms to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines [13–14].

Systematic review registration

This protocol is registered in the PROSPERO registry of the University of York (Reference number: CRD42018083467).

Objectives

The primary objective is to identify and summarize the association with of very low of HDL-C levels and with endothelial dysfunction risk in adults (34–70 years) in different ages and sexes.

Eligibility criteria

The PICOS strategy (population, intervention (changed to exposure for the purposes of this review of observational studies), comparator, outcome, study characteristics) was used to define the eligibility criteria for this study.

Inclusion criteria: studies will be considered if they include: endothelial dysfunction patients in the diagnosis of the low and very low HDL levels (<20; 20–30; 30–40 vs.> 40 mg/dL as ref. according to sex).

Exclusion: Reviews or abstracts from congresses/conferences, letters, editorials, case reports, interventional studies or clinical trials. We excluded studies that did not provide information on low and very low HDL levels (<20; 20–30; 30–40 vs.> 40 as ref. according to sex) in endothelial dysfunction and a control group.

Data will be extracted using a standardized template. We will use the PICOS (Population, Intervention, Comparator, Outcomes and Study design) framework, originally devised to formulate a research question, as a basis to develop data extraction criteria. As this is an aetiological study, ‘exposure’ will replace ‘intervention’ and ‘study characteristics’ will replace ‘study design’. Data items on the following five domains will be extracted:

  1. Population: characteristics of the study population (e.g., mean/median age, ethnic distribution), inclusion and exclusion criteria
  2. Exposure: definition and identification of very low HDL-C.
  3. Comparators: definition and identification of unexposed individuals, number of unexposed subjects
  4. Outcomes: definition and identification of primary (HDL-concentration of +/- endothelial dysfunction is the main exposure of interest. Patients with a diagnosis of endothelial dysfunction that present CVD outcomes, and death (CV mortality, all-cause mortality) and secondary outcomes (Biomarkers of endothelial cell dysfunction and endothelial cell activation, as well as non-invasive techniques to measure endothelial function), number of subjects with outcome
  5. Study characteristics: authors, publication year, setting/source of participants, design, methods of recruitment and sampling, period of study, length of follow-up time (if relevant), aims and objectives.

Outcomes

Primary outcomes

HDL-concentration of +/- endothelial dysfunction is the main exposure of interest. Patients with a diagnosis of endothelial dysfunction that present CVD outcomes, and death (CV mortality, all-cause mortality)

Secondary outcomes

Biomarkers of endothelial cell dysfunction, endothelial cell activation, as well as non-invasive techniques to measure endothelial function.

Study design

This is a systematic review and meta-analysis protocol of prospective cohort studies, following the PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocols) guideline [14]. The systematic review and meta-analysis will be reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline [15]. The whole process of study selection is summarized in the PRISMA flow diagram (Fig. 1). This study will not involve any private patient data; ethics approval was waived (see online supplementary file 1 for PRISMA-P checklist).

Search strategy

A systematic review of the literature will be conducted. A language restriction shall not be applied to the search. If there are relevant non-English abstracts, attempts shall be made to translate them wherever possible.  The following bibliographic databases (Embase, PubMed-MEDLINE, Web of Science, Cochrane Library, and Google Scholar) will be searched for articles published until January 2018.The search strategy will be developed by LR and HRZ; we anticipate that the databases will be searched from their inception to 30 December 2018 (see online supplementary file1 for the search strategies for PubMed, EMBASE, Cochrane Library, Web of Science, Embase, Google Scholar.

IMROJ-LeonardoRover_F1

Figure 1. Flow diagram of study selection process

Our search focuses on studies examining the association between very low HDL-C diagnosis and endothelial dysfunction in adults (34–70 years) [11]. At each step of the selection process, reasons for inclusion/exclusion will be recorded in the PRISMA Flowchart [13].

Data collection

A record will be kept of all searches and search decisions to ensure reproducibility. Search results will be exported to a citation management program (EndNote ver. 7.0). Duplicates will be removed and retained separately. The resulting references will be exported separately to the two reviewers for independent review using MS Excel.

Selection of studies

Two authors (LR, FCV) will independently screen all titles and abstracts identified through the literature searches and will exclude all records clearly not meeting inclusion criteria. Disagreements will be resolved by consensus. The selection process will be pilot tested to ensure a high degree of agreement between reviewers. Full text of the remaining studies will then be retrieved. The same two authors (LR, FCV) will independently assess the papers for fulfilment of inclusion criteria. In case of differences of opinion regarding study inclusion, a third review author (GBZ) will serve as arbiter. To avoid double counting, if multiple publications based on the same cohort of participants are retrieved, only the study reporting the largest sample size will be used. The reasons for excluding papers for which the full text was retrieved will be documented.

Data extraction and management

A data extraction form will be used to collect details from the included studies. The form includes information on study design, patient population, and presence of stroke. Two review authors (LR and FCV) will independently extract the data. The data extraction form will be pilot tested on several papers to ensure consistency and that all relevant information is being captured. If necessary, a statistician will review the extraction of data to further ensure quality and reliability. Authors will be contacted for missing data.

In terms of the study results, unadjusted and fully adjusted effect estimates for the association between very low HDL-C and endothelial dysfunction will be recorded. Details of the confounders measured and adjusted for will also be noted. Results of any additional stratified analyses will also be recorded. Where possible, results from additional subgroup analyses with evidence regarding our non-primary objectives will also be recorded, for example, the association between very low HDL-C and the secondary outcomes.

Assessment of methodological quality

Two investigators (LR and FCV) will independently assess each selected study for study quality using the Newcastle-Ottawa Quality Assessment Scale (NOS) [16]. The NOS evaluates cohort studies based on eight items categorized into the following three groups: (1) selection of the study cases, (2) comparability of the population, and (3) ascertainment of whether the exposure or outcome includes any risk of bias (i.e., selection bias or bias from lost to follow-up). The NOS is scored ranging from 0 to 9, and studies with scores ≥7 are considered as high quality [16]. Discrepancy of quality assessment among the investigators will be solved by discussion and consensus among all authors.

Data synthesis and statistical analysis

We anticipate that there may be significant heterogeneity in the prevalence of very low HDL-C features of endothelial dysfunction. There are several factors that could contribute to such heterogeneity. The relative risk (RR), and odds ratio (OR) are the way the result will be expressed statistically.

These factors include the following: differences in demographic and clinical features (e.g., age, hypertension, renal disease, smoking, duration and severity of diabetes) among study cohorts; differences in definitions of HDL-C. An I2 statistic will be calculated for the studies to be included in each proposed meta-analysis (i.e. for each neuroradiology correlate of interest) with values of 25, 50, and 75% suggesting low, moderate, or high degrees of heterogeneity, respectively, which report a dichotomized (i.e., present or absent) or categorical (i.e., absent, mild, moderate, severe) shall be harmonized for meta-analysis if deemed appropriate by our statistician. Other types of rating scales shall not be included in a meta-analysis and the data based on any such data scale would be presented in narrative form.

If significant heterogeneity between studies, as determined by consultation with our statistician, prevents meaningful pooling of the data, we will limit ourselves to providing a narrative description of observed trends. Given the heterogeneity of the populations studied, assumption of a fixed effect size across populations would not be justified, thus analyses would be performed using a random effects model. Given the dichotomized (presence or absence) or categorical (severity measure) nature of our data of, meta-analysis will be performed a random effects analysis. We will also add funnel graphs, publication bias analysis and a meta-regression analysis.

If there are sufficient data to allow such analyses (in principle from as few as a single high quality study, but if possible by pooling data from multiple studies), we will perform subgroup analyses for participants with renal disease and participants with hypertension. In addition, if sufficient data are available, we shall perform subgroup analyses by age and diabetes duration. Funding sources and conflict of interest will be extracted from included studies. Statistical analysis will be performed using RevMan software.

Strategy for data synthesis

The data of interest presented as continuous (mean value and SD) will be used to perform meta-analysis to obtain the standardized mean difference (SMD) and 95% confidence interval (CI). Cocharn’s Q-statistic and I-squared test will be used to test for heterogeneity between the included studies. If a I-squared value will be greater than 50% or a p value of the Q-test will be less than 0.05, indicating maximal heterogeneity among the included studies, a random-effect model will be put into use.

Analysis of subgroups or subsets

The subgroup meta-analyses will be conduct according to the pre-specified study-level characteristics using a fixed-effects meta-analysis and if there is substantial heterogeneity, we will use the random effects model. The sources included location, sex, age, method of HDL-C assessment, the definition of endothelial dysfunction. We also will conduct sensitivity analyses to evaluate the potential sources of heterogeneity in the analyses.

Summary of Evidence

We will produce a narrative synthesis of the main results extracted from articles in full text. A summary of the included studies will provide information on the authors, study design, participants, number and age of the subjects, theoretical structure (if relevant), alcohol consumption (as primary outcome of interest), main findings, Study information. Special emphasis will be placed on the identification of very low of HDL-C and the risk of endothelial dysfunction. In the presentation of the results, we will try to separate the factors for which the evidence of causality is strong (from longitudinal studies) and factors for which the causal nature of the relationship is less secure (cross-sectional data). A graphical summary of all the data they represent will be provided and take into account the number of studies that provide evidence of a factor and the relative strength of the association presented based on study design and quality assessment. The membership level will be evaluated based on adjusted data.

Discussion

This systematic review will synthesize research evidence to establish whether the risk of developing endothelial dysfunction is relatively high in adults with very low HDL-C. Strengths and limitations will be highlighted in the identified evidence. Strength of observational data may include large sample size, high rate of follow-up and frequency of stroke more likely to be representative of the population at risk. Limitations may include the quality of data extracted which may not allow studies to be combined in a meta-analysis. This may be overcome by presenting the findings in a descriptive manner. This review will conducted in collaboration with an experienced librarian who helped appraise the search criteria, refine the keywords and MeSH terms and identify appropriate database(s). To the best of our knowledge, no reviews have been published exploring the study question; however, if a review addressing a similar question is published, it will be incorporated in this review and added in a meta-analysis if feasible.

Implications of results

This systematic review will provide an updated and quantifiable estimate of the risk of endothelial dysfunction in adults with very low HDL-C. Furthermore, the systematic search will identify where future research is required. For instance, this review may inform a prognostic study which may be useful in understanding the course and factors associated with endothelial dysfunction development.

Amendments

If it is necessary we will update this protocol in the future. We will submit the original protocol, final protocol and summary of changes as a supplement.

Ethics and dissemination

Ethical issues

No ethical approval is required because this study includes no confidential personal data or interventions with the patients.

Publication plan

The procedures of this systematic review and NAM will be conducted in accordance with the PRISMA-compliant guideline. The results of this systematic review and NAM will be submitted to a peer-reviewed journal for publication.

Authors’ information: Not applicable

Competing interests: The authors declare that they have no competing interests.

Consent for publication: Not applicable

Ethics approval and consent to participate: Not applicable

Availability of supporting data: Not applicable

Funding: Not applicable

Authors’ contributions

LR, ASRB, ALDD, ACF, NPS, PMMD, RMLS, JLO, MN, AD, PARD, FRS, GBFO, GBZ, SAH, PEOR, AJG, RMP, ACF, PMMD, TMF, NN, SA, CD, TL GT, AJCN, LMAS, ROF, PFSG, A.A, AVH, MIR, RDL and FCV conceived the study idea and devised the study methodology. LR, ASRB, ACPC and ESR participated in the design and coordination of the study. LR was primarily responsible for protocol writing and developed the search strategy. LR and FCV will screen identified literature, conduct data extraction and analyses the review findings. All authors read the drafts, provided comments and agreed on the final version of the manuscript.

Acknowledgements: Not applicable

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