bluuebunny/crossref_metadata_2025 huggingface dataset:
832 Dose-Dependent Quetiapine-Induced Somnambulism and Sleep-Related Eating Disorder
Authors: Pham Tuyet , Malhotra Sonal
Published: May 2021

Introduction

Parasomnias are abnormal sleep-related movements that can occur during non-rapid eye movement sleep, rapid eye movement sleep, or transition of sleep. The prevalence of parasomnias in young children ranges from 9–40% which may be underestimated as this relies on parental recall. There are multiple reported cases of pharmacologically-induced parasomnias. Quetiapine is an atypical antipsychotic medication associated with somnambulism and sleep-related eating disorder.

Report of case(s)

A 9-year-old female with a history of attention deficit hyperactivity disorder, post-traumatic-stress disorder, depression, and sexual abuse during childhood presented to the Sleep Medicine Clinic for two years of worsened sleepwalking and sleep eating. Her medications included Methylphenidate, Quetiapine, Clonidine, and Duloxetine. She has had parasomnias since she was 3-years-old, initially presenting as abnormal sleeping positions (standing or sitting). She was initiated on Seroquel at 4-years-old, but parasomnias worsened over the last two years when Quetiapine was increased from 50 mg to 200 mg for behavioral and mood issues. Her somnambulism began to occur nightly. The family was required to remove all items from her bedroom except for the bed to prevent major injuries. She also had significant changes to her eating habit: she would eat two to three times her normal quantity as well as eating while asleep. The family would find her eating ice cream, chips, grapes, cold tortillas, or anything she was able to access. Fortunately, she did not consume raw meat or other frozen foods. The child did not have any recollection of eating at night. Psychiatry worked with her to cross-taper Quetiapine and Topiramate. At the lower dose of Quetiapine, she had exacerbation of her mood symptoms, paranoia, and insomnia; therefore, Topiramate was discontinued and Quetiapine was titrated to 150 mg with improvement in mood symptoms, insomnia, and resolution of sleep-related eating disorder. She continues to have somnambulism.

Conclusion

This case illustrates that quetiapine-induced somnambulism and sleep-related eating disorder can be dose-dependent; thus, important for clinicians to educate patients and/or family members of adverse effects while titrating quetiapine.

Support (if any):
846 Pulmonary Arterial Hypertension as a Sequela of Untreated Obstructive Sleep Apnea in a Patient with Prader-Willi Syndrome
Authors: Emanuel Hina , Kaplan Kevin
Published: May 2021

Introduction

Prader-Willi Syndrome (PWS) is a complex neurogenetic disorder characterized by hypotonia, behavioral problems, endocrinopathies, sleep and respiratory abnormalities. Morbidity and mortality in the PWS population is attributable to obesity, cardiovascular problems, and sleep apnea. We report a patient with PWS presenting with pulmonary arterial hypertension (PAH) due to untreated obstructive sleep apnea (OSA).

Report of case(s)

Our patient is a 17-year-old female with a past medical history of PWS, scoliosis, obesity (BMI 52.46), hypogonadotropic hypogonadism, and type II diabetes. Baseline echocardiogram (ECHO) performed at age 9 revealed an estimated right ventricular systolic pressure (eRVSP) of 32mmHg above right atrial pressure (RAP), tricuspid regurgitation (TR) at 2.8 m/sec with no interventricular septal flattening (IVSF) and right ventricle (RV) systolic dysfunction suggestive of mild PAH. Given significant scoliosis the patient did not qualify for growth hormone therapy. She underwent a polysomnogram (PSG) at age 14 showing severe obstructive sleep apnea; apnea-hypopnea index (AHI) of 22.6 (oAHI 22.6). Patient was subsequently lost to follow up until presenting in acute respiratory failure at age 17. She required endotracheal intubation and was extubated to bilevel PAP (BPAP) with inability to wean off BPAP. At that time an ECHO revealed eRVSP of 55 mmHg above RAP, IVSF, TR at 3.7 m/sec, and RV systolic dysfunction suggestive of moderate to severe PAH and developing right sided heart failure. A PAP titration PSG during this admission revealed hypoxemia with oxygen saturation less than 90% (O2 nadir 70%) 12.6% of total sleep time (TST) and hypoventilation (transcutaneous CO2 max of 57 mmHg with an elevation above 50 mmHg for 100% of TST). Using an inspiratory PAP (IPAP) of 24 cmH2O and expiratory PAP (EPAP) of 14 cmH20 with supplemental O2 of 4LPM the respiratory events and hypoxemia resolved but there was persistence of hypoventilation. Tadalafil was initiated for PAH and BPAP therapy for OSA. Follow up visits 4- and 8-weeks post discharge shows improving PAH (TR 3.6 m/sec, eRSVP 52 mmHg, and mild IVSF) due to BPAP and tadalafil therapies.

Conclusion

This case highlights the importance of treating OSA in patients with PWS to prevent cardiorespiratory complications and reduce morbidity and mortality.

Support (if any)

None
848 Refractory Hypoventilation in Congenital Central Hypoventilation Syndrome: A Case for Average Volume-Assured Pressure Support
Authors: Gubichuk Megan , McHugh Erin , Malhotra Sonal , Sockrider Marianna , Kancherla Binal
Published: May 2021

Introduction

Congenital Central Hypoventilation Syndrome (CCHS) is a rare cause of alveolar hypoventilation in children resulting in lifelong ventilatory support. In older children requiring nocturnal support alone, the use of diaphragmatic pacing in conjunction with or independent of non-invasive ventilatory (NIV) support has been demonstrated to improve quality of life. We present a case of refractory hypoventilation despite escalation of NIV.

Report of case(s)

20-year-old female with Hirschsprung’s disease and CCHS (20/26 polyalanine repeats) with history of invasive ventilation via tracheostomy who underwent bilateral diaphragmatic phrenic nerve stimulator placement at 13 years-of-age with subsequent tracheostomy decannulation. Diaphragmatic pacing was discontinued three years later in the setting of pneumonia and patient discomfort because of receiver positioning. At that time, she had improved subjective sleep quality and adequate ventilatory support on bi-level positive airway pressure (PAP) despite discontinuation of diaphragmatic pacing. Titration of bi-level PAP was done via polysomnogram four years later demonstrating nocturnal hypoventilation with transcutaneous CO2 values greater than 50 mmHg for 80% of the study and an oxygen nadir of 87% despite titration of inspiratory pressure and respiratory rate to maximize ventilatory assistance. The patient was subsequently admitted to the intensive care unit for transition to non-invasive average volume-assured pressure support (AVAPS) mode. Ventilation improved with nocturnal pCO2 values via capillary blood gas of 31 mmHg and 45 mmHg at 2 am and 6 am respectively. The patient was discharged on AVAPS therapy while undergoing evaluation to resume diaphragmatic pacing via cervical phrenic nerve stimulators for improved comfort.

Conclusion

Several ventilatory strategies may be employed in the care of patients with CCHS, with individualization of support based on phenotype, comorbidities, and patient and family preference. This case highlights the unique challenges of adequately ventilating patients as they age. The use of NIV via an AVAPS mode in patients with CCHS has been infrequently reported in the literature, though is promising in reported efficacy with regards to ensured ventilation. This, in conjunction with diaphragmatic pacing, may allow patients to achieve appropriate ventilation while maintaining quality of life, and could be considered in patients with refractory hypoventilation despite other modes of NIV.

Support (if any):
852 Severe Central Sleep Apnea in a Patient with Cornelia de Lange Syndrome
Authors: Willis Aaron , Petitto Lacie , Revana Amee
Published: May 2021

Introduction

Cornelia de Lange syndrome (CdLS) is a rare multisystem disorder with characteristic facial dysmorphisms, upper airway structural abnormalities, and varying degrees of intellectual and neurologic deficits. Affected patients can have many sleep problems including chronic insomnia and obstructive sleep apnea; however, there is no literature indicating central sleep apnea as a common sleep disorder in this patient population. We describe a patient with CdLS with an unusual presentation of both severe obstructive and central sleep apnea.

Report of case(s)

The patient is a 12-year-old female with CdLS, global developmental delay, repaired bilateral cleft-palate, and oropharyngeal dysphagia. She was referred for diagnostic polysomnography for evaluation of snoring. Physical examination findings were significant for distinctive features of the head and face including microcephaly, micrognathia, and synophrys. Neurologically, the patient was non-verbal and wheelchair bound. Pre-evaluation screening indicated no concerns from the caregiver regarding problems with sleep initiation, maintenance, or daytime symptoms. Polysomnography (PSG) at age 7 years revealed severe obstructive and central sleep apnea with an apnea-hypopnea index (AHI) of 78.2/hr. The majority of these were central events (68.44/hr). There were no epileptiform foci recorded. Bilevel Positive Airway Pressure (BPAP) in Spontaneous/Timed (S/T) mode was titrated during the study which resolved all central events. Magnetic resonance imaging of the brain was obtained indicating mild hypoplasia of the corpus callosum. Since the initial PSG, 5 additional routine studies were conducted and progressive worsening of central sleep apnea was noted with the highest recorded AHI of 108.8/hr (central events: 81.4/hr). Apneic events were fairly managed with BPAP in ST mode.

Conclusion

Sleep-disordered breathing in CdLS is an increasingly diagnosed entity. While previous literature indicates airway obstruction as a common cause for sleep apnea in children with CdLS, our case suggests that clinicians should consider central causes of sleep apnea in these patients. Given the sub-clinical progression of sleep apnea in this case study, routine follow up PSGs should be considered. Further research is necessary to increase knowledge of the incidence and management of central sleep apnea in children with CdLS.

Support (if any):
853 Severe Obstructive Sleep Apnea after Treatment with Phrenic Nerve Implant for Central Sleep Apnea: A Case for Dual Stimulation?
Authors: Sussman Sarah , Ananth Ashwin , Fares Elie , Huntley Colin , Boon Maurits , Fast Zhanna
Published: May 2021

Introduction

The remedē® system is a transvenous phrenic nerve stimulator used to treat central sleep apnea (CSA). It is a safe and effective implantable device that has demonstrated significant improvements in objective sleep and quality of life. While complex sleep apnea represents development of central sleep apnea during treatment with continuous positive airway pressure (CPAP) for obstructive sleep apnea, and has been well-described in the literature, we present a novel case of predominantly central sleep apnea treated with phrenic nerve stimulation with augmentation of obstructive events thereafter. This patient is, at the time of submission, being evaluated for hypoglossal nerve stimulation.

Report of case(s)

A 63-year-old male patient with a past medical history of hypertension, atrial fibrillation, asthma, chronic obstructive pulmonary disease, GERD, obesity, and prior pulmonary embolism presented to the sleep medicine clinic with complaints of difficulty initiating and maintaining sleep, snoring, multiple nocturnal awakenings, excessive daytime sleepiness, and physical fatigue. On exam, BMI was 30.4, and airway classification was Mallampati 4. Split night polysomnography revealed severe mixed sleep apnea with an overall apnea hypopnea index (AHI) of 58.6 and a central AHI of 53.8 per hour after successful PAP titration at 7 cm H2O. He underwent phrenic nerve stimulator implantation and activation without complications. Phrenic nerve stimulation titration study four months after activation showed a normal central AHI of 4.6 per hour at a therapeutic voltage of 1.6 to 1.9mA, but significantly worse OSA with obstructive AHI of 53.1. In follow up, he reported intolerance of CPAP due to significant nasal congestion as well as asthma. Presently, he is scheduled for drug induced sleep endoscopy to visualize airway obstruction and is being evaluated for Inspire hypoglossal nerve stimulation and nasal surgery.

Conclusion

The treatment of sleep apnea has recently evolved rapidly with the development of implantable devices to treat both central and obstructive sleep apnea. We present a novel case of the first known patient to be considered for dual nerve stimulation for sleep apnea. Further study needs to be done to determine the safety and efficacy of concurrent implantable devices for the simultaneous treatment of OSA and CSA.

Support (if any):
856 Sleep-writing, sleep-talking in uncontrolled REM-predominant obstructive sleep apnea
Authors: Ho Minh Tam , Ghildiyal Naomi , Liendo Cesar , Monceaux Brittany , Asghar Sheila , Anne Pratibha , Koothirezhi Rupa , Okorie Ugorji , Chernyshev Oleg
Published: May 2021

Introduction

Abnormal movements and behaviors during sleep are part of a larger group of nocturnal events that may occur during the sleep-wake cycle and/or the transitions into and out of sleep. We are presenting the case of OSA-related confusional arousals associated with sleep-writing and sleep-talking during REM-sleep.

Report of case(s)

46 year old female with history of CAD, HTN, RLS, Anxiety, Depression, and REM predominant OSA (AHI of 2.9 per hour of sleep, REM AHI of 40 per hour of sleep, and oxygen saturation nadir of 91%), noncompliant with PAP therapy, returned to reestablish sleep medicine care and restart PAP therapy. The patient reported worsening of her OSA symptoms while being without PAP therapy. In addition to traditional OSA symptoms (snoring, frequent nighttime awakenings, restless legs, daytime sleepiness/fatigue), she reported episodes of sleep-talking, sleep-writing with demonstrated evidence of these events in her personal diary. She maintains a collective diary that incorporates her blood pressure readings, her weight loss accounts with records of meals in a day, as well as a separate log of letters that she will write and mail. In this diary, she has noticed sleep writing instances in each field, with no recollections subsequently on the act of writing them. The patient reported that these episodes of sleep writing would occur 3–4 times in a week, during this period of PAP noncompliance. Last reported instance of her sleep writing was October 2020. After re-initiation of PAP therapy, the patient has not reported further episodes of sleep-writing or sleep-talking.

Conclusion

The sleep-writing is a very rare clinical symptom in the presentation of REM-predominant OSA as well as in REM/NREM parasomnias. We were not able to come across a case of it in the sleep literature review. Sleep-talking is a well-documented phenomenon. Confusional arousals may be responsible for symptoms of sleep-writing and sleep-talking in this case. We may repeat a sleep study with split protocol and parasomnia montage using AutoBipap if needed to investigate further. Further research should be done to explore the nature and correlation of sleep-writing in clinical practice.

Support (if any)

N/A
860 Variable Sleep Apnea Syndromes Complicated by Neurosurgeries in a Patient with Chiari Malformation Type 1
Authors: Ananth Ashwin , Fares Elie , Sagalow Emily , Nemargamulla Swetha , Fast Zhanna
Published: May 2021

Introduction

Chiari malformations (CM) are congenital conditions defined by craniocervical junction anatomic anomalies with downward displacement of cerebellar structures. Sleep-disordered breathing (SDB) including obstructive sleep apnea (OSA), bradypnea, central sleep apnea (CSA), and hypoventilation are described in CM patients.

Report of case(s)

31-year-old male with history of CM type 1 presented to the sleep medicine clinic for management of OSA and CSA diagnosed at age 16. PSG showed an apnea-hypopnea index (AHI) of 14.2, RDI of 29, and no central events. He was started on auto-CPAP with pressures of 5–20 with subsequent visits showing high residual AHI. A subsequent CPAP-titration study resulted in a pressure of 16cm H2O yielding AHI of 0. CPAP pressure was fixed, but a high residual AHI persisted despite excellent compliance. A split-night study resulted in a BiPAP prescription, for which a titration study noted PAP-emergent CSA. He was started on auto Bilevel with IPAP of 30, EPAP of 8 and backup rate of 12bpm. Despite treatment, elevated AHI persisted so he was switched to adaptive servo-ventilation (ASV) with nightly oxygen blended in resulting in controlled complex sleep apnea. SDB management was complicated by multiple neurosurgical decompressions. During the most recent procedure, he was found to have syringomyelia, syringobulbia, and a mass at the brainstem. Surgery, including placement of a 4th ventricle stent and mass excision, initially led to a decrease of residual AHI to a low of 0.7, before progressively increasing to 15. A repeat PSG demonstrated severe OSA (AHI of 35), without evidence of CSA or nocturnal hypoventilation. ASV was resumed and patient’s AHI progressively decreased to an average of 8, with improvement in his sleep apnea symptoms.

Conclusion

SDM in CM patients can be explained by condition-related anatomical changes and depression of respiratory centers due to possible extrinsic compression leading to complex sleep apnea presentations. While it is unclear why this patient’s sleep apnea improved then worsened after his latest decompression surgery, we believe that CSF recirculation and postoperative inflammation may be responsible. Close monitoring of SDB in patients with CM is important as they may require advanced therapies for proper control.

Support (if any):
861 Vascular dementia presenting as rapidly progressive dementia secondary to zolpidem
Authors: Barber Cameron , Carroll Dylan , Suryadevara Bhavani
Published: May 2021

Introduction

Rapidly progressive dementia is a condition with a wide differential which remains difficult to accurately diagnose. The potential pathologies responsible include thyroid, vitamin, and electrolytes abnormalities, infectious, and malignant causes. Vascular dementia, however, typically has a slow and insidious presentation. Zolpidem (Ambien) is among the top 50 prescribed medications in the US.

Report of case(s)

An 84-year-old Caucasian male with a past medical history of insomnia, and sleep apnea who is noncompliant with CPAP presented after a fall associated with altered mental status. He has taken zolpidem 10 mg nightly for over six years. The patient and wife reported notable personality changes beginning six months prior, as well as four months of progressively worsening auditory and visual hallucinations. Additionally, the patient noted developing urinary incontinence, and worsening gait steadiness with recurrent falls. The patient then developed sleep-wake inversion during the three weeks prior to his fall, and an outpatient referral to neurology was subsequently sent for dementia evaluation. On the night prior to his presentation, the patient took his usual nighttime zolpidem at 22:00 and later fell and was unable to get up. Subsequent testing was negative for reversible causes of dementia and MRI Brain revealed only chronic microvascular disease. His zolpidem dose was decreased to 5 mg and scheduled earlier which resulted in the resolution of his hallucinations, gait abnormalities, and acute encephalopathy.

Conclusion

One month later, the patient presented to the hospital after a repeat fall secondary to taking his zolpidem at his previously scheduled time. Once more, his dosage was further decreased to 2.5 mg and scheduling earlier, resulting again, in the complete resolution of his symptoms. Zolpidem, has an increased potential for delirium in elderly patients and especially those with dementia. Chronic use of zolpidem with insidiously progressive vascular dementia led to a worsening delirium which resolved after adjustment of timing and reduction of zolpidem dosing.

Support (if any):
862 Volume-Assured Pressure Support improves outcomes in a patient with Congenital Central Hypoventilation Syndrome
Authors: Ianus Vlad , Grigg-Damberger Madeleine , Diaz Shanna , Cutrufello Nicholas
Published: May 2021

Introduction

Congenital Central Hypoventilation Syndrome (CCHS) is a condition caused by a mutation of the PHOX2B gene and an incidence of 1 in 50,000 live births. Clinically the condition is characterized by autonomic nervous system dysfunction, the most prominent feature of which is the failure of respiratory homeostasis during sleep. In patients severely affected, life-long ventilatory support is required. This might start as early as the newborn period. Subsequent adjustments are required due to their growth and development. The role of Volume-Assured Pressure Support (VAPS) ventilation in treatment of CCHS was only described in a couple reports before.

Report of case(s)

A 17-year-old female patient born at term and diagnosed with CCHS at birth at our center with a PHOX2B mutation confirmed. Her daytime ventilatory support was weaned at age 18 months and the tracheostomy was removed at age 10 years old. She relocated to another state, was lost to follow-up, and returned this year for adjustments of her ventilator whose settings had not been adjusted for several years. She was on a Trilogy 100 ventilator, in pressure-controlled mode with settings of EPAP 5, IPAP 20, and a rate of 22/min without supplemental oxygen. Her measured weight is 69kg, body mass index (BMI) 27. The patient complained of difficulty breathing while on those settings and reported decreased desire to use the machine. The patient was empirically switched to VAPS due to titration availability limitations during the COVID-19 pandemic. Initial AVAPS settings were: EPAP 4–7, PS 3–12, breath rate 16/min, TV 350mL. Upon implementing the changes, the patient reported improved comfort and increased usage. Average minute ventilation decreased from 10.5 to 5.8 L/min, patient triggered breaths increased from 1.1% to 12.3%, average breaths per minute decreased from 22.0/min to 16.2/min, the average peak flow 31.8 to 26.2L/min, tidal volume decreased from 463 to 355mL.

Conclusion

AVAPS ventilation can be successfully used in managing patients with CCHS, and it might be superior to pressure-controlled mode in certain cases, improving patient comfort and compliance.

Support (if any)

Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM.
Patient and surgical factors affect postoperative opioid prescription for orthopaedic trauma patients undergoing single-admission, single-surgery fracture fixation: a retrospective cohort study
Authors: Mickley John , Roebke Austin J. , Everhart Joshua S. , Goyal Kanu S. , Ly Thuan V.
Published: May 2021

Background:

The authors sought to determine patient and surgical factors associated with increased postoperative opioid prescription requirements as an inpatient, during the first 6 wk, and beyond 6 wk for orthopaedic trauma patients undergoing single-admission, single-surgery fracture fixation.

Methods:

Two hundred patients who underwent fixation of isolated fractures (pelvis n=50, hip n=50, periarticular n=50, long bone n=50) were included in the study. Multivariate regression modeling was utilized to determine predictors of inpatient opioid usage.

Results:

Patients were prescribed an average of 7.9±9.1 5-milligram (mg) pills of oxycodone during the last 24 hr of inpatient opioid administration, 131±132.1 pills during 6-week outpatient period, and 23 (11%) patients continued to be prescribed opioids beyond 6 wk. Twenty-nine (14.5%) patients received opioids from a provider other than the treating surgeon or emergency department. Seventy-eight (39%) patients received at least one additional prescription for opioids after the initial discharge prescription. Predictors of increased inpatient opioid requirements during the last 24 hr were: younger age, baseline opioid use, longer length of surgery, and tobacco use. Predictors of higher 6-week outpatient opioid prescription amounts were younger age, increased operative time, baseline opioid use, unemployment, pelvic fractures, and inpatient opioid use during the 24 hr before discharge. Baseline opioid use, tobacco use, and pelvic fracture were all independent risk factures for opioid prescription beyond the 6-week follow-up period.

Conclusions:

Opioid use and prescription for orthopaedic trauma patents following single-admission, single-surgery fracture fixation is strongly predicted by surgical and patient factors.

Level of Evidence:

Level III.
Aspirin as venous thromboembolism prophylaxis in total joint arthroplasty: a narrative review of the current evidence
Authors: Rinehart Dustin , Youngman Tyler , Huo Michael
Published: May 2021

The utilization of aspirin (acetylsalicylic acid [ASA]) as primary prophylaxis for venous thromboembolism (VTE) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) in the United States has increased in concordance with the number of arthroplasty procedures being completed. The available literature regarding dosage, duration, efficacy, and safety varies considerably. This review assessed the recent published literature for both the efficacy and safety of aspirin as VTE prophylaxis. Overall, the rates of symptomatic VTE found in the literature ranged from 0.1% to 4.1%, of deep vein thrombosis (DVT) 0.1% to 3.0%, and of pulmonary embolism (PE) 0.1% to 1.5%. As for secondary outcome measures, the rate of major bleeding from either a gastrointestinal source or at the surgical site ranged from 0% to 3.2%, and the rate of transfusion between 7.0% to 20.0%. Among the studies that reported the infection rates, it ranged from 0.1% to 6.1%. The 90-day mortality rate was 0% to 0.23%. The available data and evidence remain inconclusive with regard to ASA dosage or the duration for patients after TKAs and THAs. However, ASA appears to be an effective option for VTE prevention when utilized as part of a multimodal approach to prophylaxis that includes early mobilization and mechanical compression devices.
Conservative management of posterior cruciate ligament avulsion with a large bony fragment: a prospective cohort study
Authors: Bagherifard Abolfazl , Jabalameli Mahmoud , Khezri Mahsa , Hadi Hosseinali , Mirzaei Alireza , Yahyazadeh Hooman
Published: May 2021

Background:

Internal fixation is the standard choice for treatment of posterior cruciate ligament (PCL) avulsion with a large bony fragment. However, it is not without complication. This study investigated PCL avulsions with large bony fragments to determine if conservative management resulted in acceptable outcomes.

Methods:

In a prospective cohort study, the outcome of conservative management of PCL avulsion with large bony fragment was evaluated in 40 patients. The inclusion criteria were a fracture size of more than 20 mm and a displacement of less than 2 mm. The outcomes were evaluated after 12 mo and included the evaluation knee range of motion and scoring of the modified Lysholm questionnaire and the International Knee Documentation Committee. Knee instability was checked by the drawer test and confirmed by stress radiography.

Results:

The mean patient age was 36.9±16.1 yr. The mean final knee range of motion (ROM) was 125.6±8.2 degrees. The mean Lysholm score was 92.3±6.1 points. Accordingly, the excellent, good, and fair results were observed in 29 (72.5%), eight (20%), and three (7.5%) patients, respectively. The mean International Knee Documentation Committee score of the patients was 94.2±5.3 points. Postoperative instability was seen in two patients. Nonunion was observed in two other patients. The size of the bony fragment was 30 and 32 mm in patients with nonunion.

Conclusions:

Conservative management of the PCL avulsion with a large bony fragment could result in acceptable outcome. However, application of this technique needs further characterization, particularly with respect to the size of bony fragment.

Level of Evidence:

Level II.
Racial and socioeconomic disparities among patients undergoing hip arthroplasty: a New York State population analysis
Authors: Darbandi Aria
Published: May 2021

Background:

Hip arthroplasty places a large economic burden on the United States healthcare system, and there is a need to better understand influencing factors to help prepare for and limit expenditures. We aimed to assess racial and socioeconomic factors that influence hospital charges and length of stay using the New York State population.

Methods:

This study used the publicly available New York Statewide Planning and Research Cooperative System (SPARCS) database to identify hip replacement cases from 2013 to 2016 in New York State. Multivariable logistic regression models were used to examine characteristic differences between white and black patients. Multivariable linear models were used to identify predictive variables for hospital charges and length of stay.

Results:

White patients had lower mean length of stay (3.61 vs. 4.35, P<0.0001) and hospital charges ($55,988 vs. $67,742, P<0.0001). Medicaid patients were more likely to be black compared to the privately insured (OR: 4.37, CI: 4.08 to 4.68). Black race predicted higher hospital charges and length of stay (P<0.0001). Medicaid predicted longer length of stay (P<0.0001).

Conclusions:

Racial and insurance-based disparities exist among hip replacement patients, and these factors influence length of stay and hospital charges. These tendencies should be noted by healthcare administrators to limit the economic burden of hip arthroplasty.

Level of Evidence:

Level III
Quality Evaluation of Visual Display Terminal Syndrome Videos Shared on YouTube
Authors: Kang Ji-Soon , Lee Shin-Young , Lee Seonah
Published: May 2021

Visual display terminal syndrome is a health problem that occurs when an individual looks at a visual display terminal for a long time. This study aimed to evaluate the quality of YouTube videos on visual display terminal syndrome. YouTube was searched using the keywords “visual display terminal syndrome” and “a prolonged user of a computer or smartphone” on October 16, 2019. A total of 45 videos were evaluated using DISCERN and the Journal of the American Medical Association scoring systems. The variables extracted from the videos were the uploading agency; content; presentation format; days since upload; the number of views, likes, dislikes, and comments; and the video power index. The mean DISCERN and Journal of the American Medical Association scores were 35.64 and 3.08 points, respectively, indicating that the information on visual display terminal syndrome in YouTube videos was inaccurate and unreliable. The major reason for the low quality of the videos was that the sources of information presented in the videos were not provided. The DISCERN and Journal of the American Medical Association scores showed significant differences in the uploading agency and presentation format variables. Nurses must be familiar with evaluating the quality of videos presenting health information. Guidelines informing patients that YouTube might provide misinformation about health need to be developed.
Nursing Informatics in Israel From a Historical Perspective
Authors: Gonen Ayala , Segev Ronen
Published: May 2021

The field of nursing informatics is expanding in Israel, which is known as a start-up nation. This study is a systematic literature review aimed to obtain a historical perspective of the Israel's nursing informatics development. To study how nursing informatics has evolved in Israel over the past 20 years, we analyzed two major issues: (1) the development of the nursing informatics field over these years; and (2) nursing informatics studies that were carried out by nurses. The main criteria for choosing these studies were: (1) nursing informatics research conducted in Israel; (2) investigated by nurses; and (3) published in academic international journals, including PhD dissertations. Thirty studies were located, and two main issues were identified: nurse managers who were engaged in health information technology were not recognized as nursing informatics practitioners, and a minority of nurses performed nursing informatics researches. Although many health information technology projects were and are performed in Israel, the nursing informatics field is not fully recognized by Israeli nurses. Therefore, it is essential for Israeli nurses to understand the importance of advancing the nursing informatics body of knowledge, which will give nurses the authorization to become influential as health information technology professionals in areas such as health education, practice, and research—for the benefit of patients.
Nursing Documentation Variation Across Different Medical Facilities Within an Integrated Healthcare System
Authors: Kang Min-Jeoung , Rossetti Sarah Collins , Knaplund Christopher , Chang Frank Y. , Schnock Kumiko O. , Whalen Kimberly , Gesner Emily J. , Garcia Jose P. , Cato Kenrick D. , Dykes Patricia C.
Published: May 2021

The purpose of this study was to demonstrate nursing documentation variation based on electronic health record design and its relationship with different levels of care by reviewing how various flowsheet measures, within the same electronic health record across an integrated healthcare system, are documented in different types of medical facilities. Flowsheet data with information on patients who were admitted to academic medical centers, community hospitals, and rehabilitation centers were used to calculate the frequency of flowsheet entries documented. We then compared the distinct flowsheet measures documented in five flowsheet templates across the different facilities. We observed that each type of healthcare facility appeared to have distinct clinical care foci and flowsheet measures documented differed within the same template based on facility type. Designing flowsheets tailored to study settings can meet the needs of end users and increase documentation efficiency by reducing time spent on unrelated flowsheet measures. Furthermore, this process can save nurses time for direct patient care.
Research Topics and Trends in Interprofessional Education in Nursing
Authors: Kim Kisook , Lee Ki-Seong
Published: May 2021

To provide nurse-led interprofessional practices in a healthcare setting, carrying out effective research that identifies the trends and characteristics of interprofessional education is necessary. This study aimed to objectively ascertain trends in the field through text network analysis of different types of interprofessional education literature. Titles and thesis abstracts were examined for terms “interprofessional education” and “nursing” and were found in 3926 articles from 1970 to August 2018. Python and Gephi software were used to analyze the data and visualize the networks. Keyword ranking was based on the frequency, degree centrality, and betweenness centrality. The terms “interprofessional,” “education,” “student,” “nursing,” and “health” were ranked the highest. According to topic analysis, the methods, provided programs, and outcome measures differed according to the research field. These findings can help create nurse-led research and effective future directions for interprofessional education pathways and topic selection. This will emphasize the importance of expanding research on various education programs and accumulating evidence regarding the professional and interdisciplinary impact these programs have on undergraduate and graduate students.
Enhancing Self-Advocacy After Traumatic Brain Injury: A Randomized Controlled Trial
Authors: Hawley Lenore , Morey Clare , Sevigny Mitch , Ketchum Jessica , Simpson Grahame , Harrison-Felix Cynthia , Tefertiller Candace
Published: May 2021

Objective:

To evaluate the efficacy of a novel intervention aimed at enhancing self-advocacy in individuals living with traumatic brain injury (TBI).

Setting:

Community.

Participants:

Sixty-seven (35 allocated to treatment, 32 to control) community-dwelling adults 9 months or more post-TBI (mean of 8.9 years postinjury); previously discharged from inpatient or outpatient TBI rehabilitation; able to travel independently in the community, indicating a level of independence needed to engage in self-advocacy.

Design:

Longitudinal randomized 2-arm controlled trial (NCT no. 03385824). Computer-generated block randomization allocated participants to treatment/intervention or control/no-intervention. All outcome assessments completed by blinded study staff.

Intervention:

A manualized group intervention, Self-Advocacy for Independent Life (SAIL), addressing the self-efficacy beliefs, knowledge, and skills for self-advocacy following TBI.

Main Outcome Measures:

The Self-Advocacy Scale (SAS) (primary); General Self-Efficacy Scale (GSE); Personal Advocacy Activity Scale (PAAS); Satisfaction With Life Scale (SWLS).

Results:

The treatment group showed significantly greater improvement than controls from baseline to posttreatment on the primary measure (SAS) of self-efficacy specific to self-advocacy after TBI (effect size = 0.22). Similar improvements were found on secondary measures of general self-efficacy and satisfaction with life from baseline to posttreatment. However, significant between-groups gains for primary and secondary measures were not maintained over 6- and 12-week follow-up.

Conclusions:

Individuals living with chronic TBI sequelae can increase self-efficacy specific to self-advocacy, general self-efficacy, and satisfaction with life, through a TBI-specific intervention aimed at empowering individuals to advocate for their own needs and wishes. Sustaining gains over time may require ongoing community collaboration and support. This could involve community-based systems of self-advocacy education, resources, and peer support.
Mini-DSAEK for Macro Corneal Perforations
Authors: Vasquez-Perez Alfonso , Din Nizar , Phylactou Maria , Kriman Nunez Jaime , Allan Bruce
Published: May 2021

Purpose:

We present a technique that preserves good vision in paracentral macroperforations and avoids challenges of tectonic lamellar or penetrating keratoplasty in eyes with poor visual potential.

Method:

A wet laboratory was implemented for mini-Descemet stripping endothelial keratoplasty to seal macroperforations ab interno. This included a suture support technique designed to prevent graft herniation. We also present 3 cases who were treated successfully with this technique.

Results:

The laboratory test confirmed that mini-Descemet stripping endothelial keratoplasty can successfully seal macroperforations without the need of large incisions. The minidisc is introduced through the perforation, and a double mattress suture prevents graft herniation. The technique allowed us to preserve 20/15 unaided vision in a case with paracentral macroperforation. It also restored eye globe integrity and achieved long-term stability in 2 cases with limbal stem-cell deficiency.

Conclusions:

Mini-Descemet stripping–automated endothelial keratoplasty technique can be an alternative approach to avoid poor visual outcomes of tectonic keratoplasty in paracentral perforations. It also offers host tissue preservation in eyes with high risk of rejection for tectonic grafts.
Role of Reverse Transcriptase Polymerase Chain Reaction in Cornea Donors During the COVID-19 Pandemic
Authors: Arora Ritu , Sharda Shipra , Sahu Jigyasa , Manchanda Vikas , Jain Parul , Gupta Isha , Gotmare Nikhil , Bharti Nisha
Published: May 2021

Purpose:

The purpose of this study was to report the analysis of reverse transcriptase polymerase chain reaction (RT-PCR) of nasopharyngeal (NP) samples of cornea donors dying because of causes unrelated to severe acute respiratory coronavirus (SARS-CoV-2).

Methods:

A retrospective analysis of all cornea donors dying from causes other than SARS-CoV-2 between August 2020 and December 2020 was performed. Informed consent was obtained from the next of kin of the deceased for RT-PCR testing from NP swabs. Rapid antigen testing from all the deceased was performed before in situ cornea excision. In addition, NP samples in viral transport media for RT-PCR were also collected for SARS-CoV-2 analysis. Corneas were released from the eye bank only after a negative RT-PCR report.

Result:

One hundred eighteen corneas from 59 donors were obtained by the eye bank. Eleven donors (18.64%) were positive for SARS-CoV-2 on RT-PCR testing. Six of these 11 donors had a Ct value of E gene less than 25.

Conclusions:

NP samples of cornea donors dying due to causes other than coronavirus disease-19 were positive for SARS-CoV-2 on RT-PCR. This implicates that donors could be having asymptomatic/undetected coronavirus disease infection. We recommend adding the routine testing of NP samples of all cornea donors in the eye banking protocol in this ongoing SARS-CoV-2 pandemic.
Cardiovascular Disease Incidence and Risk in Family Caregivers of Adults With Chronic Conditions
Authors: Ahn Soojung , Esquivel Jill Howie , Davis Eric M. , Logan Jeongok G. , Chung Misook Lee
Published: May 2021

Background

Family caregivers experience psychological distress or physical strain that may lead to an increased risk of cardiovascular disease (CVD) morbidity and mortality.

Objective

This systematic review aimed to describe the current evidence and gaps in the literature on measures used to assess CVD outcomes in family caregivers, the association of caregiving with CVD incidence/risk outcomes, and associated factors in family caregivers of patients with chronic disease.

Methods

Medline, PubMed, CINAHL, Web of Science, and Google Scholar were searched for English-language, peer-reviewed studies published from 2008 to 2020 that examined CVD incidence and risk among family caregivers of adults with chronic conditions.

Results

Forty-one studies were included in this review. The measures used to assess CVD risk were categorized into biochemical, subclinical markers, components of metabolic syndrome, and global risk scores. Compared with noncaregivers, caregivers were more likely to have higher CVD incidence rates and objectively measured risk. Cardiovascular disease risks were also increased by their caregiving experience, including hours/duration of caregiving, caregivers' poor sleep status, psychological symptoms, poor engagement in physical/leisure activities, and care recipient's disease severity.

Conclusions

Although there were limited longitudinal studies in caregivers of patients with diverse health conditions, we found evidence that caregivers are at high risk of CVD. Further research for various caregiver groups using robust methods of measuring CVD risk is needed. Caregiver factors should be considered in developing interventions aimed at reducing CVD risk for caregivers.
Yield and Risk Factors for Advanced Colorectal Neoplasia and Long-term Outcomes in Veterans With 3 or More Nonadvanced Adenomas
Authors: Ha John , Walker Megan J. , Myers Laura E. , Ballard Carrie J. , Imperiale Thomas F.
Published: May 2021

Background and Aims:

Until recently, guidelines recommended a 3-year surveillance colonoscopy for persons with 3 to 10 nonadvanced adenomas (NAA). In this study, we quantify yield for metachronous advanced neoplasia (AN); attempt to identify risk factors for AN; and measure colorectal cancer (CRC) incidence and mortality.

Methods:

We used natural language processing to screen an existing data set for Veterans with 3 to 10 NAA. We manually reviewed colonoscopy and pathology reports to verify baseline findings and determine results of subsequent colonoscopy (sCY). Baseline features were extracted from the electronic medical record (EMR) and a national data set, CRC incidence was obtained from the Veterans Affairs cancer registry, and CRC mortality from the National Death Index through September 30, 2017. CRC incidence and mortality were compared between Veterans who did versus did not have sCY.

Results:

Natural language processing identified 3673 Veterans who potentially had 3 to 10 NAA, of which 1672 were excluded after EMR review. In the analytical cohort of 2001 subjects, 1178 (59%) had sCY at a mean (SD) follow-up of 4.3 (2.2) years. The sCY group was younger (mean age: 61 vs. 67 y; P<0.01) and were less likely to have diabetes (27% vs. 31%; P=0.02) and congestive heart failure (4% vs. 9%; P<0.01). sCY showed AN in 182 subjects (15.5%). Baseline features were no different between those with versus without metachronous AN. Subjects with sCY had a greater CRC incidence (n=7 vs. n=0; P=0.046), but there was no difference in CRC mortality (0 for both subgroups).

Conclusions:

Among patients with 3 to 10 NAA on index colonoscopy who underwent sCY, AN was present in 15.5% at mean follow-up of 4.3 years. No risk factors for AN were identified. CRC incidence, but not CRC mortality, was higher among those with sCY.
Coronavirus disease 2019 respiratory disease in children: clinical presentation and pathophysiology
Authors: Steffes Lea C. , Cornfield David N.
Published: May 2021

Purpose of review

Pediatric coronavirus disease 2019 (COVID-19) respiratory disease is a distinct entity from adult illness, most notable in its milder phenotype. This review summarizes the current knowledge of the clinical patterns, cellular pathophysiology, and epidemiology of COVID-19 respiratory disease in children with specific attention toward factors that account for the maturation-related differences in disease severity.

Recent findings

Over the past 14 months, knowledge of the clinical presentation and pathophysiology of COVID-19 pneumonia has rapidly expanded. The decreased disease severity of COVID-19 pneumonia in children was an early observation. Differences in the efficiency of viral cell entry and timing of immune recognition and response between children and adults remain at the center of ongoing research.

The clinical spectrum of COVID-19 respiratory disease in children is well defined. The age-related differences protecting children from severe disease and death remain incompletely understood.
Severe acute respiratory syndrome coronavirus 2 infection and critically ill children
Authors: Damania Rahul , Moore Whitney , Viamonte Heather C. , Kamat Pradip , Basu Rajit K.
Published: May 2021

Purpose of review

Amidst an ongoing pandemic, the delineation of the pediatric consequence of infection from the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) virus is emerging. This review summarizes available pediatric data and covers the aspects of epidemiology, critical illness with acute infection [coronavirus disease 2019 (COVID-19)], the discovered multi-inflammatory syndrome in children (MIS-C), and management options.

Recent findings

The available data from the source of the initial viral transmission and then through Europe, Africa, and the Western Hemisphere identifies important aspects of the SARS-CoV2 pandemic: 1) Pediatric infection occurs commonly, is likely underestimated, and transmission patterns remain incompletely described, 2) Pediatric patients suffer multiple end-organ injuries but COVID-19 is not the same prevalence in terms of severity as in adults, 3) MIS-C is a novel and life-threatening manifestation of exposure to the virus, 4) Management using a combination of supportive care, standard practice intensive care management, and anti-inflammatory agents is associated with recovery, 5) Long-term sequelae of viral exposure is unknown at this time.

Emerging evidence suggests pediatric patients are at risk for severe and life-threatening effects of exposure to SARS-CoV2. As the pandemic continues, further research is warranted – particularly as a vaccine is not yet available for use in children.