bluuebunny/crossref_metadata_2025 huggingface dataset:
The Gun-Site and Percutaneous Portocaval Techniques for the Challenging TIPS
Authors: Kahn S. Lowell
Published: August 2018

Since its inception, the “Achilles’ heel” of the transjugular intrahepatic portosystemic shunt (TIPS) procedure has been catheterization of the portal vein from the systemic venous circulation. In the majority of TIPS procedures, the portal vein is readily identified with conventional technique and the procedure is completed in no more than 60–90 minutes, if not less. However, there are certain anatomic situations that can make performance of a TIPS procedure difficult. A small cirrhotic liver with an abnormal hepatic to portal venous orientation, t hrombosis or cavernous transformation of the portal vasculature, and atrophic or absent (Budd–Chiari) hepatic veins all produce unique challenges for the interventionalist. In such situations, the use of alternative TIPS techniques may be warranted. In this chapter, two alternative TIPS techniques are discussed to assist with challenging anatomy.
Balloon-Assisted, Fluoroscopically Guided Percutaneous Gastrostomy Tube Placement
Authors: Farnam Joseph , Iannuccilli Jason , Soares Gregory
Published: August 2018

Fluoroscopic placement of gastrostomy tubes requires creation and dilation of a percutaneous tract through which the tube is placed. Given the relatively large caliber of these tubes, aggressive dilation of the percutaneous tract is necessary prior to their insertion. Tract dilation is most commonly performed via the use of several sequential dilators or a single telescoping serial dilator. These methods are cumbersome and relatively time-consuming, and as a result this portion of the procedure can result in considerable patient discomfort as well as technical complications. This chapter describes the use of a balloon catheter for gastrostomy creation. It describes clinical scenarios that would benefit from gastrostomy tube placement. The procedure is described in a step-by-step manner with a focus on gastrostomy tract dilatation.
Advancing the Difficult Drainage Catheter
Authors: Heithaus Evans , Syed Almas , Rees Chet R.
Published: August 2018

Advancing a drainage catheter can be difficult in certain situations, particularly when the catheter “accordions” upon itself. Most tubes are built with a small shelf in the tip of the catheter, and metal and plastic stiffeners are provided. Applying the majority of the advancing force at the hub of the metal stiffener rather than along the midportion of the catheter exerts force at the tip of the catheter via the internal metal stiffener, which is lodged against the small shelf inside the catheter. Using this method, the operator is able to translate a majority of the forward force to the catheter tip, thereby “pulling” the rest of the catheter through tissues and thus reducing the accordion effect.
Creation of an Additional Side Hole as a Method to Exchange Obstructed Percutaneous Drainage Catheters
Authors: Ho Jessica M. , Katz Michael D.
Published: August 2018

Percutaneous drainage catheter placement is a frequently performed interventional radiology procedure. One of the common management complications of such catheters is obstruction or clogging of the catheter. Occluded drainage catheters are routinely exchanged over a guidewire under fluoroscopic guidance. At times, however, a guidewire cannot be passed through the catheter obstruction, and exchanging the catheter over a guidewire may become difficult or even impossible without losing access. Because salvaging an obstructed catheter, without risking loss of access, can be difficult, multiple techniques to preserve organ access have been developed. This chapter describes a technique whereby the creation of a new side hole in the catheter is used to re-establish wire access and facilitate catheter exchange. It is frequently useful for exchanging enteric tubes, urologic drainage catheters, biliary drainage catheters, and abscess drains.
The Genetic Structure of Populations of the Douglas-Fir Swiss Needle Cast Fungus Nothophaeocryptopus gaeumannii in New Zealand
Authors: Bennett P. I. , Hood I. A. , Stone J. K.
Published: August 2018

Swiss needle cast is a foliar disease of Douglas-fir (Pseudotsuga menziesii) that results in premature foliage loss and reduced growth. The causal fungus, Nothophaeocryptopus gaeumannii, was first detected in New Zealand in 1959 and spread throughout the North and South Islands over the following decades. The contemporary genetic structure of the N. gaeumannii population in New Zealand was assessed by analyzing 468 multilocus SSR genotypes (MLGs) from 2,085 N. gaeumannii isolates collected from 32 sites in the North and South Islands. Overall diversity was lower than that reported from native N. gaeumannii populations in the northwestern United States, which was expected given that N. gaeumannii is introduced in New Zealand. Linkage disequilibrium was significantly higher than expected under random mating, suggesting that population structure is clonal. Populations of N. gaeumannii in the North and South Islands were weakly differentiated, and the isolates collected from sites within the islands were moderately differentiated. This suggests that gene flow has occurred between the N. gaeumannii populations in the North and South Islands, and between the local N. gaeumannii populations within each island. Eighteen isolates of N. gaeumannii Lineage 2, which has previously been reported only from western Oregon, were recovered from two sites in the North Island and four sites in the South Island. The most likely explanation for the contemporary distribution of N. gaeumannii in New Zealand is that it was introduced on infected live seedlings through the forestry or ornamental nursery trade, as the fungus is neither seed borne nor saprobic, and the observed population structure is not consistent with a stochastic intercontinental dispersal event.
Can Point-of-Care Ultrasound Predict Spinal Hypotension During Caesarean Section? A Prospective Observational Study
Authors: Zieleskiewicz L. , Noel A. , Duclos G. , Haddam M. , Delmas A. , Bechis C. , Loundou A. , Blanc J. , Mignon A. , Bouvet L. , Einav S. , Bourgoin A. , Leone M.
Published: August 2018

(Anaesthesia 2018;73:15–22)

When spinal anesthesia is administered for cesarean delivery, maternal hypotension occurs in ∼70% of women, due primarily to decreases in systemic vascular resistance and cardiac output. This hypotension can be detrimental to the fetus. Therefore, the ability to identify patients at increased risk for developing spinal-induced hypotension and then implementing preventive strategies in these women could be clinically beneficial. The main purpose of this prospective observational study was to investigate the effectiveness of certain transthoracic echocardiographic (TTE) measurements to determine a patient’s intravascular volume and predict her risk of developing hypotension resulting from spinal anesthesia for cesarean delivery. In addition, they aimed to determine whether certain subgroups at increased risk for hypotension could be identified with this point-of-care echocardiographic examination.
The Effect of Glycopyrrolate on the Incidence of Hypotension and Vasopressor Requirement During Spinal Anesthesia for Cesarean Delivery: A Meta-Analysis
Authors: Patel S.D. , Habib A.S. , Phillips S. , Carvalho B. , Sultan P.
Published: August 2018

(Anesth Analg. 2018;126:552–558)

Spinal-induced hypotension, if not treated, can result in adverse maternal and neonatal outcomes (maternal cardiovascular collapse and fetal acidosis). Glycopyrrolate, an anticholinergic with quaternary amine structure, has limited ability to cross-membranes and may thereby have potential to reduce hemodynamic changes after spinal anesthesia in obstetric patients. The authors of this meta-analysis evaluated the literature to determine if prophylactic glycopyrrolate reduces the incidence of hypotension and total vasopressor dose required during elective cesarean delivery under spinal anesthesia.
Association Between Prepregnancy Body Mass Index and Severe Maternal Morbidity
Authors: Lisonkova S. , Muraca G.M. , Potts J. , Liauw J. , Chan W.S. , Skoll A. , Lim K.I.
Published: August 2018

(JAMA 2017;318(18):1777–1786)

Overweight and obesity are associated with increased risks of adverse maternal and neonatal events such as preterm birth, stillbirth, and neonatal or infant death; underweight is also associated with adverse outcomes. However, it is unclear if the risk of severe maternal morbidity increases as body mass index (BMI) increases. This study aimed to determine the association between prepregnancy BMI and severe maternal morbidity or mortality.
Prepregnancy Obesity and Severe Maternal Morbidity: What Can Be Done?
Authors: Caughey A.B.
Published: August 2018

(JAMA 2017;318(18):1765–1766)

In the United States, approximately half of all pregnant women were overweight or obese in 2014, which increases the risk of maternal and fetal complications. Obesity may contribute to the recent increase in maternal mortality in the US, but the cause of this relationship is unknown. It is not clear if mortality is caused by comorbid events in obese women or if the care of obese women is more difficult to manage. Since severe maternal morbidity in obese women may contribute to and precede mortality, studying the associations between obesity and severe maternal morbidity in pregnancy may shed additional light on this connection.
Pregnancy Outcomes After ZIKV Infection in French Territories in the Americas
Authors: Hoen B. , Schaub B. , Funk A.L. , Ardillon V. , Boullard M. , Cabié A. , Callier C. , Carles G. , Cassadou S. , Césaire R. , Douine M. , Herrmann-Storck C. , Kadhel P. , Laouénan C. , Madec Y. , Monthieux A. , Nacher M. , Najioullah F. , Rousset D. , Ryan C. , Schepers K. , Stegmann-Planchard S. , Tressières C. , Voluménie J.L. , Yassinguezo S. , Janky E. , Fontanet A.
Published: August 2018

(N Engl J Med 2018;378:985–994)

It is well recognized that Zika virus (ZIKV) infection during pregnancy can cause severe birth defects. Fortunately, the presence of centralized maternal care facilities in French territories in the Americas (French Guiana, Guadeloupe, and Martinique) allowed for enhanced surveillance of all pregnancies during the 2016 ZIKV epidemic. The authors of the present study present pregnancy outcomes in a cohort of women living in these territories who had symptomatic, laboratory-confirmed ZIKV infection during pregnancy (ZIKA-DFA-FE cohort study).
Are Anesthesia and Surgery During Infancy Associated With Decreased White Matter Integrity and Volume during Childhood?
Authors: Block R.I. , Magnotta V.A. , Bayman E.O. , Choi J.Y. , Thomas J.J. , Kimble K.K.
Published: August 2018

(Anesthesiology. 2017;127(5):788–799)

In the United States, >250,000 infants are exposed to anesthesia each year. While general anesthesia causes functional and histopathologic changes in the central nervous systems (CNS) of late fetal and neonatal animals, it is not clear if these findings apply to humans. This study assessed possible associations of surgery and anesthesia in infants with later brain structure abnormalities in children who have no potential confounding risk factors. They hypothesized anesthesia and surgery may be associated with decreased white and gray matter volumes and and white matter integrity.
Effect of Post-cesarean Delivery Oral Cephalexin and Metronidazole on Surgical Site Infection Among Obese Women: A Randomized Clinical Trial
Authors: Valent A.M. , DeArmond C. , Houston J.M. , Reddy S. , Masters H.R. , Gold A. , Boldt M. , DeFranco E. , Evans A.T. , Warshak C.R.
Published: August 2018

(JAMA 2017;318(11):1026–1034)

Previous studies estimated 3% to 12% of all cesarean deliveries in the United States are complicated by surgical site infection (SSI). This risk increases as maternal weight increases, and despite preoperative antibiotic regimens, obesity is an independent risk factor for SSI. While standard care has been the use of preoperative cephalosporin antibiotics, other antibiotic combinations have been studied. However, conflicting benefits have been found and none of these studies focused specifically on obese women. In this study, the effects of an additional 48-hour course of postoperative prophylactic oral cephalexin plus metronidazole was compared with the current standard of care (preoperative intravenous cephalosporin alone) in obese women who delivered via cesarean section.
Effects of Therapeutic Hypothermia Initiated After 6 Hours of Age on Death or Disability Among Newborns With Hypoxic-ischemic Encephalopathy
Authors: Laptook A.R. , Shankaran S. , Tyson J.E. , Munoz B. , Bell E.F. , Goldberg R.N. , Parikh N.A. , Ambalavanan N. , Pedroza C. , Pappas A. , Das A. , Chaudhary A.S. , Ehrenkranz R.A. , Hensman A.M. , Van Meurs K.P. , Chalak L.F. , Hamrick S.E.G. , Sokol G.M. , Walsh M.C. , Poindexter B.B. , Faix R.G. , Watterberg K.L. , Frantz I.D. , Guillet R. , Devaskar U. , Truog W.E. , Chock V.Y. , Wyckoff M.H. , McGowan E.C. , Carlton D.P. , Harmon H.M. , Brumbaugh J.E. , Cotten C.M. , Sánchez P.J. , Hibbs A.M. , Higgins R.D.
Published: August 2018

(JAMA 2017;318(16):1550–1560)

Previous trials have shown therapeutic hypothermia reduces death or disability when infants with hypoxic-ischemic encephalopathy are treated within 6 hours after birth. Getting infants treated in this window can be difficult when transportation is necessary or when encephalopathy is not recognized within 6 hours. This study aimed to determine whether hypothermia treatment can reduce the risk of death or disability due to hypoxic-ischemic encephalopathy at 18 months when treatment is initiated between 6 and 24 hours after birth.
The Analgesic Effect of Ultrasound-guided Quadratus Lumborum Block After Cesarean Delivery: A Randomized Clinical Trial
Authors: Krohg A. , Ullensvang K. , Rosseland L.A. , Langesæter E. , Sauter A.R.
Published: August 2018

(Anesth Analg. 2018;126:559–565)

Ultrasound (US)-guided transversus abdominis plane (TAP) blocks, although widely used for postoperative analgesia in inferior abdominal wall incision surgeries, are known to provide inferior analgesia when compared to neuraxial morphine and other multimodal regimens. A modified quadratus lumborum (QL) block technique, with injection at the posterior border of the QL muscle, may provide better and longer lasting analgesia compared with US-guided anterior TAP blocks. The authors of the present study evaluated the postcesarean analgesic effects of US-guided lateral bilateral QL block with ropivacaine compared with bilateral placebo injections with saline.
Preoperative Warming Versus no Preoperative Warming for Maintenance of Normothermia in Women Receiving Intrathecal Morphine for Cesarean Delivery: A Single-blinded, Randomized Controlled Trial
Authors: Munday J. , Osborne S. , Yates P. , Gosden E.
Published: August 2018

(Anesth Analg. 2018;126:183–189)

In women undergoing cesarean delivery, a cooling of core temperature to below 36°C during surgery and the postoperative phase is associated with detrimental physiological effects and adverse neonatal outcomes. The rates of perioperative hypothermia in this population range from 32% to 80%. Although current guidelines advise 30 minutes of preoperative warming as a prophylactic measure, there have been studies showing that that 15 minutes plus continuation of forced air warming during surgery has efficacy. The authors of the present study compared the effects of a 20-minute preoperative period of forced air warming plus intraoperative intravenous (IV) fluid warming on women receiving intrathecal morphine during elective cesarean delivery to that of women receiving IV fluid warming alone.
Comparison of the TOFscan and the TOF-Watch SX during Recovery of Neuromuscular Function
Authors: Murphy Glenn S. , Szokol Joseph W. , Avram Michael J. , Greenberg Steven B. , Shear Torin D. , Deshur Mark , Benson Jessica , Newmark Rebecca L. , Maher Colleen E.
Published: August 2018

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Quantitative neuromuscular monitoring is required to ensure neuromuscular function has recovered completely at the time of tracheal extubation. The TOFscan (Drager Technologies, Canada) is a new three-dimensional acceleromyography device that measures movement of the thumb in multiple planes. The aim of this observational investigation was to assess the agreement between nonnormalized and normalized train-of-four values obtained with the TOF-Watch SX (Organon, Ireland) and those obtained with the TOFscan during recovery from neuromuscular blockade.

Methods

Twenty-five patients were administered rocuronium, and spontaneous recovery of neuromuscular blockade was allowed to occur. The TOFscan and TOF-Watch SX devices were applied to opposite arms. A preload was applied to the TOF-Watch SX, and calibration was performed before rocuronium administration. Both devices were activated, and train-of-four values were obtained every 15 s. Modified Bland–Altman analyses were conducted to compare train-of-four ratios measured with the TOFscan to those measured with the TOF-Watch SX (when train-of-four thresholds of 0.2 to 1.0 were achieved).

Results

Bias and 95% limits of agreement between the TOF-Watch SX and the TOFscan at nonnormalized train-of-four ratios between 0.2 and 1.0 were 0.021 and −0.100 to 0.141, respectively. When train-of-four measures with the TOF-Watch SX were normalized, bias and 95% limits of agreement between the TOF-Watch SX and the TOFscan at ratios between 0.2 and 1.0 were 0.015 and −0.097 to 0.126, respectively.

Conclusions

Good agreement between the TOF-Watch SX with calibration and preload application and the uncalibrated TOFscan was observed throughout all stages of neuromuscular recovery.
Neonatal Morbidity in the Offspring of Obese Women Without Hypertension or Diabetes
Authors: Polnaszek Brock E. , Raghuraman Nandini , Lopez Julia D. , Frolova Antonina L. , Wesevich Victoria , Tuuli Methodius G. , Cahill Alison G.
Published: August 2018

OBJECTIVE:

To compare the independent risk of neonatal morbidity between the offspring of obese and nonobese women without hypertension or diabetes.

METHODS:

This is a secondary analysis of a prospective single-center cohort study of singleton deliveries at or beyond 37 weeks of gestation from 2010 to 2014. Women with diabetes (pregestational or gestational) and hypertensive disorders were excluded. The primary outcomes were 1) a composite neonatal morbidity including death, mechanical ventilation, respiratory distress, meconium aspiration, suspected sepsis, confirmed sepsis, hypoxic–ischemic encephalopathy, therapeutic hypothermia, or seizures; and 2) a composite of neonatal neurologic morbidity including hypoxic–ischemic encephalopathy, therapeutic hypothermia, or seizures. The primary outcomes were compared between the offspring of obese (body mass index 30 or greater) and nonobese women. Adjusted odds ratios (ORs) were estimated using multivariable logistic regression.

RESULTS:

Of 6,458 women without diabetes or hypertensive disorders, 3,311 (51%) were obese. After adjusting for race, neonates of obese patients were at significantly increased risk for the composite neonatal morbidity (9.2% vs 7.2%, adjusted OR 1.39, 95% CI 1.15–1.67) and neurologic neonatal morbidity (0.7% vs 0.3%, adjusted OR 2.84, 95% CI 1.22–6.65). Specifically, neonates of obese patients were more likely to have hypoxic–ischemic encephalopathy (0.5% vs 0.2%, adjusted OR 2.80, 95% CI 1.02–7.68), hypothermia treatment (0.6% vs 0.2%, adjusted OR 2.92 95% CI 1.17–7.30), and suspected sepsis (7.6% vs 5.8%, adjusted OR 1.45, 95% CI 1.18–1.79).

CONCLUSION:

In patients who labor, maternal obesity is an independent risk factor for significant neonatal morbidity, even in the absence of hypertensive disorders or diabetes.
Clinical Assessment of Functional Hearing Deficits: Speech-in-Noise Performance
Authors: Phatak Sandeep A. , Brungart Douglas S. , Zion Danielle J. , Grant Ken W.
Published: August 2018

Objective:

The clinical evaluation of hearing loss, using a pure-tone audiogram, is not adequate to assess the functional hearing capabilities (or handicap) of a patient, especially the speech-in-noise communication difficulties. The primary objective of this study was to measure the effect of elevated hearing thresholds on the recognition performance in various functional speech-in-noise tests that cover acoustic scenes of different complexities and to identify the subset of tests that (a) were sensitive to individual differences in hearing thresholds and (b) provide complementary information to the audiogram. A secondary goal was to compare the performance on this test battery with the self-assessed performance level of functional hearing abilities.

Design:

In this study, speech-in-noise performance of normal-hearing listeners and listeners with hearing loss (audiometric configuration ranging from near-normal hearing to moderate-severe hearing loss) was measured on a battery of 12 different tests designed to evaluate speech recognition in a variety of speech and masker conditions, and listening tasks. The listening conditions were designed to measure the ability to localize and monitor multiple speakers or to take advantage of masker modulation, spatial separation between the target and the masker, and a restricted vocabulary.

Results:

Listeners with hearing loss had significantly worse performance than the normal-hearing control group when speech was presented in the presence of a multitalker babble or in the presence of a single competing talker. In particular, the ability to take advantage of modulation benefit and spatial release from masking was significantly affected even with a mild audiometric loss. Elevated thresholds did not have a significant effect on the performance in the spatial awareness task. A composite score of all 12 tests was considered as a global metric of the overall speech-in-noise performance. Perceived hearing difficulties of subjects were better correlated with the composite score than with the performance on a standardized clinical speech-in-noise test. Regression analysis showed that scores from a subset of these tests, which could potentially take less than 10 min to administer, when combined with the better-ear pure-tone average and the subject’s age, accounted for as much as 93.2% of the variance in the composite score.

Conclusions:

A test that measures speech recognition in the presence of a spatially separated competing talker would be useful in measuring suprathreshold speech-in-noise deficits that cannot be readily predicted from standard audiometric evaluation. Including such a test can likely reduce the gap between patient complaints and their clinical evaluation.
Service Preferences of Parents of Children With Mild Bilateral or Unilateral Hearing Loss: A Conjoint Analysis Study
Authors: Fitzpatrick Elizabeth M. , Coyle Doug , Gaboury Isabelle , Durieux-Smith Andrée , Whittingham JoAnne , Grandpierre Viviane , Na Eunjung , Salamatmanesh Mina
Published: August 2018

Objective:

Universal newborn hearing screening results in substantially more children with mild bilateral and unilateral hearing loss identified in the early years of life. While intervention services for children with moderate loss and greater are generally well-established, considerable uncertainty and variation surrounds the need for intervention services for children with milder losses. This study was undertaken with parents of young children with permanent mild bilateral and unilateral hearing loss to examine their preferences for characteristics associated with intervention services.

Design:

Conjoint analysis, a preference-based technique, was employed to study parents’ strength of preferences. Using a cross-sectional survey that consisted of eight hypothetical clinic scenarios, we invited parents to make a discrete choice (to select one of two or more different services) between available services with different characteristics. The survey was informed by qualitative interviews conducted for this purpose. The questionnaire was administered to parents receiving intervention services in the province of Ontario, Canada, who were enrolled in a mixed-methods longitudinal study examining outcomes in early-identified children with mild bilateral/unilateral hearing loss. Data were analyzed using a generalized linear model (probit link) to identify attributes of interest for the respondents. Characteristics of the children were entered into the model to control for differences in age of diagnosis, sex, laterality of hearing loss, and hearing aid use.

Results:

A total of 51 of 62 invited parents completed the questionnaire. All four attributes of care that were included in the survey were found to be statistically significant, that is, parents valued support for amplification, support for speech-language development, emotional support, and communication from professionals. Analysis showed greater preference for enhanced levels relating to support for speech-language development than for support for amplification. Preference for attributes relating to emotional support and communication were also greater than for support for amplification use.

Conclusions:

Conjoint analysis was used to quantify parents’ preferences for service attributes. Parents’ values provide insights into the aspects of a service model that should receive consideration in the development of intervention programs for young children with mild bilateral or unilateral hearing loss and their families. Although parents of young children with mild bilateral or unilateral hearing loss valued several components of care, they indicated a clear preference for speech-language support compared with support for amplification use.
Outcomes of Operative Treatment of Triangular Fibrocartilage Tears in Pediatric and Adolescent Athletes
Authors: Fishman Felicity G. , Barber Jarrad , Lourie Gary M. , Peljovich Allan E.
Published: August 2018

Background:

Triangular fibrocartilage complex (TFCC) tears have been treated with increasing frequency in pediatric and adolescent patients over the past decade. There is little information on these injuries in young athletes and a scarcity of data regarding their ability to return to preinjury levels of athletic participation. The purpose of this study was to review the outcomes of pediatric and adolescent athletes with operatively treated TFCC tears with or without a concurrent ulnar shortening osteotomy and to determine their ability to return to their preoperative level of activity.

Methods:

A retrospective chart review was performed for all patients who underwent operative treatment of TFCC tears between 2006 and 2012 within one Upper Extremity practice. Patients were included if they were high-level athletes, unable to participate in their sport secondary to wrist pain and desired to return to their sport. All operative patients had imaging studies and clinical findings consistent with TFCC injury as the primary source of their activity-limiting pain and had failed nonoperative management prior to surgery. Patients without at least 3 months of documented postoperative follow up were excluded.

Results:

In total, 22 patients were included in the chart review with 20 patients willing to participate in a telephone survey and PODCI. Eighty percent of patients returned to their sport following operative treatment of their injury at an average of 4.8 months. Seven of the 22 patients underwent a concurrent ulnar shortening osteotomy for ulnar positive variance. All 20 patients reported satisfaction with the outcomes of their surgery and treatment.

Conclusions:

Operative treatment of TFCC injuries in adolescent and pediatric athletes after failure of conservative treatment allowed return to sport at the previous level of participation. Concurrent ulnar shortening osteotomy in the setting of ulnar positive variance did not prohibit return to high-level athletic participation.

Level of Evidence:

Level IV.
Youth Baseball Coach Awareness of Pitch Count Guidelines and Overuse Throwing Injuries Remains Deficient
Authors: Knapik Derrick M. , Continenza Sara M. , Hoffman Kyle , Gilmore Allison
Published: August 2018

Background:

Baseball is one of the most popular youth sporting activities. Youth pitchers remain at high risk for shoulder and elbow overuse injuries despite well-established recommendations on pitch count limits. The purpose of this investigation was to conduct surveys of youth baseball coaches evaluating the current state of understanding and compliance with youth pitch count guidelines and risk factors for overuse injuries.

Methods:

A total of 82 youth baseball coaches in surrounding suburban areas outside 2 separate Midwestern metropolitan cities were asked to answer an anonymous 13-question survey. Survey questions solicited demographic information of youth athletes coached, while assessing for incidence, knowledge of, and compliance with established recommendations on pitch count limits and upper extremity overuse injuries in youth pitchers.

Results:

In total, 61 of 82 (74%) coaches returned surveys. The majority of coaches reported coaching male athletes (89%, n=54) primarily between the ages of 11 to 12 years (51%, n=31). A total of 56% (n=34) of coaches reported “always” keeping track of pitch counts; however, 92% (n=56) reporting not keeping track of pitches based on established recommendations by the American Sports Medicine Institute, whereas 56% were noncompliant with age appropriate pitch count recommendations as established by the 2006 US Baseball Medical and Safety Advisory Committee. Only 13% (n=8) of coaches were able to correctly identify risk factors for overuse injuries while acknowledging the necessity of off-season strengthening. Thirty-eight percent (n=23) of coaches reported sitting out an athlete because of overuse injury, with the highest rates found in those coaching the youngest (≤8 and younger) and oldest (≥17 and older) age groups. Meanwhile, 15% (n=9) of coaches were noncompliant with age-based recommendations against throwing breaking pitches.

Conclusions:

Knowledge regarding pitch count guidelines established to prevent overuse injuries to the shoulder and elbow in youth pitchers remains deficient in the cohort of coaches surveyed.

Level of Evidence:

Level IV—Case Series.
Perioperative Outcome of Single Stage Posterior Spinal Fusion for Severe Adolescent Idiopathic Scoliosis (AIS) (Cobb Angle ≥90°)
Authors: Kwan Mun Keong , Chiu Chee Kidd , Hasan Mohd Shahnaz , Tan Shun Herng , Loh Ling Hui , Yeo Kye Sheng , Lee Wei Hong , Chan Chris Yin Wei
Published: August 2018

Study Design.

Retrospective study.

Objective.

To evaluate the perioperative outcome of dual attending surgeon strategy for severe adolescent idiopathic scoliosis (AIS) patients with Cobb angle more than or equal to 90°.

Summary of Background Data.

The overall complication rate for AIS remains significant and is higher in severe scoliosis. Various operative strategies had been reported for severe scoliosis. However the role of dual attending surgeon strategy in improving the perioperative outcome in severe scoliosis has not been investigated.

Methods.

The patients were stratified into two groups, Cobb angles 90° to 100° (Group 1) and more than 100° (Group 2). Demographic, intraoperative, preoperative, and postoperative day 2 data were collected. The main outcome measures were intraoperative blood loss, use of allogeneic blood transfusion, operative time, duration of hospital stay postsurgery, and documentation of any perioperative complications.

Results.

Eighty-five patients were recruited. The mean age for the whole cohort was 16.2 ± 5.2 years old. The mean age of Group 1 was 16.7 ± 5.7 and Group 2 was 15.6 ± 4.8 years old. The majority of the patients in both groups were Lenke 2 curves with the average Cobb angle of 93.9 ± 3.0° in Group 1 and 114.2 ± 10.2° in Group 2. The average operative time was 198.5 ± 47.5 minutes with an average blood loss of 1699.5 ± 939.3 mL. The allogeneic blood transfusion rate was 17.6%. The average length of stay postoperation was 71.6 ± 22.5 hours. When comparing the patients between Group 1 and Group 2, the operating time, total blood loss, allogeneic transfusion rate showed significant intergroup differences. Five complications were documented (one intraoperative seizure, one massive blood loss, one intraoperative loss of somatosensory evoked potential (SSEP) signal, and two superficial wound breakdown).

Conclusion.

Dual attending surgeon strategy in severe AIS more than or equal to 90° demonstrated an average operative time of 199 minutes, intraoperative blood loss of 1.7 L, postoperative hospital stay of 71.6 hours, and a complication rate of 5.9% (5/85 patients). Curves with Cobb angle more than 100° lead to longer operating time, greater blood loss, and allogeneic transfusion rate.

Level of Evidence: 4
A Comparison of the Quick Sequential (Sepsis-Related) Organ Failure Assessment Score and the National Early Warning Score in Non-ICU Patients With/Without Infection
Authors: Redfern Oliver C. , Smith Gary B. , Prytherch David R. , Meredith Paul , Inada-Kim Matthew , Schmidt Paul E.
Published: August 2018

Objectives:

The Sepsis-3 task force recommended the quick Sequential (Sepsis-Related) Organ Failure Assessment score for identifying patients with suspected infection who are at greater risk of poor outcomes, but many hospitals already use the National Early Warning Score to identify high-risk patients, irrespective of diagnosis. We sought to compare the performance of quick Sequential (Sepsis-Related) Organ Failure Assessment and National Early Warning Score in hospitalized, non-ICU patients with and without an infection.

Design:

Retrospective cohort study.

Setting:

Large U.K. General Hospital.

Patients:

Adults hospitalized between January 1, 2010, and February 1, 2016.

Interventions:

None.

Measurements and Main Results:

We applied the quick Sequential (Sepsis-Related) Organ Failure Assessment score and National Early Warning Score to 5,435,344 vital signs sets (241,996 hospital admissions). Patients were categorized as having no infection, primary infection, or secondary infection using International Classification of Diseases, 10th Edition codes. National Early Warning Score was significantly better at discriminating in-hospital mortality, irrespective of infection status (no infection, National Early Warning Score 0.831 [0.825–0.838] vs quick Sequential [Sepsis-Related] Organ Failure Assessment 0.688 [0.680–0.695]; primary infection, National Early Warning Score 0.805 [0.799–0.812] vs quick Sequential [Sepsis-Related] Organ Failure Assessment 0.677 [0.670–0.685]). Similarly, National Early Warning Score performed significantly better in all patient groups (all admissions, emergency medicine admissions, and emergency surgery admissions) for all outcomes studied. Overall, quick Sequential (Sepsis-Related) Organ Failure Assessment performed no better, and often worse, in admissions with infection than without.

Conclusions:

The National Early Warning Score outperforms the quick Sequential (Sepsis-Related) Organ Failure Assessment score, irrespective of infection status. These findings suggest that quick Sequential (Sepsis-Related) Organ Failure Assessment should be reevaluated as the system of choice for identifying non-ICU patients with suspected infection who are at greater risk of poor outcome.
Survival Benefit of Adjuvant Radiation Therapy in Node-positive Vulvar Cancer
Authors: Xanthopoulos Eric P. , Grover Surbhi , Puri Priya M. , Corradetti Michael N. , Heilbroner Samuel P. , Mitra Nandita , Simone Charles B. , Lin Lilie L.
Published: August 2018

Background:

Adjuvant radiation therapy improves overall survival in patients with vulvar cancer with 2+ positive lymph nodes, but its benefit remains uncertain for 1 positive lymph node.

Methods:

Using the Surveillance, Epidemiology, and End Results (SEER) database, we identified node-positive, American Joint Committee on Cancer version 6-staged women with squamous cell vulvar carcinoma treated with and without radiation following surgery. The Kaplan-Meier approach assessed overall and cause-specific survival. Propensity score-based, multiply imputed Cox modeling accounted for missing data and selection bias.

Results:

From 2004 to 2013, 488 versus 206 women did and did not receive adjuvant radiation after surgery. Patient characteristics were well balanced, including home county, index tumor diameter, number of nodes excised, provider type, race, and surgery type (P>0.05). Unbalanced covariates—including median age, grade, number of positive nodes, N-stage—were adjusted using Cox regression. At a median follow-up of 36 months, adjuvant radiation was associated with improved median overall survival across all node-positive patients (54 vs. 24 mo; P<0.01). This survival benefit persisted in women with just one (not reached vs. 39 mo; P<0.01) and 2+ (26 vs. 16 mo; P<0.01) positive lymph nodes. Likewise, all node-positive groups saw a cause-specific survival benefit with adjuvant radiation (all P<0.02). On multivariable Cox regression, adjuvant radiation, age, tumor diameter, number of positive nodes, race, and N-stage associated with survival (P<0.05).

Conclusions:

All node positive vulvar cancer patients should benefit from and thus should receive adjuvant radiation, including those with one positive node.
Maternal peripartum urinary pyrethroid metabolites are associated with thinner children at 3.5 years in the VHEMBE birth cohort (Limpopo, South Africa)
Authors: Huang Jonathan Y. , Eskenazi Brenda , Bornman Riana , Rauch Stephen , Chevrier Jonathan
Published: August 2018

Background:

Pyrethroids are the most widely used insecticides globally for domestic, agricultural, and malaria vector control. In 10 countries, dichlorodiphenyl trichloroethane (DDT) is also used for the latter. Thus, high exposure to pyrethroids and DDT have been reported among women and children from rural and/or malaria-endemic areas. Experimental studies suggest that fetal exposure to pyrethroids, particularly cypermethrin, and DDT may have sex-specific growth effects. However, epidemiologic investigations are scarce and inconsistent and have not considered postnatal environment or susceptibility factors.

Methods:

In 665 mother–child dyads participating in the Venda Health Examination of Mothers, Babies, and their Environment (VHEMBE), a rural South African birth cohort with high insecticide exposure, we examined associations of maternal peripartum urinary pyrethroid metabolites and serum DDT concentrations with child anthropometrics at 3.5 years using multivariable linear regression. We investigated effect modification by child sex, maternal nutrition and HIV status, and household poverty.

Results:

Pyrethroid metabolites cis-3-(2,2-dibromovinyl)-2,2-dimethyl-cyclopropane carboxylic acid (cis-DBCA), cis-3-(2,2,-dicholorvinyl)-2,2-dimethyl-cyclopropane carboxylic acid (cis-DCCA), trans-DCCA, and 3-phenoxybenzoic acid (3-PBA) were quantified in nearly all mothers. A 10-fold increase in cis-DCCA concentration was associated with 0.21 kg/m2 lower body mass index (95% confidence interval = −0.41, −0.01), with similar estimates for other cypermethrin or permethrin metabolites (trans-DCCA and 3-phenoxybenzoic acid). In stratified analyses, stronger associations were observed with lower weight, body mass index, arm circumference, and weight-for-height among boys relative to girls. Associations with cis-3-(2,2-dibromovinyl)-2,2-dimethyl-cyclopropane carboxylic acid, a metabolite specific to deltamethrin, were weaker or absent. No substantial associations were observed with DDT.

Discussion:

In a population with ubiquitous pyrethroid exposure, maternal concentrations of metabolites of cypermethrin and permethrin were associated with thinness at 3.5 years.
Status of bone strength and factors associated with vertebral fracture in postmenopausal women with type 2 diabetes
Authors: Chen Fang-Ping , Kuo Sheng-Fong , Lin Yu-Ching , Fan Chih-Ming , Chen Jung-Fu
Published: August 2018

Objective:

The aim of this study was to assess the status of bone mass, microarchitecture, and factors associated with vertebral fracture in postmenopausal women with type 2 diabetes mellitus (T2DM).

Methods:

We consecutively enrolled 285 women (aged 60.7 ± 6.9 y) with T2DM who underwent bone mineral density (BMD) and trabecular bone score (TBS) assessment using dual-energy x-ray absorptiometry; T8-S1 lateral spine radiographs; laboratory evaluation; and interviews regarding clinical risk factors based on the fracture risk assessment tool (FRAX).

Results:

Low bone mass and deteriorated bone microarchitecture were observed in 63.2% and 72.6% of women with T2DM, respectively. TBS was correlated with lumbar spine, femoral neck, and total hip BMD. Significant differences in TBS were observed between the normal BMD, osteopenia, and osteoporosis groups. Age, vertebral fracture, and bone-specific alkaline phosphatase significantly differed among groups with different T scores or those classified by TBS categories. Bone-specific alkaline phosphatase was inversely correlated with BMD and TBS but positively with glycated hemoglobin. BMD showed a weaker correlation with vertebral fracture than TBS, TBS and BMD, FRAX, and TBS-adjusted FRAX.

Conclusions:

Low bone mass and deteriorated TBS were noted in approximately two-thirds of T2DM women and was also associated with vertebral fracture. In addition to aging, poor glycemic control may play an important role in bone remodeling, which may be associated with changes in bone strength in T2DM women. Bone strength together with clinical risk factors has the strongest association with fracture, and may potentially be useful to identify women with T2DM at risk.
Bazedoxifene-induced vasodilation and inhibition of vasoconstriction is significantly greater than estradiol
Authors: Zimmerman Margaret A. , Hutson Dillion D. , Mauvais-Jarvis Franck , Lindsey Sarah H.
Published: August 2018

Objective:

A new strategy for menopausal hormone therapy replaces medroxyprogesterone with the selective estrogen receptor modulator bazedoxifene. While the agonist or antagonist activity of bazedoxifene has been examined in other tissues, the current study explored the impact of bazedoxifene on resistance artery reactivity. We hypothesized that bazedoxifene may induce greater vasoprotective effects than estradiol due to enhanced activation of the G-protein-coupled estrogen receptor.

Methods:

We measured the vasodilation of mesenteric resistance arteries from adult male and female wild-type and G-protein-coupled estrogen receptor knockout mice (n = 58) in response to increasing concentrations of bazedoxifene, medroxyprogesterone, and estradiol, and also the impact of these compounds on the responses to phenylephrine and sodium nitroprusside.

Results:

Bazedoxifene-induced vasorelaxation was greater than estradiol and blunted phenylephrine-induced contraction—an effect not observed with estradiol. Neither estradiol nor bazedoxifene altered relaxation to sodium nitroprusside. The combination of bazedoxifene + estradiol promoted greater vasodilation than medroxyprogesterone + estradiol, and opposed phenylephrine-induced contraction, whereas medroxyprogesterone + estradiol failed to attenuate this response. Both bazedoxifene + estradiol and medroxyprogesterone + estradiol enhanced sodium nitroprusside-induced relaxation in females. Vascular responses were similar in both sexes in wild-type and G-protein-coupled estrogen receptor knockout mice.

Conclusion:

Bazedoxifene and bazedoxifene + estradiol relaxed mesenteric arteries and opposed vasoconstriction to a greater degree than estradiol or medroxyprogesterone + estradiol. These effects were independent of sex and G-protein-coupled estrogen receptor expression. We conclude that bazedoxifene may provide vascular benefits over estrogen alone or estrogen plus progestogen combinations in postmenopausal women.
Comparison of Disposable Goldmann Applanation Tonometer, ICare ic100, and Tonopen XL to Standards of Care Goldmann Nondisposable Applanation Tonometer for Measuring Intraocular Pressure
Authors: Wong Benny , Parikh Deep , Rosen Lisa , Gorski Matthew , Angelilli Allison , Shih Carolyn
Published: August 2018

Purpose:

To compare intraocular pressure (IOP) measurements by Goldmann applanation tonometer (GAT), disposable Goldmann applanation prism, ICare, and Tonopen.

Materials and Methods:

A total of 74 patients with varying glaucoma status were examined in our outpatient clinic and IOP was measured with 3 tonometers. The disposable Tonojet prism (dGAT), Tonopen XL, and ICare ic100 were compared with the GAT.

Results:

There were good intraclass correlation coefficients between IOP measurements by GAT and dGAT (0.95), Tonopen (0.83), and ICare (0.77), all P<0.001. The IOP mean differences between dGAT and GAT were mean 0.80 mm Hg; 95% limits of agreement: −3.35 to 4.96 mm Hg. For Tonopen and GAT: mean, −1.67 mm Hg; limits of agreement, −8.55 to 5.21 mm Hg. For ICare and GAT: mean, 0.44 mm Hg; limits of agreement, −8.18 to 9.06 mm Hg.

Conclusions:

The most reliable modality, with good correlation with the Goldmann tonometer values, was the GAT with dGAT, followed in descending order by the Tonopen XL and ICare. There was good interdevice agreement and consistency between all devices. On subgroup analysis, all 3 modalities were found to be less reliable at extreme IOP values (<10 and >24 mm Hg). These disposable modalities should be avoided in extreme IOP ranges outside the normal range.
Cost and Outcome of Minimally Invasive Techniques for Coronary Surgery Using Robotic Technology
Authors: Pasrija Chetan , Kon Zachary N. , Ghoreishi Mehrdad , Lehr Eric J. , Gammie James S. , Griffith Bartley P. , Bonatti Johannes , Taylor Bradley S.
Published: August 2018

Objective

Totally endoscopic coronary artery bypass (TECAB) with robotic distal anastomosis and robotic-assisted minimally invasive coronary artery bypass (RA-MIDCAB) with robotic internal mammary artery harvest and direct hand-sewn distal anastomosis via an anterior thoracotomy have both been reported as safe and efficacious. We compared hospital cost and short-term outcomes between these techniques.

Methods

Patients who underwent robotic-assisted minimally invasive single-vessel Coronary artery bypass grafting (2011–2014) were retrospectively reviewed. One hundred consecutive patients underwent either TECAB (n = 50) or RA-MIDCAB (n = 50). The two groups were sequential with TECAB performed by one surgeon in the first portion of the study interval and RA-MIDCAB by another surgeon in the latter. Demographics, short-term outcomes, and hospital cost data were compared between the two groups.

Results

Patient demographics and preoperative risk factors were similar between the TECAB and RA-MIDCAB groups, as total operating room time. Cardiopulmonary bypass was used for 56% of TECAB and 0% of RA-MIDCAB cases ( P < 0.001). Intensive care unit and hospital lengths of stay, along with postoperative morbidities, were similar between the two groups. Operative mortality was 2% in the TECAB and 0% in the RA-MIDCAB group ( P = NS). Total hospital cost was significantly higher with TECAB compared with RA-MIDCAB (US $33,769 vs. $22,679, P < 0.001), which was primarily driven by operative costs (US $17,616 vs. $26,803, P < 0.001).

Conclusions

Totally endoscopic coronary artery bypass and RA-MIDCAB both demonstrated excellent short-term clinical outcomes. However, TECAB was associated with significantly higher hospital costs. Further comparisons, including long-term outcomes, patient satisfaction, and functional status, are needed to evaluate whether this additional cost is justified.