bluuebunny/crossref_metadata_2025 huggingface dataset:
Speed and agility training
Authors: Oliver Jon L , Lloyd Rhodri S
Published: April 2017

Speed and agility are fundamental locomotive skills that form the basis of many physical activities, and contribute to success in youth sport. Speed and agility represent unique qualities; speed is the ability to move quickly in a straight line, whereas agility is the ability to rapidly change direction in response to a stimulus. Agility can be further sub-divided into the physical component of change-of-direction-speed and a perceptual component related to the ability to respond to external stimuli. The natural development and trainability of speed has become relatively well understood in children and adolescents, whereas our understanding of agility is predominantly limited to a smaller body of research examining change-of-direction-speed. This chapter focuses on describing the natural development of maximal speed and agility throughout childhood and adolescence, as well as examining interactions between training and maturity in both the short- and long-term across a range of different modes of training.
Drug distribution and elimination in anaesthetic practice
Authors: van Dorp Eveline L. A. , Eleveld Douglas , Olofsen Erik , Vuyk Jaap
Published: April 2017

An understanding of pharmacokinetics is vital for the practice of anaesthesia. Drugs are, after administration, distributed throughout the body to the effect site (mostly the brain) to exert their effects. This can be influenced by differences in protein binding, systemic blood flow, and concomitant medication. Elimination of drugs from the body is through two main routes: either unchanged through the kidneys or through metabolism by the liver (and consecutive excretion through the kidneys). This process depends on the amount of hepatic blood flow and the amount of hepatic extraction. This in turn depends on the amount of protein binding and the intrinsic hepatic clearance. The cytochrome P450 enzyme family also plays an important role in drug elimination. Individual differences in enzyme activity can lead to differences in drug effect and clearances. Changes in enzyme activity by enzyme induction and inhibition can also be of influence on drug clearance. Compartmental, non-compartmental, and physiologically based models, and various statistical approaches to estimate these models, may be used to analyze the distribution and elimination of anaesthetic agents.
Intravenous anaesthetics
Authors: Absalom Anthony , Sear John
Published: April 2017

In recent decades, increasing attention has been focused on the intravenous anaesthetic agents. This interest has been stimulated by the discovery and availability of agents with increasingly favourable pharmacokinetic and dynamic properties, coupled with advances in knowledge of pharmacology and advances in computer technology. For most patients and operative procedures, anaesthesia is induced with a bolus or fast infusion of a short-acting drug, most commonly propofol. Increasingly, anaesthesia is thereafter also maintained with an infusion of an agent with favourable kinetics, again usually of propofol, commonly supplemented with boluses or infusions of opioids. Propofol is also commonly used for procedural and intensive care sedation. It has highly favourable pharmacokinetics and pharmacodynamics for these applications as sedative or hypnotic agent—rapid, smooth onset, minimal accumulation, and rapid smooth offset of effect—but is by no means an ideal agent. In some specific situations, such as when its haemodynamic or respiratory effects are detrimental, use of alternative agents such as ketamine and etomidate are warranted. All the currently available agents have adverse effects, some of which are related to the active compound and some of which are related to the vehicle. Efforts are thus being made to develop new formulations, with fewer adverse effects, and to develop newer and better drugs. In the future we are also likely to see increasing use of older agents, but for newer indications (such as the use of ketamine as an antidepressant).
Physics in anaesthesia
Authors: Magee Patrick , Tooley Mark
Published: April 2017

This chapter covers the basic science of physics relevant to anaesthetic practice. Equipment and measurement devices are covered elsewhere. Starting with fundamentals, atomic structure is introduced, followed by dimensions and units as used in science. Basic mechanics are then discussed, focusing on mass and density, force, pressure, energy, and power. The concept of linearity, hysteresis, and frequency response in physical systems is then introduced, using relevant examples, which are easy to understand. Laminar and turbulent fluid flow is then described, using flow measurement devices as applications of this theory. The concept of pressure and its measurement is then discussed in some detail, including partial pressure. Starting with the kinetic theory of gases, heat and temperature are described, along with the gas laws, critical temperature, sublimation, latent heat, vapour pressure and vaporization illustrated by the function of anaesthetic vaporizers, humidity, solubility, diffusion, osmosis, and osmotic pressure. Ultrasound and its medical applications are discussed in some detail, including Doppler and its use to measure flow. This is followed by an introduction to lasers and their medical uses. The final subject covered is electricity, starting with concepts of charge and current, voltage, energy, and power, and the role of magnetism. This is followed by a discussion of electrical circuits and the rules governing them, and bridge circuits used in measurement. The function of capacitors and inductors is then introduced, and alternating current and transformers are described.
Equipment in anaesthesia
Authors: Wilkes Antony R.
Published: April 2017

The anaesthetist will routinely use many different types of medical devices during normal working practice, and will have access to many other devices for more challenging use in emergency and other difficult scenarios. The anaesthetist will expect and rely on each medical device to work first time and not to compromise the safety of the user, the patient, their relatives, or other healthcare workers in the vicinity. The equipment will also be expected to be effective, that is, that it will perform as expected when used in a defined population of patients (e.g. small children). Manufacturers and users of equipment use risk management procedures to reduce the risk to patients and others of using the equipment. Following use, the equipment will need to be reprocessed to make it safe for use for a subsequent patient, or disposed of safely.
Mathematical models and anaesthesia
Authors: Cruickshank Steven
Published: April 2017

The use of mathematics in medicine is not as widespread as it might be. While professional engineers are instructed in a wide variety of mathematical techniques during their training in preparation for their daily practice, tradition and the demands of other subjects mean that doctors give little attention to numerical matters in their education. A smattering of statistical concepts is typically the main mathematical field that we apply to medicine. The concept of the mathematical model is important and indeed familiar; personal finance, route planning, home decorating, and domestic projects all require the application of the basic mathematical tools we acquire at school. This utility is why we learn them. The insight that can be gained by applying mathematics to physiological and other problems within medical practice is, however, underexploited. The undoubted complexity of human biology and pathology perhaps leads us to give up too soon. There are useful and practical lessons that can be learned from the use of elementary mathematics in medicine. Anaesthetic training in particular lends itself to such learning with its emphasis on physics and clinical measurement. Much can be achieved with simple linear functions and hyperbolas. Further exploration into exponential and sinusoidal functions, although a little more challenging, is well within our scope and enables us to cope with many time-dependent and oscillatory phenomena that are important in clinical anaesthetic practice. Some fundamental physiological relationships are explained in this chapter using elementary mathematical functions. Building further on the foundation of simple models to cope with more complexity enables us to see the process, examine the predictions, and, most importantly, assess the plausibility of these models in practice. Understanding the structure of the model enables intelligent interpretation of its output. Some may be inspired to investigate some of the mathematical concepts and their applications further. The rewards can be intellectually, aesthetically, and practically fruitful. The subtle, revelatory, and quite beautiful connection between exponential and trigonometric functions through the concept of complex numbers is one example. That this connection has widespread practical importance too is most pleasing.
The history of anaesthesia
Authors: McKenzie Alistair G.
Published: April 2017

Even though ether was prepared in 1540 and nitrous oxide in 1774, it was not until the 1840s that these agents were used to induce anaesthesia to enable painless surgery. Modern inhalation anaesthesia has evolved from the public demonstration of ether anaesthesia by William Morton at the Massachusetts General Hospital, Boston, United States, on 16 October 1846. In the United Kingdom, from 1847 John Snow applied scientific principles to develop safer anaesthetic practice. Newer and safer agents have replaced ether in most countries. Successful intravenous anaesthesia began with chloral hydrate in 1874; progress was hesitant until the wide acceptance of thiopental from 1934—in turn superseded by propofol from 1985. Regional anaesthesia has evolved from the first use of the local anaesthetic, cocaine, to enable awake eye surgery by Carl Koller in 1884. This progressed to nerve blocks, spinal and epidural anaesthesia with a high degree of sophistication, through provision of better and safer local anaesthetics: lidocaine and bupivacaine. The introduction of neuromuscular blocking agents into anaesthetic practice began with the use of curare by Griffith and Johnson in Montreal in 1942. Muscle relaxation became a component of ‘balanced anaesthesia’—necessitating advances in airway management, including tracheal intubation and safe mechanical ventilation of the lungs. The modern anaesthetic workstation for inhalation anaesthesia has evolved from the early anaesthetic machines over 100 years. Of all the advances in anaesthesia during the past 50 years, developments in monitoring techniques—particularly pulse oximetry and capnography—have probably made the greatest contribution to patient safety. Anaesthetists have embraced enhanced postoperative recovery.
Ethics, consent, benefit, and risk in anaesthetic practice
Authors: White Stuart
Published: April 2017

Anaesthesia involves risk. Anaesthetists are asked routinely to anaesthetize increasingly sicker patients for increasingly invasive surgery, challenging the morality that underpins the doctor–patient relationship, and placing themselves at relatively increased risks of litigation. This chapter reviews the ethical principles that govern anaesthetists’ interactions with patients, and describes how the common law and statutes affecting the practice of anaesthesia have evolved from these principles, focusing on consent and the provision of information about risk for patients.
Choice and interpretation of preoperative investigations
Authors: Stolker Robert Jan , van Lier Felix
Published: April 2017

Preoperative risk assessment is one of the most important steps in perioperative management. In the last decades, considerable progress has been achieved. However, as more high-risk procedures are performed in more aged patients, suffering more morbidity, this may lead to an increased risk of adverse outcomes. The goal of preoperative assessment is to identify patients at extreme risk and discuss whether they should be operated on, or undergo an alternative procedure with a lower risk profile, or if conservative treatment should be continued. Furthermore, it gives the opportunity to optimize patients prior to surgery, adapt intraoperative anaesthetic management and monitoring, and select patients for postoperative treatment at an intensive care unit or post-anaesthesia care unit. The cornerstone of preoperative assessment is the estimation of functional capacity. Accurate anamnesis and physical examination are crucial. Several procedures have been used to optimize the preoperative risk stratification. In this chapter, the value of these additional preoperative investigations is reviewed. These investigations are to be performed only in patients with considerable co-morbidity undergoing high-risk surgery. As cardiovascular adverse events are a major determinant of postoperative outcome, the chapter focuses on the management of the two most important cardiac risk factors, that is, myocardial ischaemia and impaired left ventricular function.
Post-surgery, post-anaesthesia complications
Authors: Toner Andrew , Hamilton Mark , Cecconi Maurizio
Published: April 2017

Postoperative complications are common in high-risk surgical populations and are associated with poor short-term and long-term outcomes. Morbidity can be identified using prospective assessment of pathological criteria, or deviations from the ideal postoperative course requiring clinical intervention. While infections are the most prevalent complication type, morbidity affecting the heart, lungs, kidneys, or brain carry the worst prognosis. Specific pathophysiological processes drive morbidity in each organ system. In addition, dysfunction of the cardiovascular and immune systems can lead to multiorgan impairment, and have been the focus of many clinical trials. Perioperative strategies backed by the strongest evidence base include smoking cessation, surgical safety checklists, perioperative warming, pre-emptive antibiotics, venous thromboembolism prophylaxis, enhanced recovery protocols, and early critical care rescue when complications arise. Isolated attempts to optimize cardiovascular function or attenuate inflammatory responses have not been consistently successful in improving outcomes. As the proportion of surgical patients meeting high-risk criteria rises, reducing the incidence of postoperative complications has become a priority in many developed healthcare systems. To meet this need, improved implementation of proven strategies should be combined with routine and rigorous surgical outcome reporting. In addition, advances in pathophysiological understanding may lead to novel interventions offering multisystem protection in the surgical period.
Vascular access during anaesthesia
Authors: Bodenham Andrew R.
Published: April 2017

Vascular access, both arterial and venous, at peripheral and more central sites is relatively new in historical medical terms and has only really developed into mainstream practice in the last 60 years. Other routes of drug and fluid administration via the gut and inhalation preceded it by centuries. It is a core skill for anaesthetists and intensivists, yet is not always well taught or is left out of core training curricula, with the assumption that skills will just be picked up early along the way. Like many procedures, it can be surprisingly easy to learn the basics, but many hazards and difficulties await the less skilled or inexperienced operator. A thorough knowledge of applied anatomy, practical skills, and recognition and management of complications are essential for safe practice. The increasing use of ultrasound, ECG guidance, X-ray screening, and other devices, and improved design of access devices allow much safer and more successful procedures. Many patients will now have long-term devices in situ, which can be used during anaesthesia and critical care. Such devices are increasingly inserted or removed by anaesthetists. Space precludes a detailed description of actual techniques for all routes of access; only general principles will be covered in this chapter.
Regional anaesthesia of the upper limb
Authors: McCartney Colin J. L. , Macfarlane Alan J. R.
Published: April 2017

Peripheral nerve blocks of the upper limb can provide excellent anaesthesia and postoperative analgesia. A variety of well-established traditional approaches to the brachial plexus exist, namely interscalene, supraclavicular, infraclavicular, and axillary techniques. Individual terminal nerves such as the median, radial, ulnar, and other smaller nerves can also be blocked more distally. The traditional and ultrasound-guided approach to each of these nerve blocks is discussed in turn in this chapter, along with specific indications and complications. The introduction of ultrasound guidance has generated significant excitement in this field in the last 10 years and has been demonstrated to improve efficacy and reduce complications. However, a sound knowledge of anatomy of the nerve supply to the upper limb remains essential during any upper limb regional anaesthesia technique.
Anaesthesia for neurosurgery and electroconvulsive therapy
Authors: Klimek Markus , Lobo Francisco A. , Steiner Luzius A. , Kalkman Cor J.
Published: April 2017

Neuroanaesthesia is the subspecialty of anaesthesiology that deals with patients undergoing surgical procedures in or close to the brain and the spinal cord. Neuroanaesthesia can be challenging, because sometimes apparently contradictory demands must be managed, for example, achieving optimal conditions for neurophysiological monitoring while maintaining sufficient anaesthetic depth, or maintaining oxygen delivery to neuronal tissue and simultaneously preventing high blood pressures that might induce local bleeding. Atypical patient positioning, management of increased intracranial pressure, and the need for early postoperative neurological evaluation are other typical challenges. This chapter addresses the general principles of neuroanaesthesia and special aspects of the most relevant procedures. A section on anaesthesia for electroconvulsive therapy is also included.
Anaesthesia for transplant surgery
Authors: Ramsay Michael A. E.
Published: April 2017

The provision of anaesthesia for organ transplantation requires a team of specialist anaesthetists who are available 24 hours a day. The cold and warm ischaemia times may have very deleterious effects on the graft. The team must have a basic understanding of the immune system and the strategies of immunosuppression therapy. The preoperative assessment of the patient requires an understanding of the cause and effects of the compromised organ that is to be replaced. The procedure in many instances will result in a reperfusion syndrome when the graft is revascularized and also an ischaemia–reperfusion injury. The understanding of these entities is essential as is the preparation and protocols to treat or ameliorate the effects of these syndromes if they occur. The preparation for many organ transplants includes invasive monitoring of haemodynamics, cardiac function, pulmonary function, and acid–base balance. Access for massive transfusion therapy and coagulation assessment is essential for many transplant procedures. The maintenance of body temperature and fluid balance may be challenging. The protection and monitoring of the function of major organs such as the brain, heart, lungs, and kidneys is essential but the homeostasis of endocrine function and electrolytes is also important. The provision of excellent anaesthesia is a key component of a successful transplant programme. A small team of highly trained professionals with extensive training and experience in transplant anaesthesia provide the best results.
Anaesthesia for the infant and older child
Authors: Gottlieb Erin A. , Moores Anthony , Pettigrew Tom , Walker Alyson
Published: April 2017

Anaesthesia for infants and older children is, in many respects, similar to the practice of anaesthesia in adults. However, there are important differences in physiology, pathology, and pharmacology between children and adults, and there are the additional overlays of childhood personality and parental involvement. This chapter considers anaesthesia for children beyond the neonatal stage. It deals with the important aspects of the pre-, intra-, and postoperative periods, and particularly details those aspects of paediatric anaesthesia where practice differs from that in adult patients.
Resuscitation, stabilization, and transfer of sick and injured children
Authors: Jenkins Ian A. , Rowney David A.
Published: April 2017

Even though anaesthetists may not regard themselves as specialists in the care of critically ill children, they are still at the forefront of the immediate care of critically ill children. Whether they have developed an interest in paediatric anaesthesia or because they have subspecialized in general intensive care, anaesthetists will find themselves called upon by colleagues in the emergency department or in paediatrics to exercise the knowledge and skills that no other group in the hospital possess. Additionally, when these children need to be moved either to a scanner or hyper-acutely to a tertiary unit (e.g. for neurosurgical intervention), then the skills and specific knowledge of the anaesthetist will be called upon again. These elements are recognized in the syllabi of both the Fellowship of the Royal College of Anaesthetists and the Fellowship of the Faculty of Intensive Care Medicine. This chapter gives the background to the characteristics of critically ill children, sets out the important elements of the conditions that will be commonly encountered, and provides a full résumé of the preparations that transferring teams will need in terms of personnel, their knowledge, skills, and equipment, and also a full exploration of the various methods of transport, road ambulance, rotary- and fixed-wing aircraft, and what all these entail for the clinical team.
Ethics, consent, and safeguarding in paediatric anaesthesia
Authors: Cranston Alistair , McFadzean Jillian , Wheeler Robert
Published: April 2017

This chapter explores the important principles of ethics, consent, and safeguarding in paediatric anaesthesia. While these issues also have relevance in adult anaesthetic practice, they are particularly important (and complex) in paediatric practice because of concerns regarding children’s vulnerability, the difficulties of their varied ability to communicate, and the potential for emotional overlay and the involvement of parents/guardians. The shifting landscape of safeguarding and consent also adds a layer of complexity that makes a thorough understanding of these issues vital in paediatric anaesthetic practice. This chapter deals with the basics of child protection, followed by ethics and consent in paediatric practice. Some ethical dilemmas in paediatric anaesthetic practice are also explored, illustrating the complexities and challenges in this arena.
Military anaesthesia
Authors: Mahoney Peter F. , Kirkman Emrys , Watts Sarah , Smyth Karen , Nordmann Giles , Tarmey Nicholas T. , Mercer Simon J. , Woolley Tom , Aldington Dominic , Turner Simon , Small Charlotte , Wood Paul
Published: April 2017

War and conflict have long been associated with improvements in medical care. The recent conflicts in Afghanistan and Iraq have been no exception. The high tempo of operations has presented the United Kingdom’s Defence Medical Services (DMS) with the need to care for injured service personnel and local nationals with highly complex patterns of injury. Patients have presented to the DMS with injuries not commonly encountered in civilian practice—typically the result of blast and ballistic mechanisms. The deployed anaesthetist is involved in all stages of the patient pathway from point of wounding to the emergency department, through the resuscitative period encompassed by the damage control construct; to the critical care delivered on the ground and in the air and finally back in the United Kingdom at the interface with the civilian National Health Service. The high quality of care delivered in association with rigorous clinical audit and research including laboratory physical science, has produced developments that not only impact on military outcomes, but which are being introduced in wider civilian practice. This chapter covers all these areas from first principles to the management of pain and advances in the understanding of coagulopathy.
Haematological and coagulation disorders and anaesthesia
Authors: Hendriks Herman G. D. , de Wolf Joost T. M.
Published: April 2017

This chapter covers the principal haematological disorders and their implications for anaesthesia. Haemoglobin concentration is the main determinant of oxygen delivery to the tissues making anaemia a potential concern for the anaesthetist. In deciding whether to correct anaemia with a red blood cell transfusion, the anaesthetist must consider the nature of the surgery and the underling cause of the anaemia as well as the haemoglobin concentration. Techniques to limit the need for blood transfusion and the complications of transfusion are discussed. Perfect haemostasis means control of bleeding without the occurrence of thrombotic events. Coagulation management requires an understanding of this balance and the knowledge that altered coagulation activity may result in clinically relevant bleeding or, in contrast, thrombosis. Therefore, the key in haemostasis is an understanding that every anticoagulant action enhances the risk of bleeding and every procoagulant action enhances the risk of thrombosis. If a specific defect in the haemostatic system is known, treatment is tailored to restore this defect. However, tests to predict surgical bleeding do not exist, as it is for test to predict thrombotic events. The strengths and limitations of coagulation tests should be appreciated before they are used to assist clinical decision-making in the perioperative period. An excellent coagulation test is the clinical field (i.e. the surgical wound). If there are abnormalities in the coagulation tests without clinical bleeding, a correction is hardly necessary. In patients taking anticoagulant medication, consideration must be given on an individual patient basis, to the relative risks of continuing (bleeding) or stopping (thrombotic events) the medication.
Advanced life support
Authors: Nolan Jerry P.
Published: April 2017

Anaesthetists have a central role in cardiopulmonary resuscitation (CPR). The incidence of treated out-of-hospital cardiopulmonary arrest is 40 per 100 000 population and is associated with a survival rate to hospital discharge of 8–10%. The incidence of in-hospital cardiac arrest (IHCA) is 1–5 per 1000 admissions and is associated with a survival rate to hospital discharge of 13–17%. The most effective strategy for reducing mortality from IHCA is to prevent it occurring by detecting and treating those at risk or to identify in advance those with no chance of survival and to make a decision not to attempt resuscitation. The European Resuscitation Council and the Resuscitation Council (UK) publish guidelines for CPR every 5 years and the evidence supporting these is described in the international consensus on CPR science. The advanced life support algorithm forms the core of the guidelines but the precise interventions depend on the circumstances of the cardiac arrest and the skills of the healthcare providers. High-quality CPR with minimal interruptions will optimize survival rates. Shockable rhythms are treated with defibrillation while minimizing the pause in chest compressions. Although adrenaline (epinephrine) is used in most cardiac arrests, no studies have shown that it improves long-term outcome. The post-cardiac arrest syndrome is common and requires multiple organ support in an intensive care unit. Therapy in this phase is aimed at improving neurological (e.g. targeted temperature management) and myocardial (e.g. percutaneous coronary intervention) outcomes. Based on standard outcome measurements (e.g. cerebral performance category), 75–80% of survivors will have a ‘good’ neurological outcome, but many of these will have subtle neurocognitive deficits.
Frequency and Type of Situational Awareness Errors Contributing to Death and Brain Damage
Authors: Schulz Christian M. , Burden Amanda , Posner Karen L. , Mincer Shawn L. , Steadman Randolph , Wagner Klaus J. , Domino Karen B.
Published: April 2017

AbstractAbstract

Situational awareness errors resulting in death or brain damage remain prevalent causes of malpractice claims in the 21st century.

Background

Situational awareness errors may play an important role in the genesis of patient harm. The authors examined closed anesthesia malpractice claims for death or brain damage to determine the frequency and type of situational awareness errors.

Methods

Surgical and procedural anesthesia death and brain damage claims in the Anesthesia Closed Claims Project database were analyzed. Situational awareness error was defined as failure to perceive relevant clinical information, failure to comprehend the meaning of available information, or failure to project, anticipate, or plan. Patient and case characteristics, primary damaging events, and anesthesia payments in claims with situational awareness errors were compared to other death and brain damage claims from 2002 to 2013.

Results

Anesthesiologist situational awareness errors contributed to death or brain damage in 198 of 266 claims (74%). Respiratory system damaging events were more common in claims with situational awareness errors (56%) than other claims (21%, P < 0.001). The most common specific respiratory events in error claims were inadequate oxygenation or ventilation (24%), difficult intubation (11%), and aspiration (10%). Payments were made in 85% of situational awareness error claims compared to 46% in other claims (P = 0.001), with no significant difference in payment size. Among 198 claims with anesthesia situational awareness error, perception errors were most common (42%), whereas comprehension errors (29%) and projection errors (29%) were relatively less common.

Conclusions

Situational awareness error definitions were operationalized for reliable application to real-world anesthesia cases. Situational awareness errors may have contributed to catastrophic outcomes in three quarters of recent anesthesia malpractice claims.
Trends and Outcomes of Early Versus Late Percutaneous Endoscopic Gastrostomy Placement in Patients With Traumatic Brain Injury: Nationwide Population-based Study
Authors: Chaudhry Rabail , Kukreja Naveen , Tse Alex , Pednekar Greesha , Mouchli Anas , Young Linda , Didyuk Oksana , Wegner Robert C. , Grewal Navneet , Williams George W.
Published: April 2017

Background:

Oral intake for traumatic brain injury (TBI) patients is often not an option because of facial trauma, swallowing dysfunctions, altered consciousness, etc. These patients often require percutaneous endoscopic gastrostomy (PEG) placement for nutrition support. To date, there is lack of studies examining the relationship between the timing of PEG placement and patient outcome in the TBI group.

Methods:

We conducted a population-based study in a retrospective cohort of TBI patients undergoing PEG, using the national inpatient sample for years 2011 to 2013.

Results:

A total of 96,625 patients were identified for TBI and 3343 of those patients received PEG. TBI patients who undergo an early or late PEG placement had a higher rate of in-hospital mortality, when compared with patients with a standard timing of PEG placement. Late PEG was preferably placed in patients with higher Charlson index and trauma-related comorbidities, and these patients had a higher incidence of complications, that is, sepsis, urinary tract infection, acute respiratory distress syndrome/pneumonia, and deep vein thrombosis/pulmonary embolism. When stratified by mortality-risk groups, early PEG was associated with higher rates of in-hospital mortality while standard PEG was associated with best mortality outcomes in low–mortality-risk group and moderate–mortality-risk group.

Conclusions:

The results of this study suggest that if a PEG placement is indicated for a TBI patient, a standard (7 to 14 d) timing may be associated with better patient outcomes. However, secondary to limitations associated with the use of administrative databases, further prospective studies are needed to establish clear guidelines regarding the optimal timing of placing PEG in TBI patients.
Osteonecrosis of the Shoulders in Pediatric Patients Treated for Leukemia or Lymphoma: Single-Institutional Experience
Authors: Kaste Sue C. , DeFeo Brian M. , Neel Michael D. , Weiss Kenneth S. , Fernandez-Pineda Israel , Ness Kiri K.
Published: April 2017

Background:

Osteonecrosis of the hips and knees is an often debilitating adverse event in children treated with glucocorticoids for leukemia and lymphoma but the impact of shoulder involvement has been understudied. Thus, we investigated the severity and functional impairment of shoulder osteonecrosis in a well-characterized population of pediatric patients treated for acute lymphoblastic leukemia or lymphoma.

Methods:

We retrospectively reviewed orthopaedic clinic and physical therapy evaluations to determine range of motion (ROM), pain, and impact of magnetic resonance-defined osteonecrosis (ON) on activities of daily living. Adverse events were classified according to the National Cancer Institute’s Common Terminology Criteria for Adverse Events version 4.03.

Results:

We identified 35 patients (22 female), median age at cancer diagnosis 14.2 (range, 4.3 to 19) years; median age at ON diagnosis 16.7 (range, 5.5 to 28) years. Median time to last follow-up from diagnosis of primary malignancy was 6.4 (range, 0 to 12.7) years and from diagnosis of ON was 4.0 (range, 0 to 8.9) years. Twenty-two patients had magnetic resonance evidence of ON; 43 shoulders involved at least 30% of the articular surface of the capital humeral epiphyses.

Common Terminology Criteria for Adverse Events mean scores for initial assessments of 55 shoulders (29 patients) showed moderate negative impact of ON on activity of daily living (1.94), decreased ROM limiting athletic activity (0.98), and mild to moderate levels of pain (1.38). Analysis of this group’s most recent assessment showed improvement in pain and ON over time, with an average pain grade of 0.58 indicating no pain to mild pain, and 1.37 for ON grade, indicating asymptomatic to mildly symptomatic impact on activities of daily living. We also found minimal worsening average ROM grades (1.11).

Conclusions:

Shoulder ON is an underappreciated adverse late effect of therapy in children treated for leukemia/lymphoma which can limit quality of life and functionality. In most cases, pain and disability can be improved with treatment.

Level of Evidence:

Level IV—case series.
Best Practices in Spinal Cord Stimulation
Authors: Sitzman B. Todd , Provenzano David A.
Published: April 2017

Study Design.

A review of clinical best practices for spinal cord stimulation (SCS).

Objective.

The aim of this study is to summarize published and evidence based guidelines with regards to utilizing SCS, including patient selection, disease indication, perioperative management, complication mitigation strategies, and device selection. Additional focus has been provided on quality care to individual patients by acknowledging the importance of durable outcomes and care delivery costs.

Summary of Background Data.

For more than 30 years, SCS has successfully alleviated patient suffering and enhanced the lives of patients with refractory pain conditions. Prospective studies of SCS have consistently demonstrated benefits through reduction of pain, improvement in function, and reduced healthcare expenditures in select patient diagnosis groups. Although the benefits of SCS are well-supported, the clinical application of this therapy varies widely based on physician training and experience, regional clinical practice variations, and insurance coverage.

Methods.

This article provides a summary of published studies, case reports, evidence-based guidelines and expert consensus, with the intent of increasing physician competency and enhancing patient care through improved clinical outcomes.

Results.

A guide to SCS implantation, appropriate patient selection, ranked recommendations for diseases that may most benefit for SCS treatment, complication mitigation strategies, and finally, indications for choosing the most efficacious modality of SCS therapy for specific patients and pain conditions.

Conclusion.

Although SCS has been shown to be safe and effective for a number of pain conditions, emerging SCS modalities promise even greater efficacy over traditional SCS. To achieve this promise, physicians must carefully select and manage their patients and the SCS device.

Level of Evidence: N\A
Physical long-term side-effects in young adult cancer survivors: germ cell tumors model
Authors: Kourie Hampig Raphael , Klastersky Jean A.
Published: April 2017

Purpose of review

After the important advances in the treatment of germ cell tumors (GCTs) leading to high cure rates, physical long-term side-effects represent an important cause of death in these young adult survivors. Highlighting these physical long-term side-effects, their monitoring and their prevention modalities is necessary for a better management of these cancer survivors.

Recent findings

Impaired fertility, increased risk of developing a second cancer, cardiac, pulmonary, renal and neural toxicity, hearing and vision impairment are the major physical side-effects in young adult cancer survivors. Long-term cardiac toxicity, next to second malignancies, represents life-threatening conditions in testicular cancer survivors. The long-term nephrotoxity in testicular GCTs survivors is most frequently associated to the treatment either in those treated with cisplatin-based chemotherapy, mainly Bleomycine, Etoposide, Cisplatin, or those receiving infradiaphragmatic radiation therapy, whereas pulmonary toxicity is mainly attributed to bleomycin related toxicities.

There are no clear and comprehensive data concerning the monitoring and prevention of long-term side-effects in testicular cancer survivors. Physical activity and interventions in modifiable cardiovascular risk factors and lifestyles may reduce the incidence of long-term side-effects in these cancer survivors.
Ipilimumab-induced Guillain-Barré Syndrome Presenting as Dysautonomia: An Unusual Presentation of a Rare Complication of Immunotherapy
Authors: Wu W. Kelly , Broman Kristy K. , Brownie Evan R. , Kauffmann Rondi M.
Published: April 2017

Immune-related adverse events are common and well-documented in patients treated with ipilimumab, a cytotoxic T-lymphocyte antigen-4 monoclonal antibody approved for the treatment of metastatic and stage III melanoma. Neurological complications are rare, but widely variable and potentially devastating. Here, we discuss a case of a patient who was treated with a single dose of ipilimumab for resected stage III melanoma. She subsequently developed pandysautonomia that manifested as a tonically dilated pupil, gastrointestinal dysmotility, urinary retention, and profound orthostatic hypotension. Guillain-Barré syndrome was diagnosed on electromyography. She was treated with intravenous immunoglobulin, droxidopa, and supportive care, with prolonged but eventual recovery. Given the broadening use of ipilimumab in the treatment of advanced and metastatic melanoma, awareness and recognition of its profound immune-mediated adverse effects are essential.
GAS-FOVEAL CONTACT
Authors: Alberti Mark , la Cour Morten
Published: April 2017

Purpose:

To compare gas-foveal contact in face-down positioning (FDP) and nonsupine positioning (NSP), to analyze causes of gas-foveal separation and to determine how gas-foveal contact affects clinical outcome after idiopathic macular hole repair.

Methods:

Single center, randomized controlled study. Participants with an idiopathic macular hole were allocated to either FDP or NSP. Primary outcome was gas-foveal contact, calculated by analyzing positioning in relation to intraocular gas fill. Positioning was measured with an electronic device recording positioning for 72 hours postoperatively.

Results:

Positioning data were available for 33/35 in the FDP group and 35/37 in the NSP group, thus results are based on 68 analyzed participants. Median gas-foveal contact was 99.82% (range 73.6–100.0) in the FDP group and 99.57% (range 85.3–100.0) in the NSP group (P = 0.22). In a statistical model, gas fill had a significant relation to gas-foveal contact (P < 0.0001), whereas whether the surgeon prescribed FDP or NSP was not significant (P = 0.20). Of clinical relevance, gas-foveal contact seemed to influence idiopathic macular hole closure (P = 0.02).

Conclusion:

We found no significant difference in gas-foveal contact between the positioning groups. The role of positioning after idiopathic macular hole surgery seems to be better characterized from examining both patient positioning and gas fill objectively. We propose gas-foveal contact as a new outcome for evaluating positioning regimens.
Immunologic Rejection Episodes After Deep Anterior Lamellar Keratoplasty: Incidence and Risk Factors
Authors: Gonzalez Andres , Price Marianne O. , Feng Matthew T. , Lee Christopher , Arbelaez Juan G. , Price Francis W.
Published: April 2017

Purpose:

To assess the rejection episode rate after deep anterior lamellar keratoplasty (DALK) and to identify associated risk factors.

Methods:

This retrospective review of 251 primary DALK procedures performed by 14 surgeons at a single center between February 2008 and November 2015 evaluated the rejection episode rate and associated risk factors using Kaplan–Meier survival and proportional hazards analyses, which took the length of follow-up into consideration.

Results:

Transplant indications were keratoconus or ectasia after laser refractive surgery (n = 170, 68%), corneal opacity (n = 72, 28%), and other anterior corneal disease (n = 9, 4%). The median recipient age was 46 years. The overall rejection episode rate was 14% with 18-month median follow-up and a 7-week median postoperative corticosteroid duration. In univariate analysis, increased risk of rejection episodes was associated with younger recipient age [relative risk (RR): 2.1, 95% confidence interval (CI): 1.4–5.2], African American race (RR: 2.1, 95% CI: 1.1–4.1), and use of manual trephination (compared with the femtosecond laser) for the side-cut incisions (RR: 2.7, 95% CI: 1.4–5.2). In multivariate analysis, the combined effect of patient age and race (P = 0.0012) and the side-cut method (P = 0.021) were each significant risk factors.

Conclusions:

This study demonstrates the substantial rate of rejection episodes that can be induced by corneal stroma in DALK and suggests that postoperative topical corticosteroids should be continued longer than the study's 7-week median and that young African Americans need higher-dose, longer-duration topical corticosteroids. The association between the side-cut method and rejection risk merits further investigation.
Comparison of Daptomycin and Linezolid in the Treatment of Vancomycin-Resistant Enterococcus faecium in the Absence of Endocarditis
Authors: Suleyman Geehan , Mahan Meredith , Zervos Marcus J.
Published: April 2017

Background

Although linezolid and daptomycin are frequently used for the management of vancomycin-resistant Enterococcus (VRE) bloodstream infection, optimal treatment is undefined.

Methods

We conducted a retrospective cohort study from January 2010 to December 2013 of patients with VRE faecium (VREF) bloodstream infection in the absence of endocarditis treated with daptomycin or linezolid at a single 802-bed teaching hospital in Detroit, Mich. Ninety-day all-cause mortality, length of stay, bacteremia duration, antibiotic duration, and recurrence at 30 days were evaluated. Multivariable analysis was performed to determine the effect of treatment selection on mortality.

Results

One hundred eighteen patients were included. Seventy-four patients received daptomycin and 44 linezolid. There was no significant difference in baseline characteristics between the 2 groups with the exception of nursing home residence (P = 0.007), intensive care unit admission (P = 0.049), receipt of chemotherapy (P = 0.013), and neutropenia (P = 0.007). Ninety-day all-cause mortality was 46% and 27% (odds ratio = 2.27; 95% confidence interval, 1.1–5.07; P = 0.044) and mean bacteremia duration was 3.6 and 2.6 days (odds ratio = 2.52; 95% confidence interval, 1.17–5.42; P = 0.037) for daptomycin and linezolid, respectively. There was no significant difference in mean length of stay, mean antibiotic duration, and recurrence between the 2 groups. Moreover, there were no significant differences in mortality between the 2 groups after controlling for variables such as chemotherapy, neutropenia, and renal replacement therapy that were associated with increased mortality.

Conclusions

Our study showed that there was no significant difference in mortality between linezolid and daptomycin for therapy of VRE bacteremia in the absence of endocarditis after controlling for other variables that were associated with increased mortality.
Pyogenic Liver Abscess
Authors: Jaiswal Shubham Suresh , Nanjappa Sowmya , Greene John N.
Published: April 2017

Pyogenic liver abscess (PLA) is an uncommon but potentially lethal disease affecting humans worldwide. Despite the improvement in diagnostic imaging techniques and therapeutic modalities, the case fatality rate of PLA in patients with an underlying malignancy is high. There is little microbiological data available regarding PLA in patients with cancer. We found that the single most common organism isolated from PLAs was Escherichia coli (26.31%), followed by Enterococcus faecium (10.52%) and Pseudomonas aeruginosa (10.52%). More than half the cases were polymicrobial (20/38, 52.63%). Our data suggest that polymicrobial PLAs are common in patients with cancer. Further information is needed to determine how these trends might optimize prevention and treatment strategies for PLA in patients with cancer.
Patellar Instability: When is Trochleoplasty Necessary?
Authors: Carstensen S. Evan , Menzer Heather M. , Diduch David R.
Published: April 2017

Trochleoplasty is a very effective procedure for correcting trochlear dysplasia and addressing instability of the patella. With an increasing knowledge about the anatomy and biomechanics of the anterior distal femur, a wider array of surgical techniques may be applied to address specific conditions. Patients must be carefully selected to undergo trochleoplasty by use of a thorough history and physical examination as well as basic and advanced imaging. The presence of a “J sign” on physical examination, a history of recurrent instability, patella alta, trochlear dysplasia, and elevated tibial tubercle to trochlear groove are signs and symptoms for which the patient should be evaluated. We attempt to elucidate when trochleoplasty is indicated by means of addressing all aspects of evaluation.