bluuebunny/crossref_metadata_2025 huggingface dataset:
Fetal Scalp Blood Sampling During Second Stage of Labor—Analyzing Lactate or pH? A Secondary Analysis of a Randomized Controlled Trial
Authors: Stål Ingrid , Wennerholm Ulla-Britt , Nordstrom Lennart , Ladfors Lars , Wiberg-Itzel Eva
Published: September 2022

(Abstracted from J Matern Fetal Neonatal Med 2022;35(6):1100–1107)

Cardiotocography (CTG) is widely used in pregnancy as a method to assess the well-being of the fetus. Although CTG has high sensitivity, it also has low specificity.
Restrictive State Abortion Bans—A Reproductive Injustice
Authors: Wilkinson Barbara , Onwuzurike Chiamaka , Bartz Deborah
Published: September 2022

(Abstracted from N Engl J Med 2022;386:1197–1199)

In this perspective, the authors call on the medical community to come together to preserve reproductive rights in light of the challenge to Roe v Wade and Planned Parenthood of Southeastern Pennsylvania v Casey, both of which permit abortion before fetal viability under the constitutional right to privacy since 1973.
Pulse Oximetry and Race in Critically Ill Adults
Authors: Seitz Kevin P. , Wang Li , Casey Jonathan D. , Markus Shannon A. , Jackson Karen E. , Qian Edward T. , Self Wesley H. , Rice Todd W. , Semler Matthew W.
Published: September 2022

OBJECTIVES:

For critically ill adults, oxygen saturation is continuously monitored using pulse oximetry (Spo
2) as a surrogate for arterial oxygen saturation (Sao
2). Skin pigmentation may affect accuracy of Spo
2 by introducing error from statistical bias, variance, or both. We evaluated relationships between race, Spo
2, Sao
2, and hypoxemia (Sao
2 < 88%) or hyperoxemia (Pao
2 > 150 mm Hg) among adults receiving mechanical ventilation in a medical ICU.

DESIGN:

Single-center, observational study.

SETTING:

Medical ICU at an academic medical center.

PATIENTS:

Critically ill adults receiving mechanical ventilation from July 2018 to February 2021, excluding patients with COVID-19, with race documented as Black or White in the electronic medical record, who had a pair of Spo
2 and Sao
2 measurements collected within 10 minutes of each other.

INTERVENTIONS:

None.

MEASUREMENTS:

We included 1,024 patients with 5,557 paired measurements within 10 minutes, of which 3,885 (70%) were within 1 minute. Of all pairs, 769 (14%) were from Black patients and 4,788 (86%) were from White patients. In analyses using a mixed-effects model, we found that across the range of Spo
2 values of 92–98%, the associated Sao
2 value was approximately 1% point lower for Black patients compared with White patients. Among patients with a Spo
2 value between 92% and 96%, Black patients were more likely to have both hypoxemia (3.5% vs 1.1%; p = 0.002) and hyperoxemia (4.7% vs 2.4%; p = 0.03), compared with White patients.

CONCLUSIONS:

Among patients with a measured Spo
2 of 92–96%, greater variation in Sao
2 values at a given Spo
2 resulted in a higher occurence rate of both hypoxemia and hyperoxemia for Black patients compared with White patients.
Lymphatic Function Decreases over Time in the Arms of Breast Cancer Patients following Treatment
Authors: Johannessen Andreas L. , Alstrup Mathias , Hjortdal Vibeke E. , Offersen Birgitte V. , Mohanakumar Sheyanth
Published: September 2022

Background:

In patients with breast cancer-related lymphedema, distinct lymphatic patterns and changed lymphatic contractile function have been described, but it is unknown how these characteristics change over time and to what extent they appear before clinical edema is detectable. Recently, we described the lymphatic morphology and function in a cohort of breast cancer patients shortly after radiation therapy (RT). In the current study, we investigate lymphatic function and morphology in the same cohort after 1 year of follow-up.

Methods:

The study population consisted of 28 breast cancer patients investigated 12 months after adjuvant locoregional RT. Lymphatic contraction frequency (CF), propulsion velocity, and the morphology of lymphatic vessels in the upper extremities were described in vivo using near-infrared fluorescence imaging. Lymphatic stress test was performed using hyperthermia.

Results:

At 1 year after RT, (n = 28) 46% of the patients presented with lymphatic morphological abnormalities with a degree of dermal backflow and 21% had developed clinical breast cancer-related lymphedema. In the ipsilateral arm, CF was 23% lower than in the contralateral arm (P = 0.04). Since primary examination, CF in the ipsilateral arm decreased by 40% (P = 0.03), whereas no change was observed in the contralateral arm. During hyperthermia, the ipsilateral arms with lymphatic complications were not able to increase CF as the remaining subgroups.

Conclusions:

Lymphatic function in the ipsilateral arm deteriorated over time after adjuvant breast cancer therapy. Furthermore, the presence of abnormal torturous lymphatic vessels in asymptomatic arms appeared to be associated with weak lymphatic reserve pumping capacity.
Optical Coherence Tomography and Visual Outcomes in Pediatric Abusive Head Trauma
Authors: Kelly John P. , Feldman Kenneth W. , Weiss Avery
Published: September 2022

Purpose:

Compare follow-up optical coherence tomography (OCT) with visual function in children with abusive head trauma (shaken baby syndrome).

Methods:

Retrospective follow-up studies of 3 children who were victims of abusive head trauma (AHT) within the first year of life.

Results:

OCTs showed disrupted retinal layering, thick detached internal limiting membrane, focal posterior vitreous separation, and multilayered tractional retinoschisis. Significant vision loss occurred in 3 out of 4 eyes with a history of traumatic retinoschisis. Normal visual acuity and low-normal visual evoked potentials were measured in a child with foveal distortion, reduced global nerve fiber layer thickness, detached internal limiting membrane, and history of vitreous hemorrhage.

Discussion:

Significant abnormalities of retinal anatomy can be detected on OCT years after AHT. OCTs and assessment of visual pathways help to elucidate causes of visual dysfunction in children with AHT.
New pharmacologic agents for obstructive sleep apnoea: what do we know and what can we expect?
Authors: Hedner Jan , Zou Ding
Published: September 2022

Purpose of review

This review provides a condensed description of pharmacological remedies explored in patients with obstructive sleep apnoea (OSA) as well as projections of what we might expect in terms of clinical performance of these drugs.

Recent findings

Conventional drug therapies explored in OSA have generally produced disappointing results and there is a shortage of pharmacological treatment alternatives in this disorder. Recent insights into pathophysiological mechanisms potentially involved in OSA suggest that the condition may be divided into distinct subgroups based on clusters or defined by means of unique functional endotypic criteria. In fact, positive outcomes in clinical trials have now resulted in several drug candidates that show a convincing reduction of sleep disordered breathing in both short and intermediate term. Such drugs may be particularly useful in certain variants of OSA but not in others. These insights have also raised the ambition to create personalized therapies in OSA. Another recent development is the insight that OSA-linked conditions such as obesity, daytime somnolence and various forms of cardiovascular/metabolic disease may provide drug-based targets. For instance, pharmacological obesity therapy may provide not only positive metabolic effects but may also be a way to eliminate the anatomic component in obese OSA patients.

Recent insights into the pathophysiology of OSA have opened possibilities to develop personalized therapy. Drugs addressing fundamental aspects of the sleep and breathing disorder provide a particularly promising avenue for development of novel forms of treatment in OSA.
Research into the mechanism of intervention of SanQi in endometriosis based on network pharmacology and molecular docking technology
Authors: Lin Zhiheng , Fan Weisen , Yu Xiao , Liu Jinxing , Liu Pengfei
Published: September 2022

Background:

By using network pharmacology and molecular docking technology, we have explored the mechanism of action of Sanqi in the treatment of endometriosis (EMS), in order to provide reference for clinical studies of Chinese medicine treatment of Ems and Chinese medicine pharmacology.

Methods:

There are 123 intersecting targets between the active ingredients of Sanqi and disease targets. In the Protein-Protein Interaction network, Jun proto-oncogene, AP-1 transcription factor subunit, tumor necrosis factor, interleukin 6, etc., are the core proteins. The top 20 genes ranked by degree have been analyzed according to the Kyoto Encyclopedia of Genes and Genomes pathway and Gene Ontology analysis, and 20 pathways have been identified.

Results:

On the Kyoto Encyclopedia of Genes and Genomes pathway, the most important part is the phosphatidylinositol 3’-kinase-Akt signaling pathway, and on the Gene Ontology pathway, it is the Heme binding. The top 3 targets docked to quercetin have a certain affinity when it is docked to their degree value. Among the chemical components of Sanqi, quercetin has the most targets, suggesting that it may play a major role in the treatment of EMS.

Conclusion:

The results of molecular docking provide further evidence of the potential role of Sanqi for EMS. Overall, our study provides a new direction for the treatment of EMS and provides the basis for Sanqi as a drug for the treatment of EMS.
Analysis of correlation between the consumption of beverages and the risk of radiographic knee osteoarthritis in Korean people: A cross-sectional study using the Fifth Korea National Health and Nutrition Examination Survey (KNHANES V-1, 2)
Authors: Lim Chae Ouk , Park Hyung Jun , Koo Bong Mo , Kim Bo Taek , Kim Jae Gyoon , Choi Gi Won
Published: September 2022

The purposes were to analyze correlations between the frequency of beverage drinking (coffee, green tea, milk, and soft drinks) and the presence of radiographic knee osteoarthritis (OA) in relation to sex. We performed this study using the Korea National Health and Nutrition Examination Survey (KHANES V-1, 2). We examined data from 5503 subjects after exclusion. We utilized the food frequency questionnaires from KHANES, and reorganized them into 2 or 3 groups according to the frequency of beverage consumption. We analyzed the relationship between radiographic knee OA and beverage consumption statistically after adjusting confounding factors with multivariable logistic regression analysis. Knee OA was inversely associated with coffee consumption only in women (P < .05). The odds ratio of knee OA was lower in those who drank at least a cup of coffee than in those who did not drink coffee in women (P for trend < .05). However, there was no significant linear trend of the odds ratio of each group in both sexes for drinking other beverages. As the coffee consumption increased, the radiographic knee OA group showed decreasing linear trend only in women. However, other beverages did not show a significant relation to the radiographic knee OA in both sexes.
CYP2A6 gene polymorphism and severity of coronary atherosclerosis in Indonesian male smokers: A pilot study
Authors: Mappangara Idar , Yusuf Irawan , Aspar Mappahya Ali , Qanitha Andriany
Published: September 2022

Nicotine is a toxic alkaloid known to be responsible for the addictive feature of cigarettes. CYP2A6 genetic polymorphism among individuals was suspected to explain the relationship between cigarette smoking and related diseases. CYP2A6 works to slow nicotine metabolism and thus maintain a more prolonged nicotine concentration and increase nicotine exposure to the blood. We aimed to investigate the correlation between the CYP2A6 gene with the severity of coronary atherosclerosis. This cross-sectional study was conducted from April to July 2010 in Makassar Cardiac Centre, Dr Wahidin Sudirohusodo Hospital, Indonesia. Sixty-four male active smokers at the age of ≥45 years, diagnosed with coronary artery disease (CAD), were recruited and asked to smoke the usual number of cigarettes in the last 1 month prior to blood collection for CYP2A6 genotyping. Spearman correlation was performed to analyze the association between the allele variants and coronary stenosis degree, adjusted for CAD risk factors. Furthermore, we estimated the risk ratio to quantify the correlation. Of the 64 male smokers with CAD, the mean duration of smoking was 36.9 ± 8.6 years, and 49 (76.6%) were heavy smokers with >20 cigarettes per day. All 128 alleles were observed. Our results showed that all participants with CYP2A6 variants had a significant correlation with severe coronary artery stenosis (P = .006). Thus, this study suggests that the mutant CYP2A6 gene allele significantly increased the risk of having severe coronary stenosis 1.2 times higher compared to the wild type. This pilot study showed that CYP2A6 gene has an influential role in atherosclerotic development in male smokers. However, our findings should be confirmed with further more extensive studies.
Blood glucose levels and the risk of HPV multiple infections in high-grade squamous intraepithelial lesions: A retrospective cross-sectional study of Chinese patients
Authors: Zhou Jie , Wei Xiang Cai , Xu Hong Yan , Hu Hong Bo , Li Fan Xiang , Zhou Wei Juan , Chen Ye , Liu Zhen
Published: September 2022

Besides the controversy of the association of high glycemic index and glycemic load with precancerous cervical lesions, only a few studies have examined the impact of fasting blood glucose levels on human papillomavirus (HPV) multiple infections. In the present study, we appraised the relationship between blood glucose levels and multiple HPV infections in a population of HPV-positive women with cervical high-grade squamous intraepithelial lesions (HSIL). The present study was designed as a cross-sectional correlative analysis. A total of 560 participants with a pathologically confirmed HSIL with HPV infection were included from a hospital in China during January 1, 2018, and December 31, 2019. The target variables and the outcome variables were the glucose levels at the baseline and HPV multiplicity, respectively. The odds ratio and 95% confidence intervals were calculated to estimate the risk of multiple infections via logistic regression analysis. The average age of the 560 participants was 44.63 ± 10.61 years; the nonlinear relationship was detected between the glucose levels and multiplicity of HPV, with an inflection point at 5.4. After adjusting for the full range of variables, the effect sizes and confidence intervals for the left and right sides of the inflection points were found to be 0.379 (0.196–0.732) and 5.083 (1.592–16.229), respectively. In this cross-sectional study, both high and low blood glucose levels increased the risk of multiple HPV infections, demonstrating a U-shaped relationship between the blood glucose levels and multiple HPV infections.
Reduction of C-reactive protein, low-density lipoprotein cholesterol, and its relationship with cardiovascular events of different lipid-lowering therapies: A systematic review and meta-analysis of randomized controlled trials
Authors: Yang Wenjia , Cai Xiaoling , Lin Chu , Lv Fang , Zhu Xingyun , Han Xueyao , Ji Linong
Published: September 2022

Background:

To evaluate the reductions of C-reactive protein (CRP) and low-density lipoprotein cholesterol (LDL-C) in different lipid-lowering drugs, and to assess the relationships between the reductions of CRP, LDL-C, and cardiovascular (CV) events.

Methods:

We searched MEDLINE, EMBASE, and Cochrane CENTRAL up to September 1, 2021. Randomized controlled trials (RCTs) comparing statins, proprotein convertase subtilisin/kexin type 9 monoclonal antibodies (PCSK9-mAbs), or ezetimibe against placebo with a treatment duration of at least 4 weeks and data on the effects of cholesterol-lowering interventions on LDL-C and CRP were included in this meta-analysis. The weighted mean difference (WMD) and 95% confidence interval (CI) were calculated.

Results:

Compared with placebo treatment, statins and ezetimibe treatments resulted in a significant decrease in LDL-C level (statins: WMD −47.94 mg/dL, 95% CI −51.21 to −44.67 mg/dL; ezetimibe: WMD −22.84 mg/dL, 95% CI −26.76 to −18.92 mg/dL) and CRP level (statins: WMD −0.67 mg/L, 95% CI −0.90 to −0.45 mg/dL; ezetimibe: −0.64 mg/L, 95% CI −1.07 to −0.21 mg/dL). Compared with placebo treatment, treatment with PCSK9-mAbs resulted in significant decrease in LDL-C level (WMD −54.24 mg/dL, 95% CI −59.77 to −48.70 mg/dL), while the concentration of CRP did not decrease significantly. Meta-regression analysis showed no significant association between change in CRP level and change in LDL-C level. Subgroup comparisons suggested that treatment with PCSK9-mAbs showed a greater reduction in LDL-C level when compared with the statins group and ezetimibe group, while the risks of CV death, myocardial infarction (MI), and stroke showed no significant differences.

Conclusion:

Based on the current study, our results suggested that statins, ezetimibe, and PCSK9-mAbs are effective in reducing LDL-C levels. Treatment with statins and ezetimibe also demonstrated a significant effect on CRP. The traditional lipid-lowering strategy including statin and ezetimibe showed similar benefit on CV outcomes compared with the PCSK9-mAbs treatment.
Metabolism of barium in the human body after suicidal ingestion: A CARE-compliant case report
Authors: Zhang Qiantong , Wang Yuchao , Li Xueyan , Wang Zhoubo , Wang Heng , Yan Jianbo
Published: September 2022

Rationale:

Thus far, barium poisoning has been seldom reported and the metabolism of barium in human body has not been explored.

Patient concerns:

A 21-year-old young man was taken to the local hospital by “120 emergency medical services” after a suicidal attempt. About 100 mL of barium chloride solution with a concentration of 100 g/L was ingested, while the actual amount of ingested barium chloride solution was unclear because of immediate vomiting after the ingestion.

Diagnoses:

About 2 hours after the suicidal ingestion, the patient was presented with somnolence, the pulse rate was 67 beats per minute, the blood pressure was 158/92 mm Hg, but he exhibited no nausea or vomiting. About 3 hours after the ingestion, the blood concentration of potassium was 1.5 mmol/L.

Interventions:

The patient received gastric lavage by magnesium sulfate solution, intravenous sodium thiosulfate, and potassium supplementation. Other symptomatic treatments were applied simultaneously. To investigate the metabolism of barium in the human body, we measured the concentration of barium in 9 groups of paired serum and urine samples sequentially collected from the patient.

Outcomes:

The patient was rescued successfully.

Lessons:

The serum concentration of barium decreased rapidly in the first 24 hours. In this period, prompt and massive potassium supplementation and other symptomatic treatments are effective and recommended.
A quick scoping review of the first year of vaccination against the COVID-19 pandemic: Do we need more shots or time?
Authors: El-Menyar Ayman , Khan Naushad Ahmad , Mekkodathil Ahammed , Rizoli Sandro , Consunji Rafael , Elmenyar Eman , Galwankar Sagar , Al-Thani Hassan
Published: September 2022

Background:

The emergence of new severe acute respiratory syndrome coronavirus 2 variants, along with the waning of vaccine-induced immunity, has increased breakthrough infections and urged booster jabs and debates. In the short term, the administration of booster doses has been reported to be safe and enhance severe acute respiratory syndrome coronavirus 2–specific neutralizing antibody levels. However, the effects of these doses on the pandemic trajectory and herd immunity are unclear. There is insufficient evidence that a third booster shot of the coronavirus disease 2019 (COVID-19) vaccine maintains longer immunity and covers new viral variants. The lack of sufficient evidence, combined with the fact that millions of people have not yet received 1 or 2 jabs of the COVID-19 vaccine, has raised concerns regarding the call for booster vaccinations.

Methods:

We conducted a quick scoping review to explore the literature on the need for a booster COVID-19 vaccination from January 1, 2021, to April 30, 2022.

Results:

Sixty-one relevant publications were identified, of which 17 were related to waning immunity after 2 doses of the vaccine among the general population or healthcare workers, 19 were related to the third or booster dose of vaccination after the second dose among the general population or healthcare workers, and 25 were related to booster dose among immunocompromised patient.

Conclusions:

Initially, the need for a booster dose was equivocal; however, several studies demonstrated the benefit of the booster dose over time. Adequate scientific information is required regarding the administration of booster doses to the general population as well as the high-risk individuals.
Cigarette smoking is associated with an increase in blood monocytes in people with tuberculosis: A cross-sectional study
Authors: Baluku Joseph Baruch , Nabwana Martin , Kansiime Grace , Nuwagira Edwin
Published: September 2022

The effect of smoking on immune responses in people with tuberculosis (TB) is not well elucidated. We aimed to compare peripheral blood counts of CD4+ and CD87 + T-lymphocytes, monocytes, and neutrophils and the CD4:CD8 ratio in TB patients with and without history of cigarette smoking. We further determined factors associated with current smoking. Participants with TB were consecutively enrolled in a cross-sectional study at a national TB treatment center in Uganda in 2018. We compared cell counts and the CD4:CD8 ratio using the median test among never smokers, past smokers (>6 months ago) and current smokers (≤6 months). Factors associated with current smoking were determined using logistic regression. A post hoc analysis for factors associated with an increase in the monocytes was also performed. Of 363 participants, there were 258 (71.1%) never smokers, 50 (13.8%) past smokers, and 55 (15.2%) current smokers. Most current smokers (49.1%) had a high sputum mycobacterial load. They also had the lowest body mass index and the highest axillary temperature. The median (interquartile range [IQR]) monocyte count among current smokers was 815 (540–1425) cells/mm3 and was significantly higher than that among past smokers (610 (350–900) cells/mm3, P = .017) and never smokers (560 [400–800] cells/mm3, P = .001). The monocyte counts positively correlated with the number of cigarettes smoked per day among current smokers (R = 0.43, P = .006). Current smokers also had higher neutrophil and CD4+ T-cell counts than never smokers. In a multivariable logistic regression model, an increase in the monocyte count was associated with current cigarette smoking (adjusted odds ratio [aOR] = 4.82, 95% confidence interval 1.61–14.39, P = .005). Similarly, current cigarette smoking was independently associated with an increase in the monocyte count (aOR = 1.80, 95% CI 1.39–2.32, P < .001). Cigarette smoking is associated with an increase in the blood monocytes in people with TB in a dose- and time-dependent manner. Further, current smoking is associated with an increase in neutrophils and CD4+ T-lymphocytes. The findings suggest that current smokers have systemic inflammation that is not necessarily beneficial to TB control in TB patients.
Optic neuropathy caused by orbital Kimura disease: A rare case report
Authors: Tsai Yung-En , Chen Yi-Hao , Liu Tung , Chien Ke-Hung , Hsu Chih-Kang
Published: September 2022

Rationale:

Kimura disease (KD) is a rare, chronic inflammatory disease characterized by painless subcutaneous nodules predominantly located in the head and neck regions. Orbital KD, which intrudes into the intraconal space and results in compressive optic neuropathy, is rare and has not been previously reported.

Patient concerns:

A 68-year-old man presented with blurred vision and progressive proptosis in the left eye that had been present for 2 years.

Diagnosis:

Magnetic resonance imaging of the brain revealed soft tissue lesions with contrast enhancement and restricted diffusion involving the bilateral eyelids, orbits, and intraconal region; those on the left side were more prominent than those on the right side. The lesion encased the left optic nerve. Laboratory test results revealed elevated serum immunoglobulin E level and peripheral eosinophilia. An orbital mass biopsy demonstrated hyperplastic lymphoid follicles with germinal centers in the subcutaneous area and abundant mononuclear and binuclear eosinophils infiltrating the interfollicular area. A pathological diagnosis of KD was made based on the blood test results.

Interventions:

Orbital decompression and debulking surgery of the orbital tumor in the left eye were performed to treat the compressive optic neuropathy.

Outcomes:

After systemic oral steroid and immunosuppressive agent therapies, the patient’s visual acuity in the left eye improved, and the KD activity was stable.

Conclusions:

We present a rare case of orbital KD-associated optic neuropathy, wherein early diagnosis and treatment preserved the patient’s vision. This complication should be considered in patients with a history of compressive optic neuropathy during the differential diagnosis.
Human Chorionic Gonadotropin—A Review of the Literature
Authors: Herkert Darby , Meljen Vivienne , Muasher Lisa , Price Thomas M. , Kuller Jeffrey A. , Dotters-Katz Sarah
Published: September 2022

Importance

The measurement of human chorionic gonadotropin (hCG) levels in different body fluids is a commonly utilized tool in obstetrics and gynecology, as well as other fields. It is often one of the first steps in the medical workup of female patients, and the results and interpretation of this test can have significant downstream ramifications. It is essential to understand the uses and limitations of hCG as a testing and therapeutic measure to appropriately evaluate, counsel, and treat patients.

Objective

The purpose of this article is to review the current literature on hCG, including its origins, structure, pharmacokinetics, metabolism, and utility in testing and medical treatment.

Evidence Acquisition

Original research articles, review articles, and guidelines on hCG use were reviewed.

Conclusions and Relevance

While the primary function of hCG is to maintain early pregnancy, testing for hCG demonstrates that this molecule is implicated in a multitude of different processes where results of testing may lead to incorrect conclusions regarding pregnancy status. This could affect patients in a myriad of settings and have profound emotional and financial consequences. In addition, hCG testing may be revealing of alternative pathology, such as malignancy. It is imperative to understand the nuances of the physiology of hCG and testing methods to effectively use and interpret this test for appropriate patient management.

Target Audience

Obstetricians and gynecologists, family physicians

Learning Objectives

After participating in this activity, the provider should be better able to describe the origins, molecular structure, and effects of hCG and its isoforms; explain the mechanism, strengths, and limitations of different hCG testing modalities as well as potential causes of false-positive and false-negative tests; and evaluate the recommendations for, as well as the implications and limitations of, hCG testing in clinical research, the perioperative setting, and other common clinical scenarios.
Dropped head syndrome: report of a rare complication after multilevel bilateral cervical radiofrequency neurotomy
Authors: Bajaj Harnek S. , Chapman Andrew W.
Published: September 2022

Introduction:

Cervical radiofrequency neurotomy is a safe and relatively low-risk procedure commonly used to treat facet joint–mediated axial neck pain. Severe complications are extremely rare and can be avoided with proper technique and appropriate imaging guidance. This article describes the development and subsequent management of a case of dropped head syndrome after cervical radiofrequency neurotomy.

Methods:

A 77-year-old man with cervicalgia, multilevel facet arthropathy, and a known kyphosis in the setting of cervical degenerative disk disease underwent successful conventional radiofrequency neurotomy to the bilateral C3, C4, and C5 medial branches. No immediate complications were noted.

Results:

Six weeks subsequent to the procedure, the patient reported difficulty keeping his head erect, and physical examination revealed weakness of the cervical paraspinal musculature, with restriction of active extension to about neutral. A diagnosis of dropped head syndrome was made. The patient was successfully managed with temporary use of soft cervical collar and physical therapy for progressive range of motion and strengthening.

Discussion:

Dropped head syndrome is a known, but likely underappreciated, complication of cervical radiofrequency neurotomy, with only 2 other cases reported and published in the literature to our knowledge. Mild cases may resolve with conservative management, but this is a potentially debilitating condition that we recommend should be routinely discussed during procedural consent for cervical radiofrequency neurotomy. Future studies should explore specific mitigating factors to reduce the risk of development of this possible complication.
The Utility of Vessel Wall Imaging in the Postulation of Acute Ischemic Stroke With Spontaneous Recanalization Pathophysiology
Authors: Md Noh Mohamad Syafeeq Faeez , Abdul Rashid Anna Misyail , Hoo Fan Kee , Bahari Norafida
Published: September 2022

Recent advances in technology, particularly in the field of magnetic resonance imaging, have brought forth new sequences, including vessel wall imaging (VWI). Traditionally, the workup for intracranial vascular pathology has always turned to luminal imaging using computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography. Since its introduction, VWI has enabled researchers and practicing clinicians to better understand disease processes and manage patients to the best standard of care possible. Spontaneous recanalization in acute ischemic stroke (AIS) is a known but understudied phenomenon. Available literature has looked at this phenomenon and postulated the occurrence based on conventional cross-sectional imaging and angiography; however, objective evidence pointing to the occurrence of this phenomenon is scarce. We would like to share our experience using VWI in a patient who was clinically suspected to have a middle cerebral artery syndrome at onset, with resolution of the symptoms 3 hours after initial presentation. VWI showed vessel wall enhancement at the suspected vessel involved, with evidence of acute infarcts at the vascular territory supplied. A presumptive diagnosis of AIS with spontaneous recanalization was made. Our experience could potentially aid in the understanding of spontaneous recanalization in patients with AIS, particularly in the postulation of the pathophysiology.
The Operating Room Black Box: Understanding Adherence to Surgical Checklists
Authors: Al Abbas Amr I. , Sankaranarayanan Ganesh , Polanco Patricio M. , Cadeddu Jeffrey A. , Daniel William , Palter Vanessa , Grantcharov Teodor , Bartolome Sonja , Dandekar Priya , Evans Kim , Zeh Herbert J.
Published: September 2022

Objective:

We report for the first time the use of the Operating Room Black Box (ORBB) to track checklist compliance, engagement, and quality.

Background:

Implementation of operative checklists is associated with improved outcomes. Compliance is difficult to monitor. Most studies report either no assessment of checklist compliance or deployed in-person short-term assessment. The ORBB a novel artificially intelligence-driven data analytic platform affords the opportunity to assess checklist compliance without disrupting surgical workflow.

Methods:

This was a retrospective review of prospectively collected ORBB data. Operative cases included elective surgery at a quaternary referral center. Cases were analyzed as prepolicy change (first 9 months) or as a postpolicy change (last 9 months). Measures of checklist compliance, engagement, and quality were assessed.

Results:

There were 3879 cases that were performed and monitored for checklist compliance between August 15, 2020, and February 20, 2022. The overall scores for compliance, engagement, and quality were 81%, 84%, and 67% respectively. When broken down by phase, the scores for time-out were compliance 100%, engagement 98%, and quality 61%. Scores for the debrief phase were 81% for compliance, 98% for engagement, and 66% for quality. After a hospital policy change, the debrief scores improved significantly (85%;P<0.001 for compliance, 88%;P<0.001 for engagement and 71%;P<0.001 for quality).

Conclusions:

ORBB provides the unprecedented ability to assess not only compliance with surgical safety checklists but also engagement and quality. Utilization of this technology allows the assessment of compliance in near real time and to accurately address safety threats that may arise from noncompliance.
Recognizing life-threatening bleeding in pediatric trauma: A standard for when to activate massive transfusion protocol
Authors: Morgan Katrina M. , Gaines Barbara A. , Richardson Ward M. , Strotmeyer Stephen , Leeper Christine M.
Published: September 2022

BACKGROUND

Traumatic hemorrhage is the most common cause of preventable death in civilian and military trauma. Early identification of pediatric life-threatening hemorrhage is challenging. There is no accepted clinical critical administration threshold (CAT) in children for activating massive transfusion protocols.

METHODS

Children 0 to 17 years old who received any transfusion in the first 24 hours after injury between 2010 and 2019 were included. The type, volume, and time of administration for each product were recorded. The greatest volume of weight-adjusted products transfused within 1 hour was calculated. The cut point for the number of products that maximized sensitivity and specificity to predict in-hospital mortality, need for urgent surgery, and second life-threatening bleeding episode was determined using Youden's index. A binary variable (CAT+) was generated using this threshold for inclusion in a multivariable logistic regression model.

RESULTS

In total, 287 patients were included. The median (interquartile range) age was 6 (2–14) years, 60% were males, 83% sustained blunt trauma, and the median (interquartile range) Injury Severity Score was 26 (17–35). The optimal cutoff to define CAT+ was >20 mL/kg of product; this optimized test characteristics for mortality (sensitivity, 70%; specificity, 77%), need for urgent hemorrhage control procedure (sensitivity, 65%; specificity, 74%). and second bleeding episode (sensitivity, 77%; specificity, 74%). There were 93 children (32%) who were CAT+. On multivariate regression, being CAT+ was associated with 3.4 increased odds of mortality (95% confidence interval, 1.67–6.89; p = 0.001) after controlling for age, hypotension, Injury Severity Score, and Glasgow Coma Scale. For every unit of product administered, there was a 10% increased risk of mortality (odds ratio, 1.1; p < 0.001).

CONCLUSION

Transfusion of more than 20 mL/kg of any blood product within an hour should be used as a threshold for activating massive transfusion protocols in children. Children who meet this CAT are at high risk of mortality and need for interventions; this population may benefit from targeted, timely, and aggressive hemostatic resuscitation.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.
Rib fixation in patients with severe rib fractures and pulmonary contusions: Is it safe?
Authors: Van Wijck Suzanne F.M. , Pieracci Fredric M. , Smith Elizabeth F. , Madden Kelley , Moore Ernest E. , Wijffels Mathieu M.E. , Werner Nicole L.
Published: September 2022

BACKGROUND

Pulmonary contusion has been considered a contraindication to surgical stabilization of rib fractures (SSRFs). This study aimed to evaluate the association between pulmonary contusion severity and outcomes after SSRF. We hypothesized that outcomes would be worse in patients who undergo SSRF compared with nonoperative management, in presence of varying severity of pulmonary contusions.

METHODS

This retrospective cohort study included adults with three or more displaced rib fractures or flail segment. Patients were divided into those who underwent SSRF versus those managed nonoperatively. Severity of pulmonary contusions was assessed using the Blunt Pulmonary Contusion 18 (BPC18) score. Outcomes (pneumonia, tracheostomy, mechanical ventilation days, intensive care unit (ICU) length of stay, hospital length of stay, mortality) were retrieved from patients' medical records. Comparisons were made using Fisher's exact and Kruskal-Wallis tests, and correction for potential confounding was done with regression analyses.

RESULTS

A total of 221 patients were included; SSRF was performed in 148 (67%). Demographics and chest injury patterns were similar in SSRF and nonoperatively managed patients. Surgical stabilization of rib fracture patients had less frequent head and abdominal/pelvic injuries (p = 0.017 and p = 0.003). Higher BPC18 score was associated with worse outcomes in both groups. When adjusted for ISS, the ICU stay was shorter (adjusted β, −2.511 [95% confidence interval, −4.87 to −0.16]) in patients with mild contusions who underwent SSRF versus nonoperative patients. In patients with moderate contusions, those who underwent SSRF had fewer ventilator days (adjusted β, −5.19 [95% confidence interval, −10.2 to −0.17]). For severe pulmonary contusions, outcomes did not differ between SSRF and nonoperative management.

CONCLUSION

In patients with severe rib fracture patterns, higher BPC18 score is associated with worse respiratory outcomes and longer ICU and hospital admission duration. The presence of pulmonary contusions is not associated with worse SSRF outcomes, and SSRF is associated with better outcomes for patients with mild to moderate pulmonary contusions.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.
DeepBackRib: Deep learning to understand factors associated with readmissions after rib fractures
Authors: Choi Jeff , Alawa Jude , Tennakoon Lakshika , Forrester Joseph D.
Published: September 2022

BACKGROUND

Deep neural networks yield high predictive performance, yet obscure interpretability limits clinical applicability. We aimed to build an explainable deep neural network that elucidates factors associated with readmissions after rib fractures among nonelderly adults, termed DeepBackRib. We hypothesized that DeepBackRib could accurately predict readmissions and a game theoretic approach to elucidate how predictions are made would facilitate model explainability.

METHODS

We queried the 2017 National Readmissions Database for index hospitalization encounters of adults aged 18 to 64 years hospitalized with multiple rib fractures. The primary outcome was 3-month readmission(s). Study cohort was split 60-20-20 into training-validation-test sets. Model input features included demographic/injury/index hospitalization characteristics and index hospitalization International Classification of Diseases, Tenth Revision, diagnosis codes. The seven-layer DeepBackRib comprised multipronged strategies to mitigate overfitting and was trained to optimize recall. Shapley additive explanation analysis identified the marginal contribution of each input feature for predicting readmissions.

RESULTS

A total of 20,260 patients met the inclusion criteria, among whom 11% (n = 2,185) experienced 3-month readmissions. Feature selection narrowed 3,164 candidate input features to 61, and DeepBackRib yielded 91%, 85%, and 82% recall on the training, validation, and test sets, respectively. Shapley additive explanation analysis quantified the marginal contribution of each input feature in determining DeepBackRib's predictions: underlying chronic obstructive pulmonary disease and long index hospitalization length of stay had positive associations with 3-month readmissions, while private primary payer and diagnosis of pneumothorax during index admission had negative associations.

CONCLUSION

We developed and internally validated a high-performing deep learning algorithm that elucidates factors associated with readmissions after rib fractures. Despite promising predictive performance, standalone deep learning algorithms are insufficient for clinical prediction tasks: a concerted effort is needed to ensure that clinical prediction algorithms remain explainable.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.
Serum levels of copeptin predict adverse outcomes and improve risk prediction of TRISS and MGAP scores in patients with multiple trauma: A single-center prospective cohort study
Authors: Hsein Yenh-Chen , Wu I-Ju , Tan Jasmine , Huang Sih-Shiang , Lu Kuan-Ting , Su Chin-Hua , Hsu Wan-Ting , Chen Shyr-Chyr , Lee Chien-Chang
Published: September 2022

BACKGROUND

Multiple trauma deserves early prognostication and stratification. Copeptin, a precursor of vasopressin, is produced in response to stress. We examined the association between serum levels of copeptin and mortality risk in patients with multiple trauma. We aimed to also enhance the previously established Trauma-Related Injury Severity Score (TRISS) and Mechanism, GCS, Age, and Arterial Pressure (MGAP) score with the additional consideration of copeptin levels.

METHODS

This single-center prospective cohort study enrolled patients who presented to the emergency department with potential major injuries. The serum levels of copeptin were measured, and the correlation to clinical severity in terms of 30-day mortality and requirement of intensive care management was analyzed. By combining copeptin levels with TRISS or MGAP, comparison between performance of the original models with the copeptin-enhanced models was performed via discrimination, calibration, and reclassification analyses.

RESULTS

There was a significant increase in copeptin levels in patients who died within 30 days (median 644.4 pg/L, interquartile range [472.5, 785.9]) or were admitted to intensive care units (233.8 pg/L, [105.7, 366.4]), compared with those who survived (37.49 pg/L, [17.88, 77.68]). Adding the natural log of copeptin levels to the established TRISS and MGAP models improved the AUC of TRISS from 0.89 to 0.96, and that of MGAP from 0.82 to 0.95. Both calibrations as measured by Brier’s scores and reclassification as measured by net reclassification improvement or integrated discrimination improvement demonstrated significant improvements. A Web-based calculator was built to generate predicted mortality rates of various models for convenient clinical use.

CONCLUSION

Admission serum copeptin levels were correlated with clinical severity in multiple trauma. Coupling copeptin with preexisting trauma severity scores improved prediction accuracy. Copeptin shows promise as a novel biomarker for the prediction of trauma outcome.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level III.
The Evolution of a Chest Wall Injury and Reconstruction Clinic During a Pandemic
Authors: Eriksson Evert A. , Waite Amanda M. , Shivers Shaune D.
Published: September 2022

Background

In 2019, we sought to develop a Chest Wall Injury and Reconstruction Clinic(CWIRC) to treat patients with chest wall pain and rib fractures. This initiative was fueled by the recognition of an unmet need as well as evolving research demonstrating improved patient care and experience. We will describe the evolution of this clinic program from an Acute Care Surgery/General Surgery(ACS/GS) clinic to a CWIRC.

Methods

We identified outpatient encounters generated from a general surgery clinic staffed by a physician and nurse practitioner team. A retrospective cohort review was performed to identify all outpatient encounters and surgeries associated with these encounters from 1/1/2017–11/30/2021. Outpatient and operative wRVU production as well as payer mix was compared as the primary outcome.

Results

Over this time period, the number of clinic interactions decreased (2017-284 vs. 2021-229). Clinic productivity increased however from 181 wRVU in 2017 to 295 wRVU in 2021. The CWIRC patient visits increased from 4% to 70%. Additionally, telehealth visits increased from 0% to 23% of encounters. The operative wRVU productivity attributable to outpatient clinic visits increased (2017–253 vs. 2021–591). Combined, the CWIRC resulted in an overall growth of 104% in total wRVU. The payer mixes for patients with rib diagnosis have a higher number of Blue Cross Blue Shield, Medicare, and Managed Care compared to ACS/GS. The most common diagnosis was rib fracture initial evaluation (37%), rib fracture subsequent encounter (25%), rib pain (24%), and flail chest initial evaluation (4%).

Conclusions

The initiation of a CWIRC increased wRVU production despite a decrease in clinical encounters. These clinics may produce more wRVU per encounter than ACS/GS clinics. An underserved population has been identified of chest wall pathology patients presenting for initial evaluation as outpatients. Further investigation into this concept is warranted to serve this population.

Level of Evidence

IV Therapeutic / care management
The Molecular Diagnosis Might Be Clinically Useful in Discrepant Kidney Allograft Biopsy Findings: An Analysis of Clinical Outcomes
Authors: Schachtner Thomas , von Moos Seraina , Kokkonen Sanna M. , Helmchen Birgit , Gaspert Ariana , Mackova Martina , Halloran Philip F. , Mueller Thomas F.
Published: September 2022

Background.

The Molecular Microscope Diagnostic System (MMDx) may overcome histology shortcomings. Previous studies have simply examined discrepant findings but have not attempted to determine clinical endpoints. To measure performance, clinical outcomes are strongly required.

Methods.

This single-center cohort study described discrepancies between MMDx and histology from 51 kidney transplant recipients (KTRs) and analyzed 72 indication biopsies, including 21 follow-up biopsies. Clinical performance was assessed by a combined endpoint of graft failure, rejection on follow-up biopsy, de novo donor-specific antibody, and improvement of kidney allograft function upon antirejection treatment.

Results.

MMDx agreed in 33 (65%) and differed in 18 (35%) of 51 KTRs. Most discrepancies occurred in biopsies called no rejection by MMDx and rejection by histology (15/24, 63%). In contrast, in biopsies called rejection by MMDx, 3 were classified as no rejection by histology (3/27, 11%). Discrepant findings between MMDx and histology occurred following delayed graft function and MMDx from biopsies with a low percentage of cortex. Among 15 biopsies classified as no rejection by MMDx but rejection by histology, the clinical course suggested no rejection in 9 cases. Six KTRs reached the endpoint, showing predominant t ≥ 2 lesions.

Conclusions.

The most often occurring discrepancy is rejection by histology but no rejection by MMDx. As more KTRs do not meet the combined endpoint for rejection, MMDx might be clinically useful in these discrepant cases. Although strong histological findings have priority in indicating the treatment, clinical implementation of MMDx could strengthen treatment strategies.