bluuebunny/crossref_metadata_2025 huggingface dataset:
Hemodynamic Changes in Women With Congenital Heart Disease: Effect of the Duration of the Active Second Stage [18N]
Authors: Patterson Jenna , Pippen Jessica , Rood Kara M. , Cakovic Michael
Published: April 2020

INTRODUCTION:

Women with congenital heart disease (CHD) are a growing population and represent 1% of pregnant women. Due to hemodynamic changes associated with labor, an assisted second stage of labor is recommended for some women with CHD. We investigated the effect of the duration of the active second stage of labor on maternal heart rate and blood pressure.

METHODS:

Retrospective chart review of women with CHD who received prenatal care and delivered at a single academic institution from 2010 – 2018. Maternal demographic, baseline cardiac health and peripartum outcome information was collected. Vital signs were recorded before the active second stage and postpartum. Vitals signs prior to active second stage were compared with vital signs in the postpartum period using appropriate statistical analysis.

RESULTS:

During study period 146 women were identified. There was no difference in demographic or baseline cardiac health between women with active second stage <30 minutes and >30 minutes. For active second stage <30 minutes, pre active second stage and postpartum heart rate (83 vs 87, P=.08), systolic blood pressure (123 vs 123, P=.80) and diastolic blood pressure (69 vs 67, P=.19) were similar. For active second stage >30 minutes, pre active second stage and postpartum heart rate (94 vs 95, P=.48), systolic blood pressure (124 vs 124, P=.73) and diastolic blood pressure (74 vs 66, P=.08) were similar.

CONCLUSION:

Duration of the active second stage of labor is not associated with significant hemodynamic differences between pre and post active second stage.
Comparison of Minimally Invasive and Open Management of Cesarean Wound Complications: A Retrospective Chart Review [08N]
Authors: Qadri Farnoosh , Khan Ayesha , Al-azawi Hind , Sengstock David , Chehab Monzer
Published: April 2020

INTRODUCTION:

Superficial abscesses are common surgical site infections (SSI) following cesarean sections. Standard of care is open drainage but optimal management is not known. We compared superficial abscess (SA) management by image guided (IG) percutaneous drainage to open surgical (OS) drainage.

METHODS:

We performed a retrospective chart review between 1/1/2010 and 12/31/2018 of SSI following cesarean section. IRB waiver was obtained. All patients with SA measuring >3 cm by CT or ultrasound were included. Endpoints included: length of stay (LOS), opioids on discharge, and need for home health care or readmission (combined outcome).

RESULTS:

Of 2,000 charts, n=8 IG (32%) and n=17 OS (68%) met inclusion criteria. Compared to IG patients, OS were significantly older (27.6±4.2 vs 33±6.0 years, P<.05), but had similar BMI (35.2±10.8 vs 39.8±10.2 kg/m2, P>.1), smoking (25% vs 24%, P>.1), hypertension (38% vs 29%, P>.1), diabetes (13% vs 47%, P>.1), parity (2.8±2.5 vs 1.8±1 births, P>.1). Although antibiotic use was lower in OS group (3±1.9 vs 3.7±1.0, P>.1) and a suggestion of lower LOS (6.0±4.0 vs 5.0±2.3, P>.1), IG patients showed a trend of less home-care or readmissions (38% vs 65%, P>.1). Significantly, IG patients were discharged less frequently on opiates (40% vs 88%, P<.01).

CONCLUSION:

This study suggests that minimally invasive drainage of SA following cesarean section is a viable option and may be preferable in certain situations. Although, limited by small sample size, IG appears less painful than OS drainage. The difference in the outcome of home-care or readmissions was lower, though not statistically significant and deserves further study.
Incidence of Pregnancy Following Uterine Artery Embolization Performed for Uterine Arteriovenous Malformations [22N]
Authors: Kole Monica , Keerthy Madhurima , Fotouhi Audrey , Sangha Roopina
Published: April 2020

INTRODUCTION:

There are limited data available regarding the rate of success and pregnancy outcomes for women after undergoing embolization for uterine artery arteriovenous malformation (AVM) which mostly comprise of case series and reports with small sample sizes. The purpose of this study is to evaluate fertility and pregnancy outcomes in patients who underwent interventional radiology-guided uterine artery embolization for uterine AVM at our institution.

METHODS:

IRB approval was obtained. A retrospective chart review was performed from 2008 to present looking at patients who had interventional radiology-guided uterine artery embolization. These patients' charts were reviewed for subsequent pregnancy incidence and outcome of those pregnancies.

RESULTS:

37 patients were diagnosed with uterine AVM. 18 chose to undergo UAE. Of those 18 patients, 7 attained subsequent pregnancies. Of the subsequent pregnancies, 4 patients had full-term deliveries and two of these four also had at least one miscarriage. One patient had only a miscarriage without any deliveries, and 1 had a voluntary termination of pregnancy with no other pregnancies documented for the duration of their follow up in our health system. No patients had preterm deliveries. No patients had post-procedure placental abnormalities in their subsequent pregnancies (no documented placenta previa, accreta, or percreta).

CONCLUSION:

Our data show that successful term pregnancies are possible after IR-guided treatment of uterine AVM. Future multi-institutional prospective studies are required to further prove or disprove results shown in this study. This data has the potential to impact counseling and management for patients who present with uterine artery AVM and desire future fertility.
Implementation of GBS Self-Swabbing Protocol at the Women's Institute at Banner University Medical Center—Phoenix [21N]
Authors: Gilbert Molly , Cheney Megan Clair , Gerkin Richard
Published: April 2020

INTRODUCTION:

To implement a group B streptococcus (GBS) self-swabbing protocol at The Women's Institute and to determine patient satisfaction in self-swabbing. Secondarily, to confirm physician and patient-collected swabs yield similar rates of GBS colonization.

METHODS:

This is a prospective quality project. Patients were provided the option to self-swab for GBS at their 35 to 37 week visit from January 3 to July 12, 2019. The patient was consented and educated on how to perform the swab. They then completed a short, three question survey to evaluate comfort and satisfaction. A retrospective chart review was performed from September 1, 2018 to July 12, 2019 to determine GBS colonization rates of provider-collected swabs.

RESULTS:

The rate of GBS colonization in patient-collected swabs was 14/67 (20.9%). Most patients felt comfortable performing the swab (92.5% CI 83.4–97.5%), felt educated in how to perform the swab (98.5% CI 92.0–100.0%), and either preferred to self-swab or had no preference of who performed future swabs (94.0% CI 85.4–98.4%). A retrospective chart review determined the rate of GBS colonization to be 47/238 (19.8%) in provider-collected swabs, which was not significantly different (19.8 vs 20.9, P .86) from patient-collected swabs.

CONCLUSION:

The rate of GBS colonization between patient and provider-collected swabs was not significantly different, which is consistent with prior studies. Survey results demonstrated patient satisfaction and comfort performing the self-swab. This study supports providing our patients the option of self-swabbing for GBS.
Clinical Presentation and Management of Nephrolithiasis in the Obstetric Patient: A Matched Cohort Study [07N]
Authors: Sebastian Natasha , Abenhaim Haim Arie , Spence Andrea , Czuzoj-Shulman Nicholas
Published: April 2020

INTRODUCTION:

Nephrolithiasis is a common medical condition, but little is known about its occurrence in pregnant patients. The study objective is to compare the clinical presentation and management of nephrolithiasis in pregnant women compared with non-pregnant women.

METHODS:

A retrospective matched-cohort study was conducted using the United States' Healthcare Cost and Utilization Project-Nationwide Inpatient Sample database from 1999 to 2015. ICD-9 coding was used to identify women with nephrolithiasis within this cohort. Pregnant women with nephrolithiasis were identified and age matched (1:1) to non-pregnant women with nephrolithiasis. Conditional logistic regression, adjusted for baseline characteristics, was used to compare the clinical presentation and management of nephrolithiasis in pregnant versus non-pregnant women.

RESULTS:

There were 30,006 pregnant patients with nephrolithiasis in the cohort. Pregnant women, relative to non-pregnant women, were more likely to be treated in urban teaching hospitals and to have private health insurance. Pregnant patients were less likely to present with classic clinical symptoms of nephrolithiasis, such as flank pain, OR 0.48 (95% CI 0.45–0.53), hematuria, 0.79 (0.73–0.86), and fever, 0.17 (0.13–0.22). Pregnant patients displayed shorter lengths of stay in hospital (3 days or more, 0.81 (0.78–0.84) and were less likely to be affected by infectious conditions, namely urinary tract infections, 0.56 (0.53–0.58), sepsis, 0.14 (0.12–0.16), and pyelonephritis, 0.38 (0.36–0.42). All invasive and surgical procedures were more frequently practiced in the non-pregnant group.

CONCLUSION:

Pregnant women admitted with nephrolithiasis appear to have a milder disease course as compared to age-matched non-pregnant women, likely suggesting better access to care and a lower threshold for admission.
Non-Obstetric Surgery During Pregnancy [24N]
Authors: Spiegel Strauss Tirtza N. , Goldberg Gary
Published: April 2020

INTRODUCTION:

Non-obstetric surgery is performed every 2 in 1000 pregnancies. With the increase in minimally invasive surgery, we aimed to review the surgery performed and the incidence of complications.

METHODS:

We conducted a 5 year institutional review of non-obstetric surgery in pregnancy. Patient demographics, procedure, indication, admission length, complications and delivery mode were collected. Descriptive analyses and student's t tests were performed to evaluate associations between gestational age, procedure type, presence of complications, mode and timing of delivery.

RESULTS:

From 2015–2019, 87 pregnant women underwent non-obstetric surgery at our tertiary care academic center. The mean age was 30.9 years and the mean weight was 83.4 kg. 45/87 surgical procedures (51.7%) were performed during the second trimester. 56/87 were general surgical procedures (64.3%) and 19 (21.8%) were performed for gynecologic indications. 83/84 had benign disease. 78.1% were laparoscopic surgeries and 68/87 (78.1%) patients were discharged the following day. 9/87 patients (10%) had a complication: infection (3), VTE (1), hospital re-admission (2) and preterm labor (3). 3 women miscarried (3.4%). Thirteen women experienced later complications in pregnancy. 4 women (4.5%) had intra-uterine fetal deaths and 10 had preterm births (10.5%). Most women had vaginal deliveries. Delivery mode was not significantly associated with surgical procedure or gestational age at time of surgery.

CONCLUSION:

Our data suggests that non-obstetric surgery during pregnancy is relatively safe. Minimally invasive surgery was performed in most cases. The immediate pregnancy loss of 3.4% was low and the overall surgical complication rate was low. The most common adverse outcome was preterm birth.
The Prevalence of Expired GBS Screens Among Women Delivering at Term [36N]
Authors: Guzman Colleena , Howard David
Published: April 2020

INTRODUCTION:

A 2019 committee opinion from the American College of Obstetrics and Gynecology [ACOG] recommended delaying the antenatal GBS screen until 36–37 weeks to reduce the number of women delivering at term with an expired GBS screen. The purpose of this pilot study was to determine, in a large private practice setting, the proportion of women delivering at term (37 weeks or greater) with an expired GBS negative screen.

METHODS:

We retrospectively examined the charts of all women in a large multispecialty practice in Nevada who delivered between January 1 and June 30, 2018.

RESULTS:

We initially examined 199 charts. The median gestational age at delivery was 39.1 weeks (IQR 38.4 to 40 weeks). The median age of our study population was 30 (IQR 24 to 33 yrs). There were 149 patients who had a documented GBS result and of these 149 patients, 123 (82.5%) had a negative GBS screen. There were 103 patients who delivered at term, were GBS negative at their initial screen, and for whom both delivery date and GBS screen date were available. Among this subgroup, 9 patients had an interval greater than 35 days (8.74%). These 9 patients had GBS screen-to-delivery intervals of 36 (n=5), 37 (n=1), 39 (n=2), and 49 days (n=1), respectively.

CONCLUSION:

We found that approximately 1 out of 11 women in our practice delivered at term with an expired GBS screen. If our results are replicated in larger studies, it would provide further evidence to support the recent ACOG recommendations to delay GBS screening to 36–37 weeks.
Accuracy of Maternal Substance Use History Among Infants at Risk of Neonatal Abstinence Syndrome [02O]
Authors: Humphreys Meredith , Smid Marcela Carolina , Gavin Erin , Fung Camille , Johnson Erin , Allshouse Amanda A.
Published: April 2020

INTRODUCTION:

Prenatal substance exposure increases risk of neonatal abstinence syndrome (NAS). The objective of this study was to determine the concordance between documented maternal substance use history and neonatal results among mother-infant dyads at risk of NAS.

METHODS:

We performed a retrospective chart review of mother-infant dyads at risk for NAS, defined as those infants receiving neonatal withdrawal inventory scores. We included those dyads with available maternal charts and infant biological testing (meconium or cord toxicology results). Maternal substance use defined as maternal reported use or positive urine toxicology. We excluded multiple gestation and preterm infants (<37 weeks). We calculated positive predictive value (PPV), negative predictive value (NPV) and accuracy of maternal history of opioid, stimulant, marijuana and anti-depressant use with infant biological results. IRB approval was obtained.

RESULTS:

From May 2017–May 2018, 197 dyads met study criteria. Maternal opioid history (n=135, 69%) had PPV 83.7% (95% CI 78.6–87.8%), NPV 56.5% (95% CI 46.6–65.8%) and accuracy 75.1% (95% CI 68.5–81%). Maternal stimulant history (n=91, 46%) had PPV 58.2% (95% CI 51.2–64.9%), NPV 94.3% (95% CI 88.6–97.3%) and accuracy 77.6% (95% CI 72.2–83.3%). Maternal marijuana history (n=65, 33%) had PPV 42.4% (95% CI 35.7–49.3) and accuracy 80.7% (95% CI 74.5–85.9%) (NPV could not be calculated). Maternal anti-depressant history (n=52, 26%) had PPV 59.0% (95% CI 47.2–70.0%), NPV 99.4% (95% CI 95.8–99.9%) and accuracy 91.4% (95% CI 86.5–94.9%).

CONCLUSION:

Maternal history and infant biological testing accuracy varies by substance and may miss up to a quarter of infants at risk of NAS. Improved screening procedures for maternal substance use are needed.
Fluoroscopic Cholangiography: Anatomy, Pathology, and Intervention
Authors: Sridhar Shravan , Thompson William M.
Published: April 2020

Direct intraoperative cholangiography, endoscopic retrograde cholangiopancreatography, T-tube cholangiography, and percutaneous transhepatic cholangiography are routine procedures performed by interventionalists. Radiologists must understand how to interpret direct cholangiography to facilitate multidisciplinary communication, correlate findings with magnetic resonance cholangiopancreatography, and improve patient care.
First Treatment for Rare Soft Tissue Cancer
Authors: Aschenbrenner Diane S.
Published: April 2020

Tazemetostat (Tazverik) is the first drug therapy approved for the treatment of epithelioid sarcoma.

Serious adverse effects include secondary malignancies and embryo-fetal toxicity.
Revised Warning for the Antipsychotic Clozapine
Authors: Aschenbrenner Diane S.
Published: April 2020

The Food and Drug Administration has strengthened the warning on clozapine's labeling regarding the risk of serious complications from constipation, an adverse effect of this drug.
Original Research: Exploring the Effects of a Nurse-Initiated Diary Intervention on Post–Critical Care Posttraumatic Stress Disorder
Authors: Torres Lorrie , Nelson Francine , West Gordon
Published: April 2020

Background:

Critical illness survivors may develop posttraumatic stress disorder (PTSD) following critical illness and hospitalization. Left untreated, PTSD may result in poor health outcomes.

Purpose:

This study sought to examine the effects of a nurse-initiated diary intervention on PTSD development and symptom severity in critical illness survivors with varying levels of mentation.

Methods:

The study used a pretest–posttest control group design. Patients who were hospitalized in a critical care unit for more than 24 hours were recruited at a single medical center with two such units. All participants completed a pretest on day 2 of critical care hospitalization; the intervention group participants also received a diary. All participants received a posttest one month after critical care discharge. The variables examined were PTSD severity and symptoms of avoidance, intrusion, and hyperarousal. Variables were measured using the Impact of Event Scale–Revised. Diaries were written by the patient, visitors, and interdisciplinary team members, and kept by the patient.

Results:

A total of 134 participants completed the study. The intervention group participants experienced significantly fewer PTSD symptoms than the control group participants. PTSD was found to be of concern in 35 (26%) of all participants: five in the intervention group and 30 in the control group.

Conclusions:

For critical illness survivors, a collaborative diary-writing intervention during hospitalization and after discharge can mitigate post–critical care PTSD. Participants who received diaries had a lower incidence of PTSD symptoms than controls; and at follow-up, they indicated that the diary intervention was worthwhile. We recommend the use of collaborative diary writing to help critical illness survivors in working through their experiences.
CE: Managing Pain in Critically Ill Adults: A Holistic Approach
Authors: Delgado Sarah A.
Published: April 2020

Nurses caring for critically ill adults are challenged to balance patient comfort with the risk of complications associated with analgesic therapy. Evidence gathered since 2013, when the Society of Critical Care Medicine (SCCM) published the Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit, known as the PAD guidelines, gave rise to the SCCM 2018 publication of the Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU, known as the PADIS guidelines. This article discusses how the PADIS guidelines go beyond the PAD guidelines, providing specific guidance related to risk factors for pain, the assessment and management of pain in critical illness, and the ways in which the experience of pain in critical illness is intertwined with that of agitation, delirium, immobility, and sleep disruption. Tables summarize the key points in the PADIS guidelines, clarify the distinctions between PADIS and PAD, and describe the implications for nurses.
Caring for Visually Impaired Patients in the Hospital: A Multidisciplinary Quality Improvement Project
Authors: Carlson Christine , Howe Tami , Pedersen Chase , Yoder Linda H.
Published: April 2020

Background:

People with low vision or blindness may experience anxiety, fear, and depression—sometimes severe—as a result of the challenges encountered when they seek medical care. Such patients deserve, and health care professionals must provide, equal opportunities to participate in and benefit from their health care in a safe environment. A search of the literature yielded information on the needs of visually impaired people but failed to find a comprehensive program that health care facilities could use to meet the needs of this vulnerable population. This gap in the literature on visually impaired patients (VIPs) and implications for their care led us to conduct focused meetings with this population.

Objective:

The specific aims of this quality improvement (QI) project were to determine the needs of hospitalized VIPs, develop educational and other resources that would help clinicians and ancillary hospital staff in their interactions with VIPs, and assemble a toolbox of useful materials for VIPs themselves.

Methods:

A VIP care team identified the needs of VIPs as reported in the literature and in personal meetings with visually impaired people in the community. The team also surveyed interdisciplinary hospital staff members to determine their experience in caring for VIPs as well as their educational needs, and then developed strategies and educational modules to help clinicians and ancillary staff members accommodate the unique needs of VIPs in accordance with the Americans with Disabilities Act of 1990. The team also assembled a VIP toolbox that contained several items useful to VIPs themselves. Supplementary information tailored to the function of each hospital department (such as nursing, admissions, environmental services, dietary, and radiology) was also provided to help staff members improve VIPs' hospital experience.

Results:

The hospital's interdisciplinary staff members participated in an education program to improve their care of VIPs. Before the program, only 23.6% of 161 staff members reported having received education on caring for VIPs. After the program, however, 56.4% of 140 staff members reported having received such education. Former patients requested bracelets and room identifiers that would alert staff members to VIPs' needs, and the team provided these. The team also introduced a braille version of the hospital menu and provided VIP toolboxes at each nursing station that contained many useful daily care items.

Conclusions:

VIPs have specific needs when hospitalized. Patients' and staff members' responses to this QI project were overwhelmingly positive; both groups were appreciative of the newly implemented initiatives to meet the special needs of the visually impaired.
One in 4 Million: The Nurse Who Mentored Me
Authors: Paradisi Julianna
Published: April 2020

Updated several times a week with posts by a wide variety of authors, AJN's blog Off the Charts allows us to provide more timely—and often more personal—perspectives on professional, policy, and clinical issues. Best of the Blog is a regular column to draw the attention of AJN readers to posts we think deserve a wider audience. To read more, please visit: www.ajnoffthecharts.com.
Confronting compassion fatigue in oncology nurses
Authors: Reiser Victoria L. , Gonzalez Judith F. Zedreck
Published: April 2020

Oncology nurses are at increased risk for compassion fatigue compared with those in other specialties. This article describes a quality improvement project to create self-compassion tool kits by incorporating the input and opinions of the frontline staff.
A Randomized Controlled Comparison of Epidural Analgesia Onset Time and Adverse Reactions During Labor With Different Dose Combinations of Bupivacaine and Sufentanil
Authors: Wang Tingting , Lu Yaojun , Zhou Peiwen , Huang Shaoqiang , Yu Xinhua
Published: April 2020

Objectives:

The purpose was to compare the effects of 3 different dose combinations of bupivacaine and sufentanil on the onset of analgesia and the occurrence of side effects.

Materials and Methods:

One hundred sixty-nine pregnant women were randomly assigned to 3 groups: the B1S5 group received 0.1% bupivacaine+5 μg sufentanil in 15 mL; the B125S5 group received 0.125% bupivacaine+5 μg sufentanil in 15 mL; and the B1S10 group received 0.1% bupivacaine+10 μg sufentanil in 15 mL. The primary outcome was the analgesic onset time, and the secondary outcomes were mode of delivery, patient satisfaction, maternal and neonatal side effects (pruritus, hypotension, sedation, motor block, decreased fetal heart rate, fever, and interference with breastfeeding).

Results:

The median (inter-quartile range) time to achieve effective analgesia was significantly faster in the B125S5 group than in the B1S5 group (10 [11-14 {4-30}] min vs. 15 [17-20 {5-30}] min, P<0.001). There was no significant difference in the analgesia onset time between the B1S10 and B125S5 groups (10 [11-14 {4-30}] min vs. 12 [13-15 {3-30}] min, P=0.202). Pruritus, hypotension, motor block, maternal satisfaction, delivery mode, decreased fetal heart rate, total bupivacaine dose and breastfeeding scores were not significantly different among the 3 groups except the sufentanil dosage and incidence of mild drowsiness and fever (the B1S10 group had significantly higher fever than the other groups).

Discussion:

The B125S5 combination may be superior to the B1S5 and B1S10 combinations as an initial dose for epidural analgesia to achieve rapid effective analgesia with minimal side effects.
Aging Women and the Office Assessment
Authors: Miller Myron
Published: April 2020

This monograph is intended to serve as a practical guide to the office assessment of the aging woman and recognizes the time constraints that characterize current office practice. Obstetrician–gynecologists are increasingly becoming the primary care providers to women in their practices and especially to older women who have been long-time patients. This monograph should serve as a guide to the many tools needed to assess the health and functional and cognitive status of the aging woman. Illustrative cases demonstrate how to use these tools in a time-efficient manner to achieve a positive effect on the well-being of the patient.
Protection by Exclusion
Authors: Costantine Maged M. , Landon Mark B. , Saade George R.
Published: April 2020

Coronavirus disease 2019 (COVID-19) is a novel infectious disease that started in Wuhan, China, and has rapidly spread all across the world. With limited ability to contain the virus and relatively high transmissibility and case fatality rates, governmental institutions and pharmaceutical companies are racing to find therapeutics and vaccines that target this novel coronavirus. However, once again, pregnant and breastfeeding women are excluded from participating in clinical trials during this pandemic. This “protection by exclusion” of pregnant women from drug development and clinical therapeutic trials, even during epidemics and pandemics, is not unprecedented. Moreover, it is both misguided and not justifiable and may have excluded them from potentially beneficial interventions. This is another missed opportunity to obtain pregnancy-specific safety and efficacy data, because therapeutics developed for men and nonpregnant women may not be generalizable to pregnant women. Therefore, we recommend and urge the scientific community and professional societies that, without clear justification for exclusion, pregnant women should be given the opportunity to be included in clinical trials for COVID-19 based on the concepts of justice, equity, autonomy, and informed consent.
Development of Abbreviated Versions of the Word Auditory Recognition and Recall Measure
Authors: Smith Sherri L. , Ryan David B. , Pichora-Fuller M. Kathleen
Published: April 2020

Objectives:

The objective of this study was to develop and evaluate abbreviated versions of the Word Auditory Recognition and Recall Measure (WARRM) as part of an iterative process in the development of a feasible test for potential future clinical use.

Design:

The three original WARRM (O-WARRM) randomizations were modified by altering the presentation paradigm. Instead of presenting 5 trials per set size with set size increasing from 2 to 6 as in the O-WARRM (n = 100 words), the experimental WARRM (E-WARRM) paradigm consisted of one trial from each of set sizes 2 to 6 to create a “run” (n = 20 words) with each randomization consisting of 5 runs (n = 100 words). A total of 24 younger listeners with normal hearing and 48 older listeners with hearing loss (OHL) were administered 1 randomization of the O-WARRM and 1 different randomization of the E-WARRM.

Results:

The recognition and recall performances on the O-WARRM and all versions of the E-WARRM (five individual runs and overall) were similar within each listener group, with the younger listeners with normal hearing outperforming the OHL listeners on all measures. Correlation analyses revealed moderate to strong associations between the abbreviated WARRM runs and the O-WARRM for the OHL listener group. Hierarchical regression modeling suggested that run 1 of the E-WARRM was a good predictor of O-WARRM performance and that adding additional runs did not improve the prediction. Taken together, these findings suggest that administering one run from the E-WARRM warrants further examination for clinical use. Additional analyses revealed equivalent scores on all five runs from the three E-WARRM randomizations for both listener groups.

Conclusions:

Abbreviated versions of the O-WARRM were developed as part of this study. This was accomplished by modifying the original presentation paradigm and creating 15 unique “runs” among the original 3 randomizations. The resulting 15 runs could be considered 15 unique and abbreviated WARRM lists that have potential, in the future after further studies are conducted to establish important properties, for clinic use. The abbreviated WARRM lists may be useful for quantifying auditory working memory of listeners with hearing loss during the audiologic rehabilitation process.
Comparison of Pure-Tone Thresholds and Cochlear Microphonics Thresholds in Pediatric Cochlear Implant Patients
Authors: Coulthurst Sarah , Nachman Alison J. , Murray Mike T. , Koka Kanthaiah , Saoji Aniket A.
Published: April 2020

Objectives:

In adult cochlear implant patients, conventional audiometry is used to measure postoperative residual hearing which requires active listening and patient feedback. However, audiological measurements in pediatric cochlear implant patients are both challenging as well as time consuming. Intracochlear electrocochleography (ECOG) offers an objective and a time-efficient method to measure frequency-specific cochlear microphonic or difference thresholds (CM/DIF) thresholds that closely approximate auditory thresholds in adult cochlear implant patients. The correlation between CM/DIF and behavioral thresholds has not been established in pediatric cochlear implant patients. In the present study, CM/DIF thresholds were compared with audiometric thresholds in pediatric cochlear implant patients with postoperative residual hearing.

Design:

Thirteen (11 unilateral and 2 bilateral) pediatric cochlear implant patients (mean age = 9.2 years ± 5.1) participated in this study. Audiometric thresholds were estimated using conventional, condition play, or visual reinforcement audiometry. A warble tone stimulus was used to measure audiometric thresholds at 125, 250, 500, 1000, and 2000 Hz. ECOG waveforms were elicited using 50-msec acoustic tone-bursts. The most apical intracochlear electrode was used as the recording electrode with an extra-cochlear ground electrode. The ECOG waveforms were analyzed to determine CM/DIF thresholds that were compared with pediatric cochlear implant patients’ audiometric thresholds.

Results:

The results show a significant correlation (r = 0.77, p < 0.01) between audiometric and CM/DIF thresholds over a frequency range of 125 to 2000 Hz in pediatric cochlear implant patients. Frequency-specific comparisons revealed a correlation of 0.82, 0.74, 0.69, 0.41, and 0.32 between the audiometric thresholds and CM/DIF thresholds measured at 125, 250, 500, 1000, and 2000 Hz, respectively. An average difference of 0.4 dB (±14 dB) was measured between the audiometric and CM/DIF thresholds.

Conclusions:

Intracochlear ECOG can be used to measure CM/DIF thresholds in pediatric cochlear implant patients with residual hearing in the implanted ear. The CM/DIF thresholds are similar to the audiometric thresholds at lower test frequencies and offer an objective method to monitor residual hearing in difficult-to-test pediatric cochlear implant patients.
Perfusion Pressure Lacks Diagnostic Specificity for the Diagnosis of Acute Compartment Syndrome
Authors: Schmidt Andrew H. , Di Junrui , Zipunnikov Vadim , Frey Katherine P. , Scharfstein Daniel O. , O'Toole Robert V. , Bosse Michael J. , Obremskey William T. , Stinner Daniel J. , Hayda Roman , Karunakar Madhav A. , Hak David J. , Carroll Eben A. , Collins Susan C.J. , MacKenzie Ellen J. ,   METRC
Published: April 2020

Objective:

To evaluate the diagnostic performance of perfusion pressure (PP) thresholds for fasciotomy.

Design:

Prospective observational study.

Setting:

Seven Level-1 trauma centers.

Patients/Participants:

One hundred fifty adults with severe leg injuries and ≥2 hours of continuous PP data who had been enrolled in a multicenter observational trial designed to develop a clinical prediction rule for acute compartment syndrome (ACS).

Main Outcome Measurements:

For each patient, a given PP criterion was positive if it was below the specified threshold for at least 2 consecutive hours. The diagnostic performance of PP thresholds between 10 and 30 mm Hg was determined using 2 reference standards for comparison: (1) the likelihood of ACS as determined by an expert panel who reviewed each patient's data portfolio or (2) whether the patient underwent fasciotomy.

Results:

Using the likelihood of ACS as the diagnostic standard (ACS considered present if median likelihood ≥70%, absent if <30%), a PP threshold of 30 mm Hg had diagnostic sensitivity 0.83, specificity 0.53, positive predictive value 0.07, and negative predictive value 0.99. Results were insensitive to more strict likelihood categorizations and were similar for other PP thresholds between 10- and 25-mm Hg. Using fasciotomy as the reference standard, the same PP threshold had diagnostic sensitivity 0.50, specificity 0.50, positive predictive value 0.04, negative predictive value 0.96.

Conclusion:

No value of PP from 10 to 30 mm Hg had acceptable diagnostic performance, regardless of which reference diagnostic standard was used. These data question current practice of diagnosing ACS based on PP and suggest the need for further research.

Level of Evidence:

Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.
Compression of Nonunions With the PRECICE Magnetic Intramedullary Compression Nail
Authors: Fragomen Austin T.
Published: April 2020

The magnetic intramedullary lengthening nail can be predistracted and used to compress bony interfaces to assist in the healing of nonunions of long bones and to accelerate union at difficult to heal fractures and osteotomy sites. This requires no special implant apart from the lengthening nail. Technical considerations include predistraction of the nail on the back table, overreaming of the canal, shortening at the defect site, and applying compression over several days. Patients can weight-bear immediately and often return to work quickly. The same nail can be used for bone lengthening, after union is achieved, by creating an osteotomy around the implant. Results show high union rates with minimal morbidity.
Brain Injury and Neurologic Outcome in Patients Undergoing Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis
Authors: Migdady Ibrahim , Rice Cory , Deshpande Abhishek , Hernandez Adrian V. , Price Carrie , Whitman Glenn J. , Geocadin Romergryko G. , Cho Sung-Min
Published: April 2020

Objectives:

Extracorporeal cardiopulmonary resuscitation has shown survival benefit in select patients with refractory cardiac arrest but there is insufficient data on the frequency of different types of brain injury. We aimed to systematically review the prevalence, predictors of and survival from neurologic complications in patients who have undergone extracorporeal cardiopulmonary resuscitation.

Data Sources:

MEDLINE (PubMed) and six other databases (EMBASE, Cochrane Library, CINAHL Plus, Web of Science, and Scopus) from inception to August 2019.

Study Selection:

Randomized controlled trials and observational studies in patients greater than 18 years old.

Data Extraction:

Two independent reviewers extracted the data. Study quality was assessed by the Cochrane Risk of Bias tool for randomized controlled trials, the Newcastle-Ottawa Scale for cohort and case-control studies, and the Murad tool for case series. Random-effects meta-analyses were used to pool data.

Data Synthesis:

The 78 studies included in our analysis encompassed 50,049 patients, of which 6,261 (12.5%) received extracorporeal cardiopulmonary resuscitation. Among extracorporeal cardiopulmonary resuscitation patients, the median age was 56 years (interquartile range, 52–59 yr), 3,933 were male (63%), 3,019 had out-of-hospital cardiac arrest (48%), and 2,289 had initial shockable heart rhythm (37%). The most common etiology of cardiac arrest was acute coronary syndrome (n= 1,657, 50% of reported). The median extracorporeal cardiopulmonary resuscitation duration was 3.2 days (interquartile range, 2.1–4.9 d). Overall, 27% (95% CI, 0.17–0.39%) had at least one neurologic complication, 23% (95% CI, 0.14–0.32%) hypoxic-ischemic brain injury, 6% (95% CI, 0.02–0.11%) ischemic stroke, 6% (95% CI, 0.01–0.16%) seizures, and 4% (95% CI, 0.01–0.1%) intracerebral hemorrhage. Seventeen percent (95% CI, 0.12–0.23%) developed brain death. The overall survival rate after extracorporeal cardiopulmonary resuscitation was 29% (95% CI, 0.26–0.33%) and good neurologic outcome was achieved in 24% (95% CI, 0.21–0.28%).

Conclusions:

One in four patients developed acute brain injury after extracorporeal cardiopulmonary resuscitation and the most common type was hypoxic-ischemic brain injury. One in four extracorporeal cardiopulmonary resuscitation patients achieved good neurologic outcome. Further research on assessing predictors of extracorporeal cardiopulmonary resuscitation-associated brain injury is necessary.
Direct-Acting Oral Anticoagulants in Atrial Fibrillation
Authors: Ferrari Filipe , da Silveira Anderson Donelli , Martins Vitor Magnus , Franzoni Leandro Tolfo , Zimerman Leandro Ioschpe , Stein Ricardo
Published: April 2020

Atrial fibrillation (AF) is considered the most common sustained cardiac arrhythmia, and it is associated with a significant risk of adverse events, especially ischemic stroke. Oral anticoagulation is the cornerstone for stroke prevention in AF; for many years, only vitamin K antagonists were used for this purpose, with an absolute risk reduction >60%. However, these agents have limitations, such as narrow therapeutic margins and drug–food and drug–drug interactions. More recently, 4 direct-acting oral anticoagulants (DOACs)—non–vitamin K antagonists—have become available for patients with AF: dabigatran, rivaroxaban, apixaban, and edoxaban. In addition to a comparable efficacy to warfarin in large randomized controlled trials, DOACs were found to promote a lower risk of intracranial bleeding. The strategic dosage and lack of need for periodic prothrombin-time testing make their use attractive, especially for primary or secondary prevention of stroke in older adults. Furthermore, among patients with AF presenting with acute coronary syndrome or undergoing percutaneous coronary intervention, apixaban is associated with a reduction in serious bleeding events when compared with warfarin. On the other hand, there is no evidence of benefit of DOACs in patients with mechanical prosthetic valves or moderate/severe mitral stenosis. Furthermore, the suitability of DOACs in patients with liver disease is still poorly understood, and their safety in patients requiring renal replacement therapy remains uncertain. This review provides an overview of the main trials of DOACs, their pharmacology and safety profile, clinical implications, and best indications in light of the current evidence.
The Reversed Glove Sleeve: A Readily Available and Cost-effective Way to Achieve “No Touch” Breast Implant Insertion
Authors: Barker Anthony S. , Law Jenaleen , Nicholson Margaret , Collett David , Deva Anand K.
Published: April 2020

The reversed glove sleeve technique is a simple, available, reproducible, and cost-effective method of achieving “no touch” breast implant insertion. It allows a new glove to be used for each side, thus reducing the risk of contamination by reusing a sleeve/funnel for the subsequent implant insertion. The link between bacterial contamination of breast implants and capsular contracture is established. Further prospective evaluation of this technique is underway to show if there is benefit in reducing the risk of capsular contracture.
Biplanar Technique for Breast Implant Replacement through Mastectomy Scar
Authors: Kruchevsky Dani , Tobias Tal , Halperin Ben-Ami Tamar , Shoufani Aziz
Published: April 2020

Background:

Implant-based breast reconstruction is the most commonly used modality for breast reconstruction. A 2-stage reconstruction is employed when the skin envelope is insufficient. In the first stage, a tissue expander is placed in a pocket created beneath the pectoralis major muscle and an acellular dermal matrix (ADM). In the second stage, the expander is replaced with a permanent implant. Though the second stage is safer, some studies have published an immediate complication rate of up to 11.4%, and even higher in the event of prior radiotherapy.

Methods:

We present a novel biplanar technique for implant replacement through the mastectomy scar. The goal of our technique is to make incisions of the skin and the incorporated ADM in 2 separate planes, hopefully lowering the risk for dehiscence, deep infection, and reconstruction failure. We conducted a retrospective review of patients who underwent tissue expander or implant replacement surgery using the biplanar technique between January 2012 and January 2018 by the senior author.

Results:

Eleven consecutively presenting patients underwent 8 tissue expanders and 6 silicone implant replacement surgeries. Three patients had received prior radiation therapy in the operated breast. None of the patients had complications nor needed a revision surgery.

Conclusions:

The biplanar technique for implant or tissue expander replacement through the mastectomy scar following breast reconstruction shows promising results in our series of patients and may prove useful in reducing postoperative incisional dehiscence, deep infection, and implant exposure. Nonetheless, further large-scale studies are required to evaluate the effectiveness of this technique.
Ulnar Nerve Entrapment in Diabetes: Patient-reported Outcome after Surgery in National Quality Registries
Authors: Zimmerman Malin , Anker Ilka , Karlsson Anna , Arner Marianne , Svensson Ann-Marie , Eeg-Olofsson Katarina , Nyman Erika , Dahlin Lars B.
Published: April 2020

Background:

Ulnar nerve entrapment at the elbow (UNE) is overrepresented in patients with diabetes, but the outcome of surgery is unknown. We aimed to evaluate patient-reported outcome in patients with and without diabetes, and to assess potential sex differences and compare surgical treatment methods.

Methods:

Data on patients operated for UNE (2010–2016, n = 1354) from the Swedish National Registry for Hand Surgery were linked to the Swedish National Diabetes Register. Symptoms were assessed preoperatively (n = 389), and 3 (n = 283), and at 12 months postoperatively (n = 267) by QuickDASH and HQ-8 (specific hand surgery questionnaire—8 questions). Only simple decompressions were included when comparing groups.

Results:

Men with diabetes reported higher postoperative QuickDASH scores than men without diabetes. Women scored their disability higher than men on all time-points in QuickDASH, but showed larger improvement between preoperative and 12 months postoperative values. Patients operated with transposition scored 10.8 points higher on QuickDASH than patients who had simple decompression at 12 months (95% confidence interval 1.98–19.6).

Conclusions:

Women with diabetes benefit from simple decompression for UNE to the same extent as women without diabetes. Men with diabetes risk not to benefit from simple decompression as much as women do. Ulnar nerve transposition had a higher risk of residual symptoms compared to simple decompression.
Unusual Intranodular Collagenase Injection: A Case of Bilateral Ledderhose Disease
Authors: De Vitis Rocco , Passiatore Marco , Perna Andrea , Starnoni Marta , Taccardo Giuseppe
Published: April 2020

Ledderhose disease (LD) is a rare plantar fibromatosis of the foot, frequently associated with Dupuytren disease. Collagenase of Clostridium hystoliticum has recently revolutionized the way to treat Dupuytren disease. Nevertheless, the literature is still critically lacking about the use of collagenase injection in LD. We report a case of a man with bilateral symptomatic LD treated with collagenase. Injections (0.58 mg of collagenase of C. hystoliticum) were performed into nodules. Forced extension after injection was not performed. The patient could walk normally immediately after procedure. The procedure was a complete success without side effects or complications on either foot. Currently, at 14 months after treatment of the right foot and 12 months after treatment of the left foot, no recurrence has been observed. Collagenase injection was only effective in treating symptomatic LD in this one patient we reported on.
The Reconstruction after a Giant Phyllodes Tumor Resection Using a DIEP Flap
Authors: Tsuruta Yuki , Karakawa Ryo , Majima Koya , Yamamoto Satoru , Shibata Tomoyoshi , Yoshimatsu Hidehiko , Miyashita Hiroki , Tanakura Kenta , Yano Tomoyuki
Published: April 2020

A phyllodes tumor of the breast is a rare neoplasm, accounting for 0.3%–1% of all breast cancers. The size is 4–5 cm on average but sometimes the tumor grows more and involves the entire breast. As for treatment, complete surgical resection is the standard for localized breast phyllodes tumors. The reconstruction of a large defect is challenging. Herein, we present a case where a deep inferior epigastric artery perforator (DIEP) flap was used in breast reconstruction for a 48-year-old woman who was suffering from a giant phyllodes tumor. Immediate reconstruction was performed after tumor excision; the specimen weighed 4,230 g and the skin defect was 22 × 24 cm. The deep inferior epigastric artery and vein were anastomosed to the right internal mammary artery and vein, and the superficial inferior epigastric vein was anastomosed to the right lateral thoracic vein. The postoperative course was uneventful and the DIEP flap survived completely. In the setting of the reconstruction for a large defect, we must make maximum use of the limited human tissue available and ensure minimum damage, while also considering the functional and aesthetic outcome of the donor site. Various ideas and technologies have been reported that can assist in achieving this goal, but few reports have commented especially on the reconstruction of giant phyllodes tumor using autologous tissues. There were some other options for the way of the reconstruction such as a latissimus dorsi flap and a rectus abdominis flap. Compared with these approaches, using a DIEP flap has some disadvantages such as the need for the microsurgical skill and the risk of postoperative hernia. However, a DIEP flap provides the enough tissue to cover the large defect without any damage of the muscle. To our knowledge, this case was the largest phyllodes tumor reconstruction ever, in terms of the amount of the skin needed and resected tissue involved. Although more studies and longer follow-up will be required in the future, this case may show the usefulness of DIEP flaps for reconstruction of a giant phyllodes tumor.