Internal joint stabilizer for varus posteromedial rotatory instability of the elbow.

BACKGROUND: Management of varus posteromedial rotatory instability (VPMRI) of the elbow presents a challenging problem, sometimes requiring supplemental external fixation or ulnohumeral cross-pinning. A relatively new treatment adjunct for posterolateral rotatory instability of the elbow has become available with the development of the internal joint stabilizer (IJS) implant. However, this has not been studied for VPMRI because the implant is thought to be ineffective at treating this instability when placed in the usual manner on the lateral side of the elbow. We hypothesize that modifying the IJS technique to place the implant medially will make it as effective as external fixation at preventing VPMRI. METHODS: Nine whole-arm cadaveric specimens were tested on a rig that allowed for gravity stress of the elbow at 60° of abduction. Intact specimens (INT) were tested to find the baseline stability with all structures intact. Then, O'Driscoll type 2-subtype III coronoid fractures were created with a microsagittal saw, and these same specimens were again tested without any fixation (WAF), with a static lateral external fixator (SLEF), and with a medially placed IJS (MIJS). The method for medial IJS placement is detailed within. RESULTS: The WAF specimens were significantly more unstable than the INT, SLEF, and MIJS groups (P < .001). There was no difference in stability between the INT and the SLEF (P = .59) or MIJS group (P = .21). CONCLUSION: In this cadaveric model, a medially placed IJS was as effective as an SLEF at maintaining elbow stability in a coronoid-deficient elbow. This technique allows for early elbow range of motion, with no external hardware, and may eliminate the complications associated with external fixation or ulnohumeral cross-pinning.

Ultrasound-Accelerated, Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism: Single-Center Retrospective Review with Intermediate-Term Outcomes.

PURPOSE: To evaluate ultrasound-accelerated, catheter-directed thrombolysis (CDT) for treatment of acute submassive pulmonary embolism (PE). MATERIALS AND METHODS: This single-center, retrospective study included patients who underwent CDT for acute submassive PE (N = 113, 52% men/48% women) from 2013 to 2017. Baseline characteristics included history of deep venous thrombosis (12%), history of PE (6%), and history of cancer (18%). Of cohort patients, 88% (n=99) had a simplified PE severity index score of ≥ 1 indicating a high risk of mortality. RESULTS: A technical success rate of 100% was achieved with 84% of patients having bilateral catheter placements. Average tissue plasminogen activator (tPA) therapy duration was 20.7 hours ± 1.5, and median tPA dose was 21.5 mg. Three patients (2.6%) experienced minor hemorrhagic complications. Mean hospital length of stay was 6 days. Mean pulmonary arterial pressure decreased from 55 mm Hg on presentation to 37 mm Hg (P < .01) 1 day following initiation of thrombolytic therapy. All-cause mortality rate of 4% (n = 4) was noted on discharge, which increased to 6% (n = 7) at 6 months. At 6-month follow-up compared with initial presentation, symptom improvements (93%), physiologic improvements (heart rate 72 beats/min vs 106 beats/min, P < .01), oxygen requirement improvements (fraction of inspired oxygen 20% vs 28%, P < .01), and right ventricular systolic pressure improvements by echocardiography (30 mm Hg vs 47 mm Hg, P < .01) were observed. CONCLUSIONS: CDT for acute submassive PE was associated with low complications and mortality, decreased right ventricular systolic pressure, high rates of clinical improvement, and improved intermediate-term clinical outcomes.

Single-center experience of the FIRM technique to ablate paroxysmal and persistent atrial fibrillation.

INTRODUCTION: Focal impulse and rotor modulation (FIRM)-guided ablation has had mixed results of published success, and most studies have had a follow-up for a year or less. We aimed to study a consecutive group of patients followed for at least 1.5 years, subgrouped into those with an initial FIRM ablation and those with a previous, failed ablation who now received a FIRM guided one, to evaluate for success in each group and factors that might affect success. METHODS: Of 181 patients, 167 were available for analysis. Group 1 (n = 122) had a first or primary ablation (paroxysmal atrial fibrillation [PAF] 51; persistent atrial fibrillation [PeAF] 71) and group 2 (n = 45) had a redo ablation (PAF 18; PeAF 27). All patients were done under general anesthesia. FIRM mapping was done in the right atrium first and then the left, and only rotors consistently seen on multiple epochs were ablated, using 15 to 30 W. Rotor ablation was discontinued when remapping showed elimination of rotational activity at the site. Wide area catheter ablation was done for pulmonary vein isolation (PVI). Routine follow-up was at 3, 6, and 12 months of the first year, with a Holter monitor at 6 months, and then every 6 months thereafter. Event recorders were given to patients with potential arrhythmic symptoms. RESULTS: Mean follow-up was 16 months. Nearly 40% of patients had obstructive sleep apnea; mean body mass index was 32; and average left atrial size was 39.7 mm and 46.2 mm for PAF and PeAF patients, respectively. Freedom from atrial arrhythmia recurrence was: in group 1 patients, 82.4% for PAF and 67.6% for PeAF patients; in group 2 patients, 83.3% for PAF, but only 40.7% for PeAF patients. Comparing outcomes for the first 10 patients studied to the next 20 or more done by three operators showed no difference, suggesting no learning curve affecting the ablation results. Furthermore, the univariate analysis did not show any demographic factor to have an independent significance for ablation success or failure. Spontaneous termination during rotor ablation occurred in 76.8% of PAF and 27.6% of PeAF patients but did not affect the long-term outcomes for maintenance of sinus rhythm. CONCLUSIONS: FIRM-guided atrial ablation plus PVI in our patient population resulted in good success from a recurrence of atrial arrhythmias in patients undergoing an initial ablation procedure. For those with persistent AF undergoing a second procedure now using FIRM guidance plus PVI, the results are lower. Further research is needed to define better the appropriate population for FIRM-guided ablation and the degree of ablation needed for success in these patients.

Can Teamwork and High-Volume Experience Overcome Challenges of Lymphadenectomy in Morbidly Obese Patients (Body Mass Index of 40 kg/m2 or Greater) with Endometrial Cancer?: A Cohort Study of Robotics and Laparotomy and Review of Literature.

OBJECTIVE: This study aimed to compare surgical outcomes and the adequacy of surgical staging in morbidly obese women with a body mass index (BMI) of 40 kg/m or greater who underwent robotic surgery or laparotomy for the staging of endometrioid-type endometrial cancer. METHODS: This is a retrospective cohort study of patients who underwent surgical staging between May 2011 and June 2014. Patients' demographics, surgical outcomes, intraoperative and postoperative complications, and pathological outcomes were compared. RESULTS: Seventy-six morbidly obese patients underwent robotic surgery, and 35 underwent laparotomy for surgical staging. Robotic surgery was associated with more lymph nodes collected with increasing BMI (P < 0.001) and decreased chances for postoperative respiratory failure and intensive care unit admissions (P = 0.03). Despite a desire to comprehensively stage all patients, we performed successful pelvic and paraaortic lymphadenectomy in 96% versus 89% (P = 0.2) and 75% versus 60% (P = 0.12) of robotic versus laparotomy patients, respectively. In the robotic group, with median BMI of 47 kg/m, no conversions to laparotomy occurred. The robotic group experienced less blood loss and a shorter length of hospital stay than the laparotomy group; however, the surgeries were longer. CONCLUSIONS: In a high-volume center, a high rate of comprehensive surgical staging can be achieved in patients with BMI of 40 kg/m or greater either by laparotomy or robotic approach. In our experience, robotic surgery in morbidly obese patients is associated with better quality staging of endometrial cancer. With a comprehensive approach, a professional bedside assistant, use of a monopolar cautery hook, and our protocol of treating morbidly obese patients, robotic surgeries can be safely performed in the vast majority of patients with a BMI of 40 kg/m or greater, with lymph node counts being similar to nonobese patients, and with conversions to laparotomy reduced to a minimum.

Transabdominal Cerclage.

The transabdominal cerclage procedure was first introduced 50 years ago as an approach in those patients who had failed transvaginal cerclage. We review the history, indications, surgical technique, complications, and reported outcomes of the procedure. The procedure has evolved over time in its application and risks appear to be less than previously perceived. Physicians have found additional patient situations in which the procedure may be beneficial outside the indications defined 50 years ago. This is a valuable surgical technique which is likely underused.

Evaluating the Clinical Value of Oblique-View Radiographs in the Initial Intervention of Closed Distal Radius Fractures: An External Survey of Hand Surgeons.

Purpose: Traditionally, an acute wrist radiograph series comprises posteroanterior, oblique, and lateral projections. There is controversy within the field of orthopedics, however, over the value of the oblique view in determining a plan of care for a given fracture. An external survey of practicing hand surgeons was conducted to evaluate whether the addition of the oblique view to a 2-view (posteroanterior and lateral) series resulted in a difference in the initial intervention plan for closed distal radius fractures (DRFs). Methods: Participants, licensed and practicing hand surgeons in the United States, reviewed 30 sets of wrist radiograph studies twice (once as a complete 3-view series and again with the oblique omitted) in a randomized order. Cases were randomly selected to include 10 pediatric, 10 geriatric, and 10 intermediate/adult DRFs. After reviewing the films and demographic information, the participants selected their preferred initial intervention from the following list: (1) treatment using a cast or orthosis without reduction, (2) closed reduction under or without fluoroscopy with treatment using a cast or orthosis, (3) closed reduction and percutaneous fixation with treatment using a cast or orthosis, and (4) open reduction internal fixation and subsequent treatment in a cast or orthosis. Results: A calculated Cohen kappa for the entire sample revealed a statistically significant and strong association between 2- and 3-view survey answers (κ = 0.81, P < .001). Each pairing was examined separately, and 90% of the questions had a statistically significant (P < .05) Cohen kappa pairing; however, many were in the 0.5-0.75 range. Conclusions: The data support the hypothesis that the addition of an oblique view radiograph to a posteroanterior and lateral series does not change surgical decision-making in the initial evaluation of acute closed DRF in many situations. However, although most cases had a statistically significant (P < .05) agreement between the surveys, the oblique view did result in some meaningful intervention changes. Therefore, the elimination of the oblique view cannot be supported by our findings. Clinical relevance: This is a decision analysis survey study designed to investigate how the oblique-view radiograph influences DRF surgical decision-making.

Change in BMI in Children Over the First 30 Months After the Start of the SARS-CoV-2 Pandemic.

Our study aim was to assess body mass index (BMI) change in children in the immediate 6 months of the pandemic, to follow longitudinal BMI change up to 30 months after the pandemic start, and to identify sociodemographic factors associated with these changes. Our study included a retrospective chart review of 1298 children 2 to 18 years old with office visits at an Indianapolis primary care clinic. Body mass index and sociodemographic information were collected at visits during 3 time periods: Prepandemic (March 1, 2019-February 28, 2020), Early Pandemic (June 1, 2020-November 30, 2020), and Late Pandemic (December 1, 2020-September 30, 2022). Data analysis indicated statistically significant increases in BMI monthly rate of change from Prepandemic to Early Pandemic periods. Interestingly, BMI rate of change stabilized from Early Pandemic to Late Pandemic periods but remained positive, suggesting children had slower, but persistent, continued BMI increase after the pandemic initiation.

Longitudinal assessment of physician wellness during the COVID-19 pandemic.

Physician wellness was greatly impacted during the COVID-19 pandemic. Busy clinical services, personal safety concerns, changing guidelines, and compassion fatigue weighed on physicians. Although studies have examined physician wellness, few have studied how it changed over time. A survey about wellness was distributed to 299 physicians at Ascension St. Vincent Hospital-Indianapolis March 2020, July 2020, November 2020, and March 2021. Physicians also free-texted about their well-being during the pandemic. Participation rates over the four time periods averaged 22.23%. Responses were compared among the time periods using Pearson Chi-Square and Fisher's Exact Tests. Six wellness factors (anxiety, worry about becoming ill, worry about infecting family, worry about caring for children, concern about personal finances) were reported as worse after the pandemic began, but statistically significantly improved over the course of the study. In contrast, seven wellness measures (increased issues with depression, frustration, hopelessness, fatigue, dread going to work, worry about missing work, worry about caring for family), that also worsened after the pandemic began, did not statistically improve over time. Physician wellness was impacted by the pandemic; however, not all measures followed the same course over time. Longitudinal assessments of wellness can help inform programs to best support physicians.

Patients' and Loved Ones' Expectations of Chaplain Services.

A study assessing the expectations patients and loved ones have of hospital chaplains was conducted at Ascension St. Vincent Indiana hospitals. In-person interviews were conducted with 452 patients and loved ones during an inpatient stay. The survey instrument was a modified version of a survey developed by Dr. Katherine Piderman of the Mayo Clinic. Participants answered questions regarding demographics, awareness of availability, expectations of visits, reasons for wanting to see a chaplain and gave feedback regarding visits if they had seen a chaplain. Results showed that patients and loved ones value chaplains with 93% saying they wanted a chaplain visit. This study was unique in seeking feedback from loved ones as well as patients. It may be equally important to reach out to loved ones during times of crisis when patients themselves are in surgery or sedated and loved ones are experiencing heightened anxiety.

An outpatient critical care transition clinic model reduces admissions/readmissions in medically complex patients.

OBJECTIVES: Reducing hospital admissions in patients with multiple complex chronic conditions is both a quality indicator and cost-effective to health care systems. This study assesses and compares utilization rates and cost of encounters between patients referred and seen in an outpatient critical care transition clinic (Healthy Transitions Clinic [HTC]) and those referred and not seen. STUDY DESIGN: Retrospective cohorts. METHODS: Patients with complex chronic conditions discharged from a tertiary/quaternary acute care hospital or emergency department (March 1, 2015, to February 29, 2016) were referred to an outpatient critical care transition clinic. Comparative cohorts were those patients who attended this transition clinic and those who did not. Pre- and post-HTC referral visits, with health care utilization evaluations including admissions/readmissions, attention to social determinants of health, and cost assessments, were compared among the cohorts. RESULTS: Insurance coverage differed significantly in its distribution between the groups (χ2 = 22.99; P < .001); therefore, an adjusted relative risk model was used. Inpatient admissions significantly increased, by 31%, in the non-HTC cohort (P = .03); a significant increase in the rate of 30-day readmissions (69%) occurred in the HTC group (P < .001) at 6 months post index admission. Length of stay did not differ pre- and post HTC visit. Although not statistically significant, visits to the HTC reduced median all-cost and HTC cohort cost by more than $1 million. CONCLUSIONS: In patients with complex chronic medical conditions with recent hospital admissions, the HTC model appears to reduce both admissions and encounter costs. Further community/regional studies are needed to better define this observation on a longitudinal basis.

Does Use of a Night Extension Orthosis Improve Outcomes in Patients With Dupuytren Contracture Treated With Injectable Collagenase?

Purpose: Current prescribing information for the treatment of patients with Dupuytren contracture with injectable collagenase Clostridium histolyticum (CCH) recommends use of a night extension orthosis for 4 months after treatment. The present study examines whether this treatment improves the outcomes. Methods: Adult patients with Dupuytren contracture treated with CCH during the study period were eligible for inclusion. The patients were randomized to orthosis or no orthosis groups and were stratified based on the severity of contracture prior to randomization. The orthosis group was fitted postmanipulation with a hand-based custom orthosis that held the treated finger in maximal comfortable extension, and the patients were instructed to wear the orthosis at night for 3 months. The patients were assessed at 7-10 days, 30 days, and 90 days postmanipulation. Orthosis compliance was measured with a survey. The primary outcome measure was improvement in total active extension (TAE), defined as the sum of active metacarpophalangeal (MCP), proximal interphalangeal, and distal interphalangeal joint extension in the treated finger at 90 days after treatment. Secondary outcomes included total active flexion (TAF), Michigan Hand Questionnaire scores, patient satisfaction, and clinical success. Results: Twenty-six patients completed the study, 12 in the orthosis group and 14 in the no orthosis group. The majority of contractures (90%) were primarily through the MCP joint. The patients in both the groups demonstrated significant improvements in TAE at 90-day follow-up (orthosis P = .002, no orthosis P = .001) . The difference in improvement in the median TAE between the 2 groups was not significant (P = .40). There were no significant differences between groups for TAE, TAF, Michigan Hand Questionnaire scores, patient satisfaction, or clinical success at any of the time points assessed (P > .05). Conclusions: In patients with Dupuytren contracture with primarily MCP joint involvement, providing an orthosis after treatment with CCH may not offer a short-term benefit compared with CCH treatment alone in terms of TAE, TAF, or patient-reported outcome measures. Type of study/level of evidence: Therapeutic I.

Gender Correlation to the Prevalence of Pedal Neuromas in Various Interspaces - A Retrospective Study.

BACKGROUND: Morton's neuromas are abnormalities of the common digital nerve branch located between the lesser metatarsal heads. Historically, interdigital (Morton's) neuromas have been characterized as being most common in the third interspace and predominantly identified in females. The principal investigator observed Morton's neuromas commonly in both the 2nd and 3rd interspaces in both genders. To the best of our knowledge, no literature exists to evaluate Morton's neuroma location with a focus on each gender independently. The present study evaluates Morton's neuroma interspace location and if there is a variation between males and females. METHODS: In this retrospective study, 582 de-identified ProScan magnetic resonance imaging reports, with a diagnosis code for Morton's neuroma (ICD Code 355.6), were obtained from their centralized database. These reports were evaluated for patients scanned from January 2015-April 2016. Incomplete records and those where the radiologist findings were not consistent with Morton's neuroma were eliminated. For the remaining 379 patients, data was collected on several factors such as gender, laterality, history of trauma, plantar plate tear, age and interspace location. Special focus was given to second and third interspace Morton's neuromas. Data was then evaluated statistically utilizing the Pearson Chi-Square and Independent Samples Mann-Whitney U Test with statistical significance deemed p<0.05. RESULTS: No statistically significant distribution between gender and second and third interspace Morton's neuromas were noted. Additionally, right vs left foot, age and history of trauma did not vary between genders in a significant way. Lastly, there was a statistically significant difference between the presence of plantar plate tears between genders. Male patients with Morton's neuromas were found to have a higher rate of plantar plate tears (34/92, p=0.01). CONCLUSION: Our study found that there was not a statistically significant difference between female and male and Morton's neuromas location, laterality or age.

Sex Correlation to the Prevalence of Pedal Neuromas in Various Interspaces: A Retrospective Study.

BACKGROUND: Morton's neuromas are abnormalities of the common digital nerve branch located between the lesser metatarsal heads. Historically, interdigital (Morton's) neuromas have been characterized as being most common in the third interspace and in females. The principal investigator observed Morton's neuromas commonly in the second and third interspaces in both sexes. To our knowledge, no literature exists to evaluate Morton's neuroma location with a focus on each sex independently. The present study evaluates Morton's neuroma interspace location and whether there is a variation by sex. METHODS: In this retrospective study, 582 deidentified magnetic resonance imaging reports with a diagnosis code for Morton's neuroma were evaluated for patients scanned from January 2, 2015, through April 19, 2016. Incomplete records and those with radiologist findings inconsistent with Morton's neuroma were eliminated. For the remaining 379 patients, data were collected on sex, laterality, history of trauma, plantar plate tear, age, and interspace location. Special focus was given to second and third interspace Morton's neuromas. Data were evaluated using the Pearson χ2 and independent-samples Mann-Whitney U tests, with P < .05 indicating statistical significance. RESULTS: No statistically significant distribution between sex and second and third interspace Morton's neuromas was noted. Right vs left foot, age, and history of trauma did not vary statistically significantly between sexes. There was a statistically significant difference between the presence of plantar plate tears between sexes. Male patients with Morton's neuromas were found to have a higher rate of plantar plate tears (P = .01). CONCLUSIONS: This study found that there were no statistically significant differences between sexes and Morton's neuromas location, laterality, or age.

Impact of a Process Change on Prevalence of Prescribed Unmeasurable Liquid Doses in a Neonatal Intensive Care Unit.

OBJECTIVES: Most prescribing through the electronic health record (EHR) in the NICU at St. Vincent Women's Hospital use a weight-based dosing calculator. Prescribers receive no alert if the resulting volume is unmeasurable. Study definition of measurable was a dose volume with a visible hash mark on an appropriately sized oral syringe. The primary objective was to compare the rate of unmeasurable oral liquid doses prescribed at discharge before and after implementation of educational process changes. Secondary objectives assessed patient and discharge medication characteristics in relation to the unmeasurable doses prescribed. METHODS: This study was a 2-phase retrospective analysis of patients discharged from the NICU between January 1 and June 30, 2016 (phase I), and between October 1, 2017, and March 31, 2018 (phase II). Patients were included in the analysis if they were discharged on at least 1 oral liquid medication, excluding vitamins. Demographic and discharge medication information was collected. RESULTS: There were 58 patients discharged on a total of 118 oral liquid medications in phase I and 63 patients discharged on a total of 111 oral liquid medications in phase II. Following implementation of the process change, the percentage of unmeasurable discharge prescriptions decreased from 27 (23%) to 5 (4.5%) (p < 0.001). CONCLUSIONS: The educational process change implemented in the NICU effectively reduced the rate of unmeasurable doses prescribed at discharge from 1 in 4 to 1 in 25. Additional system-level changes may result in further reductions.

Burden of illness for super-refractory status epilepticus patients.

OBJECTIVE: To provide an estimate of the annual number of super-refractory status epilepticus (SRSE) cases in the US and to evaluate utilization of hospital resources by these patients. METHODS: The Premier Hospital Database was utilized to estimate the number of SRSE cases based on hospital discharges during 2012. Discharges were classified as SRSE cases based on an algorithm using seizure-related International Classification of Diseases-9 (ICD-9) codes, Intensive Care Unit (ICU) length of stay (LOS), and treatment protocols (e.g. benzodiazepines, anti-epileptic drugs (AEDs), and ventilator use). Secondary analyses were conducted using more restrictive algorithms for SRSE. RESULTS: A total of 6,325 hospital discharges were classified as SRSE cases from a total of 5,300,000 hospital discharges. Applying a weighting based on hospital characteristics and 2012 US demographics, this projected to an estimated 41,156 cases of SRSE in the US during 2012, an estimated incidence rate of ∼13/100,000 annually for SRSE in the US. Secondary analyses using stricter SRSE algorithms resulted in estimated incidence rates of ∼11/100,000 and 8/100,000 annually. The mean LOS for SRSE hospitalizations was 16.5 days (median =11; interquartile range [IQR] = 6-20), and the mean ICU LOS was 9.3 days (median =6; IQR =3-12). The mean cost of an SRSE hospitalization was $51,247 (median = $33,294; 95% CI = $49,634-$52,861). LIMITATIONS: The analysis uses ICD-9 diagnostic codes and claims information, and there are inherent limitations in any methodology based on treatment protocol, which created challenges in distinguishing with complete accuracy between SRSE, RSE, and SE on the basis of care patterns in the database. CONCLUSION: SRSE is associated with high mortality and morbidity, which place a high burden on healthcare resources. Projections based upon the findings of this study suggest an estimated 25,821-41,959 cases of SRSE may occur in the US each year, but more in-depth studies are required.

Sustained release veterinary parenteral products.

Controlled release parenteral dosage forms have application in veterinary medicine. Systems that minimize the need for repeated injections while achieving therapeutic effects for extended periods offer benefits that make commercial development of these products desirable. While some products have already found commercial success, others will result from application of new controlled release technologies. This review highlights the formulation and technology challenges in developing some of these controlled release technologies into products. Further, examples of application of controlled release technologies in the veterinary field are discussed.