Transient Acute Diplopia as a Rare Side Effect of Hydromorphone: A Case Report.

Diplopia, or double vision, has been listed as a rare adverse effect of intravenous hydromorphone, although there are no case studies or literature documenting this. We detail a case of acute transient diplopia correlated with the use of intraoperative hydromorphone and postoperative hydromorphone patient-controlled analgesia. Although the mechanism for this adverse effect is unknown, there may be risk factors that predispose patients to the potential toxic metabolic effects of hydromorphone. We share the first published case of diplopia as a clinically relevant adverse effect of hydromorphone and propose a potential reason behind this association.

Surgical strategies to address re-operative complex left ventricular outflow tract and thoracic aortic pathology: Cleveland Clinic children's experience.

BACKGROUND: Complex patients requiring operations on the left ventricular outflow tract, aortic valve, or thoracic aorta after previous repair of aortopathy constitute a challenging group, with limited information guiding decision-making. We aimed to use our institutional experience to highlight management challenges and describe surgical pearls to address them. METHODS: Forty-one complex patients with surgery on the left ventricular outflow tract, aortic valve, or aorta at Cleveland Clinic Children's between 2016 and 2021 following previous repair of aortic pathology were retrospectively reviewed. Patients with known connective tissue disease or single ventricle circulation were excluded. RESULTS: Median age at index procedure was 23 years (range 0.25-48) with median of 2 prior sternotomies. Previous aortic operations included subvalvular (n = 9), valvular (n = 6), supravalvular (n = 13), and multi-level surgeries (n = 13). Four deaths occurred in median follow-up of 2.5 years. Mean left ventricular outflow tract gradients improved significantly for patients with obstruction (34.9 ± 17.5 mmHg versus 12.6 ± 6.0 mmHg; p < 0.001). Technical pearls include the following: 1) liberal use of anterior aortoventriculoplasty with valve replacement; 2) primarily anterior aortoventriculoplasty following the subpulmonary conus in contrast to more vertical incision for post-arterial switch operation patients; 3) pre-operative imaging of mediastinum and peripheral vasculature for cannulation and sternal re-entry; and 4) proactive use of multi-site peripheral cannulation. CONCLUSIONS: Operation to address the left ventricular outflow tract, aortic valve, or aorta following prior congenital aortic repair can be accomplished with excellent outcomes despite high complexity. These procedures commonly include multiple components, including concomitant valve interventions. Cannulation strategies and anterior aortoventriculoplasty in specific patients require modifications.

Characterizing the anatomic spectrum, surgical treatment, and long-term clinical outcomes for patients with Shone's syndrome.

OBJECTIVE: Shone's syndrome (SS) has a varied anatomic spectrum without consensus on need and timing for mitral valve intervention (MVI). We sought to (1) characterize the anatomic spectrum and treatment pathways; (2) describe long-term outcomes and their determinants; and (3) define the impact of MVI timing on survival. METHODS: In total, 121 patients with SS who underwent operation at Cleveland Clinic between 1956 and 2021 were reviewed. Multivariable parametric hazard analyses including time-varying covariables, and modulated renewal to account for repeated events, were performed. End points included time-related survival and reintervention. RESULTS: Median follow-up was 9.9 years. Mitral stenosis (MS) (98%), coarctation (80%), and aortic stenosis (70%) predominated. The most common combination was MS + aortic stenosis + coarctation (26%). Median initial mean mitral and aortic gradients were 3.6 (15th/85th percentiles: 2.0/6.8) and 9.0 (2.1/46) mm Hg, respectively. Median initial surgery age was 0.041 (0.011/3.2) years. Initial surgeries included coarctation repair (43%), arch repair (18%), and staged biventricular repair (18%). Overall survival was 92% at 20 years. Freedom from reoperation was 66% and 24% at 1 and 20 years. Patients with no MVI or initial MVI (N = 7) tended to be associated with better early survival compared with those with MVI at subsequent operation (N = 29) (P = .06). Risk factors for early reintervention included initial Norwood operation, with younger age and arch hypoplasia increasing later reintervention. CONCLUSIONS: Despite excellent long-term survival, reoperation in SS is frequent and occurs most commonly on left ventricular outflow tract and mitral valve. Although MS is present in most, few require MVI. Delaying MVI may compromise early survival.

Ultrasonographic comparison of the lateral epicondyle in wheelchair-user (and able-bodied) tennis players: A pilot study.

Objective: To evaluate whether manual wheelchair use and wheelchair tennis are associated with increased risk of lateral epicondylosis (LE). We hypothesized that the prevalence of LE would be highest in WC tennis players, followed by tennis players, WC users, and able-bodied subjects.Study design: Prospective cross-sectional pilot study.Setting: Milwaukee VAMC (clinic), National Veterans Wheelchair Games 2016 (medical event coverage).Participants: Wheelchair users, able-bodied controls, tennis players, non-tennis players.Interventions: Subjects meeting inclusion criteria underwent ultrasound examination of the dominant elbow evaluating for characteristics of LE (n = 83).Outcome measurements: Prevalence of LE between groups. Statistical analysis included odds ratios (OR), univariate and multivariate logistic regression.Results: There was no significant difference in diagnosis of LE between groups when comparing prevalence, unadjusted odds ratios, and predicted probabilities. When adjusted for age, able-bodied controls and tennis players had a similar increase in probability of LE with age; this effect was not seen for wheelchair users. Wheelchair users diagnosed with LE on US had spent significantly more time in a wheelchair (23 vs 13 years) than those with a negative diagnosis.Conclusions: Tennis playing in able bodied controls did not increase risk of LE. In wheelchair users, tennis playing does not appear to be associated with LE, though duration of wheelchair use appears to be a significant predictor of LE.Level of evidence: Level II.

Perception of Employment by the Veterans Participating in the National Veterans Wheelchair Games: A Survey Study.

BACKGROUND: Employment in those with disability is an important rehabilitation goal, along with achieving some measure of functional independence and is at the same time one of the most difficult goals to achieve. The number of people with disabilities participating in adaptive sports has been increasing steadily over the years. A few studies have looked at the relationship between physical fitness and employment status in those with disability, but there have been no studies that focused on the results of organized adaptive sports events affecting employment outcome. OBJECTIVE: To determine whether participation in the National Veterans Wheelchair Games (NVWG) has a positive impact on employment in those with disability. STUDY DESIGN: Prospective, cross-sectional survey. SETTING: 2015 NVWG in Dallas, Texas (nonclinic setting). PARTICIPANTS: A total of 338 survey participants; 36 surveys were excluded due to incompletion. METHODS: Veterans who participated at the 2015 NVWG were given the opportunity to complete a 2-page survey. Survey participants received $5.00 gift card as compensation. MAIN OUTCOME MEASUREMENTS: Percentage of those who perceived NVWG made a difference in attaining employment, risk ratio analyses. RESULTS: A total of 50% of the participants stated that the NVWG made a difference in attaining employment. Those currently working were 1.5 times more likely to say that the NVWG had a positive effect on employment than those not currently working (P < .01). Those who felt that the NVWG had a positive effect on employment attended 3-4 more wheelchair games on average than those reporting that the NVWG did not have an impact on employment (P < .001). Positive responses were obtained from the Likert scale distribution. CONCLUSIONS: Our study suggests that participating in the NVWG provides psychosocial support to the veterans and may have a positive influence in employment outcomes. LEVEL OF EVIDENCE: III.

Somatic and Germline TP53 Alterations in Second Malignant Neoplasms from Pediatric Cancer Survivors.

Purpose: Second malignant neoplasms (SMNs) are severe late complications that occur in pediatric cancer survivors exposed to radiotherapy and other genotoxic treatments. To characterize the mutational landscape of treatment-induced sarcomas and to identify candidate SMN-predisposing variants, we analyzed germline and SMN samples from pediatric cancer survivors.Experimental Design: We performed whole-exome sequencing (WES) and RNA sequencing on radiation-induced sarcomas arising from two pediatric cancer survivors. To assess the frequency of germline TP53 variants in SMNs, Sanger sequencing was performed to analyze germline TP53 in 37 pediatric cancer survivors from the Childhood Cancer Survivor Study (CCSS) without any history of a familial cancer predisposition syndrome but known to have developed SMNs.Results: WES revealed TP53 mutations involving p53's DNA-binding domain in both index cases, one of which was also present in the germline. The germline and somatic TP53-mutant variants were enriched in the transcriptomes for both sarcomas. Analysis of TP53-coding exons in germline specimens from the CCSS survivor cohort identified a G215C variant encoding an R72P amino acid substitution in 6 patients and a synonymous SNP A639G in 4 others, resulting in 10 of 37 evaluable patients (27%) harboring a germline TP53 variant.Conclusions: Currently, germline TP53 is not routinely assessed in patients with pediatric cancer. These data support the concept that identifying germline TP53 variants at the time a primary cancer is diagnosed may identify patients at high risk for SMN development, who could benefit from modified therapeutic strategies and/or intensive posttreatment monitoring. Clin Cancer Res; 23(7); 1852-61. ©2016 AACR.