Disparities in Use of Virtual Primary Care During the Early COVID-19 Pandemic.

Background: The COVID-19 pandemic increased the use of virtual health care. However, certain factors may disparately affect some patients' utilization of virtual care. Associations between age, racial categories (White or Black), and socioeconomic disadvantage were evaluated during the early COVID-19 pandemic. Methods: This cross-sectional retrospective study included adult patients with virtual or in-person primary care encounters at a large, midwestern hospital system with widespread urban and suburban offices between March 1, 2020, and June 30, 2020. Virtual visits included synchronous video and telephone visits and asynchronous patient portal E-visits. Chi-squared tests and multivariable logistic analysis assessed the associations between ages and racial categories, and area deprivation index with the use of virtual versus in-person primary care. Results: Of 72,153 patient encounters, 43.0% were virtual visits, 54.6% were White patients, and 45.4% were Black. Across equivalent age ranges, black patients were slightly less likely to utilize virtual care than similarly aged White patients, but not consistently across virtual modalities. Women were more likely to use virtual care across all modalities, and individuals >65 years were more likely to use telephone visits and less likely to use video and E-visits, regardless of race. Patients residing in areas with the greatest socioeconomic advantage were more likely to utilize video and E-visits. Conclusions: Differential patterns of utilization emerged across racial categories and age ranges, suggesting that racial disparities are exacerbated depending upon patient age and mode of utilization.

N-acetyl-seryl-aspartyl-lysyl-proline treatment protects heart against excessive myocardial injury and heart failure in mice.

Myocardial infarction (MI) in mice results in cardiac rupture at 4-7 days after MI, whereas cardiac fibrosis and dysfunction occur later. N-acetyl-seryl-aspartyl-lysyl-proline (Ac-SDKP) has anti-inflammatory, anti-fibrotic, and pro-angiogenic properties. We hypothesized that Ac-SDKP reduces cardiac rupture and adverse cardiac remodeling, and improves function by promoting angiogenesis and inhibiting detrimental reactive fibrosis and inflammation after MI. C57BL/6J mice were subjected to MI and treated with Ac-SDKP (1.6 mg/kg per day) for 1 or 5 weeks. We analyzed (1) intercellular adhesion molecule-1 (ICAM-1) expression; (2) inflammatory cell infiltration and angiogenesis; (3) gelatinolytic activity; (4) incidence of cardiac rupture; (5) p53, the endoplasmic reticulum stress marker CCAAT/enhancer binding protein homology protein (CHOP), and cardiomyocyte apoptosis; (6) sarcoplasmic reticulum Ca2+ ATPase (SERCA2) expression; (7) interstitial collagen fraction and capillary density; and (8) cardiac remodeling and function. Acutely, Ac-SDKP reduced cardiac rupture, decreased ICAM-1 expression and the number of infiltrating macrophages, decreased gelatinolytic activity, p53 expression, and myocyte apoptosis, but increased capillary density in the infarction border. Chronically, Ac-SDKP improved cardiac structures and function, reduced CHOP expression and interstitial collagen fraction, and preserved myocardium SERCA2 expression. Thus, Ac-SDKP decreased cardiac rupture, ameliorated adverse cardiac remodeling, and improved cardiac function after MI, likely through preserved SERCA2 expression and inhibition of endoplasmic reticulum stress.

The Mediating Effect of Sleep Disturbance on the Relationship Between Nonmalignant Chronic Pain and Suicide Death.

IMPORTANCE: Few studies have examined the relationship between nonmalignant chronic pain (NMCP) and suicide death, and even fewer have specifically explored what role sleep disturbance might play in the association between NMCP and suicide death. OBJECTIVE: To assess whether sleep disturbance mediates the relationship between NMCP and suicide death. DESIGN: This case-control study included 2,674 individuals who died by suicide between 2000 and 2013 (cases) and 267,400 matched individuals (controls). SETTING: Eight Mental Health Research Network (MHRN)-affiliated healthcare systems. PARTICIPANTS: All cases and matched controls were health plan members for at least 10 months during the year prior to the index date. MAIN OUTCOMES AND MEASURES: Sociodemographic data and diagnosis codes for NMCP and sleep disorders were extracted from the MHRN's Virtual Data Warehouse. Suicide mortality was identified using International Statistical Classification of Diseases and Related Health Problems (ICD)-10 codes from official government mortality records matched to health system records. RESULTS: After accounting for covariates, there was a significant relationship between NMCP and sleep disturbance; those who were diagnosed with NMCP were more likely to develop subsequent sleep disturbance. Similarly, sleep disturbance was significantly associated with suicide death. Finally, a significant indirect effect of NMCP on suicide death, through sleep disturbance, and a nonsignificant direct effect of NMCP on suicide death provide support for a fully mediated model. CONCLUSIONS AND RELEVANCE: There is a need for clinicians to screen for both sleep disturbance and suicidal ideation in NMCP patients and for health systems to implement more widespread behavioral treatments that address comorbid sleep problems and NMCP.

The advantages of tomosynthesis for evaluating bisphosphonate-related atypical femur fractures compared to radiography.

OBJECTIVE: To investigate the advantages of using tomosynthesis (TS) compared to radiographs in the detection, characterization, and follow-up of bisphosphonate-related atypical femur fractures (BP-AFF). SUBJECTS AND METHODS: Eight patients were identified retrospectively who underwent TS for radiographic findings suspicious for BP-AFF. Two radiologists independently interpreted 15 radiographs and 16 TS examinations, indicating the presence or absence of the following: (1) cortical "beaking" on radiographs, (2) radiolucent fracture line on radiographs, and (3) fracture lucency on TS corresponding to the site of radiographic abnormality. Radiation dose data were calculated for radiographs and TS using Monte Carlo analysis. RESULTS: There was agreement on 100 % of radiographs regarding the presence or absence of a cortical beak. Regarding the presence or absence of a fracture lucency, there was agreement on 100 % of TS examinations (Kappa = 1.0) and 73 % of radiographs (Kappa = 0.40 ± 0.24). For the 46 % of radiographs in which one or both radiologists did not visualize a fracture line, there was 100 % agreement for the presence of a fracture line on the corresponding TS. The interobserver agreement for fracture line detection was significantly higher for TS than for radiographs (p = 0.012). The effective radiation dose using TS was approximately 96 % lower compared to radiography. CONCLUSION: TS outperformed radiographs in the detection and characterization of BP-AFF. TS may also have advantages over radiography for BP-AFF follow-up through its unique ability to visualize fracture healing with lower effective radiation doses to the patient.

Predictors of repeated "no-showing" to clinic appointments.

OBJECTIVE: To determine the variables that contribute to repeated patient non-compliance with showing up to clinic appointments. STUDY DESIGN: Retrospective chart review. SETTING: Single tertiary care academic institution. SUBJECTS AND METHODS: Patients who did not show up to 3 or more clinic appointments in the otolaryngology department in the Henry Ford Health System in metro Detroit, Michigan between July 1, 2011 to June 30, 2012 area were compared to control patients randomly chosen from those who had appointments on the same day with the same provider as the no-show patients. RESULTS: 105 patients were identified who no-showed to 3 or more clinic appointments. Younger age, black race, and lower income were all found to be significant factors for patients missing appointments in a multiple variate model. On logistic regression, Medicaid insurance, closer distance from home to appointment, less bus transfers, and less time by bus travel were also found to correlate with no-showing. CONCLUSION: Age, race, and income are significantly related to patient non-compliance with clinic appointments. Paradoxically, proximity to the clinical appointment location is also significantly related - we hypothesize this may be the result of significant income inequality in the metro Detroit population distribution. Follow up studies include analyzing factors that precluded patient access and interventions to improve compliance and decrease cost.

The effect of insomnia on tinnitus.

OBJECTIVE: The objective is to see how chronic tinnitus sufferers who are unmanageable to maximized medical therapy can benefit by decreasing their subjective complaints from a sleep evaluation and treatment. However, the proper identification of these particular patients has not been described well in the literature when attempting to correlate these 2 diagnoses. Thus, tinnitus patients with and without insomnia, based on ICD-9 diagnosis, were evaluated using the Tinnitus Reaction Questionnaire and Insomnia Severity Index to determine correlations between insomnia and tinnitus. METHODS: Patients with a diagnosis of tinnitus and tinnitus along with insomnia who were treated at our institution from 2009 to 2011 were identified. Tinnitus Reaction Questionnaire and Insomnia Severity Index responses were obtained through written and telephone interviews. A Pearson product moment correlation was used to determine the effect of insomnia on tinnitus. Additional analyses identified whether Tinnitus Reaction Questionnaire scores were associated with a possible benefit from an evaluation for insomnia in tinnitus patients. RESULTS: A total of 117 patients met inclusion criteria. A significant correlation was found between the Insomnia Severity Index score and Tinnitus Reaction Questionnaire severity (r = 0.64; P = .001). Tinnitus Reaction Questionnaire severity was shown to be a good predictor of sleep disturbance and good in predicting group association, especially the "emotional" subscore component (sensitivity 96.9% and specificity 55.3% for identifying tinnitus patients with insomnia). The greater the insomnia disability as exhibited by an elevated Insomnia Severity Index score, the more severe the patient's complaints were regarding the tinnitus. CONCLUSION: Results suggest that if the emotional score on the Tinnitus Reaction Questionnaire is ≥ 15, the Insomnia Severity Index may be useful to identify patients who may benefit from further treatment and evaluation of insomnia. The robust correlation between the Tinnitus Reaction Questionnaire and Insomnia Severity Index objectively showed that patients with insomnia have an increased emotional distress associated with their tinnitus. Both questionnaires can be used together with a high degree of specificity and sensitivity in predicting tinnitus patients with an underlying sleep disturbance.

Comparison of hemodynamic and stress testing variables in patients undergoing regadenoson stress myocardial perfusion imaging to regadenoson with adjunctive low-level exercise myocardial perfusion imaging.

BACKGROUND: Regadenoson (REG), a selective adenosine A2a receptor agonist, is becoming the preferred pharmacologic agent for stress myocardial perfusion imaging (MPI). Hemodynamic and stress variables, immediate safety and use of aminophylline when using REG combined with low-level exercise (REG WALK MPI) compared with REG MPI, have not been well studied and formed the basis of our study. METHODS: Retrospective evaluation of patients who underwent REG MPI (n = 887) was compared to patients undergoing REG WALK MPI (n = 485) from January to November 2009. Patient demographics, hemodynamic parameters, REG MPI data, side effects, immediate major clinical events, and use of aminophylline were evaluated. RESULTS: Patients in REG WALK MPI group tended to be younger, male and obese compared to patients in REG MPI group. REG WALK MPI patients had higher stress heart rate (103 ± 20.5 vs 84 ± 19 bpm, P = .001), higher heart rate reserve (36.3 ± 19 vs 14.7 ± 15.5 bpm, P < .001), and greater systolic blood pressure rise (4.8 ± 21.3 vs -8.9 ± 19.8 mm Hg, P < .001), compared to REG MPI patients. No major adverse events were reported immediately after REG WALK MPI. There were no differences in drug-related side effects in between the two groups; however, the use of aminophylline was lower in REG WALK MPI Group (5.6% vs 11.4%, P = .001). CONCLUSION: REG WALK MPI gives more favorable hemodynamic response with lesser use of aminophylline and no increase in adverse events when compared with REG MPI.

Treatment with N-acetyl-seryl-aspartyl-lysyl-proline prevents experimental autoimmune myocarditis in rats.

Myocarditis is commonly associated with cardiotropic infections and has been linked to development of autoimmunity. N-acetyl-seryl-aspartyl-lysyl-proline (Ac-SDKP) is a naturally occurring tetrapeptide that prevents inflammation and fibrosis in hypertension and other cardiovascular diseases; however, its effect on autoimmune-mediated cardiac diseases remains unknown. We studied the effects of Ac-SDKP in experimental autoimmune myocarditis (EAM), a model of T cell-mediated autoimmune disease. This study was conducted to test the hypothesis that Ac-SDKP prevents autoimmune myocardial injury by modulating the immune responses. Lewis rats were immunized with porcine cardiac myosin and treated with Ac-SDKP or vehicle. In EAM, Ac-SDKP prevented both systolic and diastolic cardiac dysfunction, remodeling as shown by hypertrophy and fibrosis, and cell-mediated immune responses without affecting myosin-specific autoantibodies or antigen-specific T cell responses. In addition, Ac-SDKP reduced cardiac infiltration by macrophages, dendritic cells, and T cells, pro-inflammatory cytokines [interleukin (IL)-1α, tumor necrosis factor-α, IL-2, IL-17] and chemokines (cytokine-induced neutrophil chemoattractant-1, interferon-γ-induced protein 10), cell adhesion molecules (intercellular adhesion molecule-1, L-selectin), and matrix metalloproteinases (MMP). Ac-SDKP prevents autoimmune cardiac dysfunction and remodeling without reducing the production of autoantibodies or T cell responses to cardiac myosin. The protective effects of Ac-SDKP in autoimmune myocardial injury are most likely mediated by inhibition of 1) innate and adaptive immune cell infiltration and 2) expression of proinflammatory mediators such as cytokines, chemokines, adhesion molecules, and MMPs.

Changes in Nasal Staphylococcus Colonization and Infection Rates After Nasal Surgery.

Background: The relationship between nasal flora and infection rates in patients undergoing nasal surgery is of interest. This relationship has been studied though changes that may take place due to surgery have never been elucidated. Objective: To assess colonization rates and changes in colonization patterns of methicillin-resistant or methicillin-sensitive Staphylococcus aureus (MRSA/MSSA) in nasal flora in patients undergoing nasal surgery and to determine whether colonization is a risk factor for postoperative infection. Methods: Patients undergoing nasal surgery including septoplasty, rhinoplasty, or nasal valve repair were recruited prospectively. Patients completed a survey preoperatively concerning risk factors of postoperative infection. Nasal swabs and cultures were done preoperatively and at 1 week postoperatively. Patients were assessed for surgical site infections postoperatively. Results: Fifty-five patients completed both preoperative and postoperative nasal swabs. Preoperative to postoperative colonization rates increased for MRSA (2-5%) and MSSA (22-36%). Of the 55 patients, 11 had a change in nasal flora postoperatively, 9 of whom were colonized with a Staphylococcus aureus strain. However, MSSA/MRSA colonization either preoperatively or postoperatively was not associated with surgical site infections. Gender was the only variable found to be associated with postoperative infection (p = 0.007) with all four infections occurring in females. Conclusions: MSSA and MRSA do not appear to be major risk factors for surgical site infection in nasal surgery, whereas prior nasal surgery is a risk factor. This is the first report of a change in nasal colonization after nasal surgery. This could have implications for antibiotic prophylaxis in select nasal surgery cases.

Interobserver and Intraobserver Variability in the CT Assessment of COVID-19 Based on RSNA Consensus Classification Categories.

PURPOSE: To assess the interobserver and intraobserver agreement of fellowship trained chest radiologists, nonchest fellowship-trained radiologists, and fifth-year radiology residents for COVID-19-related imaging findings based on the consensus statement released by the Radiological Society of North America (RSNA). METHODS: A survey of 70 chest CTs of polymerase chain reaction (PCR)-confirmed COVID-19 positive and COVID-19 negative patients was distributed to three groups of participating radiologists: five fellowship-trained chest radiologists, five nonchest fellowship-trained radiologists, and five fifth-year radiology residents. The survey asked participants to broadly classify the findings of each chest CT into one of the four RSNA COVID-19 imaging categories, then select which imaging features led to their categorization. A 1-week washout period followed by a second survey comprised of randomly selected exams from the initial survey was given to the participating radiologists. RESULTS: There was moderate overall interobserver agreement in each group (κ coefficient range 0.45-0.52 ± 0.02). There was substantial overall intraobserver agreement across the chest and nonchest groups (κ coefficient range 0.61-0.67 ± 0.06) and moderate overall intraobserver agreement within the resident group (κ coefficient 0.58 ± 0.06). For the image features that led to categorization, there were varied levels of agreement in the interobserver and intraobserver components that ranged from fair to perfect kappa values. When assessing agreement with PCR-confirmed COVID status as the key, we observed moderate overall agreement within each group. CONCLUSION: Our results support the reliability of the RSNA consensus classification system for COVID-19-related image findings.

Sentinel vascular access monitoring after endovascular intervention predicts access outcome.

BACKGROUND AND OBJECTIVES: The vascular access pressure ratio test identifies dialysis vascular access dysfunction when three consecutive vascular access pressure ratios are >0.55. We tested whether the magnitude of the decline in vascular access pressure ratio 1-week post-intervention could alert of subsequent access failure. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: The retrospective study included all vascular access procedures at one institution from March 2014 to June 2016. Data included demographics, comorbidities, vascular access features, %ΔVAPR = ((Pre-Post)/Pre] × 100% assessed within the first 2 weeks post-percutaneous transluminal balloon angioplasty, time-to-next procedure, and patency. The log-rank test compared the area under the curve, receiver operating curve, Kaplan-Meier arteriovenous graft and arteriovenous fistula survival curves. A multivariable Cox proportional hazard (CP) model was used to determine the association of %ΔVAPR with access patency. RESULTS: Analysis of 138 subjects (females 51%; Black 87%) included 64 arteriovenous fistulas with 104 angioplasties and 74 arteriovenous grafts with 134 angioplasties. The area under the receiver operating characteristic curve for fistula failure at 3 months was 0.59, with optimal screening characteristics of 33.3%, sensitivity of 56.1%, and specificity of 63.2%. Arteriovenous fistula with <33.3% decline compared to >33.3% required earlier subsequent procedure (136 vs 231 days), lower survival on Kaplan-Meier analysis (P = 0.01), and twofold greater risk of failure (P = .006). Area under the receiver operating characteristic for arteriovenous graft failure at 3 months had a sensitivity of 52.3% and specificity of 67.4%. Arteriovenous graft with a post-intervention vascular access pressure ratio decline of <28.8% also required earlier subsequent procedure (144 vs 189 days), lower survival on Kaplan-Meier (P = 0.04), and a 59% higher risk for failure. The area under the receiver operating characteristic curve for combined access failure (arteriovenous fistula + arteriovenous graft) at 3 months had an optimal cut-point value of 31.2%, a sensitivity of 54.6%, and a specificity of 63.1%. Access with a <31.2% drop had a 62% increase in the risk of failure (hazard ratio 1.62; confidence interval 1.16, 2.27; P = 0.005). CONCLUSION: The magnitude of post-intervention reduction in vascular access pressure ratio provides a novel predictive measure of access outcomes.

Transcatheter Aortic Valve Replacement: Comparing Transfemoral, Transcarotid, and Transcaval Access.

BACKGROUND: Despite newer-generation valves using smaller-sized sheaths, 10% to 20% of patients undergoing transcatheter aortic valve replacement (TAVR) require nonfemoral artery access for valve delivery. To avoid a transthoracic procedure, we have used transcarotid (TC) and transcaval (TCav) approaches in these patients. This study compared the results of a contemporary experience with transfemoral (TF), TC, and TCav approaches. METHODS: Between January 2015 and March 2017, 491 patients underwent TAVR at our institution, of which 463 were included in this analysis. Valve delivery was TF in 373 patients, TCav in 58, and TC in 32. Patient characteristics and outcomes, including 1-year survival, were compared. RESULTS: Preoperative demographics and postoperative outcomes were similar for the three groups with several exceptions. TCav patients had higher The Society of Thoracic Surgeons risk score than TF patients (8.0 ± 5.2 vs 6.1 ± 4.3, p = 0.004). Lung disease, cerebrovascular disease, and peripheral vascular disease were more common in TC and TCav patients. Median length of stay was 2 days for TF, 3 days for TC, and 4 days for TCav (TF vs TCav, p = 0.001). Procedural mortality, percentage discharged home, and the 30-day readmission rate were similar for all. Unadjusted Kaplan-Meier survival was also similar at 1 year (TF, 86%; TC, 83%; TCav, 80%). CONCLUSIONS: Patients unsuitable for TF TAVR treated with TC or TCav access had 30-day/in-hospital and 1-year survival similar to a contemporary cohort undergoing TF access. Avoiding surgical entry to the chest may offer procedural and intermediate-term outcomes equivalent to TF TAVR.

The Role of Tonsillectomy in Adults with Tonsillar Hypertrophy and Obstructive Sleep Apnea.

Objective To determine if tonsillectomy alone is an effective treatment in improving obstructive sleep apnea in adult subjects with tonsillar hypertrophy and to evaluate the effect of tonsillectomy on patient-reported quality-of-life indices. Study Design Case series with planned data collection. Setting Academic hospital. Subjects and Methods Thirty-four subjects completed enrollment and intervention from January 2011 to January 2016. Subjects completed pre- and postoperative quality-of-life questionnaires, including the Insomnia Severity Index, Epworth Sleepiness Scale, and the Functional Outcomes of Sleep Questionnaire-10. Surgical response to treatment was defined by a >50% decrease in the Apnea-Hypopnea Index and a decrease in the overall Apnea-Hypopnea Index to <20. Wilcoxon matched-pairs signed-rank tests were used to test each variable to assess for a change from pre- to postintervention. Subjects were then split into 3 BMI subgroups, with results also evaluated by Wilcoxon matched-pairs signed-rank tests. Results There was a significant difference discovered between the mean preoperative Apnea-Hypopnea Index of 31.57 and the mean postoperative value of 8.12 ( P < .001). All patient-reported outcomes improved significantly following tonsillectomy. After stratifying all outcome variables (Apnea-Hypopnea Index, Epworth Sleepiness Scale, Insomnia Severity Index, and Functional Outcomes of Sleep Questionnaire-10) by sex, race, and tonsil size, no statistically significant difference was noted among any of these subgroups. There was a 78% surgical response to treatment. Conclusion Tonsillectomy appears to be an effective treatment for obstructive sleep apnea in a select population of adults with tonsillar hypertrophy.

A study of otolaryngology resident quality of life and sleepiness.

OBJECTIVES: This study aimed to determine otolaryngology residents' quality of life and sleepiness. METHODS: An electronic survey was distributed to otolaryngology residents in the United States in October 2014 and May 2015. The survey included questions from the Physician Well-Being Index (PWBI) and Epworth Sleepiness Scale (ESS). Data were analyzed using standard descriptive and frequency analyses, Spearman correlations, and Student's t-test. RESULTS: The 196 respondents (13% response rate) had a mean age of 29.9 years and worked an average of 70.88 hours/week. Higher PWBI score (lower quality of life) correlated with higher ESS (more sleepiness) for all respondents regardless of rotation (Spearman coefficient of .45; p = .001). PWBI scores were higher for head/neck oncology. Both PWBI and ESS scores were highest for postgraduate year two. PWBI showed a significant positive correlation with hours worked (correlation coefficient .35; p = .001) as well as a significant negative correlation with exercise time (correlation coefficient -.18; p = .010). There was a positive correlation between hours worked and ESS (correlation coefficient .48; p = .001). CONCLUSION: For the otolaryngology survey respondents, sleepiness and overall well-being were better during the first year with a dramatic worsening during junior years followed by an improvement in the senior years. More work hours and poor quality of life was associated with less physically active residents. Focused interventions during these rotations may reduce distress, improve quality of life, and enhance learning. LEVEL OF EVIDENCE: NA.

Bleeding risk associated with resection of the middle turbinate during functional endoscopic sinus surgery.

BACKGROUND: The decision to resect the middle turbinate (MT) during functional endoscopic sinus surgery is controversial. Although there have been a variety of studies that examined the functional outcome related to this maneuver, very few studies evaluated the potential for complications, in particular, epistaxis. OBJECTIVE: We sought to determine if resection of the MT during functional endoscopic sinus surgery leads to an increased risk for postoperative bleeding. METHODS: Patients who underwent functional endoscopic sinus surgery for chronic sinusitis or nasal polyposis between 2004 and 2014 at a single institution were analyzed for bleeding and other complications after resection of the MT. RESULTS: Between 2004 and 2014, 1185 sinus surgeries were performed by 18 surgeons. A propensity matched set of 228 patients who underwent turbinate resection, and 228 controls were selected based on predicted probabilities from a logistic regression that predicted turbinate resection and that was adjusted for age, sex, and procedure. There were 89 patients with bilateral turbinates removed and 139 with unilateral turbinates removed. There was no significant difference in major bleeding or other complication rates between the two groups. Patients who underwent resection of at least one MT were 3.95 times more likely to have minor bleeding compared with those who did not; this risk increased with the number of turbinates resected (trend p = 0.008). Patients on anticoagulation medications were at a significant risk of bleeding if their MT was removed (p = 0.007), whereas patients on aspirin or antiplatelet therapy were not at a significant risk. CONCLUSION: There was no increased risk of major bleeding or other complication associated with resection of the MT. However, there was a significantly increased minor bleeding rate associated with MT resection, particularly if the patient was on anticoagulants.

Effect of Body Mass Index on Blood Transfusion in Total Hip and Knee Arthroplasty.

Perioperative blood management remains a challenge during total hip arthroplasty (THA) and total knee arthroplasty (TKA). The purpose of this study was to systematically examine the relationship between body mass index (BMI) and perioperative blood transfusion during THA and TKA while attempting to resolve conflicting results in previously published studies. The authors retrospectively evaluated 2399 patients, 896 of whom underwent THA and 1503 of whom underwent TKA. Various outcome variables were assessed for their relationship to BMI, which was stratified using the World Health Organization classification scheme (normal, <25 kg/m(2); overweight, 25-30 kg/m(2); obese, >30 kg/m(2)). Among patients undergoing THA, transfusion rates were 34.8%, 27.6%, and 21.9% for normal, overweight, and obese patients, respectively (P=.002). Among patients undergoing TKA, transfusion rates were 17.3%, 11.4%, and 8.3% for normal, overweight, and obese patients, respectively (P=.002). Patients with an elevated BMI have decreased rates of blood transfusion following both THA and TKA. This same cohort also loses a significantly decreased percentage of estimated blood volume. No trends were identified for a relationship between BMI and deep venous thrombosis, pulmonary embolism, myocardial infarction, discharge location, length of stay, 30-day readmission rate, and preoperative hemoglobin level. Elevated BMI was significantly associated with increased estimated blood loss in patients undergoing THA and those undergoing TKA. There was a statistically significant trend toward increased deep surgical-site infection in patients undergoing THA (P=.043). Patients with increased BMI have lower rates of blood transfusion and lose a significantly smaller percentage of estimated blood volume following THA and TKA. [Orthopedics.2016; 39(5):e844-e849.].

Clinical predictors of abnormal magnetic resonance imaging findings in patients with asymmetric sensorineural hearing loss.

IMPORTANCE: Asymmetric sensorineural hearing loss (ASNHL) is commonly encountered in an otolaryngologic clinical practice. Determining what factors are associated with abnormal magnetic resonance imaging (MRI) findings will help with diagnostic workup. OBJECTIVE: To evaluate the association between clinical and audiometric factors and abnormal MRI findings in patients with ASNHL. DESIGN, SETTING, AND PARTICIPANTS: Retrospective medical record review from an urban, tertiary referral center of 451 patients with ASNHL who underwent MRI testing between January 2005 and December 2011. MAIN OUTCOMES AND MEASURES: Medical records were reviewed for audiometric parameters as well as clinical presentation and compared with MRI results, which were categorized as abnormal, normal, or incidental. Data analysis included χ2 tests, logistic regression analysis, and multivariate analysis. RESULTS: A total of 48 patients (10.6%) had abnormal MRI findings. Only 21 patients (4.7%) had a mass of the cerebellopontine angle/internal auditory canal on MRI, making up 40% of all abnormal MRI findings. The next most common MRI finding was labyrinthitis (n = 13; 25%). Vertigo/dizziness (n = 20; P = .01), tinnitus (n = 18; P = .02), sudden hearing loss (n = 15; P = .054), and 15-dB asymmetry at 3 kHz (n = 39; P = .01) were associated with abnormal MRI findings. Loud noise exposure was associated with normal MRI findings. Logistic regression analysis showed that vertigo/dizziness (odds ratio [OR], 2.14; 95% CI, 1.15-3.96; P = .02), unilateral tinnitus (OR, 2.15; 95% CI, 1.14-4.03; P = .02), and 15-dB asymmetry at 3 kHz (OR, 2.62; 95% CI, 1.24-5.57; P = .01) were significantly associated with abnormal MRI findings. Multivariate analysis showed that only 15-dB asymmetry at 3 kHz (OR, 2.42; 95% CI, 1.07-5.50; P = .03) was significantly associated with an abnormal MRI finding. CONCLUSIONS AND RELEVANCE: This study found that asymmetry of 15 dB at 3 kHz on audiometry was associated with higher positive yield on use of MRI in evaluating patients with ASNHL. We recommend that patients who present with ASNHL with this audiometric characteristic undergo MRI as part of their diagnostic workup.

Snoring and carotid artery intima-media thickness.

OBJECTIVES/HYPOTHESIS: A growing body of evidence indicates that primary snoring (PS) may be the initial presentation of sleep-disordered breathing and can adversely affect an individual's health. Individuals with the sole diagnosis of PS were evaluated to determine if a relationship exists between snoring and thickening of the intima media of the carotid arteries. STUDY DESIGN: Cross-sectional study. METHODS: Our institution's sleep center database identified patients aged 18 to 50 years who had a diagnostic sleep study with apnea-hypopnea index <5 between December 2006 and January 2012. Subjects underwent a diagnostic carotid artery duplex ultrasound measuring the intima-media thickness (IMT) of the bilateral carotid arteries at four separate points. A validated Snoring Outcomes Survey (SOS) was completed and used to categorize snorers and nonsnorers. Groups were compared using a Student t test. RESULTS: Of 913 patients who met inclusion criteria, 54 patients completed both the carotid duplex ultrasound and SOS. There were no statistically significant differences in IMT for the groups defined by smoking or diabetes. Compared to nonsnorers, snorers were found to have a significantly greater IMT at two points along the left internal carotid artery and one point on the right side. When considering all eight points, IMT was significantly greater in snorers. CONCLUSIONS: This study shows a relationship between PS and IMT of the carotid arteries. Given the well-described relationship between increased carotid IMT and serious health conditions, nonapneic snoring may be a precursor to changes of the carotid artery intima and should be further investigated. LEVEL OF EVIDENCE: 3b.