Empowering Psychiatric Inpatients to Vote: Perceptions of Voting and the Barriers Encountered.

Individuals with psychiatric illness believe that voting is important. However, these individuals have lower rates of voting when compared to the general population. A survey of psychiatrically hospitalized adult patients was conducted to assess perceptions of and barriers to voting in patients with psychiatric illness. Data from 113 surveys was analyzed. A majority of survey participants agreed that they cared about voting, that their vote made a difference, and that their vote was important. 74% of individuals reported previously experiencing at least one barrier when exercising their right to vote. The most commonly experienced barriers reported were not having enough information to make an informed choice, not knowing where to vote, not having transportation, and not being registered to vote. Individuals who encountered a higher number of barriers in the past had a higher chance of encountering barriers more often. In conclusion, a high percentage of individuals with mental illness severe enough to warrant hospitalization have experienced barriers to voting, with many experiencing multiple barriers. Reduction of these barriers is important, as voting and the resultant public policies can directly affect this population's mental health and access to both mental and physical healthcare services.

Opioid versus non-opioid postoperative pain management in otolaryngology.

BACKGROUND: The opioid epidemic in the United States has had devastating consequences, with many opioid-related deaths and a significant economic toll. Opioids have a significant role in postoperative pain management. Here we aim to analyze differences in postoperative opioid and non-opioid pain medications regimens following common otolaryngological surgeries between two large tertiary care medical centers: the Milton S. Hershey Medical Center, USA (HMC) and The Chaim Sheba Medical center, Israel (SMC). METHODS: A retrospective chart review of patients undergoing common otolaryngological procedures during the years 2017-2019 was conducted at two tertiary care centers, one in the U.S. and the other in Israel. Types and doses of postoperative pain medications ordered and administered during admission were analyzed. Average doses ordered and administered in 24 h were calculated. Opioid medications were converted to a standardized unit of morphine milliequivalents (MME). Chi-square test and Wilcoxon rank-sum test were used to compare the groups. RESULTS: The study included 204 patients (103 U.S., 101 Israel). Patient demographics were similar except for a longer length of stay in Israel (p < 0.01). In the U.S., 95% of patients were ordered opioids compared to 70% in Israel (P < 0.01). In the U.S., 68.9% of patients ordered opioids received the medications compared to 29.7% in Israel. The median opioid dose ordered in the U.S. was 45MME/24 h compared to 30MME/24 h in Israel (P < 0.01), while median dose received in the U.S. was 15MME/24 h compared to 3.8MME/24 h in Israel (P < 0.01). Opioid prescriptions at discharge were given to 92% of patients in the U.S. compared to 4% of patients in Israel (p < 0.01). A significantly higher number of patients in the U.S. were prescribed acetaminophen and ibuprofen (p < 0.0001). Dipyrone was prescribed to 78% of patients in Israel. CONCLUSIONS: HMC demonstrated a significantly more permissive approach to both prescribing and consuming opioid medications for postoperative pain management than SMC for similar, common otolaryngological surgeries. Non-opioid alternatives and examining the cultural and medical practice-based differences contributing to the opioid epidemic should be discussed and reevaluated.

Characteristics and Outcomes of Intrahospital Transfers from Neonatal Intensive Care to Pediatric Intensive Care Units.

OBJECTIVE: Critically ill children may be transferred from the neonatal intensive care unit (NICU) to the pediatric intensive care unit (PICU) for further critical care, but the frequency and outcomes of this patient population are unknown. The aims of this study are to describe the characteristics and outcomes in patients transferred from NICU to PICUs. We hypothesized that a higher-than-expected mortality would be present for patients with respiratory or cardiovascular diagnoses that underwent a NICU to PICU transition and that specific factors (timing of transfer, illness severity, and critical care interventions) are associated with a higher risk of mortality in the cardiovascular group. STUDY DESIGN: Retrospective analysis of Virtual Pediatric Systems, LLC (2011-2019) deidentified cardiovascular and respiratory NICU to PICU subject data. We evaluated demographics, PICU length of stay, procedures, disposition, and mortality scores. Pediatric Index of Mortality 2 (PIM2) score was utilized to determine the standardized mortality ratio (SMR). RESULTS: SMR of 4,547 included subjects (3,607 [79.3%] cardiovascular and 940 [20.7%] respiratory) was 1.795 (95% confidence interval: 1.62-1.97, p < 0.0001). Multivariable logistic regression analysis demonstrated transfer age (cardiovascular: odds ratio, 1.246 [1.10-1.41], p = 0.0005; respiratory: 1.254 [1.07-1.47], p = 0.0046) and PIM2 scores (cardiovascular: 1.404 [1.25-1.58], p < 0.0001; respiratory: 1.353 [1.08-1.70], p = 0.0095) were significantly associated with increased odds of mortality. CONCLUSION: In this present study, we found that NICU to PICU observed deaths were high and various factors, particularly transfer age, were associated with increased odds of mortality. While the type of patients evaluated in this study likely influenced mortality, further investigation is warranted to determine if transfer timing is also a factor. KEY POINTS: · NICU patients may be transitioned to the PICU.. · NICU to PICU observed deaths were high.. · Transfer timing may be a factor..

Promoting Health Equity Through Voter Support Activities for the Inpatient Psychiatric Population.

Individuals with mental illness often face barriers to voting. One of the primary barriers is not being registered to vote. This paper describes voter support activities (VSAs) provided to hospitalized adults on the acute inpatient psychiatric units at Pennsylvania Psychiatric Institute. During the six weeks preceding the 2020 general election, adult inpatients were offered six VSAs and an optional survey examining previous voting behaviors and barriers encountered to voting. VSAs included checking voter registration status and polling location, completing a paper or electronic voter registration application, and requesting a mail-in ballot. Of 189 patients approached, 119 individuals participated in the survey and 60 individuals utilized at least one VSA. This project demonstrates that VSAs are a welcome and feasible resource for psychiatrically hospitalized adults. Psychiatric providers can serve an important role in promoting access to voting-related activities for their patients.

Rate of Rise of Platelet Count After IVIG for Pediatric Immune Thrombocytopenia.

Immune thrombocytopenia (ITP) is an autoimmune disease causing platelet destruction, and is a common cause of symptomatic thrombocytopenia in children. Intravenous immune globulin (IVIG) is a treatment for ITP that increases the platelet counts of most patients within 24 to 48 hours. This study aimed to calculate the rate of rise in pediatric ITP after a dose of IVIG and to analyze if patient characteristics affected the rate. For 116 children treated for ITP with IVIG at Hershey Medical Center, the rate of rise of the platelet count for all patients was calculated. The rate of rise ranged from -0.1 to +4.2 K/µL/hour (average 1.3, median 1.2). 78% of patients had a rate of rise of over 0.5 K/µL/hour. There was a statistically significant correlation between the rate rise of the platelet count and the initial platelet count (P=0.0197), but rate was not affected by age or sex. This study was able to demonstrate that IVIG is effective in most patients and that demographic features do not affect the rate of rise. By providing a nomogram showing when to expect a meaningful rise in the platelet count after IVIG, we give guidance for timing of the postinfusion platelet count to avoid administering a second dose. Future studies are needed to test this nomogram prospectively.

Postoperative Urinary Complications in Head and Neck Free Flap Reconstructive Surgery.

OBJECTIVE: The purpose of this study is to evaluate the postoperative urinary complications and the optimal timing of foley catheter removal in patients who underwent free flap reconstructive surgery for head and neck pathology. METHODS: A retrospective case-control study of head and neck patients who underwent free flap reconstructive surgery at a single institution between January 2009 and December 2021 was conducted. Patient risk factors for postoperative urinary retention (POUR) were analyzed. Fisher Exact and Wilcoxon Rank Sum tests were used to evaluate rates of foley replacement, straight catheterization, and catheter-associated urinary tract infection (CAUTI) and associated risk factors. RESULTS: Two hundred and eleven patients were included in this study. Older age, lower BMI, lower intraoperative fluid volumes, and need for straight catheterization were statistically significant for POUR requiring foley replacement. Shorter total (P = .04) and postoperative (P = .01) foley duration showed statistical significance for POUR requiring straight catheterization. About 60% of patients who had straight catheterization required a foley replacement (P < .001). Only one patient (0.5%) developed a urinary tract infection (UTI). CONCLUSION: Foley catheter duration impacts the risk of POUR requiring straight catheterization and subsequently, foley replacement. Optimal timing for foley catheter removal in the postoperative period remains to be elucidated. Removal of catheters between 21 and 48 hours after surgery may decrease the risk of POUR without increasing the rate of CAUTI in patients with head and neck pathology undergoing free flap reconstructive surgery.

Evaluating the Effect of Maternal Opioid Maintenance Dose on the NOWS-COS Outcome Criteria: A Pilot Study.

This retrospective cohort study included 77 mother-infant dyads that delivered term pregnancies at a single tertiary care institution. The primary objective was to investigate whether maternal dose of opioid maintenance therapy during pregnancy affects infant outcomes. All infants had prenatal exposure to opioid maintenance therapies. Maternal dose was converted into morphine milligram equivalents (MMEs) and stratified into high- (MME >1000 mg) and low-dose groups (MME ≤1000 mg). Associations between infant outcomes and MME dosage were examined using Wilcoxon rank-sum and Fisher's Exact tests. Days to symptom control were significantly higher in the high MME group (5 days vs 2.8 days, P = .016). Rates of developmental delay at 24 months were higher in the high MME group (21.2% vs 4.5%, P = .0335). Maternal MME did not predict need for NOWS treatment. Higher MME-exposed infants should have optimized nonpharmacologic interventions for consolation and be increasingly observed for signs of developmental delay.

Elucidating survival and functional outcomes in patients with primary head and neck malignancies treated in academic versus community settings.

BACKGROUND: Differences in treatment outcomes between community or academic centers are incompletely understood. METHODS: Retrospective review of head and neck cancer patients between 2010 and 2020 in a rural health region. Kaplan-Meier curves and log-rank tests were used to evaluate survival outcomes, along with bivariate and multivariable Cox proportional hazards models. Linear regression was used for functional outcomes of tracheotomy and gastrostomy tube dependence. RESULTS: Two hundred and forty-eight patients treated at an academic center were compared with 94 patients treated in community centers. In multivariable analysis, the risk of death (HR = 0.60, p = 0.019), and risk of recurrence were lower (HR = 0.29, p < 0.001) for patients treated in academic centers. Patients treated in community centers had longer gastrostomy tube dependence (p = 0.002). CONCLUSION: Our findings suggest that treatment at an academic center was associated with a lower risk of recurrence and shorter gastrostomy tube dependence compared to treatment in the community.

Importance of Genetic Testing in Children With Generalized Epilepsy.

INTRODUCTION: Epilepsy is a neurological disorder characterized by the predisposition for recurrent unprovoked seizures. It can broadly be classified as focal, generalized, unclassified, and unknown in its onset. Focal epilepsy originates in and involves networks localized to one region of the brain. Generalized epilepsy engages broader, more diffuse networks. The etiology of epilepsy can be structural, genetic, infectious, metabolic, immune, or unknown. Many generalized epilepsies have presumed genetic etiologies. The aim of this study is to compare the role of genetic testing to brain MRI as diagnostic tools for identifying the underlying causes of idiopathic (genetic) generalized epilepsy (IGE). METHODS:  We evaluated the diagnostic yield of these two categories in children diagnosed with IGE. Data collection was completed using ICD10 codes filtered by TriNetX to select 982 individual electronic medical records (EMRs) of children in the Penn State Children's Hospital who received a diagnosis of IGE. The diagnosis was confirmed after reviewing the clinical history and electroencephalogram (EEG) data for each patient. RESULTS: From this dataset, neuroimaging and genetic testing results were gathered. A retrospective chart review was done on 982 children with epilepsy, of which 143 (14.5%) met the criteria for IGE. Only 18 patients underwent genetic testing. Abnormalities that could be a potential cause for epilepsy were seen in 72.2% (13/18) of patients with IGE and abnormal genetic testing, compared to 30% (37/123) for patients who had a brain MRI with genetic testing. CONCLUSION: This study suggests that genetic testing may be more useful than neuroimaging for identifying an etiological diagnosis of pediatric patients with IGE.

Double-Versus Single-Bundle Anterior Cruciate Ligament Reconstructive Surgery: A Prospective Study With >1 Year Follow-Up.

Background The increased prevalence of knee trauma predominantly adds to the anterior cruciate ligament (ACL) tear frequencies that require single- or double-bundle reconstructive surgeries. Few studies have demonstrated the superior results of double-bundle reconstruction compared to single-bundle approaches. This study investigated the knee function improvement capacity of both reconstruction techniques in patients with ACL tears. Methods Thirty cases with ACL tears have been enrolled and segregated equally in distinct (single-bundle versus double-bundle) batches. The diagnostic assessments were undertaken through comprehensive clinical history, knee radiographs, Lysholm scoring, the International Knee Documentation Committee (IKDC) scale, the Lachman analysis, the International Knee Documentation Committee (IKDC) scale, and the pivot shift method. Results After one year, there was a significant enhancement in the postoperative versus preoperative Lysholm scores in the single-bundle (58.5 ± 21.2 vs. 82.4 ± 26.2, p<0.001) and double-bundle (86.4 ± 22.8 vs 60.3 ± 19.2, p<0.001) groups. There was a significant improvement in the IKDC scores after a follow-up period of one year (p-value: 0.012 and p-value: 0.002, respectively) in both of the study batches. After a year of follow-up, Lysholm scores (p=0.352) and IKDC scores (p=0.574) between the study groups (82.4 ± 26.2 vs. 86.4 ± 22.8) were comparable. Conclusion The clinical outcomes remained comparable between subjects with single-bundle reconstruction versus double-bundle reconstruction subjects with ACL injuries. Findings were similar between the groups after one year and two years of surgical interventions.

Anatomical Parameters and Growth of the Pediatric Skull Base: Endonasal Access Implications.

Objectives Endoscopic endonasal anterior skull base surgery has expanding use in the pediatric population, but the anatomy of pediatric patients can lead to limitations. This study aims to characterize the important anatomical implications of the pediatric skull base using computed tomography (CT) scans. Design This study is designed as retrospective analysis. Setting The study setting comprises of tertiary academic medical center. Participants In total, 506 patients aged 0 to 18 who had undergone maxillofacial and or head CTs between 2009 to 2016 were involved. Methods Measurements included piriform aperture width, nare to sella distance (NSD), sphenoid pneumatization, olfactory fossa depth, lateral lamella cribriform plate angles, and intercarotid distances (ICD) at the superior clivus and cavernous sinus. These patients were then subdivided into three age groups adjusting for sex. Analysis of covariance (ANCOVA) models were fit comparing between all age groups and by sex. Results Piriform aperture width, NSD, sphenoid sinus pneumatization as measured using lateral aeration and anterior sellar wall thickness, olfactory fossa depth, and ICD at the cavernous sinus were significantly different among all age groups ( p <0.0001). Our results show that mean piriform aperture width increased with each age group. The mean olfactory fossa depth also had consistent age dependent growth. In addition, ICD at the cavernous sinus showed age dependent changes. When comparing by sexes, females consistently showed smaller measurements. Conclusion The process of skull base development is age and sex dependent. During preoperative evaluation of pediatric patients for skull base surgery piriform aperture width, sphenoid pneumatization in both the anterior posterior and lateral directions, and ICD at the cavernous sinus should be carefully reviewed.

Update on adherence to guidelines for time to initiation of postoperative radiation for head and neck squamous cell carcinoma.

BACKGROUND: A prior study reported that over half of patients with HNSCC initiated PORT after 6 weeks from surgery during 2006-2014. In 2022, the CoC released a quality metric for patients to initiate PORT within 6 weeks. This study provides an update on time to PORT in recent years. METHODS: The NCDB and TriNetX Research Network were queried to identify patients with HNSCC who received PORT during 2015-2019 and 2015-2021, respectively. Treatment delay was defined as initiating PORT beyond 6 weeks after surgery. RESULTS: In NCDB, PORT was delayed for 62% of patients. Predictors of delay included age >50, female sex, black race, nonprivate insurance/uninsured status, lower education, oral cavity site, negative surgical margins, increased postoperative length of stay, unplanned hospital readmissions, IMRT radiation modality, treatment at an academic hospital or in the Northeast, and surgery and radiation at different facilities. In TriNetX, 64% experienced treatment delay. Additional associations with prolonged time to treatment included never married/divorced/widowed marital status, major surgery (neck dissection/free flaps/laryngectomy), and gastrostomy/tracheostomy dependence. CONCLUSIONS: There continue to be challenges to timely initiation of PORT.

Defining the clinical characteristics of mammary analog secretory carcinoma of the salivary gland: Analysis of the National Cancer Database.

Objectives: Mammary analog secretory carcinoma (MASC) is a classification of salivary gland tumors, recently included within the term secretory carcinoma. Previous descriptions of this diagnosis have largely consisted of case reports and case series with few studies investigating its clinical characteristics as compared to non-MASC tumors. Our objective was to use a large patient database to compare the clinical characteristics of mammary analog secretory carcinoma vs. non-mammary analog secretory carcinoma salivary gland tumors. Methods: The National Cancer Database was queried between September and October 2022 for histological diagnosis of mammary analog secretory carcinoma and non-MASC salivary tumors. Patients diagnosed with mammary analog secretory carcinoma and non-mammary analog secretory carcinoma salivary tumors between the period of 2004 through 2019 were included in this analysis. Various demographic and clinical variables were abstracted from the database and compared using Wilcoxon rank sum and chi-square tests. Survival was compared between cohorts using Cox proportional hazards regression. Results: Overall, compared to non-mammary analog secretory carcinoma diagnoses (n = 47668), mammary analog secretory carcinoma tumors (n = 384) affected younger individuals, displayed favorable pathologic staging and tumor grade, and were less likely to invade surrounding tissues. Patients with mammary analog secretory carcinoma tumors also received treatment more quickly following diagnosis compared to patients with non-mammary analog secretory carcinoma tumors. The risk of death was 4.3 times greater for non-mammary analog secretory carcinoma diagnoses when adjusted for patient variables (hazard ratio = 4.3, 95% confidence interval [2.37-7.71], p < 0.001). Conclusions: Clinically, mammary analog secretory carcinoma salivary tumors have a more indolent course compared to other salivary cancers. Additional studies are needed to determine the natural history of this tumor type.

Comparing Patients Diagnosed With Ineffective Esophageal Motility by the Chicago Classification Version 3.0 and Version 4.0 Criteria.

Background: The Chicago Classification version 4.0 (CCv4.0) of ineffective esophageal motility (IEM) is more stringent than the Chicago Classification version 3.0 (CCv3.0) definition. We aimed to compare the clinical and manometric features of patients meeting CCv4.0 IEM criteria (group 1) versus patients meeting CCv3.0 IEM but not CCv4.0 criteria (group 2). Methods: We collected retrospective clinical, manometric, endoscopic, and radiographic data on 174 adults diagnosed with IEM from 2011 to 2019. Complete bolus clearance was defined as evidence of exit of the bolus by impedance measurement at all distal recording sites. Barium studies included barium swallow, modified barium swallow, and barium upper gastrointestinal series studies, and collected data from these reports include abnormal motility and delay in the passage of liquid barium or barium tablet. These data along with other clinical and manometric data were analyzed using comparison and correlation tests. All records were reviewed for repeated studies and the stability of the manometric diagnoses. Results: Most demographic and clinical variables were not different between the groups. A lower mean lower esophageal sphincter pressure was correlated with greater percent of ineffective swallows in group 1 (n = 128) (r = -0.2495, P = 0.0050) and not in group 2. In group 1, increased percent of failed contractions on manometry was associated with increased incomplete bolus clearance (r = 0.3689, P = 0.0001). No such association was observed in group 2. A lower median integrated relaxation pressure was correlated with greater percent of ineffective contractions in group 1 (r = -0.1825, P = 0.0407) and not group 2. Symptom of dysphagia was more prevalent (51.6% versus 69.6%, P = 0.0347) in group 2. Dysphagia was not associated with intrabolus pressure, bolus clearance, barium delay, or weak or failed contractions in either group. In the small number of subjects with repeated studies, a CCv4.0 diagnosis appeared more stable over time. Conclusions: CCv4.0 IEM was associated with worse esophageal function indicated by reduced bolus clearance. Most other features studied did not differ. Symptom presentation cannot predict if patients are likely to have IEM by CCv4.0. Dysphagia was not associated with worse motility, suggesting it may not be primarily dependent on bolus transit.

Ilizarov Fixator-Assisted Management of Neglected Femur Fractures by Open Intramedullary Nailing: A Case Series.

Femoral shaft fractures are major life- and limb-threatening injuries. Such injuries, when neglected for months or years, can lead to a range of debilitating consequences. In the Indian subcontinent, there are multiple such cases that are presented to tertiary care hospitals late due to a lack of awareness and low socioeconomic constraints. These neglected cases on presentation are usually in a state of nonunion or malunion, with gross shortening and deformity affecting adjacent joint mobility. The management of neglected femur shaft fractures (NFFs) demands uphill tasks, such as achieving mechanical stability, restoring length and alignment, and having strong rehabilitation schedules. The functional outcomes of these cases are always not proportional to their radiological counterparts and must be taken care of separately. In this study, intramedullary nailing of the fracture after initial distraction with the Ilizarov fixator aims to reduce deformity and shortening while restoring near-optimal functional life. The study aimed to evaluate the functional and radiological outcomes of NFFs operated with distraction by an Ilizarov fixator followed by intramedullary nailing. METHODS: Fourteen cases of NFFs presented to Kalinga Institute of Medical Sciences, Bhubaneswar, India, between January 2020 and June 2022 were recruited for the study. After preoperative evaluation and explanation of available treatment options to patients, they were operated on with a two-stage procedure of Ilizarov fixator application, followed by intramedullary interlocking nailing, with a period of gradual distraction in between. They were then followed up for a minimum of 12 months to assess functional and radiological outcomes. RESULTS: The average time for all of the fractures to heal was 25.2 weeks. The average knee flexion increased from 28.2 degrees before surgery to 87.1 degrees after surgery. All 14 patients could walk with complete weight bearing on the operated limb postoperatively after proper pain control measures were taken. The mean Tegner Lysholm knee score was 77.8. There was residual limping in six of the cases, which could be attributed to muscle atrophy and/or shortening in the affected limbs. In three cases, skin blisters were formed due to the acute nature of the distraction, but they all healed with a scab and scar, otherwise uneventfully. The shortening, in 13 cases, came down to 4 cm or less, which was managed with a shoe raise. The one case with a residual 5 cm shortening had a short, limping gait, and it was attributed to an extremely overriding osteopenic femur preoperatively. CONCLUSION: A two-stage operation with distraction by an Illizarov fixator followed by an intramedullary fixation provides the basic advantage of not having to excise an excessive amount of bone, which may be required in primary open reduction and intramedullary fixation. It also allows the patient to carry on his daily activities as mobilization is not restricted, which is the case in an individual to whom skeletal traction is applied. Hence, in any NFF case, this algorithm of management can be considered a frontrunner in the comprehensive management of disability and deformity.

Treatment Engagement Following a Positive Mental Health Screening Questionnaire.

INTRODUCTION: Less than half of U.S. adolescents with major depressive disorder receive treatment. Despite the U.S. Preventive Services Task Force 2016 statement supporting primary care major depressive disorder screening, there is limited data examining whether positive screens prompt treatment engagement. This study evaluated treatment engagement following a positive Patient Health Questionnaire-Adolescent Version screen and assessed the impact of demographics, clinical variables, and provider recommendations on treatment engagement. METHODS: This was a retrospective cohort study (analysis November 2021) of adolescents aged 11-18 years seen at a primary care clinic of an academic medical center from July 2017 to December 2018 and identified with a positive Patient Health Questionnaire-Adolescent Version (broadest definition score ≥10; ≥1 for Item 9 regarding suicidal thoughts; yes for unscored Items 1, 3, or 4; or very or extremely difficult for unscored Item 2). Positive screen by score ≥10 alone was also considered. The primary outcome was treatment engagement, defined as initiation of a psychotropic medication, or a behavioral health treatment session within 1 year of symptom identification. RESULTS: Of the 1,315 eligible adolescents, 23.0% had a positive Patient Health Questionnaire-Adolescent Version (n=302) by the broadest criteria; 92/302 (30.5%) engaged in treatment. Patients whose providers recommended treatment had 7.32 times the odds (95% CI=3.76, 14.2, p<0.001) of treatment engagement. For those positive by Patient Health Questionnaire-Adolescent Version ≥10 (85/302, 28.1%), 37/85 (43.5%) engaged in treatment. The influence of provider recommendations was comparable (OR=6.96, 95% CI=3.56, 13.6, p<0.001). CONCLUSIONS: Less than half of adolescents with a positive Patient Health Questionnaire-Adolescent Version at an academic primary care clinic engaged with treatment. Provider recommendation was an impactful intervention to improve mental healthcare treatment engagement.

Management of Scaphoid Nonunion (SNU) With Ilizarov Ring Fixator Using Two Olive Wire Compression Without Bone Grafting: A Case Series.

BACKGROUND: The scaphoid is the most commonly fractured bone among the carpal bones seen in orthopedic practice. The majority have good favorable prognosis, but some develop nonunion of fracture despite optimal treatment, which can lead to further complications if left untreated. It is recommended that displaced scaphoid nonunions (SNUs) should be reduced and fixed to prevent degenerative changes from occurring, even if they are asymptomatic. Many treatments have been described, from a percutaneous fixation with a k-wire or screw to open reduction and internal fixation with or without bone grafting, but none of them is the gold standard. AIM: To evaluate the outcome of an SNU treated with an Ilizarov fixator using two olive wires without bone graft. METHODS: Eleven cases of non-union scaphoid fractures were considered in the study which was presented to the Department of Orthopedics of Kalinga Institute of Medical Sciences during the period of March 2015 to March 2018. This study has been approved by the scientific and ethical committees. The anatomical location of the fracture was graded according to the MAYO classification. An Ilizarov frame was applied with two cross olive wires for achieving compression at the fracture area and maintained for six weeks. A final outcome was assessed using the scaphoid outcome score. RESULTS: One out of 11 patients operated on during the study period was lost in follow-up, so 10 patients were considered for analysis of the results. There were nine male patients and one female patient. The majority were right-sided and dominant-handed, with varied occupations. The average duration of nonunion, when presented, was 10.7 months (a range of 6-20 months). The average follow-up was 43.6 months (range 27-60 months). Union was achieved in an average of 12.9 weeks (range 10-18 weeks). All the patients returned to their pre-injury activity level in a mean of 17.1 weeks (range 13-23 weeks). Grip strength improved from a mean of 29.5 kg preoperatively to 39.4 kg postoperatively. At the final follow-up, the mean scaphoid outcome score was 9.1. An excellent outcome was obtained in five cases (50%), a good outcome in three cases (30%), a fair outcome in one case (10%), and in one case (10%), a poor outcome. CONCLUSION: With our technique of Ilizarov fixation and compression with two cross olive wires, SNU can be treated safely even without opening the non-union site and even without bone grafting. Since we excluded SNU patients with humpback deformity, carpal instability, carpal collapse, or avascular necrosis (AVN), our results might not be directly comparable to those of other SNU series in the literature. These would have predisposed to a poor outcome. Since we did not assign the patients at random, it is challenging to compare the Ilizarov technique to other widely used SNU treatments and determine whether it is more effective. However, the study's results are encouraging and show that the Ilizarov method using two olive wires for compression.

Factors Influencing Geriatric Orthopaedic Trauma Mortality.

INTRODUCTION: This study aimed to: (1) evaluate the independent risk factors related to survival and mortality and (2) predict survival in geriatric orthopaedic trauma patients admitted to our institution's ICU as a Level 1 or 2 trauma activation. METHODS: A retrospective review was performed on patients age >60, over a 10 year period, who were involved in a multi-trauma with orthopaedic injuries. Variables evaluated include: sex, age, Injury Severity Score (ISS), mechanism of injury, number and type of orthopaedic injury, anticoagulant use, comorbidities, length of stay in intensive care unit (ICU), type of ICU, ventilator use, vasopressors use, incidence of multiple organ dysfunction syndrome (MODS), number of surgeries, and 1-month and 6-month mortality. A Kaplan-Meier estimator and Cox proportional hazards analysis were used to predict and assess survival probability. RESULTS: 174 patients were included, with an average mortality of 47.7%. Deceased patients had a significantly greater age, ISS, vasopressor usage, ICU stay, incidence of MODF, incidence of genitourinary disease, anticoagulant usage, ventilator usage, number of orthopaedic surgeries, and orthopaedic injuries. The relative risk for mortality within the first month was significantly associated with increased age, ISS, high-energy trauma, length of ICU stay, MODS, psychiatric disease, and anticoagulant use. Patients with an ISS ≤30 were significantly more likely to survive than patients with an ISS of >30. Greater age, ISS, length of ICU stay, incidence of MODS, anticoagulant, and ventilator use were significantly predictive of lower survival rates. Mechanism of injury, number of orthopaedic surgeries and orthopaedic injuries, and type of orthopaedic injury were not found to be predictive of survival. CONCLUSIONS: An ISS >30 at admission is strongly predictive of a lower probability of survival. Genitourinary disease was associated with increased mortality. Low age, ISS, length of stay in ICU, incidence of MODS, anticoagulant use, and ventilator use, are significantly predictive of survival. Number of orthopaedic surgeries, orthopaedic injuries, and type of orthopaedic injury were not found to be predictive of survival. These indications help us to better understand factors predictive of death among geriatric orthopaedic trauma patients, and improve the way we can diagnose and care for them.

Hedgehog signaling pathway gene variant influences bronchopulmonary dysplasia in extremely low birth weight infants.

BACKGROUND: Genome wide association study identified hedgehog interacting protein gene (HHIP) variants with chronic obstructive pulmonary disease and asthma. Loss of HHIP, a key regulator of the hedgehog signaling pathway, leads to impaired lung morphogenesis and lethality in animal models, through unimpeded sonic hedgehog expression blocking mesenchymal-expressed fibroblast growth factor 10 (FGF10). Since bronchopulmonary dysplasia (BPD) is also associated with altered lung development and worsens with stimuli including mechanical ventilation, reactive oxygen species, and inflammation, HHIP and FGF10 may be candidate genes. METHODS: This was an observational, cohort study including extremely low birth weight infants that who developed BPD and those who did not. DNA was isolated from buccal swabs and subjected to allelic discrimination, using specific HHIP and FGF10 probes. Protein levels were measured in tracheal aspirates. Student's t test, Chi-square, Z test and logistic regression were used. RESULTS: Demographic characteristics did not differ except that birth weight (715 ± 153 vs. 835 ± 132 g) and gestational age (25 vs. 26 weeks) were less in babies with BPD. HHIP variant rs13147758 (GG genotype) was found to be independently protective for BPD (odds ratio 0.35, 95% confidence interval 0.15-0.82, P = - 0.02). Early airway HHIP protein levels were increased in infants with BPD compared to those without [median (interquartile range) 130.6 (55.6-297.0) and 41.2 (22.1-145.6) pg/mL, respectively; P = 0.05]. The FGF10 single nucleotide polymorphisms were not associated with BPD. CONCLUSION: HHIP, as a regulator of lung bud formation, affects BPD susceptibility, and may be valuable in understanding the specific mechanisms for this disease as well as for identifying therapeutic targets in the era of personalized medicine.

Peripheral Nerve Injury in Thoracic Surgery Detected by Automated Somatosensory Evoked Potential Monitoring.

Study Objective. Our objectives were to estimate the incidence of symptoms of peripheral nerve injury (sPNI) in thoracic surgical patients undergoing video-assisted thoracic surgery or open thoracotomy and to determine whether intraoperative somatosensory evoked potentials (SSEPs) waveform changes correlate with postoperative peripheral neuropathic symptoms. Methods. We conducted a prospective observational study in the operating room of a tertiary hospital. We measured SSEPs intraoperatively and assessed patients for sPNI postoperatively. Results. Forty-four patients consented. Six were excluded from analysis. We found that 42% (95% confidence interval [CI] = 26% to 57%) of patients undergoing thoracic surgery had significant changes in SSEP amplitude and latency. Furthermore, 16% (95% CI = 4% to 28%) of patients had new postoperative symptoms of sensory or motor deficits in an upper extremity. We calculated a sensitivity of 66.7% (95% CI = 29.0% to 100%) and a specificity of 50% (95% CI = 33% to 67.3%) for the identification of sPNI based on automated intraoperative SSEP changes. Conclusions. We identified the incidence of SSEP changes in thoracic surgery (42%) and the incidence of postoperative sPNI after thoracic surgery (16%). We identified a positive correlation between intraoperative SSEP changes and postoperative sPNI, which after multivariate analysis was not significant given the small sample size of the study. By the time sensory and/or motor changes are detected postoperatively, it may be too late to reverse the nerve damage. Future versions of the EPAD device could provide anesthesiologists a way to monitor for the development of sPNI, and make changes before a potential injury becomes permanent.