Convulsive Syncope as a Complication of Outpatient Procedures: A Case Series and Review of the Literature.

ABSTRACT: Sports medicine providers often perform various outpatient procedures to manage musculoskeletal and neuropathic conditions. Vasovagal syncope is a rare but a possible complication. Convulsive syncope is one subtype that involves brief extensor stiffening and nonsustained myoclonus and can be easily mistaken for seizures. We present a case series of convulsive syncope as a complication of common sports medicine outpatient procedures. We aim to describe how to identify this condition, and offer risk stratification and management strategies to mitigate the risks of this complication. Sports medicine providers who routinely practice outpatient procedures should be aware of this complication. Simple changes in approaching the procedure may mitigate these risks. High- and intermediate-risk features of the syncopal episode should prompt physicians to seek further evaluation by a specialist to rule out more serious conditions. In all instances, appropriate on-site support and equipment for emergent resuscitation and management should be prepared.

Perceptions of Racial and Gender Microaggressions in an Academic Orthopaedic Department.

Orthopaedic surgery consistently ranks last among all medical specialties in diversity and inclusion. While active efforts have recently been implemented to enact change, no study to date has explored the potential effects that social microaggressions have on an individual's career in orthopaedic surgery. The primary aim of this study was to investigate the influence of the perceived experiences of gender and race-based microaggressions on orthopaedic surgery residents, fellows, and attendings in their decision to pursue a career in orthopaedic surgery. Methods: A 34-question institutional review board-approved, modified version of the validated Racial and Ethnic Minorities Scale and Daily Life Experiences survey was sent to a total of 84 individuals at the University of Miami (UM) Department of Orthopaedics. Responses were anonymously collected from current UM orthopaedic residents, fellows, and attendings. Survey results were analyzed for the prevalence of microaggressions in the context of sex, race, ethnicity, academic goals, daily scenarios, and department support. p-Values less than 0.05 were considered statistically significant. Results: Fifty-four of 84 respondents (64%) completed the survey. Female respondents experienced significantly more gender-based microaggressions than male respondents. On average, male participants disagreed that their experiences with microaggressions made them doubt their ability to pursue a career in orthopaedic surgery while female participants responded they were neutral. In comparison with their White counterparts, non-White and Hispanic ethnicity participants demonstrated a statistically significantly greater frequency of race and ethnicity-based microaggressions. Conclusion: Our study demonstrates that female participants, non-White participants, and Hispanic minorities across all levels of training experience a higher frequency of microaggressions. The impact of these experiences on career decisions and goals for women and persons of color in orthopaedic surgery at this single institution is mixed. Experienced microaggressions should be further investigated as a potential barrier to recruitment and retention of under-represented minorities in orthopaedic surgery. Level of Evidence: III.

Two Affordable, High-Fidelity Central Venous Models for Ultrasound-Guided Interventional Training.

INTRODUCTION: Ultrasound-guided vascular access is an increasingly popular technique due to its reduced complication and higher success rates. Commercially bought training phantoms allow providers to develop tactile skills in a low-risk setting, but are also expensive and poorly accessible. This study analyzes the efficacy of homemade, low-cost, gelatin-based central line vascular models to teach vascular anatomy and intravascular access techniques in training physicians. METHODS: A gelatin mold was created using a mixture of unflavored gelatin, hot water, psyllium husk powder, and rubbing alcohol. Latex tubing, balloons, precooked hot dog, and tofu were inserted to simulate arteries, veins, nerves, and the sternocleidomastoid muscle, respectively. Medical students from a single institution participated in a 90-minute workshop led by interventional radiology residents. Participants completed presurveys and postsurveys that assessed knowledge acquisition and confidence levels related to acquiring central access. All images were obtained using a USB-C Butterfly iQ probe. RESULTS: Twenty medical students were analyzed after the workshop. There was a statistically significant increase in self-reported confidence in basic ultrasound use (adjusting gain, depth, probe manipulation), localizing major anatomical structures, using ultrasound for vessel access, and reported ease in identifying muscle, nerves, and major blood vessels under ultrasound. There was also a significant increase in correctly identified anatomical landmarks after the workshop, including the sternocleidomastoid muscle, internal jugular vein, carotid artery, femoral nerve, femoral artery, and femoral vein. CONCLUSIONS: Our findings suggest that our homemade, low-cost, gelatin-based models were effective in teaching vascular anatomy and ultrasound-guided vascular access techniques to training physicians.

A comparison of adverse pregnancy events between ureteral stents and percutaneous nephrostomy tubes in the treatment of nephrolithiasis during pregnancy: A propensity score-matched analysis of a large multi-institutional research network.

PURPOSE: To investigate rates of adverse pregnancy events associated with the use of percutaneous nephrostomy tubes (PCN) versus ureteral stents in the treatment of nephrolithiasis during pregnancy. METHODS: We queried the TriNetX Diamond Network database to evaluate pregnant women (ICD-10 Z34, O09) with a history of nephrolithiasis (N20-23) who underwent a PCN (CPT 50432) or ureteral stent (52332) placement up to 6 months before delivery (O80-82). We controlled for the following potentially confounding variables through propensity score matching: age, race, ethnicity, acute pyelonephritis (N10), infections of the genitourinary tract in pregnancy (O23.0), and other sepsis (A41) at the time of stent or PCN placement. RESULTS: We identified 2,999 pregnant women who underwent ureteral stent placement and 321 who underwent PCN. Following propensity score matching, we found there to be no significant difference in the rate of premature labor or delivery (aOR 1.08, 95% CI 0.735-1.588), premature rupture of membranes (0.889, 0.453-1.743), intrauterine infection (0.906, 0.379-2.165), or c-Sect. (0.825, 0.408-1.667). Within 6 months of their initial procedure, women with a ureteral stent experienced a significantly decreased rate of subsequent urinary tract infection (UTI) or pyelonephritis (0.52, 0.38-0.71), inpatient hospital stay (0.40, 0.26-0.64), emergency department visit (0.65, 0.48-0.89), and repeat exchange procedure (0.70, 0.51-0.96). CONCLUSION: In the treatment of nephrolithiasis during pregnancy, PCN versus ureteral stent placement does not confer a significant difference in rates of adverse pregnancy events. However, ureteral stent placement was associated with a lower incidence of hospital admissions, emergency department visits, exchange procedures, and new UTIs or pyelonephritis.

Nutrition Education to Reduce Metabolic Dysfunction for Spinal Cord Injury: A Module-Based Nutrition Education Guide for Healthcare Providers and Consumers.

Spinal cord injury (SCI) results in a high prevalence of neurogenic obesity and metabolic dysfunction. The increased risk for neurogenic obesity and metabolic dysfunction is mainly due to the loss of energy balance because of significantly reduced energy expenditure following SCI. Consequently, excessive energy intake (positive energy balance) leads to adipose tissue accumulation at a rapid rate, resulting in neurogenic obesity, systemic inflammation, and metabolic dysfunction. The purpose of this article is to review the existing literature on nutrition, dietary intake, and nutrition education in persons with SCI as it relates to metabolic dysfunction. The review will highlight the poor dietary intakes of persons with SCI according to authoritative guidelines and the need for nutrition education for health care professionals and consumers. Nutrition education topics are presented in a module-based format with supporting literature. The authors emphasize the role of a diet consisting of low-energy, nutrient-dense, anti-inflammatory foods consistent with the Dietary Guidelines for Americans' MyPlate to effectively achieve energy balance and reduce the risk for neurogenic obesity and metabolic dysfunction in individuals with SCI.

The Effectiveness of Intraarticular Cervical Facet Steroid Injections in the Treatment of Cervicogenic Headache: Systematic Review and Meta-analysis.

BACKGROUND: Cervicogenic headache (CGH) can often be difficult to treat, given the overlapping clinical features of other headaches and the varying sources of pain that patients report. While imaging is not useful in diagnosing CGH, anesthetic blockade of the atlanto-occipital joint, lateral atlantoaxial joint, or specific cervical zygapophyseal joints can be used to confirm the diagnosis. When conservative treatment measures, such as physical therapy, fail, interventional techniques, such as intraarticular steroid injections, have been shown in observational studies to provide relief in some patients. OBJECTIVES: To determine the efficacy of intraarticular cervical facet steroid injections in the treatment of CGH. STUDY DESIGN: Systematic review and meta-analysis. METHODS: We conducted a comprehensive search of Ovid Medline, Embase, Cochrane Central Register of Controlled Trials , Cumulative Index to Nursing and Allied Health Literature Plus with Full Text, Scopus, and the Web of Science platform, from inception to April 2021, for studies using intraarticular cervical facet injections to treat CGH in adults aged 18 or older. Primary outcomes included mean postinjection pain scores. Outcomes were pooled using a random effects model and reported as mean differences (MD) with 95% confidence intervals (CI). RESULTS: Three studies with a total of 64 patients met the inclusion criteria. According to data from each of the included studies, intraarticular cervical facet injections were shown to demonstrate improvement in the mean pain score from baseline to postintervention. The overall effect size-pooled MD in the Visual Analog Scale score-was 3.299 (95% CI: 2.045 to 4.552, P < 0.001). Heterogeneity (I2) was 36.11%. LIMITATIONS: Small sample size, lack of control group, and varying pain generators and interventional technique between studies contribute to the limitations of the analysis. CONCLUSIONS: Our findings suggest that therapeutic intraarticular cervical facet injections may be effective in the treatment of CGH. Because of the heterogeneity among the studies, these results should be interpreted with caution.

Extended Neuralgic Amyotrophy Syndrome in a Confirmed COVID-19 Patient After Intensive Care Unit and Inpatient Rehabilitation Stay.

ABSTRACT: The cause of neuralgic amyotrophy is often unknown but is commonly associated with a recent upper respiratory viral tract infection. Since the beginning of the COVID-19 pandemic, there has been a tireless effort to understand the sequelae of the virus. A 46-yr-old woman who presented after a COVID-19 hospitalization complicated by hypoxic respiratory failure requiring intubation and mechanical ventilation for 23 days was subsequently found to have lower limb sensorium changes as well as upper limb weakness. Left shoulder abduction and extension were both 3/5 in motor strength, and left hip flexion strength was 4/5 with diminished sensation to crude touch in the left lateral thigh. Nerve conduction studies and electromyography findings included a mild left median neuropathy at the wrist and motor unit recruitment pattern consistent with a chronic left upper trunk plexopathy with reinnervation. The case presented describes an extended neuralgic amyotrophy syndrome from an atraumatic mechanism in a previously diagnosed COVID-19 patient. An extended neuralgic amyotrophy syndrome has at least three immune mediated etiologies postulated (1) direct neuropathogenicity, (2) molecular mimicry, and (3) direct cytotoxic effects on peripheral nerves. As COVID-19 survivors continue to be seen in outpatient settings, practitioners should remain aware of diffuse neurological complications as sequelae of the virus persist.

The impact of the national clinical outcome review programmes in England: a review of the evidence.

BACKGROUND: There is a lack of evidence about the effectiveness of the national clinical outcome review programmes in England. METHODS: We undertook a scoping review of the published literature for evidence of the impact of any of the current programmes or their predecessors, and asked programme leads to share examples of the impact of their work. Data were thematically analysed. FINDINGS: Evidence about impact related to clinicians' awareness and practice, structural aspects of healthcare, processes of care and patient outcomes. CONCLUSIONS: The national clinical outcome review programmes appear to have had significant impact, but none are funded to assess the outcome and impact of the recommendations they make or to deliver a programme of change. There is no structured and systematic way in which the findings and recommendations of each programme are taken forward, nor in which the findings from across programmes are collated and considered.

Children's surgery: a national survey of consultant clinical practice.

OBJECTIVES: To survey clinical practice and opinions of consultant surgeons and anaesthetists caring for children to inform the needs for training, commissioning and management of children's surgery in the UK. DESIGN: The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) hosted an online survey to gather data on current clinical practice of UK consultant surgeons and anaesthetists caring for children. SETTING: The questionnaire was circulated to all hospitals and to Anaesthetic and Surgical Royal Colleges, and relevant specialist societies covering the UK and the Channel Islands and was mainly completed by consultants in District General Hospitals. PARTICIPANTS: 555 surgeons and 1561 anaesthetists completed the questionnaire. RESULTS: 32.6% of surgeons and 43.5% of anaesthetists considered that there were deficiencies in their hospital's facilities that potentially compromised delivery of a safe children's surgical service. Almost 10% of all consultants considered that their postgraduate training was insufficient for current paediatric practice and 20% felt that recent Continued Professional Development failed to maintain paediatric expertise. 45.4% of surgeons and 39.2% of anaesthetists considered that the current specialty curriculum should have a larger paediatric component. Consultants in non-specialist paediatric centres were prepared to care for younger children admitted for surgery as emergencies than those admitted electively. Many of the surgeons and anaesthetists had <4 h/week in paediatric practice. Only 55.3% of surgeons and 42.8% of anaesthetists participated in any form of regular multidisciplinary review of children undergoing surgery. CONCLUSIONS: There are significant obstacles to consultant surgeons and anaesthetists providing a competent surgical service for children. Postgraduate curricula must meet the needs of trainees who will be expected to include children in their caseload as consultants. Trusts must ensure appropriate support for consultants to maintain paediatric skills and provide the necessary facilities for a high-quality local surgical service.

Good communication.

We are writing to draw senior nurses' attention to the latest report published by the National Confidential Enquiry into Patient Outcome and Death.

Death after PEG: results of the National Confidential Enquiry into Patient Outcome and Death.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is an accepted method of placing a feeding tube to enable enteral feeding in patients with swallowing difficulties. However, the factors associated with complications and death after PEG have not been studied in detail. We describe the largest audit of deaths after PEG tube insertion. OBJECTIVE: Our purpose was to determine the factors associated with death after PEG tube insertion. DESIGN: Deaths occurring within 30 days after PEG tube insertion in the United Kingdom between April 2002 and March 2003 were identified and a questionnaire was sent to the consultant endoscopist for completion. PATIENTS: A total of 719 patients (391 male, median age 80 years, range 26-98 years) who died within 30 days after PEG insertion were identified for this study. SETTING: United Kingdom hospitals. MAIN OUTCOME MEASUREMENT: Cause of death. RESULTS: A total of 97% of the identified patients had coexistent neurologic disease. PEG tubes were inserted by specialized GI physicians in 522 cases (73%). Seventy-two patients (10%) required reversal agents after sedation. After PEG tube insertion, 309 patients (43%) died within 1 week. Death was due to cardiovascular disease (n = 175), respiratory disease (n = 508), central nervous system disease (n = 358), renal disease (n = 38), and hepatic failure (n = 11). In 136 cases (19%) the National Confidential Enquiry into Patient Outcome and Death expert panel regarded the procedure as futile. LIMITATIONS: Retrospective review of case records. CONCLUSIONS: Mortality and morbidity rates after PEG tube insertion are not insignificant. Selection of patients is paramount to good patient outcomes. Multidisciplinary team assessment should be performed on all patients being referred for PEG tube insertion.

A consensus process for identifying a prioritised list of study questions.

A consensus process has been developed to assist the UK National Confidential Enquiry into Patient Outcome and Death in identifying questions to be addressed in its studies. The process utilises the knowledge and experience of a panel of experts via a facilitated brainstorming exercise and employs a robust voting system to produce a list of candidate questions ordered in terms of the preferences expressed by individual panel members. The process which is described has been used successfully to assist the design of two national studies and it is anticipated that the process will be adopted for many studies in the future.