Surrogates of Muscle Mass on Cardiac MRI Correlate with Exercise Capacity in Patients with Fontan Circulation.

BACKGROUND: Sarcopenia is an increasingly recognized marker of frailty in cardiac patients. Patients with a history of congenital heart disease and Fontan procedure have a higher risk of developing progressive muscle wasting. Our objective was to determine if we could use routine cardiac MRI (CMR) for the surveillance of muscle wasting. METHODS: A retrospective study of all Fontan patients (n = 75) was conducted at our institution, with CMR performed from 2010 to 2022 and exercise stress testing performed within 12 months (4.3 ± 4.2 months). The skeletal muscle area (SMA) for the posterior paraspinal and anterior thoracic muscles were traced and indexed for body surface area (BSA). Patients were stratified by percentile into the upper and lower quartiles, and the two groups were compared. Multivariable regression was performed to control for sex and age. RESULTS: There was a significant positive association of both anterior (r = 0.34, p = 0.039) and paraspinal (r = 0.43, p = 0.007) SMA to peak VO2. Similarly, paraspinal but not anterior SMA was negatively associated with the VE/VCO2 (r = -0.45, p = 0.006). The upper quartile group had significantly more males (18/19 vs. 8/20; p = 0.0003) and demonstrated a significantly higher peak VO2 (32.2 ± 8.5 vs. 23.8 ± 4.7, p = 0.009), a higher peak RER (1.2 ± 0.1 vs. 1.1 ± 0.04, p = 0.007), and a significantly lower VE/VCO2 (32.9 ± 3.6 vs. 40.2 ± 6.2, p = 0.006) compared to the lowest quartile. The association of SMA to VO2 peak and VE/VCO2 was redemonstrated after controlling for sex and age. CONCLUSION: Thoracic skeletal muscle area may be an effective surrogate of muscle mass and is correlated to several measures of cardiorespiratory fitness post-Fontan. CMR would be an effective tool for the surveillance of sarcopenia in post-Fontan patients given its accessibility and routine use in these patients.

Shift Work and Obesity Risk-Are There Sex Differences?

PURPOSE OF REVIEW: Shift work is prevalent among the working population and is linked to an array of adverse health outcomes. This review summarizes current evidence on the relation between shift work and risk of obesity, with a particular emphasis on potential sex differences. RECENT FINDINGS: Observational data strongly point towards an association between shift work and heightened risk of prevalent and incident obesity, and particularly abdominal obesity. Circadian misalignment and unhealthy lifestyle behaviors are the primary culprits mediating such association. As it pertains to sex differences in the impact of shift work on obesity, few studies have examined this aspect, and findings are conflicting. Shift work is an important risk factor for obesity, with likely multiple biological and behavioral mediators. However, whether there is a sex-dependent vulnerability to the obesogenic effects of shift work is unclear. This area presents opportunities for future research.

Multireader evaluation of radiologist performance for COVID-19 detection on emergency department chest radiographs.

BACKGROUND: Chest radiographs (CXR) are frequently used as a screening tool for patients with suspected COVID-19 infection pending reverse transcriptase polymerase chain reaction (RT-PCR) results, despite recommendations against this. We evaluated radiologist performance for COVID-19 diagnosis on CXR at the time of patient presentation in the Emergency Department (ED). MATERIALS AND METHODS: We extracted RT-PCR results, clinical history, and CXRs of all patients from a single institution between March and June 2020. 984 RT-PCR positive and 1043 RT-PCR negative radiographs were reviewed by 10 emergency radiologists from 4 academic centers. 100 cases were read by all radiologists and 1927 cases by 2 radiologists. Each radiologist chose the single best label per case: Normal, COVID-19, Other - Infectious, Other - Noninfectious, Non-diagnostic, and Endotracheal Tube. Cases labeled with endotracheal tube (246) or non-diagnostic (54) were excluded. Remaining cases were analyzed for label distribution, clinical history, and inter-reader agreement. RESULTS: 1727 radiographs (732 RT-PCR positive, 995 RT-PCR negative) were included from 1594 patients (51.2% male, 48.8% female, age 59 ± 19 years). For 89 cases read by all readers, there was poor agreement for RT-PCR positive (Fleiss Score 0.36) and negative (Fleiss Score 0.46) exams. Agreement between two readers on 1638 cases was 54.2% (373/688) for RT-PCR positive cases and 71.4% (679/950) for negative cases. Agreement was highest for RT-PCR negative cases labeled as Normal (50.4%, n = 479). Reader performance did not improve with clinical history or time between CXR and RT-PCR result. CONCLUSION: At the time of presentation to the emergency department, emergency radiologist performance is non-specific for diagnosing COVID-19.

Normative and isolated rapid eye movement sleep without atonia in adults without REM sleep behavior disorder.

STUDY OBJECTIVES: Values for normative REM sleep without atonia (RSWA) remain unclear. Older age and male sex are associated with greater RSWA, and isolated elevated RSWA has been reported. We aimed to describe normative RSWA and characterize isolated RSWA frequency in adults without REM sleep behavior disorder (RBD). METHODS: We visually quantified phasic, "any," and tonic RSWA in the submentalis (SM) and anterior tibialis (AT) muscles, and the automated Ferri REM Atonia Index during polysomnography in adults without RBD aged 21-88. We calculated RSWA percentiles across age and sex deciles and compared RSWA in older (≥ 65) versus younger (<65) men and women. Isolated RSWA (exceeding diagnostic RBD cutoffs, or >95th percentile) frequency was also determined. RESULTS: Overall, 95th percentile RSWA percentages were SM phasic, any, tonic = 8.6%, 9.1%, 0.99%; AT phasic and "any" = 17.0%; combined SM/AT phasic, "any" = 22.3%, 25.5%; and RAI = 0.85. Most phasic RSWA burst durations were ≤1.0 s (85th percentiles: SM = 1.07, AT = 0.86 seconds). Older men had significantly higher AT RSWA than older women and younger patients (all p < 0.04). Twenty-nine (25%, 18 men) had RSWA exceeding the cohort 95th percentile, while 17 (14%, 12 men) fulfilled diagnostic cutoffs for phasic or automated RBD RSWA thresholds. CONCLUSIONS: RSWA levels are highest in older men, mirroring the demographic characteristics of RBD, suggesting that older men frequently have altered REM sleep atonia control. These data establish normative adult RSWA values and thresholds for determination of isolated RSWA elevation, potentially aiding RBD diagnosis and discussions concerning incidental RSWA in clinical sleep medicine practice.

Trauma-Associated Sleep Disorder: A Posttraumatic Stress/REM Sleep Behavior Disorder Mash-Up?

ABSTRACT: Trauma-associated sleep disorder (TASD) is a parasomnia sharing characteristics of post-traumatic stress disorder (PTSD) and REM sleep behavior disorder (RBD) including dream-enactment behavior (DEB). Here we report REM sleep without atonia (RSWA) and other neurological features in a patient with complex vocal and motor DEB following traumatic combat military exposure. Post-discharge, his wife observed frequent yelling and jerking during sleep with dream mentation reminiscent of traumatic military experiences. He was initially diagnosed with PTSD. Polysomnography demonstrated RSWA and severe obstructive sleep apnea treated with nasal continuous positive airway pressure (CPAP). Dream-enactment behavior severity and frequency was reduced, but still persisted despite nasal CPAP and sequential fluoxetine, escitalopram, prazosin, and melatonin trials. Our case demonstrated overlapping clinical features of PTSD and RBD with polysomnography features of RSWA supportive of idiopathic RBD but no "soft signs" suggesting underlying synucleinopathy. Longitudinal follow-up of larger case series must clarify whether TASD consistently manifests REM sleep atonia loss and determine the phenoconversion risk for synucleinopathy neurodegeneration. COMMENTARY: A commentary on this article appears in this issue on page 181.

Multimodal Analgesia in Breast Surgical Procedures: Technical and Pharmacological Considerations for Liposomal Bupivacaine Use.

Enhanced recovery after surgery is a multidisciplinary perioperative clinical pathway that uses evidence-based interventions to improve the patient experience as well as increase satisfaction, reduce costs, mitigate the surgical stress response, accelerate functional recovery, and decrease perioperative complications. One of the most important elements of enhanced recovery pathways is multimodal pain management. Herein, aspects relating to multimodal analgesia following breast surgical procedures are discussed with the understanding that treatment decisions should be individualized and guided by sound clinical judgment. A review of liposomal bupivacaine, a prolonged-release formulation of bupivacaine, in the management of postoperative pain following breast surgical procedures is presented, and technical guidance regarding optimal administration of liposomal bupivacaine is provided.

Sinusitis Treatment Guideline Adherence in the E-Visit Setting: A Performance Improvement Project.

BACKGROUND: Studies demonstrate poor guideline adherence by health care providers for the treatment of upper respiratory infections, particularly acute bacterial rhinosinusitis (ABRS), in the appropriate prescribing of antibiotic medications. OBJECTIVE: The purpose of this quality improvement project was to evaluate the effect of implementing interventions for improving adherence to a clinical practice guideline for the management of ABRS for patients treated in the e-visit setting. Interventions included: providing a report to providers of their adherence to the ABRS clinical guideline prior to the intervention, providing updated education on the ABRS guideline, and implementing a clinical decision support system reminder. METHODS: A pre and post intervention evaluation design was used. Data were obtained from a retrospective electronic health record (EHR) data extract of all 316 diagnoses for ABRS in the pre-intervention 2-month time period and all 368 diagnoses of ABRS in the post-intervention 2-month time period. A review of the structured clinical data elements was performed to determine whether the provider adhered to the clinical guideline, meaning that only patients meeting the criteria for ABRS were to receive an antibiotic prescription. RESULTS AND CONCLUSION: The interventions resulted in a 3.3% improvement in adherence to the ABRS clinical guideline from 95.25% adherence pre-intervention to 98.4% post-intervention. These results demonstrated that the use of an educational intervention and clinical decision support resulted in improved adherence to the ABRS clinical guideline in the e-visit setting. The implications for practice could be significant in that these quality improvement interventions improve guideline adherence and reduce unnecessary prescribing of antibiotics.

Anesthesia duration as a marker for surgical complications in office-based plastic surgery.

BACKGROUND: Office-based plastic surgery has continued to rise in the past 2 decades with the increased demand for cosmetic surgery. Although several large studies have shown the safety of office-based surgery, current regulations place some restrictions on ambulatory office-based surgical facilities. To provide further evidence-based literature on the safety of office-based plastic surgery, we examine surgical complication rates as a function of anesthesia duration. METHODS: This is a retrospective review of 2595 patients who underwent office-based plastic surgery procedures between October 2000 and January 2005. All patients received general anesthesia for a broad range of cosmetic surgeries. The primary measured outcome was minor and major surgical complications. Complication rates were examined as a function of anesthesia duration of less than or greater than 4 hours. The follow-up period was 30 days. Statistical analysis was completed using SPSS v.19. RESULTS: Most of the patients were female with an average age of 41 years. An increase in the occurrence of minor surgical complications such as postoperative nausea and vomiting (2.8% vs 5.7%, P=0.0175) and urinary retention (0.7% vs 7.6%, P<0.0001) was noted in the greater than 4-hour anesthesia duration group. Overall, there were 66 (2.5%) patients that required reoperation because of surgical complications with no statistical difference between the 2 groups (P=0.098). The only major morbidities were 1 pulmonary embolism (<4 hours) and 1 deep vein thrombosis (>4 hours). Five (0.19%) patients were admitted to the hospital during the follow-up period for surgical and/or medical management (3 hematomas, 1 deep vein thrombosis, and 1 pulmonary embolism). There were no cases of reintubation, major cardiac complications, or death in this series. CONCLUSIONS: Duration of general anesthesia in office-based plastic surgery does not seem to be an indicator of major morbidity and mortality. Although minor complications such as postoperative nausea and vomiting and urinary retention were higher in patients with anesthesia greater than 4 hours, there was no significant increase in major complications. Change in surgical venue would not likely alter the outcome of the increase in minor complications. Therefore, anesthesia duration should not be used as a guideline for safety of office-based plastic surgery.

Quality of care in the retail health care setting using national clinical guidelines for acute pharyngitis.

Rates of adherence to an acute pharyngitis practice guideline in the retail clinic setting were measured as an indicator of clinical quality. An analysis of 57,331 patient visits for the evaluation of acute pharyngitis was conducted. In 39,530 patients with a negative rapid strep test result, nurse practitioner and physician assistant staff adhered to guidelines in 99.05% of cases by withholding unnecessary antibiotics. Of 13,471 patients with a positive rapid strep test result, 99.75% received an appropriate antibiotic prescription. The combined guideline adherence rate for groups with positive and negative rapid strep test results was 99.15%. Strep cultures were performed on 99.1% of patients with a negative rapid strep test result, and 96.2% of patients with a positive culture were treated with an antibiotic. Finally, 0.95% of patients with a negative rapid strep test result were provided an antibiotic outside clinical guidelines; however, approximately half of these prescriptions (n = 190) were supported by documentation of clinical concerns for which an antibiotic was a reasonable choice.

The effect of total shoulder arthroplasty on self-assessed deficits in shoulder function in patients with capsulorrhaphy arthropathy.

The objective of this study was to characterize self-assessed functional deficits before and after total shoulder arthroplasty (TSA) in a consecutive series of 24 patients treated for capsulorrhaphy arthropathy. Deficits were determined by use of the Simple Shoulder Test. The effects of age, type of original stabilization surgery, duration of time since the initial repair, and pattern of glenoid erosion were analyzed. Deficits were significantly reduced from 8.5 to 4 of 12 SST items after TSA (P = .003). Items related to motion and function had the largest effect on improvement. Age did not affect results. There was a trend toward greater improvement in patients whose original stabilization was less than 20 years previously (P = .06) and in those with concentric glenoid erosion (P = .06). A prior Bristow procedure was associated with the least improvement. Overall, TSA was an effective treatment for capsulorrhaphy arthropathy at midterm follow-up. Restoring range of motion appears to have the largest impact on improvement in function.

Direct injection of blood into the labrum enhances the stability provided by the glenoid labral socket.

We tested the hypothesis that the stabilizing function of the labrum can be enhanced by inflating it with blood. In 6 fresh cadaveric glenoids, the anteroinferior stability provided by the glenoid was quantitated by measuring the maximal angle between the glenoid centerline and the direction of the force applied via a ball in the glenoid before the ball dislocated from the glenoid. This stability angle was measured for each of 4 different applied loads. These measurements were repeated after the anteroinferior labrum was augmented by the injection of fresh blood. Injection augmentation of the labrum significantly increased the measured stability angles in 5 of 6 specimens. The 1 outlier had a partial labral tear. The mean increase in stability for all 6 glenoids ranged from 19% to 30% for the different test loads. Labral injection with blood may be a useful adjunct in the surgical management of glenohumeral instability.

Deficits in shoulder function and general health associated with sixteen common shoulder diagnoses: a study of 2674 patients.

The purpose of this study is to define the self-assessed deficits in function and general health perceived by a large cohort of patients with common shoulder diagnoses. For a 10-year period, all new shoulder patients presenting to the senior author were characterized by diagnosis, age, gender, and self-assessed shoulder function and general health status. This report concerns the 2674 patients having 1 of the 16 most prevalent diagnoses. The deficits in shoulder function and health status were correlated with diagnosis, age, and gender, as well as with each other. Patient self-assessment provided a standardized method for collecting data on shoulder function and health status. These assessments revealed substantial deficits; for example, 81% of patients were unable to sleep on the affected side, and 71% were unable to wash the back of the opposite shoulder. The magnitude of these deficits correlated significantly with gender and diagnosis but not with age.

Do progressive tension sutures really decrease complications in abdominoplasty?

The purpose of this study is to evaluate the efficacy of progressive tension sutures (PTS) in preventing or reducing seroma formation and local wound complications in patients undergoing abdominoplasty. Forty-nine patients who underwent abdominoplasty procedures with the use of PTS were retrospectively compared with a historical control group of 54 patients who underwent standard abdominoplasty. Primary outcomes measured were seroma formation and local wound complications, including hypertrophic scar formation, umbilical distortion, and wound necrosis. Secondary outcomes were all other complications and time to drain removal. Overall complication rates and local wound complication rates were significantly reduced with the addition of PTS to abdominoplasty. Seroma formation and the time to drain removal were reduced in the PTS group, but the findings were not statistically significant.

Characterizing the effect of diagnosis on presenting deficits and outcomes after total shoulder arthroplasty.

This study compared self-assessed deficits in comfort, function, and health status before and after total shoulder arthroplasty for 4 different diagnoses: degenerative joint disease (DJD), secondary DJD (2 degrees DJD), rheumatoid arthritis (RA), and capsulorrhaphy arthropathy (CA). Deficits were assessed by the Simple Shoulder Test and Short Form 36 (SF-36) questionnaires. There was a significant difference among diagnoses for preoperative and postoperative functional deficits. The profiles of improvement within the categories of comfort, motion, strength, and function were different for each diagnosis. Patients with DJD and CA were most improved in the category of motion, whereas those with 2 degrees DJD and RA were most improved in the category of comfort. There was also a statistically significant difference in 5 of the 8 domains of the preoperative SF-36 among diagnoses. Factors associated with each diagnosis play a significant role in determining the magnitude of preoperative deficits and postoperative improvement in shoulder function.

Patient functional self-assessment in late glenoid component failure at three to eleven years after total shoulder arthroplasty.

Failure of the glenoid component is the most common indication for late revision of a total shoulder arthroplasty (TSA). This is the first study to characterize the deterioration in patient self-assessment of shoulder function occurring with glenoid component failure at times remote from the index surgery. Of 115 total shoulders, 11 had revision by the original surgeon for isolated glenoid loosening. Simple Shoulder Test scores averaged 4.4 before TSA, rose to a mean of 11.3 after surgery, and fell to a mean of 4.6 before revision for glenoid loosening performed at a mean of 7 years after TSA. All shoulders showed a drop of at least 3 points between the peak Simple Shoulder Test score and the prerevision Simple Shoulder Test score. Periodic self-assessment of shoulder function may offer a method of screening patients for the possibility of late glenoid component failure.

Optimizing the glenoid contribution to the stability of a humeral hemiarthroplasty without a prosthetic glenoid.

BACKGROUND: In a shoulder requiring arthroplasty, if the glenoid is flat or biconcave, the surgeon can restore the desired glenoid stability by using a glenoid prosthesis with a known surface geometry or by modifying the surface of the glenoid to a geometry that provides the desired glenoid stability. This study tested the hypotheses that (1) the stability provided by the glenoid is reduced by the removal of the articular cartilage; (2) the stability contributed by the glenoid is compromised by loss of its articular cartilage, and this lost stability can be restored by spherical reaming along the glenoid centerline; and (3) the stability of a reamed glenoid is comparable with that of a native glenoid and with that of a polyethylene glenoid with similar surface geometry; and (4) the glenoid stability can be predicted from the glenoid surface geometry. METHODS: The stability provided by the glenoid in a given direction can be characterized by the maximal angle that the humeral joint reaction force can make with the glenoid centerline before the humeral head dislocates; this quantity is defined as the balance stability angle in the specified direction. The balance stability angles were both calculated and measured in eight different directions for an unused polyethylene glenoid component and eleven cadaveric glenoids in four different states: (1) native without the capsule or the rotator cuff, (2) denuded of cartilage and labrum, (3) after reaming the glenoid surface around the glenoid centerline with use of a spherical reamer with a radius of 25 mm, and (4) after reaming around the glenoid centerline with use of a spherical reamer with a radius of 22.5 mm. RESULTS: The calculated and measured balance stability angles for each direction in each glenoid were strongly correlated. Denuding the glenoids of the articular cartilage reduced the glenoid contribution to stability, especially in the posterior direction. Reaming the glenoid restored the stability to values comparable with those of the normal glenoid. For example, the average calculated balance stability angle (and standard deviation) in the posterior direction for all eleven glenoids was 24 degrees for the native glenoids, 14 degrees for the denuded glenoids, 25 degrees for the glenoids reamed to a radius of 25 mm, and 33 degrees for the glenoids reamed to a radius of 22.5 mm. The values for the glenoids reamed to 25 mm (25 degrees ) were similar to those of a polyethylene glenoid of the same radius of curvature. For glenoids reamed to 22.5 mm, the average difference between the actual balance stability angle and that predicted from the glenoid geometry was 3.4 degrees +/- 2.4 degrees. CONCLUSIONS: The glenoid contribution to shoulder stability was decreased by the removal of cartilage and labrum and was restored by spherical reaming to a level similar to resurfacing the glenoid with a polyethylene component.

Glenohumeral arthritis and its management.

Glenohumeral arthritis has many different etiologies, including osteo-arthritis, secondary degenerative joint disease, rheumatoid arthritis,avascular necrosis, cuff tear arthropathy, and capsulorrhaphy arthropathy. Each of these diagnoses may have different underlying pathoanatomy and pathomechanics. The treating physician must recognize how these characteristics impair shoulder function so that the prescribed course of treatment addresses the root causes of shoulder dysfunction. The patient's age. level of physical activity, and comorbidities should be taken into account, and the intended management should be weighed against how these factors may interfere with treatment efficacy over the long-term. The goal of treatment is to restore comfort, motion, strength, and stability to the shoulder in a safe and reliable manner. Conservative treatments should aim to optimize shoulder flexibility, maintain muscle function, and reduce inflammation. Activity modification is crucial but often unreasonable to the active patient. Temporary surgical approaches include arthroscopic debridement and synovectomy. These approaches may be appropriate for a younger patient with some remaining joint space and a functional rotator cuff. Definitive surgical treatment typically involves either a proximal humerus replace mentor a total shoulder replacement. The decision to resurface the glenoid should be based on the patient's age, diagnosis, available bone stock, and physical demands. The surgeon must be familiar with the options provided by the given implant system so that the proper balance of motion and stability can be restored with a close approximation of the native anatomy. Inexperienced hands, good-to-excellent results can be achieved in greater than 90% of properly selected patients. Glenoid component failure is one of the most common complications of shoulder arthroplasty, highlighting the need to select carefully patients in whom glenoid resurfacing is warranted.