Acute Aortic Injury and Bilateral Pulmonary Emboli in the Setting of COVID-19.

In this report, we present the case of a 72-year-old female diagnosed with an aortic dissection variant and bilateral pulmonary emboli (PE) in the setting of Coronavirus Disease of 2019 (COVID-19) infection. The patient was transported from home to the emergency department (ED) via emergency medical services (EMS) with acute chest pain and dyspnea. After arriving at the ED, she was hypoxic on her baseline supplemental O2 requirement and tachycardic and tachypneic. Computed tomography (CT) angiogram of the chest showed evidence of possible thoracic aortic dissection and bilateral PE. The patient was ultimately transported to a tertiary center for operative aortic repair and bilateral embolectomy and, fortunately, survived the procedures. Interestingly, during operative repair of the aorta, no obvious dissection flap was noted, but rather evidence of a limited tear in the intimal layer of the aorta. This is an interesting case as acute aortic injuries in the setting of COVID-19 infection have not been as widely documented as PE in the setting of COVID and highlight the need for further research on the possible association between them.

Does Resident Participation Influence Surgical Time and Clinical Outcomes? An Analysis on Primary Bilateral Single-Staged Sequential Total Knee Arthroplasty.

Background: Although several studies have indirectly compared teaching and nonteaching hospitals, results are conflicting, and evaluation of the direct impact of trainee involvement is lacking. We investigated the direct impact of resident participation in primary total knee arthroplasties (TKAs). Material and methods: Fifty patients undergoing single-staged sequential bilateral primary TKAs were evaluated. The more symptomatic side was performed by the attending surgeon first, followed by the contralateral side performed by a chief resident under direct supervision and assistance of the same attending surgeon. Surgery was subdivided into 8 critical steps on both sides. The overall time and critical stepwise surgical time and short-term clinical outcomes were then compared between the 2 sides. Results: The attending surgeon completed the surgery (skin incision to dressing) significantly faster than the resident (70.2 vs 96.9 minutes) by a mean of 26.7 minutes (P < .05) and was also faster in all steps. The most significant differences in time were in "exposure" (9.5 vs 16.5 minutes) and "closure" steps (13.2 vs 24.9 minites), all P < .001. Adverse events occurred in 7 patients; 5 of these resolved uneventfully. There were no significant differences in surgical complications, objective outcome scores, or patient satisfaction scores between both sides. Conclusion: Resident participation in TKA increased operative time without jeopardizing short-term patient clinical outcomes, satisfaction, and complications. This may alleviate concerns from patients and policymakers about TKA in an academic setting. Surgical "exposure" and "closure" were the most prolonged steps for the residents, and they may benefit with more focus and/or simulation studies during training.

Superior Trunk Block: A Phrenic-sparing Alternative to the Interscalene Block: A Randomized Controlled Trial.

BACKGROUND: Interscalene nerve blockade remains one of the most commonly used anesthetic and analgesic approaches for shoulder surgery. The high incidence of hemidiaphragmatic paralysis associated with the block, however, precludes its use among patients with compromised pulmonary function. To address this issue, recent studies have investigated phrenic-sparing alternatives that provide analgesia. None, however, have been able to reliably demonstrate surgical anesthesia without significant risk for hemidiaphragmatic paralysis. The utility of the superior trunk block has yet to be studied. The hypothesis was that compared with the interscalene block, the superior trunk block will provide noninferior surgical anesthesia and analgesia while sparing the phrenic nerve. METHODS: This randomized controlled trial included 126 patients undergoing arthroscopic ambulatory shoulder surgery. Patients either received a superior trunk block (n = 63) or an interscalene block (n = 63). The primary outcomes were the incidence of hemidiaphragmatic paralysis and worst pain score in the recovery room. Ultrasound was used to assess for hemidiaphragmatic paralysis. Secondary outcomes included noninvasively measured parameters of respiratory function, opioid consumption, handgrip strength, adverse effects, and patient satisfaction. RESULTS: The superior trunk group had a significantly lower incidence of hemidiaphragmatic paralysis compared with the interscalene group (3 of 62 [4.8%] vs. 45 of 63 [71.4%]; P < 0.001, adjusted odds ratio 0.02 [95% CI, 0.01, 0.07]), whereas the worst pain scores in the recovery room were noninferior (0 [0, 2] vs. 0 [0, 3]; P = 0.951). The superior trunk group were more satisfied, had unaffected respiratory parameters, and had a lower incidence of hoarseness. No difference in handgrip strength or opioid consumption were detected. Superior trunk block was associated with lower worst pain scores on postoperative day 1. CONCLUSIONS: Compared with the interscalene block, the superior trunk block provides noninferior surgical anesthesia while preserving diaphragmatic function. The superior trunk block may therefore be considered an alternative to traditional interscalene block for shoulder surgery.

Addition of Infiltration Between the Popliteal Artery and the Capsule of the Posterior Knee and Adductor Canal Block to Periarticular Injection Enhances Postoperative Pain Control in Total Knee Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: Periarticular injections (PAIs) are becoming a staple component of multimodal joint pathways. Motor-sparing peripheral nerve blocks, such as the infiltration between the popliteal artery and capsule of the posterior knee (IPACK) and the adductor canal block (ACB), may augment PAI in multimodal analgesic pathways for knee arthroplasty, but supporting literature remains rare. We hypothesized that the addition of ACB and IPACK to PAI would lower pain on ambulation on postoperative day (POD) 1 compared to PAI alone. METHODS: This triple-blinded randomized controlled trial included 86 patients undergoing unilateral total knee arthroplasty. Patients either received (1) a PAI (control group, n = 43) or (2) an IPACK with an ACB and modified PAI (intervention group, n = 43). The primary outcome was pain on ambulation on POD 1. Secondary outcomes included numeric rating scale (NRS) pain scores, patient satisfaction, and opioid consumption. RESULTS: The intervention group reported significantly lower NRS pain scores on ambulation than the control group on POD 1 (difference in means [95% confidence interval], -3.3 [-4.0 to -2.7]; P < .001). In addition, NRS pain scores on ambulation on POD 0 (-3.5 [-4.3 to -2.7]; P < .001) and POD 2 (-1.0 [-1.9 to -0.1]; P = .033) were significantly lower. Patients in the intervention group were more satisfied, had less opioid consumption (P = .005, postanesthesia care unit, P = .028, POD 0), less intravenous opioids (P < .001), and reduced need for intravenous patient-controlled analgesia (P = .037). CONCLUSIONS: The addition of IPACK and ACB to PAI significantly improves analgesia and reduces opioid consumption after total knee arthroplasty compared to PAI alone. This study strongly supports IPACK and ACB use within a multimodal analgesic pathway.

Sensation seeking and impulsivity: combined associations with risky sexual behavior in a large sample of young adults.

Although prior studies have shown that sensation seeking and impulsive decision-making are related to sexual risk-taking, it is still unclear whether these personality traits operate independently or synergistically. The purpose of this study was to elucidate the joint contribution of these personality traits to HIV and sexually transmitted disease (STD) risk behaviors using data from a large sample of sexually active young adults (N = 2,386). Regression modeling indicated that both sensation seeking and impulsive decision-making were consistently associated with sexual risk behaviors across 11 risk-related outcomes. Results further indicated that sensation seeking and impulsive decision-making operated synergistically with respect to the outcome variables of sex acts using drugs, acts with a partner using alcohol, and acts with a partner using drugs. In contrast to this, sensation seeking and impulsive decision-making operated independently with respect to the other sexual risk outcomes. Theoretical implications, as well as implications for HIV/STD prevention among high sensation seekers and impulsive decision-makers, are discussed.