Tarsal Buckling and Entropion after Levator Aponeurosis Advancement in Patients with Floppy Eyelid Syndrome.

Two patients with floppy eyelid syndrome presented with severe eye pain and foreign body sensation after recent levator aponeurosis advancement. The examination in both patients was notable for entropion of the upper eyelid, and upper lid eversion revealed deformity of the tarsus in both patients. Surgical revision with full-thickness horizontal tarsotomy and limited excision of the abnormal tarsus corrected the deformity. The authors propose a mechanism for this phenomenon and a modification of surgical technique that may prevent this complication.

Association of Time to Definitive Hemostasis With Mortality in Patients With Solid Organ Injuries.

Introduction The Golden Hour is a term used in the trauma setting to refer to the first 60 minutes after injury. Traditionally, definitive care within this period was believed to dramatically increase a patient's survival. Though the period of 60 minutes is unlikely to represent a point of distinct inflection in survival, the effect of time to definitive care on survival remains incompletely understood. This study aims to measure the association of time to definitive hemostasis with mortality in patients with solid organ injuries as well as the effect of survival bias and a form of selection bias known as indication by severity on the relationship between time to treatment and survival. Methodology This is a retrospective cohort study using data obtained from the American College of Surgeons National Trauma Data Bank (NTDB) from the years 2017 through 2019 selecting patients treated for blunt liver, spleen, or kidney injury who required angioembolization or surgical hemostasis within six hours. A Cox proportional hazards regression was used to analyze time to death. The association of probability of death with time was examined with a multivariate logistic regression initially treating the relationship as linear and subsequently transforming time to hemostasis with restricted cubic splines to model a non-linear association with the outcome. To model survival and indication by severity bias, we created a computer-generated data set and used LOESS regressions to display curves of the simulated data. Results The multivariate Cox proportional hazards analysis shows a coefficient of negative 0.004 for minutes to hemostasis with an adjusted hazard ratio of 0.9959 showing the adjusted hazard of death slightly diminishes with each increasing minute to hemostasis. The likelihood ratio chi-square difference between the model with time to hemostasis included as a linear term versus the model with the restricted cubic spline transformation is 97.46 (p<0.0001) showing the model with restricted cubic splines is a better fit for the data. The computer-generated data simulating treatment of solid organ injury with no programmed bias displays an almost linear association of mortality with increased treatment delay. When indications by severity bias and survival bias are introduced, the risk of death decreases with time to hemostasis as in the real-world data. Conclusion Decreasing mortality with increasing delay to hemostasis in trauma patients with solid organ injury is likely due to confounding due to indication by severity and survival bias. After taking these biases into account, the association of delayed hemostasis with better survival is not likely due to the benefit of delay but rather the delay sorts patients by severity of injury with those more likely to die being treated first. These biases are extremely difficult to eliminate which limits the ability to measure the true effect of delay with retrospective data. The findings may however be of value as a predictive model to anticipate the acuity of a patient after an interval of unavoidable delay such as with a long transfer time.

The Extremes of Constipation: A Case of Stercoral Perforation From Fecal Impaction in a Teenager.

Stercoral perforation is a rare sequela of poorly controlled constipation that is more commonly seen in older, bedridden patients than in pediatric patients. We present the case of a 13-year-old patient requiring a divided sigmoid colostomy following rectal perforation, one of the few examples in the pediatric literature of stercoral perforation from chronic constipation. The current report highlights the importance of appropriate treatment of functional constipation at onset and the life-threatening complications that can occur without appropriate follow-up.

Efficacy of teprotumumab therapy in patients with long-duration thyroid eye disease.

PURPOSE OF REVIEW: Teprotumumab, an inhibitor of the insulin-like growth factor 1 receptor (IGF-1R), was approved by the US Food and Drug Administration in January 2020 for the treatment of thyroid eye disease (TED). The clinical trials leading to its approval enrolled patients with recent disease onset and significant inflammatory symptoms and signs. Subsequent real-world teprotumumab use in patients with longer duration of disease also may be effective, and there have been several publications reporting on experience in these patient groups. RECENT FINDINGS: TED results in disfiguring changes such as ocular proptosis and affects visual function by altering extraocular muscle function, leading to diplopia. Compressive optic neuropathy also may occur, and disease manifestations may persist for years. Teprotumumab treatment in cases of TED in which prior interventions (medical or surgical) had failed, or in treatment-naïve patients whose disease had been stable for years, has been reported to improve both clinical signs and symptoms (proptosis, diplopia) and to reduce the pathologic orbital changes as assessed by orbital imaging. SUMMARY: Teprotumumab may be an appropriate treatment for TED regardless of disease duration and irrespective of the presence or absence of markers of active inflammation within the orbit.

Elevated Cardiac Troponin Is Most Often Associated With Type 2 Myocardial Infarction in Trauma Patients.

Introduction Cardiac troponin (cTn) forms an essential part of the diagnostic criteria for myocardial infarction (MI). Type 1 MI is a primary coronary arterial event, whereas type 2 MI is due to coronary oxygen supply/demand mismatch, which is common in trauma patients. In addition, cTn may be elevated for many reasons other than MI. cTn elevations in trauma may not be specific for MI amenable to revascularization. The aim of this study is to determine which subset of trauma patients benefits from measuring cTn, and which patients with elevated cTn benefit from ischemic workup. Methods This is a retrospective cohort study. All patients on the trauma service of a level 1 trauma center with cTn elevated above the upper reference value of 0.032 ng/ml from July 2017 through December 2020 were selected. Baseline characteristics were recorded. The main outcomes were cardiology determination of the etiology of elevated cTn and patient survival. Logistic regression was used for multivariate analysis. Results One hundred forty-seven (147; 1.1%) of 13746 trauma patients had maximum cTn over the 99th percentile. Forty-one (27.5%) of the 147 had ischemic changes on electrocardiogram (ECG). Sixty-four (43.0%) had chest pain. In 81 (55.1%) cases, cTn was ordered without a clearly justified indication. One hundred thirty-seven patients (93.3%) received a cardiology consult. Two (1.5%) of 137 patients had a type 1 MI, which was diagnosed by ECG and clinical symptoms before cTn results were available. One hundred thirty-five patients were evaluated for cardiac ischemia based on elevated cTn. In 91 (66.4%) cases, the elevated cTn was attributed to a cardiac oxygen supply/demand mismatch. The etiology was cardiac contusion for 26 (19.0%), with the rest attributed to various other trauma-related causes. The cardiology consult changed management for 90 (65.7%) patients, mainly consisting of further evaluation by echocardiogram for 78 (57.0%) patients. Elevated cTn was a significant independent predictor of death with an adjusted odds ratio of 2.6 (p=0.002). Conclusion Isolated cTn values in trauma are most often due to type 2 MI resulting from trauma-related issues, such as tachycardia and anemia, which affect myocardial oxygen supply and demand. Changes in management generally consisted of further workup and interventions such as monitoring and pharmacologic treatment. Elevated cTn in this cohort never led to revascularization but was valuable to identify patients who required more intensive monitoring, longer-term follow-up, and supportive cardiac care. More selective ordering of cTn would improve specificity for patients requiring specialized cardiac care.

Apigenin attenuates depressive-like behavior via modulating monoamine oxidase A enzyme activity in chronically stressed mice.

Chronic stress is a risk factor for depression and is characterized by elevated levels of brain monoamine oxidase A (MAOA). Mounting evidence has shown that MAOA is a biochemical link between stress and depression. Apigenin (API), a natural flavonoid, as demonstrated in vitro inhibitory effect on MAOA, is suggestive of antidepressant-like activity. However, the in vivo inhibitory effect of API on MAOA and how it affects depression still remain unclear. Here, we report the probable mechanisms of action of API in chronic unpredictable mild stress (CUMS)-induced depression in mice. Treatment with API reversed anhedonia, and reduced anxiety and immobility time in behavioral studies. API reduced brain corticosterone and malondialdehyde (MDA) levels but increased brain levels of glutathione and superoxide dismutase. Furthermore, interleukin-6 and tumor necrosis factor-α were attenuated by API. It also restored cell loss and inhibited the activity of MAOA in the hippocampal brain regions and prefrontal cortex. Comparative binding affinity of API for MAOA (-7.7 kcal/mol) through molecular docking studies was greater than that of reference compound, clorgyline (-6.8 kcal/mol). Favorable hydrophobic interactions important to API binding at MAOA binding cavity was revealed to include conventional hydrogen bond (Cys323 and Tyr444), π-Sulfur (Cys323), π-π Stacked (Tyr407), π-π T-shaped (Phe208), π-lone pair and π-alkyl (Ile335, Ile180) interactions. These results suggest that API is a potent, selective, reversible inhibitor of MAOA with capability of attenuating CUMS-induced depression via inhibiting MAOA enzyme activity and altering other pathomechanisms.

Fluid and Solute Intakes Show Minimal Association With Serum Sodium Levels in a Mixed ICU Population.

BACKGROUND:  Hyponatremia is common among hospital inpatients. It is generally due to excess free body water resulting from increased water intake and decreased water elimination due to underlying pathology and hormonal influence. However, supporting evidence is lacking for treating mild hyponatremia with fluid restriction. Our study examines the association between hyponatremia and fluid intake in acutely ill inpatients. We hypothesize that fluid intake is not closely associated with serum sodium (SNa). METHODS:  We conducted a retrospective study of hyponatremia using the Multiparameter Intelligent Monitoring in Intensive Care (MIMIC) III dataset, a public ICU registry. We analyzed fluid, sodium, and potassium intake with a mixed model linear regression with SNa as the outcome for hyponatremic and non-hyponatremic patients and cumulative total input from one to seven days. In addition, we compared a group of patients receiving less than one liter of fluid per day to a group receiving more than one liter. RESULTS:  The association of SNa with fluid intake was negative and statistically significant for most cumulative days of intake from one to seven for the total population and those with sporadic hyponatremia. For those with uniform hyponatremia, the negative association was significant for three and four days of cumulative input. The change in SNa was almost always less than 1 mmol/L of additional fluid intake across all groups. SNa for hyponatremic patients who received less than one liter of fluid per day were within one mmol/L of those who received more (p<0.001 for one, two, and seven cumulative intake days). CONCLUSIONS:  SNa is associated with a change of less than 1 mmol/L across a wide range of fluid and sodium intake in adult ICU patients. Patients who received less than one liter per day had SNa almost identical to those who received more. This suggests that SNa is not tightly coupled with fluid intake in the acutely ill population and that hormonal control of water elimination is the predominant mechanism. This might explain why the correction of hyponatremia by fluid restriction is often difficult.

Vacuum-Assisted Closure Treats Refractory Esophageal Leak in a Pediatric Patient.

Esophageal perforations can have iatrogenic and non-iatrogenic causes. Early identification is a predictor of good outcomes. When identified, perforations can be managed conservatively with wide drainage or repaired surgically. Endoscopic esophageal vacuum-assisted closure may be used as a definitive treatment, particularly in scenarios where conservative management and primary surgical repair fail to achieve complete healing. We present such a scenario advocating for the consideration of endoscopic esophageal vacuum-assisted closure in patients with refractory esophageal leaks.

Efficacy of Demineralized Bone Matrix for Revision Alveolar Bone Grafting in Patients Previously Treated with Bone Morphogenetic Protein 2 (BMP-2).

OBJECTIVE: This study investigates the effectiveness of demineralized bone matrix (DBX) to close alveolar clefts in patients previously treated with bone morphogenic protein-2 (BMP-2) who remained with bone nonunion. DESIGN: This is an IRB-approved retrospective, single-center study. SETTING: This study was conducted at a tertiary academic center. PATIENTS/PARTICIPANTS: We searched for all surgical encounters with the Current Procedural Terminology (CPT) code 42210 from the years 2013-2019. Included patients were diagnosed with cleft alveolus, previous BMP-2 exposure and required revision bone grafting during mixed dentition for persistent alveolar defects. INTERVENTIONS: 17 patients underwent revision alveolar bone grafting (ABG) with either DBX (n = 10) or autograft (n = 7) to repair persistent bony cleft. MAIN OUTCOME MEASURE(S): The primary study outcome measured was alveolar bone graft revision failure described as continued alveolar nonunion. RESULTS: The median age at revision ABG was 13.1 ± 3.3 years, with a mean follow-up time of 4.9 years (1.1-9.2 years). Patients were 53% male, 47% had a unilateral cleft lip and alveolus. 58.8% of patients were treated with DBX in the cleft, 41.2% treated with autograft from iliac crest. Overall, 11.8% (n = 2) of all revisions failed, requiring a second revision. The average time to reoperation was 2.06 years, and both were re-grafted with autograft. There was no statistically significant difference between the type of bone graft source used and the failure rate obtained (P = .1544). CONCLUSIONS: DBX and autologous iliac crest bone grafts achieve similar alveolar union rates during revision ABG in patients treated with previous BMP-2 to the alveolar cleft.

Surgical Reconstruction Options for a Case of Near Total Intestinal Aganglionosis.

Hirschsprung's disease is a congenital anomaly affecting neural crest cell migration and proliferation in the myenteric plexi resulting in dysmotility, which can present as bilious emesis, delayed meconium passage, and bowel obstruction in neonates, or chronic constipation in older children. Depending on the extent of aganglionosis, this disease can involve the whole gut. Treatment involves a temporary ostomy and interval definitive surgical reconstruction. In patients with near or total intestinal aganglionosis, however, there is no consensus on the most effective surgical reconstruction as consideration of the length and function of the normal remnant bowel create concerns for complications with short bowel syndrome post-operatively. We present a case of near-total intestinal aganglionosis highlighting the various options for definitive surgical reconstruction.

Traumatic Left Anterior Descending Artery Dissection in a Case of Pediatric Blunt Chest Trauma.

Despite the reserve for recovery in pediatric trauma, blunt force chest trauma can cause insidious injuries that are easy to miss. Coronary artery dissection is a rare injury associated with blunt force chest trauma in the pediatric population and can present with vague or atypical symptoms. Pediatric patients can be unreliable in reporting symptoms, and providers can mistake coronary artery injuries for myocardial contusion, especially with improving laboratory tests and equivocal imaging. We report a case showing the importance of a high index of suspicion when presented with this trauma pattern in a pediatric patient.

Presenting a Case of an Extralobar and Extrapleural Pulmonary Sequestration in a Four-Month-Old Infant.

Pulmonary sequestration is a congenital disease formed by embryogenic separation of the lung parenchyma, halting development and function. It has an aberrant blood supply and can provide a nidus for infection and respiratory compromise. It can be diagnosed prenatally with surgical resection after delivery reserved as the best mode of treatment. In literature, six to twelve months is the most optimal time for elective surgical repair giving time for some maturation to withstand single lung ventilation and operation before the risk of infection heightens after 12 months. We present a case of an infant that had an elective repair at four months of age with no postoperative sequelae highlighting that surgeons can perform elective repair sooner than six months of age and that surgical decision-making should be on a case-by-case basis.

Endpoints in Vital Signs as a Useful Tool for Measuring Successful Needle Decompression After Traumatic Tension Pneumothorax: An Analysis of the National Emergency Medicine Information System Database.

Background Needle decompression is a useful tool in the pre-hospital setting for treating tension pneumothorax. However the specific improvements in vital signs that determine a successful decompression are only reported in a few studies and Emergency Medical Services (EMS) self-reported assessments of improvement are more commonplace. We hypothesize that EMS reports may exaggerate improvement when compared to objective vital sign changes. Methodology This is a retrospective cohort study using the National Emergency Medicine Information System (NEMSIS) for the year 2020. Vital signs recorded as objective endpoints include systolic blood pressure (SBP), pulse (HR), respiratory rate (RR), and oxygen saturation (SpO2). Univariate analysis was performed using the t-test for continuous variables and the chi-square test for categorical variables. Results A total of 8,219 calls were included in the sample size analyzed. Most patients were white (2,911, 35.4%) and male (6,694, 81.4%). Abnormal vitals recorded as indications for needle decompression included SBP <100 mmHg, HR <60 or >100 beats/minute, RR <12 or >20 breaths/minute, and SpO2 <93%. Statistically significant improvements were seen in the number of abnormal vital signs after the procedure. The percentage of improvement was higher in the EMS self-reported assessment than in objective findings for oxygen saturation and SBP. Conclusions Our analysis shows objective improvement of hypoxia and hypotension after field needle decompression, supporting the efficacy of the procedure. The improvement based on vital sign change is modest and is less than that reported by EMS assessment of global improvement. This represents a target for quality improvement in EMS practice.

A Rare Occurrence of Rotational Retro-Esophageal Gastric Body Herniation Through a Nissen Fundoplication.

Anti-reflux procedures have become a mainstay in managing gastroesophageal reflux disease (GERD) and hiatal hernia. Unfortunately, post-operative events such as breakdown of the wrap, downward slippage, or transdiaphragmatic herniation of an intact wrap cause these procedures to fail and create complications such as recurrent hiatal hernia and reflux dysphagia, regurgitation, and obstruction requiring revision surgery. We discuss a case of a rotational retro-esophageal herniation of the gastric body through a Nissen fundoplication presenting as obstruction, dysphagia, and regurgitation, highlighting the peculiar nature of this presentation and the ease of misdiagnosis given its rarity.

A Case of Delayed Cecal Perforation After Abdominal (Seat Belt) Injury.

Seatbelts have reduced the number of fatal head, facial, and chest injuries. They have, however, introduced a set of injuries comprising abdominal wall bruising, Intra-abdominal injuries, and lumbar spine fractures collectively termed the seat belt syndrome. Surgical repair is the treatment for encountered bowel injuries. We present a case of delayed bowel perforation following presentation with signs of seat belt trauma identifying a decisional dilemma in the surgical management of serosal tears with no apparent signs of perforation.

A Novel Method for ECG Artifact Removal from EEG without Simultaneous ECG.

The electrocardiogram (ECG) is a common source of electrical artifact in electroencephalogram (EEG). Here, we present a novel method for removing ECG artifact that requires neither simultaneous ECG nor transformation of the EEG signals. The approach relies upon processing a subset of EEG channels that contain ECG artifact to identify the times of each R-wave of the ECG. Within selected brief epochs, data in each EEG channel is signal-averaged ± 60 ms around each R-wave to derive an ECG template specific to each channel. This template is subtracted from each EEG channel which are aligned with the R-waves. The methodology was developed using two cohorts of infants: one with 128-lead EEG including an ECG reference and another with 32-lead EEG without ECG reference. The results for the first cohort validated the methodology the ECG reference and the second demonstrated its feasibility when ECG was not recorded. This method does not require independent, simultaneous recording of ECG, nor does it involve creation of an artifact template based on a mixture of EEG channel data as required by other methods such as Independent Component Analysis (ICA). Spectral analysis confirms that the method compares favorably to results using simultaneous recordings of ECG. The method removes ECG artifact on an epoch by epoch level and does not require stationarity of the artifact. Clinical Relevance - This approach facilitates the removal of ECG noise in frequency bands known to play a central role in brain mechanisms underlying cognitive processes.

Intraoperative Doppler Ultrasound for Detection of Early Postoperative Vascular Complications in Orthotopic Liver Transplants.

Liver transplantation is currently the only curative treatment for patients with end-stage liver disease. However, liver transplantation can be associated with catastrophic complications in the early postoperative setting, including hepatic artery thrombosis (HAT) and portal vein thrombosis (PVT). Postoperative complications are associated with hepatic artery resistive index (RI) < 6, systolic acceleration time (SAT) > 0.08 seconds and peak systolic velocity (PSV) > 200 cm/s on doppler ultrasound (DUS). DUS is also used in an intraoperative setting to assess patency and early complications prior to the end of the operative period, allowing for early correction. This literature review evaluates the prevalence of DUS use in intraoperative settings to identify transplant complications. A lack of consistency and minimal knowledge of intraoperative DUS warrants additional research into its usage and standardization.

Methanol leaf extract of Paullinia pinnata exerts sleep-enhancing and anticonvulsant effects via a mechanism involving the GABAergic pathway.

PURPOSE: Leaf extracts of Paullinia pinnata L. (Sapindaceae) are used in ethnomedicine for the treatment of central nervous system-related diseases such as insomnia and epilepsy. We determined the bioactive constituents, sleep-enhancing and anti-convulsant potentials, and possible mechanisms of action of P. pinnata methanol leaf extract (PPME). METHODS: Gas Chromatography-Mass spectrometry (GC-MS) was used to identify the bioactive compounds in PPME. Adult Swiss albino mice were used. Oral LD50 was estimated before administering PPME at oral doses of 100, 200, and 400 mg/kg to test for sleep-enhancing and anticonvulsant properties. To evaluate the possible mechanisms involved, mice were pretreated for five days with isoniazid (NIH) a GABA synthesis inhibitor before re-evaluation of sleep-enhancing property. The activities of glutamic acid decarboxylase (GAD), superoxide dismutase (SOD), catalase (CAT), and the level of malondialdehyde (MAD) in the brain of mice were also evaluated after a 7-day treatment with the extract. RESULTS: Twenty-five phytochemical compounds were identified from GC-MS analysis with fatty acid esters of lauric and fumaric acids being the most abundant. The oral LD50 of PPME was estimated to be greater than 5000 mg/kg. Doses of PPME significantly (p < 0.001) reduced sleep latency and increased the duration of sleep of phenobarbital-treated mice. Except for 100 mg/kg, the doses also significantly protected mice against maximum electroshock (p < 0.001) and pentylenetetrazole (p < 0.05) but not strychnine-induced convulsions. Pretreatment with isoniazid (INH) almost completely reversed the sleep-enhancing effects of PPME. The activities of GAD, SOD, and CAT, and level of MDA in brains of the mice were significantly (p < 0.001) increased by doses of PPME administered for five days. CONCLUSION: The extract possesses sleep-enhancing and anticonvulsant properties which depend on increased level of GABA in the brain. Its antioxidant action may be neuroprotective against free radicals-induced damage.

Family nurture intervention increases term age forebrain EEG activity: A multicenter replication trial.

OBJECTIVE: This trial (RCT-2) sought to replicate the EEG findings of a randomized controlled trial of Family Nurture Intervention in the NICU (FNI-NICU) (RCT-1) comparing infants receiving standard care (SC) with infants receiving SC plus FNI . METHODS: RCT-2 (NCT02710474) was conducted at two NICUs. Subjects were randomly assigned to receive SC or FNI during their NICU stay. The primary outcome was EEG power in the frontal polar region at 39-41 weeks gestational age (GA). Sixty preterm infants (26-34 weeks GA; 33 SC, 27 FNI) were assessed. FNI-NICU consisted of repeated calming sessions (∼4 times/week) facilitated by Nurture Specialists during which mothers engaged in emotional expression during clothed or skin-to-skin holding, vocal soothing, and eye contact. EEGs were collected from 128 leads. EEG power was computed using Fast Fourier Transforms. RESULTS: RCT-2 replicated RCT-1 results; FNI-NICU led to significantly increased frontal polar power at frequencies > 12 Hz. Effects were spatially more widespread than in RCT-1, with substantial effect sizes (∼0.50) in frontal and parietal regions. CONCLUSIONS: RCT-2 results provide further evidence that FNI-NICU increases term age brain activity. SIGNIFICANCE: FNI-NICU is designed to facilitate autonomic emotional connection and coregulation between mothers and infants in the NICU resulting in profound effects on early brain development.