Forearm and elbow secondary surgical procedures in neonatal brachial plexus palsy: a systematic scoping review.

Background: Neonatal Brachial plexus palsy is an injury during delivery that can lead to loss of motor function and limited range of motion in patients due to damage of nerves in the brachial plexus. This scoping review aims to explore types of procedures performed and assess outcomes of forearm and elbow secondary surgery in pediatric patients. Methods: Searches of PubMed, Cochrane, Cumulative Index to Nursing and Allied Health Literature, Web of Sciences, and Scopus were completed to obtain studies describing surgical treatment of elbow and forearm in pediatric patients with neonatal Brachial plexus palsy. 865 abstracts and titles were screened by two independent reviewers resulting in 295 full text papers; after applying of inclusion and exclusion criteria 18 articles were included. The level of evidence of this study is level IV. Results: Ten main procedures were performed to regain function of the forearm and elbow in neonatal brachial plexus birth palsy patients. Procedures had different aims, with supination contracture (6) and elbow flexion restoration (5) being the most prevalent. The variance between preoperative and postoperative soft tissue and bony procedures outcomes decreased and showed improvement with respect to the aim of each procedure category. For soft tissue procedures, a statistically significant increase was found between preoperative and postoperative values for active elbow flexion, passive supination, and active supination. For bony procedures, there was a statistically significant decrease between preoperative and postoperative values of passive and active supination. Conclusion: Overall, all procedures completed in the assessed articles of this study were successful in their aim. Bony procedures, specifically osteotomies, were found to have a wider range of results, whereas soft tissue procedures were found to be more consistent and reproducible with respect to their outcomes. Bony and soft tissue procedures were found vary in their aims and outcomes. This study indicates the need for further research to augment knowledge about indications and long-term benefits to each procedure.

Evaluation of coagulopathy in cirrhotic patients: A scoping review of the utility of viscoelastic testing.

BACKGROUND: Cirrhosis causes significant coagulopathy. Traditional coagulation tests may not accurately measure coagulopathy in well-compensated patients with cirrhosis. Viscoelastic tests are functional tests that may better assess coagulopathy in cirrhotic patients. METHODS: We searched PubMed, ScienceDirect, Google Scholar, and grey literature using terms meaning viscoelastic testing and cirrhosis. After reviewing over 500 titles and abstracts, 40 full-text papers met inclusion criteria. RESULTS: Twenty-two papers found viscoelastic testing was a better indicator of baseline coagulation than traditional testing in cirrhosis. Nineteen additional papers evaluated the utility of peri-procedural viscoelastic testing and found they led to a reduction in blood product administration without increasing risk of hemorrhage, thrombotic events, or other complications. CONCLUSIONS: The usage of viscoelastic testing in patients with cirrhosis allows for better assessment of coagulopathy, resulting in improved outcomes. Educating physicians to optimize care of this high-risk group is necessary to further improve their treatment.

Outcomes of humeral osteotomies versus soft-tissue procedures in secondary surgical procedures for neonatal brachial plexus palsy: a meta-analysis.

Secondary surgical procedures can be used in brachial plexus birth injury to correct shoulder movement imbalances. This study compares outcomes of the two secondary surgical procedure types: humeral osteotomies and soft tissue procedures. Outcome measures assessed included active and passive internal and external rotation, active and passive abduction and adduction, active and passive flexion and extension, percentage of the humeral head anterior to the middle glenoid fossa, glenoid version, and Mallet Score. Nineteen full-text articles were included in the analysis. Humeral osteotomies resulted in a loss of internal rotation postoperatively (-15.94°). Active internal rotation was not evaluated for soft tissue procedures. All other assessed outcomes were improved postoperatively for bony and soft tissue procedures. Bony procedures exhibited a greater degree of active external rotation postoperatively when compared to soft tissue procedures (+67° vs. +40°). Both bony and soft tissue procedures Improve shoulder function in children with neonatal brachial plexus palsy, however, soft tissue procedures showed greater consistency in outcomes. Level of Evidence: IV.

Prevalence and services for the treatment of chronic pain at residential substance treatment centers.

Introduction: Studies suggest that a large proportion of patients with substance use disorders (SUDs) also have underlying chronic pain. There is limited data on prevalence of chronic pain treatment as a component of residential substance use treatment. This initiative sought to investigate the prevalence and type of chronic pain services offered at these residential programs.Methods: This study was a retrospective review of information obtained from residential substance use treatment facility websites contained in SAMHSA's treatment navigator. Nine hundred-fifty out of 2952 websites were randomly selected for analysis. The primary outcome was prevalence of facilities that had chronic pain programs. Services offered were specified as available. Descriptive statistics were used to summarize data.Results: Nine-hundred nine websites (95.7%, [94,97]) were accessible. Twenty-six facilities (2.9%,[1.9,4.2]) had a chronic pain program and of these 22 (84.6%, [64.3,95.0]) specified services offered. Common services included physical therapy (6, 27.3%), massage (12, 54.6%), and acupuncture (10, 45.5%). Of the remaining sites, 630 (69.3%, [66.2,72.3]) specified services offered, including yoga (122, 19.4%) and exercise (199, 31.6%).Conclusion: Our study demonstrated that despite most facilities offering adjunctive services, few had chronic pain programs. This suggests that there is a possible need for better updating of facility websites or possibly an area for improvement in residential substance use treatment settings.

Clinical Application of Thromboelastography in Patients With Cirrhosis: A Single Center Experience.

INTRODUCTION: Thromboelastography (TEG) is a functional test of coagulation used to guide transfusions. Despite literature supporting its utility, its use remains limited to select populations. In patients with cirrhosis, conventional coagulation tests are notoriously inaccurate, and TEG may be a better measure of coagulopathy. We aimed to assess the utilization of TEG in patients with cirrhosis to steward blood transfusions in this high-risk group. METHODS: A single-center retrospective chart review of all patients ≥18 y old with a diagnosis of liver cirrhosis who had TEG results documented in the electronic medical record from January 1 to November 1, 2021. RESULTS: There were 277 TEG results on 89 patients with cirrhosis. Overall, 91% of the TEGs performed were associated with a clinical indication for transfusion. However, of the patients who were transfused, abnormal TEG values, including elevated R time and reduced maximum amplitude, did not correspond to transfusion of indicated blood products (fresh frozen plasma and platelets). A reduction in alpha angle showed a statistically significant association with transfusion of cryoprecipitate (P < 0.05). When assessing conventional coagulation tests, abnormal values were not significantly associated with transfusion (P = 0.07). CONCLUSIONS: Despite TEG suggesting that transfusions could be avoided in many cirrhotic patients, patients are still being transfused platelets and fresh frozen plasma in the absence of evidence of coagulopathy on TEG. Our finding suggests the need for education about appropriate utilization of TEG. More research is needed to understand the role of these tests to guide transfusion practices in patients with cirrhosis.