Sound the Alarm: The Sonographer Shortage is Echoing Across Healthcare.

OBJECTIVES: The growth in ultrasound usage necessitates concurrent growth in the number of sonographers. Despite the increasing importance of ultrasound, there is a shortage of sonographers in the United States that has never been specifically quantified. This study examines recent trends in the number of ultrasound exams, sonography graduates, open sonographer positions, and wages. METHODS: This retrospective study uses public databases and surveys including the Medical Expenditure Panel Survey (MEPS), Bureau of Labor Statistics (BLS), Integrated Postsecondary Education Data System (IPEDS), and Zippia, a human resources platform to determine metrics. These metrics include the number of ultrasound exams conducted in the United States (excluding inpatient setting), number of sonographers and sonographer wages, sonography graduates, and open sonographer positions. RESULTS: Ultrasound exams in the United States from 2011 to 2021 increased from 38.6 million to 59.8 million (+55.1%,) while the number of sonographers (2011-2021) increased from 54,760 to 78,640 (+43.6%). There was a significant difference between supply and demand of sonographers with the number of sonography graduates (2011-2021) increasing from 4,386 to 5,393 (+23.0%) while the number of open sonographer positions (2012-2021) increased from 18,462 to 25,162 (+36.3%). CONCLUSIONS: From 2011 to 2021, the increase in the number of ultrasound exams has significantly outpaced the increase in the number of sonographers. Furthermore, the increase in demand for sonographers has grown significantly faster than the supply, leading to a shortage and consequent strain on the healthcare system. To address the shortage, the number of sonography school openings should be increased, and the attendant challenges addressed.

When the economy falters, hearts suffer: Economic recessions as a social determinant of health in cardiovascular emergencies.

INTRODUCTION: While the relationships between cardiovascular disease (CVD), stress, and financial strain are well studied, the association between recessionary periods and macroeconomic conditions on incidence of disease-specific CVD emergency department (ED) visits is not well established. OBJECTIVES: This retrospective observational study aimed to assess the relationship between macroeconomic trends and CVD ED visits. METHODS: This study uses data from the National Hospital Ambulatory Care Survey (NHAMCS), Federal Reserve Economic Database (FRED), National Bureau of Economic Research (NBER), and CVD groupings from National Vital Statistics (NVS) and Center for Medicare and Medicaid Services (CMS) from 1999 to 2020 to analyze ED visits in relation to macroeconomic indicators and NBER defined recessions and expansions. RESULTS: CVD ED visits grew by 79.7% from 1999 to 2020, significantly more than total ED visits (27.8%, p < 0.001). A national estimate of 213.2 million CVD ED visits, with 22.9 million visits in economic recessions were analyzed. A secondary group including a 6-month period before and after each recession (defined as a "broadened recession") was also analyzed to account for potential leading and lagging effects of the recession, with a total of 50.0 million visits. A significantly higher proportion of CVD ED visits related to heart failure (HF) and other acute ischemic heart diseases (IHD) was observed during recessionary time periods both directly and with a 6-month lead and lag (p < 0.05). The proportion of aortic aneurysm and dissection (AAA) and atherosclerosis (ASVD) ED visits was significantly higher (p = 0.024) in the recession period with a 6-month lead and lag. When controlled for common demographic factors, economic approximations of recession such as the CPI, federal funds rate, and real disposable income were significantly associated with increased CVD ED visits. CONCLUSION: Macroeconomic trends have a significant relationship with the overall mix of CVD ED visits and represent an understudied social determinant of health.

The ZorO-OrzO type I toxin-antitoxin locus: repression by the OrzO antitoxin.

Type I toxin-antitoxin loci consist of two genes: a small, hydrophobic, potentially toxic protein, and a small RNA (sRNA) antitoxin. The sRNA represses toxin gene expression by base pairing to the toxin mRNA. A previous bioinformatics search predicted a duplicated type I locus within Escherichia coli O157:H7 (EHEC), which we have named the gene pairs zorO-orzO and zorP-orzP. We show that overproduction of the zorO gene is toxic to E. coli; co-expression of the sRNA OrzO can neutralize this toxicity, confirming that the zorO-orzO pair is a true type I toxin-antitoxin locus. However, OrzO is unable to repress zorO in a strain deleted for RNase III, indicating that repression requires cleavage of the target mRNA. Sequence analysis and mutagenesis studies have elucidated a nucleotide sequence region (V1) that allows differential recognition of the zorO mRNA by OrzO and not OrzP, and a specific single nucleotide within the V1 of OrzO that is critical for repression of zorO. Although there are 18 nt of complementarity between the OrzO sRNA and the zorO mRNA, not all base pairing interactions are needed for repression; however, the amount needed is dependent on whether there is continuous or discontinuous complementarity to the target mRNA.

Intrathecal endoscopy to enhance the diagnosis of tethered cord syndrome.

OBJECT: Tethered cord syndrome (TCS) is being diagnosed in an increasing number of adults and late teens. Before referral to neurosurgeons, however, the majority of patients in this group suffers back and leg pain for a long period without a definitive diagnosis. The diagnostic difficulty derives from 2 factors: the signs and symptoms are subtle and easily overlooked, and the combination of an elongated cord and a thickened filum is lacking in 65% of patients. When a patient presents with signs and symptoms typical for TCS but demonstrates no elongated cord or thickened filum on MR imaging, one must search for a more reliable finding to establish a diagnosis of TCS. Based on the authors' earlier surgical experiences, posterior displacement of the terminal filum is consistently found at surgery in all patients with TCS. In previous publications they interpreted this finding as the lower cord and filum traveling along the concave side of the lumbosacral spinal canal to minimize cord tension. In the present prospective study, the authors attempt to confirm posterior displacement of the filum terminale by using intrathecal endoscopy prior to wide exposure of the spinal cord and filum. Further, the stretch test was applied to the terminal filum to evaluate its elasticity. METHODS: Sixty-eight patients with signs and symptoms as well as MR imaging studies indicative of TCS underwent endoscopic examination of the filum and cauda equina. After lumbar or sacral laminectomy, a flexible endoscope was inserted through a small dural and arachnoid incision into the subarachnoid space. The filum and cauda equina fibers were identified. Once the dura mater and arachnoid were opened widely, a stretch test was done to confirm filum inelasticity. In 3 patients, percutaneous endoscopy was also performed before open surgery to determine its applicability as compared with the open method. RESULTS: On inserting the endoscope into the intrathecal space, the filum was immediately identified medioposterior to the cauda equina fibers in all 68 patients. The stretch test revealed a lack of filum elasticity in all patients. Preoperative percutaneous endoscopy was equally effective in identifying the position of the filum. CONCLUSIONS: Currently, endoscopic identification of the posteriorly displaced filum, which was confirmed at open surgery, is the essential diagnostic study for TCS or the tethered spinal cord. Furthermore, the stretch test of the filum proves its inelasticity, and filum sectioning leads to ascension and relaxation of the caudal spinal cord. These results can be linked to the impaired oxidative metabolism of the lumbosacral cord under excessive tension and to the metabolic and neurological improvements seen after filum sectioning.

Bypass coaptation for cervical root avulsion: indications for optimal outcome.

OBJECTIVE: Previously, we reported bypass coaptation of the C3 and C4 anterior rami to the upper trunk of the brachial plexus for restoration of the muscles denervated as a result of C5 and C6 nerve root avulsion. This procedure is thought to be superior to the transfer of individual peripheral nerve fibers to the brachial plexus branches. Therefore, the benefits of the bypass coaptation procedures in the treatment of various root avulsions are presented. METHODS: Twenty-six patients were selected as suitable candidates for bypass coaptation procedures. They were divided into 3 groups: 1) Erb-Duchenne palsy due to C5 and C6 root avulsion, 2) Klumpke palsy due to C8 and T1 root avulsion, and 3) the flail arm (or flail upper limb) due to C5 through T1 root avulsion. The surgical techniques are described in detail. RESULTS: The coaptation procedures for the first group resulted in excellent recovery of all the denervated muscles. The patients in the second group showed reinnervation of the finger muscles and finger sensory distributions in infants within the first year after surgery. The flail arm group regained satisfactory proximal muscle function but only mild distal muscle function. One exception was a child who showed significant recovery in proximal and distal motor and sensory function. CONCLUSION: We recommend the bypass coaptation as a useful procedure for the following categories: Erb-Duchenne palsy due to C5 and C6 root avulsion in all ages, Klumpke palsy due to the C8 and T1 avulsion, and the flail arm due to C5 through T1 avulsion in young children. However, bypass procedures for the flail limb in adults require additional innovative methods to facilitate the growth rate of regenerating nerves.

Pathophysiology of tethered cord syndrome and similar complex disorders.

Tethered cord syndrome (TCS) is a stretch-induced functional disorder of the spinal cord due to the fact that its caudal portion is anchored by an inelastic structure. The functional lesion of TCS is generally situated in the lumbosacral cord, and many authors have shown that the syndrome is reversible via surgery to untether the cord. To clarify the expressions relevant to TCS, such as "cord tethering" and "tethered cord," the authors have formulated three categories. These categories include cases that show the anatomical appearance of spinal cord stretching. Among them, Category 1 is isolated to represent the "true TCS." The authors focus their discussion of the pathophysiology of TCS on Category 1 to explain the impaired oxidative metabolism and electrophysiological derangements within the tethered spinal cord, which is the primary intrinsic cause of the dysfunction. Furthermore, they extend the discussion to the extrinsic (outside the spinal cord) factors and other complex conditions that mimic TCS.

What is the true tethered cord syndrome?

INTRODUCTION: The tethered cord syndrome (TCS) is a stretch-induced functional disorder of the spinal cord with its caudal part anchored by an inelastic structure. DISCUSSION: This article clarifies the reversible lesions that occur in the cord segments above any of the inelastic abnormalities. These lesions are found mostly in the lumbosacral cord, occasionally in the cervical cord and closely correlate with clinical findings. Imaging studies alone do not allow accurate diagnosis of the TCS. The authors emphasize the importance of adhering to the physiological terms "tethered cord syndrome" and "tethered spinal cord" to avoid controversies derived from terms that are not based on the pathophysiology of TCS.

A novel, simplified pediatric syringopleural shunt. Technical note.

The diversion of fluid from an intramedullary syrinx cavity is an option for the treatment of syringomyelia. The authors have modified the technique of shunting syrinx fluid to the pleural space with the aid of a simple short tube and a single incision; this is a one-stage operation in pediatric patients. The advantages of this technique include the use of familiar standard neurosurgical techniques, the availability of shunt components, a short, direct catheter course, the minimization of a siphoning effect secondary to improved catheter tip placement, and the use of pleural rather than peritoneal space. In this small series the technique of syringopleural shunting has proved simple, safe, and well tolerated by pediatric patients.

Tethered cord syndrome: overview of diagnosis and treatment.

This article covers the basis of tethered cord syndrome as a stretch-induced spinal cord disorder, including pathophysiology, signs and symptoms, imaging diagnosis, indication for surgical treatment, and surgical procedures. Anomalies that cause mechanical spinal cord tethering are listed, and the surgical untethering technique for each anomaly is described.

Adult tethered cord syndrome: relative to spinal cord length and filum thickness.

The adults with tethered cord syndrome (TCS) are divided into two groups: group-1 adult TCS patients with spinal dysraphism; and group-2 patients without dysraphism who develop signs and symptoms in adulthood. A significant number of group-2 patients failed to show elongation of the spinal cord and abnormally thick filum terminale. This paper reports the combinations of the location of the caudal end of the spinal cord and the thickness of the filum terminale in 104 patients with group-2 adult TCS. The caudal end of the spinal cord was found at the L2-3 intervertebral space or above in 37 patients (35.6%) and below L2-3 level in 67 patients (64.4%). The diameter of the filum was <2 mm in 60 patients (57.7%) and > or =2 mm in 44 patients (42.3%). These data clearly indicate that the pre-operative diagnosis of adult TCS must rely primarily on the neurological symptomatology and the specific imaging feature, posterior displacement of the conus and filum that attach the posterior arachnid membrane.

Symptomatic protocols for adult tethered cord syndrome.

Diagnosis of tethered cord syndrome (TCS) is complicated because anatomical information is not adequate for this task. For example, recent studies have shown that the combination of an elongated cord and a thick filum terminale, demonstrated by MRI or at operation, is no longer an essential feature for the diagnosis of TCS. For TCS diagnosis, emphasis should rather be on its characteristic symptomatology and accentuated by postural changes, since TCS is a functional disorder of the lumbosacral spinal cord. In this report, the authors present the list of signs and symptoms pertinent to TCS in adult and late teenage patients to serve as a diagnostic means.

Pathophysiology of tethered cord syndrome: correlation with symptomatology.

Tethered cord syndrome (TCS) is a stretch-induced functional disorder of the spinal cord. The mechanical cause of TCS is an inelastic structure anchoring the caudal end of the spinal cord that prevents cephalad movement of the lumbosacral cord. Stretching of the spinal cord occurs in patients either when the spinal column grows faster than the spinal cord or when the spinal cord undergoes forcible flexion and extension. Research in patients and experimental animals suggests that there is a link between the clinical dysfunctions that characterize TCS and putative pathophysiological changes that accompany this syndrome. Among these changes are depression of electrophysiological activity and shifts in the reduction/oxidation ratio of cytochrome oxidase. The latter suggests that there is impairment of oxidative metabolism. These putative pathophysiological changes in TCS occur mainly within the lumbosacral cord under excessive tension. The authors discuss the pathophysiology of TCS and examine related symptoms.

Concept of arteriovenous malformation compartments and surgical management.

Cerebral AVMs are known to be a source of intracranial hemorrhages and epileptic seizures. Their natural history indicates approximately 15% mortality and 35% morbidity over a 15-year period. This significant mortality and morbidity mandates a need for satisfactory treatment of this entity, ideally by elimination of AVMs. Microsurgical resection, endovascular embolization and radiosurgery (irradiation) are the three effective modes of treatment currently available. However, no objective criteria have been established for which mode(s) of treatment should be selected for individual patients with AVMs. Considering the complexity of AVMs and variable conditions of individual patients, neurosurgeons, intravascular interventionalists and radiosurgeons must make their own decisions on how to treat each patient based on their experience. In practice, treatment of small AVMs in non-functional areas is favored equally by each of these specialists, while they tend to avoid treatment of large AVMs, particularly those in functional areas of the brain. The authors report the surgical intervention of large AVMs, including those located in functional areas of the hemisphere by special techniques. One can demonstrate AVM compartments by using angiography and with the aid of color Doppler ultrasonography, each compartment can be outlined and dissected individually until all the compartments are isolated without causing any damage to the surrounding brain and the entire AVM is rendered shrunken and then removed. The concept of compartmental treatment of AVMs may be applied in the future to radiosurgery and intravascular embolization of large AVMs.