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INTRODUCTION: The taxonomy code(s) associated with each National Provider Identifier (NPI) entry should characterize the provider’s role (e.g., physician) and any specialization (e.g., orthopedic surgery). While the intent of the taxonomy system was to monitor medical appropriateness and the expertise of care provided, this system is now being used by researchers to identify providers and their practices. It is unknown how accurate the taxonomy codes are in describing a provider’s true specialization. METHODS: Department websites of orthopedic surgery and general surgery from three large academic institutions were queried for practicing surgeons. The surgeon’s specialty and subspeciality information listed was compared to the provider’s taxonomy code(s) listed on the National Plan and Provider Enumeration System (NPPES). The match rate between these data sources was evaluated based on the specialty, subspecialty, and institution. RESULTS: There were 295 surgeons (205 general surgery and 90 orthopedic surgery) and 24 relevant taxonomies (8 orthopedic and 16 general or plastic) for analysis. Of these, 294 surgeons (99%) selected their general specialty taxonomy correctly, while only 189 (64%) correctly chose an appropriate subspecialty. General surgeons correctly chose a subspecialty more often than orthopedic surgeons (70 versus 51%, P = 0.002). The institution did not affect either match rate, however there were some differences noted in subspecialty match rates inside individual departments. CONCLUSIONS: In these institutions, the NPI taxonomy is not accurate for describing a surgeon’s subspecialty or actual practice. Caution should be taken when utilizing this variable to describe a surgeon’s subspecialization as our findings might apply in other groups.

Pseudocholinesterase deficiency, sometimes called butyrylcholinesterase deficiency, is a rare disorder in which the neuromuscular blocking drugs succinylcholine and mivacurium cannot be metabolized properly in the blood plasma. This disorder can either be acquired as a result of certain comorbidities or it can be inherited genetically. Anesthesia providers must understand the pathophysiology of pseudocholinesterase deficiency and be prepared to safely and effectively manage patients who show signs and symptoms consistent with the disorder after the use of the indicated neuromuscular blocking drugs. This article summarizes the pharmacologic and physiologic data relevant to understanding the basic pathophysiology associated with pseudocholinesterase deficiency and illustrates a case study of a young woman suspected of having the disorder after a prolonged delay in emergence from general anesthesia.

Data accuracy is essential to obtaining correct results and making appropriate conclusions in outcomes research. Few have examined the quality of data that is used in studies involving orthopedic surgery. A nonspecific data entry has the potential to affect the results of a study or the ability to appropriately risk adjust for treatments and outcomes. This study evaluated the proportion of Not Further Specified (NFS) orthopedic injury codes found into two large trauma registries.Data from the National Trauma Data Bank (NTDB) from 2011 to 2015 and from the Michigan Trauma Quality Improvement Program (MTQIP) 2011-2017 were used. We selected multiple orthopedic injuries classified via the Abbreviated Injury Scale, version 2005 (AIS2005) and calculated the percentage of NFS entries for each specific injury.There were a substantial proportion of fractures classified as NFS in each registry, 18.5% (range 2.4%-67.9%) in MTQIP and 27% (range 6.0%-68.5%) in the NTDB. There were significantly more NFS entries when the fractures were complex versus simple in both MTQIP (34.5% versus 9.6%, P 0.001) and the NTDB (41.8% versus 15.7%, P 0.001). The level of trauma center affected the proportion of NFS codes differently between the registries.The proportion of nonspecific entries in these two large trauma registries is concerning. These data can affect the results and conclusions from research studies as well as impact our ability to truly risk adjust for treatments and outcomes. Further studies should explore the reasons for these findings.

Historically, patients who developed malignant hyperthermia had an extremely high rate of mortality. Today, if treated appropriately, patients who experience an episode of malignant hyperthermia will most likely survive. This dramatic decrease in mortality associated with malignant hyperthermia is due to several factors, including an increased understanding of the disease, improved diagnostic and monitoring equipment, and the development of lifesaving pharmacologic agents. This article presents the very likely case of acute malignant hyperthermia in a 24-year-old man with special needs, who presented for restorative dentistry under general anesthesia in the outpatient clinic of The Ohio State University's College of Dentistry.

The regional anesthesia community regularly uses social media for advocacy and education. Well-known leaders in the field are willing to share their opinions with colleagues in a public forum. Some visionaries predict that the influence of social media will soon transcend that of the traditional academic journal. While physicians support the use of social media, an trend may exist toward anecdotal information. Does a lack of online regulation along with a bias towards self-promotion cloud meaningful discussion? In order to avoid the pitfalls of social media, thoughtful communication will help regional anesthesiologists promote their subspecialty. Mindful dialog, promotion of academic journals, and professional etiquette will help maintain a collegial environment.

Background Post-acute care rehabilitation is critically important to recover after trauma but many patients do not have access. A better understanding of the drivers behind inpatient rehabilitation facility (IRF) use has the potential for major cost-savings as well as higher quality, and more equitable patient care. We sought to quantify the variation in hospital rates of trauma patient discharge to inpatient rehabilitation and understand which factors (patient- vs injury- vs hospital-level) contribute the most. Methods We performed a retrospective cohort study of 668,305 adult trauma patients admitted to 900 Level I-IV trauma centers between 2011 and 2015 using the National Trauma Data Bank (NTBD). Participants were included if they met the following criteria: age >18, injury severity score (ISS) >9, identifiable injury type, and who had one of the Centers for Medicare & Medicaid Services (CMS) preferred diagnoses for inpatient rehabilitation under the "60% rule". Results The overall risk- and reliability-adjusted hospital rates of discharge to IRF averaged 18.8% in the non-elderly adult cohort (18-64 years old) and 23.4% in the older adult cohort (65 years or older). Despite controlling for all patient, injury and hospital-level factors, hospital discharge of patients to IRF varied substantially between hospital quintiles and ranged from 9-30% in the non-elderly adult cohort and from 7-46% in the older adult cohort. Proportions of total variance ranged from 2.4% (patient insurance) to 12.1% (injury-level factors) in the non-elderly adult cohort and from 0.3% (patient-level factors) to 26.0% (unmeasured hospital-level factors) in the older adult cohort. Conclusion Among a cohort of injured patients with diagnoses that are associated with significant rehabilitation needs, the hospital at which a patient receives their care may drive a patient's likelihood of recovering at an IRF just as much, if not more, than their clinical attributes. Level of evidence Level III. Epidemiological.

Ludwig's angina (LA) is a gangrenous cellulitis of the neck that spreads via continuity of the fascial planes. Treatment of LA includes aggressive antibiotic therapy as well as surgical drainage in many cases. The most common cause of infection is odontogenic and can be due to both aerobic and anaerobic bacteria. Signs and symptoms of LA include bilateral cervical swelling, dysphagia, drooling, neck tenderness, elevation and posterior distension of the tongue, restricted neck movement, trismus, dyspnea, and stridor, which can result in difficult airway management. Proper preoperative assessment of patients with LA should include identifying features that may cause difficulties with mask ventilation, direct laryngoscopy, and intubation. Alternative methods of ventilation should be considered and immediately accessible, including a plan on how and when they would be used in the event that a patient cannot be mask ventilated or intubated. Marking external anatomical airway landmarks prior to manipulating the airway can save vital time if an emergent airway becomes necessary.

Parkinson's disease (PD) and multiple system atrophy (MSA) are distinct clinical syndromes characterized by the pathological accumulation of α-synuclein (α-syn) protein fibrils in neurons and glial cells. These disorders and other neurodegenerative diseases may progress via prion-like mechanisms. The prion model of propagation predicts the existence of “strains” that link pathological aggregate structure and neuropathology. Prion strains are aggregated conformers that stably propagate in vivo and cause disease with defined incubation times and patterns of neuropathology. Indeed, tau prions have been well defined, and research suggests that both α-syn and β-amyloid may also form strains. However, there is a lack of studies characterizing PD- versus MSA-derived α-syn strains or demonstrating stable propagation of these unique conformers between cells or animals. To fill this gap, we used an assay based on FRET that exploits a HEK293T “biosensor” cell line stably expressing α-syn (A53T)-CFP/YFP fusion proteins to detect α-syn seeds in brain extracts from PD and MSA patients. Both soluble and insoluble fractions of MSA extracts had robust seeding activity, whereas only the insoluble fractions of PD extracts displayed seeding activity. The morphology of MSA-seeded inclusions differed from PD-seeded inclusions. These differences persisted upon propagation of aggregation to second-generation biosensor cells. We conclude that PD and MSA feature α-syn conformers with very distinct biochemical properties that can be transmitted to α-syn monomers in a cell system. These findings are consistent with the idea that distinct α-syn strains underlie PD and MSA and offer possible directions for synucleinopathy diagnosis.

There are numerous causes of cardiac arrest in the perioperative period, including hypoxia, hypovolemia, and vagal response to medications or procedures during routine anesthetics. Initiation of adequate cardiopulmonary resuscitation, administration of epinephrine, and application of a defibrillator, with shocking when applicable, are all essential steps in achieving return of spontaneous circulation. Knowledge and utilization of monitoring equipment can alert the provider to problems leading to cardiac arrest as well as ensure proper resuscitative efforts during the event. Polypharmacy is quite common with many of today's special needs patients. It is important to understand the medications they are taking as well as the potential interactions that may occur with drugs given during sedation and general anesthesia. The following is a case report of cardiac arrest including asystole and pulseless electrical activity in a 27-year-old man with autism and behavioral problems who presented for restorative dentistry under general anesthesia in the ambulatory surgery setting.

BackgroundIncreased time to operative intervention is associated with a greater risk of mortality and complications in adults with a hip fracture. This study sought to determine factors associated with timeliness of operation in elderly patients presenting with an isolated hip fracture and the influence of surgical delay on outcomes.MethodsTrauma quality collaborative data (July 2016 to June 2019) were analyzed. Inclusion criteria were patients ≥65 years with an injury mechanism of fall, Abbreviated Injury Scale (AIS) 2005 diagnosis of hip fracture, and AIS extremity ≤3. Exclusion criteria included AIS in other body regions >1 and non-operative management. We examined the association of demographic, hospital, injury presentation, and comorbidity factors on a surgical delay >48 hours and patient outcomes using multivariable regression analysis.Results10 182 patients fit our study criteria out of 212 620 patients. Mean age was 82.7±8.6 years and 68.7% were female. Delay in operation >48 hours occurred in 965 (9.5%) of patients. Factors that significantly increased mortality or discharge to hospice were increased age, male gender, emergency department hypotension, functionally dependent health status (FDHS), advanced directive, liver disease, angina, and congestive heart failure (CHF). Delay >48 hours was associated with increased mortality or discharge to hospice (OR 1.52; 95% CI 1.13 to 2.06; p48 hours were male gender, FDHS, CHF, chronic renal failure, and advanced directive. Admission to the orthopedic surgery service was associated with less incidence of delay >48 hours (OR 0.43; 95% CI 0.29 to 0.64; pDiscussionHospital verification level, admission service, and patient volume did not impact the outcome of mortality/discharge to hospice. Delay to operation >48 hours was associated with increased mortality. The only measured modifiable characteristic that reduced delay to operative intervention was admission to the orthopedic surgery service.Level of evidenceIII.

Background: The novel coronavirus disease (COVID-19) has afflicted millions of people worldwide since its first case was reported in December 2019. Personal protective equipment (PPE) has been tailored accordingly, but as of April 2020, close to 10 000 health care workers in the United States have contracted COVID-19 despite wearing recommended PPE. As such, standard guidelines for PPE may be inadequate for the health care worker performing high-risk aerosolizing procedures such as endotracheal intubation. In this brief technical report, we describe the integration of an orthopedic hood cover as an item for full barrier protection against COVID-19 transmission. Technical Description: The Coronavirus Airway Task Force at Virginia Commonwealth University Medical Center approved this initiative and went live with the full barrier suit during the last week of March 2020. The PPE described in this report includes a Stryker T4 Hood, normally used in conjunction with the Stryker Steri-Shield T4 Helmet. Instead of the helmet, the hood is secured to the head via a baseball cap and binder clip. This head covering apparatus is to be used as an accessory to other PPE items that include an N95 mask, waterproof gown, and disposable gloves. The motor ventilation system is not used in order to prevent airborne viral entry into the hood. Discussion: An advantage of the full barrier suit is an additional layer of droplet protection during intubation. The most notable disadvantage is the absence of a ventilation system within the hood covering. Conclusion: Modification of existing PPE may provide protection for health care workers during high-risk aerosolizing procedures such as endotracheal intubation. Although the integration of this medical equipment meets the immediate needs of an escalating crisis, further innovation is on the horizon. More research is needed to confirm the safety of modified PPE.

Epiglottitis is most commonly caused by bacterial infection resulting in inflammation and edema of the epiglottis and neighboring supraglottic structures. Acute infection was once found predominantly in children ages 2 to 6 years old, but with the introduction of the Haemophilus influenzae B (HiB) vaccine the incidence of cases in adults is increasing. Typical clinical presentation of epiglottitis includes fever and sore throat. Evidence of impending airway obstruction may be demonstrated by muffled voice, drooling, tripod position, and stridor. Radiographs can be helpful in diagnosing epiglottitis; however, they should not supersede or postpone securing the airway. An airway specialist such as an otolaryngologist, anesthesiologist, or intensivist should ideally evaluate the patient immediately to give ample time for preparing to secure the airway if necessary. All patients with epiglottitis should be admitted to the intensive care unit for close monitoring.

This case report describes a patient whose blood pressure decreased from a systolic pressure of 130-140 to 70-80 mm Hg after receiving extended-release liposomal bupivacaine in combination with plain bupivacaine. An 83-year-old woman with hepatocellular carcinoma presented for right hepatectomy and cholecystectomy. No hemodynamic instability was noted during the procedure. When an admixture of liposomal bupivacaine and bupivacaine hydrochloride was infiltrated into the surgical incision site during skin closure, the patient then became profoundly hypotensive. Her blood pressure was supported with phenylephrine boluses and continuous phenylephrine infusion. Lipid emulsion therapy was given to treat suspected local anesthetic toxicity. In response, the patient's blood pressure recovered and the vasopressor requirement was significantly reduced.

Type 2 diabetes is a disease of metabolism in which the afflicted patient cannot properly utilize carbohydrates, fats, and proteins. Because the prevalence of type 2 diabetes is rapidly increasing throughout the general population, anesthesia providers must realize that a significant percentage of their patients will present with the disease. Anesthesia providers should have an intimate knowledge of the comorbidities and complications that are associated with type 2 diabetes and know the specific pharmacokinetics and pharmacodynamics of the drugs used to treat the disease. Part 1 of this series on the anesthetic management of type 2 diabetes in the ambulatory theater addressed the pathology of diabetes and its comorbid disease states. Part 2 of the series now focuses on the pharmacology associated with the many medications used to treat the disorder and the most recent guidelines for blood glucose management recommended for patients in an ambulatory surgery setting.

The increasing prevalence of diabetes mellitus in the general population has many implications for the ambulatory anesthesia provider. Complications, particularly associated with poor glycemic control, can affect multiple organ systems and jeopardize the safety of any planned anesthetic. It is essential that anesthesiologists and sedation providers have in-depth knowledge of the pathophysiology of diabetes mellitus and the comorbid conditions that commonly accompany it. Anesthesiologists and sedation providers must also understand certain surgical and anesthetic considerations when planning an effective and safe anesthetic for diabetic patients. This is a 2-part series concerning perioperative glycemic control for patients with diabetes mellitus. Part 1 will focus on the physiology of diabetes and its associated disease states. Part 2 will address the pharmacology associated with the wide variety of medications used to treat the disorder and the most recent guidelines for blood glucose management in ambulatory surgical patients.

This case study describes a patient with suspected opioid-induced bowel dysfunction who had improved pain control when treated with intravenous (IV) lidocaine. An 80-year-old man with failed back surgery syndrome managed with an intrathecal (IT) pump presented with protracted abdominal pain. The acute pain service initiated a lidocaine infusion at 1 mg·min(−1), and the patient reported significant pain relief. The patient experienced refractory abdominal pain with 3 attempts to wean the lidocaine infusion. Eventually, a successful transitional regimen was achieved with methylnaltrexone and transdermal lidocaine patches. Lidocaine infusions may be an effective and underutilized multimodal adjunct for nonsurgical pain conditions.

OBJECTIVE: To evaluate the effect of Accountable Care Organizations (ACOs) on the use of vertebroplasty and arthroscopic partial meniscectomy, two procedures for which randomized controlled trials suggest similar outcomes to sham surgery and therefore may provide low value. Medicare Shared Savings Program Accountable Care Organizations (ACOs) aim to improve quality and decrease healthcare spending. Reducing the use of potentially low value procedures can accomplish both of these goals. METHODS: We performed a retrospective cohort study of patients who underwent potentially low value orthopedic procedures (vertebroplasty and partial meniscectomy) and a control (hip fracture) from 2010 to 2015 using a 20% sample of national Medicare claims. We performed an interrupted time-series analysis using linear spline models to evaluate the count of each procedure per 1,000 patients, stratified by ACO participation. RESULTS: We identified 76,256 patients who underwent arthroscopic partial meniscectomy, 44,539 patients who underwent vertebroplasty, and 50,760 patients who underwent hip fracture admission. Arthroscopic partial meniscectomy rates decreased, vertebroplasty rates remained stable, and hip fracture rates increased for both groups during the study period, with similar trends among ACO and non-ACO patients. After January 1, 2013, ACO and non-ACO populations had similar trends for vertebroplasty (ACO Incidence rate ratio (IRR) 1.15 [1.08–1.23] vs non-ACO IRR 1.11 [1.05–1.16]), meniscectomy (ACO IRR 1.06 [1.01–1.12] vs non-ACO IRR 1.03 [0.99–1.07]), and hip fracture (ACO IRR 1.08 [1.01–1.14] vs non-ACO IRR 1.08 [1.03–1.13]). CONCLUSIONS: ACOs were not associated with a reduction in the frequency of vertebroplasty and arthroscopic partial meniscectomy.

Background: Music has emerged as a well-received medical intervention. Patients may be uncomfortable during total joint replacement, which can result in high sedation requirements. These requirements place elderly patients at risk for delirium. This study compares the effect of noise-cancellation versus music medicine on sedation requirements, pain, and opioid consumption during elective total knee replacement. Methods: This prospective, double-blinded, randomized clinical trial was conducted at Virginia Commonwealth University Medical Center between July 2018 and July 2019. All participants underwent primary total knee arthroplasty with a combined spinal-epidural as their primary anesthetic and received noise-cancelling, wireless headphones. Patients in the control group received the noise-cancellation feature only, while patients in the experimental group were permitted to listen to music of their choice. Patients signaled a request for sedation by squeezing a noise-making rubber hippopotamus toy. The primary outcomes included whether sedation was requested by the participant, the number of sedation demand doses requested, and the amount of propofol sedation administered during the procedure. Secondary outcomes included postoperative pain scores, total opioid consumption, and time to first opioid request. Results: Seventy-one percent (n = 36) of patients agreed to participate in the study. Forty-four percent of participants in the noise-cancellation group and 19% of participants in the music group requested sedation ( P = .25). The median propofol consumption was not different between groups (0 [0-6.7] µg/kg/min vs 0 [0-0] µg/kg/min, P = .101 for noise cancellation vs music, respectively). Pain scores and opioid consumption were not different between groups. Discussion: To date, this is the first study to use Bluetooth communication, noise-cancellation, and an Internet-based music streaming service to determine whether this technology has an impact on outcomes during major orthopedic surgery. Conclusion: As an isolated intervention, the benefits of music in a complex operating room environment may be overstated. However, music integration with noise-reduction technology and patient-controlled sedation may lead to a safer and more satisfying anesthetic. More research is needed to determine the nonpharmacologic interventions that will produce positive outcomes for the geriatric population.

Pelvic ring fractures represent a complex injury that requires specific resources and clinical expertise for optimal trauma patient management. We examined the impact of treatment variability for this type of injury at Level I and II trauma centers on patient outcomes.Trauma quality collaborative data (2011-2017) were analyzed. This includes data from 29 American College of Surgeons Committee on Trauma verified Level I and Level II trauma centers. Inclusion criteria were adult patients (≥16 years), Injury Severity Score of 5 or higher, blunt injury, and evidence of a partially stable or unstable pelvic ring fracture injury coding as classified using Abbreviated Injury Scale version 2005, with 2008 updates. Patients directly admitted, transferred out for definitive care, with penetrating trauma, or with no signs of life were excluded. Propensity score matching was used to create 1:1 matched cohorts of patients treated at Levels I or II trauma centers. Trauma center verification level was the exposure variable used to compare management strategies, resource utilization, and in-hospital mortality in univariate analysis.We selected 1,220 well-matched patients, from 1,768 total patients, using propensity score methods (610 Level I and 610 Level II cohort). There were no significant baseline characteristic differences noted between the groups. Patients with pelvic ring fractures treated at Level I trauma centers had significantly decreased mortality (7.7% vs. 11.6%, p = 0.02). Patients treated at Level II trauma centers were less likely to receive interventional angiography, undergo complicated definitive orthopedic operative treatment, and to be admitted to an intensive care unit.Admission with a partially stable or unstable pelvic ring injury to a Level I trauma center is associated with decreased mortality. Level II trauma centers had significantly less utilization of advanced treatment modalities. This variation in clinical practice highlights potential processes to emphasize in the appropriate treatment of these critically ill patients.Economic/Decision, Level II.

Sugammadex is a novel drug capable of reversing paralysis induced by the common steroidal nondepolarizing neuromuscular blocking drugs, rocuronium and vecuronium. Reversal is complete at any depth of blockade dependent on the dose of sugammadex administered. This allows rocuronium to be used as a rescue agent in scenarios where succinylcholine is contraindicated. Sugammadex is considered a safe drug with minimal side effects compared with traditional reversal with neostigmine and glycopyrrolate. This article features a case report where succinylcholine was undesirable and rapid reversal of paralysis with sugammadex was used during general anesthesia for dentistry.

Background Clostridium difficile infection (CDI) is associated with significant morbidity and mortality. Computerized clinical decision support (CCDS) tools can aid process improvement in infection prevention and antibiotic stewardship, but implementation and health care workers (HCWs) uptake of these tools is often variable. The objective of this study was to describe HCWs' perceptions of barriers and facilitators related to uptake of CCDS tools as part of a CDI reduction bundle. Methods We conducted a qualitative study among HCWs at 2 acute care hospitals in Maryland. Semi-structured interviews and structured surveys were completed by HCWs to evaluate their perception to CCDS tools at 2 different stages: predevelopment and preimplementation. Emergent themes and patterns in the data were identified and condensed. Results Gaps in CDI-related knowledge and in communication between HCWs were identified throughout the evaluation. HCWs agreed on the potential of the tools to improve CDI diagnosis, prevention, and control. An important barrier for uptake was the perceived loss of autonomy and clinical judgment, whereas standardization and error reduction were perceived advantages. Conclusions These observations shaped the development and implementation of the CDI reduction bundle. Qualitative findings can provide valuable contextual information during the development stages of CCDS tools in infection prevention and antibiotic stewardship.

The purpose of this study was to biomechanically test a percutaneous pedicle screw construct for posterior pelvic stabilisation and compare it to standard fixation modalities.Utilizing a sacral fracture and sacroiliac (SI) joint disruption model, we tested 4 constructs in single-leg stance: an S1 sacroiliac screw, S1 and S2 screws, the pedicle screw construct, and the pedicle screw construct+S1 screw. We recorded displacement at the pubic symphysis and SI joint using high-speed video. Axial stiffness was also calculated. Values were compared using a 2-way ANOVA with Bonferroni adjustment (p0.05).In the sacral fracture model, the stiffness was greatest for the pedicle screw+S1 construct (p0.001). There was no significant difference between the pedicle screw construct and S1 sacroiliac screw (p=1). For the SI joint model, the S1+S2 SI screws had the largest overall load and stiffness (p0.001). The S1 screw was significantly stronger than pedicle screw construct (p=0.001).The pedicle screw construct biomechanically compares to currently accepted methods of fixation for sacral fractures when the fracture is uncompressible. It should not be used for SI joint disruptions as one SI or an S1+S2 are significantly stiffer and cheaper.

Inadvertent placement of the endotracheal tube into the right bronchus during intubation for general anesthesia is a fairly common occurrence. Many precautions should be taken by the anesthesia provider in order to minimize the incidence of endobronchial intubation, including bilateral auscultation of the lungs, use of the 21/23 rule, and palpation of the inflated endotracheal cuff at the sternal notch. These provisions, however, are not foolproof; anesthesia providers should realize that endobronchial intubation may occur from time to time because of variations in patient anatomy, changes in patient positioning, and cephalad pressures exerted during surgery. A 58-year-old man with chronic obstructive pulmonary disease received general endotracheal anesthesia for a laparoscopic cholecystectomy. His height was 165 cm (5 ft, 5 in) and the endotracheal tube was secured at his incisors at 21 cm after placement with a rigid laryngoscope. Bilateral breath sounds were confirmed with auscultation, although they were distant because of his chronic obstructive pulmonary disease. After radiographic examination in the postanesthesia care unit, a right main-stem intubation was revealed to have taken place, resulting in complete atelectasis of the left lung. After repositioning of the endotracheal tube, radiography confirmed that the patient had an anatomically short tracheal length.

Adherence to pulmonary rehabilitation (PR) is low. Previous studies have focused on clinical predictors of PR completion. We aimed to identify social determinants of adherence to PR. A cross-sectional analysis of a database of COPD patients (N = 455) in an outpatient PR program was performed. Adherence, a ratio of attended-to-prescribed sessions, was coded as low (85%). Individual-level measures included age, sex, race, BMI, smoking status, pack-years, baseline 6-minute walk distance (6MWD: 30). Fifteen area-level measures aggregated to Census tracts were obtained from the U.S. Census after geocoding patients' addresses. Using exploratory factor analysis, a neighborhood socioeconomic disadvantage index was constructed, which included variables with factor loading >0.5: poverty, public assistance, households without vehicles, cost burden, unemployment, and minority population. Multivariate regression models were adjusted for clustering on Census tracts. Twenty-six percent of patients had low adherence, 23% were moderately adherent, 51% were highly adherent. In the best fitted full model, each decile increase in neighborhood socioeconomic disadvantage increased the risk of moderate vs high adherence by 14% (p

This study finds that smoking is greatest among women who are full-time homemakers in medium and especially small towns. This is a new development and suggests the locus of smoking among women has moved away from its association with the job in cities to the home in less populated areas.

This review article addresses the concept of the social determinants of health (SDH), selected theories, and its application in studies of chronic disease. Once ignored or regarded only as distant or secondary influences on health and disease, social determinants have been increasingly acknowledged as fundamental causes of health afflictions. For the purposes of this discussion, SDH refers to SDH variables directly relevant to chronic diseases and, in some circumstances, obesity, in the research agenda of the Mid-South Transdisciplinary Collaborative Center for Health Disparities Research. The health effects of SDH are initially discussed with respect to smoking and the social gradient in mortality. Next, four leading SDH theories—life course, fundamental cause, social capital, and health lifestyle theory—are reviewed with supporting studies. The article concludes with an examination of neighborhood disadvantage, social networks, and perceived discrimination in SDH research.

Introduction This study examines the health lifestyles of a cohort of blacks and whites in relation to cardiovascular disease (CVD). The link between health lifestyles and CVD is well established, but most of the focus has been on SES and more research is needed on racial differences. Methods Data were from the Coronary Artery Risk Development in Young Adults study of black ( n =2,451) and white ( n =2,351) men and women. Data were analyzed from baseline examinations in 1985–1986 when the participants were aged 18–30 years and any fatal or nonfatal CVD event that occurred over approximately the next 28 years (until August 2013). The first stage of the analysis used latent class models to identify distinct health lifestyles on the basis of race. The second stage used multinomial logit regression models to analyze specific characteristics in relation to the health lifestyles classes, followed by the third stage in which Cox proportional hazards models analyzed associations of the lifestyle classes with CVD risk. Results Four separate health lifestyle patterns for blacks and four for whites were identified, with the “unhealthy” lifestyle among blacks (hazard ratio, 1.60) and “most unhealthy” lifestyle among whites (hazard ratio, 3.12) showing an elevated risk of CVD. An important difference is that, in every lifestyle class, blacks showed a higher probability of excessive energy intake than whites—indicative of the potential for obesity. Conclusions Health lifestyles differ by race and support the exploratory hypothesis that distinct classes of healthy–unhealthy lifestyles exist within each racial group.

Background: The cesarean section rate following a pelvic fracture is more than double the standard norms. This results from residual deformity and a lack of knowledge among obstetricians regarding the ability to deliver vaginally after a pelvic fracture. Aim: To present a case of pelvic fracture that delivered vaginally indicating vaginal delivery is possible even after pelvic fractures that are stabilized surgically with minimal or no residual displacement. Case presentation: We present a patient that delivered vaginally following internal fixation of an unstable pelvic fracture with a retained orthopedic implant that spanned the lower abdomen with a metallic bar. We also discuss the role of cesarean section in patients with pelvic fractures. Conclusion: Women with pelvic fractures may possibly deliver vaginally however decision regarding mode of delivery in such patients should be on a case by case basis.

The use of retrograde nailing for gunshot wound femur fractures is controversial due to concerns of knee sepsis after this procedure since the knee is entered to introduce the nail into the canal.We compared retrograde and antegrade nailing for gunshot femur fractures to determine whether (1) knee sepsis or other adverse events were more likely to complicate procedures using retrograde nails, (2) there were differences in surgical time or blood loss, and (3) there were differences in radiographic union.We retrospectively reviewed our prospective trauma database from 1999 to 2012 for patients with a diagnosis of gunshot and femur fracture. We performed a detailed review of medical records and radiographs for those patients with OTA Classification Type 32 femur fractures secondary to gunshot injury treated with either retrograde or antegrade femoral nailing. Eighty-one patients were treated with intramedullary nailing (53 retrograde and 28 antegrade). We reviewed elements of the operative treatment (procedure, anesthesia time, operative time, and estimated blood loss) for all 81 patients. For clinical and radiographic review, followup was adequate for 43 and 25 patients with retrograde and antegrade nailing, respectively. Minimum followup was 3 months for both groups (retrograde: mean, 41 months; range, 3-148 months; antegrade: 26 months: range, 3-112 months).No patients in either group developed knee sepsis. No significant differences were found between groups with regard to operative time, blood loss, or radiographic union.With the numbers available, immediate retrograde nailing appears as safe and effective as antegrade nailing for gunshot femur fractures. Immediate retrograde nailing is as safe as antegrade nailing for gunshot femur fractures.

Background We assessed the biomechanical performances of a trochanteric lag screw construct and a traditional inverted triangle construct in the treatment of simulated Pauwels type 3 femoral neck fractures. Methods An inverted triangle construct (three 7.3-mm cannulated screws placed in inverted triangle orientation) and a trochanteric lag screw construct (two 7.3-mm cannulated screws placed across the superior portion of the femoral neck and one 4.5-mm lag screw placed perpendicular to the fracture in superolateral to inferomedial orientation) were tested in nine matched pairs of non-osteoporotic human cadaveric femora. We used a previously described vertically oriented femoral neck fracture model and testing protocol that incrementally loaded the constructs along the mechanical axis of the femur to 1400 N. Specimens that survived incremental loading underwent cyclic loading. Apparent construct stiffness, force at 3 mm of displacement, and survival of incremental loading were recorded. Findings The trochanteric lag screw group had a 70% increase in stiffness (261 N/mm [29 standard deviation] versus 153 N/mm [16 standard deviation]; P = 0.026) and a 43% increase in force required for displacement (620 N versus 435 N; P = 0.018) compared with the inverted triangle group. One trochanteric lag screw and no inverted triangle specimen survived incremental loading. Interpretation A trochanteric lag screw construct applied to vertically oriented femoral neck fractures provides marked improvement in mechanical performance compared with the inverted triangle construct.

Crouzon syndrome is an autosomal dominant disorder characterized by cranial synostosis, hypertelorism, orbital proptosis, parrot-beaked nose, short upper lip, hypoplastic maxilla, and a relative mandibular prognathism, without extremity involvement. Surgical intervention should occur at the onset of progressive craniosynostosis to treat or to prevent intracranial hypertension and visual impairment. Throughout developing countries, early treatment is often not a viable option. Often, the only option for treatment is through humanitarian missions. Appropriate preselection of surgical patients is essential, as is having a multidisciplinary team and a well-equipped hospital and staff to perform the operations and to care for the postsurgical patient. This type of humanitarian care benefits the patient selected to receive the intense logistical and financial effort when there is no possibility of timely care in their own countries. This clinical report describes a patient with Crouzon syndrome brought to the United States from a developing country through humanitarian efforts. She presented at 19 months of age with bicoronal and sagittal synostosis and advanced visual impairment and papilledema. Surgical intervention included cranial expansion and reconstruction with a multidisciplinary team. This case illustrates not only the difficulty of delayed treatment but also some of the issues arising from this type of humanitarian medical care.

Psoriasis is a chronic skin condition that has a significant impact on quality of life, self-esteem and comorbidities. Management of this condition is complicated and heavily influenced by psychosocial and economic realities. Addressing psychosocial and treatment education issues can be facilitated by use of the National Psoriasis Foundation. Localized disease is generally treated with topical treatment for which good generic medications are available. Somewhat higher priced branded vehicles are helpful for enhancing patients' treatment adherence, and may help avoid the need for far more toxic and expensive systemic treatment. Patients with extensive disease are best managed with phototherapy as a first-line option, and there is room for improvement in how insurers promote the use of this approach. Biologic treatments continue to offer new, safer options for patients with severe disease, albeit at higher cost. This review addresses practical issues in psoriasis management that would be of interest to organizations that are involved in the delivery of care for patients with psoriasis, such as managed care pharmacists and pharmaceutical companies that develop products for psoriasis.

Anuran amphibians have provided an excellent system for the study of animal communication and sexual selection. Studies of female mate choice in anurans, however, have focused almost exclusively on the role of auditory signals. In this study, we examined the effect of both auditory and visual cues on female choice in the squirrel treefrog. Our experiments used a two-choice protocol in which we varied male vocalization properties, visual cues, or both, to assess female preferences for the different cues. Females discriminated against high-frequency calls and expressed a strong preference for calls that contained more energy per unit time (faster call rate). Females expressed a preference for the visual stimulus of a model of a calling male when call properties at the two speakers were held the same. They also showed a significant attraction to a model possessing a relatively large lateral body stripe. These data indicate that visual cues do play a role in mate attraction in this nocturnal frog species. Furthermore, this study adds to a growing body of evidence that suggests that multimodal signals play an important role in sexual selection.

We present this case to review the metabolism of oxycodone and the effects of end-stage renal disease on the elimination of oxycodone and its metabolites. A 42-year-old female with end-stage renal disease who was dependent on hemodialysis presented for left hamstring posterior capsule release. She had been receiving methadone for 2 years for chronic leg pain. On postoperative day 1, the patient's medication was changed from IV hydromorphone to oral oxycodone to treat breakthrough pain. By the next day, the patient was unarousable with notable respiratory depression. She did not fully recover after urgent hemodialysis but did have full recovery after receiving an IV naloxone infusion for 22 hours. Further study of the safety of oxycodone in hemodialysis patients is warranted.

An institutional review board-approved retrospective study was performed at a level 1 trauma center to evaluate the adequacy of current treatment guidelines in the management of humerus fractures following civilian gunshot injuries. Fifty-four patients with a humerus shaft fracture from a low-velocity gunshot wound were included in the study. Twenty-nine patients were treated nonoperatively, while 25 patients had operative treatment, with 14 undergoing plate fixation, 6 having application of an external fixator, 3 receiving an intramedullary rod, and 2 having irrigation and debridement with fracture immobilization provided by a brace. Patient demographics and injury data, radiographic analyses, and treatment complications were recorded. Healing of soft tissue and bony injuries, including fracture alignment in patients treated nonoperatively, was also evaluated. Fifty-two of 54 patients had minor soft tissue damage and were treated successfully with minimal local wound care. Two patients with larger wounds required extended wound care with repeated irrigation and debridement. Overall, 47 of 54 fractures healed with the primary mode of treatment, and 7 patients went on to nonunion requiring further intervention. Of the patients treated nonoperatively, the average deformity was 16.5°±7.4° in the coronal plane and 4.4°±4.0° in the sagittal plane. This study supports the view that the majority of humerus fractures following civilian gunshot wounds may be treated nonoperatively, with a select group of patients requiring surgical stabilization.

BACKGROUND Measures of pubic symphyseal widening are used by at least two classification systems as determinants of injury grade. Recent work has challenged the commonly used parameter of 2.5 cm of pubic symphysis as an accurate marker of pelvic injury grade and has suggested a role of rotation in the flexion-extension plane as a determinant of pelvic stability. We investigated pelvic stability in the flexion-extension plane to determine a threshold of rotational displacement of the hemipelvis above which the potential for instability exists. METHODS Cadaveric specimens were mounted onto a servohydraulic biaxial testing machine and subjected to a vertically directed flexion moment. Position of hemipelvis was recorded using a three-dimensional motion capture system and video recording. Displacement of the pubic symphysis and changes in length and position of the sacrospinous and sacrotuberous ligaments were recorded. Amount of force applied was measured and recorded. A yield point was determined as the first point at which the force plot exhibited a decrease in force and was correlated to the corresponding displacement. RESULTS The mean vertical displacement of the pubic symphysis at the yield point was 16 mm (95% confidence interval, 11-22 mm). Mean sacrospinous ligament strain at yield point was 4% (range, 1.0-9.5%). CONCLUSION Pelves with vertical rotational symphyseal displacement of less than 11 mm can reasonably be expected to have rotational stability in the flexion-extension plane. Those with displacement of greater than 22 mm can be expected to have lost some integrity regarding resistance to pelvic flexion. These values may allow clinicians to infer pelvic stability from amount of vertical symphyseal displacement.

External fixator pins are thought to have improved pullout strength if inserted into both cortices and if pilot holes are drilled. We tested these hypotheses and investigated effects of osteoporosis and pin location on pin pullout strength.Self-drilling external fixator pins were inserted using 4 techniques: 1) predrilled bicortically inserted, 2) not predrilled bicortically inserted, 3) not predrilled unicortically inserted, and 4) technique 2 with far cortex disengaged to test holding power of near cortex in isolation. Ninety-six samples were tested from four locations in 12 matched pairs of cadaveric femora [6 pairs osteoporotic (T ≤ -2.5), six pairs nonosteoporotic (T-2.5)]. Pullout force was tested on materials testing system until failure of pin-bone interface.Bicortical pin placement and location within femur had substantial effects on the holding power of the pins. Osteoporosis had statistically significant effect but with smaller effect size (P = 0.05). No significant difference in holding power was observed between predrilling and no predrilling techniques (P = 0.27). We observed only a trend toward "stripping effect" in near cortex with technique 4. Bicortical placement rendered 69% greater holding power than unicortical. Proximal placement rendered 56% greater holding power than distal. Osteoporotic samples had 15% less holding power than nonosteoporotic samples.Single-cortex pin placement, osteoporotic bone, and more distal pin location decreased pin pullout strength. We did not observe a significant mechanical advantage of predrilling for modern external fixator pins. The near cortex of a pin inserted into 2 cortices without predrilling did not exhibit substantial stripping effect.

Atopic dermatitis is a stress-responsive disorder that involves the autonomic nervous system. The current study used heart rate variability to examine the effect of itch, scratching and mental stress in atopic patients with moderate to severe disease. Twenty-one patients with active disease and 24 healthy volunteers participated in the study. Heart rate variability measurements were taken at 5 min intervals at rest and after each of 3 acute stress tests, which included histamine-induced itch at the forearm, scratching around the itch site, and the Trier Social Stress Test. Atopic patients displayed a higher heart rate than healthy controls in all 4 experimental settings, which was statistically significant using Cohen's delta analysis. The very low frequency component of the power spectrum, indicative of sympathetic activity, showed a 200% increase after scratching in patients with atopic dermatitis. The high frequency component, reflecting parasympathetic tone, responded swiftly to itch and scratching in healthy controls, but displayed a limited adaptability in atopic dermatitis. This study supports the concept that atopic dermatitis is a stress-responsive disorder and involves autonomic nervous system dysfunction. Atopic subjects exhibited an overactive sympathetic response to itch and scratching, while the parasympathetic tone was persistently and rigidly elevated, showing a lack of adaptability in response to stress.

There is a higher degree of homology between the N-terminal and C-terminal halves of the large subunit of carbamoyl phosphate synthetase from E. coli. Selected regions were isolated through genetic manipulations and the mutant proteins purified. None of the truncated mutants or chimeric proteins possessed any full or partial catalytic activities indicating that these two domains cannot function independently of each other.

The present engineering educational system is not doing an adequate job of instiling and maintaining the ideals of professionalism and ethics amongst engineering students and practicing engineers. Under the present system, there is little incentive for an engineer to familiarize himself with issues in professionalism and ethics. In fact, there are those who contend that increasing a future engineer's exposure to professionalism and ethics during the course of training is not practical. This paper presents arguments against four of the most common points that are used by those who feel professionalism and ethics cannot be effectively included in our engineering educational system. The paper concludes with several recommendations for increasing the exposure of more engineers to issues in professionalism and ethics at the academic level and at the practicing level.