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Background Smell and taste loss are highly prevalent symptoms in coronavirus disease 2019 (COVID-19), although few studies have employed objective measures to quantify these symptoms, especially dysgeusia. Reports of unrecognized anosmia in COVID-19 patients suggests that self-reported measures are insufficient for capturing patients with chemosensory dysfunction. Objectives The purpose of this study was to quantify the impact of recent COVID-19 infection on chemosensory function and demonstrate the use of at-home objective smell and taste testing in an at-risk population of healthcare workers. Methods Two hundred and fifty healthcare workers were screened for possible loss of smell and taste using online surveys. Self-administered smell and taste tests were mailed to respondents meeting criteria for elevated risk of infection, and one-month follow-up surveys were completed. Results Among subjects with prior SARS-CoV-2 infection, 73% reported symptoms of olfactory and/or gustatory dysfunction. Self-reported smell and taste loss were both strong predictors of COVID-19 positivity. Subjects with evidence of recent SARS-CoV-2 infection (

The ideal device for hemodynamic monitoring of critically ill patients in the intensive care unit (ICU) or the operating room has not yet been developed. This would need to be affordable, consistent, have a very low margin of error (

BACKGROUND Dysosmia could alter dietary quality through mechanisms including changes in appetite, food choice, and subsequent nutritional intake. However, there are few studies which directly assess olfactory performance and dietary quality. In this pilot study, we aimed to measure dietary quality in dysosmic subjects compared with normosmic controls. METHODS Community dwelling adult subjects prospectively underwent olfactory testing using the Sniffin' Sticks Test from which composite threshold, discrimination and identification (TDI) scores were used to identify dysosmic subjects (TDI < 31) and normosmic controls (TDI ≥31). Subjects completed the Diet History Questionnaire III (DHQIII), a standardized and validated tool for nutritional assessment developed by the National Institutes of Health. The Healthy Eating Index (HEI) was calculated to determine compliance with the United States Dietary Guidelines for Americans. RESULTS Sixty patients were enrolled, including 29 dysosmic subjects and 31 normosmic controls with no difference in age or gender across groups. A significant correlation between TDI score and HEI component score was seen for protein (r = 0.256; p = 0.048), dairy (r = 0.285; p = 0.027), and saturated fat scores (r = -0.262; p = 0.043). Compared with normosmic controls, dysosmic subjects were found to have less total protein and total dairy intake, as well as less total saturated fat intake. CONCLUSIONS This study found significantly altered nutritional quality in subjects with reduced olfactory function, including decreased intake of protein, dairy and saturated fats. These findings are relevant given the high prevalence of dysosmia in the aging population and previous studies showing associations with mortality. This article is protected by copyright. All rights reserved.

Background and study aims The aim of this study was to assess long-term clinical outcomes beyond 6 years in patients who underwent per-oral endoscopic myotomy (POEM) for the treatment of achalasia. Patients and methods Patients with achalasia who underwent POEM between 2010 and 2012 and had follow-up of at least 6 years were retrospectively identified at eight tertiary care centers. The primary outcome evaluated was clinical success defined by an Eckardt symptom score (ESS) ≤ 3 for the duration of the follow-up period. The clinical success cohort was compared to failure (ESS > 3 at any time during follow-up) in order to identify characteristics associated with symptom relapse. The incidence of patient-reported gastroesophageal reflux (GER) was also evaluated. Results Seventy-three patients with 6-year follow-up data were identified. Sustained clinical remission was noted in 89 % (65/73) at 6-years. Mean ESS decreased from 7.1 ± 2.3 pre-procedure to 1.1 ± 1.1 at 6 years (P Conclusions In patients with achalasia, POEM provides high initial clinical success with excellent long-term outcomes. There are high rates of patient-reported gastroesophageal reflux post-procedure which persist at long-term follow-up.

Neurodiagnostic and neurointerventional radiology (NIR) play a central role in the diagnosis and treatment of skull base disorders. Noninvasive imaging modalities, including computed tomography and magnetic resonance imaging, are important in lesion localization, evaluation of lesion extent, and diagnosis, but cannot always be definitive. Image-guided skull base biopsy and percutaneous and endovascular treatment options are important tools in the diagnosis and treatment of head, neck, and skull base disorders. NIR plays an important role in the treatment of vascular disorders of the skull base. This article summarizes the imaging evaluation and interventional therapies pertinent to the skull base.

Recent initiatives have targeted the issue of gender and ethnic/racial disparities in general surgery and vascular surgery. However, the prevalence of these disparities in general and vascular surgical training programs is unknown.A retrospective analysis was conducted using data from three separate sources, including the US Graduate Medical Education annual report, Electronic Residency Application Service database, and National Resident Matching Program annual report. Demographic information regarding gender distribution and ethnic/racial identity was collected from 328 general surgery residency programs, 59 vascular surgery residency programs, and 100 vascular surgery fellowship programs across the US. The primary outcomes of this study were to evaluate national trends in gender and ethnic diversity in general surgery and vascular surgery training programs, including both traditional fellowship and integrated residency paradigms.From 2011-2020, general surgery residency programs showed a positive trend towards both female applicants (from 31.9%-41.5%) and trainees (from 36.2%-43.1%) (p0.0001 each). The proportion of minority trainees decreased, primarily among Black (from 7.2%-5.4%) and Asian trainees (from 21.5%-19.2%) (p0.0001 each). Concurrently, the number of vascular integrated residency programs grew from 27 to 59, resulting in a fivefold increase in trainees (from 64-335). Despite this growth, there was no change in the proportion of women applicants or trainees for both vascular integrated residency (24.9% applicants; 36.2% trainees) and fellowship programs (27.4% applicants; 25.9% trainees) over the study period (p = 0.11, 0.89, 0.43, and 0.13 respectively). Moreover, there was no significant change in proportion of minority trainees in both vascular integrated residency and fellowship programs.While general surgery programs have expanded in proportion of both female applicants and trainees, racial diversity has decreased. Gender and racial diversity in vascular training has not changed. Future initiatives in general and vascular surgery should focus on recruitment and promotion of proficient women and minority trainees.

The goal of the current longitudinal study was to investigate the role of adolescents' peer victimization and aggression prior to COVID-19 on the change in their depressive and anxious symptoms from pre- to mid-pandemic. We hypothesized that, although adolescents overall would display an increase in internalizing symptoms from pre- to mid-pandemic, this response would be weakened or perhaps even reversed when adolescents experienced high levels of victimization or aggression prior to the pandemic. Participants included 96 racially/ethnically diverse adolescents (42 males, 53 females; 1 other) with an average age of 16.79 years (SD = 0.60). At Time 1 (T1; June 2019 through February 2020; pre-pandemic), adolescents completed self-report measures of their peer relations (aggression, victimization) and internalizing symptoms (depressive, anxious). At Time 2 (T2; May through July 2020; mid-pandemic), adolescents completed self-report measures of their internalizing symptoms (depressive, anxious). On average, adolescents' anxious and depressive symptoms increased from T1 to T2, although they exhibited substantial variability, with reports ranging from decreasing symptoms to increasing symptoms. Although on average adolescents reported increases in anxious symptoms from T1 to T2, adolescents with higher T1 peer victimization reported less positive change in anxious symptoms. Similarly, although on average adolescents reported increases in depressive symptoms from T1 to T2, adolescents with higher levels of T1 aggression reported less positive change in depressive symptoms from T1 to T2. Discussion focused on restrictions on in-person peer interactions necessitated by COVID-19 that may reduce adolescents' distress when their pre-pandemic daily lives were characterized by negative peer relations.

Smoking and rural residence are independently correlated with the development of presumed ocular histoplasmosis syndrome, both with and without choroidal neovascularization. Diabetes may also be correlated with ocular histoplasmosis without choroidal neovascularization., Purpose: To investigate the relationship of smoking, urbanicity, and diabetes to presumed ocular histoplasmosis syndrome (POHS) and associated choroidal neovascularization (CNV). Methods: Medical records of 751 adult patients with POHS were reviewed, including 603 patients without CNV and 148 patients with CNV. Age-matched and gender-matched controls were randomly selected from the same practice for comparison. Statistical comparisons of smoking history, urbanicity, and diabetic history were performed using chi-square and conditional logistic regression analyses. Results: Increased rates of current or former smoking, rural residence, and diabetes were found in patients with POHS compared with controls. POHS patients with CNV had increased rates of current or former smoking and rural residence as compared with controls. Conclusion: A history of current or past smoking is associated with an increased risk of developing both POHS alone and POHS with CNV. We did not find a significant additional risk of smoking on the development of CNV in patients with POHS. Patients living in rural locations are more likely than those in urban locations to develop both POHS and POHS with CNV. Diabetics may be more likely to develop POHS than nondiabetics.

The esophagogastric junction (EGJ) is a complex anti-reflux barrier whose integrity relies on both the intrinsic lower esophageal sphincter (LES) and extrinsic crural diaphragm. During hiatal hernia repair, it is unclear whether the crural closure or the fundoplication is more important to restore the anti-reflux barrier. The objective of this study is to analyze changes in LES minimum diameter (Dmin) and distensibility index (DI) using the endoluminal functional lumen imaging probe (FLIP) during hiatal hernia repair. Following implementation of a standardized operative FLIP protocol, all data were collected prospectively and entered into a quality database. This data were reviewed retrospectively for all patients undergoing hiatal hernia repair. FLIP measurements were collected prior to hernia dissection, after hernia reduction, after cruroplasty, and after fundoplication. Additionally, subjective assessment of the tightness of crural closure was rated by the primary surgeon on a scale of 1 to 5, 1 being the loosest and 5 being the tightest. Between August 2018 and February 2020, 97 hiatal hernia repairs were performed by a single surgeon. FLIP measurements collected using a 40-mL volume fill without pneumoperitoneum demonstrated a significant decrease in LES Dmin (13.84 ± 2.59 to 10.27 ± 2.09) and DI (6.81 ± 3.03 to 2.85 ± 1.23 mm2/mmHg) after crural closure (both p

Towards the larger goal of understanding factors relevant for improving visuo-motor control, we investigated the role of visual feedback for modulating the effectiveness of a simple hand-eye training protocol. The regimen comprised a series of curve tracing tasks undertaken over a period of one week by neurologically healthy individuals with their non-dominant hands. Our three subject groups differed in the training they experienced: those who received ‘Persistent’ visual-feedback by seeing their hand and trace evolve in real-time superimposed upon the reference patterns, those who received ‘Non-Persistent’ visual-feedback seeing their hand movement but not the emerging trace, and a ‘Control’ group that underwent no training. Improvements in performance were evaluated along two dimensions—accuracy and steadiness, to assess visuo-motor and motor skills, respectively. We found that persistent feedback leads to a significantly greater improvement in accuracy than non-persistent feedback. Steadiness, on the other hand, benefits from training irrespective of the persistence of feedback. Our results not only demonstrate the feasibility of rapid visuo-motor learning in adulthood, but more specifically, the influence of visual veridicality and a critical role for dynamically emergent visual information.

Introduction: Computable phenotypes allow identification of well-defined patient cohorts from electronic health record data. Little is known about the accuracy of diagnostic codes for important clinical concepts in pediatric epilepsy, such as (1) risk factors like neonatal hypoxic-ischemic encephalopathy; (2) clinical concepts like treatment resistance; (3) and syndromes like juvenile myoclonic epilepsy. We developed and evaluated the performance of computable phenotypes for these examples using electronic health record data at one center. Methods: We identified gold standard cohorts for neonatal hypoxic-ischemic encephalopathy, pediatric treatment-resistant epilepsy, and juvenile myoclonic epilepsy via existing registries and review of clinical notes. From the electronic health record, we extracted diagnostic and procedure codes for all children with a diagnosis of epilepsy and seizures. We used these codes to develop computable phenotypes and evaluated by sensitivity, positive predictive value, and the F-measure. Results: For neonatal hypoxic-ischemic encephalopathy, the best-performing computable phenotype (HIE ICD-9 /10 and [brain magnetic resonance imaging (MRI) or electroencephalography (EEG) within 120 days of life] and absence of commonly miscoded conditions) had high sensitivity (95.7%, 95% confidence interval [CI] 85-99), positive predictive value (100%, 95% CI 95-100), and F measure (0.98). For treatment-resistant epilepsy, the best-performing computable phenotype (3 or more antiseizure medicines in the last 2 years or treatment-resistant ICD-10) had a sensitivity of 86.9% (95% CI 79-93), positive predictive value of 69.6% (95% CI 60-79), and F-measure of 0.77. For juvenile myoclonic epilepsy, the best performing computable phenotype (JME ICD-10) had poor sensitivity (52%, 95% CI 43-60) but high positive predictive value (90.4%, 95% CI 81-96); the F measure was 0.66. Conclusion: The variable accuracy of our computable phenotypes (hypoxic-ischemic encephalopathy high, treatment resistance medium, and juvenile myoclonic epilepsy low) demonstrates the heterogeneity of success using administrative data to identify cohorts important for pediatric epilepsy research.

BACKGROUND The impact of multiple coexisting medical comorbidities on treatment outcomes in chronic rhinosinusitis (CRS) is unknown. In this study we sought to evaluate the effect of comorbidities on sinonasal quality of life (QOL) and general health utility values by utilizing the Functional Comorbidity Index (FCI) in CRS patients. METHODS Patients with CRS were prospectively enrolled in a cross-sectional study of medical and surgical therapies. The 22-item Sino-Nasal Outcome Test (SNOT-22) and Medical Outcomes Study Short-Form 6D (SF-6D) scores were recorded at enrollment and 6-month follow-up; Lund-Kennedy endoscopy and Lund-Mackay computed tomography scores were recorded at enrollment. The FCI was calculated using the electronic medical record. The impact of cumulative comorbidity burden on baseline and posttreatment outcomes was assessed using univariate and bivariate correlations. RESULTS A total of 428 participants with CRS were included. The average (mean standard ± deviation) FCI score was 3.03 ± 2.28 (range, 0-12). Significant linear correlations were identified between increasing FCI score and baseline SNOT-22 and SF-6D scores (R = 0.166, p = 0.001 and R = -0.245, p

Background The electronic health record (EHR) contains a wealth of clinical data that may be used to streamline the identification of potential clinical trial participants. However, there is little empirical information on site-level facilitators of and barriers to optimal use of EHR systems with respect to trial recruitment. Methods We conducted qualitative focus groups and quantitative surveys as part of the EHR Ancillary Study, which is being conducted alongside the multicenter, global, Harmony Outcomes Trial comparing albiglutide to standard care for the prevention of cardiovascular events in type 2 diabetes. Subject matter experts used findings from focus groups to draft a 20-question survey examining the use of the EHR for participant identification, common site recruitment strategies, and variation in perceived barriers to optimal use of the EHR. The final survey was fielded with 446 site investigators actively enrolling participants in the main trial. Results Nearly two-thirds of respondents were study coordinators (63.2%), 23.1% were principal investigators, and 13.7% held other research roles. Approximately half of the respondents reported using the EHR to find potential trial participants. Of these, 79.4% reported using EHR searches in conjunction with other recruitment methods, including reviewing of upcoming clinic schedules (75.3%) and contacting past trial participants (71.2%). Important barriers to optimal use of the EHR included the lack of availability of certain research-focused EHR modules and limitations on the ability to contact patients cared for by other providers. Of survey respondents who did not use the EHR to find potential participants, one-quarter reported that the EHR was not accessible in their country; this finding varied from 2.6% of respondents in North America to 50% of respondents in the Asia Pacific. Conclusions While EHR screening was commonly used for recruitment in a cardiovascular outcomes trial, important technical, governance, and regulatory barriers persist. Multifaceted, scalable, and customizable strategies are needed to support the optimal use of the EHR for trial participant identification. Trial registration ClinicalTrials.gov NCT02465515. Registered on 8 June 2015

Oral delivery of MA-[d-Leu-4]-OB3 has been shown to significantly improve energy balance, glycemic control, dyslipidemia, and episodic memory in mouse models of fully-expressed T1DM and T2DM. To assess the prophylactic capacity of MA-[d-Leu-4]-OB3 to prevent or slow the progression of obesity, insulin resistance, and cognitive dysfunction, 3- to 4-week old male C57BL/6J mice were placed on a high-fat diet immediately after weaning, and maintained on this diet, in the absence or presence of orally delivered MA-[d-Leu-4]-OB3, for 23 weeks. Control mice of the same age and sex were maintained on a low-fat diet. Body weight, caloric and water intake, glucose tolerance, and fasting blood glucose levels were measured. Episodic memory was evaluated by novel object recognition testing. In male C57BL/6J mice maintained on a high-fat diet since weaning, MA-[d-Leu-4]-OB3 (1) normalized body weight gain for the first 8 weeks of the study, and sustained a significant reduction throughout the remaining 15 weeks; (2) had no effect on caloric or water intake; (3) improved glucose tolerance within 4 weeks; (4) reduced fasting blood glucose to levels approaching or equivalent to those seen in control mice within 3 weeks; and (5) normalized episodic memory within 4 weeks. In addition to its therapeutic potential, MA-[d-Leu-4]-OB3 may have a prophylactic application to the prevention or progression of many of the dysfunctions associated with metabolic syndrome, Down Syndrome, Alzheimer’s disease (AD), and other AD-like cognitive impairments in humans.

Summary Background & aims Consumption of rapid digesting sugars by children are under increased scrutiny because of their contribution to unhealthy weight gain. Previous studies in adults and children have suggested that altering the blend of carbohydrates (CHOs) consumed may cause shifts in substrate utilization. The purpose of this study was to examine the effects of consuming a slow digesting carbohydrate (SDC) and rapid digesting carbohydrate (RDC) on CHO and fat oxidation, glucose, and insulin responses at rest, during exercise, and post-exercise rest in pre-pubescent children. Methods A randomized, double-blind, crossover design was used. Nineteen pre-pubescent children (n = 10 boys, n = 9 girls, mean ± standard error, age = 9.84 ± 0.37-yrs) participated. Visits to the laboratory began with a 30-min measurement of resting metabolism followed by consumption of either an RDC or SDC drink. Postprandial resting metabolism was recorded for 60-min, immediately followed by 60-min of submaximal cycling exercise while metabolism was recorded, which was immediately followed by another 60-min recording of post-exercise metabolism. Total CHO and fat oxidation, endogenous and exogenous CHO oxidation, blood glucose, and insulin were assessed. Results Total CHO oxidation rate (g∙min−1) was greater after the RDC drink at 60 min (p = 0.032). Endogenous CHO oxidation rate (g∙min−1) was greater after the SDC drink at 15 min (p ≤ 0.010). Cumulative endogenous CHO oxidation (g) was greater after the SDC drink at 45 min (p = 0.009). Endogenous CHO oxidation accounted for a greater proportion of substrate oxidation after the first 60-min rest period (p = 0.028), while exogenous CHO oxidation accounted for a greater proportion of substrate oxidation for the RDC at all time points (p ≤ 0.019). Conclusions The present study provides novel data suggesting that an SDC promotes greater endogenous substrate utilization in pre-pubertal children, which may have beneficial health impacts on energy intake and carbohydrate regulation/metabolism during growth and development. Clinical trials registry number NCT03185884, clinicaltrials.gov

BACKGROUND Prospective studies of surgical stabilization of rib fractures (SSRF) have excluded elderly patients, and no study has exclusively addressed the ≥80-year-old subgroup. We hypothesized that SSRF is associated with decreased mortality in trauma patients 80 years or older. METHODS Multicenter retrospective cohort study involving eight centers. Patients who underwent SSRF from 2015 to 2020 were matched to controls by study center, age, injury severity score, and presence of intracranial hemorrhage. Patients with chest Abbreviated Injury Scale score less than 3, head Abbreviated Injury Scale score greater than 2, death within 24 hours, and desire for no escalation of care were excluded. A subgroup analysis compared early (0-2 days postinjury) to late (3-7 days postinjury) SSRF. Poisson regression accounting for clustered data by center calculated the relative risk (RR) of the primary outcome of mortality for SSRF versus nonoperative management. RESULTS Of 360 patients, 133 (36.9%) underwent SSRF. Compared with nonoperative patients, SSRF patients were more severely injured and more likely to receive locoregional analgesia. There were 31 hospital deaths among the entire sample (8.6%). Multivariable regression demonstrated a decreased risk of mortality for the SSRF group, as compared with the nonoperative group (RR, 0.41; 95% confidence interval, 0.24-0.69; p < 0.01). However, SSRF patients were more likely to develop pneumonia, and had an increased duration of both mechanical ventilation and intensive care unit stay. There were no differences in discharge destination, although the SSRF group was less likely to be discharged on narcotics (RR, 0.66; 95% confidence interval, 0.48-0.90; p = 0.01). There was no difference in adjusted mortality between the early and late SSRF subgroups. CONCLUSION Patients selected for SSRF were substantially more injured versus those managed nonoperatively. Despite this, SSRF was independently associated with decreased mortality. With careful patient selection, SSRF may be considered a viable treatment option in octogenarian/nonagenarians. LEVEL OF EVIDENCE Therapeutic, Level IV.

The purpose of this study was to compare measurements of muscle strength, size, and activation of the forearm flexors in pre- and post-pubescent males and females. Forty pre-pubescent (mean ± 95% confidence interval, age = 9.79 ± 0.35 years, n = 10 males, n = 10 females) and post-pubescent (age = 17.23 ± 0.58 years, n = 10 males, n = 10 females) youth participated. Subjects completed maximal voluntary isometric contractions (MVICs) of the forearm flexors, and submaximal isometric step muscle actions at 30, 50, and 70% of the peak MVIC. Percent voluntary activation (VA) was quantified during all isometric muscle actions. Forearm flexor (biceps brachii and brachialis) muscle cross-sectional area (CSA) was quantified from ultrasound images. MVIC strength was expressed in absolute terms and normalized to CSA. Post-pubertal males were 130% stronger, had 101% greater CSA, and 17% greater maximal VA than pre-pubertal males, while post-pubertal females were 72% stronger, had 54% greater CSA, and 23% greater maximal VA than pre-pubertal females. When MVIC strength was normalized to CSA, the post-pubertal males were still 15% stronger than the pre-pubertal males, while the post-pubertal females were only 12% stronger than the pre-pubertal females. The responses for VA across intensity reflected differences in muscle activation strategies between pre- and post-pubertal males and females. These results suggest that muscle size may account for a greater proportion of the growth and development-related differences in strength among males, while females may be more affected by changes in muscle activation. Regardless of sex, changes in muscle size and neuromuscular function influence strength increases during growth and development.

Pigmented urine in a hospitalized patient has a broad differential diagnosis including urinary tract infection or bacterial colonization, hemolysis, rhabdomyolysis, and drugs. We present a case of purple urine in a patient who received methylene blue and hydroxocobalamin for catecholamine-refractory vasodilatory shock. The patient's purple urinary discoloration is presumed to have resulted from a combination of the blue and red pigments of methylene blue and hydroxocobalamin, respectively. As these drugs are increasingly being used to treat vasoplegia in cardiopulmonary bypass, it is important for clinicians to be aware of this benign cause of urine discoloration.

Intercostal nerve cryoablation (INCA) coupled with surgical stabilization of rib fractures (SSRF) has been shown to reduce post-operative pain scores but at what monetary cost. We hypothesize that in-hospital outcomes improve with the addition of INCA to SSRF and potential increased hospital charges are justified by patient benefits.Multi-institutional, retrospective review of patients undergoing SSRF with and without INCA over an 8-year period. Institutions involved were Level II or higher trauma centers. Basic demographics were obtained. Patients were included if SSRF was performed during the index hospitalization. Primary outcomes included total hospital length of stay (HLOS) and HLOS after SSRF, total hospital charges (HC), HC the day of surgery and HC after surgery. Secondary outcome included total narcotic consumption in morphine milliequivalents (MME) after SSRF. Mann-Whitney U test was used for analysis. Statistical significance p 0.05.136 patients analyzed; 92 underwent SSRF only and 44 underwent SSRF with INCA. Demographics were similar between groups. Number of ribs stabilized was comparable; 4.78 ± 1.64 SSRF only and 4.73 ± 1.66 SSRF with INCA (p = 0.463). Median ISS [16 (IQR 11.5-16) SSRF only and 14 (IQR 9-18.75) SSRF with INCA (p = 0.463)] was not statistically different. The INCA group showed a decrease in the median total HLOS, 9 versus 10 days (U = 1517.5, p = 0.026) and HLOS after SSRF, 4 versus 6 days (U = 1217.5, p 0.001). HC the day of surgery were higher for the INCA group, $93,932 versus $71,143 (U = 1106, p 0.001). However, total HC were similar between groups and total HC after SSRF was significantly less for the INCA group, $10,556 versus $20,269 (U = 1327, p = 0.001). Total median narcotic use after SSRF was significantly less for the INCA group, 88.6 vs 113.7 MME (U = 1544.5, p = 0.026).SSRF with INCA is safe and does not increase overall HC with the added benefit of decreased HLOS post-operatively and decreased narcotic consumption.

Background Focused cardiac ultrasound (FOCUS) can aid in evaluation and management of patients with cardiac arrest, but image quality in this population has been questioned. Our goal was to determine how often adequate imaging can be obtained in cardiac arrest patients. Methods We conducted a prospective cohort study to examine the utility of FOCUS in cardiac arrest. All patients who presented to the Emergency Department (ED) in cardiac arrest or who had cardiac arrest while in the ED over 6 months were prospectively identified. FOCUS images were obtained as part of routine clinical care. Patients with images obtained were paired with age- and gender-matched controls who underwent FOCUS for another indication during the study period. Image quality was scored by two blinded reviewers using a 0–4 scale, with a score of ≥ 2 considered adequate. Results There were 137 consecutive cardiac arrests, 121 out-of-hospital and 16 in-hospital, during the study period. FOCUS images were recorded in 126 (92%), who were included in the analysis. The average age was 58 years, and 45% were female. Ninety-seven studies (77%) were obtained during advanced cardiac life support while 29 (23%) were obtained after return of spontaneous circulation. The controls were appropriately matched. Of the cardiac arrest studies, 106 (84%) were rated adequate, compared to 116 (92%) in controls (p = 0.08). When compared to control FOCUS studies, the scores given to studies of cardiac arrest patients were lower (p = 0.001). Conclusions FOCUS can reliably be used during cardiac arrest to obtain images adequate to answer clinical questions and guide therapies.

Background and aims Increased receptor tyrosine kinase (RTK) activity has been historically linked to atherosclerosis. Paradoxically, we recently found that global deficiency in c-Kit function increased atherosclerosis in hyperlipidemic mice. This study aimed to investigate if such unusual atheroprotective phenotype depends upon c-Kit's function in smooth muscle cells (SMC). Methods We studied atherosclerosis in a SMC-specific conditional knockout mice (KitSMC) and control littermate. Tamoxifen (TAM) and vehicle treated mice were fed high fat diet for 16 weeks before atherosclerosis assessment in the whole aorta using oil red staining. Smooth muscle cells were traced within the aortic sinus of conditional c-Kit tracing mice (KitSMC eYFP) and their control littermates (KitWT eYFP) by immunofluorescent confocal microscopy. We then performed RNA sequencing on primary SMC from c-Kit deficient and control mice, and identified significantly altered genes and pathways as a result of c-Kit deficiency in SMC. Results Atherosclerosis significantly increased in KitSMC mice with respect to control groups. In addition, the loss of c-Kit in SMC increased plaque size and necrotic core area in the aortic sinus of hyperlipidemic mice. Smooth muscle cells from KitSMC eYFP mice were more prone to migrate and express foam cell markers (e.g., Mac2 and MCAM) than those from control littermate animals. RNAseq analysis showed a significant upregulation in genes associated with cell proliferation, migration, lipid metabolism, and inflammation secondary to the loss of Kit function in primary SMCs. Conclusions Loss of c-Kit increases SMC migration, proliferation, and expression of foam cell markers in atherosclerotic plaques from hyperlipidemic mice.

OBJECTIVE To characterize differences in vestibular testing results among patients presenting with balance-related complaints; to stratify patterns of testing abnormalities by age. STUDY DESIGN Retrospective chart review. SETTING Academic Balance Center at a Tertiary Referral Center. PATIENT POPULATION All patients who underwent vestibular testing in a 1-year period from 2017 to 2018. MAIN OUTCOME MEASURE Balance function test results. RESULTS We reviewed 1,116 patients with age ranging from 11 to 94 years, including 521 patients ≥60 years. Most patients had at least 1 abnormal result, with only 21% of patients ≥60 years and 43% of patients

INTRODUCTION The traditional treatment of traumatic hemothorax (HTX) has been an insertion of a large-bore 36- to 40-Fr chest tube. Our previous single-center randomized controlled trial (RCT) had shown that 14-Fr percutaneous catheters (PCs) (pigtail) were equally as effective as chest tube. We performed a multicenter RCT, hypothesizing that PCs are as equally effective as chest tubes in the management of patients with traumatic HTX (NCT03546764). METHODS We performed a multi-institution prospective RCT comparing 14-Fr PCs with 28- to 32-Fr chest tubes in the management of patients with traumatic HTX from July 2015 to September 2020. We excluded patients who were in extremis and required emergent tube placement and those who refused to participate. The primary outcome was failure rate, defined as a retained HTX requiring a second intervention. Secondary outcomes included daily drainage output, tube days, intensive care unit and hospital length of stay, and insertion perception experience (IPE) score on a scale of 1 to 5 (1, tolerable experience; 5, worst experience). Unpaired Student's t test, χ2, and Wilcoxon rank sum test were used with significance set at p < 0.05. RESULTS After exclusion, 119 patients participated in the trial, 56 randomized to PCs and 63 to chest tubes. Baseline characteristics between the two groups were similar. The primary outcome, failure rate, was similar between the two groups (11% PCs vs. 13% chest tubes, p = 0.74). All other secondary outcomes were also similar, except PC patients reported lower IPE scores (median, 1: "I can tolerate it"; interquartile range, 1-2) than chest tube patients (median, 3: "It was a bad experience"; interquartile range, 2-5; p < 0.001). CONCLUSION Small caliber 14-Fr PCs are equally as effective as 28- to 32-Fr chest tubes in their ability to drain traumatic HTX with no difference in complications. Patients reported better IPE scores with PCs over chest tubes, suggesting that PCs are better tolerated. LEVEL OF EVIDENCE Therapeutic, level II.

Background Military guidelines endorse early fasciotomy after revascularization of lower extremity injuries to prevent compartment syndrome, but the real-world impact is unknown. We assessed the association between fasciotomy and amputation and limb complications among lower extremitys with vascular injury. Methods A retrospectively collected lower extremity injury database was queried for limbs undergoing attempted salvage with vascular procedure (2004-2012). Limbs were categorized as having undergone fasciotomy or not. Injury and treatment characteristics were collected, as were intervention timing data when available. The primary outcome measure was amputation. Multivariate models examined the impact of fasciotomy on limb outcomes. Results Inclusion criteria were met by 515 limbs, 335 (65%) with fasciotomy (median 7.7 h postinjury). Of 212 limbs, 174 (84%) with timing data had fasciotomy within 30 min of initial surgery. Compartment syndrome and suspicion of elevated pressure was documented in 127 limbs (25%; 122 had fasciotomy). Tourniquet and shunt use, fracture, multiple arterial and combined arteriovenous injuries, popliteal involvement, and graft reconstruction were more common in fasciotomy limbs. Isolated venous injury and vascular ligation were more common in nonfasciotomy limbs. Fasciotomy timing was not associated with amputation. Controlling for limb injury severity, fasciotomy was not associated with amputation but was associated with limb infection, motor dysfunction, and contracture. Sixty-three percent of fasciotomies were open for >7 d, and 43% had multiple closure procedures. Fasciotomy revision (17%) was not associated with increased amputation or complications. Conclusions Fasciotomy after military lower extremity vascular injury is predominantly performed early, frequently without documented compartment pressure elevation. Early fasciotomy is generally performed in severely injured limbs with a subsequent high rate of limb complications.

Objectives The authors sought to evaluate the association between mean mitral valve gradient (MVG) and clinical outcomes among patients who underwent MitraClip treatment for secondary mitral regurgitation (SMR) in the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) trial. Background In the COAPT trial, patients with heart failure (HF) and severe SMR who remained symptomatic despite guideline-directed medical therapy had marked 2-year reductions in mortality and HF hospitalizations after treatment with MitraClip. Methods MitraClip-treated patients were divided into quartiles (Q) based on discharge echocardiographic MVG (n = 250). Endpoints including all-cause mortality, HF hospitalization, and health status measures at 2 years were compared between quartiles. Results Mean MVG after MitraClip was 2.1 ± 0.4 mm Hg, 3.0 ± 0.2 mm Hg, 4.2 ± 0.5 mm Hg, and 7.2 ± 2.0 mm Hg in Q1 (n = 63), Q2 (n = 61), Q3 (n = 62), and Q4 (n = 64), respectively. There was no difference across quartiles in the 2-year composite endpoint of all-cause mortality or HF hospitalization (43.2%, 49.2%, 40.6%, and 40.9%, respectively; p = 0.80), nor in improvements in New York Heart Association functional class, Kansas City Cardiomyopathy Questionnaire score, or 6-min walk time. Results were similar after adjustment for baseline clinical and echocardiographic characteristics, post-procedure MR grade, and number of clips (all-cause mortality or HF hospitalization Q4 [44.6%] vs. Q1 to Q3 [40.3%]; adjusted hazard ratio: 1.23, 95% confidence interval: 0.60 to 2.51; p = 0.57). Conclusions Among HF patients with severe SMR, higher MVGs on discharge did not adversely affect clinical outcomes following MitraClip. These findings suggest that in select patients with HF and SMR otherwise meeting the COAPT inclusion criteria, the benefits of MR reduction may outweigh the effects of mild-to-moderate mitral stenosis after MitraClip.

BACKGROUND: Complications from liver cirrhosis are a leading cause of death in children with cystic fibrosis. Identifying children at risk for developing liver cirrhosis and halting its progression are critical to reducing liver-associated mortality. OBJECTIVE: Quantitative US imaging, such as shear-wave elastography (SWE), might improve the detection of liver fibrosis in children with cystic fibrosis (CF) over gray-scale US alone. We incorporated SWE in our pediatric CF liver disease screening program and evaluated its performance using magnetic resonance (MR) elastography. MATERIALS AND METHODS: Ninety-four children and adolescents with CF underwent 178 SWE exams, aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transferase (GGT) and platelet measurements. Of these, 27 children underwent 34 MR elastography exams. We evaluated SWE performance using 6-MHz and 9-MHZ point SWE, and 9-MHz two-dimensional (2-D) SWE. RESULTS: The 6-MHz point SWE was the only method that correlated with MR elastography (r=0.52; 95% confidence interval [CI] 0.20–0.74; P=0.003). SWE of 1.45 m/s distinguished normal from abnormal MR elastography (79% sensitivity, 100% specificity, 100% positive predictive value [PPV], 55% negative predictive value [NPV], area under the receiver operating characteristic [AUROC] curve 0.94). SWE of 1.84 m/s separated mild–moderate (3.00–4.77 kPa) from severe (>4.77 kPa) MR elastography (88% sensitivity, 86% specificity, 78% PPV, 93% NPV, AUROC 0.79). Elevations of AST, ALT, GGT and thrombocytopenia were associated with higher SWE. AST-to-platelet ratio index of 0.42, fibrosis-4 of 0.29, and GGT-to-platelet ratio of 1.43 all had >95% NPV for SWE >1.84 m/s. CONCLUSION: Given its correlation with MR elastography, SWE might be a clinically useful predictor of liver fibrosis. We identified imaging criteria delineating the use of SWE to identify increased liver stiffness in children with CF. With multicenter validation, these data might be used to improve the detection and monitoring of liver fibrosis in children with CF.

I. Executive summary BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document. Methods ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. Results ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided. Conclusion This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

The goals of the current study were to use a three-reporter methodology and multi-level Latent Profile Analysis: (a) to determine the victim groups that emerge; (b) to evaluate the stability of victim groups over one school year; and (c) to examine differences among victim groups across the adjustment constructs of aggression, depression, anxiety, and negative peer relations. Our sample included 1440 racially/ethnically diverse 4th- and 5th-grade children (Mage = 10.15; 50% female). At the beginning (T1) and end (T2) of the school year, children completed both self and peer reports of victimization, teachers reported on students’ victimization, and we collected data from multiple reporters on aggression, depression, anxiety, and negative peer relations. At T1, two groups emerged: non-victims (low across all reporters) and victims (high across all reporters). At T2, four groups emerged: non-victims (low across all reporters), moderate victims (moderate across all reporters), discordant high victims (high on self report, very high on peer report, moderate on teacher report), and concordant high victims (high across all reporters). The stability of victim groups from T1 to T2 was largely driven by non-victims; T1 victims dispersed fairly evenly across the four groups at T2. In term of adjustment, non-victims fared best across time points and adjustment constructs. At T2, the three victim groups increased in maladjustment from moderate victims to discordant high victims to concordant high victims. These findings support the use of three-reporter assessment and a multi-level LPA approach to identify children victimized by their peers.

Corticosteroids are commonly used to treat refractory epilepsy in children, but the heterogeneity of the population and lack of standardized outcome measures have limited understanding of their effectiveness. We conducted a single-center study of corticosteroids for epileptic encephalopathy to (a) identify domains for measurement and estimate potential effect sizes, (b) characterize heterogeneity, and (c) identify outcomes that may need better tools for measurement. In this retrospective single-center cohort study, children with epileptic encephalopathy (excluding infantile spasms) were treated with a standardized course of oral dexamethasone or IV methylprednisolone. Long-term video electroencephalography (EEG) was assessed via novel ordinal scales for five features: seizure semiology/burden, epileptiform activity, slowing, organization, and sleep architecture. We abstracted parental assessment of functional domains (i.e., cognition) from the medical records. Pre-treatment and post-treatment EEG features, functional domains, and treatment regimens were compared. Thirty-five children with refractory epilepsy were included. Overall, 16/35 (46%) of individuals had a >50% reduction in seizure frequency from the pre-treatment EEG to the initial post-treatment EEG. In particular, tonic seizures (in a subset of 23 children) were reduced (24-hour tonic seizure count pre-treatment was 8 [4-13] and 3 [1-5] post-treatment EEG#1, p=0.04). For follow-up post-treatment EEGs, there was: (1) better formation of sleep spindles (37% normal pre-treatment to 63% normal post-treatment; p=0.04); and (2) improvement in parental reported cognition (in 43%). Improved cognition was the only outcome that differed between the dexamethasone and methylprednisolone treated groups (58% for dexamethasone [n=11/19] vs. 25% for methylprednisolone [n=4/16]; p=0.03). Large studies should be powered to detect reductions in seizures (particularly tonic as we identified a 2.6-fold reduction), improved EEG organization, and improved sleep architecture (21 percentage points). Cognitive improvements following steroid treatment, reported by parents, should be quantified and fully characterized in future work.

This study examined changes in vertical jump performance with progressively greater eccentric pre-loading in relation to growth and development in young female athletes. Twenty young female athletes ranging from 9 to 17 years old performed the following vertical jumps in random order: static jumps (SJs), counter-movement jumps (CMJs), and drop jumps (DJs) from drop heights of 20, 30, and 40 cm (DJ20, DJ30, and DJ40, respectively). Measurements included peak force (PF), peak rate of force development (RFD), peak power (PP), eccentric impulse (ECC), and concentric impulse (CON). Measurements of growth included age, maturity offset, height, body mass, fat-free mass, and thigh muscle cross-sectional area (CSA). PF increased from the SJ-DJ20 (P ≤ 0.009), then plateaued from DJ20-DJ40 (P = 1.000). RFD remained the same from SJ-CMJ (P = 1.000), increased from CMJ-DJ20 (P

Traditional management of traumatic hemothorax/hemopneumothorax (HTX/HPTX) has been insertion of large-bore 32–40 French (Fr) chest tubes (CTs). Retrospective studies have shown 14Fr percutaneous pigtail catheters (PCs) are equally effective as CTs. Our aim was to compare effectiveness between PCs and CTs by performing the first randomized controlled trial (RCT). We hypothesize PCs work equally as well as CTs in management of traumatic HTX/HPTX. Prospective RCT comparing 14Fr PCs to 28–32Fr CTs for management of traumatic HTX/HPTX from 07/2015 to 01/2018. We excluded patients requiring emergency tube placement or who refused. Primary outcome was failure rate defined as retained HTX or recurrent PTX requiring additional intervention. Secondary outcomes included initial output (IO), tube days and insertion perception experience (IPE) score on a scale of 1–5 (1 = tolerable experience, 5 = worst experience). Unpaired Student’s t-test, chi-square and Wilcoxon rank-sum test were utilized with significance set at P

Diabetic dyslipidemia, a common pattern of lipid abnormalities associated with diabetes, is characterized by hyperglycemia, elevated serum levels of triglycerides and low-density lipoprotein (LDL)-cholesterol, and reduced serum levels of high-density lipoprotein (HDL)-cholesterol. These lipid abnormalities make diabetes an independent risk-factor for the development of cardiovascular disease. Two mouse models of diabetes were used in the present study: 1) streptozotocin (STZ)-induced insulin-deficient male Swiss Webster mice (a model of T1DM), and 2) male diet-induced obese (DIO) mice rendered insulin-resistant by maintenance on a high-fat diet for 30 weeks (a model of T2DM). Both models were then treated with MA-[D-Leu-4]-OB3 by oral gavage for 14 or 17 days. At the end of the test period, the mice were exsanguinated by cardiac puncture; serum was prepared from the whole blood and analyzed by ELISA for total-, HDL-, LDL/VLDL-cholesterol, and triglyceride content. In mouse models of both T1DM and T2DM, MA-[D-Leu-4]-OB3 significantly (P

Sternal fractures are debilitating due to intractable pain, constant fracture movement and limited range of motion (ROM) of the upper extremities (UE). Traditional treatment comprises mainly of pain control, delaying return to daily activities. Recently, sternal fixation has gained popularity. There is, however, a lack of literature demonstrating efficacy. We report our experience of traumatically fractured sternal fixation. Following IRB approval, a retrospective chart review was completed for all patients undergoing sternal fixation by a single trauma surgeon at our Level I trauma center. Basic demographics were obtained. Primary outcomes included average cumulative pain scores, total cumulative narcotic amounts and total number of pain medication agents utilized prior to and after sternal fixation. Secondary outcome included physical therapy UE ROM before and after surgery. Paired t tests were used for comparison; significance set at p

» A transgender person is defined as one whose gender identity is incongruent with their biological sex assigned at birth. This highly marginalized population numbers over 1.4 million individuals in the U.S.; this prevalence skews more heavily toward younger generations and is expected to increase considerably in the future. » Gender-affirming hormone therapy (GAHT) has physiologic effects on numerous aspects of the patient's health that are pertinent to the orthopaedic surgeon, including bone health, fracture risk, and perioperative risks such as venous thromboembolism and infection. » Language and accurate pronoun usage toward transgender patients can have a profound effect on a patient's experience and on both objective and subjective outcomes. » Gaps in research concerning orthopaedic care of the transgender patient are substantial. Specific areas for further study include the effects of GAHT on fracture risk and healing, outcome disparities and care access across multiple subspecialties, and establishment of perioperative management guidelines.

Background: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a virus that is present in most bodily fluids. However, whether SARS-CoV-2 is present in the semen remains underexplored. Thus, we systematically reviewed the existing studies on the presence of SARS-CoV-2 in semen. Methods: A literature search of the PubMed, Embase, Cochrane, Web of Science, Google Scholar, and Ovid databases was performed for articles from the dates of their inception to August 2020 using the following keywords: COVID-19, SARS-CoV2, seminal, semen, and sperm. After excluding non-human studies and articles that were not in the English language, we identified 19 relevant studies. The full text of the articles were reviewed and a total of eight articles remained after applying our selection criteria. Results: After reviewing the presence of SARS-CoV-2 in the eight different studies using semen samples, only one reported the presence of the virus. Six out of 160 total semen samples with SARS-CoV-2 positive demonstrated the presence of viral RNA, of which 2 were from males in the recovery phase and 4 from the acute phase of the infection. Conclusion: The novel nature of SARS-CoV-2 has limited the number and size of studies on semen. Nevertheless, the current literature, while limited, has confirmed the presence of SARS-CoV-2 in semen in one out of the eight reported studies and totaling 4.3% of the population screened. Taken together, the risk of the presence of SARS-CoV-2 in semen appears to be extremely low and likely negligible in recovered men. Future studies need to focus on whether complete viral particles can be seen in semen and the possibility of sexual transmission.

Introduction Coronary artery bypass grafting (CABG) is a crucial intervention in acute myocardial infarction (AMI), particularly when AMI is not amenable for management with primary percutaneous coronary intervention (PCI). To optimise outcome in these patients, surgical teams must consider a host of predictive factors, with the most prominent being the timing of CABG. Despite numerous studies exploring timing of CABG following AMI in the past, optimal surgical timing remains controversial. The mortality rates vary with timing of CABG, but confounding factors such as age, impaired pulmonary function, renal insufficiency, and poor left ventricular function may contribute to varied outcomes reported. Evidence acquisiton An electronic literature search of articles that discussed acute myocardial presentation and urgent in-patient or elective CABG was conducted. Evidence synthesis The evidence was synthesised based on each reported article and their outcomes. Conclusions Current literature suggests multiple factors can guide CABG timing including, type of AMI at initial presentation, distinctive pathological status and patient characteristics. Thus, there is a need for large, multi-centre studies to identify optimal CABG timing in complex coronary artery disease or failed PCI in patients with AMI. Future guidelines should emphasise patient cohorts by taking their risk factors into consideration. As such, a need for greater cardiac screening methods and development of scoring systems can aid in the optimisation of CABG timing.

BACKGROUND Early diagnosis of HIV infection improves patient outcomes and reduces transmission. Adolescents make up one-fifth of new HIV diagnoses in the United States. We sought to quantify the number of missed opportunity encounters (MOEs) before HIV diagnosis for adolescents at a pediatric hospital (PediHosp) and a proximate adult hospital which employs universal HIV screening in its emergency department (ED) (CountyHosp). METHODS An observational study at 2 academic tertiary care hospitals in the United States that included all adolescents 13-20 years old with a new diagnosis of behaviorally-acquired HIV infection from 2006 to 2017. MOE were defined as any encounter at PediHosp or CountyHosp after the latter of the individual's 13th birthday or the date 3 months after the individual's most recent negative HIV screen, and before the encounter of HIV diagnosis. Comparisons were made by site of diagnosis and location of MOE. RESULTS Two-hundred five subjects met inclusion criteria: 68% male, 76% Black and 81% men who have sex with men. There were 264 MOE, the proportion of adolescent ED encounters that were MOE at the PediHosp ED was 8.3 MOE per 10,000 encounters and the proportion at the CountyHosp ED was 1.2 (relative risk = 6.7; 95% CI: 4.1-11.0; P < 0.001). CONCLUSIONS MOE for HIV diagnosis in adolescents occur frequently and are greater in number at a PediHosp as compared with a similar adult setting with universal screening. Universal HIV screening protocols at PediHosp may identify HIV-positive adolescents earlier.

Ventriculoseptal rupture (VSR) is a rare complication of takotsubo syndrome that often requires immediate treatment. Patients with VSR experience a range of outcomes and should be managed at centers with cardiac and surgical expertise. We present 2 cases of VSR complicating takotsubo syndrome that highlight potential outcomes. (Level of Difficulty: Intermediate.), Graphical abstract

BACKGROUND: Outcomes after surgical stabilization of rib fractures (SSRF) have not been studied in patients with multiple rib fractures and traumatic brain injury (TBI). We hypothesized that SSRF, as compared with nonoperative management, is associated with favorable outcomes in patients with TBI. METHODS: A multicenter, retrospective cohort study was performed in patients with rib fractures and TBI between January 2012 and July 2019. Patients who underwent SSRF were compared to those managed nonoperatively. The primary outcome was mechanical ventilation-free days. Secondary outcomes were intensive care unit length of stay and hospital length of stay, tracheostomy, occurrence of complications, neurologic outcome, and mortality. Patients were further stratified into moderate (GCS score, 9-12) and severe (GCS score, ≤8) TBI. RESULTS: The study cohort consisted of 456 patients of which 111 (24.3%) underwent SSRF. The SSRF was performed at a median of 3 days, and SSRF-related complication rate was 3.6%. In multivariable analyses, there was no difference in mechanical ventilation-free days between the SSRF and nonoperative groups. The odds of developing pneumonia (odds ratio [OR], 0.59; 95% confidence interval [95% CI], 0.38-0.98; p = 0.043) and 30-day mortality (OR, 0.32; 95% CI, 0.11-0.91; p = 0.032) were significantly lower in the SSRF group. Patients with moderate TBI had similar outcome in both groups. In patients with severe TBI, the odds of 30-day mortality was significantly lower after SSRF (OR, 0.19; 95% CI, 0.04-0.88; p = 0.034). CONCLUSION: In patients with multiple rib fractures and TBI, the mechanical ventilation-free days did not differ between the two treatment groups. In addition, SSRF was associated with a significantly lower risk of pneumonia and 30-day mortality. In patients with moderate TBI, outcome was similar. In patients with severe TBI a lower 30-day mortality was observed. There was a low SSRF-related complication risk. These data suggest a potential role for SSRF in select patients with TBI. LEVEL OF EVIDENCE: Therapeutic, level IV.

The Endoluminal Functional Lumen Imaging Probe (Endoflip) can be used to provide objective measurements of the gastroesophageal junction during fundoplication, and recent publications have suggested that this device could improve surgical outcomes. However, the impact of operative variables has not been clearly reported. The aim of this study is to determine the effect of these variables on functional lumen imaging probe (FLIP) measurements. Following implementation of a standardized operative FLIP protocol, all data were collected prospectively and entered into a quality database. This database was queried for patients undergoing hiatal hernia repair and fundoplication. The protocol utilized various balloon volumes (30 and 40 ml), patient positions (flat and reverse Trendelenburg) and amounts of insufflation (15 mmHg pneumoperitoneum and no pneumoperitoneum). Between August 2018 and February 2020, 97 fundoplications were performed by a single surgeon. Multivariable analysis without interactions demonstrated that a 40 ml volume fill resulted in significantly higher minimum diameter (Dmin), cross-sectional area (CSA), intra-balloon pressure (IBP) and distensibility index (DI) compared to a 30 ml volume fill (p

Background The left ventricle assist device (LVAD) patient population is rapidly expanding. Unique characteristics of these patients complicate the management of noncardiac surgical problems. Emergent general surgery (EGS) intervention is often warranted but remains poorly described. We reviewed EGS consultations in LVAD patients to better understand these patients. Methods During a 12-year period, 301 LVAD patients were reviewed. Demographics, comorbidities, reason for EGS consultation, operative intervention, transplantation, and mortality were analyzed. Wilcoxon, Fisher’s exact, and chi-square tests were used for analysis. Statistical significance was P < .05. Results A total of 139 (46.2%) patients required EGS consultation. EGS consultations were older (63 vs 57 years; P = .002), primarily Caucasian (86%), and male (83%) with average preimplant cardiac index of 1.84. Comorbidities were similar between those with and without EGS consultation. Gastrointestinal (GI) bleeding was the most common reason for consultation (53%), followed by abdominal pain (22%) and bowel ischemia/obstruction (19%). Of EGS consultations, 77% were on warfarin and 60% on aspirin. Procedures were not withheld: 46% required esophagogastroduodenoscopy (EGD) and 30% required colonoscopy. Surgical intervention was performed in 28% of EGS consults—49% emergent (within 24 hours) and 44% urgent (during hospitalization). Mean time to surgery was 48 days after LVAD placement. EGS intervention precluded 7 (18%) patients from heart transplantation and 10 (26%) patients suffered perioperative mortality. Elevated lactic acid was associated with increased mortality. Conclusion EGS consultation is necessary in almost half of all LVAD patients, most commonly for GI bleed. EGD/colonoscopy can be safely used to manage the majority of these consultations; one-third will require surgery. High lactic acid is associated with higher mortality. Additional analysis of this population is required for improving surgical management.

Background Many patients with chronic rhinosinusitis (CRS) have persistent olfactory dysfunction (OD) following endoscopic sinus surgery (ESS). Few studies compare outcomes to control subjects so it is unknown if residual OD is due to persistent CRS. Objective Compare postoperative measures of OD in case patients with CRS to healthy controls without sinonasal disease. Methods Prospective, observational, multicenter cohort study between October, 2016 and May, 2019. Case participants were selected from referred adult patients diagnosed with CRS, with or without nasal polyposis (NP), electing ESS as subsequent treatment modality. Controls voluntarily enrolled from a community-based sample without a history of CRS. Primary outcomes included measures of preoperative and postoperative OD using “Sniffin’ Stick” pens which summarize odorant threshold (T), discrimination (D), and identification (I) scores. Secondary outcomes included the Questionnaire of Olfactory Disorders-Negative Statements (QOD-NS) survey and olfactory cleft endoscopy scores (OCES). Results Outcomes were compared between 113 cases and 164 controls of similar average age and gender. Cases reported significantly worse baseline Sniffin’ Sticks TDI total scores (−6.8[SE ± 1.0]; 95% CI: −4.9 to −8.7), QOD-NS (8.9[SE ± 1.1]; 95% CI: 6.8–10.9), and OCES (3.5[SE ± 0.4]; 95% CI: 2.9–4.2) on average. Cases reported significant postoperative improvement in TDI total score (3.7[SD ± 8.2]; 95% CI: 2.2–5.2), QOD-NS (−5.9[SD ± 8.7]; 95% CI: −7.6 to −4.3), and OCES (−1.7[SD ± 3.8]; 95% CI: −2.7 to −0.8) on average, while 63% of anosmics reported improved postoperative olfaction. Multivariate regression identified that NP (OR = 0.4; 95% CI: 0.2–1.0) and previous ESS (OR = 0.3; 95% CI: 0.1–0.8) decreased the odds of postoperative improvement equal to mean TDI scores of controls, while septoplasty increased those odds (OR = 4.5; 95% CI: 1.5–13.7). Conclusion ESS improved olfactory metrics and restored olfactory function in approximately 50% of patients with CRS to that of healthy controls. Concurrent septoplasty increased the likelihood of achieving normal olfaction, while NP and previous ESS decreased those odds.

Background: Ureteral stent encrustation poses a distinct challenge to urologists. The purpose of our study is to present a patient with one of the oldest retained ureteral stents reported in the literature, effectively treated at our institution with a multimodal endourologic approach. Case Presentation: After IRB approval and patient's consent, we present the case of a 47-year-old man who was referred to our institution for gross hematuria and a right retained ureteral stent, incidentally found on imaging. This patient had a history of traumatic stab wound 22 years prior, requiring an exploratory laparotomy and a ureteral stent insertion. Preoperative CT scan revealed a fragmented and heavily encrusted right ureteral stent. The patient was effectively treated with a multimodal endourologic approach, including a cystolitholapaxy, a right retrograde flexible ureteroscopy (URS), and a prone split-leg right percutaneous nephrolithotomy combined with a right retrograde URS. The patient was rendered stone and stent free. Conclusion: To our knowledge, this 22-year-old retained stent is one of the oldest reported in the literature. As observed in our patient, multimodal endourologic techniques are safe and effective in patients with retained ureteral stents to render then stent and stone free.

INTRODUCTION Functional tricuspid regurgitation (TR) remains a challenging clinical problem with poor outcomes and few effective treatments. Atrial fibrillation (AF) has been associated with functional TR. We sought to determine whether restoring sinus rhythm through catheter ablation of AF can decrease the degree of TR. METHODS AND RESULTS A retrospective cohort study of patients undergoing AF ablation between 2011 and 2017 at a single center was conducted. We included patients with at least moderate TR on echocardiogram within the year preceding ablation, who underwent repeat echocardiogram within the year following ablation. Formal quantitative analysis was performed by an experienced research echocardiographer, blinded to arrhythmia outcomes. Arrhythmia-free survival was correlated to the extent of improvement in TR. Thirty-six patients met the inclusion criteria. A baseline echocardiogram was performed 37 ± 68 days before ablation and follow-up echocardiogram 139 ± 112 days following ablation. Patients were 63.7 ± 11.1 years old with a mean CHA2 DS2 -VASc score of 2.7 ± 1.7. The degree of TR improved by at least one grade in 23 patients (64%). TR area decreased from 11.6 ± 3.4 to 7.0 ± 3.5 cm2 (p

The purpose of this study was to analyze non-dysplastic Barrett’s esophagus (NDBE) biopsy tissue and compare the rate of somatic DNA copy number alterations (CNAs) in patients who subsequently progressed to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) to those patients who did not. A retrospectively collected database of Barrett’s esophagus (BE) patients spanning a 16-year period was queried. Patients who progressed from NDBE to HGD or EAC were identified and compared to patients who did not. Initial biopsy specimens were microdissected and extracted DNA underwent Multiplex Ligation-dependent Probe Amplification (MLPA) for CNAs. Comparisons between progressors and non-progressors were made with Fisher’s exact and two-sample t tests. Logistic regression assessed factors associated with progression. Of the 2459 patients in the BE database, 36 patients progressed from NDBE to either HGD or EAC. There were eight progressors who had biopsy specimens with adequate DNA for analysis. The progressor and non-progressor cohort had similar demographic information and medical history. The progressor group trended towards being older at diagnosis (72 ± 10 vs. 64 ± 13 years, p = 0.097) and fewer progressors reported reflux symptoms (50 vs. 94.7%, p

Currently, there are no standardized methods for quantitatively measuring fracture repair. Physicians rely on subjective physical examinations and qualitative evaluation of radiographs to detect mineralized tissue. Since most fractures heal indirectly through a cartilage intermediate, these tools are limited in their diagnostic utility of early repair. Prior to converting to the bone, cartilage undergoes hypertrophic maturation, characterized by the deposition of a provisional collagen X matrix. The objective of this study was to characterize the kinetics of a novel collagen X biomarker relative to other biological measurements of fracture healing using a murine model of endochondral fracture repair in which a closed, mid-shaft tibia fracture was created using the classic drop-weight technique. Serum was collected 5 to 42 days post-fracture in male and female mice and compared to uninjured controls (n = 8-12). Collagen X in the serum was quantified using a recently validated ELISA-based bioassay ("Cxm")1 and compared to genetic and histological markers of fracture healing and inflammation. We found the Cxm biomarker reliably increased from baseline to a statistically unique peak 14 days post-fracture that then resolved to pre-fracture levels by 3 weeks following injury. The shape and timing of the Cxm curve followed the genetic and histological expression of collagen X but did not show a strong correlation with local inflammatory states. Assessment of fracture healing progress is crucial to making correct and timely clinical decisions for patients. This Cxm bioassay represents a minimally invasive, inexpensive technique that could provide reliable information on the biology of the fracture to significantly improve clinical care.

Objective: To evaluate the effect of the COVID-19 pandemic on global access to care and practice patterns for children with epilepsy. Methods: We conducted a cross-sectional, online survey of pediatric neurologists across the world affiliated with the International Child Neurology Association, the Chinese Child Neurology Society, the Child Neurology Society, and the Pediatric Epilepsy Research Consortium. Results were analyzed in relation to regional burden of COVID-19 disease. Results: From April 10 to 24, 2020, a sample of 212 respondents from 49 countries indicated that the COVID-19 pandemic has dramatically changed many aspects of pediatric epilepsy care, with 91.5% reporting changes to outpatient care, 90.6% with reduced access to electroencephalography (EEG), 37.4% with altered management of infantile spasms, 92.3% with restrictions in ketogenic diet initiation, 93.4% with closed or severely limited epilepsy monitoring units, and 91.3% with canceled or limited epilepsy surgery. Telehealth use had increased, with 24.7% seeing patients exclusively via telehealth. Changes in practice were related both to COVID-19 burden and location. Conclusions: In response to COVID-19, pediatric epilepsy programs have implemented crisis standards of care that include increased telemedicine, decreased EEG use, changes in treatments of infantile spasms, and cessation of epilepsy surgery. The long-term impact of these abrupt changes merit careful study.

Evidence suggests that pediatric traumatic brain injury (TBI) may be causally related to alcohol misuse later in life; however, the nature and extent of the association has not been well described. This study examined the relationship between pediatric TBI and adult alcohol misuse in a population sample ≥20 years of age. We sought to determine (1) whether first self-reported incidence of TBI with loss of consciousness (LOC) before the age of 20 increased the risk for alcohol misuse later in life; and (2) whether sex, injury severity, and age at time of injury modified the association. We found a greater likelihood of binge but not heavy drinking for those whose first self-reported TBI with LOC occurred before the age of 20 when compared with those whose first self-reported TBI with LOC occurred later in life (28.5% vs. 20.4%