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Context: Dental (silver) amalgam is a widely used restorative material containing 50% elemental mercury that emits small amounts of mercury vapor. No randomized clinical trials have determined whether there are significant health risks associated with this low-level mercury exposure.Objective: To assess the safety of dental amalgam restorations in children.Design: A randomized clinical trial in which children requiring dental restorative treatment were randomized to either amalgam for posterior restorations or resin composite instead of amalgam. Enrollment commenced February 1997, with annual follow-up for 7 years concluding in July 2005.Setting and Participants: A total of 507 children in Lisbon, Portugal, aged 8 to 10 years with at least 1 carious lesion on a permanent tooth, no previous exposure to amalgam, urinary mercury level <10 microg/L, blood lead level <15 microg/dL, Comprehensive Test of Nonverbal Intelligence IQ > or =67, and with no interfering health conditions.Intervention: Routine, standard-of-care dental treatment, with one group receiving amalgam restorations for posterior lesions (n = 253) and the other group receiving resin composite restorations instead of amalgam (n = 254).Main Outcome Measures: Neurobehavioral assessments of memory, attention/concentration, and motor/visuomotor domains, as well as nerve conduction velocities.Results: During the 7-year trial period, children had a mean of 18.7 tooth surfaces (median, 16) restored in the amalgam group and 21.3 (median, 18) restored in the composite group. Baseline mean creatinine-adjusted urinary mercury levels were 1.8 microg/g in the amalgam group and 1.9 microg/g in the composite group, but during follow-up were 1.0 to 1.5 microg/g higher in the amalgam group than in the composite group (P<.001). There were no statistically significant differences in measures of memory, attention, visuomotor function, or nerve conduction velocities (average z scores were very similar, near zero) for the amalgam and composite groups over all 7 years of follow-up, with no statistically significant differences observed at any time point (P values from .29 to .91). Starting at 5 years after initial treatment, the need for additional restorative treatment was approximately 50% higher in the composite group.Conclusions: In this study, children who received dental restorative treatment with amalgam did not, on average, have statistically significant differences in neurobehavioral assessments or in nerve conduction velocity when compared with children who received resin composite materials without amalgam. These findings, combined with the trend of higher treatment need later among those receiving composite, suggest that amalgam should remain a viable dental restorative option for children.Trial Registration: clinicaltrials.gov Identifier: NCT00066118. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in reponse to the article "A significant dose-dependent relationship between mercury exposure from dental amalgams and kidney integrity biomarkers: a further assessment of the Casa Pia children's dental amalgam trial," by D. A. Geier and colleagues in the 2013 issue.

Migration of a ballistic missile through the vasculature is rare but important to recognize. It can lead to diagnostic confusion and seemingly unexplainable bullet trajectories. We have described the case of a young man with a gunshot wound to the axillary vein and initial embolus to the inferior vena cava. The bullet subsequently migrated to the right common iliac vein, allowing for straightforward retrieval.

Background: As the volume and proportion of patients treated arthroscopically for rotator cuff repair increases, it is important to recognize sex differences in utilization and outcomes. Methods: Patients who underwent arthroscopic rotator cuff repair between 2010 and 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Baseline demographic and clinical characteristics were collected, and information concerning utilization, operative time, length of hospital stay, days from operation to discharge, readmission, and adverse events were analyzed by sex. Results: Of 42,443 included patients, 57.7% were male and 42.3% were female. Comparably, females were generally older (P

Background: Since the inhibition of mercury absorption by ethanol was serendipitously discovered in 1965,(1) a limited number of small number studies with both animal and human subjects have reported results consistent with this finding.Aims: To investigate this phenomenon in a large scale human study with low level Hg exposed dentists.Methods: Data were collected for a sample of 1171 dentists, and both cross sectional and case-control methods were utilised to examine the data.Results: Abstainers (n = 345) had significantly higher urinary mercury concentrations (HgU) than drinkers (n = 826): 5.4 microg/l v 4.8 microg/l. Multiple linear regression showed a significant effect of ethanol dose on HgU after adjusting for potential confounders. A case-control analysis in which cases were defined as those individuals with urinary Hg concentrations of > or =15 microg/l (approximately top 5%), and controls as those with concentrations of <1.0 microg/l ( approximately bottom 5%), showed a clear protective dose-response relation; there was a decreasing risk of being a "case" (having an HgU > or =15 microg/l) with increasing ethanol consumption. The significance of the adjusted model is p<0.001, and the chi2 test for trend across ethanol consumption categories in the adjusted model is p<0.05, confirming the dose-response relation.Conclusion: We believe that this straightforward investigation provides the first specific confirmation in a large scale human study of the inhibitory effect of ethanol on urinary mercury concentration, and by inference, on mercury absorption. [ABSTRACT FROM AUTHOR]

Background: Surgical repair for shoulder instability includes arthroscopic Bankart, open Bankart, and Latarjet-Bristow. Methods: This is a cohort study of patients who underwent arthroscopic Bankart, open Bankart, or Latarjet-Bristow procedures that were identified within the National Surgical Quality Improvement Program database (2007-2019). Unadjusted and adjusted analyses were performed (α = 0.05). Outcomes included 30-day adverse events, readmission, and operative time. Results: This study included 10,955 patients (9128 arthroscopic Bankart, 1148 open Bankart, and 679 Latarjet-Bristow). Compared with arthroscopic Bankart, Latarjet-Bristow had longer operative times (129.96 [95% CI: 126.49-133.43] vs. 86.35 [85.51-87.19] minutes), along with a higher percentage of serious adverse events (2.5% vs. 0.4%), reoperation (1.9% vs. 0.1%), readmission (1.8% vs. 0.3%), thromboembolic complications (0.4% vs. 0.1%), and sepsis (0.4% vs. 0.0%) (P

Objective: Hand disability after hemodialysis access surgery has been common yet has remained poorly understood. Arteriovenous fistula (AVF) hemodynamic perturbations have not reliably correlated with the observed measures of hand function. Chronic kidney disease (CKD) is known to precipitate myopathy; however, the interactive influences of renal insufficiency and ischemia on limb outcomes have remained unknown. We hypothesized that CKD would contribute to access-related hand dysfunction via altered mitochondrial bioenergetics. Using a novel murine AVF model, we sought to characterize the skeletal muscle outcomes in mice with and without renal insufficiency. Methods: Male, 8-week-old C57BL/6J mice were fed either an adenine-supplemented diet to induce renal insufficiency (CKD) or a casein-based control chow (CON). After 2 weeks of dietary intervention, the mice were randomly assigned to undergo iliac AVF surgery (n = 12/group) or a sham operation (n = 5/group). Measurements of aortoiliac hemodynamics, hindlimb perfusion, and hindlimb motor function were collected for 2 weeks. The mice were sacrificed on postoperative day 14 to assess skeletal muscle histopathologic features and mitochondrial function. To assess the late outcome trends, 20 additional mice had undergone CKD induction and sham (n = 5) or AVF (n = 15) surgery and followed up for 6 weeks postoperatively before sacrifice. Results: The adenine-fed mice had had a significantly reduced glomerular filtration rate and elevated blood urea nitrogen, confirming the presence of CKD. The sham mice had a 100% survival rate and AVF cohorts an 82.1% survival rate with an 84.4% AVF patency rate. The aorta and inferior vena cava velocity measurements and the vessel diameter had increased after AVF creation (P < .0001 vs sham). The AVF groups had had a 78.4% deficit in paw perfusion compared with the contralateral limb after surgery (P < .0001 vs sham). Mitochondrial function was influenced by the presence of CKD. The respiratory capacity of the CKD-sham mice (8443 ± 1509 pmol/s/mg at maximal energy demand) was impaired compared with that of the CON-sham mice (12,870 ± 1203 pmol/s/mg; P = .0001). However, this difference was muted after AVF creation (CKD-AVF, 4478 ± 3685 pmol/s/mg; CON-AVF, 5407 ± 3582 pmol/s/mg; P = .198). The AVF cohorts had had impairments in grip strength (vs sham; P < .0001) and gait (vs sham; P = .012). However, the presence of CKD did not significantly alter the measurements of gross muscle function. The paw perfusion deficits had persisted 6 weeks postoperatively for the AVF mice (P < .0001 vs sham); however, the myopathy had resolved (grip strength, P = .092 vs sham; mitochondrial respiration, P = .108 vs sham). Conclusions: CKD and AVF-induced distal limb ischemia both impaired skeletal muscle mitochondrial function. Renal insufficiency was associated with a baseline myopathy that was exacerbated by the acute ischemic injury resulting from AVF creation. However, ischemia was the primary driver of the observed phenotype of gross motor impairment. This model reliably reproduced the local and systemic influences that contribute to access-related hand dysfunction and provides a platform for further mechanistic and therapeutic investigation. : Clinical Relevance: Access-related hand dysfunction (ARHD) has remained a common hemodialysis access surgery complication. Because of the poor mechanistic insight, the currently available therapies have been limited to surgical remediation of the hemodynamic changes in the limb for only the most severe clinical manifestations. Furthermore, expectant management or access revision will not be ideal options, especially for patients with mild to moderate ARHD, owing to the perioperative risk and implications for long-term access durability. Therefore, skeletal muscle mitochondrial-based therapy represents an intriguing treatment strategy. However, the characteristics of mitochondrial function after arteriovenous fistula placement are unknown. In the present study, we have characterized the ischemic and uremic influences on skeletal muscle physiology to identify the pathogenic drivers of ARHD.

Background: As the proportion of anatomic total shoulder arthroplasty (aTSA) operations performed at outpatient surgical sites continues to increase, it is important to evaluate the clinical implications of this evolution in care. Methods: Patients who underwent TSA for glenohumeral osteoarthritis from 2007 to 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Demographic data and 30-day outcomes were collected, and patients were separated into inpatient and outpatient (defined as same day discharge) groups. To control for confounding variables, a propensity score–matching algorithm was utilized. Outcomes included 30-day adverse events, readmission, and operative time. Results: A total of 20,035 patients who underwent aTSA between 2007 and 2019 were identified: 18,707 inpatient aTSAs and 1328 outpatient aTSAs. On matching, there were no significant differences in patient characteristics between inpatient and outpatient cohorts. Patients who underwent outpatient aTSA were less likely to experience a serious adverse event when compared with their matched inpatient aTSA counterparts (outpatient: 1.1% vs. inpatient: 2.1%, P = .03). Outpatient aTSA was associated with similar rates of all specific individual complications and readmissions (1.5% vs. 1.9%, P = .31). Conclusion: When compared with a propensity score–matched cohort of inpatient counterparts, the present study found outpatient aTSA was associated with significantly reduced severe adverse events and similar readmission rates. These findings support the growing use of outpatient aTSA in appropriately selected patients.

Aortoenteric fistula is a life-threatening emergency and is associated with high morbidity and mortality. Prompt surgical intervention before the aneurysm ruptures lowers the mortality rate to about 50%. Potential imaging mimics for aortoenteric fistula include retroperitoneal fibrosis, mycotic aortic aneurysm, and infectious aortitis. Secondary aortoenteric fistula has relative higher incidence compared to primary and is more common with open aortic repair versus endovascular stent graft repair. Ectopic gas in the aneurysm sac and extravasation of enteric contrast into the aneurysm sac is diagnostic for aortoenteric fistula. However, enteric contrast is not recommended for routine evaluation of aortoenteric because the aforementioned finding is extremely rare. More common imaging findings include bowel loop appearing adherent to aneurysm sac with associated inflammatory stranding and foci or ectopic gas within the aneurysm sac or interposed between the bowel and aneurysm sac. Here we present a case of 52-year-old male who presents with incidental primary aortoenteric fistula.

Colloid carcinomas are rare pancreatic tumors characterized by the presence of mucin pools with scarce malignant cells. Most of these neoplasms arise from intestinal-type intraductal papillary mucinous neoplasms (IPMNs). We report a case of a 77-year-old male patient who presented with weight loss, asthenia, lumbar pain and diabetes. Imaging studies revealed a mixed-type IPMN with high-risk features and a possible invasive component. The patient underwent surgical resection and the histology confirmed an invasive colloid carcinoma of the pancreas associated with an intestinal-type IPMN. Although invasive ductal and colloid carcinomas may look similar on imaging studies, its distinction is important because the latter have a better prognosis.

Background: Using mobile health, vital signs such as heart rate (HR) can be used to assess a patient’s recovery process from acute events including acute myocardial infarction (AMI). Objective: We aimed to characterize clinical correlates associated with HR change in the subacute period among patients recovering from AMI. Methods: HR measurements were collected from 91 patients (4447 HR recordings) enrolled in the MiCORE study using the Apple Watch and Corrie smartphone application. Mixed regression models were used to estimate the associations of patient-level characteristics during hospital admission with HR changes over 30 days postdischarge. Results: The mean daily HR at admission was 78.0 beats per minute (bpm) (95% confidence interval 76.1 to 79.8), declining 0.2 bpm/day (-0.3 to -0.1) under a linear model of HR change. History of coronary artery bypass graft, history of depression, or being discharged on anticoagulants was associated with a higher admission HR. Having a history of hypertension, type 2 diabetes mellitus (T2DM), or hyperlipidemia was associated with a slower decrease in HR over time, but not with HR during admission. Conclusion: While a declining HR was observed in AMI patients over 30 days postdischarge, patients with hypertension, T2DM, or hyperlipidemia showed a slower decrease in HR relative to their counterparts. This study demonstrates the feasibility of using wearables to model the recovery process of patients with AMI and represents a first step in helping pinpoint patients vulnerable to decompensation.

OBJECTIVES:. To identify and characterize clinical decline after completion of dexamethasone in severe COVID-19 and determine whether interleukin (IL)-6 and other inflammatory biomarkers predict the occurrence of clinical decline. DESIGN:. Prospective observational cohort. SETTING:. ICUs in three University of Washington affiliated hospitals between July 2020 and April 2021. PATIENTS:. Patients admitted to an ICU with COVID-19 who completed a course of dexamethasone. MEASUREMENTS AND MAIN RESULTS:. We identified 65 adult patients with severe COVID-19 who completed a 10-day course of dexamethasone, of whom 60 had plasma samples collected within 3 days of dexamethasone completion. We measured IL-6 with a clinical-grade electrochemiluminescent assay and a larger panel of inflammatory biomarkers (IL-8, Monocyte Chemoattractant Protein-1, Monocyte Inflammatory Protein-1 alpha, interferon gamma, C-X-C Motif Chemokine Ligand 10, WBC, bicarbonate) with a research immunoassay. We defined clinical decline by the occurrence of incident severe kidney injury, incident or escalating shock or fever, worsening hypoxemia, or death within 5 days of completion of dexamethasone. We estimated risk for clinical decline by standardized log2 transformed biomarker concentration using multivariable logistic regression. Clinical decline post-dexamethasone was common, occurring in 49% of patients (n = 32). Among all biomarkers, IL-6 levels were most strongly associated with clinical decline. After adjustment for age, sex, and study site, the odds of post-dexamethasone clinical decline were 7.33 times higher per one sd increase in log2 transformed IL-6 concentrations (adjusted odds ratio, 7.33; CI, 2.62–20.47; p < 0.001). The discriminatory power of IL-6 for clinical decline was high (cross-validated mean area under the receiver operating characteristic curve, 0.90; 95% CI, 0.79–0.95). CONCLUSIONS:. Clinical decline after completion of dexamethasone for severe COVID-19 is common. IL-6 concentrations obtained prior to completion of dexamethasone may have utility in identifying those at highest risk for subsequent worsening. If validated, future work might test whether plasma IL-6 could be used as a tool for a personalized approach to duration of dexamethasone treatment in severe COVID-19.

Importance:. Adults hospitalized with sepsis/septic shock commonly develop acute kidney injury (AKI) which imposes a significant burden on the healthcare system. The administration of early human albumin in this patient population may yield more efficient healthcare resource utilization. Objectives:. To examine the association between early use of albumin and time to discharge in adults who develop severe AKI while hospitalized with sepsis/septic shock. Design:. Retrospective cohort study using de-identified electronic health records from a national database (Cerner Health Facts; Cerner Corp., Kansas City, MO). Setting and Participants:. Patients (n = 2,829) hospitalized between January 2013 and April 2018 with a diagnosis of sepsis/septic shock (identified using International Classification of Diseases, 9th Revision and 10th Revision codes) who developed severe AKI (stage 3 according to Kidney Disease Improving Global Outcomes criteria) during hospitalization (n = 2,845 unique encounters). Main Outcomes and Measures:. Patients were grouped according to timing of albumin exposure: within less than or equal to 24 hours of admission (“early albumin”) or unexposed/exposed late (“nonearly albumin”). A cause-specific hazard model, censoring for death/discharge to hospice, was used to examine the association between “early albumin” and the rate of hospital discharge with clinical stability. Results:. Albumin was administered early in 8.6% of cases. Cases with early albumin administration had a median time to discharge of 13.2 days compared with 17.0 in the nonearly group (Log-rank p < 0.0001). An adjusted analysis showed that the rate of hospital discharge with clinical stability increased by 83% in the early albumin group compared with the nonearly group (hazard ratio, 1.832; 95% CI, 1.564–2.146; p < 0.001 nonearly group. Conclusions and Relevance:. The use of albumin within 24 hours of hospital admission was associated with a shorter time to discharge and a higher rate of discharge with clinical stability, suggesting an improvement in healthcare resource utilization among patients with sepsis/septic shock who developed stage 3 AKI during hospitalization.