Search

The primary objective of this study was to report surgical outcomes for cesarean delivery (CD) patients following the implementation of an Enhanced Recovery after Surgery (ERAS) pathway based on the ERAS Society recommendations. The primary outcome for which the study was powered was the length of stay (LOS).This IRB-approved cohort study was conducted at a single tertiary-care labor and delivery unit and utilized a pre-post intervention design. Our ERAS for CD protocol was designed using the ERAS Society recommendations and implemented globally for every patient admitted to the labor and delivery unit including both scheduled and unscheduled cases. The study was designed to have at least 85% power to detect a 6-h difference in length of stay (LOS) between the pre-intervention and post-intervention cohorts, assuming a standard deviation of 18 h. A total of 339 records were included for data analysis, 170 in the pre-intervention cohort and 169 in the post-intervention cohort. To assess the difference between groups with respect to the primary outcome of LOS, linear regression was used with and without adjusting for covariates. Differences in dichotomous secondary outcomes were assessed using binary logistic regression. Differences in continuous secondary outcomes were assessedMean LOS was 80.5 ± 22.9 h and 82.3 ± 28.0 h, pre- and post-intervention respectively. There was no difference in LOS between the 2 cohorts (difference of means = 1.8 h; 95% confidence interval (CI): (-3.7, 7.3);The results of this study support the implementation of an ERAS for CD protocol based on ERAS Society recommendations as evidenced by the statistically significant decrease observed in both procedure-related infection rates and inpatient opioid use. We did not find a significant difference in LOS, which leaves room for further investigation into factors that impact LOS after CD.

Background: The preferred method of fixation and surgical treatment for ligamentous Lisfranc injuries is controversial. Transarticular screws, bridge plating, fusion, and flexible fixation have been described, yet none have demonstrated superiority. Furthermore, screw fixation and plating often require secondary surgery to remove implants, leading surgeons to seek alternative fixation methods. Purpose: To compare transarticular screws and a fiber tape construct under a spectrum of biomechanical loads by evaluating the diastasis at 3 joints in the Lisfranc complex. Study Design: Controlled laboratory study. Methods: Eight matched pairs of fresh, previously frozen lower extremity cadaveric specimens were fixed with either 2 cannulated transarticular crossed screws or a fiber tape construct with a supplemental intercuneiform limb. The diastasis between bones was measured at 3 midfoot joints in the Lisfranc complex: the Lisfranc articulation, the second tarsometatarsal joint, and the intercuneiform joint. Measurements were obtained for the preinjured, injured, and fixation conditions under static loading at 50% donor body weight. Specimens then underwent cyclic loading performed at 1 Hz and 100 cycles, based on 100-N stepwise increases in ground-reaction force from 100 to 2000 N, to simulate postoperative loading from the partial weightbearing stage to high-energy activities. Failure of fixation was defined as diastasis ≥2 mm at the Lisfranc articulation (second metatarsal–medial cuneiform joint). Results: There were no significant differences in diastasis detected at the Lisfranc articulation or the intercuneiform joint throughout all loading cycles between groups. All specimens endured loading up to 50% body weight + 1400 N. Up to and including this stage, there were 2 failures in the cannulated transarticular crossed-screw group and none in the fiber tape group. Conclusion: The fiber tape construct with a supplemental intercuneiform limb, which does not require later removal, may provide comparable biomechanical stability to cannulated transarticular crossed screws, even at higher loads. Clinical Relevance: Ligamentous Lisfranc injuries are common among athletes. Therefore, biomechanical evaluations are necessary to determine stable constructs that can limit the time to return to play. This study compares the biomechanical stability of 2 methods of fixation for ligamentous injury through a wide spectrum of loading, including those experienced by athletes.

Background: Acyanotic and cyanotic congenital heart disease (CHD) patients are known to have distinct operative risk profiles. However, little is known about whether pulsatile and non-pulsatile cardiopulmonary bypass (CPB) have differential effects on cerebral hemodynamics or outcomes in these two patient groups. Methods: 159 pediatric (age Results: Regional-cerebral-oxygen-saturation, gaseous microemboli counts, and mean arterial pressure were similar between groups. PELOD-2 scores decreased over time, with similar scores between perfusion modalities in either group. Analysis of additional postoperative outcomes revealed no significant differences between non-pulsatile and pulsatile perfusion in either acyanotic or cyanotic groups. Conclusions: Despite patients undergoing pulsatile CBP demonstrating a more physiologic pulsatility index in both acyanotic and cyanotic groups, no clinically significant differences in cerebral hemodynamics or clinical outcomes were appreciated. Trial Registration Number and Registration Date: NCT00862407 (16/03/2009) (first registration date)

This study aimed to identify patient and appointment characteristics associated with no-shows to new patient appointments at a US academic ophthalmology department.Cross-sectional study.This was a study of all adult patients with new patient appointments scheduled with an attending ophthalmologist at Penn State Eye Center between January 1Of 4,628 patients, 759 (16.4%) were no-shows. From the multiple logistic regression model, characteristics associated with no-shows were age (Odds Ratio (OR) for 18-40 years vs.60 years: 3.41, 95% Confidence Interval (CI) 2.57, 4.51, p0.001 and OR for 41-60 years vs.60 years: 2.14, 95% CI 1.67, 2.74, p0.001), median household income (OR for$35,667 vs.$59,445: 1.59, 95% CI 1.08, 2.34, p0.001), insurance (OR for None vs. Medicare: 6.92, 95% CI 4.41, 10.86, p0.001 and OR for Medicaid vs. Medicare: 1.54, 95% CI 1.18, 2.01, p=0.002), race (OR for Black vs. White: 2.62, 95% CI 2.00, 3.43, p0.001 and OR for Other vs. White: 2.02, 95% CI 1.58, 2.59, p0.001), and commute distance (OR for 5-10 mi vs. ≤5 mi: 1.73, 95% CI 1.17, 2.55, p=0.006). Appointments with longer lead times and scheduled with glaucoma or retina specialists were also significantly associated with greater no-shows.Certain patient and appointment characteristics were associated with no-show status. These findings may assist in the development of targeted interventions at the patient, practice, and health system levels to improve appointment attendance.

Purpose The aim of this article is to investigate the impact of a 1-minute video describing resident training with a cataract surgical simulator on patients' perceptions regarding resident involvement in cataract surgery and to identify factors associated with patient willingness to have cataract surgery performed by a resident. Design Cross-sectional survey. Methods An anonymous Likert-style survey was conducted among 430 consecutive adult patients who presented for eye examination at the Penn State Health Eye Center. The survey included questions regarding demographics, understanding of the medical training hierarchy, and patient willingness to have a resident perform their cataract surgery. There were six questions regarding patient willingness to have residents perform their cataract surgery and the second question in this set informs the patient that residents are supervised by an experienced cataract surgeon. Patients were randomly assigned to one of two groups: patients in Group 1 completed the survey only, while patients in Group 2 watched a 1-minute video describing resident training with a cataract surgical simulator prior to completing the survey. Results Four hundred fourteen of the 430 patients (96.3%) completed the survey. Overall, 24.7% (n = 102) of respondents expressed willingness to allow an ophthalmology resident to perform their cataract surgery, and that proportion increased to 54.0% (n = 223) if the patient was informed that the resident would be supervised by an experienced cataract surgeon. Patients in Group 2 were twice as likely compared with patients in Group 1 to express willingness to allow an ophthalmology resident to perform their cataract surgery (odds ratio 1.92 [1.18–3.11], p = 0.009). Conclusions A thorough informed consent process including information regarding attending supervision and a brief video detailing resident training with a cataract surgery simulator may increase patient willingness to allow resident participation in cataract surgery.

Interventions have modest impact on reducing excessive gestational weight gain (GWG) in pregnant women with overweight/obesity. This two-arm feasibility randomized control trial tested delivery of and compliance with an intervention using adapted dosages to regulate GWG, and examined pre-post change in GWG and secondary outcomes (physical activity: PA, energy intake: EI, theories of planned behavior/self-regulation constructs) compared to a usual care group. Pregnant women with overweight/obesity (N = 31) were randomized to a usual care control group or usual care + intervention group from 8 to 2 weeks gestation and completed the intervention through 36 weeks gestation. Intervention women received weekly evidence-based education/counseling (e.g., GWG, PA, EI) delivered by a registered dietitian in a 60-min face-to-face session. GWG was monitored weekly; women within weight goals continued with education while women exceeding goals received more intensive dosages (e.g., additional hands-on EI/PA sessions). All participants used mHealth tools to complete daily measures of weight (Wi-Fi scale) and PA (activity monitor), weekly evaluation of diet quality (MyFitnessPal app), and weekly/monthly online surveys of motivational determinants/self-regulation. Daily EI was estimated with a validated back-calculation method as a function of maternal weight, PA, and resting metabolic rate. Sixty-five percent of eligible women were randomized; study completion was 87%; 10% partially completed the study and drop-out was 3%. Compliance with using the mHealth tools for intensive data collection ranged from 77 to 97%; intervention women attended > 90% education/counseling sessions, and 68–93% dosage step-up sessions. The intervention group (6.9 kg) had 21% lower GWG than controls (8.8 kg) although this difference was not significant. Exploratory analyses also showed the intervention group had significantly lower EI kcals at post-intervention than controls. A theoretical, adaptive intervention with varied dosages to regulate GWG is feasible to deliver to pregnant women with overweight/obesity.

OBJECTIVE To evaluate the role of appendectomy in surgical excision of endometriosis and to assess complications associated with appendectomy. METHODS Retrospective study of women undergoing appendectomy for pelvic pain and/or endometriosis during a primary gynecologic procedure. RESULTS Record review was performed for 609 women who underwent appendectomy between 2013 and 2019 for pelvic pain (6.9%, 42/609), stage I-II endometriosis (63.7%, 388/609), or stage III-IV endometriosis (29.4%, 179/609). Appendiceal endometriosis (AppE) was present in 14.9% (91/609); 2.4% without endometriosis (1/42, reference group), 7.0% with stage I-II endometriosis (27/388, odds ratio [OR] 3.06, 95% confidence interval [CI] 0.41-23.11, P = 0.278), and 35.2% with stage III-IV endometriosis (63/179, OR 22.24, 95% CI 2.99-165.40, P = 0.002). AppE was significantly associated with endometriosis present in other locations (OR 5.27, 95% CI 2.66-10.43, P

STUDY OBJECTIVE To evaluate the diagnosis of appendiceal endometriosis (AppE) in coincidental appendectomy specimens using standard versus modified histopathologic analysis. DESIGN Prospective analysis of 300 consecutive patients undergoing coincidental appendectomy at the time of a primary gynecologic procedure. SETTING Academic tertiary referral hospital in the northeastern United States. PATIENTS Women aged 22 to 52 years undergoing gynecologic surgery for the management of endometriosis or chronic pelvic pain between 2013 and 2015. INTERVENTIONS Each appendix specimen underwent standard pathologic analysis with 4 sections performed. Modified pathologic analysis, consisting of standard analysis plus serial sectioning and complete evaluation of the appendix and mesoappendix, was then performed. The first pathologist reviewed all the slides to render a diagnosis. The slides of the subjects with abnormal pathology were rereviewed. On rereview, the diagnosis was confirmed, and the data on which protocol, standard or modified, achieved the diagnosis was rendered. The pathologist performing the second review was blinded to whether the slides from the standard or modified histopathology protocol achieved the original diagnosis. This allowed each specimen to serve as its own control. MEASUREMENTS AND MAIN RESULTS The primary outcome is the detection of AppE. The standard analysis identified endometriosis in 7.7% (n = 23) of appendiceal specimens, whereas the modified analysis identified endometriosis in 10.0% (n = 30; odds ratio 1.3; confidence interval, 1.1-1.7; p = .01). When all pathology findings were combined, the standard analysis identified abnormal pathology in 9.3% (n = 28) of the specimens, whereas the modified analysis identified abnormal pathology in 12.3% (n = 37; odds ratio 1.4; confidence interval, 1.1-1.7; p

Objective To examine the effects of common treatments for polycystic ovary syndrome (PCOS) on a panel of hormones (reproductive/metabolic). Design Secondary analysis of blood from a randomized controlled trial of three 16-week preconception interventions designed to improve PCOS-related abnormalities: continuous oral contraceptive pills (OCPs, N = 34 subjects), intensive lifestyle modification (Lifestyle, N = 31), or a combination of both (Combined, N = 29). Materials and Methods Post-treatment levels of activin A and B, inhibin B, and follistatin (FST), as well as Insulin-like growth factor 1 (IGF-1), insulin-like growth factor binding protein 2 (IGFBP-2), glucagon, glucagon-like peptide 1 (GLP-1) and 2, and oxyntomodulin were compared to baseline, and the change from baseline in these parameters were correlated with outcomes. Results Oral contraceptive pill use was associated with a significant suppression in activin A, inhibin A, and anti-mullerian hormone (AMH), but a significant increase in FST. IGF-1, IGFBP-2, glucagon, and GLP-2 levels were significantly decreased. Oxyntomodulin was profoundly suppressed by OCPs (ratio of geometric means: 0.09, 95% confidence interval [CI]: 0.05, 0.18, P Conclusions In women with PCOS, OCPs (and not Lifestyle) affect a wide variety of reproductive/metabolic hormones, but their treatment response does not correlate with live birth.

Objective To assess if a surgical boot camp improves laparoscopic skill among reproduction endocrinology and infertility (REI) fellows and increases fellow desire to incorporate surgical skills into practice and to examine whether fellowship in vitro fertilization (IVF) volume correlates with surgical efficiency. Design Prospective evaluation. Setting Simulation Center. Patient(s) Forty REI fellows. Intervention(s) Fellows were timed before and after training in laparoscopic suturing and knot tying and while using virtual simulators. Fellows were surveyed before boot camp on prior experience with IVF and reproductive surgery, and immediately and 1 month after boot camp on their desire to incorporate surgical skills into practice. Main Outcome Measure(s) Efficiency of laparoscopic suturing and knot tying before and after boot camp; likelihood and persistence of incorporating surgical skills into practice immediately and 1 month after boot camp; and correlation between fellowship IVF volume and fellow surgical efficiency. Result(s) Fellows experienced significant improvement in laparoscopic suturing (44 sec), intracorporeal knot tying (82 sec), and extracorporeal knot tying (71 sec). Fellows reported being more likely to incorporate operative hysteroscopy (89%), operative laparoscopy (87%), and laparoscopic suturing (84%) into practice immediately following boot camp with no difference 1 month later. Fifty-four percent of fellows reported being more likely to perform robotic surgery after the boot camp, increasing to 70% 1 month later. There were weak correlations between IVF case volume and efficiency in laparoscopic suturing or hysteroscopic polypectomy (Spearman correlation coefficients, -0.14 and -0.03). Conclusion(s) An intensive surgical boot camp enhances surgical skill among REI fellows.

Objective: The aim of this study was to determine the influence of immediate preoperative gabapentin on postoperative pain in patients undergoing laparoscopy for benign gynecologic indications. Mat...

Dwyer (lateral calcaneal closing wedge) osteotomy is commonly used in surgical correction of heel varus deformity. The purpose of this study was to determine the effect of wedge size and angle of osteotomy on deformity correction using preoperative imaging analysis with three-dimensional (3D) printed modeling. Seven patients diagnosed with pes cavovarus deformity who underwent Dwyer calcaneal osteotomy were identified retrospectively. Preoperative computed tomogrphy scans were used to create 3D printed models of the foot. After18 variations of osteotomy and fixation performed for each foot, Harris heel and Saltzman images were obtained. The angle between the tibia-talus axis and calcaneal-tuber axis was measured and compared to pre-osteotomy state. Change in the calcaneal lengths was also analyzed. The average degree correction of deformity per mm of bone resected was 3.8 ± 0.2 degrees in the Harris Heel view and 2.7 ± 0.8 degrees in the Saltzman view. A significant increase in correction was obtained with 10 mm compared with 5 mm wide wedges (P < .001). The difference in correction was not statistically significant between 30 and 45 degree cuts or osteotomy distance from the posterior calcaneal tuberosity, but a 45 degree sagittal angle resulted in less calcaneal shortening compared to 30 degrees (P = .02). A clinically driven method using patient-specific 3D models for determining effects of calcaneal osteotomy variables in correcting hindfoot alignment was developed. In summary, the amount of wedge resected impacts hindfoot alignment more than location and sagittal angle of the cut. Calcaneal shortening depends on sagittal angle of the cut.

Background: Optimal modalities for pain control in shoulder arthroplasty are not yet established. Although regional nerve blockade has been a well-accepted modality, complications and rebound pain have led some surgeons to seek other pain control modalities. Local injection of anesthetics has recently gained popularity in joint arthroplasty. The purpose of this study was to evaluate the effectiveness and complication rate of a low-cost local anesthetic injection mixture for use in total shoulder arthroplasty (TSA) compared with interscalene brachial plexus blockade. Methods: A total of 314 patients underwent TSA and were administered general anesthesia with either a local injection mixture (local infiltration anesthesia [LIA], n = 161) or peripheral nerve block (PNB, n = 144). Patient charts were retrospectively reviewed for postoperative pain scores, 24-hour opioid consumption, and 90-day postoperative complications. Results: Immediate postoperative pain scores were not significantly different between groups (P = .94). The LIA group demonstrated a trend toward lower pain scores at 24 hours postoperatively (P = .10). Opioid consumption during the first 24 hours following surgery was significantly reduced in the LIA group compared with the PNB group (P < .0001). There was a trend toward fewer postoperative nerve and cardiopulmonary complications in the LIA group than the PNB group (P = .22 and P = .40, respectively) Conclusion: Periarticular local injection mixtures provide comparable pain control to regional nerve blocks while reducing opioid use and postoperative complications following TSA. Local injection of a multimodal anesthetic solution is a viable option for pain management in TSA.

Cutaneous microcirculatory perfusion is commonly measured using laser Doppler flowmetry (LDF) probes, which provide a continuous, non-invasive quantification of skin blood flow (SkBF). However, inhomogeneities in the skin’s microvasculature density contribute to a decrease in reproducibility whenever an LDF probe is removed and replaced, as is the case during pre- and post-intervention or between-day measurements. Therefore, this study aimed to determine whether increasing the total number of individual LDF probes in a localized area improves the reproducibility of the measurement. Seven laser Doppler probes were secured in a custom-made acrylic holder designed to attach to the skin’s surface easily. SkBF, local skin temperature (Tsk), and blood pressure (BP) were assessed in 11 participants (6 M, 5 F, 42 ± 15 years). SkBF and Tsk were measured from the dorsal forearm (arm trial) for 5 min. Next, the multi-laser device was moved to the lateral side of the calf (leg trial), and measurements were obtained for 5 min. Each arm and leg trial was cyclically repeated three times, and all trials were separated by intermissions lasting 10–15 min. The average SkBF and the cutaneous vascular conductance (CVC) from all possible LDF probe combinations were not statistically different across the three arm and leg trials. Two-way mixed-effects models with absolute agreement were used to compute the intraclass correlation coefficient (ICC) for CVC, and the minimum ICC increased with the addition of LDF probes. The ICC of the average CVC from seven LDF probes was 0.96 between the arm trials and 0.91 between the leg trials, which suggests that there is excellent reliability and little difference between trials following the removal and replacement of the device. Moreover, all individual ICC values from ≥3 LDF probe combinations were greater than 0.70 (i.e., good reliability). These data suggest that SkBF measurements with multiple laser Doppler probes in a custom-made holder have excellent reproducibility after replacing the probes within the same participant. Therefore, this application could provide more reproducible assessments between repeated measurements (e.g., before and after exercise or clinical procedures) where the LDF probes must be removed and replaced within the same location.

ObjectiveAdverse childhood experiences (ACEs) are linked to worsening overall health outcomes and psychological diagnoses. Routine screening, particularly in patients with postpartum depression (PPD), would identify patients who could benefit from interventions to prevent the perpetuation of ACEs and establish a system of preventative care to mitigate the risks of adverse health outcomes associated with high ACE scores. The purpose of this study is to explore the link between ACEs and PPD to advocate for the use of the ACE questionnaire as a routine screening tool in all pregnant patients diagnosed with PPD. We hypothesize that a cohort of patients with PPD will be more likely to have high-risk ACE scores than the general female population.Study DesignOur IRB approved, retrospective cohort study identified all patients diagnosed with PPD at an academic medical center between January 2015 and December 2019. The subjects were identified using retrospective chart review. Subjects were recruited via telephone and asked to complete an ACE questionnaire. Questionnaires were sent via RedCap. ACE scores were calculated, categorized as 0, 1, 2, 3, or 4 or more ACEs, and compared to the prevalence in the original Kaiser-CDC ACE study female cohort using a chi-square goodness-of-fit test.ResultsThere were 132/251 surveys completed (53% response rate). In our PPD population, 19.3% had 0 ACEs, 17.0% had 1 ACE, 13.1% had 2 ACEs, 16.5% had 3 ACEs, and 34.1% had 4 or more ACEs. These percentages were significantly different from the Kaiser-CDC ACE Study percentages of 34.5, 24.5, 15.5, 10.3, and 15.2%, respectively (p < 0.001).ConclusionOur unique study showed that women with PPD are more likely to have high-risk ACE scores than the general female population. This finding has important implications in regards to counseling, intervening to prevent perpetual ACEs, and establishing important provider-patient relationships for life-long preventative care.Non-gendered language is used when possible throughout. However, the wording from studies cited in this paper was preserved.

Postoperative opioid prescribing has historically lacked information crucial to balancing the pain control needs of the individual patient with our professional responsibility to judiciously prescribe these high-risk medications.This study aimed to evaluate pain control, satisfaction with pain control, and opioid use among patients undergoing isolated midurethral sling randomized to 1 of 2 different opioid-prescribing regimens.Patients who underwent isolated midurethral sling placement from June 1, 2020, to November 22, 2021, were offered enrollment into this prospective, randomized, open-label, noninferiority clinical trial. Participants were randomized to receive either a standard prescription of ten 5-mg oxycodone tablets provided preoperatively (standard) or an opioid prescription provided only during patient request postoperatively (restricted). Preoperatively, all participants completed baseline demographic and pain surveys, including the 9-Question Central Sensitization Index, Pain Catastrophizing Scale, and Likert pain score (scale 0-10). The participants completed daily surveys for 1 week after surgery to determine the average daily pain score, number of opioids used, other forms of pain management, satisfaction with pain control, perception of the number of opioids prescribed, and need to return to care for pain management. The online Prescription Drug Monitoring Program was used to determine opioid filling in the postoperative period. The primary outcome was average postoperative day 1 pain score, and an a priori determined margin of noninferiority was set at 2 points.Overall, 82 patients underwent isolated midurethral sling placement and met the inclusion criteria: 40 were randomized to the standard arm, and 42 were randomized to the restricted group. Concerning the primary outcome of average postoperative day 1 pain score, the restricted arm (mean pain score, 3.9±2.4) was noninferior to the standard arm (mean pain score, 3.7±2.7; difference in means, 0.23; 95% confidence interval, -∞ to 1.34). Of note, 23 participants (57.5%) in the standard arm vs 8 participants (19.0%) in the restricted arm filled an opioid prescription (P.001). Moreover, 18 of 82 participants (22.0%) used opioids during the 7-day postoperative period, with 10 (25.0%) in the standard arm and 8 (19.0%) in the restricted arm using opioids (P=.52). Of participants using opioids, the average number of tablets used was 3.4±2.3, and only 3 participants used ≥5 tablets. On a scale of 1="prescribed far more opioids than needed" to 5="prescribed far less opioids than needed," the means were 1.9±1.0 in the standard arm and 2.7±1.0 in the restricted arm (P.001).Restricted opioid prescription was noninferior to standard opioid prescription in the setting of pain control and satisfaction with pain control after isolated midurethral placement. Participants in the restricted arm filled fewer opioid prescriptions than participants in the standard arm. On average, only 3.4 tablets were used by those that filled prescriptions in both groups. Restrictive opioid-prescribing practices may reduce unused opioids in the community while achieving similar pain control.

Introduction: Overprescribing by providers is a leading contributor to the opioid crisis. Despite available information regarding the role that physician prescribing plays in the community availability of opioids, guidelines for the management of acute pain remain sparse. This project aims to evaluate opioid prescribing, opioid usage patterns, and postoperative pain control in patients undergoing isolated mid-urethral sling (MUS) placement. Methods: Patients who underwent isolated MUS placement from March 19, 2019 through March 19, 2020 were contacted by telephone in May 2020 and asked a series of questions examining opioid usage, postoperative pain, what they did with unused opioids, and whether they had received education on disposal techniques. A chart review was utilized to determine the amount of opioid prescribed, the presence of any operative complications, and medical and demographic characteristics of subjects. Results: A total of 53 subjects met inclusion criteria, of which 31 participated in a phone interview. Of the 53 subjects, 54.7% received a postoperative opioid prescription, and all but two of these subjects filled their prescription. Of the interviewed subjects, only 66.6% who filled a prescription reported using opioids Fifty percent (n=6) of patients that required oxycodone reported use of four tablets (30 morphine milligram equivalents (MMEs)) or less and used for 1-2 days postoperatively. No patient reported using opioids beyond five days. Only 22.2% reported receiving instruction on opioid disposal, and 16.7% returned unused opioids to a disposal center. 87.1% of subjects rated postoperative pain as “better” or “much better” than expected. Conclusion: Patients undergoing isolated MUS placement require limited amounts of postoperative opioids, if any are needed at all, to achieve satisfactory pain control. Excess prescribed opioids, along with inadequate patient education on proper disposal techniques, may contribute towards opioids that are at risk of diversion for nonmedical use.

Parkinson's disease (PD) is a neurodegenerative movement disorder that is routinely treated with levodopa. Unfortunately, long-term dopamine replacement therapy using levodopa leads to levodopa-induced dyskinesias (LID), a significant and disabling side-effect. Clinical findings indicate that LID typically only occurs following the progression of PD motor symptoms from the unilateral (Hoehn and Yahr (HY) Stage I) to the bilateral stage (HY Stage II). This suggests the presence of some compensatory interhemispheric mechanisms that delay the occurrence of LID. We therefore investigated the role of interhemispheric connections of the nigrostriatal pathway on LID expression in a rat model of PD. The striatum of one hemisphere of rats was first injected with a retrograde tracer to label the ipsi- and cross-hemispheric nigrostriatal pathways. Rats were then split into groups and unilaterally lesioned in the striatum or medial forebrain bundle of the tracer-injected hemisphere to induce varying levels of hemiparkinsonism. Finally, rats were treated with levodopa and tested for the expression of LID. Distinct subsets emerged from rats that underwent the same lesioning paradigm based on LID. Strikingly, non-dyskinetic rats had significant sparing of their cross-hemispheric nigrostriatal pathway projecting from the unlesioned hemisphere. In contrast, dyskinetic rats only had a small proportion of this cross-hemispheric nigrostriatal pathway survive lesioning. Crucially, both non-dyskinetic and dyskinetic rats had nearly identical levels of ipsi-hemispheric nigrostriatal pathway survival and parkinsonian motor deficits. Our data suggest that the survival of the cross-hemispheric nigrostriatal pathway plays a crucial role in preventing the expression of LID and represents a potentially novel target to halt the progression of this devastating side-effect of a common anti-PD therapeutic.

The objective of this randomized clinical trial was to investigate the effects of perfusion modalities on cerebral hemodynamics, vital organ injury, quantified by the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) Score, and clinical outcomes in risk-stratified congenital cardiac surgery patients.This randomized clinical trial included 159 consecutive congenital cardiac surgery patients in whom pulsatile (n = 83) or nonpulsatile (n = 76) perfusion was used. Cerebral hemodynamics were assessed using transcranial Doppler ultrasound. Multiple organ injury was quantified using the PELOD-2 score at 24, 48, and 72 hours. Clinical outcomes, including intubation time, intensive care unit length of stay (LOS), hospital LOS, and mortality, were also evaluated.The Pulsatility Index at the middle cerebral artery and in the arterial line during aortic cross-clamping was consistently better maintained in the pulsatile group. Demographics and cardiopulmonary bypass characteristics were similar between the 2 groups. While risk stratification with The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) Mortality Categories was similar between the groups, Mortality Categories 1 to 3 demonstrated more patients than Mortality Categories 4 and 5. There were no differences in clinical outcomes between the groups. The PELOD-2 scores showed a progressive improvement from 24 hours to 72 hours, but the results were not statistically different between the groups.The Pulsatillity Index for the pulsatile group demonstrated a more physiologic pattern compared with the nonpulsatile group. While pulsatile perfusion did not increase plasma-free hemoglobin levels or microemboli delivery, it also did not demonstrate any improvements in clinical outcomes or PELOD-2 scores, suggesting that while pulsatile perfusion is a safe method, it not a "magic bullet" for congenital cardiac operations.

We analyzed the exclusion of pregnant and breastfeeding individuals and those capable of pregnancy in COVID-19 vaccine and clinical treatment trials.Inclusion and exclusion criteria were extracted from all listed COVID-19 vaccine and treatment clinical trials from May 1, 2020, to October 31, 2020, using the U.S. National Library of Medicine database. We report rates of rates of exclusion for pregnant and lactating individuals and requirements for contraception for pregnancy-capable participants in COVID-19 vaccine and treatment clinical trials. The analysis included the association between clinical trial exclusion and vaccine and treatment type, study location, sponsor, and phase.Pregnant and lactating individuals were explicitly excluded from most COVID-19 vaccine and treatment clinical trials. Of the 90 vaccine trials, 88 (97.8%) excluded pregnant individuals, 73 (81.1%) excluded lactating individuals, and 56 (62.2%) required contraception use. Of the 495 treatment trials, 350 (70.7%) excluded pregnant individuals, 269 (54.3%) excluded lactating individuals, and 91 (18.4%) required contraception use. Although vaccine type was not associated with pregnancy exclusion, it was associated with lactation exclusion (p = .01) and contraception requirement (p .001). Treatment type was associated with pregnancy exclusion, lactation exclusion, and contraception requirement (all p .001).COVID-19 vaccination and treatment clinical trials mirrored historical trends restricting participation owing to pregnancy, lactation, and contraception nonuse, despite known safety profiles. People of childbearing potential should be considered for and afforded the same opportunity as males to make informed decisions on study participation, particularly in the setting of a global pandemic.

Background Admission to the intensive care unit (ICU) after surgery can be associated with significant morbidity and mortality. This observational cohort study aims to identify perioperative factors associated with post-operative ICU admission in patients undergoing elective non-cardiac surgery. Methods Data from the ACS NSQIP® database at a tertiary care academic medical center were analyzed from January 2011 to September 2016. Univariable and multivariable logistic regression of patient and surgery-specific characteristics was performed to assess association with post-operative ICU admission. The Current Procedural Terminology (CPT) and International Classification of Diseases (ICD-9) billing codes, as well as associated outcomes, were reviewed. Results Of 5254 database patient records, 1150 met our inclusion criteria. Elevated body mass index (BMI), longer procedure duration and a diagnosis of disseminated cancer were associated with post-operative ICU admission. Prostatectomy and morbid obesity were the most common CPT and ICD-9 codes identified. Patients who were admitted to the ICU after surgery had a longer hospital length of stay (LOS), had a higher frequency of readmission, re-operation, and in-hospital mortality. Conclusion Admission to the ICU after elective non-cardiac surgery is common. Our analysis of the ACS NSQIP® database identified elevated BMI, longer duration of surgery and disseminated cancer as predictors of post-operative ICU admissions in patients undergoing elective non-cardiac surgery.

Rapid-eye-movement (REM) sleep without atonia (RSWA), a marker of REM sleep behavior disorder (RBD), is frequently comorbid with Parkinson’s disease (PD). Although rodent models are commonly used for studying PD, the neurobiological and behavioral correlates of RBD remain poorly understood. Therefore, we developed a behavior-based criteria to identify RSWA in the hemiparkinsonian rat model of PD. Video recordings of rats were analyzed, to develop a criteria consisting of behavioral signs that occurred during polysomnographically confirmed epochs of sleep-wake stages. The sleep-slouch, a postural shift of the body or head caused only by gravity, was identified as a unique behavioral sign of REM sleep onset and was altered in hemiparkinsonian rats during RSWA. There was a significant correlation between the behavior-based criteria and polysomnograms for all sleep-wake stages in control but not hemiparkinsonian rats indicating a deterioration of sleep-wake architecture in parkinsonism. We then tested the efficacy of levodopa in ameliorating RSWA using intermittent and around-the-clock (ATC) dosing regimens. ATC levodopa dosing at 4 mg/kg for 48 h caused a significant reduction of RSWA as measured by polysomnography and the behavioral-based criteria along with an amelioration of forelimb motor deficits. Our findings show that the phenomenological correlates of RSWA can be reliably characterized in the hemiparkinsonian rat model. ATC levodopa administration ameliorates RSWA in this model without deleterious consequences to the overall sleep-wake architecture and therapeutic benefits for parkinsonian motor deficits. These findings suggest that further study may allow for the application of a similar approach to treat RBD in PD patients.

Quetiapine, an atypical antipsychotic medication has lacked pre-clinical validation for its purported benefits in the treatment of delirium. This laboratory investigation examined the effects of quetiapine on the attentional set shifting task (ASST), a measure of cognitive flexibility and executive functioning, in a rodent model of lipopolysaccharide (LPS) mediated neuroinflammation. 19 Sprague Dawley female rats were randomly selected to receive intraperitoneal placebo (N = 5), LPS and placebo (N = 7) or LPS and quetiapine (n = 7) and performed the ASST. We measured trials to criterion, errors, non-locomotion episodes and latency to criterion, serum cortisol and tumor necrosis factor alpha (TNF-α) levels. TNF-α levels were not different between groups at 24 h. Cortisol levels in the LPS + Quetiapine group were reduced compared to LPS + Placebo (P 0.0167). We demonstrated preserved reversal learning, no effect on attentional set shifting and normalized cortisol levels in quetiapine-treated rats in this neuroinflammatory model of delirium. This suggests that quetiapine’s beneficial effects in delirium may be related to the preservation of reversal learning and potential downstream effects related to reduction in cortisol production.

In 2017, we surveyed long-term care facilities in Pennsylvania regarding antimicrobial stewardship and infection prevention and control (IPC) practices. Among 244 responding facilities, 93% had IPC programs and 47% had antimicrobial stewardship programs. There was significant variation in practices across facilities, and a number of program implementation challenges were identified.

Weibin Shi,1,2 Renuka Rudra,1,2 To-Nhu Vu,3 Yuri Gordin,1,2 Ryan Smith,1,2 Allen R Kunselman4 1Department of Physical Medicine and Rehabilitation, Penn State Health Milton S Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA; 2Penn State Hershey Rehabilitation Hospital, Hummelstown, PA, USA; 3Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA; 4Department of Public Health Sciences, Penn State Hershey College of Medicine, Hershey, PA, USACorrespondence: Weibin Shi; To-Nhu Vu Email wshi@pennstatehealth.psu.edu; tonhuvu@pennstatehealth.psu.eduBackground: Sensory stimulation threshold (SST) has been used as a surrogate marker to target a nerve branch for radiofrequency (RF) denervation; however, the validity of SST as a prognostic marker is still under debate.Objective: To assess whether lower SST values correlate with better outcomes of radiofrequency denervation for facetogenic low back pain.Design: Prospective cohort study.Patients: Sixty-seven patients who underwent radiofrequency denervation for low back pain.Methods: Correlations, between the average percentage of pain relief from diagnostic medial branch block (MBB) and RF denervation procedure outcome, and between SST and RF denervation procedure outcome, were analyzed using Spearman correlation coefficient (rs). Wilcoxon rank sum test was performed to assess whether magnitude and duration of pain relief following RF denervation differed by the levels of SST (< 0.5 and ≥ 0.5) or pain relief (< 80% and ≥ 80%) from diagnostic MBB.Results: There was a positive correlation between pain relief after diagnostic MBB and pain relief 2 weeks after denervation (rs 0.31, 95% CI 0.08 to 0.51, p < 0.01), but not between pain relief after MBB and pain relief 6 months after denervation, nor pain relief duration after denervation. There was a negative correlation between SST and pain relief 6 months after denervation (rs − 0.41, 95% CI − 0.59 to − 0.18, p < 0.001). There was also a negative correlation between SST and pain relief duration after denervation (rs − 0.33, 95% CI − 0.53 to − 0.09, p < 0.01).Conclusion: SST is a viable measurement with which to guide needle placement during RF denervation for lumbar facet pain, and enhances pain relief outcomes.Keywords: sensory stimulation threshold, radiofrequency ablation, lower back pain, lumbar facet arthropathy, outcome

Background: Psychiatric disorders, including anxiety and depression, are significantly more common in patients with inflammatory bowel disease (IBD). We established an integrated psychiatry clinic for IBD patients at our tertiary center IBD clinic to provide patients with critical, but frequently unavailable, coordinated mental health services. We undertook this study to evaluate the impact of this service on psychiatric outcomes, quality of life, and symptom experience. Methods: We performed a longitudinal prospective study comparing patients who had been cared for at our integrated IBD-psychiatry clinic to those who had not. We abstracted demographic and clinical information as well as contemporaneous responses to validated surveys. Results: Thirty-six patients cared for in the IBD psychiatry clinic were compared to a control cohort of 35 IBD patients. There was a significant reduction in the Hospital Anxiety and Depression Scale (HADS) depression score over time in the study cohort (p = 0.001), though not in the HADS anxiety score. When compared to the control group, the study cohort showed a significant reduction in the HADS depression score. No significant differences were observed in the Harvey-Bradshaw Index, Simple Clinical Colitis Activity Index, or Short IBD Questionnaire. Conclusions: This is the first study to evaluate the impact of an integrated psychiatry clinic for IBD patients. Unlike their control counterparts, individuals treated in this clinic had a significant reduction in the mean HADS depression score. Larger scale studies are necessary to verify these findings. However, this study suggests that use of an integrated psychiatry IBD clinic model can result in improvement in mental health outcomes, even in the absence of significant changes in IBD activity.

To determine whether an inpatient post-cesarean analgesic regimen which separated oxycodone and acetaminophen resulted in less inpatient opioid use, when compared to a regimen using combination medications containing both acetaminophen and oxycodone in a cohort including patients of all gestational ages, acuity levels, and modes of operative anesthesia.This is a retrospective cohort study which was conducted at a single tertiary care center Labor and Delivery unit. Data were collectedThe primary outcome was inpatient opioid medication use per 12-h period in intravenous morphine mg equivalents (MME). Patients received an average of 4.6 ± 3.5 MME IV morphine per 12 h in the Separate Medication group and 5.7 ± 3.7 MME IV morphine per 12 h in the Combined Medication group. When controlled for several covariates, the Separate Medication group took significantly fewer MME per 12-h period (mean difference = -1.2, 95% CI: (-2.3, -0.1),An analgesic regimen where oxycodone is ordered separately from acetaminophen is associated with reduced inpatient opioid medication use in patients of all gestational ages, acuity levels, and modes of operative anesthesia.

Background Lisfranc ligamentous injuries are complex, and their treatment, along with the preferred method of fixation, is controversial. Implementing a flexible synthetic augmentation device (fibertape) has been described as an alternative to traditional screw fixation. This biomechanical study evaluated two fibertape devices with interference screw fixation: InternalBrace, and InternalBrace with supplementary intercuneiform stabilization. Methods The diastasis and relative angular displacement between bones were measured at three midfoot joints in the Lisfranc articulation. Measurements were obtained for the pre-injured, injured, and post-fixation stages under static loading. Specimens then underwent stepwise increases in cyclic loading performed at 1 Hz and 100 cycles, at 100 N ground reaction force intervals from 500 to 1200 N to simulate postoperative loading, and then up to 1800 N to simulate high loads. Failure of fixation was defined as diastasis greater than 2 millimeters at the second-metatarsal – medial-cuneiform joint. Results InternalBrace specimens demonstrated failures in 3 of 9 (33%) specimens at cyclic loads of 1000 N. Conversely, InternalBrace with Supplementary Limb specimens had 1 failure at 1200 N. The difference in diastasis at the second metatarsal-medial cuneiform joint was statistically significant between the two groups at higher loads of 1600N (p = 0.019) and 1800N (p = 0.029). Conclusion The use of InternalBrace for ligamentous Lisfranc injuries appears to provide a biomechanically viable alternative for withstanding early postoperative protected weight bearing. Furthermore, the use of a supplementary limb in addition to the InternalBrace fibertape fixation method appears to enhance its biomechanical efficacy.

Category: Trauma; Basic Sciences/Biologics; Midfoot/Forefoot; Sports Introduction/Purpose: Lisfranc ligamentous injuries are complex. Controversy exists regarding their treatment and preferred method of fixation. Fixation methods employing a FiberTape device and interference screw fixation have been described as an alternative to traditional screw fixation. The purpose of this biomechanical study was to evaluate two methods of fixation utilizing interference screw fixation with FiberTape augmentation in a cadaveric model. Methods: 9 paired cadaveric feet (mid tibia/fibula) were separated into two groups based on fixation method: FiberTape alone and FiberTape with supplementary limb into the middle cuneiform via anchor. At three joints of the midfoot (second metatarsal - medial cuneiform, intermediate cuneiform - medial cuneiform, second metatarsal - intermediate cuneiform), the diastasis and relative angular displacement between bones in the coronal plane were measured for static and cyclic loading. Measurements were obtained for the native (pre-injured), injured, and post-fixation in static loading. Fixed specimens then underwent stepwise increases in cyclic loading performed at 1 Hz and 100 cycles, at 100 N intervals from 500 to 1800 N ground reaction force. The Achilles tendon was also loaded to simulate postoperative weightbearing. Failure of fixation was defined as diastasis at the second metatarsal - medial cuneiform joint greater than 2 millimeters. Results: FiberTape specimens demonstrated diastasis failures of 3 of 9 (33%) specimens at cyclic loads of 1000 N. Conversely, FiberTape with supplementary limb specimens all survived past this loading magnitude, with 1 failing at supraphysiologic loads (>1200 N). The difference in diastasis at the second metatarsal-medial cuneiform joint was statistically significant between the two groups at forces of 1600N (p = 0.019) and 1800N (p = 0.029). There were no significant differences between the other joint diastases and relative angular displacements. Conclusion: The use of FiberTape for fixation of ligamentous Lisfranc injuries appears to provide a biomechanically viable alternative for withstanding early post-operative protected weightbearing. Furthermore, the use of a supplementary limb in addition to the FiberTape fixation method appears to enhance its biomechanical efficacy under cyclic loading especially at higher loads.

Introduction:corneal transplantation is a surgical procedure requiring consistent long-term follow-up to maximize the chance of graft survival. The purpose of this study was to explore patient characteristics and reasons for being lost to follow-up (LTFU). Methods:a retrospective review of clinical records from January 2012 to October 2014 was conducted of patients who received corneal transplantation at Tenwek Hospital. At the time of chart review, all patients who provided a mobile phone number were contacted to answer a phone questionnaire. Logistic regression was used to assess the association of each patient characteristic, separately, with the outcome of LTFU. Results:of the 118 patients that met inclusion criteria, 40 (33.9%) were considered LTFU by failing to follow up at Tenwek Hospital to at least one year postoperatively. The odds of LTFU for patients age 60 and older were 3.78 times that of those who were 18-59 (95% CI: 1.21-11.80]; p-value=0.02). The odds of LTFU for patients with a preoperative diagnosis of pseudophakic bullous keratopathy were 3.83 times that of those with a preoperative diagnosis of keratoconus (95% CI: [1.13-12.94]; p-value=0.03). Education level, employment status, distance from the hospital, and possession of a mobile contact number appeared marginally associated with follow-up status, though not statistically significant at the 0.05 significance level. Financial barriers were the most commonly cited reason for LTFU (42.4%, n=14). Conclusion:certain reasons and patient characteristics may be associated with follow-up adherence. Identifying these factors may help providers identify patients who are at a higher risk of LTFU and influence providers in medical decision-making and system-based interventions when offering corneal transplantation.

Successful tibiotalar joint fusion relies on adequate compression. Compression following joint preparation may be affected by the extent to which the fibula holds the joint out to anatomical length. The purpose of this study was to evaluate the effect of various distal fibula osteotomies on tibiotalar joint compression.Eight adult cadaveric lower extremity specimens with an intact ankle joint and syndesmotic complex were evaluated. The ankle joint cartilage was denuded to subchondral bone. The fibula was surgically modified with three progressing procedures including an oblique fibula osteotomy, 1 cm resection, and distal fibula resection. A transducer was utilized to measure tibiotalar joint force, contact area, and peak pressure values while compressive forces of 30 N, 50 N, and 100 N were applied to the proximal tibia/fibula.Distal fibula resection significantly increased tibiotalar joint force, contact area, and peak pressure the most of all fibula conditions tested compared to intact fibula control (p .05). Tibiotalar joint force and peak pressures were significantly increased with a distal fibula oblique osteotomy, 1 cm resection, and complete resection under both 30 and 50 N applied compressive force (p .05).Complete distal fibular resection results in higher tibiotalar joint force, contact area, and peak pressure which may improve clinical rates of successful ankle fusion.

The purpose of this study was to evaluate the hemodynamic properties and microemboli capture associated with different vacuum-assisted venous drainage (VAVD) vacuum levels and venous reservoir levels in a neonatal cardiopulmonary bypass circuit. Trials were conducted in 2 parallel circuits to compare the performance of Capiox Baby RX05 oxygenator with separate AF02 arterial filter to Capiox FX05 oxygenator with integrated arterial filter. Arterial cannula flow rate to the patient was held at 500 mL/min and temperature maintained at 32°C, while VAVD vacuum levels (0 mm Hg, -15 mm Hg, -30 mm Hg, -45 mm Hg, -60 mm Hg) and venous reservoir levels (50 mL, 200 mL) were evaluated in both oxygenators. Hemodynamic parameters measuring flow, pressure, and total hemodynamic energy were made in real time using a custom-made data acquisition system and Labview software. Nearly 10 cc bolus of air was injected into the venous line and gaseous microemboli detected using an Emboli Detection and Classification Quantifier. Diverted blood flow via the arterial filter's purge line and mean pressures increased with increasing VAVD levels (P < 0.01). Mean pressures were lower with lower venous reservoir levels and were greater in RX05 groups compared to FX05 (P < 0.01). Microemboli detected at the preoxygenator site increased with higher VAVD vacuum levels and lower venous reservoir levels (P < 0.01). The amount of microemboli captured by the FX05 oxygenator with integrated arterial filter was greater than by the RX05 oxygenator alone, although both oxygenators were able to clear microemboli before reaching the pseudo-patient.

To compare surgical excision and ablation of endometriosis for treatment of chronic pelvic pain.Randomized clinical trial with 12-month follow-up (Canadian Task Force classification I).Single academic tertiary care hospital.Women with minimal to mild endometriosis undergoing laparoscopy.Excision or ablation of superficial endometriosis at the time of robot-assisted laparoscopy.Primary outcome was visual analog scale (VAS) scoring at baseline and 6 and 12 months for menstrual pain, nonmenstrual pain, dyspareunia, and dyschezia. Secondary outcomes included survey results at baseline and 6 and 12 months from the Short Form Health Survey, Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire, and the International Pelvic Pain Assessment. From December 2013 to October 2014, 73 patients were randomized intraoperatively to excision (n = 37) or ablation (n = 36) of endometriosis. Patients were followed at 6 and 12 months to evaluate the above outcomes. After ablation of endometriosis, dyspareunia (VAS scores) improved at 6 months (mean change [MC], -14.07; 95% confidence interval [CI], -25.93 to -2.21; p = .02), but improvement was not maintained at 12 months. Dysmenorrhea improved at 6 months (MC, -26.99; 95% CI, -41.48 to -12.50; p .001) and 12 months (MC, -24.15; 95% CI, 39.62 to -8.68; p = .003) with ablation. No significant changes were seen in VAS scores after excision at 6 or 12 months. When comparing ablation and excision, the only significant difference was a change in dyspareunia at 6 months (MC, -22.96; 95% CI, -39.06 to -6.86; p = .01).Treatment with ablation improved dysmenorrhea at 6 and 12 months and improved dyspareunia at 6 months as compared with preoperative data. However, only dyspareunia demonstrated a significant difference between ablation and excision. Excision and ablation showed similar effectiveness for the treatment of pain associated with superficial endometriosis, with ablation showing more significant individual changes. Careful patient counseling regarding expectations of surgical intervention is vital in the management of endometriosis.

Objective To describe the prevalence of female sexual dysfunction in a well-defined polycystic ovary syndrome (PCOS) population, and to assess the impact of common PCOS treatments on sexual function. Design Secondary analysis of a randomized controlled trial, oral contraceptive pills and weight loss in PCOS. Setting Two academic medical centers. Patients Women with PCOS (N = 114) defined by the Rotterdam criteria. Interventions Continuous oral contraceptive pill (OCP) or intensive lifestyle modification (Lifestyle) or the combination (Combined) for 16 weeks. Main Outcome Measures Change in Female Sexual Function Index (FSFI) and Female Sexual Distress Scale−Revised (FSDS-R) scores after 16 weeks. Results There was no change in total FSFI or FSDS-R score in any treatment group; however, an increase in the FSFI desire domain subscore was observed in the Lifestyle and Combined treatments, indicating improved sexual desire over the 16-week period. Overall, 33 participants (28.9%) met criteria for sexual dysfunction by FSFI criteria (baseline score ≤26.55). Among this group, FSFI score improved after 16 weeks of Lifestyle and Combined treatments. There was no change in prevalence of sexual dysfunction in treatment groups at 16 weeks. Use of OCPs did not alter FSFI scores. Conclusion(s) Female sexual dysfunction is highly prevalent among women with PCOS. Our findings suggest that common treatments for PCOS, including intensive lifestyle modification and the combination of intensive lifestyle modification and OCPs, have the potential to improve sexual function in these women; the mechanism for these improvements is likely multifactorial. Clinical Trial Registration Number NCT00704912.

Objective To investigate the relationship between maximal placental thickness during routine anatomy scan and birthweight at delivery. Methods This retrospective descriptive study analyzed 200 term, singleton deliveries in 2016 at Penn State Hershey Medical Center. We measured maximal placental thickness in the sagittal plane from the ultrasound images of the placenta obtained at the 18–21-week fetal anatomy screen. The relationship between placental thickness and neonatal birthweight was assessed using Pearson’s correlation coefficient (r) with 95% confidence interval (CI). Logistic regression was used to assess the association between placental thickness and secondary binary outcomes of neonatal intensive care unit (NICU) admission and poor Apgar scores. Two-sample t-tests, or exact Wilcoxon rank-sum test for non-normally distributed data, were used to assess for differences attributable to medical comorbidities (pre-gestational diabetes, gestational diabetes, chronic hypertension, gestational hypertension, preeclampsia and eclampsia). Results Placental thickness had a positive correlation with neonatal birthweight [r=0.18, 95% CI=(0.05, 0.32)]. The mean placental thickness measured 34.2±9.7 mm. The strength of the correlation remained similar when adjusting for gestational age (r=0.20) or excluding medical comorbidities (r=0.19). There was no association between placental thickness and NICU admission, Apgar scores Conclusion Our study demonstrated a positive correlation between sonographic placental thickness and birthweight. Future prospective studies are warranted in order to further investigate whether a clinically significant correlation exists while adjusting for more covariates.

The objective of this study is to evaluate the hemodynamic characteristics of two femoral arterial cannulae in terms of circuit pressure, pressure drop, and hemodynamic energy transmission under non-pulsatile and pulsatile modes in a simulated adult extracorporeal life support (ECLS) system. The ECLS circuit consisted of i-cor diagonal pump and console (Xenios AG, Heilbronn, Germany), an iLA membrane ventilator (Xenios AG), an 18 Fr or 16 Fr femoral arterial cannula (Xenios AG), and a 23/25 Fr Estech remote access perfusion (RAP) femoral venous cannula (San Ramon, CA, USA). The circuit was primed with lactated Ringer's solution and packed red blood cells to achieve a hematocrit of 35%. All trials were conducted at room temperature with flow rates of 1-4 L/min (1 L/min increments). The pulsatile flow settings were set at pulsatile frequency of 75 bpm and pulsatile amplitudes of 1000-4000 rpm (1000 rpm increments). Flow and pressure data were collected using a custom data acquisition system. Total hemodynamic energy (THE) is calculated by multiplying the ratio between the area under the hemodynamic power curve (∫flow × pressure dt) and the area under the pump flow curve (∫flow dt) by 1332. The pressure drop across the arterial cannula increased with increasing flow rate and decreasing cannula size. The pressure drops of 18 Fr and 16 Fr cannulae were 19.4-24.5 and 38.4-45.3 mm Hg at 1 L/min, 55.2-56.8 and 110.9-118.3 mm Hg at 2 L/min, 94.1-105.1 and 209.7-215.1 mm Hg at 3 L/min, and 169.2-172.6 and 376.4 mm Hg at 4 L/min, respectively. Pulsatile flow created more hemodynamic energy than non-pulsatile flow, especially at lower flow rates. The percentages of THE loss across 18 Fr and 16 Fr cannula were 16.0-18.7 and 27.5-30.8% at 1 L/min, 35.1-35.7 and 52.3-53.8% at 2 L/min, 48.3-50.3 and 67.3-68.4% at 3 L/min and 62.9-63.1 and 79.0% at 4 L/min. The hemodynamic performance of the arterial cannula should be evaluated before use in clinical practice. The pressure drops and percentages of THE loss across two cannulae tested using human blood were higher compared to the manufacturer's data tested using water. The cannula size should be chosen to match the expected flow rate. In addition, this novel i-cor ECLS system can provide non-pulsatile and ECG-synchronized pulsatile flow without significantly increasing the cannula pressure drop and hemodynamic energy loss.

The objective of this study is to compare hemodynamic performances under different pulsatile control algorithms between Medos DeltaStream DP3 and i-cor diagonal pumps in simulated pediatric and adult ECLS systems. An additional pilot study was designed to test hemolysis using two pumps during 12h-ECLS. The experimental circuit consisted of parallel combined pediatric and adult ECLS circuits using an i-cor pump head and either an i-cor console or Medos DeltaStream MDC console, a Medos Hilite 2400 LT oxygenator for the pediatric ECLS circuit, and a Medos Hilite 7000 LT oxygenator for the adult ECLS circuit. The circuit was primed with lactated Ringer's solution and human packed red blood cells (hematocrit 40%). Trials were conducted at various flow rates (pediatric circuit: 0.5 and 1L/min; adult circuit: 2 and 4L/min) under nonpulsatile and pulsatile modes (pulsatile amplitude: 1000-5000rpm [1000 rpm increments] for i-cor pump, 500-2500rpm [500 rpm increments] for Medos pump) at 36°C. In an additional protocol, fresh whole blood was used to test hemolysis under nonpulsatile and pulsatile modes using the two pump systems in adult ECLS circuits. Under pulsatile mode, energy equivalent pressures (EEP) were always greater than mean pressures for the two systems. Total hemodynamic energy (THE) and surplus hemodynamic energy (SHE) levels delivered to the patient increased with increasing pulsatile amplitude and decreased with increasing flow rate. The i-cor pump outperformed at low flow rates, but the Medos pump performed superiorly at high flow rates. There was no significant difference between two pumps in percentage of THE loss. The plasma free hemoglobin level was always higher in the Medos DP3 pulsatile group at 4 L/min compared to others. Pulsatile control algorithms of Medos and i-cor consoles had great effects on pulsatility. Although high pulsatile amplitudes delivered higher levels of hemodynamic energy to the patient, the high rotational speeds increased the risk of hemolysis. Use of proper pulsatile amplitude settings and intermittent pulsatile mode are suggested to achieve better pulsatility and decrease the risk of hemolysis. Further optimized pulsatile control algorithms are needed.

Translational research is a useful tool to provide scientific evidence for cannula selection during extracorporeal life support (ECLS). The objective of this study was to evaluate four Avalon Elite bi-caval dual lumen cannulas and nine femoral arterial cannulas in terms of flow range, circuit pressure, pressure drop, and hemodynamic energy transmission in a simulated adult ECLS model. A veno-venous ECLS circuit was used to evaluate four Avalon Elite bi-caval dual lumen cannulas (20, 23, 27, and 31 Fr), and a veno-arterial ECLS circuit was used to evaluate nine femoral arterial cannulas (15, 17, 19, 21, and 23 Fr). The two circuits included a Rotaflow centrifugal pump, a Quadrox-D adult oxygenator, and 3/8 in ID tubing for arterial and venous lines. The circuits were primed with lactated Ringer's solution and packed human red blood cells (hematocrit 40%). Trials were conducted at rotational speeds from 1000 to 5000 RPM (250 rpm increments) for each Avalon cannula, and at different flow rates (0.5-7 L/min) for each femoral arterial cannula. Real-time pressure and flow data were recorded for analysis. Small caliber cannulas created higher circuit pressures, higher pressure drops and higher M-numbers compared with large ones. The inflow side of Avalon dual lumen cannula had a significantly higher pressure drop than the outflow side (inflow vs. outflow: 20 Fr-100.2 vs. 49.2 mm Hg at 1.1 L/min, 23 Fr-93.7 vs. 41.4 mm Hg at 1.6 L/min, 27 Fr-102.3 vs. 42.8 mm Hg at 2.6 L/min, 31 Fr-98.1 vs. 44.7 mm Hg at 3.8 L/min). There was more hemodynamic energy lost in the veno-arterial ECLS circuit using small cannulas compared to larger ones (17 Fr vs. 19 Fr vs. 21 Fr at 4 L/min-Medtronic: 71.0 vs. 64.8 vs. 60.9%; Maquet: 71.4 vs. 65.6 vs. 62.0%). Medtronic femoral arterial cannulas had lower pressure drops (Medtronic vs. Maquet at 4 L/min: 17 Fr-121.7 vs. 125.0 mm Hg, 19 Fr-71.2 vs. 73.7 mm Hg, 21 Fr-42.9 vs. 47.4 mm Hg) and hemodynamic energy losses (Medtronic vs. Maquet at 4 L/min: 17 Fr-43.6 vs. 44.4%, 19 Fr-31.0 vs. 31.4%, 21 Fr-20.8 vs. 22.4%) at high flow rates when compared with the Maquet cannulae. The results for this study provided valuable hemodynamic characteristics of all evaluated adult cannulas with human blood in order to guide ECLS cannula selection in clinical practice. Use of larger cannulas are suggested for VV- and VA-ECLS.

The aim of this systematic review with meta-analysis was to evaluate the effect on length of labor when patients receive IVF with or without dextrose. Searches were performed in electronic databases from inception of each database to May 2018. Trials comparing intrapartum IVF containing dextrose (i.e. intervention group) with no dextrose or placebo (i.e. control group) were included. Only trials examining low-risk pregnancies in labor at ≥36 weeks were included. Studies were included regardless of oral intake restriction. The primary outcome was the length of total labor from randomization to delivery. The meta-analysis was performed using the random effects model. Sixteen trials (n = 2503 participants) were included in the meta-analysis. Women randomized in the IVF dextrose group did not have a statistically significant different length of total labor from randomization to delivery compared to IVF without dextrose (MD −38.33 min, 95% CI −88.23 to 11.57). IVF with dextrose decreased the length of the first stage (MD −75.81 min, 95% CI −120.67 to −30.95), but there was no change in the second stage. In summary, use of IVF with dextrose during labor in low-risk women at term does not affect total length of labor, but it does shorten the first stage of labor.

Background: The pathophysiology of adult-acquired flatfoot deformity (AAFD) is not fully explained by degeneration of the posterior tibial tendon alone. While a shortened or dysplastic lateral column has been implicated in flatfoot deformity in pediatrics, there is no study that has quantified the degree of dysplasia in adults with a stage IIb flatfoot deformity, or if any exists at all. Methods: An institutional radiology database was queried for patients with posterior tibial tendon dysfunction (PTTD) who had computed tomography (CT) performed. Controls were patients receiving CT scan for an intra-articular distal tibia fracture without preexisting foot or calcaneal pathology. Clinical notes, physical examination, and weightbearing radiographs were used to find patients that met clinical criteria for stage IIb PTTD. Morphometric measurements of the calcanei were performed involving the length of the calcaneal axis (LCA), height of the anterior process (HAP), and length of the anterior process (LAP). All measurements were performed independently by separate observers, with observers blinded to group assignment. We considered a difference of ±4 mm as our threshold. Results: 7 patients and 7 controls were available for reconstruction and analysis. On average, the LCA was 3.1 mm shorter in patients with stage IIb PTTD compared with controls ( P < .05). The LAP was shorter in PTTD patients compared with controls 3.4 mm ( P < .001). Conclusions: Our results support the hypothesis that the calcaneus of adult patients with stage IIb AAFD is dysplastic when compared with healthy controls, which further supports the utility of lateral column lengthening. Levels of Evidence: Level III: Case-control study