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Background: Approximately 2500 pediatric patients are awaiting kidney transplantation in the United States, with <5% comprising those ≤15 kg. Transplant in this cohort is often delayed by center-based growth parameters, often necessitating transplantation after the initiation of dialysis. Furthermore, prognostication remains somewhat ambiguous. In this report, we scrutinize the Organ Procurement and Transplantation Network (OPTN) data from 2001 to 2021 to help better understand specific variables impacting graft and patient outcomes in these children., Methods: The OPTN kidney transplant dataset from 2001 to 2021 was analyzed. Inclusion criteria included age <18 years, weight ≤15 kg, and recipient of primary living donor kidney transplantation (LDKT) or deceased donor kidney transplantation (DDKT). Patient and graft survival probabilities were calculated using the Kaplan-Meier method. The Cox proportional hazards model was used to calculate hazard ratio (HR) and identify variables significantly associated with patient and graft survival., Results: Two thousand one hundred sixty-eight pediatric transplant recipients met inclusion criteria. Patient survival at 1 and 3 years was 98% and 97%, respectively. Graft survival at 1 and 3 years was 95% and 92%, respectively. Dialysis was the sole significant variable impacting both patient and graft survival. Graft survival was further impacted by transplant era, recipient gender and ethnicity, and donor type. Infants transplanted at Age 1 had better graft survival compared with older children, and nephrotic syndrome was likewise associated with a better prognosis., Conclusion: Pediatric kidney transplantation is highly successful. The balance between preemptive transplantation, medical optimization, and satisfactory technical parameters seems to suggest a "Goldilocks zone" for many children, favoring transplantation between 1 and 2 years of age., (© 2024 The Author(s). Pediatric Transplantation published by Wiley Periodicals LLC.)

Objective: Our goal was to assess the fertility knowledge and educational experiences of graduating U.S. medical students to evaluate areas of improvement for future educational interventions. Design: Web-based cross-sectional survey. Subjects: Medical students graduating in 2023 from the University of Miami Miller School of Medicine (SOM), New York University (NYU) Grossman SOM, Wayne State University SOM, Perelman SOM at the University of Pennsylvania, and Mayo Clinic Alix SOM. Main Outcome Measures: Fertility-related knowledge and educational experiences of U.S. medical students in their final year of school. Results: In total, 117 students (14.4%) completed the survey. The average knowledge score was 78%. Twenty-three (22%) overestimated the age of most precipitous fertility decline, and 50 (52%) overestimated the chance of getting pregnant for a 40-year-old person with ovaries. One-third of students (30, 32%) incorrectly believe that physicians have equivalent infertility rates to the general population. Students were less cognizant of male fertility issues, incorrectly believing there was no negative impact on male fertility by age (43, 42%) among other factors. Seventy-five (81%) reported less than 5 hours of fertility-related education in medical school. Only one-third (32%) were satisfied or very satisfied with the fertility education they received. In an open-response question, students expressed interest in additional education on transgender and cancer patient care, fertility preservation, assisted reproductive technologies, and reproductive life planning in medicine. Conclusions: There is a need and an opportunity for medical education programs to enhance fertility education. Giving students and trainees the knowledge required to make informed decisions for their family-building purposes and improving their ability to counsel patients adequately should be a goal of future educational endeavors. The data collected in this study will serve as a guide for the development of fertility-related learning modules for medical students and trainees.

Solid pseudopapillary neoplasm of the pancreas (SPNP) is a rare entity. In this study, we present a woman in her 20's who presented for evaluation of two separate pancreatic masses. On imaging and biopsy, the tail lesion was thought to be a neuroendocrine tumour and the body lesion was thought to be a metastatic lymph node. The patient was brought to the operating room and underwent a distal pancreatectomy and splenectomy. The patient had an uneventful postoperative course and was discharged home on postoperative day 4. Pathology confirmed both masses were consistent with the diagnosis of well-differentiated SPNP with no signs of malignancy including lymphovascular or perineural invasion, or lymph node involvement., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This retrospective study sought to describe the association between preoperative diagnosis of depression and major adverse events after infrainguinal bypass surgery or peripheral vascular intervention (PVI)., Methods: We retrospectively analyzed a consecutive series of all patients undergoing PVI and/or infrainguinal bypass surgery at a single tertiary institution between 2010 and 2019. Propensity matching and Cox regression analysis were conducted to examine the impact of comorbid depression on the incidence of major adverse events (MAEs), defined as re-intervention, major amputation, or death, within 2 years of surgery., Results: Of all patients ( n = 512) undergoing intervention at our institution, 166 (32.4%) suffered an MAE and 169 (33.0%) patients had a preoperative diagnosis of depression. After propensity score matching, univariate (HR, 1.7; 95% CI, 1.1-2.7) and multivariable hazard analyses (aHR, 1.50; [1.1-2.2]) demonstrate that there is a statistically significant relationship between the diagnosis of depression and increased MAE., Conclusion: Over one-third of our lower extremity revascularization patients were noted to have a preoperative diagnosis of depression. After intervention, these patients had worse outcomes compared to patients without depression; this finding was more evident in patients who underwent PVI mainly due to high overall mortality rate. Prospective studies are necessary to better understand this association and to ascertain if early intervention can improve post-procedure vascular outcomes., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: This study evaluates the personal and professional experiences of physician mothers during the coronavirus disease 2019 (COVID-19) pandemic and the impact of the pandemic on the lives of physician mothers., Methods: Using social media to reach a broad range of physicians, a convenience sample of physician mothers completed an on-line survey posted between April 27 and May 11. Members were encouraged to repost on social media and share with personal contacts resulting in a passive snowball sampling effect., Results: A total of 2709 physician mothers from 48 states, Puerto Rico, and 19 countries representing more than 25 medical specialties completed the survey. Most were between 30 and 39 y of age, 67% self-identified as white, 17% as Asian, 4% as African American. Most had been working for 11-16 y. A total of 91% had a spouse/partner of the opposite sex. Over half were practicing in an area they identified as high COVID-19 density, while 50% had personally cared for a person with COVID-19. Physician mothers were most concerned about exposing their children to COVID-19 and about the morale and safety of their staff., Conclusions: This is one of the first studies to explore the personal and professional challenges facing physician mothers during a pandemic. Physician mothers were most concerned about exposing their families to COVID-19. Mothers continued to work and at times increased their work, despite having domestic, childcare, and schooling responsibilities.

Objective: To determine the impact of infection (INF) on medical resource utilization (MRU) and cost of care in patients with venous leg ulcers (VLU)., Methods: We performed a retrospective case-control study of 78 patients followed for a minimum of 12 months with C 6 VLUs treated by vascular surgeons, at our wound center. To eliminate minor episodes of INF or incorrectly diagnosed episodes, only patients who had an inpatient admission specifically for INF comprised the INF group, whereas all other admissions were excluded for this group. MRU was defined as the number of clinic visits, Visiting Nurse Association (VNA) visits, and inpatient admissions. The actual cost for treatment was determined using financial data provided by both the hospital and physician organization billing units. The total cost over the 1-year follow-up period comprised individual cost centers: inpatient and outpatient facility fees, physician fees, and visiting nurse services. Mean MRU and cost data were compared using the two-sample t-test between INF and NON-INF., Results: Of the 78 patients with C 6 VLU, 9 (11.5%) had at least one inpatient admission for INF related to their VLU in the 1-year treatment period, with an additional five recurrent admissions for a total of 14 admissions, whereas 69 NON-INF had three NON-INF-related admissions. There was no difference between INF and NON-INF for usual risk factors, but INF had a greater proportion of congestive heart failure (44%; 13%, P < .02). Regarding MRU, both the number of outpatient wound center visits (INF 16.89 ± 6.41; NON-INF 9.46 ± 7.7, P = .008) and VNA blocks (INF 3.89 ± 2.93; NON-INF 1.94 ± 2.24, P < .02) were greater for INF. Total costs for INF ($27,408 ± $10,859) were threefold higher than those for NON-INF ($11,088 ± $9343, P < .0001) and subsequent VNA costs were doubled for INF ($9956 ± $4657) vs NON-INF ($4657 ± $5486, P = .01)., Conclusions: INFs in patients with VLU led to an overall increase in MRU and cost of care, with the INF cohort requiring more inpatient admissions, outpatient visits, and VNA services than NON-INF. Given the major impact INF has on cost and MRU, better treatment modalities that prevent INF as well as identifying risk factors for INF in patients with VLU are needed., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: Parental leave for new parents is essential as they adjust to the physical and psychological changes that accompany childbirth and caring for a newborn. This study sought to determine the current state of parental leave policies for medical students at medical schools in the United States., Method: From November to December 2019, 2 researchers independently reviewed the websites of 199 U.S. MD-granting and DO-granting medical schools (including in U.S. territories). Online student handbooks and school webpages were searched for the following keywords: "pregnant" OR "pregnancy" OR "maternity" OR "parent" OR "family" OR "child" OR "birth." Data were analyzed using descriptive statistics. Fisher's exact tests evaluated differences in proportion by group., Results: Of 199 schools, 65 (32.66%) had parental leave policies available online or in the handbook: 39 of 155 (25.16%) MD-granting and 26 of 44 (59.09%) DO-granting schools. Of those policies, 59 (90.77%) were included in the student handbook. Most policies (28, 43.08%) were included as an option within the school's general leave of absence policy. Both parents were included in 38 (58.46%) policies; 23 (35.38%) policies mentioned only mothers; and 4 (6.15%) were unknown. An option to maintain original graduation date was offered in 21 (32.1%) schools' policies. Three schools (4.62%) included adoption as qualifying for parental leave. When comparing MD and DO programs, DO programs were statistically more likely to have a parental leave policy: 39 (25.16%) vs 26 (59.09%); P < .001., Conclusions: Balancing medical school with pregnancy and childbirth necessitates administrative support to address the inherent scheduling challenges. Currently, many schools lack parental leave policies for medical students that are easily accessible, are separate from formal leaves of absence, allow for at least 12 weeks, and are tailored to the student academic year to ensure on-time completion of medical education., (Copyright © 2021 by the Association of American Medical Colleges.)

A variety of U.S. Food and Drug Administration-approved hormone therapy options are currently used to successfully alleviate unwanted symptoms associated with the changing endogenous hormonal milieu that occurs in midlife with menopause. Depending on the primary indication for treatment, different hormone therapy formulations are utilized, including estrogen-only, progestogen-only, or combined estrogen plus progestogen options. There is little known about how these formulations, or their unique pharmacodynamics, impact neurobiological processes. Seemingly disparate pre-clinical and clinical findings regarding the cognitive effects of hormone therapies, such as the negative effects associated with conjugated equine estrogens and medroxyprogesterone acetate vs. naturally circulating 17β-estradiol (E2) and progesterone, signal a critical need to further investigate the neuro-cognitive impact of hormone therapy formulations. Here, utilizing a rat model of transitional menopause, we administered either E2, progesterone, levonorgestrel, or combinations of E2 with progesterone or with levonorgestrel daily to follicle-depleted, middle-aged rats. A battery of assessments, including spatial memory, anxiety-like behaviors, and depressive-like behaviors, as well as endocrine status and ovarian follicle complement, were evaluated. Results indicate divergent outcomes for memory, anxiety, and depression, as well as unique physiological profiles, that were dependent upon the hormone regimen administered. Overall, the combination hormone treatments had the most consistently favorable profile for the domains evaluated in rats that had undergone experimentally induced transitional menopause and remained ovary-intact. The collective results underscore the importance of investigating variations in hormone therapy formulation as well as the menopause background upon which these formulations are delivered., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Koebele, Hiroi, Plumley, Melikian, Prakapenka, Patel, Carson, Kirby, Mennenga, Mayer, Dyer and Bimonte-Nelson.)

Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a means of providing cardiopulmonary support that is being increasingly used in patients with acute heart failure. When ECMO cannulae are placed peripherally, their large diameters pose a risk of limb ischemia. Distal perfusion cannulae (DPC) have been proposed as means to reduce risk, but their use is not recommended by the most recent ECMO guidelines. We sought to establish their utility at our institution., Methods: We performed a retrospective review of of all patients treated with peripheral VA-ECMO at our institution from 2013-2018. During the first 2 years, DPC were not routinely placed, whereas in the final 4 years, DPC were recommended as part of the ECMO cannulation routine., Results: One hundred and one patients were treated with peripheral VA-ECMO, with an overall mortality of 61%. By univariate analysis, obesity (47% vs. 75%, P<0.01) and limb ischemia (57% vs. 83%, P<0.05) were associated with increased mortality. DPC were placed prophylactically in 49% of patients. Prophylactic placement of a DPC at the time of cannulation significantly reduced the incidence of limb ischemia (2% vs. 32%, P<0.05), but did not impact mortality (53% vs. 69%, P=0.0953). In patients who did not have a DPC placed during ECMO cannulation and subsequently developed limb ischemia, late DPC placement for limb salvage did not impact mortality., Conclusions: Limb ischemia portends a poor outcome in VA-ECMO patients, and prophylactic DPC placement significantly reduces the risk of limb ischemia. We propose prophylactic DPC placement be considered in patients requiring peripheral VA-ECMO.

Objective: We assessed the quality of current clinical practice guidelines (CPGs) for lymphedema using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. CPGs provide recommendations for the management of medical conditions such as lymphedema. However, their evidentiary quality and methodology should determine their reliability. The AGREE II instrument was developed to externally and objectively evaluate the quality of CPGs and has been used to assess other nonvascular CPGs. A systematic review identified four CPGs for lymphedema of varying content: Lymphedema Framework's Best Practice for the Management of Lymphedema (LED F); Japanese Lymphedema Study Group-A Practice Guideline for the Management of Lymphedema (J LED); Clinical Resource Efficiency Support Team (CREST) Guidelines for the Diagnosis, Assessment and Management of Lymphedema; and Guidelines of the American Venous Forum (AVF). The quality of these CPGs appeared to vary., Methods: The four CPGs were analyzed using the AGREE II instrument by three independent graders, who were unaware of each other's scores. Six domains with 23 items were graded using a Likert scale (1, strongly disagree; to 7, strongly agree) regarding whether the CPG had satisfied the requirements of each item. The score for each domain was calculated by summing the scores for each item in that domain and scaling the total as a percentage of the maximum possible score for that domain (ie, obtained score - minimum score/maximum possible score - minimum possible score × 100 = percentage)., Results: CREST had the highest overall score (66.8%), as an average of all domains, and J LED had the lowest (37%). CREST also had five of five domains rated >50%. In contrast, J LED had only one and AVF had only two domains that scored >50%. Although two domains, rigor of development and applicability, scored low, with only one CPG scoring >50%, the editorial independence domain scored the lowest of all six domains., Conclusions: In addition to limitations in content and the lack of contemporary references, the four CPGs studied were judged objectively to be of low quality using the AGREE II instrument. A contemporary CPG for lymphedema, guided by the AGREE II requirements, is needed., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Percutaneous thermal ablation of hepatic tumors continues to play an integral role in the treatment of early-stage primary or secondary hepatic malignancies. Interventional radiologists must be familiar with potential complications of this procedure, associated risk factors, and methods for prevention. The authors report a devastating case of septic shock and death following percutaneous microwave ablation of a solitary hepatocellular carcinoma in a liver transplant patient with a bilioenteric anastomosis (BEA). We review the literature regarding prophylactic antibiotic regimens and bowel preparation prior to performing thermal ablation in patients with BEAs.

Background: Despite regular treatment of venous leg ulcers (VLUs), some fail to heal. Although several risk factors have previously been identified to be associated with the failure of VLUs to heal, the majority of studies are limited to <24-week follow-up., Methods: A retrospective cohort study was performed at an academic vascular and wound center. A total of 65 patients with VLUs who were observed for a year or more were identified. These patients underwent a variety of treatments following the Society for Vascular Surgery and American Venous Forum VLU guidelines. Risk factors, which were based on previously defined elements for failure of VLUs to heal after a period of treatment, were examined. Both univariate (unadjusted) and multivariate (adjusted) logistic regression analyses were used to assess the magnitude of effect that a given risk factor had on healing., Results: Of 65 patients treated for a minimum of 52 weeks, 19 (29%) remained unhealed. By univariate analysis, deep venous disease (P = .01; odds ratio [OR], 5.82; 95% confidence interval [CI], 1.49-22.72), history of deep venous thrombosis (P < .001; OR, 14.06; 95% CI, 3.77-52.39), and depression (P = .04; OR, 3.89; 95% CI, 1.10-13.80) were all shown to be significant risk factors for nonhealing. The patient's race (ie, being nonwhite; P = .02; OR, 103.45; 95% CI, 1.94-5.53 × 10 3 ), deep venous disease (P = .05; OR, 37.0; 95% CI, 1.05-1.31 × 10 3 ), and history of deep venous thrombosis (P = .01; OR, 122.4; 95% CI, 3.09-4.84 × 10 3 ), however, were all shown to be significant for nonhealing under multivariate analysis. In addition, identification of an incompetent perforator (P = .02; OR, 0.006; 95% CI, 9.27 × 10 -5 -0.44) was conversely shown to be a good prognostic factor for healing., Conclusions: This study confirmed that risk factors known to be associated with the failure of a VLU to heal-deep venous disease and post-thrombotic etiology-were significant at 52 weeks, whereas depression and race (nonwhite) are novel risk factors. An analysis of markers of access to care showed no difference between white and nonwhite, suggesting other factors as a cause. The predominance of deep venous disease in the unhealed vs healed cohort (84% vs 48%) highlights the need for a viable treatment option for deep venous disease due to reflux. Overall, this study emphasizes the need to consider all risk factors when evaluating a patient for VLU to coordinate an effective treatment plan and to identify gaps in our treatment., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Approximately one-third of women experience hysterectomy, or the surgical removal of the uterus, by 60 years of age, with most surgeries occurring prior to the onset of natural menopause. The ovaries are retained in about half of these surgeries, whereas for the other half hysterectomy occurs concurrently with oophorectomy. The dogma is that the nonpregnant uterus is dormant. There have been no preclinical assessments of surgical variations in menopause, including hysterectomy, with and without ovarian conservation, on potential endocrine and cognitive changes. We present a novel rat model of hysterectomy alongside sham, ovariectomy (Ovx), and Ovx-hysterectomy groups to assess effects of surgical menopause variations. Rats without ovaries learned the working memory domain of a complex cognitive task faster than did those with ovaries. Moreover, uterus removal alone had a unique detrimental impact on the ability to handle a high-demand working memory load. The addition of Ovx, that is, Ovx-hysterectomy, prevented this hysterectomy-induced memory deficit. Performance did not differ amongst groups in reference memory-only tasks, suggesting that the working memory domain is particularly sensitive to variations in surgical menopause. Following uterus removal, ovarian histology and estrous cycle monitoring demonstrated that ovaries continued to function, and serum assays indicated altered ovarian hormone and gonadotropin profiles by 2 months after surgery. These results underscore the critical need to further study the contribution of the uterus to the female phenotype, including effects of hysterectomy with and without ovarian conservation, on the trajectory of brain and endocrine aging to decipher the impact of common variations in gynecological surgery in women. Moreover, findings demonstrate that the nonpregnant uterus is not dormant, and indicate that there is an ovarian-uterus-brain system that becomes interrupted when the reproductive tract has been disrupted, leading to alterations in brain functioning.

Background: Gender bias has been identified as one of the drivers of gender disparity in academic medicine. Bias may be reinforced by gender subordinating language or differential use of formality in forms of address. Professional titles may influence the perceived expertise and authority of the referenced individual. The objective of this study is to examine how professional titles were used in the same and mixed-gender speaker introductions at Internal Medicine Grand Rounds (IMGR)., Methods: A retrospective observational study of video-archived speaker introductions at consecutive IMGR was conducted at two different locations (Arizona, Minnesota) of an academic medical center. Introducers and speakers at IMGR were physician and scientist peers holding MD, PhD, or MD/PhD degrees. The primary outcome was whether or not a speaker's professional title was used during the first form of address during speaker introductions at IMGR. As secondary outcomes, we evaluated whether or not the speakers professional title was used in any form of address during the introduction., Results: Three hundred twenty-one forms of address were analyzed. Female introducers were more likely to use professional titles when introducing any speaker during the first form of address compared with male introducers (96.2% [102/106] vs. 65.6% [141/215]; p < 0.001). Female dyads utilized formal titles during the first form of address 97.8% (45/46) compared with male dyads who utilized a formal title 72.4% (110/152) of the time (p = 0.007). In mixed-gender dyads, where the introducer was female and speaker male, formal titles were used 95.0% (57/60) of the time. Male introducers of female speakers utilized professional titles 49.2% (31/63) of the time (p < 0.001)., Conclusion: In this study, women introduced by men at IMGR were less likely to be addressed by professional title than were men introduced by men. Differential formality in speaker introductions may amplify isolation, marginalization, and professional discomfiture expressed by women faculty in academic medicine.

Purpose: We aimed to determine which intravenous contrast-enhanced multidetector computed tomography (MDCT) protocol produced the most accurate results for the detection of splenic vascular injury in hemodynamically stable patients who had sustained blunt abdominal trauma., Methods: We retrospectively reviewed 88 patients from 2003 to 2011 who sustained blunt splenic trauma and underwent contrast-enhanced MDCT and subsequent angiography. Results of MDCT scans utilizing single phase (portal venous only, n=8), dual phase (arterial + portal venous or portal venous + delayed, n=42), or triple phase (arterial + portal venous + delayed, n=38) were compared with results of subsequent splenic angiograms for the detection of splenic vascular injury., Results: Dual phase imaging was more sensitive and accurate than single phase imaging (P = 0.016 and P = 0.029, respectively). When the subsets of dual phase imaging were compared, arterial + portal venous phase imaging was more sensitive and accurate than portal venous + delayed phase imaging (P = 0.005 and P = 0.002, respectively). Triple phase imaging was more accurate (P = 0.015) than dual phase; however, when compared with the dual phase subset of arterial + portal venous, there was no statistical difference in either sensitivity or accuracy., Conclusion: Our results support the use of dual phase contrast-enhanced MDCT, which includes the arterial phase, in patients with suspected splenic injury and question the utility of obtaining a delayed sequence.

Study Design: Cadaveric biomechanical study., Objective: To determine the degree of segmental correction that can be achieved through lateral transpsoas approach by varying cage angle and adding anterior longitudinal ligament (ALL) release and posterior element resection., Summary of Background Data: Lordotic cage insertion through the lateral transpsoas approach is being used increasingly for restoration of sagittal alignment. However, the degree of correction achieved by varying cage angle and ALL release and posterior element resection is not well defined., Methods: Thirteen lumbar motion segments between L1 and L5 were dissected into single motion segments. Segmental angles and disk heights were measured under both 50 N and 500 N compressive loads under the following conditions: intact specimen, discectomy (collapsed disk simulation), insertion of parallel cage, 10° cage, 30° cage with ALL release, 30° cage with ALL release and spinous process (SP) resection, 30° cage with ALL release, SP resection, facetectomy, and compression with pedicle screws., Results: Segmental lordosis was not increased by either parallel or 10° cages as compared with intact disks, and contributed small amounts of lordosis when compared with the collapsed disk condition. Placement of 30° cages with ALL release increased segmental lordosis by 10.5°. Adding SP resection increased lordosis to 12.4°. Facetectomy and compression with pedicle screws further increased lordosis to approximately 26°. No interventions resulted in a decrease in either anterior or posterior disk height., Conclusion: Insertion of a parallel or 10° cage has little effect on lordosis. A 30° cage insertion with ALL release resulted in a modest increase in lordosis (10.5°). The addition of SP resection and facetectomy was needed to obtain a larger amount of correction (26°). None of the cages, including the 30° lordotic cage, caused a decrease in posterior disk height suggesting hyperlordotic cages do not cause foraminal stenosis., Level of Evidence: N/A.

Background Context: Spinal epidural abscess (SEA) is a serious condition that can lead to significant morbidity and mortality if not expeditiously diagnosed and appropriately treated. However, the nonspecific findings that accompany SEAs often make its diagnosis difficult. Concurrent noncontiguous SEAs are even more challenging to diagnose because whole-spine imaging is not routinely performed unless the patient demonstrates neurologic findings that are inconsistent with the identified lesion. Failure to recognize a separate SEA can subject patients to a second operation, continued sepsis, paralysis, or even death., Purpose: To formulate a set of clinical and laboratory predictors for identifying patients with concurrent noncontiguous SEAs., Study Design: A retrospective, case-control study., Patient Sample: Patients aged 18 years or older admitted to our institution during the study period who underwent entire spinal imaging and were diagnosed with one or more SEAs., Outcome Measures: The presence or absence of concurrent noncontiguous SEAs on magnetic resonance imaging or computed tomography (CT)-myelogram., Methods: A retrospective review was performed on 233 adults with SEAs who presented to our health-care system from 1993 to 2011 and underwent entire spinal imaging. The clinical and radiographic features of patients with concurrent noncontiguous SEAs, defined as at least two lesions in different anatomical regions of the spine (ie, cervical, thoracic, or lumbar), were compared with those with a single SEA. Multivariate logistic regression identified independent predictors for the presence of a skip SEA, and a prediction algorithm based on these independent predictors was constructed. Institutional review board committee approval was obtained before initiating the study., Results: Univariate and multivariate analyses comparing patients with skip SEA lesions (n=22) with those with single lesions (n=211) demonstrated significant differences in three factors: delay in presentation (defined as symptoms for ≥7 days), a concomitant area of infection outside the spine and paraspinal region, and an erythrocyte sedimentation rate of >95 mm/h at presentation. The predicted probability for the presence of a skip lesion was 73% for patients possessing all three predictors, 13% for two, 2% for one, and 0% for zero predictors. Receiver operating characteristic curve analysis, used to evaluate the predictive accuracy of the model, revealed a steep shoulder with an area under the curve of 0.936 (p<.001)., Conclusions: The proposed set of three predictors may be a useful tool in predicting the risk of a skip SEA lesion and, consequently, which patients would benefit from entire spinal imaging., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: To investigate whether inclusion of the volar plate in repair of flexor digitorum profundus avulsions increases the strength of the repair and resists gapping., Methods: Cadaveric fingers (n = 18) were divided into 3 equal groups. The first technique involved 2 micro-suture anchors only (A). The second used only volar plate repair (VP). The third group was a hybrid, combining a micro-suture anchor with volar plate augmentation (AVP). Specimens were loaded cyclically to simulate passive motion rehabilitation before being loaded to failure. Clinical failure was defined as 3 mm of gapping, and physical failure as the highest load associated with hardware failure, suture breakage, anchor pullout, or volar plate avulsion., Results: Gapping throughout cycling was significantly greater for the A group than VP and AVP with no difference detected between VP and AVP groups. Gapping exceeded 3 mm during cycling of 3 A specimens, but in none of the VP or AVP specimens. Load at clinical and physical failure for A was significantly lower than for VP and AVP, whereas no difference was detected between VP and AVP., Conclusions: In this cadaveric model, incorporating the volar plate conferred a significant advantage in strength, increasing the mean load to physical failure by approximately 100 N., Clinical Relevance: According to previous biomechanical studies, current reconstructive strategies for flexor digitorum profundus zone I avulsions are not strong enough to withstand active motion rehabilitation. We demonstrated the potential use of volar plate augmentation and the prospective advantageous increase in strength in this cadaveric model. In vivo performance and effects on digital motion are not known., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background Context: The notion that all patients with spinal epidural abscess (SEA) require surgical decompression has been recently challenged by reports of successful medical management of select patients with SEA., Purpose: The purpose of this study was to identify the independent variables that determine success or failure of medical management of SEA., Study Design/setting: This was a retrospective, case-control study., Patient Sample: Patients 18 years or older with diagnosis of SEA admitted to our institution during the study period were included in the sample., Outcome Measures: The outcome measure was successful management of SEA by eradication of the infection without worsening of neurologic deficits., Methods: All patients admitted to our health-care system with a diagnosis of SEA from 1993 to 2011 were identified and the data were retrospectively collected. Patients 18 years or older diagnosed with SEA were included. Excluded were those with postsurgical SEA or phlegmon without an abscess and those with a complete spinal cord injury from SEA for longer than 48 hours., Results: A total of 355 patients with average age of 60 years met our inclusion criteria. Of the patients who initially underwent nonoperative treatment, 54 patients failed medical management and 73 patients were successfully treated without surgery. Univariate and multivariate analysis identified incomplete or complete spinal cord deficits as the most significant risk factor for failure of medical management. Age older than 65 years, diabetes, and methicillin-resistant Staphylococcus aureus (MRSA) were also independent risk factors for failure. An algorithm for probability of failed antibiotic management of spinal epidural abscess predicted 99% probability of failure for patients with all four of these risk factors., Conclusions: SEA treated with medical management alone has a very high risk for failure if the patient is older than 65 years with diabetes, MRSA infection, or neurologic compromise. In the absence of these risk factors, nonoperative management of spinal epidural abscess may be considered as the initial line of treatment with close monitoring., (Copyright © 2014 Elsevier Inc. All rights reserved.)