Bilateral Quadriceps Tendon Rupture in a Healthy Individual Following a Motor Vehicle Accident: A Case Report

Bilateral quadriceps tendon rupture (QTR) is a rare injury that typically affects middle-aged men presenting underlying medical conditions, while only a few cases have been reported in healthy individuals. The gold standard treatment of such injuries is prompt surgical repair, followed by postoperative immobilization and physiotherapy. We present the case of a 51-year-old previously healthy man who experienced bilateral, simultaneous, and complete QTR following a high-velocity motor vehicle accident. Physical examination revealed bilateral extensor mechanism disruption and palpable defects at the superior poles of the patellae. MRI confirmed the diagnosis, and the patient underwent surgical repair using three anchor sutures on each side. Postoperative management involved a brief period of immobilization followed by progressive passive motion exercises and protected weight bearing. At a six-month follow-up, the patient had excellent functional outcomes and was satisfied with the treatment.

Bridge enhanced ACL repair vs. ACL reconstruction for ACL tears: A systematic review and meta-analysis of comparative studies

INTRODUCTION

Anterior cruciate ligament (ACL) tear is one of the most frequent ligamentous injuries. The gold standard for ACL tears is autograft reconstruction. However, ACL repair has regained enthusiasm with more recent results showing comparable outcomes to its reconstructive counterpart.

METHODS

PubMed, Cochrane, and Google Scholar (pp. 1-20) were searched until November 2022. The clinical outcomes consisted of the International Knee Documentation Committee (IKDC) score, Knee Injury and Osteoarthritis Outcome Score (KOOS), the side-to-side difference in Anteroposterior (AP) knee laxity, the forces of the hamstring, quadriceps, and hip abduction as well as hopping tests.

RESULTS

Only two studies were included in this meta-analysis. ACL repair was shown to have better Hamstrings strength. The rest of the analyzed outcomes were comparable.

DISCUSSION

This is the first meta-analysis comparing these two treatments. The ACL repair showed no differences in muscle strength (quadriceps and hip abductors), postoperative knee scores, and knee joint laxity when compared to ACL reconstruction. However, it showed better hamstring strength. Further randomized clinical studies will be needed to compare both of these techniques.

National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK

A national, multi-centre audit of non-melanoma skin cancer excisions by plastic surgery.

Semimembranosus Tendon Entrapment by an All-Inside Meniscal Suture

Meniscal suturing has become the gold standard when it comes to meniscal tears in vascularized areas, especially in the younger population. The all-inside meniscal suturing technique has gained popularity in the past year due to decreased operative time as well as decreased risk of adverse events, as compared to other modalities. However, several complications have been reported with the all-inside technique, including soft tissue and neurovascular injury. This is the first case reporting a semimembranosus tendon entrapment following an all-inside medial meniscal suture. Being aware of such complications is crucial in order to avoid them and treat them promptly should they arise.

The gracilis and semitendinosus muscles: a morphometric study on 18 specimens with clinical implications

INTRODUCTION

The pes anserinus consists of the sartorius, semitendinosus, and gracilis muscles. They coalesce together with the leg fascia to form the anserine plate. The semitendinosus and gracilis both form the deep layer of this plate and are clinically relevant for ligament reconstruction. The aim of the study is to report a detailed morphometric evaluation of the semitendinosus and gracilis muscles and assess their clinical implications.

METHODS

Using a rigorous dissection process on 18 cadaveric hips, measurements of both the semitendinosus and gracilis muscles with bone parameters were conducted. We measured the following: (a) total femur, femoral shaft, and neck lengths, (b) total muscle lengths, and (c) intra-muscular and extra-muscular (free) tendon lengths. Correlation values between bone variables, muscle variables, and in-between muscle variables were computed.

RESULTS

The total muscle and the distal intra-muscular tendon length of the St and Gr are correlated with the total femur length. When compared to gracilis, the total muscle and distal intra-muscular tendon lengths of the ST are much better correlated with the total femur length. The free distal tendon length for both muscles did not show a significant correlation with any of the femoral bone lengths.

CONCLUSION

The variability of tendon length of the ST/Gr poses a significant challenge to surgeons. This study reports a detailed morphometric evaluation of the ST/Gr hamstring muscle and tendons. It revealed a positive correlation between the femoral length and the ST/Gr graft lengths. This could help orthopedic surgeons in predicting the graft lengths pre-operatively and develop better planning for reconstructive surgeries.

371 Use of Trello as a Project Management Tool for Collaborative Surgical Research and Audit

Introduction

Managing surgical research projects alongside clinical commitments requires organisation, prioritisation, and communication. Our unit is a tertiary plastic surgery centre with a large workforce, high volume case load and abundant research opportunity. In a busy department, co-ordination and communication is imperative for timely high-quality research and audit output and maximum productivity. Tools can be used to support this output; we trialled use of Trello project management software to increase productivity in this context.

Method

We set up a Trello account for our unit’s plastic surgery department. All consultants and trainees have access, and each project has a timeline and standardised progress checklist to support completion of projects to a uniform high standard.

Results

Our Trello for Surgical Research pilot has promoted organised collaborative working and reduced duplication and partial completion of audit and research projects within our department. It has encouraged engagement between smaller subgroups within the unit, and a platform to monitor progression through key stages of project development with oversight of an appointed Research Lead, resulting in an increase in completion of closed loop audits and research projects.

Conclusions

Similar experiences have been described in mathematics and engineering research groups, and delivery of educational material for English Literature study, but we have not identified description of Trello as a tool for medical research. Use of such platforms increases productivity and likelihood of completion of projects, as well as providing a clear outline of a departments’ research priorities and accessible opportunities for rotating juniors.

1465 Anaesthetic Preferences in a Tertiary Hand Surgery Unit & Aetiology of Hand Trauma Presentations During the First UK lockdown: Lessons for the Future

Introduction

Our tertiary plastics unit serves a 4.3 million population in the South East, providing a seven-day hand trauma service. Our aim was to assess differences in quantity and aetiology of hand trauma during the April 2020 lockdown compared with the equivalent period in 2019, and our ability to reduce risk by carrying out more procedures under local anaesthetic.

Method

Retrospective notes review for hand trauma surgery patients in April 2020 (3 weeks in first UK lockdown), with a comparative period in April 2019. Fisher’s Exact Test was applied to assess for difference in method of anaesthetia, injury location (workplace vs home) and DIY versus non-DIY aetiology.

Results

2020 group: n = 165. 2019: n = 239. (31% reduction). Mean age 45 during lockdown vs 49 in 2019. There was significant reduction in the proportion of workplace injuries in 2020 (22% vs 29%), but the proportion of power tool injuries was similar (31.6% 2020 vs 26.6%). DIY injuries increased significantly (33.5% versus 9.2%). Use of local anaeshesia including increased significantly in our unit (84.2% vs 66.1% 2019) with reduction in use of regional and general anaesthesia.

Conclusions

Caseload somewhat reduced during lockdown. Fewer injuries occurred in the workplace. Our unit made good use of local anaesthetic techniques to avoid regional anaesthesia (and risk of need for GA conversion) wherever possible. Public safety warnings existed (BAPRAS and BSSH), but perhaps were less publicly available than desirable. Improving awareness further could reduce trauma surgery burden as we enter a third wave of the pandemic.

Dilemmas in the management of rhinophyma in pigmented individuals

Rhinophyma affects predominantly the Caucasian population and is rare in those with Fitzpatrick skin type IV-VI. Diagnosis is based on clinical evaluation. Prominent features include abnormal coloration and texture of skin, impaired vascularity, irregular nodular exophytic growth and telangiectasia. Management can be surgical or dermatological. Surgery remains the mainstay of treatment but achieving an acceptable aesthetic result can be challenging, particularly in those with pigmented skin. Postsurgical hyper- and hypopigmentation make for unpredictable outcomes requiring appropriate preoperative counselling. We present a case that exemplifies this issue and discuss our recommended approach to counselling, consenting and managing such dilemmas in these patients, and a proposal for further investigation into the role of autologous melanocyte transplantation in reducing the effect particularly of hypopigmentation on aesthetic outcomes in this group.

Pharmacological treatment in pregnant women with moderate symptoms of coronavirus disease 2019 (COVID-19) pneumonia

OBJECTIVE

Pregnant women with moderate symptoms of COVID-19 are at risk for progressing to severe or critical illness. While there are limited data on the management of severe COVID-19 during pregnancy, information on pharmacological treatments of moderate COVID-19 is lacking. We report clinical outcomes of pregnant women hospitalized due to moderate COVID-19 illness treated with a 5-day course of remdesivir, antibiotics, and/or glucocorticoids.

MATERIALS AND METHODS

Case series of pregnant women hospitalized with moderate symptoms of COVID -19 pneumonia at two INOVA Health System hospitals from April 1 to December 31, 2020. Primary outcome was clinical recovery (breathing on ambient air and/or hospital discharge) on hospital day 7 (HD7). Cox regression analysis was performed to evaluate which variables were associated with the primary outcome.

RESULTS

Out of 748 pregnant women with confirmed infection by reverse transcriptase polymerase chain reaction, 35 were hospitalized due to moderate symptoms of COVID-19 pneumonia (median gestational age 29 weeks). There was no maternal death. Seventeen patients received remdesivir within 48 hours of hospitalization: 15 remained with moderate symptoms and 2 (who also received glucocorticoids) had progressed to critical COVID-19 at remdesivir initiation; all 17 women in this group achieved clinical recovery on HD7. Seven women received remdesivir >48 hours following admission after they began treatment with glucocorticoids ± antibiotics and worsened to severe or critical disease; they all required supplemental oxygen on HD7. Eleven women were treated with antibiotics ± glucocorticoids but no remdesivir; on HD7, 3/11 achieved clinical recovery. Clinical recovery was significantly different among treatment groups; p < 0.001. When analyzing only women who remained with moderate symptoms at pharmacological treatments initiation, all 15 on remdesivir and only 3 of 11 on antibiotics achieved clinical recovery on HD7; p < 0.001. Delaying remdesivir for >48 hours after admission (HR 2.32, 95% CI 1.45-4.16) and >4-day duration of symptoms prior to hospitalization (HR 1.65, 95% CI 1.27-3.50) had an inverse association with clinical recovery. Incidental oligohydramnios was seen in 3/24 (12.5%) of women within 5 days of completing remdesivir treatment. Elevated transaminases was prevalent in women treated with remdesivir (8/24, 33.3%).

CONCLUSION

In our cohort, prompt initiation of remdesivir in pregnant women hospitalized with moderate symptoms of COVID-19 pneumonia within 48 hours of admission prevented worsening and allowed a fast clinical recovery by HD7. Deferring remdesivir for >48 hours after hospitalization and duration of symptoms >4 days before admission were independently associated with delayed clinical recovery and longer hospital admission. Ultrasound evaluation of the amniotic fluid in patients recovering from COVID-19 hospitalization should be considered.

Fetal acute cerebral vasoreactivity to maternal hyperoxia in low-risk pregnancies: a cross-sectional study

OBJECTIVE

To establish whether fetal cerebral vasoreactivity (CVR_O2 ), following maternal hyperoxia, is predicted by fetal cerebral and uteroplacental Doppler pulsatility indices (PI) at baseline, fetal pulmonary vasoreactivity to oxygen (PVR_O2 ), gestational age (GA), or sex.

METHODS

Pulsatility index of middle (MCA), anterior (ACA), posterior cerebral (PCA), umbilical (UA), uterine (UtA), and branch of the pulmonary arteries (PA) were obtained, by ultrasound, before (baseline), during (hyperoxia) and after 15 minutes of maternal administration of 8 L/min of 100% oxygen, through a non-rebreathing face mask, in normal singleton pregnancies within 20 to 38 weeks' gestation. CVR_O2 was defined as changes greater than zero in z score of PI of the cerebral arteries from baseline to hyperoxia. Logistic modeling was applied to identify CVR_O2 predictors.

RESULTS

A total of 97 pregnancies were eligible. In the overall population, median z scores of PI of MCA, ACA, and PCA did not differ between study phases. Based on the logistic model, baseline z scores for cerebral PI and GA were the best predictors of CVR_O2 .

CONCLUSIONS

In low-risk pregnancies, fetal CVR_O2 to hyperoxia does not occur uniformly but depends on cerebral PI and GA at baseline. These findings may provide useful reference points when oxygen is administered in high-risk pregnancies.

Prevalence of eosinophilic esophagitis: A multicenter study on a pediatric population evaluated at thirty-six Latin American gastroenterology centers

INTRODUCTION AND OBJECTIVE

Eosinophilic esophagitis is a chronic, immune-mediated disease described in case series and publications worldwide. Over the past twenty years, the authors of different studies have attempted to evaluate its incidence and prevalence. The objetive of the present study was to estimate the prevalence of eosinophilic esophagitis in a group of children seen at 36 pediatric gastroenterology centers in ten Latin American countries.

MATERIALS AND METHODS

A multicenter, observational, and cross-sectional study was conducted that estimated the period prevalence of eosinophilic esophagitis in children seen at outpatient consultation and that underwent diagnostic upper gastrointestinal endoscopy for any indication at 36 centers in 10 Latin American countries, within a 3-month time frame.

RESULTS

Between April and June 2016, 108 cases of eosinophilic esophagitis were evaluated. Likewise, an average of 29,253 outpatient consultations and 4,152 diagnostic upper gastrointestinal endoscopies were carried out at the 36 participating centers. The period prevalence of eosinophilic esophagitis in the population studied (n=29,253) was 3.69 cases×1,000 (95% CI: 3.04 to 4.44), and among the children that underwent routine upper gastrointestinal endoscopy (n=4,152), it was 26x1,000 (95% CI: 22.6 to 29.4).

CONCLUSIONS

The general period prevalence of eosinophilic esophagitis in a group of children evaluated at 36 Latin American pediatric gastroenterology centers was 3.69×1,000, and in the children that underwent endoscopy, it was 26×1,000. There was important prevalence variability between the participating countries and centers. The present analysis is the first study conducted on the prevalence of pediatric eosinophilic esophagitis in Latin America.

Time to resolution: A prospective evaluation from the Society for Fetal Urology hydronephrosis registry

INTRODUCTION

The resolution rate of prenatal urinary tract dilation (UTD) has been documented in several retrospective studies. The present study analyzed prospective observational registry data, with the aim of determining time to resolution among patients prenatally identified with mild postnatal UTD.

MATERIALS AND METHODS

A total of 248 subjects, from four centers, were prospectively enrolled from 2008 to 2015. Exclusion criteria included other anomalies (n = 69), fewer than two ultrasounds, and/or <3 months follow-up (n = 26). Resolution was defined as Outcome A (SFU 0) and Outcome B (SFU 0/1). Fisher's exact test, Mann-Whitney U or Kruskal-Wallis test and Kaplan-Meier were used for analysis.

RESULTS/DISCUSSION

The median follow-up for 179 (n = 137 males) subjects was 15 months (IQR 7-24), range 0-56 months. VCUG was performed in 100 (57%) and VUR identified in 15 (15%). There was no association with reflux and resolution (P = 0.72). For resolution assessment (n = 153), lower grades were likely to resolve and demonstrated a higher rate in the Outcome B classification. Time to resolution also favored lower grades, with the majority resolving within 2 years (Figure). Surgical intervention was performed in 14 (8%). It is interesting to note that regardless of grade of UTD, there was no difference in frequency of US or the time that RUS was first performed. Practitioners performed the first RUS of life within a narrow window ranging from 0.27 RUS/month for Grade 1 UTD to 0.30 RUS/month for Grade 4 UTD. It was speculated that this practice pattern occurrence likely reflected the deficiency in knowledge by primary care providers, and identified a potential opportunity for education. The SFU registry substantiates that the vast majority of patients will demonstrate transient UTD and most cases that do not resolve will improve within 2 years of life. This data could be used to further an evidenced-based approach towards the evaluation and management of prenatal UTD, as outlined in the multidisciplinary consensus statement for prenatal urinary tract dilation.

CONCLUSIONS

This prospective registry confirms that the majority of prenatal UTD is transient, resolution occurs within the first 3 years of life, and most patients will not need intervention. Redefining SFU 1 as normal increased the resolution rate. A large proportion of patients were not evaluated with a VCUG, therefore impact of VUR could not be determined.

Lebanon's experience in surveillance of communicable diseases during a mass gathering: Sixth Francophone Games, 2009

In 2009, Lebanon hosted the 6th Francophone Games. Pandemic A(H1N1)2009 virus presented significant health threat at the time. A surveillance strategy was implemented for the timely detection and management of epidemiological events and outbreaks, in particular for A(H1N1)2009 virus cases. Data were collected and managed daily and feedback was generated through daily bulletins. A total of 299 medical consultations were reported, 29% of which related to infectious diseases. There were 10 cases reported as acute respiratory infections; all tested negative for A(H1N1)2009 virus within 24 hours. Twenty-three cases of gastroenteritis were reported, for which 11 stool cultures were negative. While pandemic A(H1N1)2009 did not interfere with the Games, it was essential to strengthen surveillance and to have timely epidemiological information. This was achieved through preparedness, a multi-disciplinary approach, timely management and coordination.

Diverse outcome following early prenatal diagnosis of pulmonary stenosis

OBJECTIVE

To assess the natural history and outcome of fetal pulmonary stenosis (PS), particularly that detected at 14-17 weeks' gestation.

METHODS

In this retrospective study we searched an electronic database of women from the general Israeli population attending a private ultrasound institute (Al-Kol ultrasound institute in Haifa) for routine complete early fetal ultrasound, including all fetal systems and a fetal echocardiogram, between 2004 and 2015. Ninety-seven percent of the women were at low risk of fetal malformations, and 3% had risk factors such as maternal Type-1 diabetes mellitus, exposure during pregnancy to teratogenic drugs, or anomalies in previous pregnancies or in other family members. At presentation at 14-17 weeks of gestation, color and pulsed Doppler imaging were performed across the four cardiac valves. We identified cases in which abnormal flow was detected, leading to suspicion of PS; in these cases, a follow-up examination was carried out at 17-19 weeks and then monthly until delivery or resolution of the finding, and postnatal echocardiography was performed at birth, 4-6 weeks thereafter, and yearly afterwards. Outcome data for suspicious cases, including postnatal diagnosis and general or specific symptoms, were collected by contacting the parents via email or telephone.

RESULTS

Among 24 185 early prenatal transvaginal ultrasound screening examinations, 23 cases of suspected PS were identified. They were classified into three groups, according to their ultrasound findings. In Group A (n = 8), the ultrasound screen was normal except for high flow velocity across the pulmonary valve. In six cases, this finding had resolved by 20-21 weeks of gestation and all were found to be normal at postnatal follow-up, one case underwent termination of pregnancy at 19 weeks and PS was confirmed at autopsy and one case was lost to follow-up. In Group B (n = 12), there was aliasing across the pulmonary valve. Two of these cases were normal postnatally and eight had mild-to-moderate PS; the remaining two cases developed hypoplastic right ventricle and pulmonary atresia at 19-20 weeks and the pregnancies were terminated. In Group C (n = 3) PS was associated with other anomalies; all three pregnancies were terminated. There were an additional six cases (Group D) not identified in early gestation, in which PS was late-onset. One had tricuspid regurgitation at the early screen, but was subsequently diagnosed with Ebstein's anomaly and pulmonary atresia, at 22 weeks, and was terminated. The other cases had completely normal early ultrasound screening examinations: one case had Ebstein's anomaly and PS was diagnosed at birth; four had isolated mild PS, of which one was diagnosed at 22 weeks' gestation and the other three were diagnosed postnatally, before 3 months of age. The sensitivity for detection of the ascertained cases of PS was 64% (11/17) and the specificity was > 99%.

CONCLUSION

There is a diverse spectrum of presentation of fetal PS in the early mid-trimester. A possible explanation for this could be different pathophysiological pathways. Further study is needed to explain the different prenatal sonographic presentations in an unselected population. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Femoral neck pseudoarthrosis in a polio patient treated with closed reduction and cell therapy

Poliomyelitis disease affects the anterior horns cells of the spinal cord and certain motor nuclei of the brain stem. Paralysis type is flaccid and asymmetrical and result in muscular imbalance.

Due to this, in case of having a hip muscles involvement, degenerative or posttraumatic, total hip arthroplasty is normally contraindicated because of the excessive risk of hip dislocation. In cases of subcapital femoral neck fractures the femoral head vascularization is a main concern, and in cases of neglected fracture with pseudoarthrosis the vascular status to the head must be investigated prior to further decisions.

We report the case of a femoral neck fracture non-union after a missed femoral neck fracture in a polio affected leg treated with cannulated screws and percutaneous autologous injection of processed total nuclear cells (TNC) mixed with putty demineralized bone matrix.

Outcome of femoral fractures care as a measure of trauma care between level I and level II trauma systems in Israel

Background

Our hypothesis in this study was that the outcome of patients with femur fractures would be favorable in a level I trauma center (LITC).

Methods

A prospective multicenter cohort study. 5 LITC and 6 regional (level II) trauma centers (RTCs) were enrolled to participate in the study. A total of 238 patients suffering from a femoral fracture were recruited to the study. 125 patients were treated in LITCs and 113 in RTCs. Data were extracted from the emergency medical services ambulances, emergency department records, patient hospitalization and discharge records, operating room records, and the national trauma registry (for LITCs). A study questionnaire was administered to all participating patients at discharge, 6 weeks and 6 months postoperatively. The following parameters were studied: mechanism of injury, time from injury to the hospital, Injury Severity Score, classification of femoral fracture, additional injuries, medical history, time to surgery, implant type, skill level of the surgical team, type of anesthesia, length of stay and intensive care unit (ICU) stay, postoperative and intraoperative complications and mortality.

Results

There was a significant difference in the modality of patient transfer between the 2 study groups-with the LITC receiving more patients transported by helicopters or medical intensive care. Time to surgery from admission was shorter in the LITC. Length of stay, ICU stay, and mortality were similar. In the LITCs, 47% of the procedures were performed by residents without the supervision of an attending surgeon, and in the RTCs 79% of the procedures were performed with an senior orthopaedic surgeon. Intraoperative and immediate complication rates were similar among the 2 groups.

Conclusions

A femoral shaft fracture can be successfully treated in an LITC and RTC in the state of Israel. Both research and policy implementation works are required. Also, a more detailed outcome analysis and triage criteria for emergency are desired.

Level of evidence

II.

Performance of manual ventilation: how to define its efficiency in bench studies? A review of the literature

Bench studies have become the preferred way to evaluate the performance of airway equipment, since clinical trials are not specifically required before marketing these devices. However, it is difficult to assess the efficiency of ventilation without recording physiological data. This review analyses how efficiency of manual ventilation has been defined in recent studies, and how their results may be affected. We searched electronic databases from 2000 to April 2014. The main inclusion criterion was the analysis of performance of ventilation. Nine relevant articles were selected from 53 eligible publications. Most studies used the same parameters; tidal volume and ventilation rate. However, there were significant differences between the definitions of performance of ventilation, both in terms of criteria of judgement and methods of analysis. None of these approaches is able to provide a clear understanding of variability of ventilation during a given period. A new definition may increase the relevance of bench studies to clinical medicine, by more appropriately assessing the performance of ventilation.

Reliability of manikin-based studies: an evaluation of manikin characteristics and their impact on measurements of ventilatory variables

Findings from manikin-based studies on ventilation are commonly directly extrapolated to clinical practice. The aim of this study was to determine how the use of manikins affects measurements of ventilatory variables. We connected a lung simulator to a manikin, which was then ventilated at different inspiratory flows. We defined three experimental models to compare measurements of ventilatory variables between the mechanical ventilator and the lung simulator. Even when no leakage occurred, significant tidal volume deviations were observed; from a mean (SD) of 21 (2) ml to 49 (9) ml, and from 40 (4) ml to 88 (5) ml for invasive and non-invasive ventilation, respectively (p < 0.001). Significant peak pressure deviations from 0.7 (0.1) cmH2 O to 10.6 (0.3) cmH2 O were also recorded during non-invasive ventilation (p < 0.001). Evaluation of manikin resistance and airway dead space may be essential to limit study bias. We suggest a recalibration of the recorded data if comparisons are made between different tests performed at different inspiratory flows.

Generalized lock-in detection for interferometry: application to phase sensitive spectroscopy and near-field nanoscopy

A generalized lock-in detection method is proposed to extract amplitude and phase from optical interferometers when an arbitrary periodic phase or frequency modulation is used. The actual modulation function is used to create the reference signals providing an optimal extraction of the useful information, notably for sinusoidal phase modulation. This simple and efficient approach has been tested and applied to phase sensitive spectroscopy and near-field optical measurements. We analyze the case where the signal amplitude is modulated and we show how to suppress the contribution of unmodulated background field.

Subtle adverse effects of late preterm birth: a cautionary note

OBJECTIVE

Late preterm birth increases risk of perinatal health complications that typically resolve in the short term. Thus, early elective delivery is thought to have no long-term effects. Whether there is increased risk of adverse psychological outcomes that emerge in early childhood remains uncertain.

METHOD

The authors compared intellectual, neuropsychological, and behavioral outcomes in 278 late preterm (35-36 weeks) and 192 term (37-41 weeks) participants at age 3 years recruited from a single center, using analysis of variance, analysis of covariance, and regression analyses. Late-preterm participants were further subgrouped by admission to the neonatal intensive care unit (NICU; n = 202) or a well-baby unit (n = 76). Analyses included 132 additional participants born at 34 weeks.

RESULTS

Late preterm participants had lower general conceptual ability (GCA; i.e., IQ); lower verbal, nonverbal, spatial, visuomotor, and dexterity scores; and poorer adaptability than term participants (p < .01; -0.271 to -0.511 SDs). Gestational age was the most important predictor of these subtle outcomes, not neonatal medical variables; no differences were found between NICU admitted and nonadmitted late-preterm groups. A 1-week increase in gestational age resulted in a 1.941 increase in GCA (d = 0.127).

CONCLUSION

Gestation is a developmental continuum best not interrupted during its natural course. Our data showing subtle but appreciable effects have important implications for obstetric practice and parental decision making regarding early elective delivery in the absence of maternal or fetal adverse indications.

The morphological applicability of a novel endovascular aneurysm sealing (EVAS) system (Nellix) in patients with abdominal aortic aneurysms

OBJECTIVE

Endovascular aneurysm sealing (EVAS) using the Nellix system is a promising alternative to endovascular repair (EVR) and open surgery for abdominal aortic aneurysms (AAA). The aim of this study was to investigate the proportion of patients with AAA who are morphologically suitable for treatment with Nellix.

METHODS

Patients presenting with AAA were investigated at two regionalised vascular units. Separate cohorts were identified, who had undergone infrarenal EVR, open aneurysm repair, fenestrated endovascular repair (FEVR) or non-operative management. Pre-operative morphology was quantified using three-dimensional computed tomography according to a validated protocol. Each aneurysm was assessed for compliance with the instructions for use (IFU) of Nellix

RESULTS

776 patients were identified with mean age 75 ± 9 years. 730/776 (94.1%) had undergone infrarenal EVR, 6/776 (0.8%) open repair, 27/776 (3.5%) FEVR and 13/776 (1.7%) had been managed non-operatively. 544/776 (70.1%) of all AAA were morphologically suitable for Nellix. 533/730 (73.0%) of patients who had undergone infrarenal EVR were compliant with Nellix IFU, compared with 497/730 (68.1%), 379/730 (51.9%) and 214/730 (29.3%) with the IFU for Medtronic Endurant (p = .04) or Cook Zenith (p < .01) and Gore C3 Excluder (p < .01) endografts respectively.

CONCLUSIONS

Nellix technology appears widely applicable to contemporary infrarenal AAA practice, and may provide an option for patients that are outside current EVR device instructions for use. However, formal outcomes study is still required, and will ultimately dictate the clinical relevance of this feasibility study. The major limitation to anatomic suitability for Nellix is currently the maximum patent lumen diameter of large AAA.

Tracheostomy in the critically ill: the myth of dead space

Benefits and advantages of tracheostomy have been vigorously debated. There is a lack of consensus as to whether perceived clinical improvement is attributable to fundamental changes in respiratory dynamics. We compare the effect of tracheostomy versus endotracheal tube on dead space, airway resistance and other lung parameters in critically ill ventilated patients. Data collected included patients who were admitted to surgical, burn and neurosurgical intensive care units at the University of North Carolina. Twenty-four intubated patients were included in our analysis with various aetiologies of respiratory failure. Tracheostomy was deemed necessary either for severe neurological devastation or failure to wean from the ventilator. The diameter of the endotracheal tubes ranged from 6-8 mm and the tracheostomy tube diameters were from 6.4-8.9 mm. Internal diameters between endotracheal tube and tracheostomy tubes, ventilator settings and sedation were kept consistent throughout the study. Respiratory parameters were measured using the Respironics' non-invasive cardiac output 2 device (Phillips, Andover, MA) immediately prior to tracheostomy and repeated within 24 hours of tracheostomy. Only two (8%) of the patients had slight improvement (>6% decrease in dead space). The average dead space of endotracheal versus tracheostomy tubes was 41±12.6% and 40±14.6%, respectively (P=0.75). The remaining 22 patients (92%) had no significant change in dead space, compliance or other respiratory parameters. This study shows that there is no significant difference in respiratory mechanics and dead space with a tracheostomy versus endotracheal tube.

Orthogonal double plate fixation for long bone fracture nonunion

PURPOSE OF THE STUDY

The treatment of long bone diaphyseal fracture-nonunion is challenging. While taking into account biological needs, a stable mechanical environment is pertinent for fracture healing. This work aims at evaluating the surgical management of stubborn ununited fractures using orthogonal double plating of diaphyseal fractures with limited periosteal stripping and soft tissue dissection.

PATIENTS AND METHODS

Retrospective analysis in a level I trauma center. Between the years 2007-2009, 22 patients were treated with double plating due to nonunion of long bone fractures. Long bones included three clavicles, six humeri, three femora, seven ulnae, two tibiae and one radius. The mean period between index procedures (if existed) and revision procedures was 53.35 weeks (range 6 months-3 years). The same surgical technique, independent on the anatomical location was utilized. Perioperative intravenous antibiotics were withheld until intraoperative cultures were obtained in all patients. An approach to the fracture site was performed with removal of all previous existing hardware, including aggressive debridement of the nonunion site while keeping stripping to the necessary minimum. After primary plate fixation of the fracture with adequate compression, a second plate, with at least two well spaced screws on each side, was placed at a ninety degree angle to the primary plate. Autologous bone graft or bone graft substitute was placed in most, but not all cases. All procedures and assessment of union were done by fellowship trained trauma surgeons. In the infected cases, culture specific intravenous antibiotics were administered for six weeks. Quality of life measures included DASH score of the upper extremity, lower extremity functional score (LEFS) for the lower extremity and Short From 12 (SF-12) for all patients.

RESULTS

Union was achieved in all patients, with an average time to union of 5.8 months (range 2-24 months). One patient healed after a repeat double plating, since the first procedure was unsuccessful. Tissue culture were positive in 11 out of 22 patients. One clavicular plate was removed, due to irritation. No hardware failure was noted in these cases. Mean LEFS was 59%, quick DASH score -18.5 20 and SF-12 MCS and PCS were 50.37 15.22 and 49.96 8.5 receptively.

CONCLUSION

Double plating is a biomechanically sound option for treating long bone fracture nonunion with reasonable results, provided adequate biological conditions are met including eradication of infection.

Household characteristics and allergen and endotoxin levels in Aleppo, Syrian Arab Republic

Few data are available from Eastern Mediterranean countries about levels of domestic allergens and endotoxins. Dust samples were collected from mattresses and floors of 457 homes in the Syrian city of Aleppo and analysed for antigens and endotoxins. The most important predictors for detectable levels of house-dust mite allergen Der p 1 were Arabic-style houses (OR 3.21) and newer houses (OR 1.56). In homes without cats, rubber mattresses were associated with detectable cat allergen Fel d 1 in mattress dust (OR 1.6). Cockroach allergen Bla g 2 was significantly more likely to be detected in houses over 20 years old than newer houses. Endotoxin levels were significantly higher in wool/cotton mattresses and older houses.

Out-of-hospital ventricular fibrillation in three adolescents

We describe three adolescents who experienced sudden cardiac arrest due to ventricular fibrillation in an out-of-hospital setting and survived with good neurological outcome despite delayed time to defibrillation. All three were treated with prolonged cardiopulmonary resuscitation (CPR) by certified basic life support providers prior to first defibrillation. This report stresses the importance of early, minimally interrupted, chest compression CPR in children who suffer sudden cardiac arrest in the out-of-hospital setting where defibrillation could be delayed.

Intraoperative cone-beam CT for image-guided tibial plateau fracture reduction

OBJECTIVES

A mobile isocentric C-arm was modified in our laboratory in collaboration with Siemens Medical Solutions to include a large-area flat-panel detector providing multi-mode fluoroscopy and cone-beam CT (CBCT) imaging. This technology is an important advance over existing intraoperative imaging (e.g., Iso-C(3D)), offering superior image quality, increased field of view, higher spatial resolution, and soft-tissue visibility. The aim of this study was to assess the system's performance and image quality in tibial plateau (TP) fracture reconstruction.

METHODS

Three TP fractures were simulated in fresh-frozen cadaveric knees through combined axial loading and lateral impact. The fractures were reduced through a lateral approach and assessed by fluoroscopy. The reconstruction was then assessed using CBCT. If necessary, further reduction and localization of remaining displaced bone fragments was performed using CBCT images for guidance. CBCT image quality was assessed with respect to projection speed, dose and filtering technique.

RESULTS

CBCT imaging provided exquisite visualization of articular details, subtle fragment detection and localization, and confirmation of reduction and implant placement. After fluoroscopic images indicated successful initial reduction, CBCT imaging revealed areas of malalignment and displaced fragments. CBCT facilitated fragment localization and improved anatomic reduction. CBCT image noise increased gradually with reduced dose, but little difference in images resulted from increased projections. High-resolution reconstruction provided better delineation of plateau depressions.

CONCLUSION

This study demonstrated a clear advantage of intraoperative CBCT over 2D fluoroscopy and Iso-C(3D) in TP fracture fixation. CBCT imaging provided benefits in fracture type diagnosis, localization of fracture fragments, and intraoperative 3D confirmation of anatomic reduction.

Neonatal atrial fibrillation after surgical repair of tracheoesophageal fistula with esophageal atresia

Atrial fibrillation is rare in childhood that had not been reported in neonates with normal cardiac morphology and function. The authors present a newborn who underwent surgical repair of a tracheoesophageal fistula with esophageal atresia at the age of 2 days and experienced atrial fibrillation 16 days after the procedure. A report of 35 pediatric patients in a single center over a period of 22 years identified atrial fibrillation in children with a variety of ailments including congenital cardiac anomalies before and after corrective surgery, rheumatic valve disease, Marfan's syndrome with mitral regurgitation, infective endocarditis, cardiomyopathy, endocardial fibroelastosis, paroxysmal atrial tachycardia of infants, and cardiac tumors [2]. All these patients had underlying cardiac disease.

The use of intraoperative three-dimensional imaging (ISO-C-3D) in fixation of intraarticular fractures

INTRODUCTION

The purpose of this study was to analyse the applicability and advantages of the intraoperative use of a mobile isocentric C-arm with three-dimensional imaging (Siremobil ISO-C-3D) in fixation of intraarticular fractures.

METHODS

After the fixation was judged to be satisfactory relying on the images provided by routine fluoroscopy, intraoperative CT visualisation with ISO-C-3D was performed to evaluate the fracture reduction and implant position. Intraoperative revision was performed based on the additional information ISO-C-3D provided beyond routine fluoroscopy. ISO-C-3D was used on a series of 72 closed-intraarticular fractures in 70 patients. Fracture distribution was: calcaneus (25), tibial plateau (17), tibial plafond (12), acetabulum (11), distal radius (3), ankle Weber-C (3) and femoral head (l). The primary outcome measure was revision rate after final ISO-C-3D data acquisition and prior to wound closure. Secondary objectives were to measure the additional time required for ISO-C-3D use and to determine the rate of further re-do surgeries.

RESULTS

Eight out of 72 (11%) fracture fixations were judged by the surgeon to require intraoperative revision following ISO-C-3D imaging. Prior to leaving the operating room, the surgeon was satisfied with fracture alignment in all the procedures. The mean additional operative time using ISO-C-3D was 7.5 min (8.2% of the mean total operative time). No patient required re-do surgery.

CONCLUSION

: Intraoperative three-dimensional visualisation of intraarticular fractures enables the surgeon to identify inadvertent malreductions or implant malpositions which may be overlooked by routine C-arm fluoroscopy and hence may eliminate the need for re-do procedures. ISO-C-3D adds little operative time and may preclude the need for pre-operative and post-operative CT-scans in selected cases.

Osteoid osteoma: CT-guided radiofrequency ablation using a water-cooled probe

BACKGROUND

The purpose of this study was to assess the safety and efficacy of computed tomography (CT) guided percutaneous radiofrequency (RF) ablation of osteoid osteoma by using the water-cooled probe.

METHODS

During the period from July 2002 to February 2006, fifty-one patients with osteoid osteomas localized in femur (29), tibia (10), calcaneus (2), talus (2), metatarsus (2), humerus (1), sacrum (1), scapula (1), olecranon (1), patella (1) and thoracic vertebra (1) were treated with CT-guided RF ablation using the Cooltiptrade mark Tyco Healthcare probe. Mean age was 20 (range, 3.5-57 years) and male to female ratio was 36/15. Mean follow-up period was reported 2 years (range, 9-51 months). The procedures were carried out under general anesthesia and the patients were discharged from the hospital within 24 h.

RESULTS

Technical failure was reported in only one procedure. Pain disappeared postoperatively in all the patients within 2-3 days and no patients needed analgesic treatment after a week. All patients were allowed fully weight bear and function without limitation after the procedure. Recurrence of the pain was observed in one patient who was treated successfully with a second ablation. Our primary and secondary clinical success rates were 98 and 100% respectively. In one case, wound infection was observed after the procedure as the only post-operative complication in our series.

CONCLUSION

CT-guided percutaneous RF ablation of osteoid osteomas using the water-cooled probe is a safe, effective and minimally invasive procedure with high success rate and lack of relapses.

Size and geometry of hepatic radiofrequency lesions

AIM

To report and compare the size and geometry of hepatic radiofrequency (RF) lesions using the currently available commercial devices.

METHODS

A literature search was carried out for the period from January 1st 1990 to June 15th 2003. The commercial suppliers were asked to provide all available data. For each electrode and protocol, size and geometry of single-cycle thermal lesions were registered.

RESULTS

No information at all on size and geometry of the inducible lesions was available for 17 of the 28 current commercial electrodes. Many descriptions of RF lesions are limited to the mean transverse diameter. With normal blood flow, diameter of lesions is often smaller than suggested by the length of the electrode tip or the diameter of the deployed prongs. Lesions are rarely perfect spheres but either ellipses or flattened spheres. Distortion of the RF lesion by nearby blood vessels is very common. Fusion of thermal zones between prongs of expandable electrodes can be incomplete. Blood flow interruption using a Pringle maneuver yields larger lesions that are less distorted and more complete.

CONCLUSIONS

There is insufficient experimental data for many electrodes that are currently used in patients. RF companies should provide these data before releasing electrodes for use. For those electrodes for which data exist, coagulation lesions are often smaller, less spherical, less complete and less regular than generally presumed. Accurate knowledge of size and geometry of RF lesions is crucial to prevent local recurrence.

Management of oesophageal perforation after delayed diagnosis: the merit of tissue flap reinforcement

Oesophageal perforation remains a life-threatening situation and its management represents a challenge for the surgeon, especially if diagnosis has been delayed. In most cases, a surgical approach is indicated. Simple primary repair often result in leakage. In order to avoid leakage, the primary repair should be buttressed with some kind of tissue flap. We here report our experience with 15 esophageal perforations and 10 tissue flap reinforcements performed during the last decade. The different types of tissue flap are illustrated and their results are compared with more aggressive alternatives such as oesophagectomy, T-tube drainage and oesophageal exclusion.

Mentored retroperitoneal laparoscopic renal surgery in children: a safe approach to learning

OBJECTIVE

To review the feasibility of introducing advanced retroperitoneal renal laparoscopic surgery (RRLS) to a paediatric urology division, using the mentorship-training model. Although the scope of practice in paediatric urology is currently adapting endoscopic surgery into daily practice, most paediatric urologists in North America have had no formal training in laparoscopic surgery.

METHODS

The study included four paediatric urologists with 3-25 years of practice; none had had any formal laparoscopic training or ever undertaken advanced RRLS. An experienced laparoscopic surgeon (the mentor) assisted the learning surgeons over a year. The initial phases of learning incorporated detailed lectures, visualization through videotapes and 'hands-on' demonstration by the expert in the technique of the standardized steps for each type of surgery. Over 10 months, ablative and reconstructive RRLS was undertaken jointly by the surgeons and the mentor. After this training the surgeons operated independently. To prevent lengthy operations, conversion to open surgery was planned if there was no significant progression after 2 h of laparoscopic surgery.

RESULTS

Over the 10 months of mentorship, 36 RRLS procedures were undertaken in 31 patients (28 ablative and eight reconstructive). In all cases the mentored surgeons accomplished both retroperitoneal access and the creation of a working space within the cavity. The group was able to initiate ablative RRLS but the mentor undertook all the reconstructive procedures. After the mentorship period, over 10 months, 12 ablative procedures were undertaken independently, and five other attempts at RRLS failed.

CONCLUSION

Although the mentored approach can successfully and safely initiate advanced RRLS in a paediatric urology division, assessing the laparoscopic practice pattern after mentorship in the same group of trainees is warranted. Ablative RRLS is easier to learn for the experienced surgeon, but reconstructive procedures, e.g. pyeloplasty, require a high degree of skill in laparoscopic technique, which may only be acquired through formal training focusing primarily on suturing techniques.

Percutaneous transaortic occlusion of patent ductus arteriosus using a new versatile angiographic and delivery catheter

We evaluated the usefulness of patent ductus arteriosus (PDA) occlusion using a new catheter that combines good angiographic properties, easy manipulation across the duct, documentation of aortic and pulmonary artery pressure, and coil delivery for percutaneous transaortic ductal occlusion. Thirty patients (13 females and 17 males) who met the clinical and echocardiographic criteria for the percutaneous closure of PDA were catheterized. The patients selected for this study had a small to moderate PDA with a conal or tubular shape, adequate aortic ampula, and normal or mildly elevated pulmonary artery pressure. The median age was 4.8 years (range, 10 months-20 years). Patients were catheterized by the transaortic approach using the new angiographic and coil delivery catheter specially designed for this procedure. A PDA was closed in every case. A single DuctOcclud pfm coil was delivered in 28 patients, and 2 patients had NitOcclud pfm coils for ductal occlusion. The screening time was measured and found to be 50% less than the measured screening time using other catheters in our laboratory. Only one catheter and one guidewire were used per procedure, with no need for exchange wires or the establishment of an arteriovenous loop. The procedure time was also reduced by 50%. A minimal residual shunt, demonstrated by color-flow Doppler mapping, was present in 2 patients. The new combined angiographic and coil delivery catheter is most suitable for transaortic PDA coil occlusion, significantly decreasing the procedure and screening time.