Ischemia but no obstructive coronary artery disease: more than meets the eye

Symptomatic women with angina are more likely to have ischemia with no obstructive coronary arteries (INOCA) compared to men. In both men and women, the finding of INOCA is not benign and is associated with adverse cardiovascular events, including myocardial infarction, heart failure and angina hospitalizations. Women with INOCA have more angina and a lower quality of life compared to men, but they are often falsely reassured because of a lack of obstructive coronary artery disease (CAD) and a perception of low risk. Coronary microvascular dysfunction (CMD) is a key pathophysiologic contributor to INOCA, and non-invasive imaging methods are used to detect impaired microvascular flow. Coronary vasospasm is another mechanism of INOCA, and can co-exist with CMD, but usually requires invasive coronary function testing (CFT) with provocation testing for a definitive diagnosis. In addition to traditional heart disease risk factors, inflammatory, hormonal and psychological risk factors that impact microvascular tone are implicated in INOCA. Treatment of risk factors and use of anti-atherosclerotic and anti-anginal medications offer benefit. Increasing awareness and early referral to specialized centers that focus on INOCA management can improve patient-oriented outcomes. However, large, randomized treatment trials to investigate the impact on major adverse cardiovascular events (MACE) are needed. In this focused review, we discuss the prevalence, pathophysiology, presentation, diagnosis and treatment of INOCA.

The effect of the COVID-19 pandemic on revision total hip and knee arthroplasty at a large academic hospital network

We sought to quantify the impact of COVID-19 on canceled revision total joint arthroplasty (TJA) in a large academic hospital network. We performed a retrospective analysis of revision TKA and THA in a healthcare system containing 5 hospitals in a time period of 8 months prior to and 8 months after the cessation of elective surgery. We found a 30.1% decrease in revision TKA and a 6.80% decrease in revision THA. Revision TJA volume decreased in our healthcare system during COVID-19 compared to prior to the pandemic, which will likely have lasting financial and clinical ramifications for the healthcare system.

Interventional procedure plans generated by telemedicine visits in spine patients are rarely changed after in-person evaluation

BACKGROUND AND OBJECTIVES

The role of telemedicine in the evaluation and treatment of patients with spinal disorders is rapidly expanding, brought on largely by the COVID-19 pandemic. Within this context, the ability of pain specialists to accurately diagnose and plan appropriate interventional spine procedures based entirely on telemedicine visits, without an in-person evaluation, remains to be established. In this study, our primary objective was to assess the relevance of telemedicine to interventional spine procedure planning by determining whether procedure plans established solely from virtual visits changed following in-person evaluation.

METHODS

We reviewed virtual and in-person clinical encounters from our academic health system's 10 interventional spine specialists. We included patients who were seen exclusively via telemedicine encounters and indicated for an interventional procedure with documented procedural plans. Virtual plans were then compared with the actual procedures performed following in-person evaluation. Demographic data as well as the type and extent of physical examination performed by the interventional spine specialist were also recorded.

RESULTS

Of the 87 new patients included, the mean age was 60 years (SE 1.4 years) and the preprocedural plan established by telemedicine, primarily videoconferencing, did not change for 76 individuals (87%; 95% CI 0.79 to 0.94) following in-person evaluation. Based on the size of our sample, interventional procedures indicated solely during telemedicine encounters may be accurate in 79%-94% of cases in the broader population.

CONCLUSIONS

Our findings suggest that telemedicine evaluations are a generally accurate means of preprocedural assessment and development of interventional spine procedure plans. These findings clearly demonstrate the capabilities of telemedicine for evaluating spine patients and planning interventional spine procedures.

A Thoracoscopic Technique Used in Anterior Vertebral Tethering for Adolescent Idiopathic Scoliosis

Anterior vertebral tethering (AVT) is a relatively recent alternative to posterior spinal fusion for progressive curves in growing patients with idiopathic scoliosis. AVT uses a thoracoscopic approach to minimize trauma to the thoracic wall and chest cavity. There are limited technical descriptions of this method. Patients benefit from proficiency and reproducibility to allow for appropriate spinal curve correction over time. This Technical Note outlines the steps of the thoracoscopic approach to AVT and reviews the current indications for AVT over posterior spinal fusion, as well as the most recently published clinical outcomes of this procedure.

Hip Arthrography Complicated by Air Embolism in Infants: A Report of 2 Cases

CASE

We report 2 cases of infants with developmental dysplasia of the hip who underwent arthrography of the hip with use of air for structure identification, which resulted in a presumed air embolism and deep oxygen desaturation. This led to the hypothesis that there is an increased potential of air embolism in the pediatric population given the vascular anatomy of the hip.

CONCLUSION

These 2 cases document the important and not well-known complication of air embolism during air arthrography, which resulted in a change of practice for the authors. We strongly recommend against the use of air as an adjunct to routine arthrography in children.

Prognostic value of laboratory values in older patients with cervical spine fractures

OBJECTIVES

To understand the prognostic value of laboratory markers at presentation on post-treatment survival of patients 50 and older following cervical spine fracture.

PATIENTS AND METHODS

We obtained clinical data on patients 50 and older treated for cervical spine fracture in a single healthcare system (2006-2016). Our primary outcome consisted of 1-year mortality, with mortality within 3-months of presentation considered secondarily. Our primary predictors included serum glucose, serum creatinine, platelet-lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR) at presentation. We used multivariable logistic regression to adjust for confounding from sociodemographic and clinical characteristics. Point estimates and 95 % confidence intervals (CI) from the final model were refined using Bayesian regression techniques.

RESULTS

We included 1781 patients in this analysis, with an average age of 75.3 (SD 12.0). The mortality rate at 3-months was 12 % and 17 % at 1-year. In multivariable testing, neither elevated PLR or NLR were significant predictors of 1-year mortality. Elevated serum creatinine was associated with increased mortality at 1-year (OR 1.89; 95 % CI 1.30, 2.74), as was hyperglycemia (OR 1.50; 95 % CI 1.06, 2.13). Elevated serum creatinine remained influential (OR 1.64; 95 % CI 1.06, 2.54) on mortality at 3-months.

CONCLUSIONS

This is the first study to evaluate laboratory values at presentation in conjunction with survival following cervical fractures. The results can be used to help forecast natural history and in expectation management. They may also help formulate treatment plans, especially when the need for surgical intervention is not clearly defined.

Reproductive factors and Parkinson's disease risk in Danish women

BACKGROUND AND PURPOSE

Parkinson's disease is more common in men than women by a ratio of about 1.5:1 and yet there is no consensus to date as to whether female reproductive factors including hormone use affect Parkinson's disease risk. Our objective was to examine the relationship between Parkinson's disease and female reproductive factors in the largest population-based Parkinson's disease case-control study to date.

METHODS

Seven hundred and forty-three female Parkinson's disease cases diagnosed between 1996 and 2009 were selected from the Danish National Hospital Register, diagnoses confirmed by medical record review, and the cases were matched by birth year to 765 female controls randomly selected from the Danish Civil Registration System. Covariate information was collected in computer-assisted telephone interviews covering an extensive array of topics including reproductive and lifestyle factors.

RESULTS

After adjusting for smoking, caffeine and alcohol use, education, age, and family Parkinson's disease history, inverse associations between Parkinson's disease and early menarche (first period at ≤11 years), oral contraceptives, high parity (≥4 children) and bilateral oophorectomy were found; adjusted odds ratios and 95% confidence limits were respectively 0.68 (0.45-1.03) for early menarche, 0.87 (0.69-1.10) for oral contraceptives, 0.79 (0.59-1.06) for high parity and 0.65 (0.45-0.94) for bilateral oophorectomy. Little support for associations between Parkinson's disease and fertile life length, age at menopause or post-menopausal hormone treatment was found.

CONCLUSIONS

Reproductive factors related to women's early- to mid-reproductive lives appear to be predictive of subsequent Parkinson's disease risk whereas factors occurring later in life seem less important.

Frontomaxillary facial angle in fetuses with spina bifida at 11-13 weeks' gestation

OBJECTIVE

To determine whether in fetuses with open spina bifida at 11-13 weeks' gestation the frontomaxillary facial angle is decreased.

METHODS

The frontomaxillary facial angle was measured in 20 fetuses with open spina bifida and in 100 normal controls matched for crown-rump length (CRL) at 11 + 0 to 13 + 6 weeks and the values in the two groups were compared.

RESULTS

In the control group the frontomaxillary facial angle decreased significantly with CRL from a mean of 84.0 degrees at a CRL of 45 mm to 76.5 degrees at a CRL of 84 mm (SD, 3.26 degrees). In the spina bifida group the mean frontomaxillary facial angle, corrected for CRL, was 9.9 degrees lower than in the controls and it was below the 5(th) centile in 18 (90%) of the cases (P < 0.0001).

CONCLUSIONS

In fetuses with open spina bifida at 11-13 weeks' gestation the frontomaxillary facial angle is decreased and this measurement may be useful in early screening for this abnormality.

First-trimester trisomy screening: nuchal translucency measurement training and quality assurance to correct and unify technique

OBJECTIVE

To describe the process of training for measuring nuchal translucency at five clinical centers in North America and to evaluate methods of quality assurance and feedback.

DESIGN

Throughout a period of 18 months, the performance of sonographers in measuring fetal nuchal translucency was monitored using qualitative and quantitative methods of review. After 12 months, different approaches (written and personal feedback) were used to inform sonographers of technical aspects that needed to or could be improved.

RESULTS

On initial qualitative review, discrepancies in judgment from different reviewers coincided with suboptimal magnification, failure to visualize the amniotic membrane and/or use of cross-shaped calipers. At subsequent global review, 13 (29%) images of nuchal translucency measurements were considered unacceptable. Quantitative assessment revealed that, during the first part of the study, the means from four sonographers were significantly smaller and the mean from the fifth sonographer was significantly larger than expected on the basis of findings from The Fetal Medicine Foundation (P < 0.0001). Following feedback, sonographers who underestimated nuchal translucency and who received a written report only did not change measurements overall (P = 0.9759). In contrast, those who received additional intervention showed a marked difference (P < 0.0001).

CONCLUSIONS

Global qualitative review of images from one sonographer may be preferable to assessment of individual aspects of images. Results from global qualitative review correspond well with findings from quantitative analysis, indicating that the latter can be applied for ongoing audit. Observation of divergent results should prompt extensive personal feedback, rather than a written report, to prevent sonographers from settling in their own, inappropriate technique.

Fetal echogenic bowel: parameters to be considered in differential diagnosis

OBJECTIVES

To evaluate the extent that associated findings aid in the differential diagnosis and/or prognosis of fetal echogenic bowel.

METHODS

Medical history, obstetric records and outcome details were examined for 131 consecutive pregnancies with fetal hyperechogenic bowel.

RESULTS

In 62 (47%) cases, there were no visible anomalies other than hyperechogenic bowel and no evidence of growth restriction. This group included four (7%) pregnancies with Down syndrome, 15 (24%) with infection or a recent episode of influenza and eight (13%) with blood staining of amniotic fluid. In the remaining 69 (53%) cases, hyperechogenic bowel was accompanied by hydrops or nuchal edema (n = 16, 12.2%), growth restriction (n = 9, 6.9%), other markers for chromosome anomalies (n = 33, 25.2%) or multiple structural anomalies (n = 11, 8.4%). In this group, the prevalence of Down syndrome was 12%, infection or influenza was reported in 14 (20%) cases and there was blood staining of amniotic fluid in seven (10%). Cystic fibrosis screening was performed in 65 (50%) pregnancies; the results were negative in all cases and clinical assessment did not indicate cystic fibrosis in any of the 91 infants who were born alive. Maternal serum screening was performed in 41 (31%) pregnancies. High alpha-fetoprotein levels were associated with multiple abnormalities or severe growth restriction.

CONCLUSIONS

In many pregnancies with fetal hyperechogenic bowel, there are multiple factors that may explain these findings. Thus identification of one potential underlying cause should not preclude further testing. Once chromosome defects, cystic fibrosis, structural abnormalities, infection and growth restriction have been excluded, parents can be counseled that the prognosis is good, irrespective of the presence or absence of blood stained amniotic fluid.

Femur length and trisomy 21: impact of gestational age on screening efficiency

OBJECTIVE

This study assesses two methods used to define relatively short femur in screening for trisomy 21 and examines changes in performance of screening with gestational age.

DESIGN

Retrospective analysis of data on menstrual age, femur length (FL) and biparietal diameter (BPD) in 49 trisomy 21 pregnancies and 6069 normal controls. Reference ranges were derived for BPD/FL versus menstrual age and for FL versus BPD. Two methods of defining short femur (BPD/FL and observed-to-expected FL ratio) were examined for false-positive rates and detection rates for trisomy 21 at different gestational ages.

RESULTS

In the control group the BPD/FL ratio and its standard deviation decreased with menstrual age. Trisomy 21 was associated with a significantly higher BPD/FL ratio (P < 0.001) and the deviation increased significantly with menstrual age (P < 0.05). Eleven percent of 28 fetuses examined at 15-17 weeks had a BPD/FL above the 95th centile compared with 24% of 21 fetuses examined at 18-20 weeks (P = 0.40). The median observed-to-expected FL ratio in the control group was 1.0 throughout the gestational age range but the standard deviation decreased significantly with menstrual age (P < 0.01). Trisomy 21 was associated with a significantly reduced observed-to-expected FL ratio (P < 0.001) and the deviation increased significantly with menstrual age (P < 0.05). A fixed cut-off of 0.91 for observed-to-expected FL ratio provided a false-positive rate of 12% at 15-17 weeks compared with 6% at 18-20 weeks of gestation (P < 0.001) with detection rates of 29 and 38%, respectively (P = 0.73).

CONCLUSION

Irrespective of the definition used to define the condition, relatively short femur is a poor marker for trisomy 21 particularly when the assessment takes place before 18 weeks of gestation.

The use of chorionic villus biopsy catheters for saline infusion sonohysterography

BACKGROUND

Saline infusion sonohysterography is one of the recent refinements of ultrasonography that has the ability to enhance imaging of the uterine cavity in a safe, inexpensive and expedient manner. The technique can be difficult in women with a stenotic cervical os. This report describes a single-pass technique using chorionic villus sampling (CVS) catheters for saline infusion sonohysterography.

METHOD

Saline infusion sonohysterography requires the transcervical passage of a catheter, through which saline is infused. The subsequent distension of the uterine cavity enhances the ability to detect intrauterine pathology with ultrasonography. In women with cervical stenosis, a catheter can be used in place of the more conventional two-pass technique, which requires the use of a uterine sound or probe followed by a conventional catheter.

EXPERIENCE

We have used CVS catheters in women with cervical stenosis on 12 occasions. All have been successful and without significant discomfort to the patient.

CONCLUSION

The use of CVS catheters for saline infusion sonohysterography in women with cervical stenosis can alleviate the need to remove the cervical probe prior to introduction of the catheter.

Culture results in open wound treatment with muscle transfer for tibial osteomyelitis

Fifty-three patients who underwent a two-staged protocol of debridement and muscle flap coverage for chronic osteomyelitis of the tibia between 1991 and 1996 were evaluated. All patients underwent a thorough debridement of all nonviable tissue and bone at initial debridement. Multiple cultures were taken, including aerobic, anaerobic and fungal cultures from the pus, soft tissue, bone curettings and bone. All patients were treated with open wound management and dressing changes. Between 2 to 7 days, median 4 days, all patients underwent a second debridement with a complete set of identical cultures, and immediate soft tissue muscle transfer. There were 42 free vascularized and 11 local tissue transfers. The 53 patients were classified according to the Cierny-Mader classification for chronic osteomyelitis. Twenty-four patients had Stage IVA osteomyelitis, 10 patients had Stage IIIA osteomyelitis, nine patients had Stage IIIB osteomyelitis, eight patients had Stage IVB osteomyelitis, one patient had Stage IA osteomyelitis, and one patient had Stage IIB osteomyelitis. All 53 patients had positive cultures at the time of their initial debridement, and 14 of 53 (26%) had a positive culture at the time of the second debridement. Based on the results, it seems from a bacteriologic stand-point that the second debridement allows for the opportunity for redebridement and wound sterilization of organisms that still may be present.

Knowledge-based expert systems for toxicity and metabolism prediction: DEREK, StAR and METEOR

It has long been recognised that the ability to predict the metabolic fate of a chemical substance and the potential toxicity of either the parent compound or its metabolites are important in novel drug design. The popularity of using computer models as an aid in this area has grown considerably in recent years. LHASA Limited has been developing knowledge-based expert systems for toxicity and metabolism prediction in collaboration with industry and regulatory authorities. These systems, DEREK, StAR and METEOR, use rules to describe the relationship between chemical structure and either toxicity in the case of DEREK and StAR, or metabolic fate in the case of METEOR. The rule refinement process for DEREK often involves assessing the predictions for a novel set of compounds and comparing them to their biological assay results as a measure of the system's performance. For example, 266 non-congeneric chemicals from the National Toxicology Program database have been processed through the DEREK mutagenicity knowledge base and the predictions compared to their Salmonella typhimurium mutagenicity data. Initially, 81 of 114 mutagens (71%) and 117 of 152 non-mutagens (77%) were correctly identified. Following further knowledge base development, the number of correctly identified mutagens has increased to 96 (84%). Further work on improving the predictive capabilities of DEREK, StAR and METEOR is in progress.

Facilitating edema resolution with a foot pump after calcaneus fracture

OBJECTIVES

To determine whether the use of a foot pump (intermittent pneumatic pedal compression device) in patients with excessive edema precluding surgery after acute fracture of the calcaneus leads to more rapid resolution of the edema.

DESIGN

Prospective randomized setting. Standard hospital in-patient ward at a Level I trauma center.

PATIENTS

Those patients with excessive edema precluding operative intervention upon admission after an intraarticular calcaneus fracture who signed an informed consent participated in the study. Twenty-eight patients were enrolled and completed the study: thirteen patients in the foot pump group and fifteen patients in the control group.

INTERVENTION

In the control group, patients had a bulky compression dressing, posterior splint, and elevation while awaiting surgery. In the study group, the patients had a foot pump applied to the foot with a posterior splint and elevation while awaiting surgery.

MAIN OUTCOME MEASUREMENTS

The volumetric change of the foot at twenty-four-hour intervals for up to seventy-two hours in both the control and study groups.

RESULTS

All thirteen patients tolerated the foot pump. The differences in the volume between Day I (baseline) and Day 2 for the foot pump and control groups were minus forty and plus seventy-six milliliters, respectively (p = 0.02). Between Days 1 and 3, the differences were minus ninety-six milliliters for the foot pump group and plus thirty-seven milliliters for the control group (p = 0.02).

CONCLUSIONS

A significant progressive decrease in the foot volume was noted during the first forty-eight hours after application of the foot pump in patients with excessive edema precluding operative fixation of a calcaneus fracture upon presentation. The pump was well tolerated by all the patients in the study group. Thus, we believe the pump serves as a useful adjunct in the preoperative edema resolution following these complicated fractures.

Three-dimensional ultrasonography in obstetrics and gynecology: preliminary experience

OBJECTIVE

Technologic advances in ultrasonographic imaging have revolutionized the management of women's health care. We recently began to evaluate the clinical applications of three-dimensional ultrasonography.

STUDY DESIGN

This study prospectively evaluated 161 obstetric and gynecologic patients. Both two- and three-dimensional imaging data were acquired from real-time ultrasonography. Three orthogonal planes were displayed on a monitor and were used to create the rendered three-dimensional images.

RESULTS

To date, 201 three-dimensional ultrasonographic studies have been performed, 165 transabdominally and 36 transvaginally. Transabdominally, an average of eight acquisitions per patient were obtained. Of the clinically suspected abnormalities, 29 of 32 (91%) were confirmed by three-dimensional imaging. Three of 32 (9%) improved the diagnostic capabilities or changed the diagnosis. Of the 36 transvaginal studies, an average of four acquisitions per patient were done. Thirty (83%) of these patients had suspected abnormalities and all were confirmed.

CONCLUSIONS

Three-dimensional ultrasonographic imaging appears to be highly promising in the clinical setting.

In vitro elution of tobramycin and vancomycin polymethylmethacrylate beads and spacers from Simplex and Palacos

In vitro studies of antibiotic elution from polymethylmethacrylate cement comparing Simplex (Howmedica, Rutherford, NJ) with Palacos brands (Richards, Memphis, TN) have shown variable results. This study compares the elution of tobramycin and vancomycin from Simplex and Palacos beads and spacers. Six-millimeter beads and spacers were incubated in phosphate-buffered saline, and the solution was sampled and changed daily until the concentration of antibiotic fell below the minimum inhibitory concentration (MIC) for Staphylococcus aureus. In all groups, the Palacos PMMA beads and spacers showed elution at higher levels and remained above the MIC longer than did the Simplex PMMA beads. Tobramycin had superior elution to vancomycin in all groups. This in vitro study shows that Palacos PMMA has superior elution properties to Simplex PMMA in tobramycin and vancomycin beads and spacers.