Focal magnetic coil stimulation reveals motor cortical system reorganized in humans after traumatic quadriplegia

A figure of '8' magnetic coil (MC) was used to stimulate focally the motor cortex of two adult, traumatic quadriplegics and three normal adults. The two patients were injured approximately 2 years previously and had intense physiotherapy, including biofeedback training of biceps and deltoid muscles, respectively, which were the most caudal muscles spared. The focal MC elicited compound motor action potentials (CMAPs) from these muscles from a much wider area of scalp than in the normal subjects. Latency of biceps and deltoid CMAPs were inversely related to CMAP amplitude. A reorganization of the motor cortical projection system is inferred, in which areas normally eliciting digit movements instead activate muscles in quadriplegics just above the spinal level. The reorganization applies also to the central sense of movement normally elicited by focal frontal cortex stimulation. Possible mechanisms of the reorganization and an implication for rehabilitation are discussed.

Absence of HIV infection in blood donors with indeterminate western blot tests for antibody to HIV-1

To determine whether apparently healthy persons who have had repeatedly reactive enzyme immunoassays and an indeterminate Western blot assay for antibody to the human immunodeficiency virus type 1 (HIV-1) are infected with HIV-1 or HIV-2, we studied 99 such volunteer blood donors in a low-risk area of the country. The subjects were interviewed about HIV risk factors. Coded blood specimens were tested again for HIV-1 antibody (by two different enzyme immunoassays, a Western blot assay and a radioimmunoprecipitation assay) and for HIV-2 antibody by enzyme immunoassay, for HIV-1 by the serum antigen test, for HIV-1 by culture, for human T-cell leukemia virus Type I or II antibody by enzyme immunoassay, and for sequences of HIV DNA by the polymerase chain reaction. Of the 99 blood donors, 98 reported no risk factors for HIV-1 infection; 1 donor had used intravenous drugs. After a median of 14 months (range, 1 to 30) from the time of the initial test, 65 subjects (66 percent) were still repeatedly reactive for HIV-1 antibody on at least one immunoassay. In 91 subjects (92 percent) the Western blot results were still indeterminate, whereas in 8 they were negative. No donor met the criteria for a positive Western blot assay for HIV-1, and none had evidence of HIV-1 or HIV-2 infection on culture or by any other test. We conclude that persons at low risk for HIV infection who have persistent indeterminate HIV-1 Western blots are rarely if ever infected with HIV-1 or HIV-2.

A new method using neuromagnetic stimulation to measure conduction time within the cauda equina

Using principles derived from electric field measurements and studies of phrenic nerve in vitro, neuromagnetic stimuli in humans were predicted to excite selective low threshold sites in proximal and distal cauda equina. Physical models, in which induced electric fields were recorded in a segment of human lumbosacral spine immersed in a saline filled tank, supported this prediction. Conclusions from the model were tested and confirmed in normal human subjects. Ipsilateral motor evoked potentials were elicited in lower limb muscles and striated sphincters by magnetic coil (MC) stimulation of both proximal and distal cauda equina. Over proximal cauda equina a vertically oriented MC junction and cranially directed induced current elicited a newly identified compound muscle action potential (CMAP). The F response latency and lack of attenuation when the target muscle was vibrated suggest that the proximal response is a directly elicited M response arising near or at the rootlet exit zone of the conus medullaris. Over distal cauda equina, lumbar roots were optimally excited by a horizontally oriented MC junction, and sacral roots by an approximately vertically oriented MC junction, eliciting CMAPs with similar appearance but shorter latency consistent with the known intrathecal lengths of the lower lumbar and sacral nerve roots. The induced current was usually most effective when directed towards the spinal fluid filled thecal sac. Normal subjects showed stable CMAP onset latencies elicited at proximal and distal cauda equina despite wide variation in amplitude. Thus, cauda equina conduction time can be directly calculated. This new method may improve the detection and classification of peripheral neuropathies affecting lower limbs and striated sphincters.

In vitro evaluation of a 4-leaf coil design for magnetic stimulation of peripheral nerve

The performance of a 4-leaf magnetic coil was evaluated during magnetic stimulation of a peripheral nerve in vitro. The site of stimulation was below the coil center, and a 90 degrees rotation of the coil was equivalent to a change in current polarity. A hyperpolarizing magnetic stimulus failed to slow or block a propagating action potential.

U.S. Attending Anesthesiologist Burnout in the Postpandemic Era

BACKGROUND

Anesthesiologists are experiencing unprecedented levels of workplace stress and staffing shortages. This analysis aims to assess how U.S. attending anesthesiologist burnout changed since the onset of the COVID-19 pandemic and target well-being efforts.

METHODS

The authors surveyed the American Society of Anesthesiologists' U.S. attending anesthesiologist members in November 2022. Burnout was assessed using the Maslach Burnout Inventory Human Services Survey with additional questions relating to workplace and demographic factors. Burnout was categorized as high risk for burnout (exhibiting emotional exhaustion and/or depersonalization) or burnout syndrome (demonstrating all three burnout dimensions concurrently). The association of burnout with U.S. attending anesthesiologist retention plans was analyzed, and associated factors were identified.

RESULTS

Of 24,680 individuals contacted, 2,698 (10.9%) completed the survey, with 67.7% (1,827 of 2,698) at high risk for burnout and 18.9% (510 of 2,698) with burnout syndrome. Most (78.4%, n = 2,115) respondents have experienced recent staffing shortages, and many (36.0%, n = 970) were likely to leave their job within the next 2 yr. Those likely to leave their job in the next 2 yr had higher prevalence of high risk for burnout (78.5% [760 of 970] vs. 55.7% [651 of 1,169], P < 0.001) and burnout syndrome (24.3% [236 of 970] vs. 13.3% [156 of 1,169], P < 0.001) compared to those unlikely to leave. On multivariable analysis, perceived lack of support at work (odds ratio, 9.2; 95% CI, 7.0 to 12.1), and staffing shortages (odds ratio, 1.96; 95% CI, 1.57 to 2.43) were most strongly associated with high risk for burnout. Perceived lack of support at work (odds ratio, 6.3; 95% CI, 3.81 to 10.4) was the factor most strongly associated with burnout syndrome.

CONCLUSIONS

Burnout is more prevalent in anesthesiology since early 2020, with workplace factors of perceived support and staffing being the predominant associated variables. Interventions focused on the drivers of burnout are needed to improve well-being among U.S. attending anesthesiologists.

EDITOR’S PERSPECTIVE

Gender differences in cutaneous melanoma: Demographics, prognostic factors, and survival outcomes

Several recent studies have reported a considerably higher overall survival (OS) rate in females in various geographic regions This study further investigates the characteristics of melanoma that contribute to OS of women residing in the United States. Chi-square, Kaplan-Meier, and Cox regression models were used to analyze differences in demographics, treatment, and survival of invasive cutaneous melanoma in men and women diagnosed from 2004 to 2016 in the National cancer database. In 316 966 patients met inclusion criteria. Men had a significantly higher median age of diagnosis at 61 years (interquartile range or IQR: 51-72) in comparison to women where the median age of diagnosis was 55 years (IQR: 43-68) (P < .0001). The most common primary site for men was the trunk (35.5%), whereas the lower extremities were the most common primary site for women (30.3%). Women had a higher 5 year (82.6%) and 10 year (73.1%) OS compared to 5 year and 10 year OS of 72.2% and 58.7%, respectively, in men (P < .0001). When adjusting for confounders, female gender was independently associated with improved OS (ref: male HR = 0.791; 95% confidence interval 0.773-0.809; P < .0001). Overall, we conclude that female gender is an independent favorable prognostic factor for melanoma survival.

The use of a cap-shaped coil for transcranial magnetic stimulation of the motor cortex

A cap-shaped coil is introduced as a superior design for inducing transcranial magnetic motor evoked potentials for spinal cord monitoring. Evaluation of the magnetic characteristics of the cap coil showed higher induced electrical fields at and below the depth of the cortical surface, compared to a 9-cm, butterfly-shaped coil. Twenty normal adults were stimulated with the cap coil and a 9-cm round coil in three positions. Compound muscle action potentials were recorded from the left and right abductor digiti minimi and anterior tibialis muscles. The cap coil induced potentials with higher intensities and lower variability between consecutive stimuli. The cap coil was also more able to simultaneously induce motor evoked potentials from the four muscles studied. This coil design should provide superior means of inducing transcranial magnetic motor evoked potentials in multiple muscles.

Trends in Female Plastic Surgery Resident Authorship - Signs of Changing Times?

OBJECTIVE

Gender discrepancies exist in academia for leadership positions, advancement opportunities, and research. As of 2019, the ratio of total male-to-female attending plastic and reconstructive surgeons was 4.8:1. However, the ratio of male-to-female residents in integrated plastic surgery programs fell to 1.3:1, indicating rising female representation. With more balanced gender distributions of residents, the authors sought to determine whether this translates to greater equality of opportunities and achievements. Specifically, this study compares the academic productivity of male and female integrated plastic surgery residents.

METHODS

A list of integrated plastic surgery residency programs was obtained from the Accreditation Council for Graduate Medical Education website and ranked by reputation using the Doximity Residency Navigator. Integrated plastic surgery residents from 2019 to 2020 were identified via program websites and social media accounts. Works published during residency were identified through PubMed and Scopus from July 1 of each resident's intern year through August 10, 2020. Demographic variables for residents, including training class and medical school, as well as for programs, including geographic region, Doximity ranking, and medical school affiliation, were collected. Medical schools were ranked according to US News by research. Research productivity was assessed through the number of total research articles with authorship position (first, second, or last), the number of articles published in plastic surgery journals with the highest impact factors (Plastic and Reconstructive Surgery and Aesthetic Surgery Journal), and H-indices. Chi-Squared tests and Mann-Whitney U-tests were used to make comparisons between male and female residents (α = 0.05).

RESULTS

In total, 931 residents in 81 integrated plastic surgery programs were identified, including 534 (57.4%) male and 397 (42.6%) female residents. There were no differences between male and female residents in terms of training year or program geography. Female residents were more likely to come from a top-50 medical school than males (54.7% vs. 48.1%, p = 0.049). There were no significant differences in gender distribution of residents from top-20 programs or programs affiliated with a top-20 medical school. The median (IQR) number of publications in total, and for each gender, was 3 (1-6). There was no difference in the number of total publications by training year by gender, besides the second-year resident class where male residents had a median (IQR) of 2 (1-4) compared to 1 (0-3) (p = 0.028). Male and female residents did not differ with regards to authorship position or proportion of times publishing in top journals. The distribution of H-indices for male residents was slightly higher than female residents (p = 0.003), but the median (IQR) was the same at 3 (1-5).

CONCLUSIONS

Currently, male and female integrated plastic surgery residents have similar levels of academic productivity. This suggests that female representation is slowly increasing along the pipeline in academia, representing a paradigm shift from previous trends of gender inequality in plastic surgery.

The Medical Student Race to Research: Who Presents More at National Plastic Surgery Conferences?

BACKGROUND

presentations increase research output and facilitate networking for medical students applying to plastic surgery. We aim to determine predictors of increased medical student presentation at national plastic surgery conferences, identifying disparities in access to research opportunities.

METHODS

Abstracts presented at the 2 most recent meetings of the American Society of Plastic Surgeons, American Association of Plastic Surgeons, and Plastic Surgery Research Council were extracted from online archives. Presenters without MDs or other professional credentials were classified as medical students. Presenter gender, medical school ranking, plastic surgery division/department, National Institutes of Health funding, number of total and first-author publications, H-index, and research fellowship completion status were recorded. Students with 3 or more (>75th percentile) presentations were compared with those with less by χ2 tests. Univariate and multivariable regressions identified factors associated with 3 or more presentations.

RESULTS

Of 1576 abstracts, 549 (34.8%) were presented by 314 students. The gender distribution was 46.5% male and 53.5% female. Most were from the Northeast (36.9%), 35% came from top 20 medical schools, and 85% attended schools with home plastic surgery programs. While 61.8% presented once, 14.6% presented 3 or more times. Those who previously presented, completed research fellowships or had more publications or higher H-indices were likely to present more ( P ≤ 0.007). On multivariable-adjusted analysis, completing research fellowships (odds ratio [OR], 2.34-2.52; P = 0.028-0.045), affiliation with institutions having higher National Institutes of Health funding (OR, 3.47-3.73; P = 0.004-0.006), or having more total number of publications (OR, 3.81; P = 0.018) or first-author publications (OR, 3.84; P = 0.008) was associated with 3 or more presentations. Presenter gender, geographic region, medical school ranking, home program status, and H-indices were not significant predictors on multivariable analysis.

CONCLUSIONS

There are several potential inequities in access to research opportunities for medical students, disadvantaging those with less well-funded plastic surgery programs and existing research experience. Improving the equitability of these opportunities is crucial for limiting bias in trainee recruitment and diversifying representation in the field.

Comparison of mortality and medical complications between older and younger malignant melanoma inpatients

Previous studies have identified older age as a negative prognostic factor in malignant melanoma patients. To compare comorbidities, medical complications, and inpatient mortality between younger and older malignant melanoma inpatients. All adult patient encounters with a diagnosis of cutaneous malignant melanoma were identified using the 2003 to 2012 National Inpatient Sample database. Concurrent comorbidities and inpatient medical complications were queried. Comparisons were made between older and younger adults, defined as ≥65 years and 18 to 64 years, respectively. In total, 8153 patient encounters were identified in the database (51.6% older and 48.4% younger). Older adults had a higher prevalence of numerous comorbidities, including chronic pulmonary disease, chronic renal failure, congestive heart failure, diabetes mellitus, hypertension, hypothyroidism, peripheral vascular disease, and pulmonary circulation disorder (P < .001). In contrast, younger adults were more likely to have obesity (P < .001) and coagulopathy (P = .005). On multivariable analysis of medical complications, older adult inpatients were more likely to experience urinary tract infection (OR = 1.54, P = .021), but less likely to experience acute respiratory failure (OR = 0.46, P = .012) and venous thromboembolism (OR = 0.44, P = .026). Notably, inpatient mortality did not significantly differ. Older adult inpatients with malignant melanoma have different comorbidities than younger patients and have a larger overall comorbidity burden. Surprisingly, however, the odds of most inpatient medical complications and mortality were found to be similar in younger vs older patients.

Medical Weight-Loss Outcomes in Patients Receiving Concomitant Psychotropic Medication: A Retrospective Cohort Study

OBJECTIVE

This study aimed to elucidate medical weight-loss outcomes in patients unexposed or exposed to psychotropic medication(s).

METHODS

This retrospective cohort study evaluated weight-loss outcomes of completers treated at an academic weight-management center between April 1, 2014, and April 1, 2016. Patients were classified as either unexposed (not prescribed psychotropic medication) or exposed (prescribed psychotropic medication) based on use of antidepressants, mood stabilizers, or antipsychotics during the study.

RESULTS

Of 1,932 patients seen during the study period, 885 were eligible for inclusion, of whom 619 (70.0%) were unexposed and 266 (30.0%) were exposed to psychotropic medications. In the unexposed and exposed groups, the mean age, sex distribution, proportion with type 2 diabetes, initial BMI, and number of weight-loss medications prescribed were similar. At 12 months, the unexposed group lost 1.6% more weight on average than the exposed group (9.1% [SD 7.6%] vs. 7.5% [SD 8.1%], respectively; P = 0.02); 71.0% and 41.2% of the unexposed group achieved ≥ 5% and ≥ 10% weight loss at 12 months, respectively, compared with 63.1% and 31.8% in the exposed group at 12 months (P = 0.04 at 5%; P = 0.02 at 10%).

CONCLUSIONS

Exposure to psychotropic medications was associated with diminished weight loss in patients with medically managed overweight and obesity.

Global Cardiac Anesthesia Workforce Assessment: A Cross-Sectional Observational Survey Study

OBJECTIVE

The primary aim of this survey was to assess the demographics, training background, practice setting, and work environment of cardiac anesthesiologists globally.

DESIGN

Cross-sectional study of the global cardiac anesthesia workforce. A multilingual web-based survey was conducted between June 1 and December 31, 2023.

SETTING

The survey was distributed via cardiac anesthesia societies, special interest groups, and social media using a non-probabilistic sample and with snowballing techniques.

PARTICIPANTS

Anesthesiologists actively practicing cardiac anesthesia.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In total, 3,430 participants from 99 countries responded. Results were summarized as descriptive data comparing geographical regions, and noticeable differences for individual countries were assessed. Most of the workforce (85.9%, n = 2,913/3,390) that responded to the survey were between 31 and 60 years of age. Australia/New Zealand/Oceania (51.1%, n = 48/94) and Asia (45.2%, n = 606/1,341) had the largest percentages of respondents working in the above 50 years of age group. Globally, 48.4% (n = 1,347/2,780) of respondents reported having completed an accredited adult cardiac fellowship, and 42.7% (n = 918/2,148) replied to have had only informal training "on the job." When it comes to transesophageal echocardiography, 44.6% (n = 1,240/2,780) of the global workforce reports not having had any formal training. Large differences in training background were noticed by country and region. Most of the workforce (43.3%, n = 1,149/2,652) indicated working between 41 and 60 hours per week. However, more than one of four (26.8%, n = 711/2,652) cardiac anesthesiologists work between 61 to 80 hours, and one out of ten (10.5%, n = 279/2,652) has a workload of more than 81 hours per week. A majority (68%, n = 1,778/2,609) of cardiac anesthesiologists evaluated their compensation/salary as less than adequate or just adequate but not enough to save for retirement. Regarding work-life balance, there was a significant variation in how practitioners assessed their personal situations. Almost half (46.3%, n = 1,185/2,560) of the workforce consider making changes to reduce their workload, and only 23.1% (n = 592/2,560) evaluated their work-life balance as just right. A validated, non-proprietary single-question item assessing emotional exhaustion as one of the three established criteria for burnout was incorporated into the survey. The overall prevalence of burnout, i.e. emotional exhaustion, among cardiac anesthesiologists was 31.7% (n = 827/2,609). In the regression analysis, an increase in clinical work hours (OR = 1.28; CI [1.16, 1.42]; p < 0.001), the number (OR = 1.05; CI [1.02, 1.08]; p < 0.001) and type (OR =1.09; CI [1.0, 1.19]; p = 0.03) of cardiac call, all increased the odds for burnout. Compared to taking all cardiac call in the hospital, taking no cardiac call at all, significantly decreased the risk for burnout. Similarly, compared to compensation that was perceived as less than adequate, i.e., even needing a second income, higher compensation assessment was associated with an increasingly lower risk for burnout. Other factors mitigating burnout risk include older age groups (OR = 0.78; CI [0.67, 0.90]; p < 0.001), and a more positive outlook on work-life balance (OR = 0.88; CI [0.85, 0.92]; p < 0.001). The geographical region had a small but significant association with burnout (OR 1.12; CI [1.06, 1.18]; p < 0.001). Asia, as the geographical region of practice, had the highest odds for burnout overall (41.3%, n = 342/829) and also the most respondents (15.6%, n = 129/829) in the highest answer option category, i.e., feeling completely burned out.

CONCLUSIONS

A global survey of the cardiac anesthesia workforce found inconsistency in the training, job satisfaction, and daily practice of cardiac anesthesiologists. The rate of burnout was high, and many respondents would like to make work-related changes to improve work-life balance.

The impact of diabetes mellitus on medical complication and mortality rates among inpatients with bullous pemphigoid

BACKGROUND

There is currently limited population-based data on the effect of type 2 diabetes mellitus (T2DM) on bullous pemphigoid (BP) inpatients.

AIMS

To evaluate the relative comorbidities, medical complications, and mortality rates between BP inpatients with and without T2DM.

METHODS

All inpatients with a primary BP diagnosis in the National Inpatient Sample from 2003 to 2012 were queried. BP inpatients with or without T2DM were compared to identify disparities in relative comorbidities and medical complications. Comorbidities were established using the Agency for Healthcare Research and Quality standardized values. Medical complications were classified using ICD-9 codes.

RESULTS

Of the 1978 BP patients identified, 660 (33.4%) had a concurrent diagnosis of T2DM. These patients had significantly higher rates of concurrent comorbidities, including chronic renal failure, congestive heart failure, iron deficiency anemia, hypertension, obesity, and peripheral vascular disease. On bivariate analysis, T2DM patients also had significantly higher rates of medical complications including acute kidney injury (14.5% vs. 10.1%, p = 0.004) and venous thromboembolism (1.8% vs. 0.5%, p = 0.012). On multivariable-adjusted analysis, the odds of venous thromboembolism (OR = 3.01, p = 0.027) remained increased. Inpatient mortality did not differ between the groups.

CONCLUSIONS

Our findings suggest that BP inpatients with T2DM have a greater medical comorbidity and complication burden. However, inpatient mortality was not increased.

Social determinants of health and outcomes of ventral hernia repair in a safety-net hospital setting

PURPOSE

Lower socioeconomic status has been shown to be predictive of poorer surgical outcomes in ventral hernia repair. Recently, safety-net hospitals have been attempting to address these disparities to improve the care of patients of lower socioeconomic status.

METHODS

A query of all patients undergoing ventral hernia repair at our institution between 2010 and 2019 was completed (n = 580). Patients not from identifiable New Jersey ZIP-codes were excluded (n = 572). ZIP codes were assigned quartiles based off socioeconomic variables including median household income, percent below poverty line, and high school graduation rate. Patients were then assigned to socioeconomic status quartiles based off their residential ZIP-code. Outcomes of ventral hernia surgery were compared across ZIP-code quartiles. Logistic regression was used to analyze predictors of poor outcomes.

RESULTS

Patients from lower socioeconomic brackets were more likely to be younger (p < 0.001), female (p = 0.014), black (p < 0.001), and/or Hispanic (p = 0.003). Most notably, outcomes of ventral hernia were not significantly different between patients of different socioeconomic status ZIP-code quartiles. The risk of any post-operative morbidity was higher for longer procedures (p < 0.001) and for hernia repairs being done with other procedures (p < 0.001). Risk of prolonged length of stay and related 30-day readmission was higher with longer procedures (p < 0.001 and p = 0.003, respectively).

CONCLUSION

We found that outcomes of ventral hernia repair at a safety-net hospital were unaffected by socioeconomic status. This supports the important role that safety-net institutions play in providing quality care to their vulnerable populations. Future studies at other safety-net hospitals should be done to further assess the updated impact of socioeconomic status on ventral hernia outcomes.

Evaluation of Complication Rates of Free Flap Reconstruction in Pediatric Patients

Introduction

While there is extensive literature investigating surgical outcomes in free flaps for adults, there is a dearth of information on the efficacy of flap use in the pediatric population. This study is the first to measure complication rates following pediatric free flap reconstruction on a national level.

Methods

All pediatric free flap cases between 2012 and 2018 were identified and stratified by type of flap using current procedural terminology codes assigned to the primary procedure in the National Surgical Quality Improvement Program database. Each entry included the recipient location of the flap, postoperative complications, and demographics. Chi-square analysis was used to compare complication rates across various flap groupings. In addition, univariate and multivariate analyses were used to identify independent predictors of flap complications or failure.

Results

Multivariate regression analysis demonstrated that compared to bone flaps, there is increased risk of nonbleeding complications in skin (Odds Ratio (OR) =7.7, P = 0.029), muscle (OR = 10.6, P = 0.012), and osteocutaneous flaps (OR = 10.8, P = 0.018). Flap of the trunk (OR = 40.9, P = 0.003) and upper extremities (OR = 32.9, P = 0.041) had a higher odds of bleeding complications compared to head-and-neck flaps. Regression analysis also showed that older age is associated with bleeding complications, with patients aged 5-11 years (OR = 38.5, P = 0.027) and 12-17 years (OR = 30.6, P = 0.038) having greater rates compared to patients under the age of 2. The pediatric flap reoperation rate was found to be 3.6%-4.7%, with the highest flap anastomotic complication rate in the head-and-neck region (6.9%-8.0%).

Conclusion

Free flap reconstruction across flap type, anatomic location, and age ranges are safe and efficacious in the pediatric population.

Survival Predictors of Head and Neck Burkitt's Lymphoma: An Analysis of the SEER Database

OBJECTIVE

To analyze population-level data for Burkitt's lymphoma of the head and neck.

STUDY DESIGN

Retrospective study of a national cancer database.

SETTING

Academic medical center.

METHODS

The SEER database (Surveillance, Epidemiology, and End Results) identified all patients with primary Burkitt's lymphoma of the head and neck from 1975 to 2015. Demographic, clinicopathologic, and treatment characteristics were analyzed. Multivariable Cox regressions analyzed factors associated with survival while controlling for baseline differences.

RESULTS

A total of 920 patients with a mean (SD) age of 37.6 years (25.0) were identified. A majority of patients were White (82.8%) and male (72.3%). The most primary common sites included the lymph nodes (61.3%), pharynx (17.7%), and nasal cavity/paranasal sinuses (5.2%). The majority of patients received chemotherapy (90.5%), while fewer underwent surgery (42.1%) or radiotherapy (12.8%). Choice of treatment differed significantly among patients of different ages, year of diagnosis, primary site, nodal status, and Ann Arbor stage. Overall 10-year survival was 67.8%. On multivariable Cox regression, patients with older age (hazard ratio [HR], 1.05 per year; P < .001) and higher stage at presentation had increased risk of mortality (P < .001). Furthermore, cases diagnosed between 2006 and 2015 (HR, 0.35; P < .001) and 1996 and 2005 (HR, 0.53; P = .001) had lower mortality when compared with those diagnosed between 1975 and 1995. Treatment including surgery and chemotherapy tended to have the best survival (P < .001).

CONCLUSION

Burkitt's lymphoma of the head and neck diagnosed in more recent years has had improved survival. Factors significantly associated with survival include age, Ann Arbor stage, and treatment regimen. Treatment including surgery and chemotherapy was associated with the highest survival.

Perioperative considerations for cancer patients with obesity: A narrative review

Cancer in patients with obesity has become increasingly common throughout much of the world. Based on our experiences in a specialized cancer center, we have developed a set of standards and expectations that should streamline the surgical journey for this patient population. These recommendations should inform the perioperative management of oncology patients with obesity and help raise awareness of this critical and under-discussed topic.

Perioperative gabapentin usage in pediatric patients: A scoping review

BACKGROUND

There has been a recent focus among anesthesiologists on reducing the use of perioperative opioids in favor of multimodal analgesic regimens. Gabapentin has played an integral role in this evolution of practice. This comprehensive review assesses the current clinical evidence on the efficacy of perioperative gabapentin regarding postoperative pain and opioid requirements among the pediatric surgery population.

DATA SOURCES

Pubmed, CINAHL, Embase, Scopus, and Web of Science Review.

METHODS

This scoping review of the above databases includes all studies examining the use of gabapentin perioperatively in pediatric patients and its association with postoperative pain intensity and postoperative opioid consumption through July 2021. The inclusion criteria encompassed all studies evaluating gabapentin in the perioperative pediatric population through randomized controlled trials (RCTs) and retrospective studies. Relevant metadata from each study were abstracted and descriptive statistics were used to summarize the results.

RESULTS

Fifteen papers met the inclusion criteria for this review, including 11 RCTs and 4 retrospective studies. Sample sizes ranged from 20 to 144 patients. Administered doses varied widely, mainly between 5 and 20 mg/kg. The studies included primarily orthopedic (10) and neck surgery cases (3). Seven papers had gabapentin provided preoperatively only, two postoperative only, and six both pre- and postoperatively. Of the studies assessing postoperative pain, 6/11 studies saw a decrease in postoperative pain in at least one period for the gabapentin group. Of the studies considering opioid requirements, 6/10 reported a reduction, 1/10 an increase, and 3/10 no difference in opioid requirements for the gabapentin groups. Yet, most of these pain and opioid requirement findings were only significant at one to two time points in the study follow-up periods, and the actual decreases had minimal clinical significance.

CONCLUSIONS

The current data on perioperative gabapentin in pediatric patients are insufficient to support the routine use of gabapentin in pediatric patients. Additional high-quality RCTs with more standardized protocols for gabapentin administration and outcome measures are necessary to provide more definitive conclusions.

Impact of Age on Surgical Outcomes Following Mandible Fracture Repair

OBJECTIVES

Open repair of mandibular fractures are frequently performed surgical procedures. Increasing rates of such fractures are seen in older adults following falls. This study assesses the impact of older age on early complications following mandible fracture repair.

STUDY DESIGN

Retrospective analysis of national registry.

METHODS

The 2013-2018 National Surgical Quality Improvement Program database was queried for all cases of open mandible fracture repair and cases were categorized into younger (18-40), middle (41-65), and older (>65) age cohorts. Demographics and comorbidities were compared between the age groups. Rates of surgical, medical, and wound complications within 30-days of surgery were determined. Multivariable logistic analyses were performed to assess the relationship between age and complications.

RESULTS

Altogether, 1818 cases were included for analysis, of which 1269 (69.8%) were younger, 459 (25.2%) were middle, and 90 (5.0%) were older age. Increased rates of complications were seen in the older groups, including unplanned reoperation, unplanned readmission, wound disruption, and medical complications (p < 0.01). On unadjusted analysis, the older (>65) age group had an increased odds of experiencing a complication compared to the younger (18-40) group (OR: 4.19, p < 0.001). The older age group continued to have a significantly increased odds of medical complications after multivariable adjustment (adjusted OR: 8.64, p < 0.001).

CONCLUSIONS

On this analysis of a national database, advanced age was associated with an increased frequency of early postoperative complications following open mandibular fracture repair. Following multivariable adjustment, advanced age continued to be associated with increased odds of postoperative medical complications within 30 days of surgery.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:287-293, 2023.

Magnetoelectric stimulation of human motor cortex: normal values and potential safety issues in spinal cord injury

Upon magnetoelectric stimulation (MES) of the motor cortex, maximal amplitude and minimal latency of compound muscle action potentials were recorded for four limbs in 20 able-bodied volunteers after ten sequential stimulations. The ratio of maximal cortical to maximal peripheral compound muscle action potential was calculated. Standard statistical parameters were calculated for values from each limb. A paired t-test revealed a statistically significant difference in lower extremity side-to-side amplitude. Regression analysis of patient height vs upper extremity and lower extremity latency demonstrated a strong correlation: r = .720 and r = .601, respectively. A pendulum model demonstrated that a miniscule amount of energy is imparted onto metallic fixation devices by the magnetic coil, but no significant paraspinal activity could be measured in any of five volunteers upon stimulation of the motor cortex. This study has established a normal MES data base that might be useful in evaluating spinal cord injured patients. It has also demonstrated that initial safety concerns about the use of MES in this population are likely unfounded.

Determinants of community placement of institutionalized mentally retarded persons

A systematic examination of the decision process used when deinstitutionalizing mentally retarded persons was undertaken to determine what criteria, if any, institutional review teams employed when making placement recommendations. A multivariate analysis of variance and a discriminant analysis revealed that demographic and Adaptive Behavior Scale (ABS) measures varied significantly with placement recommendations for skill development homes, group homes, small intermediate facilities, and large intermediate facilities. In general, higher functioning residents were placed in less restrictive settings. Specific differences among residents placed in skill development homes and group homes were examined. Implications for preparing institutionalized residents for community placement were drawn and directions for future research outlined.

Discrepancies in Work Relative Value Unit Assignment Based on Operative Time in Hand Surgery

BACKGROUND

Work relative value units (wRVUs) are an intricate component of physician reimbursement determination in the United States. This paper assesses whether wRVUs appropriately consider operative time in hand surgery.

METHODS

The 50 most common single Current Procedural Terminology code hand surgery cases were queried from the 2013 to 2018 National Surgical Quality Improvement Program database. The average assigned wRVUs and median operative times were calculated for each CPT. Linear regressions were calculated between operative time, wRVUs, and wRVUs per hour. Cases deviating the most from the expected wRVUs based on operative time were identified.

RESULTS

In all, 46 800 cases comprising the top 50 most common hand surgery procedures were identified. Among these cases, the median (range) assigned operative time was 62 minutes (18-110), wRVUs were 7.5 (3.5-18.0), and wRVUs per hour was 8.3 (4.9-14.2). There was a positive linear correlation between operative time and wRVUs (R2 = 0.60). Each additional operative hour was associated with an additional 6.3 wRVUs (P < .001). Based on this relationship, the assigned wRVUs for included cases ranged from 59.7% to 172.6% of expected. There was a weak negative relationship between wRVUs per hour and operative time (R2 = 0.25). Cases shorter than 1 hour had more wRVUs per hour than those longer than 1 hour (10.0 vs. 8.1, P = .003). However, this relationship disappeared when considering case turnover.

CONCLUSION

This study suggests a moderately strong positive correlation between wRVUs and operative time in hand surgery. Yet, numerous outliers from this trend exist, suggesting some discrepancies in reimbursement.

Intraoperative haemodynamics and postoperative intensive care unit admission in older patients with cancer

PURPOSE

Research on the impact of various intraoperative haemodynamic variables on the incidence of postoperative ICU admission among older patients with cancer is limited. In this study, the relationship between intraoperative haemodynamic status and postoperative intensive care unit admission among older patients with cancer is explored.

METHODS

Patients aged ≥75 who underwent elective oncologic surgery lasting ≥120min were analysed. Chi-squared and t-tests were used to assess the associations between intraoperative variables with postoperative intensive care unit admission. Multivariable regressions were used to analyse potential predict risk factors for postoperative intensive care unit admission.

RESULTS

Out of 994 patients, 48 (4.8%) were admitted to the intensive care unit within 30 days following surgery. Intensive care unit admission was associated with the presence of ≥4 comorbid conditions, intraoperative blood loss ≥100mL, and intraoperative tachycardia and hypertensive urgency. On multivariable analysis, operation time ≥240min (Odds Ratio [OR] = 2.29, p = 0.01), and each minute spent with intraoperative hypertensive urgency (OR = 1.06, p = 0.01) or tachycardia (OR = 1.01, p = 0.002) were associated with postoperative intensive care unit admission.

CONCLUSION

Intraoperative hypertensive urgency and tachycardia were associated with postoperative intensive care unit admission in older patients undergoing cancer surgery.