Huntington Hospital

BACKGROUND: Subcortical injury resulting from conventional surgical management of intracranial hemorrhage may counteract the potential benefits of hematoma evacuation. OBJECTIVE: To evaluate the safety and potential benefits of a novel, minimally invasive approach for clot evacuation in a multicenter study. METHODS: The integrated approach incorporates 5 competencies: (1) image interpretation and trajectory planning, (2) dynamic navigation, (3) atraumatic access system (BrainPath, NICO Corp, Indianapolis, Indiana), (4) extracorporeal optics, and (5) automated atraumatic resection. Twelve neurosurgeons from 11 centers were trained to use this approach through a continuing medical education-accredited course. Demographical, clinical, and radiological data of patients treated over 2 years were analyzed retrospectively. RESULTS: Thirty-nine consecutive patients were identified. The median Glasgow Coma Scale (GCS) score at presentation was 10 (range, 5-15). The thalamus/basal ganglion regions were involved in 46% of the cases. The median hematoma volume and depth were 36 mL (interquartile range [IQR], 27-65 mL) and 1.4 cm (IQR, 0.3-2.9 cm), respectively. The median time from ictus to surgery was 24.5 hours (IQR, 16-66 hours). The degree of hematoma evacuation was ≥90%, 75% to 89%, and 50% to 74% in 72%, 23%, and 5.0% of the patients, respectively. The median GCS score at discharge was 14 (range, 8-15). The improvement in GCS score was statistically significant ( P < .001). Modified Rankin Scale data were available for 35 patients. Fifty-two percent of those patients had a modified Rankin Scale score of ≤2. There were no mortalities. CONCLUSION: The approach was safely performed in all patients with a relatively high rate of clot evacuation and functional independence.

BACKGROUND: Continuous femoral or lumbar plexus blocks have been demonstrated to provide effective postoperative analgesia of the lower extremity following total joint arthroplasty. The purpose of this study was to compare these two techniques when used with intravenous patient-controlled analgesia and the use of patient-controlled analgesia alone for postoperative pain management following unilateral primary hip arthroplasty. METHODS: Two hundred and twenty-five patients undergoing unilateral total hip arthroplasty for a diagnosis of osteoarthritis were randomly allocated into one of three postoperative treatment groups: continuous lumbar plexus block with patient-controlled analgesia, continuous femoral block with patient-controlled analgesia, and patient-controlled analgesia alone. Scores on a visual analog pain scale administered during physiotherapy twenty-four hours postoperatively were used as the primary outcome measured. Secondary outcomes included scores on a visual analog pain scale at rest, hydromorphone consumption, opioid-related side effects, complications, sensory and motor blockade, and patient satisfaction. RESULTS: Continuous lumbar plexus block significantly reduced pain scores during physiotherapy on postoperative day 1 (p < 0.0001) and day 2 (p < 0.0001) compared with either continuous femoral block or patient-controlled analgesia alone. There were no significant differences for pain at rest between the two regional analgesic techniques. Both regional anesthesia techniques significantly reduced total hydromorphone consumption (p < 0.05) and delirium (disorientation to time and/or place) compared with patient-controlled analgesia alone (p < 0.023). In addition, the use of continuous lumbar plexus block was associated with fewer patients with opioid-related side effects (p < 0.05), greater distances walked (p < 0.05), and enhanced patient satisfaction (p < 0.05) compared with the use of a continuous femoral nerve block with patient-controlled analgesia or with patient-controlled analgesia alone. CONCLUSIONS: Continuous lumbar plexus and femoral blocks significantly reduce the need for opioids and decrease related side effects. Continuous lumbar plexus block is a more effective analgesic modality than is a continuous femoral block or patient-controlled intravenous administration of hydromorphone alone during physical therapy following primary unilateral total hip arthroplasty.

PROLONGED gastric intubation may be a factor in the development of peptic esophagitis and stricture in some patients, but whether acid reflux into the esophagus is the primary mechanism is uncertain. A previous study utilizing cineradiographic technics showed no reflux of barium into the esophagus during short-term gastric intubation.1 In contrast, this study of simultaneously recorded intraluminal esophageal pressures and pH reports that gastric acid is refluxed and maintained in the distal esophagus during prolonged gastric intubation under certain conditions.Methods and ResultsThree water-filled polyethylene catheters, each with an internal diameter of 1.5 mm., were fastened together and sealed . . .

OBJECTIVE: We studied the prevalence of injuries of the articular cartilage and subchondral bone after acute trauma in skeletally immature knees using high-resolution MRI. MATERIALS AND METHODS: We reviewed knee MRIs of 126 young children and adolescents suspected to have internal knee derangement, including 82 with open physes and a control group of 44 who were skeletally mature. High-resolution proton density and T2-weighted pulse sequences were used in all patients. The prevalence of common injuries in the two groups was compared using chi-square analysis. Levels of interobserver agreement for evaluation of chondral lesions in the skeletally immature group were determined using the kappa statistic. RESULTS: In the skeletally immature group, chondral lesions were the most prevalent injuries (prevalence = 0.34, p = 0.009) followed by meniscal and anterior cruciate ligament injuries (prevalence = 0.23 and 0.24, respectively). No significant difference in the prevalence of chondral injury before and after physeal closure was seen (p = 0.45). There was no significant difference in the prevalence of anterior cruciate ligament injuries between the two groups, but meniscal injuries were more prevalent in the skeletally mature patients (prevalence = 0.41, p = 0.037). Interobserver agreement for chondral injuries in the group with open physes was good (weighted kappa = 0.45-0.51). CONCLUSION: The most common injuries occurring as a result of acute trauma to the immature knee were chondral. In patients with open physes, chondral injuries were significantly more prevalent than anterior cruciate ligament and meniscal injuries.

Normozoospermic men who do not fertilize human eggs in vitro constitute a clearly identifiable class of occult male factor infertility. We have studied the relationships between in-vitro fertilization (IVF) outcomes and the appearance of sperm surface mannose lectin/zona pellucida ligand activity measured by the binding of fluorescein isothiocyanate (FITC)-labelled mannosylated albumin. Of 338 semen specimens with normal profiles, 10 (2.96%) failed to fertilize in vitro (IVF-). Motile spermatozoa from six of these were analysed retrospectively for zona ligand binding activity on the sperm head in relation to acrosome status and the free cholesterol content of their plasma membrane. IVF+ males and fertile donors served as controls. The six IVF- occult male factor cases were distinguished from controls by their failure to show time-dependent increases in the percentage of spermatozoa exhibiting head-directed mannose ligand activity, by the slow loss or apparent increase in membrane cholesterol and by the absence of spontaneous and/or mannose-induced acrosome exocytosis.

Due to similarities in cell pathways and developmental mechanisms, regenerative technologies developed in one therapeutic area may be applicable to others. Approaches that proceed from human genomic or other big data sources to models are becoming increasingly common and will likely suggest novel therapeutic avenues. To fully capitalize on the advances in regenerative medicine, studies must demonstrate the value of new therapies in identified patient populations, and sponsors must work with regulatory agencies to develop appropriate dossiers supporting timely approval.

Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease is characterized by the accumulation of pyrophosphate dihydrate crystals in articular and periarticular tissues. Various terms have been utilized to describe this arthropathy, which has led to some confusion. CPPD crystal deposition disease is among many conditions that may result in crystal deposition within cartilage. Chondrocalcinosis is a pathologic and radiographic term denoting calcification of cartilage within joints including both hyaline articular cartilage and fibrocartilage. Pseudogout is a clinical term applied to an acute inflammatory process in a joint(s) mimicking a gout attack. Pseudogout is just one of the multiple clinical presentations for CPPD crystal deposition disease. Pyrophosphate arthropathy is a term that has been used to describe the peculiar pattern of joint destruction associated with CPPD crystal deposition disease. This article reviews the protean manifestations of CPPD crystal deposition disease with emphasis on diagnostic imaging.

Abstract Many autistic adults experience psychiatric conditions such as anxiety and depression. However, autistic adults often do not receive effective and affordable mental health (MH) treatment. Untreated psychiatric conditions in autistic adults are associated with a host of negative outcomes, including adaptive functioning impairments, difficulties with employment and independent living, and poor quality of life. The purpose of this Perspectives piece is to shed light on the current state of community MH services in the United States for autistic adults with co-occurring psychiatric conditions. Drawing on the available research and clinical experiences, we aim to (1) highlight positive developments in community mental health care for autistic adults; (2) summarize the barriers that continue to exist for autistic adults in need of MH services; and (3) provide recommendations for autistic adults and their families, community MH clinicians, and MH systems administrators to consider. Significant work is needed to provide autistic adults with affordable quality MH services. This Perspectives piece presents a summary of the needed changes and specific methods to continue to improve community MH services for autistic adults. Lay Summary Many autistic adults experience mental health problems, such as anxiety and depression. However, autistic adults and their families often do not know where to turn for effective and affordable mental health treatment. The purpose of this Perspectives piece is to (1) highlight positive developments in community mental health care for autistic adults; (2) summarize the barriers that continue to exist for autistic adults in need of mental health services; and (3) provide recommendations for autistic adults and their families, community mental health clinicians, and mental health systems administrators to consider. Recommendations for autistic adults and their families include joining autism-related support and advocacy networks, looking for word-of-mouth referrals from peers who have had success with local mental health providers, and searching for therapists who have the core skills needed to treat the presenting problem at hand, even if they are not experts in autism per se. Recommendations for clinicians focus on the importance of adopting the same individualized approach they would use for any of their clients without autism. Recommendations for systems administrators include improving communication between the developmental disabilities and mental health systems, adding more courses and practicum experiences related to autistic adults in the required general training for physicians, psychologists, and social workers, and offering trainings to clinicians that focus on the treatment of mental health problems in autistic adults.

BACKGROUND: Despite descriptions of various cardiovascular manifestations in patients with coronavirus disease 2019 (COVID-19), there is a paucity of reports of new onset bradyarrhythmias, and the clinical implications of these events are unknown. METHODS: Seven patients presented with or developed severe bradyarrhythmias requiring pacing support during the course of their COVID-19 illness over a 6-week period of peak COVID-19 incidence. A retrospective review of their presentations and clinical course was performed. RESULTS: Symptomatic high-degree heart block was present on initial presentation in three of seven patients (43%), and four patients developed sinus arrest or paroxysmal high-degree atrioventricular block. No patients in this series demonstrated left ventricular systolic dysfunction or acute cardiac injury, whereas all patients had elevated inflammatory markers. In some patients, bradyarrhythmias occurred prior to the onset of respiratory symptoms. Death from complications of COVID-19 infection occurred in 57% (4/7) patients during the initial hospitalization and in 71% (5/7) patients within 3 months of presentation. CONCLUSIONS: Despite management of bradycardia with temporary (3/7) or permanent leadless pacemakers (4/7), there was a high rate of short-term morbidity and death due to complications of COVID-19. The association between new-onset bradyarrhythmias and poor outcomes may influence management strategies for acutely ill patients with COVID-19.

BACKGROUND: The risk of psychological effects from the COVID-19 pandemic is significant and manifests as stress, anxiety, depression, sleeplessness, and, in some cases, suicide. The need for psychological support services for healthcare providers should be included in all pandemic and disaster planning. OBJECTIVES: The aim of this article is to explore the potential psychological sequelae of nursing during a pandemic and to provide recommendations to support a psychologically healthy work environment. METHODS: Highlights from the literature on psychological sequelae, symptoms, and outcomes related to COVID-19 and prior pandemics is presented, along with insight from the experiences of oncology nurses caring for patients with COVID-19. FINDINGS: Destigmatizing mental health needs for healthcare providers empowers them to seek support. Hospital administrators must develop proactive wellness plans for the triage and management of mental and emotional health needs during a pandemic that prioritize transparent communication, resources for healthcare providers within and beyond the clinical setting, and training.

Many lines of evidence have indicated that both genetic and non-genetic determinants can contribute to intra-tumor heterogeneity and influence cancer outcomes. Among the best described sub-population of cancer cells generated by non-genetic mechanisms are cells characterized by a CD44+/CD24- cell surface marker profile. Here, we report that human CD44+/CD24- cancer cells are genetically highly unstable because of intrinsic defects in their DNA-repair capabilities. In fact, in CD44+/CD24- cells, constitutive activation of the TGF-beta axis was both necessary and sufficient to reduce the expression of genes that are crucial in coordinating DNA damage repair mechanisms. Consequently, we observed that cancer cells that reside in a CD44+/CD24- state are characterized by increased accumulation of DNA copy number alterations, greater genetic diversity and improved adaptability to drug treatment. Together, these data suggest that the transition into a CD44+/CD24- cell state can promote intra-tumor genetic heterogeneity, spur tumor evolution and increase tumor fitness.

A well coordinated plan that includes a mechanism for surveillance, rapid antigen detection testing and viral culture, infection control techniques and chemoprophylaxis is effective for aborting outbreaks of influenza A in the nursing home. Amantadine has been better studied in this situation, and experience with rimantadine is limited. The safety and efficacy of our dose guidelines for nursing home residents need to be studied and directly compared with rimantadine dose guidelines. Except for chemoprophylaxis, these guidelines can be applied to outbreaks of influenza B as well.

BACKGROUND: Normal wound healing processes have been shown to be altered in diabetes, and the effect of the diabetes on bone-to-implant contact (BIC) once osseointegration has been established is still unknown. The purpose of this study was to histologically evaluate the bone-to-implant contact in uncontrolled and insulin-controlled rats in which diabetes was induced following the establishment of osseointegration. METHODS: Thirty-two rats were assigned to eight different treatment groups of four each. Titanium plasma-sprayed (TPS) implants were placed in the femora of each animal, and allowed to osseointegrate for 28 days before diabetic induction. Daily insulin injections were given to four groups of rats and the other four groups received no insulin (uncontrolled). The rats were sacrificed at 1, 2, 3, and 4 months following diabetic induction. RESULTS: The results indicated that at 1, 2, 3, and 4 months, there was more BIC in the insulin-controlled groups compared to the uncontrolled groups. The differences were significantly greater at 2, 3, and 4 months (P < or =0.001). CONCLUSIONS: This study demonstrated that osseointegrated dental implants in insulin-controlled diabetic rats maintained bone-to-implant contacts over a 4-month period. However, boneto- implant contact appears to decrease with time in uncontrolled diabetic rats.

Two premenopausal female patients with Graves' hyperthyroidism and propylthiouracil (PTU)-induced agranulocytosis are presented. The first patient, age 47, received 300 mg of PTU per day and developed agranulocytosis within 6 weeks of the commencement of therapy. There were no granulocytes in the peripheral smear and a bone marrow biopsy demonstrated an absence of the entire myeloid cell line as well as the presence of many granulomas. The second patient, age 39, received PTU 1600 mg per day for two and half weeks and then 2 days of methimazole, 200 mg per day. She developed complete agranulocytosis on peripheral smear within 3 weeks of the initiation of therapy. Her bone marrow biopsy demonstrated maturation arrest of the granulocytic cell line at the myelocyte stage. In addition to discontinuing their antithyroid drugs, both patients were treated with G-CSF subcutaneously. The first patient received 300 micrograms of G-CSF on days 2 and 4 after discontinuing PTU with the appearance of 4.7 x 10(9)/L granulocytes and granulocyte precursors on day 4. The second patient received 575 micrograms of G-CSF for 2 days and 300 micrograms for 1 additional day beginning on the third day after discontinuing antithyroid drugs. On the second treatment day there were 5.8 x 10(9)/L granulocytes and granulocyte precursors on the peripheral smear. A comparison to previously published cases on antithyroid drug induced agranulocytosis suggests that the use of G-CSF decreased the amount of time required for marrow recovery after the cessation of the offending drug.

BACKGROUND: The current knowledge of wound healing around implant surfaces is quite limited, particularly as it relates to the effects of systemic diseases such as diabetes. The purpose of our research is to histologically evaluate the effects of aminoguanidine and doxycycline in the modification of peri-implant wound healing around endosseous implants in diabetic rats. METHODS: Thirty-two Sprague-Dawley rats were randomly assigned to four different treatment groups. One group served as the non-diabetic control, while diabetes was induced in other groups. Titanium plasma-sprayed (TPS) implants were placed in the femora of each animal 2 weeks following diabetic induction. One group of diabetic rats was given aminoguanidine via intraperitoneal injection, and another given doxycycline via oral gavage for 28 days beginning on the day of implantation. The third group of diabetic rats received no medication (controls). All animals were sacrificed following 28 days of healing. RESULTS: The results were measured by marrow bone-to implant contact (MBIC) between the groups. Values for MBIC were greater for the non-diabetic control group than the diabetic control group (P < 0.001). Aminoguanidine-treated diabetic animals had a significantly greater MBIC than the diabetic control group (P < 0.01). Diabetic animals receiving doxycycline did not differ significantly from the diabetic control group (P > 0.05). CONCLUSIONS: The results of this study using a rat model con- firm previous reports that diabetes inhibits osseointegration, as defined by MBIC. In addition, this study demonstrates that the detrimental effects of diabetes on osseointegration can be modified using aminoguanidine systemically. However, systemic administration of doxycycline only slightly enhances osseointegration.

Orthopaedic surgery is recognized as one of the most popular but least diverse medical subspecialties. Although significant efforts have been made in recent years to improve gender diversity, orthopaedic surgery continues to lag behind other surgical subspecialties. A recent study predicted that it would take 217 years for orthopaedic surgery to reach gender parity matching the 36.3% of practicing female physicians in the United States. The purpose of our study was to evaluate the annual percentages of female medical student applicants in orthopaedic surgery over the past 15 years and to determine when this gender parity percentage may be reached among residency applicants. Methods: The Electronic Residency Application Service was queried for orthopaedic residency applicant data from 2007 to 2022. The annual percentage of female applicants as well as the annual change in percentage of female applicants was recorded. A best-fit trendline was calculated and extrapolated to predict future rates of female applicants. Results: The percent of female applicants has increased from 11.8% in 2007 to 23.0% in 2022. Between 2007 and 2022, there were 9 years with annual increases in percentage of females applying into orthopaedic surgery with a statistically significant increase in 4 of those years (2008, 2014, 2019, and 2022). There were 6 years with annual decreases in percentage of females applying to orthopaedic surgery, none of which were statistically significant. The best-fit curve is exponential with a correlation coefficient of 0.8 (p < 0.001). This predicts reaching the predetermined gender parity percentage of 36.3% in 16 years. Conclusion: In the past 15 years, there has been a near-doubling in the percentage of female medical students applying to orthopaedic surgery residency. Although orthopaedic surgery remains the least gender-diverse field of medicine, these trends are encouraging and support the initiatives currently in place including early education and increased mentorship to help close the gender gap in orthopaedic surgery.

STUDY DESIGN: A retrospective analysis of a case series was performed. OBJECTIVE: To describe a novel technique to monitor femoral nerve function by analyzing the saphenous nerve somatosensory evoked potential (SSEP) during transpsoas surgical exposures of the lumbar spine. SUMMARY OF BACKGROUND DATA: During transpsoas direct lateral approaches to the lumbar spine, electromyography monitoring is frequently advocated; however, sensory and motor neurological complications are still being reported. Femoral nerve injury remains a feared complication at the L3-L4 and L4-L5 levels. The current neurophysiological monitoring modalities are not specific or sensitive enough to predict these injuries after the retractors are placed. The authors have developed a technique that is hypothesized to reduce femoral nerve injuries caused by retractor compression by adding saphenous nerve SSEPs to their neurophysiological monitoring paradigm. METHODS: Institutional review board approval was granted for this study and the medical records along with the intraoperative monitoring reports from 41 consecutive transpsoas lateral interbody fusion procedures were analyzed. The presence or absence of intraoperative changes to the saphenous nerve SSEP was noted and the postoperative symptoms and physical examination findings were noted. RESULTS: SSEP changes were noted in 5 of the 41 surgical procedures, with 3 of the patients waking up with a femoral nerve deficit. None of the patients with stable SSEP's developed sensory or motor deficits postoperatively. No patient in this series demonstrated intraoperative electromyography changes indicative of an intraoperative nerve injury. CONCLUSION: Saphenous nerve SSEP monitoring may be a beneficial tool to detect femoral nerve injury related to transpsoas direct lateral approaches to the lumbar spine. LEVEL OF EVIDENCE: 4.

Orthopaedic surgery is well recognized as one of the most competitive and least diverse medical specialties. Despite efforts toward improving diversity, studies have shown that gender and racial/ethnic disparities continue to persist in orthopaedic graduate medical education. Therefore, we sought to identify the match rates of traditionally under-represented groups within orthopaedic surgery-female candidates, racial and ethnic minorities under-represented in medicine (URiM), and osteopathic physicians-compared with their application rates. Methods: A retrospective review of the Electronic Residency Application Service (ERAS) application data from the 2017 to 2021 application cycles was performed, and the total number of applicants, sex, race/ethnicity, and degree type of all students applying for orthopaedic surgery were recorded. A separate database, the Orthopaedic Residency Information Network (ORIN), which is a database self-reported by residency programs to provide information to applicants, was also queried to identify the total number of residents, sex, race/ethnicity, and degree type of all current residents in June 2022, corresponding to those residents who matched in 2017 to 2021. Results: From the ERAS application data, a total of 7,903 applicants applied to orthopaedic surgery during the study period. A total of 1,448 applicants (18%) were female, 1,307 (18%) were URiM, and 1,022 (15%) were from an osteopathic medical school. Based on the ORIN database, 688 of 3,574 residents (19%) were female, 1,131 of 7,374 (19%) were URiM, and 1,022 of US medical school graduates (12%) had a DO degree. The application and match rates were not significantly different for female (p = 0.249) and URiM (0.187) applicants; however, there was a significant difference in the application and match rates (15% vs 12%; p = 0.035) for US medical graduates with a DO degree. Conclusion: In recent years, there has been a significant and necessary push to increase diversity in the field of orthopaedic surgery. From 2017 to 2021, match rates of female and URiM candidates are reflective of their application rates. Osteopathic applicants in orthopaedic surgery have a lower match rate than their allopathic counterparts. Level of Evidence: III.

The rapid progression of the coronavirus disease 2019 (COVID-19) outbreak presented extraordinary challenges to the US health care system, particularly straining resources in hard hit areas such as the New York metropolitan region. As a result, major changes in the delivery of obstetrical care were urgently needed, while maintaining patient safety on our maternity units. As the largest health system in the region, with 10 hospitals providing obstetrical services, and delivering over 30,000 babies annually, we needed to respond to this crisis in an organized, deliberate fashion. Our hospital footprint for Obstetrics was dramatically reduced to make room for the rapidly increasing numbers of COVID-19 patients, and established guidelines were quickly modified to reduce potential staff and patient exposures. New communication strategies were developed to facilitate maternity care across our hospitals, with significantly limited resources in personnel, equipment, and space. The lessons learned from these unexpected challenges offered an opportunity to reassess the delivery of obstetrical care without compromising quality and safety. These lessons may well prove valuable after the peak of the crisis has passed.

The steady decline with time in patency of expanded polytetrafluoroethylene (e-PTFE) dialysis shunts led to a trial protocol of postimplantation surveillance to identify those grafts at risk for thrombosis. Duplex scanning is a noninvasive, reproducible method of monitoring anatomic and hemodynamic aspects of graft function that provides the surgeon with an opportunity for early operative intervention. The data from this randomized prospective study suggest that early intervention based on surveillance findings is more successful in terms of access site salvage and morbidity reduction than intervention prompted by graft thrombosis or malfunction is. Duplex scanning appears to be the preferred modality that, together with timely reoperation, impacts favorably on functional graft survival.