Springfield Regional Medical Center

BACKGROUND: Yannas and Burke developed the concept of the dermal regeneration template in the 1970s. It is now a widely accepted tool in the treatment of burns as well as in reconstructive surgery. METHODS: The authors present a previously published study of Integra used in 20 consecutive patients to reconstruct 30 anatomical sites and then analyze the histologic and clinical outcomes. Wound healing was evaluated by examination of weekly punch biopsy specimens with standard and immunohistochemical stains. Patient satisfaction was assessed using a visual analogue scale, and scar appearance was assessed using a modified Vancouver Scar Scale. RESULTS: Four distinct phases of dermal regeneration could be demonstrated histologically: imbibition, fibroblast migration, neovascularization, and remodeling and maturation. Full vascularization of the neodermis occurred at 4 weeks. Patients reported increased range of movement and improvement in appearance compared with their preoperative states. CONCLUSIONS: The color of the matrix reflected the stage of neodermal vascularization. No adnexa, nerve endings, or elastic fibers were seen in any of the specimens. The new collagen was histologically indistinguishable from normal dermal collagen. The authors also present their current protocol and experience with using Integra for a range of reconstructive procedures.

PURPOSE Hereditary cancer syndromes infer high cancer risks and require intensive surveillance. Identification of high-risk individuals among patients with colorectal cancer (CRC) needs improvement. METHODS Three thousand three hundred ten unselected adults who underwent surgical resection for primary invasive CRC were prospectively accrued from 51 hospitals across Ohio between January 1, 2013, and December 31, 2016. Universal Tumor screening (UTS) for mismatch repair (MMR) deficiency was performed for all, and pathogenic germline variants (PGVs) were identified using multigene panel testing (MGPT) in those who met at least one inclusion criterion: MMR deficiency, diagnosed < 50 years, multiple primary tumors (CRC or endometrial cancer), or with a first-degree relative with CRC or endometrial cancer. RESULTS Five hundred twenty-five patients (15.9%) had MMR deficiency. Two hundred thirty-four of 3,310 (7.1%; 16% of the 1,462 who received MGPT) had 248 PGVs in cancer susceptibility genes. One hundred forty-two (4.3%) had a PGV in an MMR gene, and 101 (3.1%) had a PGV in a non-MMR gene. Ten with Lynch syndrome (LS) also had a non-MMR PGV and were included in both groups. Two (0.06%) had constitutional MLH1 hypermethylation. Of unexplained MMR-deficient patients, 88.4% (76 of 86) had double somatic MMR mutations. Testing for only MMR genes in MMR-deficient patients would have missed 18 non-MMR gene PGVs (7.3% of total PGVs identified). Had UTS been the only method used to screen for hereditary cancer syndromes, 38.6% (91 of 236) would have been missed, including 6.3% (9 of 144) of those with LS. These results have treatment implications as 5.3% (175 of 3,310) had PGVs in genes with therapeutic targets. CONCLUSION UTS alone is insufficient for identifying a large proportion of CRC patients with hereditary syndromes, including some with LS. At a minimum, 7.1% of individuals with CRC have a PGV and pan-cancer MGPT should be considered for all patients with CRC.

Testing for BRCA1 mutation has important clinical implications such as identifying risk of second primary cancers and risk of cancer in the family. This study seeks to quantify the risk of having BRCA1 mutation in female breast cancer patients with triple-negative phenotype compared with those with other phenotypes. We undertook a search of MEDLINE and EMBASE databases for relevant studies through 10 May 2013. Outcomes were calculated and reported as risk ratio and risk difference. 12 studies comprising 2533 breast cancer patients were included in the analysis. It was found that almost all eligible studies were performed on high-risk population with breast cancer. By analyzing the incidence rates of BRCA1 mutation in patients with triple-negative breast cancer (TNBC) and non-TNBC, our meta-analysis provides a relative risk of 5.65 [95% confidence interval (CI), 4.15-7.69] and risk difference of 0.22 (95% CI, 0.15-0.29). This implies that, in selected population with high-risk features, women with TNBC are approximately five and a half times more likely to have BRCA1 mutation compared with non-TNBC phenotype, and approximately two in nine women with TNBC harbor BRCA1 mutation. Triple-negative phenotype significantly increases the risk of having BRCA1 mutation in high-risk breast cancer patients compared with non-TNBC.

The purposes of this study of low back pain patients were to determine: 1) if presence of sacrospinalis myoelectric activity is a consistent phenomenon in supine and prone positions; 2) if there is a difference between magnitudes of myoelectric activity for two types of lumbar traction (static and intermittent); and 3) if there is a difference in patient perceived pain level after traction between the two types of traction. Results show that surface electrode myoelectric activity is absent in resting supine and prone positions, there is no significant difference in magnitude of myoelectric activity between the two different types of traction, and more than 50% of patients in both traction groups experienced decreased pain after traction.

SUMMARY A study of infants suffering episodes of apnoea, stridor or bradycardia in association with spina bifida cystica suggests that neither anatomical nor hydrodynamic abnormalities fully explain these complications. The episodes were often heralded by a rise in the capillary pCO 2 , an increase in the amount of periodic breathing during sleep, and a possible increase in the proportion of rapid‐eye‐movement sleep. Episodes of life‐threatening apnoea, stridor or bradycardia were most frequent and severe at 10 to 12 weeks of age, which was also the period at which death was most frequent in 75 infants dying with apnoea or stridor. In infants surviving this risk period, the episodes declined and most infants were symptom‐free at the age of six months. These findings of an age‐related abnormality in which the cause of death leaves little sign at post‐mortem suggest that a similar mechanism could operate in other cases of unexplained death in infancy ( sids ), and that both conditions may be part of a spectrum of disease characterised by abnormalities of sleep and respiratory control. RÉSUMÉ Une étude de nourrissons présentant des épisodes d'apnée, de stridor ou de bradycardie et présentant un spina bifida indique que ni les anomalies anatomiques, ni les anomalies hydrodynamiques ne peuvent expliquer complètement ces complications. Les épisodes sont souvent annoncés par une elevation de la pCO 2 capillaire, un accroissement des temps de respiration périodique pendant le sommeil et une augmentation possible de la proportion de sommeil rapide. Les épisodes d'apnée menaçante, de stridor ou de bradycardie sont surtout frequents et graves entre dix et douze semaines, ce qui est également l'âge le plus fréquemment noté chez 75 nourrissons morts d'apnée ou de stridor. Chez les nourrissons survivants à cette période de risque, les episodes se raréfient et à l'âge de six mois, la plupart des nourrissons ne présentent plus de symptômes. Ces découvertes d'anomalies reliées à l'âge, dans lesquelles la cause de la mort laisse peu de signes au contrôle anatomique, font penser qu'un mécanisme semblable pourrait intervenir dans d'autres cas de mort inexpliquée du nourrisson. ZUSAMMENFASSUNG Eine Studie an Kindern, die an Episoden von Apnoen, Stridor oder Bradykardie in Verbindung mit Spina bifida cystica litten, läßt vermuten, daß weder anatomische noch hydrodynamische Abnormitäten diese Komplikationen vollständig erklären. Diese Episoden wurden oft angekündigt durch einen Anstieg des kapillären pCO 2 einer Zunahme der Dauer der periodischen Atmung im Schlaf und einer möglichen Zunahme des Anteils von REM‐Schlaf. Diese Episoden lebensbedrohlicher Apnoen, Stridor oder Bradykardie waren am häufigsten und schwersten im Alter von 10–12 Wochen, welches auch die Zeit war, in der der Tod bei 75 Säuglingen, die mit Apnoen oder Stridor sterben, am häufigsten war. Bei den Säuglingen, die diese Risikoperiode überlebten, nahmen diese Episoden ab und die meisten waren symptomfrei im Alter von sechs Monaten. Diese Befunde übsr eine altersbezogene Abnormität, bei der die Todesursache nur geringe Zeichen bei der Sektion hinterläßt, lassen vermuten, daß ein ähnlicher Mechanismus bei anderen Fällen den unerklärlichen Tod im Säuglingsalter bewirken könnte. RÉSUMÉ Un estudio de niños sufriendo episodios de apnea, estridor o bradicardia en asociación con espina bífida cística sugiere que ni las anomalías anatómicas ni hidrodinámicas explican por completo estas complicaciones. Los episodios eran precedidos con frecuencia por un aumento en el pCO 2 capilar, un aumento en la cantidad de respiración periódica durante el sueño y un posible aumento en la proporción de sueño con movimientos oculares rápidos. Los episodios de apnea con amenaza de muerte, estridor o bradicardia eran más frecuentes y graves a la edad de 10 a 12 semanas, que era también el periodo en que la muerte era más frecuente en 75 lactantes que murieron con apnea o estridos. En los lactantes supervivientes de este periodo de riesgo, los episodios declinaron y la mayoría de los lactantes estaban libres de síntomas a la edad de seis meses. Estos hallazgos de una anomalía en relación con la edad, en la que la causa de muerte deja pequeños signos a la necropsia, sugieren que un mecanismo similar podría operar en otros casos de muerte inexplicada en la lactancia.

Evidence to date suggests that capnography monitoring during gastrointestinal endoscopic procedures (GEP) reduces the incidence of hypoxemia, but the association of capnography monitoring with the incidence of other adverse outcomes surrounding these procedures has not been well studied. Our aims were to estimate the incidence of pharmacological rescue events and death at discharge from an inpatient or outpatient hospitalization where GEP was performed with sedation, and to determine if capnography monitoring was associated with reduced incidence of these adverse outcomes. This retrospective Premier Database analysis included medical inpatients and all outpatients undergoing GEP with sedation. Patients were grouped as follows: (1) pulse oximetry (SpO2) only, (2) capnography only, (3) SpO2 with capnography, and (4) neither SpO2 nor capnography. Multivariable logistic regression and propensity-score matching were used to compare patients with capnography sensor use to patients with only SpO2 sensor use. Outcome measures included the incidence of pharmacological rescue events, as defined by administration of naloxone and/or flumazenil, and death. Two hundred fifty eight thousand and two hundred sixty two inpatients and 3,807,151 outpatients were analyzed. For inpatients, capnography monitoring was associated with a 47% estimated reduction in the odds of death at discharge (OR: 0.53 [95% CI: 0.40–0.70]; P < 0.0001) and a non-significant 10% estimated reduction in the odds of pharmacological rescue event at discharge (0.91 [0.65–1.3]; P = 0.5661). For outpatients, capnography monitoring was associated with a 61% estimated reduction in the odds of pharmacological rescue event at discharge (0.39 [0.29, 0.52]; P < 0.0001) and a non-significant 82% estimated reduction in the odds of death at discharge (0.18 [0.02, 1.99]; P = 0.16). In hospital medical inpatients and all outpatients undergoing GEP performed with sedation, capnography monitoring was associated with a reduced likelihood of pharmacological rescue events in outpatients and death in inpatients when assessed at discharge. Despite the limitations of the retrospective data analysis methodology, the use of capnography during these procedures is recommended.

A seven-day course of cephazolin and metronidazole chemoprophylaxis for clean-contaminated head and neck oncological procedures is compared to results with previously published antibiotic regimens. Aetiological factors associated with increased rates of wound complications are analyzed. Retrospective analysis of procedures over a six-year period was performed. The overall wound complication rate was 28.1 per cent, comparing favourably with previously published results. A major fistula was the most common complication with a rate of 9.2 per cent. Factors statistically associated with increased rates of wound complications included: radical neck dissection, extended surgical procedures requiring flap reconstruction, previous tracheotomy, and race. This is the largest single institutional study to show that a seven-day course of cephazolin and metronidazole is an effective chemoprophylactic regimen in head and neck surgery.

An account is given of a repeat survey in 1964–65 of the genetically significant doses arising from diagnostic radiology in the hospitals of the Sheffield Hospital Region. The techniques adopted were those used in the country wide survey of 1957–58 on behalf of the Adrian Committee. Some reduction in genetic dose is apparent.

INTRODUCTION: The Center for Medicare and Medicaid Services established 30-day readmission rate as a key metric in measuring high-value, cost-conscious care; therefore, our aim is to develop a risk score for 30-day readmission in ulcerative colitis (UC) patients undergoing colectomy or proctectomy. METHODS: This study used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant user file (2011-2015). Patients with UC undergoing colectomy or proctectomy were identified using ICD-9, 10, and CPT codes. Stepwise multivariate analyses were used to determine risk factors associated with readmission including pre-operative conditions, laboratory results, operative variables, and post-operative complications. For readmission risk score assessment, a weighted logistic regression model was built and validated using ACS NSQIP 2011-2014 and 2015 data, respectively. RESULTS: A total of 4797 patients were included with 963 (20%) patients readmitted within 30 days. Potentially modifiable risk factors included deep vein thrombosis, pulmonary embolism, renal insufficiency, wound infection, urinary tract infection, sepsis/septic shock, and pre-existing congestive heart failure. Ten percent of patients with a risk score between 0 and 9 were readmitted, 18.5% with a score between 10 and 19, 52.2% with a score between 20 and 29, and 59.6% in patients with a risk score >29. CONCLUSIONS: Multiple potentially preventable risk factors are associated with 30-day readmission following colectomy or proctectomy in UC patients. Higher risk scores are associated with increased risk of unplanned readmission.

A 2-year-old female Siberian Husky was referred for evaluation of a rectocutaneous fistula of unknown etiology. On evaluation, a rectal tear and an associated perivulvar abscess and draining tract were identified. Several attempts were made to repair the rectocutaneous fistula and associated rectal tear. Primary repair and fascia lata graft repair failed. Successful management was achieved via a laparoscopic-assisted end-on jejunostomy for fecal diversion, and the wound healed readily by second intention. During the period of hospitalization, the dog lost a considerable amount of weight. Particular care should be taken regarding fluid therapy, administration of antimicrobials, and adequate nutrition in patients with rectocutaneous fistulas. Overall, the use of laparoscopic-assisted end-on jejunostomy for fecal diversion in the management of rectocutaneous fistulas in dogs appears to be feasible; end-on or loop jejunostomy may also be an option for the treatment of other diseases of the distal portion of the gastrointestinal tract.

Several previous studies reported various immunosuppressive effects of hyperbaric oxygen on nonspecific and specific cell-mediated reactions. A highly immunogenic skin allograft mouse model was used to evaluate the clinical relevance of the previously described immunosuppressive effects of hyperbaric oxygen. A 1.5 x 2.0-cm full-thickness skin allograft was cross-grafted between paired immunohistoincompatible mouse strains (N = 40, C57BL/6 and BALB/c female mice) that were randomly assigned to four groups receiving (1) no treatment (controls), (2) cyclosporine 1 mg per kilogram intraperitoneally daily, (3) cyclosporine plus a low-dose hyperbaric oxygen treatment (two treatments per day, once a week), and (4) cyclosporine plus a high-dose hyperbaric oxygen treatment (two treatments per day, three times a week) following surgery (N = 32). Allograft samples were taken from each group at day 9 after cross-grafting (N = 8). Skin allograft rejection was significantly delayed in all treatment groups compared to controls. No difference was found between animals who received cyclosporine only and the combined treatment regimen including low-dose hyperbaric oxygen. High-dose hyperbaric oxygen treatment in combination with cyclosporine substantially prolonged skin allograft survival compared to other treatments. These findings were histologically confirmed. We conclude that hyperbaric oxygen treatment as an adjunct to standard immunosuppressive therapy may only be advantageous if frequently applied.

PURPOSE: To describe an entirely percutaneous treatment for carotid artery stenting in a type IIa aortic arch via the superficial temporal artery (STA) for through-and-through guidewire access. TECHNIQUE: The technique is demonstrated in an 83-year-old man status post left carotid endarterectomy 3 months prior who presented with 2.5 hours of confusion and dysphasia following diagnostic carotid arteriography. The patient was known to have a type IIa bovine aortic arch and a severe 70% stenosis of the left internal carotid artery. The patient was referred for carotid artery stenting by his vascular surgeon. Due to the bovine arch, a percutaneous ultrasound-guided approach via the STA for through-and-through wire access facilitated carotid artery stenting from the right common femoral artery. The procedure was successful, and follow-up duplex ultrasound confirmed patency of the STA the next day. CONCLUSION: A percutaneous ultrasound-guided STA access can help facilitate transfemoral carotid artery stenting in an otherwise difficult type IIa aortic arch setting.

Three case studies illustrate the complexities and opportunities in providing community-based occupational therapy services to persons with HIV. An infectious disease physician recommended three clients for therapy sessions in both the home and community. The Model of Human Occupation (MOHO) in conjunction with the Conceptual Framework for Therapeutic Occupation (CFTO) was used to guide the therapeutic process. Assessments measured challenges to clients and client progress in the following areas: leisure, mobility, organization, problem solving, community involvement, transitioning to independent living, fatigue, childcare/play, and home management. This paper describes the three cases with findings suggesting that community-based occupational therapy has potential to address important issues such as habits, roles, and volition in the HIV/AIDS population.

BACKGROUND: ABT-751 is a novel orally available antimitotic agent that targets microtubule polymerization. This mechanism may suggest potential activity in canine lymphoma. OBJECTIVE: Determine a maximum tolerated dose for ABT-751, and assess long-term tolerability and activity in canine lymphoma. ANIMALS: Thirty dogs with newly diagnosed (n = 19) or relapsed (n = 11) non-Hodgkin's lymphoma. METHODS: Dogs (n = 11) were enrolled in a rapid dose escalation study to define the maximum tolerated dose. Upon definition of a maximally tolerated dose, a cohort expansion of 19 dogs allowed verification of long-term tolerability and assessment of activity. Study endpoints in the cohort expansion included chronic tolerability, response rate, response duration, and time to progression. Additional endpoints included serum pharmacokinetics, lymph node drug concentrations, and changes in circulating endothelial cells. RESULTS: The maximum tolerated dose of ABT-751 was 350 mg/m(2) PO q24h. Dose-limiting toxicities included vomiting and diarrhea, which resolved with a schedule adjustment to 350 mg/m(2) PO q48h. ABT-751 was consistently detected in lymphoma tissue samples from dogs treated at or above the maximum tolerated dose. In the cohort expansion, objective responses were seen in 3/15 (20%) dogs with a response duration ranging from 21 to 111 days. Decreases in circulating endothelial cells were seen in 10 dogs at day 7 (2 responding dogs and 8 nonresponding dogs). CONCLUSION: ABT-751 was well tolerated at 350 mg/m(2) PO q24h for 7 days and then q48h thereafter. Activity of ABT-751 suggested a rationale for additional studies of ABT-751 as part of a combination chemotherapy protocol for lymphoma or other canine cancers.

Introduction This qualitative study systematically examined occupational therapists’ use of a model of human occupation intervention, the Remotivation Process, for individuals with dementia. Method An international sample of therapists participated in an on-line survey and in-depth interviews, resulting in 33 respondents and eight participants, respectively. The survey gathered general information regarding therapists’ use of the Remotivation Process with persons experiencing dementia, and was used to recruit interview participants. Interviews were conducted using SKYPE or telephone, and were audio-recorded and transcribed. Descriptive statistics were derived from the survey results, and van Manen’s phenomenological approach was used to describe therapists’ experiences using the intervention. Results Use of the Remotivation Process for this population was most common among mid-career therapists, and a majority of respondents had been using the intervention less than two years. Three themes identified from the interviews were: (1) Therapist beliefs: Commitment to the Remotivation process; (2) Does it work? Evaluating success; (3) It's more than me: External factors. Conclusion Survey and interview data revealed that use of the Remotivation Process intervention for persons experiencing dementia is fairly complex yet clinically applicable. Therapists’ experiences of using the Remotivation Process underscored the importance of therapist volition and clinical reasoning in achieving desired outcomes.

We present the case of a 45 Y/o morbidly obese male who - unable to lose weight despite extensive lifestyle interventions, presented to us for an experimental procedure known as bariatric embolization. This arterial embolization procedure was performed targeting the left gastric artery with aims to restrict blood flow to the gastric fundus, and lowering serum ghrelin levels. In this case the left gastric artery arose cephalad from the celiac, earlier than where it normally branches; a variation known as a "false tripod", causing some initial difficulty with selection. We describe how introducing a tertiary curve on the guidewire proved successful. Adapting the guidewire for difficult anatomy is an often a very underutilized skillset for many interventionalists - but led to success in this rather nascent procedure.

We present a case of vertebral osteomyelitis following multiple vertebral augmentations in a patient with an insidious presentation. Vertebral augmentation (kyphoplasty and/or vertebroplasty) is a minimally invasive procedure that has become a fairly common and highly effective method in treating compression fractures. A large majority of patients that undergo this procedure suffer from osteoporosis. Numerous studies have shown that patients who undergo the procedure obtain substantial pain relief and improve functional status, often times to a greater extent than other surgical and nonsurgical management. Although its prevalence is low, infection after vertebral augmentation can be a serious consequence of the procedure. Blood cultures in this case were positive for Clostridium septicum. C septicum is a gram-positive, spore forming bacteria that is part of the normal gut flora in humans and is commonly associated with GI malignancy, necrosis, and inflammation. The patient did not respond to long-term intravenous antibiotics and required vertebral corpectomy and debridement with instrumentation. Vertebral body cultures obtained intraoperatively were positive for C septicum. It was noted historically that the patient had a hemorrhoidectomy 4 weeks prior to her initial fracture presentation. Although the risk of infection after vertebral augmentation is low, it is imperative that careful pre- and postoperative evaluation as well as follow-up is completed in order to prevent catastrophic consequences for patients. In patients with recent gastrointestinal tract manipulation/surgery, appropriate antibiotic prophylaxis should be considered prior to vertebral augmentation procedures.

The decreased applicant pool caused one hospital program admission committee to wonder if there were student characteristics, other than grade point average (GPA), that could provide some insight into an applicant’s chance of academic success in the medical technology (MT) program. Several students with borderline GPAs seemed to be excellent candidates except they failed to meet the science GPA cutoff criteria of 2.5 on a 4.0 scale. The hospital program studied the usefulness of their MT program’s preclinical faculty recommendation form. The common rating form contained 10 student characteristics that were judged by preclinical faculty. The students in the study population were from five different academic affiliates of the hospitalbased program. School records of 31 students, over a 5-year period, were studied. Results showed that a combination of three student characteristics—initiative/originality, comprehension, and judgment—appeared to correlate highly with success on the American Society of Clinical Pathologists Board of Registry examination.

Purpose: This study's purpose was to describe the vital sign assessment (VSA) practices of physical therapists (PTs) during evaluation and treatment of patients with neurologic conditions. Methods: A survey was distributed to clinicians from a clinical site database and the Academy of Neurologic Physical Therapy's list serve. Respondents included US licensed PTs who treat patients with neurologic conditions. Results: Usable surveys included 133 US PTs with 69.2% doctorally prepared and 79.7% American Physical Therapy Association (APTA) members. Although 58.6% of survey respondents indicated that VSA is an essential part of the PT evaluation, at evaluation, only 37.6% and 39.1% of respondents always take heart rate (HR) and blood pressure (BP), and only 8.3% of respondents always take respiratory rate (RR). During treatment, only 14.3% of respondents report taking HR or BP at each session, while only 5.3% always take RR. Board certification was correlated with an increased frequency of HR assessment ( P = .0027) and BP ( P = 0.038) at evaluation, while importance of VSA strongly correlated with increased assessment of HR ( P = 0.000), BP ( P = 0.000), and RR ( P = 0.003) at evaluation and with HR ( P = 0.000) and BP (0.000) during treatment. Conclusions: Although VSA by neurologic PTs is higher than other identified PT groups, it is still below-recommended assessment guidelines.

The "gold standard" for the determination of susceptibility to malignant hyperthermia has long been the caffeine-halothane-contracture test, which is costly and invasive. As the workings of molecular genetics are better understood, research is being applied to finding the causative gene for malignant hyperthermia. Once this gene is identified, genetic testing will involve a much simpler, less invasive test that uses blood samples to detect susceptibility. To reach this goal, researchers have been attempting to identify the deoxyribonucleic acid (DNA) mutations responsible for malignant hyperthermia by using techniques such as linkage analysis. Review of the literature reveals that malignant hyperthermia has been linked to the ryanodine receptor in swine and in some humans. It has also been linked to chromosome 19q12-13.1, which is where the gene encoding the ryanodine receptor lies. The literature further reveals that malignant hyperthermia may be a heterogeneous disorder, which means that more than one gene is responsible for its expression.