Public Health Interventions Guided by Houston's Wastewater Surveillance Program During the COVID-19 Pandemic

Since the start of the COVID-19 pandemic, wastewater surveillance has emerged as a powerful tool used by public health authorities to track SARS-CoV-2 infections in communities. In May 2020, the Houston Health Department began working with a coalition of municipal and academic partners to develop a wastewater monitoring and reporting system for the city of Houston, Texas. Data collected from the system are integrated with other COVID-19 surveillance data and communicated through different channels to local authorities and the general public. This information is used to shape policies and inform actions to mitigate and prevent the spread of COVID-19 at municipal, institutional, and individual levels. Based on the success of this monitoring and reporting system to drive public health protection efforts, the wastewater surveillance program is likely to become a standard part of the public health toolkit for responding to infectious diseases and, potentially, other disease-causing outbreaks.

Pediatric Lateral Humeral Condyle Fractures: Reliability of a Modified Jakob Classification System and its Impact on Treatment Planning With or Without Arthrography

BACKGROUND

Various lateral humeral condyle fracture (LHCF) classification systems have been in use since the 1950s, but limited research exists on their reliability. The most widely utilized, yet un-validated system is that of Jakob and colleagues. The purpose of the current study was to analyze the reliability of a modified Jakob classification system and its value in guiding treatment either with or without arthrography.

METHODS

Interrater and intrarater reliability studies were performed using radiographs and arthrograms from 32 LHCFs. Radiographs were presented to 3 pediatric orthopaedic surgeons and 6 pediatric orthopaedic surgery residents who were asked to classify the fractures according to a modified Jakob classification system, enunciate their treatment plan, and whether they would utilize arthrography. Classification was repeated within 2 weeks to assess intrarater reliability. The treatment plan using radiographs only and radiographs with arthrography were compared at both rating points.

RESULTS

The modified Jakob system had excellent interrater reliability using only radiographs with a kappa value of 0.82 and an overall agreement of 86%. The average kappa for intrarater reliability using only radiographs was 0.88 with a range of 0.79 to 1.00 and an average overall agreement of 91% with a range of 84% to 100%. Interrater and intrarater reliability was poorer using both radiographs and arthrography. On average, arthrography changed the treatment plan in 8% of cases.

CONCLUSIONS

The modified Jakob classification system proved to be a reliable classification system for LHCFs, independent of arthrography, given the excellent free-marginal multirater kappa values.

LEVEL OF EVIDENCE

Level III-diagnostic.

Kwashiorkor in an 8-Month-Old Infant Due to Homemade Formula Use

INTRODUCTION

Kwashiorkor is a malnutrition syndrome most commonly seen in the United States among patients with malabsorptive conditions. While it is rare in otherwise healthy individuals, cases can develop where low nutritional literacy or unorthodox diets are a factor.

CASE PRESENTATION

We present an 8-month-old infant who developed kwashiorkor after transitioning to homemade infant formula.

DISCUSSION

This patient developed severe malnutrition due to consumption of homemade formula that did not meet nutritional standards. The recipe was promoted by an alternative health organization as a healthy option, and the difficulty in identifying reliable health information online also played a significant role.

CONCLUSIONS

Families of young children face many challenges, particularly during the recent infant formula shortage. Maintaining strong relationships and open communication with trusted health care professionals is vital to combating health misinformation and helping patients and families navigate these challenges safely.

Can Over-containment Prevent Recurrence in Children With Cerebral Palsy and Hip Dysplasia Undergoing Hip Reconstruction?

INTRODUCTION

Hip reconstruction is often necessary in children with cerebral palsy (CP) but is associated with high failure rates. Over-containment deeply seats the hip within the acetabulum at the time surgical reconstruction. The goal of this study is to evaluate the effect of over-containment on radiographic outcomes and failure rates in children with CP undergoing hip reconstruction.

METHODS

This study is a retrospective chart review of children with CP that underwent hip reconstruction between 2010 and 2019 with at least 2 years of radiographic follow-up. Migration percentage (MP), acetabular index (AI), and neck shaft angle (NSA) were recorded preoperatively, postoperatively and throughout follow-up. Failures were defined as a MP at latest follow-up ≥30% or need for revision hip reconstruction. Hips were divided into groups based on postoperative MP-group 1 (over-containment group) had a MP≤0% and group 2 had an MP>0%. Radiographic parameters and failure rates were compared across Gross Motor Functional Classification Score (GMFCS) level, age at the time of surgery, and degree of preoperative subluxation.

RESULTS

A cohort of 108 patients (197 hips) with an average age of 7.3±3.2 years met inclusion criteria with an average follow-up of 49.6 months (range: 24 to 118 mo). There were 147 hips in group 1 and 50 hips in group 2. At latest follow-up, group 1 demonstrated lower MP, AI, and NSA in comparison to group 2. The overall failure rate in our cohort was 8.1% (16 hips). Failure rates trended lowest in hips that were over-contained (6.1% v. 14.0%) although not statistically significant. Over-containment resulted in significantly lower failure rates in GMFCS IV/V hips, children under age 6 at the time of surgery and those with a higher degree of preoperative hip displacement (MP>50%).

CONCLUSIONS

Over-containment at the time of hip reconstruction can positively affect radiographic outcomes and failure rates in children with CP. Over-containment should be considered in hips at high risk of failure, especially non ambulatory children with significant hip subluxation at an early age.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Proximal Femoral Screw Hemiepiphysiodesis in Children With Cerebral Palsy Improves the Radiographic Measures of Hip Subluxation

BACKGROUND

Proximal femoral screw hemiepiphysiodesis (PFSH) is a promising technique for treatment of hip subluxation in children with cerebral palsy (CP). The aim of this study is to report radiographic outcomes of PFSH and to evaluate its role in changing the natural history of hip displacement in children with CP.

METHODS

This is a single center retrospective chart review of children with CP that underwent PFSH with at least 2 years of radiographic follow-up. Demographic information, surgical details, complications, additional surgical procedures, and need for screw exchange were recorded. Radiographs were assessed for migration percentage (MP), neck shaft angle (NSA), head shaft angle (HSA), and articular trochanter distance preoperatively as well as at 6 months, 1 year, 2 year, and latest follow-up postoperatively. Hips were divided into group 1 (no previous hip surgery) and group 2 (PFSH performed after hip reconstruction). Hips with 2 years of preoperative radiographic data were included in the natural history cohort.

RESULTS

Twenty-three patients (44 hips) met inclusion criteria with an average age of 7.3±1.7 years and a mean follow-up of 33.5 months. Group 1 and group 2 had 32 and 12 hips, respectively. Group 1 had significant improvement in all parameters (ΔMP=5%, ΔNSA=13 degrees, ΔHSA=15 degrees) group 2 showed improvements in NSA and HSA (ΔNSA=4 degrees ΔHSA=8 degrees) with only HSA reaching significance and MP remaining unchanged. All radiographic measurements worsened in the 2 years before surgery (N=25, natural history group) and improved after PFSH. Screw exchange occurred in 12 hips (27.2%) at an average of 33 months (range 27 to 42 mo) with 2 hips also undergoing pelvic osteotomy at that time. Three hips had a MP >50% at follow-up with 2 hips in group 1 undergoing hip reconstruction. No complications were noted.

CONCLUSION

PFSH effectively alters proximal femoral growth and can improve hip subluxation in children with CP. Screws often need to be exchanged and hips should be carefully monitored.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Med-Peds Residents' Career Plans and the Impact of Pediatric Hospital Medicine Fellowship: A Nationwide Survey

BACKGROUND

The establishment of pediatric hospital medicine (PHM) as a fellowship-trained subspecialty represents a major change in the practice landscape, particularly for combined internal medicine-pediatrics (med-peds) residents. The most recent literature on med-peds residents' career choices predates PHM fellowship and its impact has not been well studied. We aimed characterize med-peds residents' career plans and the factors influencing their choices.

METHODS

We distributed an electronic survey to the 1,505 resident members of the National Med-Peds Resident Association. In addition to sociodemographic data, participants reported their career plans, how well their residency prepared them for various aspects of practice, and their perceptions of PHM fellowship and its effect on their career choices.

RESULTS

Among the 228 participants, the most planned careers were combined hospital medicine (36.8%, 84/228), combined subspecialty practice (32.5%, 74/228), and primary care (31.1%, 71/228). Residents felt well prepared for patient care and significantly more prepared for inpatient practice than for primary care. Participants rated the potential disadvantages of PHM fellowship as major deterrents and did not view the possible advantages as strong incentives. Among those who had considered a hospital medicine careers, 91.2% (186/203) were less likely to pursue PHM after its certification as a subspecialty.

CONCLUSION

Med-peds residents have a wide range of career interests but fellowship has made them less likely to pursue PHM careers. These findings emphasize the importance of addressing the needs of med-peds trained providers as PHM certification pathways and fellowship curricula develop to avoid adverse effects on the workforce.

The corona mortis: is it a rare and dangerous anomaly in adolescents undergoing periacteabular osteotomy?

The corona mortis (CM) is a vascular connection between the obturator and external iliac or internal epigastric vessels that has historically been identified as a source of hemorrhage in pelvic surgery. However, its frequency, location, proximity to the osteotomies performed, vascular contributions and impact on blood loss in patients undergoing periacetabular osteotomy (PAO) are unknown. We sought to identify the frequency, origin, location relative to osteotomies performed during surgery and impact on blood loss of the CM. Preoperative magnetic resonance imaging (MRI) of the hips of 28 adolescent patients (56 hips) undergoing PAO was retrospectively reviewed for the presence of a CM. When identifiable, the size, nature (arterial or venous), orientation, position relative to the iliopectineal eminence (IPE) and associated estimated blood loss (EBL) were recorded. 75% (21/28) of patients possessed an identifiable, ipsilateral CM to the site of PAO, 90% of which were venous and 10% arterial. The vessel was typically 8.3 ± 3.8 mm medial and 11.1 ± 5.3 mm caudal from the anterosuperomedial edge of the IPE. There was no significant difference in the amount of EBL (519 ± 260 versus 694 ± 369 ml) or need for post-op transfusions (1/21 versus 0/7) between patients who possessed a CM and those who did not, respectively (P = 0.21). CM was more prevalent in this study than previously reported. However, the presence of an ipsilateral CM was not associated with an increase in EBL or transfusion during routine PAO surgery using modern surgical techniques.

Early versus Late Profiles of Inflammatory Cytokines after Mild Traumatic Brain Injury and Their Association with Neuropsychological Outcomes

Despite pre-clinical evidence for the role of inflammation in traumatic brain injury (TBI), there is limited data on inflammatory biomarkers in mild TBI (mTBI). In this study, we describe the profile of plasma inflammatory cytokines and explore associations between these cytokines and neuropsychological outcomes after mTBI. Patients with mTBI with negative computed tomography and orthopedic injury (OI) controls without mTBI were prospectively recruited from emergency rooms at three trauma centers. Plasma inflammatory cytokine levels were measured from venous whole-blood samples that were collected at enrollment (within 24 h of injury) and at 6 months after injury. Neuropsychological tests were performed at 1 week, 1 month, 3 months, and 6 months after the injury. Multivariate regression analysis was performed to identify associations between inflammatory cytokines and neuropsychological outcomes. A total of 53 mTBI and 24 OI controls were included in this study. The majority of patients were male (62.3%), and injured in motor vehicle accidents (37.7%). Plasma interleukin (IL)-2 (p = 0.01) and IL-6 (p = 0.01) within 24 h post-injury were significantly higher for mTBI patients compared with OI controls. Elevated plasma IL-2 at 24 h was associated with more severe 1-week post-concussive symptoms (p = 0.001). At 6 months, elevated plasma IL-10 was associated with greater depression scores (p = 0.004) and more severe post-traumatic stress disorder (PTSD) symptoms (p = 0.001). Plasma cytokine levels (within 24 h and at 6 months post-injury) were significantly associated with early and late post-concussive symptoms, PTSD, and depression scores after mTBI. These results highlight the potential role of inflammation in the pathophysiology of post-traumatic symptoms after mTBI.

Infantile Supracondylar Humeral Fractures (Patients Less Than Two Years of Age): Twice as Common in Females and a High Rate of Malunion with Lateral Column-Only Fixation

BACKGROUND

The age range for supracondylar humeral fractures spans from 1 to 14 years of age; most published studies have analyzed patients as non-age-segregated cohorts. Some isolated studies focused on the upper age range, demonstrating a male predominance and more severe fractures. The purpose of the current study was to analyze a large cohort of patients with surgically treated supracondylar humeral fractures at the low end of the age range (<2 years of age).

METHODS

Patients <2 years of age were identified from surgical billing records. Pin constructs were categorized as lateral column-only fixation or medial and lateral column fixation. All patients were followed through fracture-healing. Substantial loss of reduction was defined as a Baumann angle that changed ≥10° between surgery and healing or as a lateral rotation percentage (i.e., Gordon index) of ≥50% at the time of healing. The Fisher exact test was used for statistical analysis.

RESULTS

One hundred and three patients met our inclusion criteria. There were 69 female and 34 male patients (a 2:1 female-to-male ratio). Two patients did not have adequate follow-up radiographs. Of the 46 patients with bicolumnar fixation, 5 (11%) demonstrated loss of reduction compared with 20 (36%) of 55 patients with lateral column-only fixation. This difference between the groups was significant (p = 0.005). The group with lateral column-only fixation had 4.7-times-higher odds of loss of reduction (95% confidence interval, 1.6 to 13.8). A subset of patients had in-cast imaging that allowed calculation of the posterior sagittal cast index (a measure of cast fit). Eight of 15 patients who had a posterior sagittal cast index of ≥0.20 experienced loss of reduction, while only 1 of 19 patients with a cast index value of <0.20 had loss of reduction (p = 0.004).

CONCLUSIONS

Supracondylar humeral fractures were twice as common in females in this very young cohort. We also found a nearly 5-times-higher odds of loss of reduction when fracture fixation was of the lateral column only.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Use of Triphasic Bone Graft for the Treatment of Pediatric Bone Cysts: Experience at 2 Institutions

Unicameral/aneurysmal bone cysts can lead to pain, fracture, and limb deformity. In this study, the authors evaluated the outcome of triphasic bone graft to treat unicameral/aneurysmal bone cysts. They retrospectively evaluated 41 immature patients from a prospectively enrolled cohort from 2 institutions treated from May 9, 2007, to November 1, 2014. Medical record review and evaluation of radiographs and computed tomography scans were performed. The authors characterized replacement of the material by normal bone or recurrent cyst at final follow-up. They recorded rates of fractures and complications after treatment. Twenty-nine patients were treated in Wisconsin, and 12 patients were treated in Florida. Average follow-up was 2.8 years. At follow-up, 13 of 41 patients had cyst recurrence. Three patients had fracture after initial treatment; 2 were treated surgically. Two of 9 patients with extraosseous bone graft had soft tissue swelling, and 1 required debridement. Complications did not differ by cyst type, location, sex, age, or use of internal fixation. For 27 patients with at least 2-year follow-up, percent fill of triphasic bone graft at initial surgery correlated with rate of recurrence at final follow-up: 15 of 27 patients with no cyst recurrence at final follow-up had a mean of 100% initial fill, and 12 of 27 with cyst recurrence at final follow-up had a mean of 90% initial fill (P=.048). Using triphasic bone graft for the treatment of unicameral/aneurysmal bone cysts, the authors observed a 7% rate of clinical recurrence (3 of 41 had fracture). Because this material has the potential to be locally inflammatory, efforts are needed to keep it within the bone. [Orthopedics. 2018; 41(5):e705-e712.].

The care of VIPs in the emergency department: Triage, treatment and ethics

People identified as Very Important Persons (VIPs) often present or are referred to the Emergency Department (ED). Celebrities are a small subset of this group, but many others are included. Triage of these patients, including occasional prioritization, creates practical and ethical challenges. Treatment also provides challenges with the risks of over testing, overtreatment, over consultation, and over or under admission to the hospital. This article presents a practical and ethical framework for addressing the care of VIPs in the ED.

Out-of-Hospital Cardiac Arrest Resuscitation Systems of Care: A Scientific Statement From the American Heart Association

The American Heart Association previously recommended implementation of cardiac resuscitation systems of care that consist of interconnected community, emergency medical services, and hospital efforts to measure and improve the process of care and outcome for patients with cardiac arrest. In addition, the American Heart Association proposed a national process to develop and implement evidence-based guidelines for cardiac resuscitation systems of care. Significant experience has been gained with implementing these systems, and new evidence has accumulated. This update describes recent advances in the science of cardiac resuscitation systems and evidence of their effectiveness, as well as recent progress in dissemination and implementation throughout the United States. Emphasis is placed on evidence published since the original recommendations (ie, including and since 2010).

Impact of Regionalization of ST-Segment–Elevation Myocardial Infarction Care on Treatment Times and Outcomes for Emergency Medical Services–Transported Patients Presenting to Hospitals With Percutaneous Coronary Intervention

Background:

Regional variations in reperfusion times and mortality in patients with ST-segment–elevation myocardial infarction are influenced by differences in coordinating care between emergency medical services (EMS) and hospitals. Building on the Accelerator-1 Project, we hypothesized that time to reperfusion could be further reduced with enhanced regional efforts.

Methods:

Between April 2015 and March 2017, we worked with 12 metropolitan regions across the United States with 132 percutaneous coronary intervention–capable hospitals and 946 EMS agencies. Data were collected in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network)-Get With The Guidelines Registry for quarterly Mission: Lifeline reports. The primary end point was the change in the proportion of EMS-transported patients with first medical contact to device time ≤90 minutes from baseline to final quarter. We also compared treatment times and mortality with patients treated in hospitals not participating in the project during the corresponding time period.

Results:

During the study period, 10 730 patients were transported to percutaneous coronary intervention–capable hospitals, including 974 in the baseline quarter and 972 in the final quarter who met inclusion criteria. Median age was 61 years; 27% were women, 6% had cardiac arrest, and 6% had shock on admission; 10% were black, 12% were Latino, and 10% were uninsured. By the end of the intervention, all process measures reflecting coordination between EMS and hospitals had improved, including the proportion of patients with a first medical contact to device time of ≤90 minutes (67%–74%; P <0.002), a first medical contact to device time to catheterization laboratory activation of ≤20 minutes (38%–56%; P <0.0001), and emergency department dwell time of ≤20 minutes (33%–43%; P <0.0001). Of the 12 regions, 9 regions reduced first medical contact to device time, and 8 met or exceeded the national goal of 75% of patients treated in ≤90 minutes. Improvements in treatment times corresponded with a significant reduction in mortality (in-hospital death, 4.4%–2.3%; P =0.001) that was not apparent in hospitals not participating in the project during the same time period.

Conclusions:

Organization of care among EMS and hospitals in 12 regions was associated with significant reductions in time to reperfusion in patients with ST-segment–elevation myocardial infarction as well as in in-hospital mortality. These findings support a more intensive regional approach to emergency care for patients with ST-segment–elevation myocardial infarction.

Phase II Clinical Trial of Atorvastatin in Mild Traumatic Brain Injury

Statins constitute a class of medications commonly used in the treatment of elevated cholesterol. However, in experimental studies, statins also have other non-cholesterol-mediated mechanisms of action, which may have neuroprotective effects. The aim of this study was to determine whether administration of atorvastatin for 7 days post-injury would improve neurological recovery in patients with mild traumatic brain injury (mTBI). The hypothesis was that atorvastatin administration would reduce post-concussion symptoms and also that atorvastatin administration for 1 week post-injury would be safe. One hundred forty patients with mTBI were planned to be enrolled and randomly assigned to receive atorvastatin 1 mg/kg (up to 80 mg/kg) per day or placebo for 7 days starting within 24 h of injury. Assessments of post-concussion syndrome, post-traumatic stress and depressive symptoms, cognition, memory, verbal fluency, functional, and work status were performed at baseline, 1 week, and 1 and 3 months. The result on the Rivermead Post-Concussion Symptoms Questionnaire at 3 months was the primary outcome. Enrollment in the trial was stopped early because of difficulty in recruiting sufficient numbers of subjects. Fifty-two patients with mTBI were enrolled; 28 patients received atorvastatin and 24 received placebo. The median Rivermead score was 2 for the atorvastatin group, compared to 3.5 for the placebo group, at 3 months post-injury (χ2(1) = 0.0976; p = 0.7547). The change in the Rivermead score between baseline and 3 months was also analyzed. The median decrease in score was 4 for the atorvastatin group and 10.5 for the placebo group (χ2(1) = 0.8750; p = 0.3496). No serious adverse events occurred, and there was no significant difference in the incidence of adverse events in the two treatment groups. Atorvastatin administration for 7 days post-injury was safe, but there were no significant differences in neurological recovery post-mTBI with atorvastatin.

Comparison of 30-day mortality and myocardial scar indices for patients treated with prehospital reduced dose fibrinolytic followed by percutaneous coronary intervention versus percutaneous coronary intervention alone for treatment of ST-elevation myocardial infarction

OBJECTIVES

We investigated whether prehospital, reduced dose fibrinolysis coupled with urgent percutaneous coronary intervention (FAST-PCI) reduces mortality and cardiac magnetic resonance (CMR) measures of infarct size, compared with primary percutaneous coronary intervention (PPCI), in patients with ST-elevation myocardial infarction (STEMI).

BACKGROUND

Current standard therapy for STEMI is PPCI. However, FAST-PCI may shorten ischemic time (IT) and improve outcomes.

METHODS

Eligible STEMI patients received prehospital, reduced dose fibrinolysis along with standard therapy, and were transported for urgent percutaneous coronary intervention, or else they received usual treatment without prehospital fibrinolysis. Patients were divided retrospectively into four groups based on IT (<120, 120-179, 180-239 min, ≥240) for a mortality analysis cohort, and into three groups (<120, 120-179, ≥180 min) for a CMR analysis cohort. Within each IT group, patients were compared by FAST-PCI vs. PPCI strategy.

RESULTS

Between 1/2007 and 2/2014, 1,112 STEMI patients were treated. FAST-PCI was employed in 551 and PPCI in 561. Of these, 357 (32.1%) underwent CMR. The treatment groups were well matched. In STEMI patients with short IT (<120 and 120-179 min groups), those treated by FAST-PCI had lower 30-day mortality and myocardial scar sizes compared with PPCI treatment. For IT ≥180 min, the mortalities and myocardial scar sizes were equivalent for both groups.

CONCLUSIONS

In STEMI patients with IT <180 min, FAST-PCI may reduce 30-day mortality and myocardial scar size compared with PPCI. This suggests that infarct interventions must be instituted within 3 hr of symptom onset in order to detect an optimal beneficial effect both clinically and by CMR measurement. © 2016 Wiley Periodicals, Inc.

Cortical Thickness in Mild Traumatic Brain Injury

Magnetic resonance imaging data were acquired at ∼24 h and ∼3 months post-injury on mild traumatic brain injury (mTBI; n = 75) and orthopedic injury (n = 60) cohorts. The mTBI subjects were randomly assigned to a treatment group with atorvastatin or a non-treatment mTBI group. The treatment group was further divided into drug and placebo subgroups. FreeSurfer software package was used to compute cortical thickness based on the three dimensional T1-weighted images at both time-points. Cross-sectional analysis was carried out to compare cortical thickness between the mTBI and control groups. Longitudinal unbiased templates were generated for all subjects and cortical thickness measurements were compared between baseline and follow-up scans in the mTBI group. At baseline, significant reduction in cortical thickness was observed in the left middle temporal and the right superior parietal regions in the mTBI group, relative to the control group (p = 0.01). At follow-up, significant cortical thinning was again observed in the left middle temporal cortex in the mTBI group. Further analysis revealed significant cortical thinning only in the non-treatment group relative to the control group. In the follow-up, small regions with significant but subtle cortical thinning and thickening were seen in the frontal, temporal, and parietal lobes in the left hemisphere in the non-treatment group only. Our results indicate that cortical thickness could serve as a useful measure in identifying subtle changes in mTBI patients.

Voluntary Medical Incident Reporting Tool to Improve Physician Reporting of Medical Errors in an Emergency Department

Introduction

Medical errors are frequently under-reported, yet their appropriate analysis, coupled with remediation, is essential for continuous quality improvement. The emergency department (ED) is recognized as a complex and chaotic environment prone to errors. In this paper, we describe the design and implementation of a web-based ED-specific incident reporting system using an iterative process.

Methods

A web-based, password-protected tool was developed by members of a quality assurance committee for ED providers to report incidents that they believe could impact patient safety.

Results

The utilization of this system in one residency program with two academic sites resulted in an increase from 81 reported incidents in 2009, the first year of use, to 561 reported incidents in 2012. This is an increase in rate of reported events from 0.07% of all ED visits to 0.44% of all ED visits. In 2012, faculty reported 60% of all incidents, while residents and midlevel providers reported 24% and 16% respectively. The most commonly reported incidents were delays in care and management concerns.

Conclusion

Error reporting frequency can be dramatically improved by using a web-based, user-friendly, voluntary, and non-punitive reporting system.

Detection of Subtle Cognitive Changes after mTBI Using a Novel Tablet-Based Task

This study examined the potential for novel tablet-based tasks, modeled after eye tracking techniques, to detect subtle sensorimotor and cognitive deficits after mild traumatic brain injury (mTBI). Specifically, we examined whether performance on these tablet-based tasks (Pro-point and Anti-point) was able to correctly categorize concussed versus non-concussed participants, compared with performance on other standardized tests for concussion. Patients admitted to the emergency department with mTBI were tested on the Pro-point and Anti-point tasks, a current standard cognitive screening test (i.e., the Standard Assessment of Concussion [SAC]), and another eye movement-based tablet test, the King-Devick(®) (KD). Within hours after injury, mTBI patients showed significant slowing in response times, compared with both orthopedic and age-matched control groups, in the Pro-point task, demonstrating deficits in sensorimotor function. Mild TBI patients also showed significant slowing, compared with both control groups, on the Anti-point task, even when controlling for sensorimotor slowing, indicating deficits in cognitive function. Performance on the SAC test revealed similar deficits of cognitive function in the mTBI group, compared with the age-matched control group; however, the KD test showed no evidence of cognitive slowing in mTBI patients, compared with either control group. Further, measuring the sensitivity and specificity of these tasks to accurately predict mTBI with receiver operating characteristic analysis indicated that the Anti-point and Pro-point tasks reached excellent levels of accuracy and fared better than current standardized tools for assessment of concussion. Our findings suggest that these rapid tablet-based tasks are able to reliably detect and measure functional impairment in cognitive and sensorimotor control within hours after mTBI. These tasks may provide a more sensitive diagnostic measure for functional deficits that could prove key to earlier detection of concussion, evaluation of interventions, or even prediction of persistent symptoms.

Scaling up self-assembly: bottom-up approaches to macroscopic particle organization

This review presents an overview of recent work in the field of non-Brownian particle self-assembly. Compared to nanoparticles that naturally self-assemble due to Brownian motion, larger, non-Brownian particles (d > 6 μm) are less prone to autonomously organize into crystalline arrays. The tendency for particle systems to experience immobilization and kinetic arrest grows with particle radius. In order to overcome this kinetic limitation, some type of external driver must be applied to act as an artificial "thermalizing force" upon non-Brownian particles, inducing particle motion and subsequent crystallization. Many groups have explored the use of various agitation methods to overcome the natural barriers preventing self-assembly to which non-Brownian particles are susceptible. The ability to create materials from a bottom-up approach with these characteristics would allow for precise control over their pore structure (size and distribution) and surface properties (topography, functionalization and area), resulting in improved regulation of key characteristics such as mechanical strength, diffusive properties, and possibly even photonic properties. This review will highlight these approaches, as well as discuss the potential impact of bottom-up macroscale particle assembly. The applications of such technology range from customizable and autonomously self-assembled niche microenvironments for drug delivery and tissue engineering to new acoustic dampening, battery, and filtration materials, among others. Additionally, crystals made from non-Brownian particles resemble naturally derived materials such as opals, zeolites, and biological tissue (i.e. bone, cartilage and lung), due to their high surface area, pore distribution, and tunable (multilevel) hierarchy.

Prevalence and Predictors of Poor Recovery from Mild Traumatic Brain Injury

Although most patients with mild traumatic brain injury (mTBI) recover within 3 months, a subgroup of patients experience persistent symptoms. Yet, the prevalence and predictors of persistent dysfunction in patients with mTBI remain poorly understood. In a longitudinal study, we evaluated predictors of symptomatic and cognitive dysfunction in adolescents and young adults with mTBI, compared with two control groups-patients with orthopedic injuries and healthy uninjured individuals. Outcomes were assessed at 3 months post-injury. Poor symptomatic outcome was defined as exhibiting a symptom score higher than 90% of the orthopedic control (OC) group, and poor cognitive outcome was defined as exhibiting cognitive performance poorer than 90% of the OC group. At 3 months post-injury, more than half of the patients with mTBI (52%) exhibited persistently elevated symptoms, and more than a third (36.4%) exhibited poor cognitive outcome. The rate of high symptom report in mTBI was markedly greater than that of typically developing (13%) and OC (17%) groups; the proportion of those with poor cognitive performance in the mTBI group exceeded that of typically developing controls (15.8%), but was similar to that of the OC group (34.9%). Older age at injury, female sex, and acute symptom report were predictors of poor symptomatic outcome at 3 months. Socioeconomic status was the only significant predictor of poor cognitive outcome at 3 months.

Multi-modal MRI of mild traumatic brain injury

Multi-modal magnetic resonance imaging (MRI) that included high resolution structural imaging, diffusion tensor imaging (DTI), magnetization transfer ratio (MTR) imaging, and magnetic resonance spectroscopic imaging (MRSI) were performed in mild traumatic brain injury (mTBI) patients with negative computed tomographic scans and in an orthopedic-injured (OI) group without concomitant injury to the brain. The OI group served as a comparison group for mTBI. MRI scans were performed both in the acute phase of injury (~24 h) and at follow-up (~90 days). DTI data was analyzed using tract based spatial statistics (TBSS). Global and regional atrophies were calculated using tensor-based morphometry (TBM). MTR values were calculated using the standard method. MRSI was analyzed using LC Model. At the initial scan, the mean diffusivity (MD) was significantly higher in the mTBI cohort relative to the comparison group in several white matter (WM) regions that included internal capsule, external capsule, superior corona radiata, anterior corona radiata, posterior corona radiata, inferior fronto-occipital fasciculus, inferior longitudinal fasciculus, forceps major and forceps minor of the corpus callosum, superior longitudinal fasciculus, and corticospinal tract in the right hemisphere. TBSS analysis failed to detect significant differences in any DTI measures between the initial and follow-up scans either in the mTBI or OI group. No significant differences were found in MRSI, MTR or morphometry between the mTBI and OI cohorts either at the initial or follow-up scans with or without family wise error (FWE) correction. Our study suggests that a number of WM tracts are affected in mTBI in the acute phase of injury and that these changes disappear by 90 days. This study also suggests that none of the MRI-modalities used in this study, with the exception of DTI, is sensitive in detecting changes in the acute phase of mTBI.

Validation of sepsis screening tool using StO2 in emergency department patients

BACKGROUND

Sepsis is a deleterious systemic response to an infection with a high incidence of morbidity and mortality, affecting more than a million patients a year in the US. The purpose of this study was to develop a screening tool for the early identification of sepsis in emergency department patients using readily available information at triage.

MATERIALS AND METHODS

This prospective, observational study took place at an academic tertiary referral hospital. Over a period of 10 wk, all patients who were seen at triage were screened for study enrollment. Inclusion criteria were adult (age≥18 y) nontrauma patients and exclusion criteria were prisoners and pregnant women. Using a Spot Check StO2 device to measure StO2 value, heart rate, respiratory rate, and temperature, these values were used to generate a cumulative screening score indicating whether a patient may have sepsis.

RESULTS

A total of 500 patients were screened. The incidence of sepsis in the present study population was 8.4%. The screening tool yielded a sensitivity of 85.7%, a specificity of 78.4%, a positive predictive value of 26.7%, and a negative predictive value of 98.4%.

CONCLUSIONS

Heart rate, respiratory rate, and temperature have good diagnostic potential for the early identification of sepsis among emergency department triage personnel. Additionally, early evidence suggests StO2 may play a complementary and synergistic role in the early identification of sepsis by triage personnel.

A collaborative system to improve compartment syndrome recognition

BACKGROUND AND OBJECTIVE

Acute compartment syndrome (ACS) is a rare but serious complication of extremity injury that can cause permanent damage or death. ACS development is variable and unpredictable, and delay in recognition or treatment of ACS can lead to significant morbidity. Our objective was to create a reliable system for recognition of patients at risk and monitoring for ACS that could withstand frequent provider turnover.

METHODS

Using the Model for Improvement, we identified key drivers and failure modes for 2 processes: resident and nurse practitioner proper order entry and bedside nurse proper documentation of monitoring. Interventions were tested in frequent plan-do-study-act cycles. Effective interventions were used in combination to test for sustainability.

RESULTS

Proper order entry increased from 23% at baseline to 90%. Proper documentation for patients with correct orders increased from 15% to 70%. Individual interventions, including pocket card distribution, electronic medical record order set, and direct discussion by team leaders, were associated with improvement among residents but were not sustained with team turnover. Incorporating all 4 individual interventions into the on-boarding process for residents produced consistent success. Nursing documentation improved with education and maintenance of proper order entry.

CONCLUSIONS

We built a reliable, sustainable system to recognize and monitor patients at risk for ACS. Interventions designed to minimally disrupt existing workflows were individually associated with improvement. We achieved sustainability through staff turnover when we incorporated the interventions into routine orientation for new staff. Hospitals can use existing orders and protocols to sustain surveillance for ACS and other acute conditions.

Preinjury resilience and mood as predictors of early outcome following mild traumatic brain injury

There is significant heterogeneity in outcomes following mild traumatic brain injury (mTBI). While several host factors (age, gender, and preinjury psychiatric history) have been investigated, the influence of preinjury psychological resilience and mood status in conjunction with mild TBI remains relatively unexplored. Euthymic mood and high resilience are potentially protective against anxiety and postconcussion symptoms, but their relative contributions are currently unknown. This prospective study obtained preinjury estimates of resilience and mood measures in addition to measures of anxiety (Acute Stress Disorder Scale and PTSD-Checklist-Civilian form) and postconcussion symptom severity (Rivermead Post Concussion Symptoms Questionnaire) <24 hours (Baseline), 1 week, and 1 month postinjury in patients with either mTBI (n=46) or a comparison group with orthopedic injuries not involving the head (OI, n=29). The groups did not differ on preinjury resilience or mood status at baseline, but differed significantly on measures of anxiety and postconcussion symptom severity at each subsequent study occasion. Multivariate linear regression analyses were conducted to determine if preinjury resilience and mood were significant contributors to anxiety and postconcussion symptoms during the first month postinjury after accounting for other known host factors (e.g., age at injury, gender, and education). Injury group and preinjury mood status were significant predictors for all three dependent variables at each study occasion (all p<0.007). Preinjury resilience showed a positive trend only for acute stress severity at baseline, but demonstrated significant prediction of all three dependent measures at one week and one month postinjury. These results suggest that preinjury depressed mood and resilience are significant contributors to the severity of postinjury anxiety and postconcussion symptoms, even after accounting for effects of other specific host factors.

Ambient hypoxia enhances the loss of muscle mass after extensive injury

Hypoxia induces a loss of skeletal muscle mass and alters myogenesis in vitro, but whether it affects muscle regeneration in vivo following injury remains to be elucidated. We hypothesized that hypoxia would impair the recovery of muscle mass during regeneration. To test this hypothesis, the soleus muscle of female rats was injured by notexin and allowed to recover for 3, 7, 14, and 28 days under normoxia or hypobaric hypoxia (5,500 m) conditions. Hypoxia impaired the formation and growth of new myofibers and enhanced the loss of muscle mass during the first 7 days of regeneration, but did not affect the final recovery of muscle mass at 28 days. The impaired regeneration under hypoxic conditions was associated with a blunted activation of mechanical target of rapamycin (mTOR) signaling as assessed by p70(S6K) and 4E-BP1 phosphorylation that was independent of Akt activation. The decrease in mTOR activity with hypoxia was consistent with the increase in AMP-activated protein kinase activity, but not related to the change in regulated in development and DNA response 1 protein content. Hypoxia increased the mRNA levels of the atrogene muscle ring finger-1 after 7 days of regeneration, though muscle atrophy F box transcript levels remained unchanged. The increase in MyoD and myogenin mRNA expression with regeneration was attenuated at 7 days with hypoxia. In conclusion, our results support the notion that the enhanced loss of muscle mass observed after 1 week of regeneration under hypoxic conditions could mainly result from the impaired formation and growth of new fibers resulting from a reduction in protein synthesis and satellite cell activity.

Comparison of in-hospital outcomes with low-dose fibrinolytic therapy followed by urgent percutaneous coronary intervention versus percutaneous coronary intervention alone for treatment of ST-elevation myocardial infarction

In patients with acute ST-elevation myocardial infarction (STEMI), a strategy of prehospital reduced dose fibrinolytic administration coupled with urgent percutaneous coronary intervention (PCI), termed FAST-PCI strategy, has been found to be superior to primary PCI (PPCI) alone. A coordinated STEMI system of care that includes FAST-PCI should offer better outcomes than a system in which prehospital diagnosis of STEMI is followed by PPCI alone. The aim of this study was to compare the in-hospital outcomes for patients treated with the FAST-PCI approach with outcomes for patients treated with the PPCI approach in a common system. The in-hospital data for 253 STEMI patients (March 2003-December 2009) treated with a FAST-PCI protocol were compared with 124 patients (January 2010-August 2011) treated with PPCI strategy alone. In-hospital mortality was the primary comparator. Stroke, major bleeding, and reinfarction during index hospitalization were also compared. The in-hospital mortality was significantly lower with FAST-PCI than with PPCI (2.77% vs 10.48%, p = 0.0017). Rates of stroke, reinfarction, and major bleeding were similar in the 2 groups. There was a lower frequency of pre-PCI Thrombolysis In Myocardial Infarction 0 flow (no patency) seen in patients treated with FAST-PCI compared with the PPCI patients (26.7% vs 62.7%, p <0.0001). Earlier infarct artery patency in the FAST-PCI group had a favorable impact on the incidence of cardiogenic shock on hospital arrival (3.1% vs 20.9%, p <0.0001). In conclusion, compared with a PPCI strategy in a common STEMI system of care, the FAST-PCI strategy was associated with earlier infarct artery patency and lower incidence of cardiogenic shock, as well as with reduced in-hospital mortality.

An emergency department thawed plasma protocol for severely injured patients

IMPORTANCE

In an effort to expedite delivery of plasma for patients requiring massive transfusions, US medical centers began keeping thawed plasma (TP) in their blood banks (BBs), markedly reducing time to release of plasma; however, the time to transfusion was still excessively long.

OBJECTIVE

To expedite delivery and transfusion of TP through implementation of an emergency department (ED) protocol.

DESIGN AND SETTING

Retrospective cohort study in an American College of Surgeons-verified level I trauma center.

PARTICIPANTS

Using the Trauma Registry of the American College of Surgeons database, we evaluated all adult trauma patients admitted from June 1, 2009, through August 31, 2010, who arrived directly from the scene, were the institution's highest level trauma activation, and received at least 1 U of red blood cells and 1 U of plasma in the first 6 hours after admission. The protocol was initiated in February 2010 by giving 4 U of AB plasma to patients in the ED. Patients were then divided into 2 groups: those admitted 8 months before (TP-BB) and 8 months after implementing TP location change (TP-ED).

MAIN OUTCOME MEASURES

Primary outcome was time to first unit of plasma. Secondary outcomes included 24-hour blood use and 24-hour and 30-day mortality.

RESULTS

A total of 294 patients met the study criteria (130 in the TP-BB group and 164 in the TP-ED). Although the patient demographics were similar, TP-ED patients had greater anatomical injury (median Injury Severity Score, 18 vs 25; P = .02) and more physiologic disturbances (median weighted Revised Trauma Score, 6.81 vs 3.83; P = .008). The TP-ED patients had a shorter time to first plasma transfusion (89 vs 43 minutes, P < .001). The TP-ED protocol was associated with a reduction in 24-hour transfusion of RBCs (P = .04), plasma (P = .04), and platelets (P < .001). Logistic regression identified TP-ED as an independent predictor of decreased 30-day mortality (odds ratio, 0.43; 95% CI, 0.194-0.956; P = .04).

CONCLUSIONS

We demonstrated that implementation of an ED-TP protocol expedites transfusion of plasma to severely injured patients. This approach is associated with a reduction in overall blood product use and a 60% decreased odds in 30-day mortality.

Granular mixing and segregation in zigzag chute flow

Periodic flow inversions have been shown as an effective means to eliminate both density (D system) and size (S system) segregation. The frequency of these inversions, however, is the key to applying this technique and is directly related to the inverse of the characteristic time of segregation. In this work, we study size segregation (S system) and adapt a size segregation model to compliment existing work on density segregation and, ultimately, aid in determining the critical forcing frequency for S systems. We determine the impact on mixing and segregation of both the binary size ratio and the length of each leg of a "zigzag chute". Mixing is observed when L < U tS, where L, U, and t(S) denote the length of each leg of the zigzag chute, the average streamwise flow velocity of the particle, and the characteristic time of segregation, respectively.

Ulnar fracture with late radial head dislocation: delayed Monteggia fracture

Monteggia fractures are rare but commonly discussed lesions, with increasing complications due to late diagnosis. This article describes a case of a Monteggia fracture with delayed dislocation of the radial head. Previous radiographs of a 2-year 8-month-old boy show complete fracture of the distal ulna, with no radial head dislocation. The radial head remained well positioned after 4 weeks. Seven years later, he sustained another arm injury. He was diagnosed with a hematoma but was later believed to have nursemaid's elbow. He presented to our institution 5 weeks after the injury, and the radial head was found to be chronically dislocated, indicating a displacement occurring sometime during the past 7 years. After failing conservative treatment, the patient underwent surgical repair. The annular ligament was reconstructed using a harvested triceps fascia band, and an ulnar osteotomy was performed. A review of the literature found few reports of delayed Monteggia fractures, which accounted the delayed dislocations to ulnar angulation. However, our patient showed minimal ulnar angular deformity. We propose that the initial fracture disrupted the annular ligament and the radial head spontaneously relocated prior to being seen, which put the radial head at risk for later dislocation. We present an alternative hypothesis of dislocation after fracture healing and report the longest known period of delay between fracture and dislocation.

Prehospital 12-Lead Electrocardiogram within 60 Minutes Differentiates Proximal versus Nonproximal Left Anterior Descending Artery Myocardial Infarction

Introduction

Acute anterior myocardial infarctions caused by proximal left anterior descending (LAD) artery occlusions are associated with a higher morbidity and mortality. Early identification of high-risk patients via the 12-lead electrocardiogram (ECG) could assist physicians and emergency response teams in providing early and aggressive care for patients with anterior ST-elevation myocardial infarctions (STEMI). Approximately 25% of US hospitals have primary percutaneous coronary intervention (PCI) capability for the treatment of acute myocardial infarctions. Given the paucity of hospitals capable of PCI, early identification of more severe myocardial infarction may prompt emergency medical service routing of these patients to PCI-capable hospitals. We sought to determine if the 12 lead ECG is capable of predicting proximal LAD artery occlusions.

Methods

In a retrospective, post-hoc analysis of the Pre-Hospital Administration of Thrombolytic Therapy with Urgent Culprit Artery Revascularization pilot trial, we compared the ECG findings of proximal and nonproximal LAD occlusions for patients who had undergone an ECG within 180 minutes of symptom onset.

Results

In this study, 72 patients had anterior STEMIs, with ECGs performed within 180 minutes of symptom onset. In patients who had undergone ECGs within 60 minutes (n = 35), the mean sum of ST elevation (STE) in leads V1 through V6 plus ST depression (STD) in leads II, III, and aVF was 19.2 mm for proximal LAD occlusions and 11.7 mm for nonproximal LAD occlusions (P = 0.007). A sum STE in V1 through V6 plus STD in II, III, and aVF of at least 17.5 mm had a sensitivity of 52.3%, specificity of 92.9%, positive predictive value of 91.7%, and negative predictive value of 56.5% for proximal LAD occlusions. When the ECG was performed more than 60 minutes after symptom onset (n = 37), there was no significant difference in ST-segment deviation between the 2 groups.

Conclusion

The sum STE (V1-V6) and STD (II, III, aVF) on a 12-lead ECG can be used to predict proximal LAD occlusions if performed within the first hour of symptom onset. This should be considered a high-risk finding and may prompt prehospital direction of such patients to PCI-capable hospitals.

Sagittal plane deformity during femoral lengthening

The purpose of this study was to determine the incidence and degree of sagittal plane deformity that occurs during limb lengthening of the femur. Twenty-one patients (25 limbs) were identified who underwent femoral lengthening. The limbs were lengthened a mean of 6.1 cm, and mean follow-up was 1.5 years. The immediate postoperative deformity in the sagittal plane was 8.3°; this deformity did not progress during lengthening (P<.05). Mean displacement in the sagittal plane was 3.1 mm.Angular deformities, although typically small, can occur in the sagittal plane and may be accompanied by displacement. These deformities are usually present immediately postoperatively and typically do not worsen significantly with lengthening.

Are terminally threaded guide pins from cannulated screw systems dangerous?

Threaded and smooth pins are often used in orthopedic surgery. Although uncommon, injury to the soft tissues can and do occur, including nerve or vessel injury from aberrant pin placement. The purpose of this study was to compare the risk of nerve injury from threaded pins versus smooth guide pins due to: (1) past-point-drilling of the pin, or (2) entanglement of the pin with soft tissue. Past-point drilling was tested by a blindfolded participant drilling a 1.6-mm guide pin (terminally threaded or smooth) through a porcine femur until they felt they had drilled through the second cortex. The distance over-drilled was measured in millimeters. Twenty trials were randomly completed, 10 with each pin type. Entanglement of soft tissue was tested by placing the terminal portion of the guide pin on the nerve. Two drilling positions were tested: (1) drilling at 90° and (2) parallel to the nerve. The drill was run for 1 second and assessed for entanglement and magnitude of entanglement (measured in millimeters of nerve wrapped by the pin). Sixty trials were completed, 15 with each pin type, and in each of the 2 positions. The average past-point drilling depths were 4.6 and 16.9 mm for the smooth and threaded pins, respectively (P<.05). The mean nerve overwrapping was 0.45 and 4.7 mm, for the smooth and threaded pins, respectively (P<.05), drilled at 90° and 0.15 and 0.92 mm, respectively (P<.05) in the parallel position. In 13 of 60 trials with the smooth pin and 50 of 60 trials with the threaded pin, wrapping was observed (P<.05). This study demonstrates that it is difficult to determine by feel when the threaded pin has drilled through the second cortex of the bone, in contrast to the smooth pin. Furthermore, soft tissue entanglement is more likely and to a greater magnitude with threaded pins than with smooth.

Sex and age differences in lipid response to chronic infection with the hepatitis C virus in the United States National Health and Nutrition Examination Surveys

Low levels of serum lipids were reported in subjects chronically infected with the hepatitis C virus (HCV) and correlated with poorer clinical outcomes. Whether HCV 'hypo-lipidemia' is constant across age, sex and race has not been systematically explored. We therefore investigated the association between HCV infection and serum lipid levels in two independent National Health and Nutrition Examination Survey (NHANES) cohorts. HCV antibody status and serum lipid levels were obtained from 14 369 adults from NHANES 1999-2006 and 12 261 from NHANES III (enrolled in 1988-1994). In multivariable models, the prevalence of HCV-associated hypo-low density lipoprotein-cholesterol was highest among women >50 years of age in both NHANES 1999-2006 (OR: 10.51, 95% CI: 2.86, 38.62) and III (OR: 24.21, 95% CI: 6.17, 94.92), but among women <50 years of age, the odds ratios were 3.01 (95% CI: 1.00, 9.04) for NHANES 1999-2006 and 0.52 (95% CI: 0.14, 1.88) for III, respectively. HCV by age interaction among women was significant in both cohorts (P < 0.001 and P = 0.004, respectively). Among men, the odds ratios of HCV-associated hypo-LDL-cholesterol were 2.74 (95% CI: 1.55, 4.85) in NHANES 1999-2006 and 3.84 (95% CI: 1.66, 8.88) in III, respectively, with no significant age effects. Similar patterns were observed for total-cholesterol, but no significantly discernable patterns for high density lipoprotein-cholesterol and triglycerides. Results show that HCV infection is associated with lower total- and LDL-cholesterol in two US population-based cohorts, and this relationship varies significantly by age and sex, suggesting a possible influence of sex hormones on host lipid response to HCV infection.

Serum apolipoprotein C-III is independently associated with chronic hepatitis C infection and advanced fibrosis

BACKGROUND

The hepatitis C virus (HCV) is known to disrupt lipid metabolism, making serum lipoprotein levels good candidates to explore as markers of HCV disease progression. Assessment of the major apolipoproteins (Apo) and their relationship to hepatic fibrosis remain largely unexplored.

METHODS

We compared the levels of total cholesterol, triglycerides, low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C), and Apo A-I, -B, -C-III, and -E between patients with cleared versus active infection (n = 83), and between those chronically infected patients (n = 216) with advanced versus mild-moderate hepatic fibrosis (METAVIR stage F3-4 vs. F0-2) using multiple logistic regression.

RESULTS

Apo C-III levels were 25% higher in subjects with cleared infection versus those with active infection (p = 0.009). Low levels of Apo C-III (p = 1.3 × 10(-5)), Apo A-I (p = 2.9 × 10(-5)), total cholesterol (p = 5.0 × 10(-4)), LDL-C (p = 0.005), and HDL-C (p = 2.0 × 10(-4)) were associated with advanced fibrosis in univariate analyses. Multivariable analysis revealed Apo C-III as the most significant factor associated with advanced fibrosis (p = 0.0004), followed by age (p = 0.013) and Apo A-I (p = 0.022). Inclusion of both Apo C-III and Apo A-I in a model to predict advanced fibrosis improved the area under the receiver operator curve only modestly.

CONCLUSIONS

Relative to other lipoproteins, low serum Apo C-III levels are the most strongly associated with chronic versus cleared infection and decline with increasing severity of hepatic fibrosis. Apo C-III deserves further attention as a possible marker of HCV disease progression.

The whale pump: marine mammals enhance primary productivity in a coastal basin

It is well known that microbes, zooplankton, and fish are important sources of recycled nitrogen in coastal waters, yet marine mammals have largely been ignored or dismissed in this cycle. Using field measurements and population data, we find that marine mammals can enhance primary productivity in their feeding areas by concentrating nitrogen near the surface through the release of flocculent fecal plumes. Whales and seals may be responsible for replenishing 2.3×10⁴ metric tons of N per year in the Gulf of Maine's euphotic zone, more than the input of all rivers combined. This upward “whale pump” played a much larger role before commercial harvest, when marine mammal recycling of nitrogen was likely more than three times atmospheric N input. Even with reduced populations, marine mammals provide an important ecosystem service by sustaining productivity in regions where they occur in high densities.

Nitrogenous nutrition of marine phytoplankton in nutrient-depleted waters

Variability in the small-scale temporal and spatial patterns in nitrogenous nutrient supply, coupled with an enhanced uptake capability for nitrogenous nutrients induced by nitrogen limitation, make it possible for phytoplankton to maintain nearly maximum rates of growth at media nutrient concentrations that cannot be quantified with existing analytical techniques.

Correction of Blount's disease by a multi-axial external fixation system

BACKGROUND

Blount's disease is a multi-planar deformity affecting the pediatric population which leads to varus alignment of the lower extremities. The Multi-Axial Correction (MAC) monolateral external fixation system (Biomet, Parsippany, NJ, USA) is a non-circular fixator that was developed as a response to the technical difficulty for both patients and physicians of placing, managing, and tolerating a circular fixator. The purpose of this study was to determine the efficacy of the MAC system for the treatment of pediatric patients with Blount's disease.

METHODS

A retrospective analysis of 17 consecutive patients with surgically corrected Blount's disease using the MAC system with tibial and fibular osteotomies was identified. Patient charts and radiographs at three different time points (pre-operative, fixator removal, and final follow-up) were reviewed. The mechanical axis deviation (MAD), tibial-femoral angle (TFA), medial proximal tibial angle (MPTA), and posterior proximal tibial angle (PPTA) were measured in the MAC group at the three time points mentioned previously. The total wear time, total operative time, and post-operative complications were noted.

RESULTS

The MAC system was able to correct the deformity of Blount's disease as measured by a decrease in the MAD (40.2 +/- 29.3 mm; P </= 0.001) and TFA (15.9 +/- 13.7 degrees ; P </= 0.001), as well as an increase in the MPTA (15.7 +/- 14.6 degrees ; P = 0.001) at the time of fixator removal. The correction was maintained for these parameters at the time of final follow-up (P </= 0.025). The absolute values obtained at final follow-up for MAD (20.5 +/- 12.7 mm medial), TFA (8.0 +/- 4.1 degrees varus), and MPTA (83.7 +/- 8.1 degrees ) after correction with the MAC system were close to what is considered as normal for these indices. The most common complications noted were superficial pin tract infections and/or cellulitis, with no patients having nerve palsy, compartment syndrome, non-union, or leg length discrepancies. The total time that the fixator was on the patients prior to removal was 130.6 days (standard deviation [SD] = 44.8). The mean operative time was 120.6 min (SD = 21.2).

CONCLUSIONS

Correction of Blount's disease with osteotomy of the tibia and fibula as well as dynamic fixation with the MAC system achieved deformity correction as measured by radiographic indices with minimal intra- and post-operative complications. The ease of application and adjustment of the MAC system makes it an attractive option for Blount's deformity correction.

Dying to play video games: carbon monoxide poisoning from electrical generators used after hurricane Ike

BACKGROUND

Carbon monoxide (CO) poisoning is common after major storms because of loss of electrical power and use of alternate fuel sources for heat and electricity. In past epidemics of hurricane-related CO poisoning, the source has typically been gasoline-powered electrical generators. Although it is typically believed that generators were used to power air conditioning and refrigeration, this report demonstrates an unsuspected reason for their use.

PATIENTS AND METHODS

After Hurricane Ike's landfall in September 2008, major power outages were associated with an epidemic of CO poisoning from electrical generators, as expected. Staff at Memorial Hermann Hospital-Texas Medical Center treated or telephone-triaged cases from the Houston area. A review of the details of those cases forms the basis of this report.

RESULTS

Memorial Hermann Hospital-Texas Medical Center staff treated or triaged 37 individuals exposed to CO from gasoline-powered electrical generators in 13 incidents in the first 36 hours after landfall of the hurricane. Notably, 54% (20 of 37) of the patients were under the age of 18 years. Symptoms ranged from mild to severe, with 1 child dying at the scene. Eleven patients were treated with hyperbaric oxygen. Among 9 incidents in which the reason for generator use was determined, 5 were due to generators powering video games or televisions to watch movies or programs. These 5 incidents in which video games were being powered accounted for 75% (15 of 20) of the pediatric poisonings.

CONCLUSIONS

Generator-related CO poisoning is indeed common during power outages after hurricanes. However, generators are commonly being used to provide electricity to power entertainment devices for children, such as video games. Additional public education about CO risk is needed, perhaps directed at older children and teenagers through the schools in regions susceptible to hurricanes.

Pediatric deformity correction using a multiaxial correction fixator

Circular fixators have been used successfully to correct multiplanar deformities but are often cumbersome and may be difficult to apply. We determined whether a monolateral fixator, which allows for correction of angular deformity and displacement in three planes, can correct lower extremity deformities to within normal radiographic means (anatomic lateral distal femoral angle, anatomic medial proximal tibial angle, and tibial femoral angle). We retrospectively reviewed the clinical records and radiographs of 22 consecutive patients (25 limbs) who underwent deformity correction using a new multiaxial monolateral external fixator. The patients were 4 to 16 years of age. We had a minimum 1.2-year followup (mean, 2.14 years; range, 1.2-3.1 years). Those with primary femoral and tibial deformities had improvements in the mean deviation from normal of the anatomic lateral distal femoral angle, anatomic medial proximal tibial angle and tibial femoral angle. Patients with Blount's disease had improvements in the mean anatomic medial proximal tibial angle from 59.9 masculine to 87.8 masculine. Five patients had complications (two pin site infections, one premature consolidation, one knee flexion contracture, one recurrence of varus). Six patients developed secondary deformities, all of which were corrected using the primary or secondary hinge. We conclude this fixator can produce satisfactory results with relatively few complications.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.