Early Utilization of Ketorolac in Cleft Palate Repair

OBJECTIVE

To determine the effect of ketorolac on opiate requirement and hospital length of stay after palatoplasty.

DESIGN

This was a retrospective chart review.

SETTING

This study was completed at an urban tertiary medical center.

PATIENTS

Those who underwent palatoplasty with a pediatric otolaryngologist between 2010-2020.

INTERVENTIONS

Incorporation of standing Ketorolac into the immediate post-operative pain regimen.

MAIN OUTCOME MEASURES

T-test analysis was performed to determine whether initiation of ketorolac within 24 h post-palatoplasty was correlated with shorter length hospitalization or reduced opiate requirement.

RESULTS

A total of 55 pediatric subjects (49.1% female) were included in this study. Average age at time of surgery was 13 months (range 9.9-33.9 months). On two tailed t-test, use of ketorolac within the first 24 h after palatoplasty was associated with shorter length of stay (mean of 1.68 vs 2.57 days, t = 2.58, P = .01) and lower total opiate dosage during hospitalization (mean of 2.8 vs 9.16 morphine milligram equivalents, t = 3.37, P = .001).

CONCLUSIONS

Among patients undergoing palatoplasty, there is a significant relationship between the early utilization of ketorolac and decreased length of hospitalization as well as decreased opiate requirement. This has important consequences to help improve pain control with reduced opiates requirement as well as length of stay. Future prospective studies can help elicit the causative effect of Ketorolac on these parameters and can investigate whether use of Ketorolac has an effect on long term recovery and post-discharge opiate requirements as well.

Polysomnography-guided mandibular distraction osteogenesis in Pierre Robin sequence patients

STUDY OBJECTIVES

Craniofacial malformations with micrognathia cause high grades of obstructive sleep apnea (OSA) measured by polysomnography (PSG). Mandibular Distraction Osteogenesis (MDO) is a novel procedure for upper airway obstruction (UAO) relief. Our primary objective was to describe the utilization of PSGs to improve obstruction in patients undergoing mandibular distraction.

METHODS

This is a retrospective study. Patients with micrognathia and severe UAO, presenting with severe OSA diagnosed by PSG, were included from a single tertiary care center between 2015-2019. PSGs were done: (1) prior to surgery, (2) once cosmetic goal was achieved (Post-Op 1) (3) if residual moderate-to-severe OSA was seen, every 2 nights until mild or no OSA was achieved (Post-Op 2).

RESULTS

Thirteen patients were included. The median age at surgery was 1.1months (10 days-3 months). All thirteen patients had baseline severe OSA, with a median obstructive apnea-hypopnea index (OAHI) of 33 events/h and a median O₂ nadir of 73%. Post-Op 1 PSG was done at a median of 6 days after surgery. Median first post-operative OAHI in all 13 patients was 6.8 events/h, with a median O₂ nadir of 87%. A median additional distraction of 3 mm was needed beyond the traditionally recommended advancement. Long term follow-up studies at or after 1year were done in 5 patients, all showing persistent non-severe OSA.

CONCLUSIONS

This is the first case-series utilizing PSGs as a guide for MDO in patients with micrognathia showing the need for jaw over-correction to achieve resolution of OSA.

Predictors of cardiac implantable electronic device infection in the United States

Background

Cardiac implantable electronic devices (CIED) are important tools for managing arrhythmias, improving hemodynamics, and preventing sudden cardiac death. Device infection (DI) remains a significant complication of CIED and is associated with high morbidity, mortality, and healthcare cost.

Purpose

To analyze predictors of DI and its in-hospital outcomes.

Methods

National Inpatient Sample 2011–2018 database was analyzed for admissions for CIED implantation or DI. Baseline and hospital level characteristics were derived. The Chi-square test and student t-test were used for comparison of categorical and continuous variables respectively. Variables with p<0.20 from univariate analysis were included in the multivariate logistic regression to identify independent predictors of DI.

Results

A total of 1,604,173 admissions for CIED implantations and 71,007 (4.4%) admissions for DI were reported during 2011–2018. There was no significant change in annual admissions for DI (range 8550 to 9307, p for trend=0.98). Those with DI were more likely to be male (69.3 vs 57%, p<0.001) and had higher Charlson comorbidity index score ≥3 (46.6%-vs-36.8%, p<0.001). Multivariate analysis identified post-procedural hematoma (odds ratio (OR)=3.96; 95% Confidence Interval (CI)=3.46–4.54), congestive heart failure (CHF; OR=2.80, 95% CI=2.66–2.96), age group 45–60 years (OR=2.46, 95% CI=2.30–2.63), malnutrition (OR=1.99, 95% CI=1.85–2.15), coagulopathy (OR=1.75, 95% CI=1.64–1.86), end-stage renal disease (OR=1.65, 95% CI=1.53–1.78), atrial fibrillation (OR=1.42; 95% CI=1.35–1.49), non-Hispanic race (OR=1.25; 95% CI=1.16–1.36), coronary artery disease (OR=1.21; 95% CI=1.15–1.26), and thyroid disease (OR=1.15; 95% CI=1.09–1.12) [all p<0.001] as independent predictors of DI. Prevalence of CHF, malnutrition, and atrial fibrillation increased in those admitted with DI over the observation period as shown in Figure 1 (p for trend <0.001). Prevalence of diabetes mellitus also increased during the observation period although it was not an independent predictor of DI (p for trend <0.001). Pulmonary embolism and deep vein thrombosis were most common complications in those with DI (4.1 and 3.6% respectively). Annual in-hospital mortality ranged from 3.9 to 5.7% (mean 4.4%, p for trend=0.07).

Conclusion

DI is relatively common and continues to be associated with high morbidity and mortality. Prevalence of DI has not changed significantly despite technical and technological advances in device implantation. Evaluation of risk factors for DI and management of modifiable comorbidities may be needed to reduce the incidence of this important complication of CIED implantation.

Funding Acknowledgement

Type of funding sources: None.

Impact of gastrointestinal hemorrhage on hospital outcomes of patients with hypertrophic cardiomyopathy

Background

Patients with hypertrophic cardiomyopathy (HCM) may be at relatively high risk of gastrointestinal hemorrhage (GIH) due to acquired von Willebrand disease (aVWD) and anticoagulation for atrial fibrillation among others factors.

Purpose

We aimed to evaluate impact of GIH on in-hospital outcomes of patients with HCM.

Methods

The National Inpatient Sample reported 45,305 admissions for adults with HCM during a two-year period (2016–2017). Among them, 1,490 patients (3.3%) also had GIH. Baseline characteristics and in-hospital outcomes of the two groups were compared. Multivariable logistic regression analysis was used to assess the independent impact of GIH on in-hospital outcomes of HCM patients.

Results

Out of 45,305 HCM patients, 1490 (3.2%) also had concomitant diagnosis of GIH. HCM patients with GIH were older (70±9 vs 66±23 years), were more often male (64% vs 61%), and had higher prevalence of prior myocardial infarction (12% vs 7%, p<0.001) and cirrhosis (7.1% vs 2.6%, p<0.001) while being less often obese (15% vs 22%, p=0.01) or having a history of congestive heart failure (30% vs 36%, p=0.03) [Table 1]. Hospital mortality was significantly higher among those with GIH (6.4% vs 3.5%, p<0.001). Multivariable logistic regression analysis identified GIH as an independent predictor of higher in-hospital mortality [adjusted odds ratio (aOR)=1.60, 95% confidence interval (CI)=1.02–2.63, p=0.001], hypovolemic shock (aOR=5.17, 95% CI=2.5–10.6, p<0.001), mean length of stay (Δ +2.4 days, p<0.001) and mean hospital cost (Δ +$21,162, p=0.004).

Conclusion

Adults with HCM and GIH are older, less often obese with higher prevalence of cirrhosis and prior myocardial infarction. Presence of GIH is an independent predictor of higher mortality, hypovolemic shock, length of stay and hospital cost in HCM adults admitted to hospital.

Funding Acknowledgement

Type of funding sources: None. Table 1

Impact of cardiac rhythm abnormality on hospital outcomes of patients with hypertrophic cardiomyopathy

Background

Serious cardiac arrhythmias [atrial fibrillation/flutter (AFF), and ventricular tachycardia/fibrillation (VTF)] are associated with adverse outcomes in general population of patients with hypertrophic cardiomyopathy (HCM).

Purpose

We aimed to evaluate the impact of such rhythm abnormalities on in-hospital outcomes of adults with HCM.

Methods

The National Inpatient Sample reported 45,305 admissions for adults with HCM during a two-year period (2016–2017). Among them, 21,220 patients (47%) also had AFF and/or VTF. Baseline characteristics and in-hospital outcomes of the two groups were compared. Multivariable logistic regression analysis was used to assess the independent impact of rhythm abnormalities on in-hospital outcomes of HCM patients.

Results

HCM patients with arrhythmias were older (68±26 vs 64±29 years), were more often male (43% vs 36%), and had higher prevalence of congestive heart failure (45% vs 28%), chronic kidney disease (27% vs 22%), hyperlipidemia (52% vs 48%), obstructive sleep apnea (17% vs 13%), chronic obstructive pulmonary disease (22% vs 18%) and thyroid disease (19% vs 16%) [Table 1, all p<0.001]. Hospital mortality was significantly higher among those with arrhythmias (4.7% vs 2.7%, p<0.05). Multivariate logistic regression analysis identified arrhythmias as an independent predictor of in-hospital mortality (adjusted odds ratio=1.51, 95% confidence interval=1.19–1.91, p=0.001), increased mean length of stay (Δ +0.75 days, p<0.001) and increased mean total hospital cost (Δ +$18,263, p<0.001).

Conclusion

Adults with HCM and AFF and/or VTF are older and have higher prevalence of comorbid conditions. Presence of such rhythm abnormalities is an independent predictor of higher mortality, length of stay and total cost in HCM adults admitted to hospital.

Funding Acknowledgement

Type of funding sources: None. Table 1

Acute coronary events in patients with myeloproliferative neoplasms- a nationwide analysis of patient characteristics and in-hospital outcomes

Background

Myeloproliferative neoplasms (MPN) are characterized by clonal expansion of cells belonging to the erythroid and/or myeloid lineages. Concomitant platelet dysfunction and thrombocytosis predispose these patients to arterial thromboses, causing a high burden of morbidity and mortality. With improving survival, an increasing number of patients with MPN are presenting with acute coronary syndromes (ACS). However, data regarding in-hospital outcomes and revascularization strategies utilized in these patients is limited, due to lack of representation in trials and rarity of the disease.

Methods

We conducted a retrospective cohort study using the 2016 Nationwide Inpatient Sample.Adult patients with a primary diagnosis of ACS and a secondary diagnosis of MPN, including essential thrombocytosis, polycythemia vera, primary myelofibrosis or chronic myeloproliferative disorder, were identified using the International Classification of Diseases (ICD) 10th revision codes. Outcomes of interest were compared using a multivariate logistic regression model.

Results

Out of 677,304 patients admitted for ACS, 2,485 also had a secondary diagnosis of MPN. Patients with MPN were less frequently female and diabetic but were more likely to have heart failure. No statistical difference in race, smoking or obesity was noted between the two cohorts. There was no significant difference in the in-hospital mortality in ACS patients with or without MPN. In terms of revascularization, patients with MPN were less likely to undergo percutaneous coronary intervention (PCI) and more likely to undergo coronary arterial bypass grafting (CABG). In addition, patients with MPN had a higher odds of acute pulmonary embolism, cardiogenic shock, and acute kidney injury as well as increased length of stay (LOS) and hospitalization costs

Conclusion

In patients with ACS and concomitant MPN, CABG was the preferred mode of revascularization over PCI, which may account for the increased LOS and total cost. Although the in-hospital mortality was similar, patients with MPN had higher odds of In-hospital complications.

Funding Acknowledgement

Type of funding source: None

A comparative study of a new "off-centre:off-centre" technique of transtibial ACL reconstruction with "centre:centre" transportal ACL reconstruction

BACKGROUND & INTRODUCTION

A Single Bundle ACL Reconstruction aims at placing Tibial and Femoral attachment sites of graft from Centre of Native Tibial Foot-print to Centre of Native Femoral Footprint. In tibial tunnel independent Transportal Reconstruction, where the two points are chosen separately, the objective is easily achievable. In Tibial tunnel dependent Transtibial ACL reconstruction, Capture of Centre of femoral tunnel is dictated by Trajectory of Tibial Tunnel. Heming et al. remarked that a TT technique could produce tunnel centred in the both the tibial and femoral footprint but only if a starting point "prohibitively close" to the joint line with a correspondingly short tibial tunnel were used. A new technique wherein authors aim to place the mouths of Tibial & Femoral tunnel at off-centre location, taking care to contain these tunnels still within native footprints to achieve a tunnel which is of adequate length and does not come too close to the joint and saves MCL from violation.

OBJECTIVE

To study the clinic-radiological outcome of a new "Off-centre to Off-centre" method of Transtibial Reconstruction and compare the results with "centre to centre" method of Transportal reconstruction.

METHODS

A prospective randomised comparative study of consecutive 75 clinico-radiological cases of ACL tear with definitive clinical symptoms of knee instability who underwent arthroscopic ACL reconstruction by Same Arthroscopy Surgeon was conducted between 2016 and 2018. A modification, as described herein below, was used in Transtibial technique with placement of centre of mouth of internal opening of tibial tunnel "off-centre" that allowed a predictable capture of Femoral Footprint in "off-centre" location without tunnel being too close to joint line. Only those cases were included in which the mouths of tunnel were completely contained within footprints. Capture of footprints was verified during arthroscopy. 11 cases were excluded because either the native footprint was not clearly delineated, or surgeon failed to completely contain the mouth of tunnel/socket within the delineated footprint of tibia or femur. Hence 64 patients, 32 each in Transtibial & Transportal group were enrolled into the study. The results were analysed with the objective to arrive at recommendations for improving capture of anatomical footprints at both ends by Transtibial technique.

RESULTS

There were no statistically significant differences in Clinical outcome scores. However there were statistically significant differences in length of Femoral Tunnel, Obliquity of Femoral tunnel as well as Femoral Tunnel Placements. Likewise, Tibial Tunnel Angle in AP & Lateral View as well as Tibial tunnel placement were also significantly different.

CONCLUSION

It is concluded that tunnels follow much different trajectories in the bones in two techniques and trying to apply "Centre of Tibial footprint to Centre of Femoral footprint" philosophy of Transportal technique may be imprudent for Transtibial Technique. An "Off-centre to Off-centre but contained within Footprints" may afford a more predictable and reliable capture of anatomical foot prints without any adverse effect on outcomes.

A Comparison of the Use of Papanicolaou-stained Cervical Cytological Smears with Gram-stained Vaginal Smears for the Diagnosis of Bacterial Vaginosis in Early Pregnancy

Our objective is to compare the efficacy of using Papanicolaou (PAP)-stained cervical cytology smears with a standardized method of interpreting Gram-stained vaginal smears for the diagnosis of bacterial vaginosis (BV) in pregnancy.

High vaginal smears were Gram-stained and examined by a single observer to characterize 3 grades of vaginal flora and diagnose BV. Cervical smears were PAP-stained and examined for characteristic patterns of vaginal flora including evidence of BV by either a number of cytotechnicians or a single cytopathologist. The results of the 2 methods were compared. Seven hundred and forty-seven women attending an antenatal clinic in a district general hospital who consented to have a smear of vaginal secretions and cervical cytology in early pregnancy. The main outcome measure is the diagnosis of BV by different methods in a pregnant population.

Compared with the Gram-stain method for the diagnosis of BV, there was good agreement between PAP-stain interpretation by a single observer but the agreement was not as good with PAP-stain interpretation by multiple cytotechnicians. When the grades were consolidated to normal (grade I) and abnormal flora (grades II and III), compared to Gram-stained smears, PAP cytology undertaken by several cytotechnicians had a sensitivity of 80.7% and a specificity of 90.7%. The sensitivity and specificity increased to 87% and 97%, respectively, when the PAP-stained smears were read by a single cytopathologist. Using kappa scores, only those readings made by a single cytopathologist were reliable.

The setting in a cytopathology laboratory comprises multiple cytotechnicians, so that PAP-stain analysis of vaginal smears for the diagnosis of BV is likely to provide results which are less reliable than those obtained by Gram staining. The latter should be the first choice and every effort should be made to set up this service.

Posterior hyoid space as related to excision of the thyroglossal duct cyst

OBJECTIVES/HYPOTHESIS

The anatomy of the anterior neck in the area of the hyoid, thyrohyoid membrane, and epiglottis is herein redescribed and compared to its classical depiction. The concept of the posterior hyoid space (PHS) is defined and substantiated through review of archived tissue and cadaver larynx dissection as well as by observation at many surgical dissections. The true anatomy of these relationships provides an insight into the effectiveness of the Sistrunk procedure. The author believes that recurrence of thyroglossal duct cysts (TGDC) occurs as a consequence of incomplete resection of: 1) microscopic suprahyoid ductules and/or 2) infra- and perihyoid tissue.

STUDY DESIGN

The senior author has been using the concept of the posterior hyoid space as applied to the Sistrunk procedure for more than 20 years. A retrospective study was done on cases from April 2003 to August 2008, and outcome was reviewed and compared to historical controls to determine the impact of applying this anatomic concept.

METHODS

A retrospective chart review was undertaken on 60 surgical cases performed for a 5-year period with clinical follow-up extended to an additional 7 months. Data collected included age at surgery, presenting symptoms, imaging characteristics, thyroid status, pathology results, and postoperative complications. All 60 were under the age of 18 who underwent a modified Sistrunk procedure and had a postoperative diagnosis of TGDC. Each patient had a minimum follow-up period of 4 months to check for recurrences. No revision was included in this study.

RESULTS

Sixty patients met criteria for the study. There was one recurrence (1.67%); a complication rate of 6.67%. Complications were minor and wound related. Mean follow-up was 17 months.

CONCLUSIONS

The technique of applying the concept of a PHS to ensure the complete resection of the middle third of the hyoid bone and offending tissues is believed to decrease recurrence of TGDC secondary to incomplete resection in the perihyoid area.

A comparison of the use of Papanicolaou-stained cervical cytological smears with Gram-stained vaginal smears for the diagnosis of bacterial vaginosis in early pregnancy

Our objective is to compare the efficacy of using Papanicolaou (PAP)-stained cervical cytology smears with a standardized method of interpreting Gram-stained vaginal smears for the diagnosis of bacterial vaginosis (BV) in pregnancy. High vaginal smears were Gram-stained and examined by a single observer to characterize 3 grades of vaginal flora and diagnose BV. Cervical smears were PAP-stained and examined for characteristic patterns of vaginal flora including evidence of BV by either a number of cytotechnicians or a single cytopathologist. The results of the 2 methods were compared. Seven hundred and forty-seven women attending an antenatal clinic in a district general hospital who consented to have a smear of vaginal secretions and cervical cytology in early pregnancy. The main outcome measure is the diagnosis of BV by different methods in a pregnant population. Compared with the Gram-stain method for the diagnosis of BV, there was good agreement between PAP-stain interpretation by a single observer but the agreement was not as good with PAP-stain interpretation by multiple cytotechnicians. When the grades were consolidated to normal (grade I) and abnormal flora (grades II and III), compared to Gram-stained smears, PAP cytology undertaken by several cytotechnicians had a sensitivity of 80.7% and a specificity of 90.7%. The sensitivity and specificity increased to 87% and 97%, respectively, when the PAP-stained smears were read by a single cytopathologist. Using kappa scores, only those readings made by a single cytopathologist were reliable. The setting in a cytopathology laboratory comprises multiple cytotechnicians, so that PAP-stain analysis of vaginal smears for the diagnosis of BV is likely to provide results which are less reliable than those obtained by Gram staining. The latter should be the first choice and every effort should be made to set up this service.