Ultrasound-guided caudal epidural steroid injection for successful treatment of radiculopathy during pregnancy.

Aim: The aim of this case report is to describe ultrasound guidance for caudal epidural steroid injection during pregnancy. Case report: A 29-year-old, 32-week parturient presented with severe back and leg pain with MRI demonstrating herniation of the L5-S1 level. The disabling pain was refractory to conservative therapy, and an ultrasound-guided caudal epidural steroid injection was performed. There was significant pain relief in the first week with an uneventful subsequent pregnancy. Following delivery, the patient had no further recurrence of her presenting symptoms. Conclusion: Severe radiculopathy may be encountered during pregnancy, complicated by a limited number of treatment options. Ultrasound guidance should be considered during performance of caudal epidural injections in feasible cases.

Assessment of the Reliability of the Fiberoptic Endoscopic Evaluation of Swallowing as an Outcome Measure in Patients Undergoing Revision Anterior Cervical Discectomy and Fusion.

BACKGROUND: Dysphagia is one of the most common complications of anterior cervical spine surgery, and there is a need to establish that the means of testing for it are reliable and valid. The objective of this study was to measure observer variability of the fiberoptic endoscopic evaluation of swallowing (FEES) test, specifically when used for evaluation of dysphagia in patients undergoing revisionary anterior cervical decompression and fusion (ACDF). METHODS: Images from patients undergoing revision ACDF at a single institution were collected from May 1, 2010, through July 1, 2014. Two senior certified speech pathologists independently evaluated the swallowing function of patients preoperatively and at 2 weeks postoperatively. Their numeric evaluations of the Rosenbeck Penetration-Aspiration Scale and the Swallowing Performance Scale during the FEES were then compared for interrater reliability. RESULTS: Positive agreement between raters was 94% for the preoperative Penetration-Aspiration Scale (prevalence-adjusted bias-adjusted κ, 0.77). The postoperative Penetration-Aspiration Scale showed reliability coefficients for κ, Kendall's W, and intraclass correlation coefficient (ICC) of 0.34 (fair agreement), 0.70 (extremely strong agreement), and 0.35 (poor agreement), respectively. The preoperative Swallowing Performance Scale showed strong agreement, with a Kendall's W coefficient of 0.68, and fair reliability, with an ICC of 0.40. The postoperative Swallowing Performance Scale indicated extremely strong agreement between raters, with a Kendall's W of 0.82, and good agreement, with an ICC of 0.53. CONCLUSIONS: The FEES test appears to be a reliable assessor of dysphagia in patients undergoing ACDF and may be a useful measure for exploring outcomes in this population.

The Disparities of Coronary Artery Bypass Grafting Surgery Outcomes by Insurance Status: A Retrospective Cohort Study, 2007-2014.

BACKGROUND: Coronary artery bypass grafting (CABG) surgery is the gold standard treatment for complex coronary artery disease. Social determinants of health, including primary payer status, are disproportionately associated with adverse outcomes following surgical operations. We sought to examine associations between insurance status, in particular having Medicaid public insurance, and postoperative outcomes following isolated CABG surgeries. METHODS: A retrospective review was performed using Florida, California, New York, Maryland, and Kentucky State Inpatient Databases (2007-2014) for isolated CABG patients ≥ 18 years. Multivariate regression for postsurgical inpatient mortality, postsurgical complications, 30- and 90-day readmission rates, total charges, and length of stay yielded adjusted odds ratios (ORs) reported for outcomes by insurance status. RESULTS: Among 312,018 individuals, patients with Medicaid insurance and those designated as Uninsured incurred increased adjusted ORs of postsurgical inpatient mortality (56 and 64%, respectively) compared to Private Insurance. Additionally, Medicaid had the highest adjusted OR for 30-day readmission (OR 1.52, 95% CI 1.45-1.59), 90-day readmission (OR 1.53, 95% CI 1.47-1.59), postsurgical complications (OR 1.10, 95% CI 1.07-1.14) including pulmonary and infectious complications, postoperative length of stay, and total hospital charges (2016 dollars). CONCLUSIONS: Medicaid insurance, compared to Private Insurance, is significantly associated with worse outcomes after isolated CABG. Our results demonstrate that Medicaid as a patient's primary insurance payer is an independent predictor of perioperative risks. Further research may help explain the reasons for the differences in payer groups.

Voice and swallowing outcomes following reoperative anterior cervical discectomy and fusion with a 2-team surgical approach.

OBJECTIVE Dysphagia and vocal cord palsy (VCP) are common complications after anterior cervical discectomy and fusion (ACDF). The reported incidence rates for dysphagia and VCP are variable. When videolaryngostroboscopy (VLS) is performed to assess vocal cord function after ACDF procedures, the incidence of VCP is reported to be as high as 22%. The incidence of dysphagia ranges widely, with estimates up to 71%. However, to the authors' knowledge, there are no prospective studies that demonstrate the rates of VCP and dysphagia for reoperative ACDF. This study aimed to investigate the incidence of voice and swallowing disturbances before and after reoperative ACDF using a 2-team operative approach with comprehensive pre- and postoperative assessment of swallowing, direct vocal cord visualization, and clinical neurosurgical outcomes. METHODS A convenience sample of sequential patients who were identified as requiring reoperative ACDF by the senior spinal neurosurgeon at the University of Alabama at Birmingham were enrolled in a prospective, nonrandomized study during the period from May 2010 until July 2014. Sixty-seven patients undergoing revision ACDF were enrolled using a 2-team approach with neurosurgery and otolaryngology. Dysphagia was assessed both preoperatively and postoperatively using the MD Anderson Dysphagia Inventory (MDADI) and fiberoptic endoscopic evaluation of swallowing (FEES), whereas VCP was assessed using direct visualization with VLS. RESULTS Five patients (7.5%) developed a new postoperative temporary VCP after reoperative ACDF. All of these cases resolved by 2 months postoperatively. There were no new instances of permanent VCP. Twenty-five patients had a new swallowing disturbance detected on FEES compared with their baseline assessment, with most being mild and requiring no intervention. Nearly 60% of patients showed a decrease in their postoperative MDADI scores, particularly within the physical subset. CONCLUSIONS A 2-team approach to reoperative ACDF was safe and effective, with no new cases of VCP on postoperative VLS. Dysphagia rates as assessed through the MDADI scale and FEES were consistent with other published reports.

Reconstruction of midface defects with the osteocutaneous radial forearm flap: Evaluation of long term outcomes including patient reported quality of life.

BACKGROUND: Maxillectomy defects significantly impair quality of life. Prosthetics can overcome some of these issues, but has limitations. The role of the osteocutaneous radial forearm free flap (OC-RFFF) has been established for reconstruction of smaller maxillectomy defects, but its role in larger defects is not well defined. We aim to evaluate outcomes after midface reconstruction utilizing the OC-RFFF. METHODS: Retrospective review of prospective database collected between 2005 and 2014 of midface reconstruction using OC-RFFF in a tertiary care centre. Donor site complications and acute and long-term recipient site complications were measured. Health related quality of life was assessed using the University of Washington Quality of Life (UW-QOL) Questionnaire. RESULTS: A total of 68 midface defects were reconstructed using the OC-RFFF. Acute recipient site complications included three flap failures (4%), and two additional microvascular revision cases for vascular compromise. Late recipient complications included fistula (n = 10, 14%), ectropion (n = 7, 10%), diplopia (n = 6, 9%) and exposed hardware (n = 5, 7%). Resection of cheek skin or orbital rim correlated with orbital complications. The incidence of fistula was not affected by defect size or prior radiation. There were two donor site infections and no instances of forearm fracture. Patients undergoing OC-RFFF repair had mean scores for UW-QOL outcomes higher than published rates of obturator quality of life. CONCLUSION: The OC-RFFF is suited to a variety of midface defects and can be combined with hardware to reconstruct the orbital floor. Recipient site complications are common, but donor site morbidity is low and outcomes, including HR-QOL, are acceptable.

Survival trends in hypopharyngeal cancer: a population-based review.

OBJECTIVES/HYPOTHESIS: Recent reviews of laryngeal cancer have detected a trend toward reduced survival, linked temporally to an abrupt change in treatment of these patients during the 1990s to nonsurgical regimens. Because organ preservation also is an important goal for hypopharyngeal cancer, we sought to determine treatment trends and survival data for patients with hypopharyngeal squamous cell carcinoma (SCC). STUDY DESIGN: Retrospective cohort. METHODS: Records of 6,647 patients with SCC of the hypopharynx between 1973 and 2003 were selected for review from the Surveillance, Epidemiology and End Results database, with comparison of 1973 to 1989 and 1990 to 2003 cohorts. RESULTS: Overall 5-year survival rates for hypopharyngeal cancer have improved. Average survival of hypopharyngeal cancer patients increased to 41.3% in those diagnosed 1990 to 2003 from 37.5% in those diagnosed 1973 to 1989 (P < 0.0001). Since 1990, there is a trend toward treatment using radiation without surgery (43.1% increased to 52.1%), combined surgical and radiation therapy is relatively unchanged (43.6% to 41.8%), and fewer patients underwent surgery alone (14% reduced to 7.3%). CONCLUSION: There has been a trend away from surgical therapy for hypopharyngeal SCC. In contrast to laryngeal cancer, survival for hypopharyngeal cancer has improved since 1990.

Pre-operative intravenous dexamethasone prevents auditory threshold shift in a guinea pig model of cochlear implantation.

AIM: To protect hearing during cochlear implantation with systemic administration of dexamethasone. METHODS: Seventeen normal-hearing guinea pigs were randomly allocated to receive an intravenous injection of either normal saline (control), low- (0.2 mg/kg) or high- (2 mg/kg) dose dexamethasone 60 min prior to cochlear implantation. Auditory brainstem response (ABR) threshold shifts (2-32 kHz) were estimated between pre- and 4-week-postoperative levels. RESULTS: ABR threshold shifts (8-32 kHz) observed in control and low-dose steroid groups were significantly reduced in the high-dose steroid group. CONCLUSIONS: A single, high-dose injection of intravenous dexamethasone protected hearing during cochlear implantation.

Monitoring performance in thyroidectomy: cumulative sum analysis of outcomes.

BACKGROUND: Cumulative sum (CUSUM) analysis gives visual feedback on performance. It requires agreed benchmarks to compare binary outcomes. This process has not previously been applied to thyroidectomy. The objective of this study was to determine if CUSUM analysis can be employed to give feedback on performance of thyroidectomy. METHODS: A literature review to define the CUSUM analysis key performance indicators for thyroidectomy was performed. The key performance indicators for thyroid surgery were hematoma (return to theater for evacuation), hypocalcemia (corrected calcium <2.0 mmol/L), and vocal cord palsy (postoperative hoarseness with nasal endoscopic confirmation). Pre- and postoperative laryngoscopy was not routinely performed by all surgeons. Permanent was defined as duration longer than 6 months. A prospective audit of 216 patients undergoing thyroidectomy between January 2003 and December 2006 at the Geelong Hospital was completed. CUSUM charting of outcomes was performed after agreeing by consensus the boundaries of acceptable and unacceptable performance. RESULTS: Aggregate analysis of outcomes demonstrated acceptable performance across all clinical indicators. The incidence of temporary/permanent hypocalcemia and vocal cord palsy were 24%/2.6% and 3.2%/0.65%, respectively. About 1.39% of patients required evacuation of hematoma. CUSUM plotting of outcomes demonstrated acceptable performance. CONCLUSIONS: There is some variation of how standard outcome indicators for thyroidectomy are measured in the literature. A prospective audit using aggregate outcomes and CUSUM analysis has demonstrated that the performance of thyroid surgery at the Geelong Hospital was acceptable. These indicators and our methods of analysis could be used to monitor the performance of thyroid surgery at other hospitals.

The hepatic transcriptome as a window on whole-body physiology and pathophysiology.

Transcriptomics can be a valuable aid to pathologists. The information derived from microarray studies may soon include the entire transcriptomes of most cell types, tissues and organs for the major species used for toxicology and human disease risk assessment. Gene expression changes observed in such studies relate to every aspect of normal physiology and pathophysiology. When interpreting such data, one is forced to look "far from the lamp post:' and in so doing, face one's ignorance of many areas of biology. The central role of the liver in toxicology, as well as in many aspects of whole-body physiology, makes the hepatic transcriptome an excellent place to start your studies. This article provides data that reveals the effects of fasting and circadian rhythm on the rat hepatic transcriptome, both of which need to be kept in mind when interpreting large-scale gene expression in the liver. Once you become comfortable with evaluating mRNA expression profiles and learn to correlate these data with your clinical and morphological observations, you may wonder why you did not start your studies of transcriptomics sooner. Additional study data can be viewed at the journal website at (www.toxpath.org). Two data files are provided in Excel format, which contain the control animal data from each of the studies referred to in the text,including normalized signal intensity data for each animal (n=5) in the 6-hour, 24-hour, and 5-day time points. These files are briefly described in the associated 'Readme' file, and the complete list of GenBank numbers and Affymetrix IDs are provided in a separate txt file. These files are available at http://taylorandfrancis.metapress.comlopenurl.asp?genre=journal&issn=0192-6233. Click on the issue link for 33(1), then select this article. A download option appears at the bottom of this abstract. In order to access the full article online, you must either have an individual subscription or a member subscription accessed through (www.toxpath.org).