SARS-CoV-2 Infection and Associated Rates of Diabetic Ketoacidosis in a New York City Emergency Department.

INTRODUCTION: In early March 2020, coronavirus 2019 (COVID-19) spread rapidly in New York City. Shortly thereafter, in response to the shelter-in-place orders and concern for infection, emergency department (ED) volumes decreased. While a connection between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and hyperglycemia/insulin deficiency is well described, its direct relation to diabetic ketoacidosis (DKA) is not. In this study we describe trends in ED volume and admitted patient diagnoses of DKA among five of our health system's EDs, as they relate to peak SARS-CoV-2 activity in New York City. METHODS: For the five EDs in our hospital system, deidentified visit data extracted for routine quality review was made available for analysis. We looked at total visits and select visit diagnoses related to DKA, across the months of March, April and May 2019, and compared those counts to the same period in 2020. RESULTS: A total of 93,218 visits were recorded across our five EDs from March 1-May 31, 2019. During that period there were 106 diagnoses of DKA made in the EDs (0.114% of visits). Across the same period in 2020 there were 59,009 visits, and 214 diagnoses of DKA (0.363% of visits) CONCLUSION: Despite a decrease in ED volume of 26.9% across our system during this time period, net cases of DKA diagnoses rose drastically by 70.1% compared to the prior year.

Advanced Techniques for Endoscopic Intracerebral Hemorrhage Evacuation: A Technical Report With Case Examples.

BACKGROUND: Multiple surgical techniques to perform minimally invasive intracerebral hemorrhage (ICH) evacuation are currently under investigation. The use of an adjunctive aspiration device permits controlled suction through an endoscope, minimizing collateral damage from the access tract. As with increased experience with any new procedure, performance of endoscopic minimally invasive ICH evacuation requires development of a unique set of operative tenets and techniques. OBJECTIVE: To describe operative nuances of endoscopic minimally invasive ICH evacuation developed at a single center over an experience of 80 procedures. METHODS: Endoscopic minimally invasive ICH evacuation was performed on 79 consecutive eligible patients who presented a single Health System between March 2016 and May 2018. We summarize 4 core operative tenets and 4 main techniques used in 80 procedures. RESULTS: A total of 80 endoscopic minimally invasive ICH evacuations were performed utilizing the described surgical techniques. The average preoperative and postoperative volumes were 49.5 mL (standard deviation [SD] 31.1 mL, interquartile range [IQR] 30.2) and 5.4 mL (SD 9.6, mL IQR 5.1), respectively, with an average evacuation rate of 88.7%. All cause 30-d mortality was 8.9%. CONCLUSION: As experience builds with endoscopic minimally invasive ICH evacuation, academic discussion of specific surgical techniques will be critical to maximizing its safety and efficacy.

A Near-Peer Educational Model for Online, Interactive Learning in Emergency Medicine.

INTRODUCTION: The COVID-19 pandemic led to a large disruption in the clinical education of medical students, particularly in-person clinical activities. To address the resulting challenges faced by students interested in emergency medicine (EM), we proposed and held a peer-led, online learning course for rising fourth-year medical students. METHODS: A total of 61 medical students participated in an eight-lecture EM course. Students were evaluated through pre- and post-course assessments designed to ascertain perceived comfort with learning objectives and overall course feedback. Pre- and post-lecture assignments were also used to increase student learning. RESULTS: Mean confidence improved in every learning objective after the course. Favored participation methods were three-person call-outs, polling, and using the "chat" function. Resident participation was valued for "real-life" examples and clinical pearls. CONCLUSION: This interactive model for online EM education can be an effective format for dissemination when in-person education may not be available.

Quality and Variability of Online Available Physical Therapy Protocols From Academic Orthopaedic Surgery Programs for Medial Patellofemoral Ligament Reconstruction.

BACKGROUND: Unlike the literature on anterior cruciate ligament reconstruction, studies on medial patellofemoral ligament (MPFL) reconstruction lack evidence-based guidelines regarding postoperative rehabilitation. An effective postoperative protocol may contribute greatly to a successful outcome following MPFL reconstruction, yet the quality and variability of these published protocols remain unknown. PURPOSE: To assess the quality and variability of MPFL rehabilitation protocols publicly available on the internet and associated with US academic orthopaedic programs. STUDY DESIGN: Systematic review. METHODS: All available isolated MPFL reconstruction rehabilitation protocols from US academic orthopaedic programs participating in the Electronic Residency Application Service were collected and included in this review. These protocols were evaluated for inclusion of various rehabilitation components, the timing of suggested initiation of these activities, and whether the protocol used evaluation-based guidelines. RESULTS: A total of 27 protocols were included. Of these, 25 (93%) recommended immediate postoperative bracing. Time to initiation of full weightbearing ranged from 2 to 8 weeks. The most common strengthening exercises endorsed were quadriceps sets (89%), straight-legged raise (85%), and leg press (81%). The most common proprioception exercises endorsed were balance board (41%), single-legged balance (41%), and TheraBand control (33%). The median time suggested to return to play was 17 weeks. No functional test appeared in the majority of the protocols. Of the 27 protocols, 20 (74%) used evaluation-based guidelines. CONCLUSION: There is substantial variability in content and timing across rehabilitation protocols following MPFL reconstruction. This lack of clear guidelines can cause confusion among patients, therapists, and surgeons, leading to suboptimal patient outcomes and making it difficult to compare outcomes across the literature.

Return to work after shoulder arthroplasty: a systematic review and meta-analysis.

BACKGROUND: With the rising incidence of shoulder arthroplasty, there is increasing emphasis on improving functional outcomes and ability to return to work (RTW). The purpose of this study was to determine the rate of RTW after shoulder arthroplasty. METHODS: This systematic review and meta-analysis were performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search of 4 electronic databases was performed from database conception through April 2018 to identify studies reporting data on RTW after shoulder arthroplasty. The primary outcome was the rate of RTW after shoulder arthroplasty. Random-effects meta-analysis was used to pool the rate of RTW across studies. RESULTS: Seven studies were reviewed, including 447 patients at an average follow-up of 4.4 years (range, 1.0-12.6 years). The overall rate of RTW was 63.6% (95% confidence interval, 58.8%-68.2%) at a mean 2.3 months postoperatively (range, 0.3-24.0 months). RTW was significantly lower for patients with heavy-intensity occupations vs. all intensity types (61.7% vs. 67.6%; P = .04). RTW did not differ between anatomic total shoulder arthroplasty (63.4%) and hemiarthroplasty (66.1%) or reverse total shoulder arthroplasty (61.5%; P = .53). There were no significant differences in RTW among underlying diagnoses (osteoarthritis, 64.4%; cuff tear arthropathy, 65.6%; proximal humerus fracture, 69.1%; P = .41) or by workers' compensation status (61.2% vs. 65.3%; P = .41). CONCLUSIONS: A majority of patients return to work after shoulder arthroplasty at an average of 2.3 months postoperatively. Those with heavy-intensity occupation return at significantly lower rates, whereas no differences in RTW by arthroplasty type, underlying diagnosis, or workers' compensation were found.

Obesity Paradox in Intracerebral Hemorrhage.

Background and Purpose- Although obesity is an established risk factor for cardiovascular disease and stroke, studies have shown evidence of an obesity paradox-a protective effect of obesity in patients who already have these disease states. Data on the obesity paradox in intracerebral hemorrhage is limited. Methods- Clinical data for adult intracerebral hemorrhage patients were extracted from the National Inpatient Sample between 2007 and 2014. Multivariable logistic regression analyzed the association of body habitus with in-hospital mortality, discharge disposition, length of stay, tracheostomy or gastrostomy placement, and ventriculoperitoneal shunt placement. Results- There were 99 212 patients who were eligible. Patients with both obesity (OR=0.69; 95% CI=0.62-0.76; P<0.001) and morbid obesity (OR=0.85; 95% CI=0.74-0.97; P=0.02) were associated with decreased odds of in-hospital mortality. Morbid obesity was significantly associated with increased odds of a tracheostomy or gastrostomy placement (OR=1.42; 1.20-1.69; P<0.001) and decreased odds of a routine discharge disposition (OR=0.84; 0.74-0.97; P=0.014). Conclusions- Obesity and morbid obesity appear to protect against mortality in intracerebral hemorrhage.

Effects of music therapy on anxiety and physiologic parameters in angiography: a systematic review and meta-analysis.

BACKGROUND: Given the anxiety patients experience during angiography, evidence supporting the efficacy of music therapy during these angiographic procedures is potentially of clinical value. OBJECTIVE: To analyze the existing literature forthe use of music therapy during cerebral, coronary, and peripheral angiography to determine whether it improves patient anxiety levels, heart rate, and blood pressure during the procedure. METHODS: PubMed, Embase, and Scopus were searched to identify studies of interest. Inclusion criteria included studies reporting using music therapy in either cerebral, coronary, or peripheral angiography. Studies focused on a pediatric population; animal studies and case reports were excluded. Participant demographics, interventions, and outcomes were collected by two study authors. Bias and study quality of randomized controlled trials (RCTs) were assessed using the Cochrane Risk of Bias Tool. Separate meta-analyses of the RCTs were performed to compare State Trait Anxiety Inventory (STAI), heart rate (HR), and systolic and diastolic blood pressure (SBP and DBP) in the music intervention group versus control group. Heterogeneity was determined by calculating I2 values, and a random-effects model was used when heterogeneity exceeded 50%. RESULTS: The preprocedure to postprocedure improvement in STAI was significantly greater in the experimental group than the control group (p=0.004), while the decrease in HR, SBP, and DBP was not significant. CONCLUSIONS: Recorded music and/or music therapy in angiography significantly decreases patients' anxiety levels, while it has little to no effect on HR and BP. This meta-analysis is limited by the relatively few RCTs published on this subject. PROSPERO REGISTRATION NUMBER: CRD42018099103.

Biopsy During Minimally Invasive Intracerebral Hemorrhage Clot Evacuation.

BACKGROUND: The safety and efficacy of brain parenchyma biopsy during minimally invasive (MIS) intracerebral hemorrhage (ICH) clot evacuation has not been previously reported. The objective of this study was to establish the safety and diagnostic efficacy of brain biopsy during MIS ICH clot evacuation and to validate the modified Boston criteria as a predictor of cerebral amyloid angiopathy (CAA) in this cohort. METHODS: From October 2016 to March 2018, superficial and perihematomal biopsies were collected for 40 patients undergoing MIS ICH clot evacuation and analyzed by the pathology department to assess for various ICH etiologies. Additionally, the admission magnetic resonance imaging or computed tomography scan of each patient was analyzed and evaluated for the likelihood of a CAA etiology based on the modified Boston criteria. Student t test was used to analyze intergroup differences in continuous variables, and a 2-tailed Fisher exact test was used to determine intergroup differences of categorical variables, with significance set at P < 0.05. RESULTS: Two of the 40 patients (5%) experienced postoperative rebleed. Four of the 40 patients (10%) had evidence of CAA on biopsy. Patients with CAA on biopsy were older (P = 0.005) and had a higher prevalence of parietal lobe (P = 0.02) and occipital lobe (P = 0.001) hemorrhage. The modified Boston criteria had a sensitivity of 100% (95% confidence interval [CI], 39.6%-100%) and a specificity of 72.2% (95% CI, 54.6%-84.2%) for predicting CAA on biopsy. CONCLUSIONS: Brain biopsy in MIS ICH clot evacuation is safe and allows for the diagnosis of various ICH etiologies.

Nutrition, Energy Expenditure, Dysphagia, and Self-Efficacy in Stroke Rehabilitation: A Review of the Literature.

While significant research has been performed regarding the use of thrombolytic agents and thrombectomy in the setting of acute stroke, other factors, such as nutritional status of stroke patients, is a less explored topic. The topic of nutrition is critical to the discussion of stroke, as up to half of stroke survivors may be considered malnourished at discharge. Dysphagia, old age, restricted upper limb movement, visuospatial impairment, and depression are all important risk factors for malnutrition in this cohort. The purpose of this review is to analyze current literature discussing neuroprotective diets, nutritional, vitamin, and mineral supplementation, dysphagia, and post-stroke coaching in stroke patients.

Variable reporting of functional outcomes and return to play in superior labrum anterior and posterior tear.

BACKGROUND: Outcomes assessments after superior labrum anterior and posterior (SLAP) tear/repair are highly varied, making it difficult to draw comparisons across the literature. This study examined the inconsistency in outcomes reporting in the SLAP tear literature. We hypothesize that there is significant variability in outcomes reporting and that although most studies may report return to play, time to return reporting will be highly variable. METHODS: The PubMed, Medline, Scopus, and Embase databases were systematically reviewed for studies from January 2000 to December 2014 reporting outcomes after SLAP tear/repair. Two reviewers assessed each study, and those meeting inclusion criteria were examined for pertinent data. Outcomes included objective (range of motion, strength, clinical examinations, and imaging) and subjective (patient-reported outcomes, satisfaction, activities of daily living, and return to play) measures. RESULTS: Of the 56 included studies, 43% documented range of motion, 14% reported strength, and 16% noted postoperative imaging. There was significant variation in use of patient-reported outcomes measures, with the 3 most commonly noted measures reported in 20% to 55% of studies. Return to play was noted in 75% of studies, and 23% reported time to return, with greater rates in elite athletes. Eleven studies (20%) did not report follow-up or noted data with <12 months of follow-up. CONCLUSIONS: The SLAP literature is characterized by substantial variability in outcomes reporting, with time to return to play noted in few studies. Efforts to standardize outcomes reporting would facilitate comparisons across the literature and improve our understanding of the prognosis of this injury.