Is bigger better? A comparison of growth restriction rates using the crown-rump length derived due date from the smaller versus larger twin.

BACKGROUND: Although the smaller twin's crown-rump length is most accurate in establishing the estimated due date in dichorionic gestations, societal guidelines favor the use of the larger twin measurements based on concern for missing a diagnosis of fetal growth restriction. OBJECTIVE: This study aimed to compare the accuracy of the diagnosis of early- and late-onset fetal growth restriction in dichorionic twin gestations conceived by assisted reproductive technology using the estimated due date as established by the crown-rump length of the smaller vs larger twin. STUDY DESIGN: This was a 10-year retrospective cohort study of nonanomalous, dichorionic gestations conceived with assisted reproductive technology at 2 institutions. The incidence of early-onset (<32 weeks of gestation) and late-onset (≥32 weeks of gestation) growth restriction derived from the Hadlock formula using the smaller and larger crown-rump length estimated due date was compared with the true estimated due date by assisted reproductive technology. Statistical significance was determined using the Fisher exact test. The incidence of missed fetal growth restriction cases, false-positive rate, and error were calculated along with the relative risk for a missed diagnosis using the smaller crown-rump length. RESULTS: A total of 176 subjects were screened: 81 had a fetal growth ultrasound at 24 to <32 weeks of gestation, and 58 had a fetal growth ultrasound at ≥32 weeks of gestation. There was a significant difference in the incidence of fetal growth restriction using the 3 dating strategies in both gestational age ranges (P<.001) with the smaller crown-rump length estimated due date more closely approximating the true rate. Before 32 weeks of gestation, the smaller crown-rump length estimated due date missed 2.5% of fetal growth restriction cases, whereas the larger crown-rump length estimated due date missed 0.6% of fetal growth restriction cases, with false-positive and error rates of 1.2% and 3.7% and 5.5% and 6.2%, respectively. After 32 weeks of gestation, the smaller crown-rump length estimated due date missed 1.8% of cases, whereas the larger crown-rump length estimated due date missed 0% of cases, with false-positive and error rates of 2.6% and 4.4% and 5.3% and 5.3%, respectively. The relative risk for a missed diagnosis of fetal growth restriction using the smaller crown-rump length estimated due date was 1.77 for early-onset growth restriction and 1.22 for late-onset growth restriction. CONCLUSION: Using the estimated due date derived from the smaller twin led to a more accurate detection of fetal growth restriction at a cost of a higher missed diagnosis rate.

Timing of Circumcision and Breastfeeding Frequency: A Multicenter, Randomized Clinical Trial.

OBJECTIVE: To date, there is little in the literature that describes any relationship between newborn circumcision, its timing, and breastfeeding outcomes. We sought to determine if the timing of circumcision in term, healthy newborns affects exclusive breastfeeding rates during the first 6 months of life. METHODS: One hundred and forty-eight maternal-infant dyads were enrolled in a randomized, multicenter, clinical trial between June 2016 and July 2019. Study participants included parent-infant dyads who desired both circumcision and breastfeeding. Newborns were randomized into 3 groups for circumcision: "early," circumcised within 24 hours of delivery; "intermediate," circumcised between 24 to 72 hours of age; and "late," circumcised between 1 and 3 weeks of age. The primary outcome was exclusive breastfeeding duration, assessed at discharge, 2 weeks, and 2, 4, and 6 months. RESULTS: Baseline characteristics between groups were similar. Exclusive breastfeeding decreased more rapidly over 6 months in the intermediate group (by 74%, 89% to 23%), as compared to the early (by 34%, 81% to 53%) or late (by 50%, 88% to 44%) groups (P = .04). Exclusive breastfeeding was less common in the intermediate group (circumcision between 24 and 72 hours), as compared to the early and late circumcision groups, at each measured time point beyond 2 weeks of age. CONCLUSIONS: Circumcision before 24 hours of age may be advantageous with respect to increased exclusive breastfeeding throughout the first 6 months of life. Deferral of circumcision beyond the immediate newborn period was not superior to performing the procedure within the first 24 hours.

Establishing the Most Accurate Due Date in Dichorionic Twin Gestations by First and Second Trimester Ultrasound.

OBJECTIVE: To determine the optimal sonographic dating of dichorionic gestations. MATERIALS AND METHODS: We reviewed dichorionic pregnancies conceived with assisted reproductive technologies (ART) at 2 institutions between 2006-2016, excluding fetuses with major anomalies. Gestational age was calculated with smaller, larger, and mean of the crown-rump lengths (CRL) and biometry midgestation and compared to the ART age. The mean and mean absolute deviation of the observed gestational age from the ART age was calculated to assess accuracy, precision, and presence of bias. The incidence of small for gestational age using the smaller and larger CRLs was compared to the ART age via McNemar's test. RESULTS: Based on 140 ultrasounds, the CRL from the smaller twin best approximates the true gestational age with least bias compared to the larger twin or average (mean absolute deviation: 2.8, mean deviation: -0.1 [95% CI: -0.4, 0.2] versus 2.7, -0.9 [-1.1, -0.6] and 2.9, -1.5 [-1.8, -1.3], in days, respectively). Based on 165 ultrasounds, biometry from the smaller fetus is least accurate compared to the larger or mean (11.8, 2.5 [1.5, 3.6] versus 11.7, 0.8 [-0.3, 1.8] and 11.9, -1.0 [-2.0, 0.04], respectively). The incidence of small for gestational age neonates did not differ from the true rate using either the CRL from the larger or smaller twin (p > .05). CONCLUSION: In ART dichorionic gestations, ultrasound of the smaller fetus is most accurate in establishing gestational age in the first trimester but least accurate in the second, though all methods performed well with little clinical difference.

Contrast-Enhanced MRI Evaluation of Bone-Patellar Tendon-Bone and Hamstring ACL Autograft Healing in Humans: A Prospective Randomized Study.

BACKGROUND: Gadopentetate dimeglumine-enhanced magnetic resonance imaging (MRI), or gadolinium-enhanced MRI, was used to prospectively study the postoperative course of bone-patellar tendon-bone (BPTB) and combined semitendinosus and gracilis (STG) tendon autografts following arthroscopically assisted reconstruction of the anterior cruciate ligament (ACL) in humans. Gadopentetate dimeglumine is a contrast agent that has been shown to enhance the signal of vascularized tissue when examined by MRI. PURPOSE: To prospectively determine and compare the pattern and timing of autograft revascularization following arthroscopically assisted ACL reconstruction by BPTB or STG autografts. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 73 patients (63 males, 10 females) with ACL tears who were scheduled to undergo reconstruction consented to participate in this study. The patients were randomized to receive arthroscopically assisted reconstruction of the ACL employing either BPTB or STG autografts. Gadolinium-enhanced MRI scans were scheduled at 3-month intervals during the first postoperative year to assess the integrity, timing, and pattern of enhancement of the ACL graft. The temporal sequence and morphologic characteristics of imaged signals were compared for both types of ACL reconstructions. RESULTS: Based on all knees with 1 exception, there were no statistically significant differences in gadopentetate dimeglumine-mediated graft enhancement grade observed between BPTB and STG autografts. CONCLUSION: The results suggest that autograft revascularization probably varies in intensity and location during the time course of graft healing. The interval signal changes observed 3 to 9 months, but especially 6 to 9 months, postoperatively are due to increased contrast uptake as a reflection of ongoing neovascularization during the process of ligamentization.

Comparison of Temporal Artery Versus Rectal Temperature in Emergency Department Patients Who Are Unable to Participate in Oral Temperature Assessment.

INTRODUCTION: In the emergency department, pediatric and geriatric patients who present with illnesses and are unable to participate in oral evaluation of temperature must undergo a rectal temperature (RT) assessment. This study asks if a temporal artery temperature (TAT) measure can supplant the RT measure. METHODS: A convenience sample, using a within-subject design, was used to evaluate the efficacy of TAT compared with RT in patients ≤ 3 and ≥ 65 years of age, who were unable to participate in oral temperature assessments. RESULTS: Instrument reliability of the TAT is adequate for both the pediatric and geriatric populations. An unadjusted TAT did not provide acceptable temperature measurements. We also found that adjusting a TAT reading by adding -17.22°C (1° F) rendered the TAT average (either mean or median) adequately similar to RT averages for research purposes for both pediatric and geriatric groups. DISCUSSION: No influence was detected on the differences between RT and TAT due to age, sex, or emergency severity index (ESI) score in patients or due to profession, years of education, or years of experience in caregivers for either the pediatric or geriatric groups. Furthermore, the adjusted TAT reading could detect fever in individual patients adequately in both the pediatric and geriatric groups. However, the adjusted TAT readings were too frequently divergent from RT readings to be used to measure temperature in individual patients for both pediatric and geriatric groups.

The Intraoperative Effect of Methadone on Somatosensory Evoked Potentials.

BACKGROUND: Evoked potentials (EP), both somatosensory evoked potentials (SSEP) and transcranial motor evoked potentials (TcMEP), are often used during complex spine surgery to monitor the integrity of spinal pathways during operations in or around the spine. Changes in these monitored EP signals (increased latency and decreased amplitude) may result from ischemia, direct surgical injury, changes in blood pressure, hypoxia, changes in CO2 tension, and anesthetic agents. Typically, a clinically significant change for SSEPs is defined as an increase in latency >10% or a decrease of amplitude >50%. A clinically significant change for TcMEPs is much more complex but is also described in terms of large signal loss or decrease. Opioids have been shown to both increase latency and decrease the amplitude of SSEPs, although this change is usually not clinically significant. There has been a renewed interest in methadone for use in spine and other complex surgeries. However, the effect of methadone on intraoperative monitoring of SSEPs and TcMEPs is unknown. We present the first study to directly look at the effects of methadone on SSEP and TcMEP monitoring during complex spine surgery. METHODS: The goal of this study was to observe the effect of methadone on an unrandomized set of patients. The primary endpoint was methadone's effect on SSEPs, and the secondary endpoint was methadone's effect on TcMEPs. Adult patients undergoing spine surgery requiring intraoperative neuromonitoring were induced with general anesthesia and had a baseline set of SSEPs and TcMEPs recorded. Next, methadone dosed 0.2 mg/kg/lean body weight was given. Repeat SSEPs and TcMEPs were recorded at 5, 10, and 15 minutes, with the timing based on distribution half-life of methadone between 6 and 8 minutes. Postoperatively, adverse events from methadone administration were collected. RESULTS: There was a statistically significant difference found in SSEPs for N20 latency (95% confidence interval [CI], 0.17-0.53; P=0.028), P37 latency (95% CI, 0.65-1.25; P=0.001), and N20 amplitude (95% CI, 0.09-0.32; P=<0.001), but not for P37 amplitude (95% CI, -0.19 to 0.00; P=0.634). There was no significant effect found for TcMEPs, the secondary endpoint of the study, and there were minimal adverse events recorded postoperatively. CONCLUSIONS: The data demonstrate that a single intravenous dose of methadone has a statistically significant difference on the amplitude and latency of SSEPs. However, this statistical difference does not translate into a clinical significance.

Single Versus Multiple Hyperbaric Sessions for Carbon Monoxide Poisoning in a Murine Model.

Hyperbaric oxygen (HBO) has been advocated for treatment of acute carbon monoxide (CO) poisoning. There exists considerable debate as to whether HBO prevents delayed neurologic sequelae (DNS) due to CO poisoning. Additionally, existing data in the literature supporting HBO efficacy do not identify an optimal number of HBO treatments. We sought to determine in a mouse model whether there is a difference between one versus multiple HBO sessions for the prevention of DNS. Fifty mice were randomized into five groups of ten mice each: (1) control, receiving no CO exposure or treatment; (2) CO poisoned, receiving no treatment (CO group); (3) CO poisoned, receiving normobaric oxygen for 58 min following the end of exposure (CO + NBO group); (4) CO poisoned, followed by one session of HBO(CO + HBO1); and (5) CO poisoned, followed by three HBO treatment sessions, one every 6 h (CO + HBO3). Prior to poisoning, all animals were trained in step-down latency (SDL) and step-up latency (SUL) tasks. One week after exposure and treatment, all five groups were retested to evaluate the retention of this training. There was no difference detected among groups in SDL (p = 0.67 among all groups) when evaluated using a Kruskal-Wallis test. There was a significant difference among groups in SUL (p = 0.027 among all groups) when evaluated using a Kruskal-Wallis test. When individual groups were compared using a Wilcoxon signed-rank test with Bonferroni correction, there were no statistically significant differences in either SDL or SUL. There was no difference between groups treated with either one or three HBO sessions. One possibility to explain this might be that HBO sessions administered some time after a CO exposure may enhance the lipid peroxidation cascade and worsen neurologic outcomes; alternatively, HBO may simply impart no benefit when compared to NBO.

Immersion team training in a realistic environment improves team performance in trauma resuscitation.

BACKGROUND: In the US military, it is common for health care teams to be formed ad hoc and expected to function cohesively as a unit. Poor team dynamics decreases the effectiveness of trauma care delivery. The US Navy Fleet Surgical Team Three has developed a simulation-based trauma initiative-the Shipboard Surgical Trauma Training (S2T2) Course-that emphasizes team dynamics to improve the delivery of trauma care to the severely injured patient. METHODS: The S2T2 Course combines classroom didactics with hands-on simulation over a period of 6 days, culminating in a daylong, mass casualty scenario. Each resuscitation team was initially evaluated with a simulated trauma resuscitation scenario then retested on the same scenario after completing the course. A written exam was also administered individually both before and after the course. A survey was administered to assess the participants' perceived effectiveness of the course on overall team training. RESULTS: From the evaluation of 20 resuscitation teams made up of 123 medical personnel, there was a decrease in the mean time needed to perform the simulated trauma resuscitation, from a mean of 24.4 minutes to 13.5 minutes (P < .01), a decrease in the mean number of critical events missed, from 5.15 to 1.00 (P < .01), and a mean improvement of 41% in written test scores. More than 90% of participants rated the course as highly effective for improving team dynamics. CONCLUSION: A team-based trauma course with immersion in a realistic environment is an effective tool for improving team performance in trauma training. This approach has high potential to improve trauma care and patient outcomes. The benefits of this team-based course can be adapted to the civilian rural sector, where gaps have been identified in trauma care.

Fibrinogen and prothrombin complex concentrate in trauma coagulopathy.

BACKGROUND: Coagulopathy after injury contributes to hemorrhage and death. Treatment with specific coagulation factors could decrease hemorrhage and mortality. Our aim was to compare fibrinogen and prothrombin complex concentrate (PCC) in a rabbit model of hemorrhagic shock. MATERIALS AND METHODS: New Zealand white rabbits were anesthetized. Blood was withdrawn to a mean arterial pressure (MAP) of 30-40 mm Hg for 30 min. Animals were resuscitated with lactated Ringer to a MAP of 50-60 mm Hg and randomized to receive 100 mg/kg of fibrinogen, PCC 25 IU/kg, or lactated Ringer. A liver injury was created. A MAP of 50-60 mm Hg was maintained for 60 min. The primary outcome was blood loss, and secondary outcomes were fluid administered and coagulopathy as measured by plasma-based tests. RESULTS: There were eight animals in each group. Median blood loss was significantly higher in the fibrinogen group, at 122 mL (95% confidence interval [CI], 75-194), when compared with that in the control group, 35 mL (95% CI, 23-46; P value = 0.001), and the PCC group, 26 mL (95% CI, 4-54; P value = 0.002). Resuscitation fluid requirement was highest in the fibrinogen group, at 374 mL (95% CI, 274-519), and lowest in the PCC group, at 238 mL (95% CI, 212-309) (P = 0.01). Plasma-based coagulation tests were not different among groups. CONCLUSIONS: In a rabbit model, PCC did not have a significant effect on blood loss. Fibrinogen increased blood loss and fluid requirements.

A comprehensive model for correcting RNFL readings of varying signal strengths in cirrus optical coherence tomography.

PURPOSE: To develop a model for the Cirrus HD-OCT that allows for the comparison of retinal nerve fiber layer (RNFL) thickness measurements with dissimilar signal strengths (SS) and accounts for test-retest variability. METHODS: Retinal nerve fiber layers were obtained in normals using the Cirrus optic disc cube 200 × 200 protocol during a single encounter. Five RNFL scans were obtained with a SS of 9 or 10. Diffusion lens filters were used to degrade SS to obtain five scans at each SS group of 7 or 8, 5 or 6, and 3 or 4. The relationship between average RNFL thickness and SS was established, and an equation was developed to allow for adjustment of an RNFL measurement had it been a SS of 7. Intravisit interclass correlation coefficient (ICC) and coefficient of variation (CV) parameter estimates for each SS group were calculated. Repeatability and upper tolerance limit were calculated as 1.96 × âˆš2 × within-subject standard deviation (Sw) and 1.645 × âˆš2 × Sw, respectively. RESULTS: There was a linear relationship between average RNFL and SS. RNFLadj = RNFL - 1.03*SS + 7.21 allows for the adjustment of RNFL readings to the same SS. Interclass correlation coefficients and CVs were good for all measurements down to SS of 3 or 4. Repeatability and upper tolerance limit were 5.24 and 4.40 µm, respectively. CONCLUSIONS: Our model adjusts RNFL readings based on SS and includes an upper tolerance limit of 5 µm. If validated, this model could improve the detection of real RNFL changes. Further study to validate this model should be performed before widespread use is adopted.

Ondansetron compared with doxylamine and pyridoxine for treatment of nausea in pregnancy: a randomized controlled trial.

OBJECTIVE: To evaluate whether ondansetron or the combination of doxylamine and pyridoxine was superior for the treatment of nausea and vomiting of pregnancy. METHODS: This was a double-blind, randomized, controlled trial in which women with nausea and vomiting of pregnancy were assigned to 4 mg of ondansetron plus a placebo tablet or 25 mg pyridoxine plus 12.5 mg of doxylamine for 5 days. The primary outcome was an improvement in nausea as reported on a 100-mm visual analog scale (VAS). Secondary outcomes were a reduction in vomiting on the VAS and the proportion of patients reporting sedation or constipation while using either study regimen. RESULTS: Thirty-six women (18 in each group) were randomized to either ondansetron or pyridoxine and doxylamine, of whom 13 (72%) and 17 (94%) completed follow-up, respectively. There were no differences among the groups with regard to demographic characteristics or baseline nausea. Patients randomized to ondansetron were more likely to have an improvement in their baseline nausea as compared with those using pyridoxine and doxylamine over the course of 5 days of treatment (median VAS score decreased 51 mm [interquartile range 37-64] compared with 20 mm [8-51]; P=.019). Furthermore, women using ondansetron reported less vomiting (median VAS decreased 41 [interquartile range 17-57] compared with 17 [-4 to 38]; P=.049). There was no significant difference between the groups regarding sedation or constipation. CONCLUSION: Our investigation showed ondansetron to be superior to the combination of pyridoxine and doxylamine in the treatment of nausea and emesis in pregnancy. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01668069. LEVEL OF EVIDENCE: : I.

Intravenous lidocaine for the emergency department treatment of acute radicular low back pain, a randomized controlled trial.

BACKGROUND: Acute radicular back pain is a frequent complaint of patients presenting to the Emergency Department. STUDY OBJECTIVE: Determine the efficacy of intravenous lidocaine when compared to ketorolac for the treatment of acute radicular low back pain. METHODS: Randomized double-blind study of 41 patients aged 18-55 years presenting with acute radicular low back pain. Patients were randomized to receive either 100 mg lidocaine or 30 mg ketorolac intravenously over 2 min. A 100-mm visual analog scale (VAS) was used to assess pain at Time 0 (baseline), and 20, 40, and 60 minutes. Changes in [median] VAS scores were compared over time (within groups) by the signed-rank test and between groups by the rank-sum test. A 5-point Pain Relief Scale (PRS) was administered at the conclusion of the study (60 min) and again at 1 week by telephone follow-up; [median] scores were compared between groups by rank-sum. RESULTS: Forty-four patients were recruited; 41 completed the study (21 lidocaine, 20 ketorolac). Initial VAS scores were not significantly different between the lidocaine and ketorolac groups (83; 95% confidence interval [CI] 74-98 vs. 79; 95% CI 64-94; p = 0.278). Median VAS scores from baseline to 60 min significantly declined in both groups (lidocaine [8; 95% CI 0-23; p = 0.003]; ketorolac [14; 95% CI 0-28; p = 0.007]), with no significant difference in the degree of reduction between groups (p = 0.835). Rescue medication was required by 67% receiving lidocaine, compared to 50% receiving ketorolac. No significant change in PRS between groups was found at the conclusion or at the follow-up. CONCLUSION: Intravenous lidocaine failed to clinically alleviate the pain associated with acute radicular low back pain.

Comparison of laparoscopic sleeve gastrectomy to laparoscopic Roux-en-Y gastric bypass for morbid obesity in a military institution.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is gaining acceptance in the bariatric community as a definitive weight loss procedure; however, longitudinal data remain limited. The objective of this study was to compare weight loss results of LSG with laparoscopic Roux-en-Y gastric bypass (LRYGB) up to 5 years postoperatively using anthropometric measurements. METHODS: Prospectively collected bariatric database at the Naval Medical Center San Diego was retrospectively reviewed from 2005-2011 . Anthropometric factors, including weight and hip circumference were measured during standard yearly follow-up appointments. Surgical outcomes were tested by the Student t test and demographic variables by Fisher's exact and Wilcoxon rank-sum tests. RESULTS: Follow-up was achieved in 147/226 LRYGB versus 130/208 LSG at year 1, 92/195 versus 81/151 at year 2, 64/145 versus 50/100 at year 3, 32/81 versus 18/54 at year 4, and 12/42 versus 14/15 at year 5. The excess weight loss (EWL) for LRYGB versus LSG was 72% versus 64.7% at 1 year (P = .002), 71.3% versus 65.5% at 2 years (P = .113), and 68.3% versus 57.4% at 5 years (P = .252), respectively. Similarly, the body mass index (BMI) decrease was statistically significant at 1 year (P = .001) but not on subsequent annual visits. Mean percent body adiposity index (BAI) decrease was 28.4% for LRYGB versus 26.8% for LSG at 1 year (P = .679) and 21.8% versus 29.8% at 2 years (P = .134), respectively. Weight loss measured in terms of %EWL and decrease in BMI and BAI did not show significance between LRYGB and LSG 2 years after surgery. CONCLUSION: Our study provides similar long-term weight loss between LSG and LRYGB, and therefore, LSG is a viable option as a definitive bariatric procedure.

Negative predictive value of acetaminophen concentrations within four hours of ingestion.

OBJECTIVES: The objective was to ascertain whether acetaminophen (APAP) concentrations less than 100 µg/mL obtained between 1 and 4 hours after acute ingestion accurately predict a nontoxic 4-hour concentration. METHODS: The authors performed a multicenter, prospective cohort study involving five emergency departments (EDs) participating in the ToxIC Research Network. Data were collected from May 2009 to December 2011. Patients with APAP concentrations <100 µg/mL drawn between 1 and 4 hours after acute ingestions, and concentrations drawn 4 or more hours after ingestions, were included in the study. Exclusion criteria included initial concentration >100 µg/mL, initial APAP concentration drawn prior to 1 hour, two undetectable APAP concentrations, the second concentration drawn prior to 4 hours, and unknown time of ingestion. Toxic concentrations 4 or more hours after ingestion were defined as concentrations that plotted above the 150 µg/mL line on the Rumack-Matthew nomogram. RESULTS: Data were collected on 83 patients who met inclusion criteria. Of the 83 patients with APAP concentrations <100 µg/mL between 1 and 4 hours, one patient (1.2%) had a ≥ 4-hour toxic concentration. Negative predictive value (NPV) for an APAP concentration <100 µg/mL obtained between 1 and 4 hours after an acute ingestion was 98.8% (95% confidence interval [CI] = 93.5% to 99.8%). CONCLUSIONS: An APAP concentration of <100 µg/mL obtained between 1 and 4 hours after ingestion has a high NPV for excluding toxic ingestion. We do not recommend reliance on concentrations obtained between 1 and 4 hours to exclude toxicity, because of a potential false-negative rate of 6.5%.

A comparison of ultrasound-guided and landmark-based approaches to saphenous nerve blockade: a prospective, controlled, blinded, crossover trial.

BACKGROUND: Blockade of the saphenous nerve is often used for surgeries below the knee. Depending on the approach, success rates vary widely ranging from 33% to 88%. In this prospective volunteer study, we compared 2 ultrasound-guided techniques, the modified vastus medialis and perifemoral saphenous nerve block with a below the knee field block. METHODS: Twenty volunteer adults, in a single-blinded, crossover, prospective trial underwent 3 different saphenous nerve blocks. The primary end point of block success was loss of sensation in the distal two-thirds distribution of the saphenous nerve. Secondary variables included time to perform the block, time to sensory loss, pain during block, and motor weakness. RESULTS: Compared with the below the knee field block success rate (30%), both the modified vastus medialis and perifemoral techniques had significantly higher success rates (80%, difference 50% with confidence interval [CI], 23%-77%, P = 0.009, and 100%, difference 70% with CI, 41%-91%, P < 0.001, respectively). However, the difference when comparing the perifemoral ultrasound technique against the modified vastus medialis ultrasound technique did not show significance (difference 20% with CI, -7% to 49%, P = 0.125). Also, no statistical differences were found with the other variables measured, except the perifemoral technique showed faster block performance times than below the knee field block (P = 0.007). CONCLUSION: In our prospective study, we have demonstrated that ultrasound-guided above the knee saphenous nerve blocks have higher success rates than a below the knee field block and are easily performed in a short amount of time.

Resource utilization in the emergency department of a tertiary care university-based hospital in Tokyo before and after the 2011 Great East Japan earthquake and tsunami.

INTRODUCTION: The objective of this study was to determine the resource utilization of a tertiary care Japanese emergency department (ED) that was not immediately adjacent to the area of the 2011 Great East Japan earthquake and tsunami. METHODS: A retrospective chart review was performed at a tertiary care university-based urban ED located approximately 290 km from the primary site of destruction secondary to an earthquake measuring 9.0 on the Richter Scale and the resulting tsunami. All patients who presented for a period of twelve days before and twelve days after the disaster were included. Data were collected using preformed data collection sheets, and stored in an Excel file. Abstracted data included gender, time in the ED, intravenous fluid administration, blood transfusion, oxygen, laboratories, electrocardiograms (ECGs), radiographs, ultrasound, diagnoses, surgical and medical referrals, and prescriptions written. Ten percent of the charts were reviewed for accuracy, and an error rate reported. Data were analyzed using 2-tailed t-tests, Fisher's exact tests or rank sum tests. Bonferroni correction was used to adjust P values for multiple comparisons. RESULTS: Charts for 1193 patients were evaluated. The error rate for the abstracted data was 3.2% (95% CI, 2.4%-4.1%). Six hundred fifty-seven patients (53% male) were evaluated in the ED after the earthquake, representing a 23% increase in patient volume. Mean patient time spent in the ED decreased from 61 minutes to 52 minutes (median decrease from 35 minutes to 32 minutes; P = .005). Laboratory utilization decreased from 51% to 43% (P = .006). The percentage of patients receiving prescriptions increased from 48% to 54% (P = .002). There was no change in the number of patients evaluated for surgical complaints, but there was an increase in the number treated for medical or psychiatric complaints. CONCLUSION: There was a significant increase in the number of people utilizing the ED in Tokyo after the Great East Japan earthquake and tsunami. Time spent in the ED was decreased along with laboratory utilization, possibly reflecting decreased patient acuity. This information may help in the allocation of national resources when planning for disasters.

Pacific partnership 2010: Anesthesia support aboard the USNS Mercy humanitarian civic assistance.

INTRODUCTION: The USNS Mercy has been integral in providing humanitarian and civic assistance as part of the Department of Defense's ongoing Combatant Commander Theater Security Cooperation Plans. The purpose of this study was to critically assess patient demographics and procedures performed to provide guidance for future missions. METHODS: A retrospective review was performed on a cohort of 825 surgical patients who underwent surgery during a 4-month period during Pacific Partnership 2010. Patient demographics, anesthesia exam findings, comorbidities, and surgical data were compared among the mission sites. RESULTS: Of the 825 patients, the mean age ranged from 39.7 to 24.7 with a statistical difference between Vietnam (39.7, p < 0.0087 for all tests) and the remaining sites. Poorer health by American Society of Anesthesiologist grading was noted in Vietnam (1.61) as compared to patients in Cambodia (1.21, p < 0.001) and Timor-Leste (1.40, p = 0.001). No difference in complication rates was noted. DISCUSSION: The reason for apparent differences in age or health status by site weren't clearly explained, but these differences had no bearing on surgical outcome. CONCLUSION: Analysis of anesthesia data compiled during Pacific Partnership 2010 provided meaningful data for future humanitarian efforts at these sites.

Acute bacterial osteoarticular infections: eight-year analysis of C-reactive protein for oral step-down therapy.

BACKGROUND: One of the most important decisions in the treatment of osteoarticular infections is the time at which parenteral therapy can be changed to oral therapy. C-reactive protein (CRP) is an acute inflammatory indicator with a half-life of 19 hours and thus can be helpful in assessing the adequacy of therapy for bacterial infections. At our institution, a combination of CRP and clinical findings is used to determine the transition to oral therapy. METHODS: A search of 8 years of electronic records identified children with osteoarticular infections. Only children with culture-positive acute bacterial arthritis (ABA) or acute bacterial osteomyelitis (ABO) were studied further. A primary chart review of demographic and clinical data was conducted, and a secondary chart review of complicated outcomes was performed. RESULTS: Of 194 total patients, complicated outcomes occurred in 40, of which 35 were prolonged therapy. Only 1 microbiologic failure occurred, presumably due to a retained intra-articular fragment of infected bone. CRP was highest initially among patients with simultaneous ABO + ABA and among those with complicated outcomes, and was lower at the transition to oral therapy in the complicated outcome group (1.5 vs 2.1 mg/dL; P = .012). CONCLUSIONS: The combination of clinical findings and CRP is a useful tool to transition children with osteoarticular infections to oral therapy. Complicated outcomes were associated with higher early CRP at diagnosis and lower CRP at the end of parenteral therapy, suggesting that clinicians were more conservative with prolonged initial parenteral therapy in this group.

Bedside method to estimate actual body weight in the Emergency Department.

BACKGROUND: Actual body weight (ABW) is important for accurate drug dosing in emergency settings. Oftentimes, patients are unable to stand to be weighed accurately or clearly state their most recent weight. OBJECTIVE: Develop a bedside method to estimate ABW using simple anthropometric measurements. METHODS: Prospective, blinded, cross-sectional convenience sampling of adult Emergency Department (ED) patients. A multiple linear regression equation from Derivation Phase (n = 208: 121 males, 87 females) found abdominal and thigh circumferences (AC and TC) had the best fit and an inter-rater correlation of 0.99 and 0.96, respectively: Male ABW (kg) = -47.8 + 0.78 ∗ (AC) + 1.06 ∗ (TC); Female ABW = -40.2 + 0.47 ∗ (AC) + 1.30 ∗ (TC). RESULTS: Derivation phase: Number of patients (%) with a body weight estimation (BWE) > 10 kg from ABW for males/females were: 7 (6%)/1 (1%) for Patients, 46 (38%)/28 (32%) for Doctors, 38 (31%)/24 (27%) for Nurses, 75 (62%)/43 (49%) for 70 kg/60 kg convention, and 14 (12%)/8 (9%) using the anthropometric regression model. For validation phase (55 males, 44 females): Gold standard ABW mean (SD) male/female = 83.6 kg (14.3)/71.5 kg (18.9) vs. anthropometric regression model = 86.3 kg (14.7)/73.3 kg (15.1). R(2) = 0.89, p < 0.001. The number (%) for males/females with a BWE > 10 kg using the anthropometric regression model = 8 (15%)/11 (27%). CONCLUSIONS: For male patients, a regression model using supine thigh and abdominal circumference measurements seems to provide a useful and more accurate alternative to physician, nurse, or standard 70-kg male conventional estimates, but was less accurate for use in female patients.