The Impact of Computed Tomography Scans on the Management and Wait Times in Perianal Abscess Diagnoses.

Background Diagnosis and management of perianal abscesses (PAA) are based on history and clinical examination. Imaging is not indicated except in complicated cases, as determined by the surgical team. The monetary, ionizing radiation, and resource utilization costs of a computed tomography (CT) scan in the emergency room must be considered when used for diagnostic purposes of PAAs. Methods A retrospective analysis of 129 patients diagnosed with a diagnosis of PAA between 2015-2020 was performed. The primary endpoints included length of stay, CT performed, time from patient presentation to CT, and CT scan completion prior to surgical consultation. Data is reported as n (%) or median (IQR). Results Of the 129 patients diagnosed with PAA, 81 underwent CT, and 48 did not. General surgery was consulted in 88% of cases. There were no statistically significant differences in age (p=0.562), sex (p=0.531), or ethnicity (p=0.356). The median hospitalization time was two days when CT was performed (p=0.001). The median time elapsed from presentation to the emergency department and CT scan performed was 16 hours (p=0.001). CT scans were ordered before the surgical consultation in 65% of cases (p=0.001) and 17% after a surgical consultation was placed (p=0.009). Conclusion Performing CT scans prior to surgical evaluation for the diagnosis of PAA is not a responsible practice. The cost, resources, and radiation exposure must be considered. This study demonstrated that more CT scans are ordered prior to surgical consultation for PAA, resulting in a prolonged wait time in the emergency department.

Novel Treatment of Ventilator Dyssynchrony From Central Alveolar Hypoventilation Syndrome Utilizing Scheduled 5-Hydroxytryptamine-3 Receptor Antagonist.

Traumatic brain injury (TBI) occurs in a large percentage of surgical trauma patients and is one of the leading causes of death amongst young teens and adults. Furthermore, individuals with TBIs often require mechanical ventilation and admission to the intensive care unit. As a result of their TBIs, these patients can develop central alveolar hypoventilation (CAH) secondary to disruptions in neuromodulatory respiratory brainstem control and neural signal initiation and integration. Prior studies have primarily focused their attention on treatment of congenital disorders of CAH, and limited research is available on intubated trauma patients who have signs of ventilator dyssynchrony. Current case reports and animal studies have suggested that noradrenergic and specific serotonergic medications are able to target specific neurologic pathways in the respiratory circuit and induce ventilator synchrony. This case series describes the clinical course of TBI patients treated for ventilator dyssynchrony secondary to CAH with a daily scheduled 5-hydroxytryptamine-3 (5-HT3) receptor antagonist. All patients were ultimately extubated and discharged from the hospital.

Investigation of the relationship between anthropometric measurements and maximal handgrip strength in young adults.

BACKGROUND: To identify physical measures that predict maximal handgrip strength (MHGS) and provide evidence for identifying lack of sincerity of effort when assessing upper extremity weakness. OBJECTIVE: This study investigated anthropometric measurements associated with MHGS of healthy young adults. METHODS: A convenience sample of 150 healthy adults ages 19 to 34 years old completed the MHGS assessment, which was measured using a Jamar dynamometer according to the protocol of the American Society of Hand Therapists, for both dominant and non-dominant hands. Several anthropometric data were collected, which included height, body weight, forearm length, forearm circumference, hand length, and hand width. RESULTS: Multivariable linear regression analysis indicated gender and hand width were uniquely and significantly associated with participants' MHGS for dominant and non-dominant hand and accounted for more than 60% of the variance, with R2 = 0.60, P < 0.001 for the dominant hand model and R2 = 0.64, P < 0.001 for the non-dominant hand model. CONCLUSIONS: Among the forearm and hand anthropometric measures, hand width is the best predictor of MHGS in both the non-dominant and dominant hands for healthy young adults.

Measures of clinical outcome before, during, and after implementation of a comprehensive geriatric hip fracture program: is there a learning curve?

OBJECTIVES: To evaluate the effects of implementing a multidisciplinary geriatric hip fracture program on clinical outcome measures at our institution. DESIGN: Retrospective comparative cohort study of consecutive patients treated before, during, and after implementation of this program, including patient data from electronic medical records and state death records. SETTING: Single metropolitan level 2 regional trauma center and community hospital. PATIENTS/PARTICIPANTS: Patients aged 60 years and older with operatively treated low-energy hip fractures were included. Patients with active cancer or a high-energy mechanism (motor vehicle crash or fall >3 ft) were excluded. INTERVENTION: Patients were divided into 1 of 3 groups: (1) those treated before our hip fracture program (July 2008-April 2009), (2) during implementation of the hip fracture program (May 2009-Feb 2010), and (3) after the hip fracture program was instituted and participation was well established (March 2010-Dec 2010). MAIN OUTCOME MEASURES: Patient demographics, injury factors, and clinical outcomes, including performance measures (eg, time to medical clearance and surgery and length of stay) and patient deaths (in-hospital, 30 days, and 1 year), were compared. RESULTS: There was significant improvement in clinical performance measures, including time to surgery and length of stay during and after implementation of our geriatric hip fracture program. The in-hospital mortality rate increased during the implementation phase of this program (P = 0.04). Once established, however, the in-hospital mortality decreased to a more typical level. Thirty-day and 1-year mortality rates were not significantly different among the 3 groups. CONCLUSIONS: Most clinical outcome measures improved significantly with implementation of our geriatric hip fracture program. Increased in-hospital mortality, however, was an unintended consequence seen while establishing this program and may represent a learning curve by health care providers. Patient demise in the longer term seemed to be unaffected by implementation of the program. LEVEL OF EVIDENCE: Therapeutic level III.

The effects of clopidogrel (Plavix) and other oral anticoagulants on early hip fracture surgery.

OBJECTIVE: Risk for bleeding complications during and after early hip fracture surgery for patients taking clopidogrel and other anticoagulants have not been defined. The purpose of this study is to assess the perioperative bleeding risks and clinical outcome after early hip fracture surgery performed on patients taking clopidogrel (Plavix) and other oral anticoagulants. DESIGN: Study design is a retrospective cohort analysis using data extracted from hospital records and state death records. SETTING: Regional medical center (level II trauma). METHODS: Data for 1118 patients ≥60 years of age who had surgical treatment for a hip fracture between 2004 and 2008 were reviewed. Eighty-two patients undergoing late surgery (>3 days after admission) were excluded. Patients taking clopidogrel were compared against those not taking clopidogrel. In addition, patients taking clopidogrel only were compared against cohorts of patients taking both clopidogrel and aspirin, aspirin only, warfarin only, or no anticoagulant. RESULTS: Seventy-four of 1036 patients (7%) were taking clopidogrel, although control groups included 253 patients on aspirin alone, 90 patients on warfarin, and 619 taking no anticoagulants. No significant differences were noted between patients taking clopidogrel and those not taking clopidogrel in estimated blood loss, transfusion requirement, final blood count, hematoma evacuation, hospital length of stay (LOS), or mortality while in hospital or at 1 year. A higher American Society of Anesthesiologists score was seen in the clopidogrel and warfarin groups (P = 0.05 each), increased LOS in the clopidogrel group (P = 0.05), and higher rate of deep vein thrombosis seen in those patients taking warfarin (P = 0.05). Clopidogrel only versus aspirin versus both aspirin and clopidogrel, versus no anticoagulant versus warfarin showed no significant differences in estimated blood loss, transfusion requirement, final blood count, bleeding or perioperative complications, or mortality. CONCLUSIONS: Patients undergoing early hip fracture surgery who are taking clopidogrel, aspirin, or warfarin (with regulated international normalized ratio) are not at substantially increased risk for bleeding, bleeding complications, or mortality. Comorbidities and American Society of Anesthesiologists scores were significantly higher in the clopidogrel group, which may have resulted in the increased postoperative LOS in this group.

Manganese exposure inhibits the clearance of extracellular GABA and influences taurine homeostasis in the striatum of developing rats.

Manganese (Mn) accumulation in the brain has been shown to alter the neurochemistry of the basal ganglia. Mn-induced alterations in dopamine biology are fairly well understood, but recently more evidence has emerged characterizing the role of γ-aminobutyric acid (GABA) in this dysfunction. The purpose of this study was to determine if the previously observed Mn-induced increase in extracellular GABA (GABA(EC)) was due to altered GABA transporter (GAT) function, and whether Mn perturbs other amino acid neurotransmitters, namely taurine and glycine (known modulators of GABA). Extracellular GABA, taurine, and glycine concentrations were collected from the striatum of control (CN) or Mn-exposed Sprague-Dawley rats using in vivo microdialysis, and the GAT inhibitor nipecotic acid (NA) was used to probe GAT function. Tissue and extracellular Mn levels were significantly increased, and the Fe:Mn ratio was decreased 36-fold in the extracellular space due to Mn-exposure. NA led to a 2-fold increase in GABA(EC) of CNs, a response that was attenuated by Mn. Taurine responded inversely to GABA, and a novel 10-fold increase in taurine was observed after the removal of NA in CNs. Mn blunted this response and nearly abolished extracellular taurine throughout collection. Striatal taurine transporter (Slc6a6) mRNA levels were significantly increased with Mn-exposure, and Mn significantly increased (3)H-Taurine uptake after 3-min exposure in primary rat astrocytes. These data suggest that Mn increases GABA(EC) by inhibiting the function of GAT, and that perturbed taurine homeostasis potentially impacts neural function by jeopardizing the osmoregulatory and neuromodulatory functions of taurine in the brain.

Pulmonary vein isolation and autonomic denervation for the management of paroxysmal atrial fibrillation by a minimally invasive surgical approach.

BACKGROUND: Advances in technology such as epicardial bipolar radiofrequency pulmonary vein isolation, ganglionated plexi identification, and isolation and thoracoscopic left atrial appendage exclusion have enabled less invasive surgical options for management of atrial fibrillation. METHODS: We performed a prospective, nonrandomized study of consecutive patients with symptomatic paroxysmal atrial fibrillation undergoing a video-assisted, minimally invasive surgical ablation procedure. The procedure consisted of bilateral, epicardial pulmonary vein isolation with bipolar radiofrequency, partial autonomic denervation, and selective excision of the left atrial appendage. Minimum follow-up was 1 year with long-term monitoring (24-hour continuous, 14-day event or pacemaker interrogation). RESULTS: Between March 2005 and January 2008, 52 patients (35 male), mean age 60.3 years (range, 42-79 years) underwent the procedure. The left atrial appendage was isolated in 88.0% (44/50). Average hospital stay was 5.2 days (range 3-10 days). There were no operative deaths or major adverse cardiac events. On long-term monitoring, freedom from atrial fibrillation/flutter/tachycardia was 86.3% (44/51) and 80.8% (42/52) at 6 and 12 months, respectively. Antiarrhythmic drugs were stopped in 33 of 37 patients and warfarin in 30 of 37 of the patients in whom ablation was successful at 12 months. Freedom from symptoms attributed to atrial fibrillation/flutter/tachycardia was 78.0% (39/50) at 6 months and 63.8% (30/47) at 12 months. CONCLUSIONS: Minimally invasive surgical ablation is effective in the management of paroxysmal atrial fibrillation as evidenced by freedom from atrial arrythmias by long-term monitoring at 12 months. Measuring success using clinical symptoms underestimated clinical success as compared with long-term monitoring.

Extracellular norepinephrine, norepinephrine receptor and transporter protein and mRNA levels are differentially altered in the developing rat brain due to dietary iron deficiency and manganese exposure.

Manganese (Mn) is an essential trace element, but overexposure is characterized by Parkinson's like symptoms in extreme cases. Previous studies have shown that Mn accumulation is exacerbated by dietary iron deficiency (ID) and disturbances in norepinephrine (NE) have been reported. Because behaviors associated with Mn neurotoxicity are complex, the goal of this study was to examine the effects of Mn exposure and ID-associated Mn accumulation on NE uptake in synaptosomes, extracellular NE concentrations, and expression of NE transport and receptor proteins. Sprague-Dawley rats were assigned to four dietary groups: control (CN; 35 mg Fe/kg diet), iron-deficient (ID; 6 mg Fe/kg diet), CN with Mn exposure (via the drinking water; 1 g Mn/L) (CNMn), and ID with Mn (IDMn). (3)H-NE uptake decreased significantly (R=-0.753, p=0.001) with increased Mn concentration in the locus coeruleus, while decreased Fe was associated with decreased uptake of (3)H-NE in the caudate putamen (R=0.436, p=0.033) and locus coeruleus (R=0.86; p<0.001). Extracellular concentrations of NE in the caudate putamen were significantly decreased in response to Mn exposure and ID (p<0.001). A diverse response of Mn exposure and ID was observed on mRNA and protein expression of NE transporter (NET) and alpha(2) adrenergic receptor. For example, elevated brain Mn and decreased Fe caused an approximate 50% decrease in NET and alpha(2) adrenergic receptor protein expression in several brain regions, with reductions in mRNA expression also observed. These data suggest that Mn exposure results in a decrease in NE uptake and extracellular NE concentrations via altered expression of transport and receptor proteins.

Manganese exposure alters extracellular GABA, GABA receptor and transporter protein and mRNA levels in the developing rat brain.

Unlike other essential trace elements (e.g., zinc and iron) it is the toxicity of manganese (Mn) that is more common in human populations than its deficiency. Data suggest alterations in dopamine biology may drive the effects associated with Mn neurotoxicity, though recently gamma-aminobutyric acid (GABA) has been implicated. In addition, iron deficiency (ID), a common nutritional problem, may cause disturbances in neurochemistry by facilitating accumulation of Mn in the brain. Previous data from our lab have shown decreased brain tissue levels of GABA as well as decreased (3)H-GABA uptake in synaptosomes as a result of Mn exposure and ID. These results indicate a possible increase in the concentration of extracellular GABA due to alterations in expression of GABA transport and receptor proteins. In this study weanling-male Sprague-Dawley rats were randomly placed into one of four dietary treatment groups: control (CN; 35mg Fe/kg diet), iron-deficient (ID; 6mg Fe/kg diet), CN with Mn supplementation (via the drinking water; 1g Mn/l) (CNMn), and ID with Mn supplementation (IDMn). Using in vivo microdialysis, an increase in extracellular GABA concentrations in the striatum was observed in response to Mn exposure and ID although correlational analysis reveals that extracellular GABA is related more to extracellular iron levels and not Mn. A diverse effect of Mn exposure and ID was observed in the regions examined via Western blot and RT-PCR analysis, with effects on mRNA and protein expression of GAT-1, GABA(A), and GABA(B) differing between and within the regions examined. For example, Mn exposure reduced GAT-1 protein expression by approximately 50% in the substantia nigra, while increasing mRNA expression approximately four-fold, while in the caudate putamen mRNA expression was decreased with no effect on protein expression. These data suggest that Mn exposure results in an increase in extracellular GABA concentrations via altered expression of transport and receptor proteins, which may be the basis of the neurological characteristics of manganism.

Minimally invasive pulmonary vein isolation and partial autonomic denervation for surgical treatment of atrial fibrillation.

BACKGROUND: We seek to demonstrate the rationale and efficacy of a minimally invasive surgical approach to the treatment of atrial fibrillation (AF) that combines pulmonary vein antral isolation with targeted partial autonomic denervation. METHODS: The literature supporting the rationale of this approach is reviewed. Seventy-four patients underwent video-assisted bilateral pulmonary vein antral isolation with confirmation of block and partial autonomic denervation with follow-up of 6 months or greater and have a long-term rhythm monitor at 6 months. RESULTS: Success was defined as no episodes greater than 15 seconds of AF on long-term monitoring. Treatment was successful in 83.7% of patients with paroxysmal AF and 56.5% of patients with persistent/long-standing persistent AF. CONCLUSIONS: There are evidence-based data that support both pulmonary vein electrical isolation and targeted partial autonomic denervation in the treatment of AF. These techniques can be combined in a minimally invasive surgical approach. Early data suggest this is a safe and efficacious approach for the treatment of paroxysmal AF. Techniques are being developed for the minimally invasive surgical treatment of persistent AF from an epicardial approach.