Subtotal Parathyroidectomy vs Total Parathyroidectomy with Autotransplantation for Secondary Hyperparathyroidism in Dialysis Patients: Short- and Long-Term Outcomes.

BACKGROUND: Two operations are performed for management of secondary hyperparathyroidism, subtotal parathyroidectomy (SPTX) and total parathyroidectomy with autotransplantation (TPTX-AT). There is no consensus among endocrine surgeons about which operation is the preferred treatment. This study compares the short- and long-term outcomes of SPTX and TPTX-AT for dialysis patients with secondary hyperparathyroidism. STUDY DESIGN: This is a retrospective review of 46 dialysis patients undergoing PTX from 2006 to 2017 at a 719-bed tertiary care hospital. RESULTS: Calcium on postoperative day 1 was 7.7 ± 0.8 mg/dL for SPTX and 7.9 ± 1.3 mg/dL for TPTX-AT (p = 0.49). Parathyroid hormone values on postoperative day 1 were 32.6 ± 26.0 pg/mL for SPTX and 9.5 ± 4.2 pg/mL for TPTX-AT (p ≤ 0.05). Hospital length of stay was 3.7 ± 1.9 days for SPTX and 4.4 ± 3.5 days for TPTX-AT (p = 0.46). The required doses of calcium and calcitriol at discharge did not differ significantly. Reoperation for recurrence or persistence of disease was required in 6 SPTX patients and 2 TPTX-AT patients (p = 0.12). Parathyroid hormone values <15 pg/mL at long-term follow-up occurred in 5.6% of SPTX patients and 26.7% of TPTX-AT patients (p = 0.09). Parathyroid hormone values >200 pg/mL at long-term follow-up occurred in 38.9% of SPTX patients vs 6.7% of the TPTX-AT patients (p ≤ 0.05). Calcium supplementation at more than 6 months was required for 36.8% of SPTX and 71.4% of TPTX-AT patients (p < 0.05). CONCLUSIONS: The long-term control of parathyroid hormone elevation and avoidance of recurrent disease is improved with TPTX-AT, but carries a higher risk of long-term hypocalcemia.

The geometric preference subtype in ASD: identifying a consistent, early-emerging phenomenon through eye tracking.

Background: The wide range of ability and disability in ASD creates a need for tools that parse the phenotypic heterogeneity into meaningful subtypes. Using eye tracking, our past studies revealed that when presented with social and geometric images, a subset of ASD toddlers preferred viewing geometric images, and these toddlers also had greater symptom severity than ASD toddlers with greater social attention. This study tests whether this "GeoPref test" effect would generalize across different social stimuli. Methods: Two hundred and twenty-seven toddlers (76 ASD) watched a 90-s video, the Complex Social GeoPref test, of dynamic geometric images paired with social images of children interacting and moving. Proportion of visual fixation time and number of saccades per second to both images were calculated. To allow for cross-paradigm comparisons, a subset of 126 toddlers also participated in the original GeoPref test. Measures of cognitive and social functioning (MSEL, ADOS, VABS) were collected and related to eye tracking data. To examine utility as a diagnostic indicator to detect ASD toddlers, validation statistics (e.g., sensitivity, specificity, ROC, AUC) were calculated for the Complex Social GeoPref test alone and when combined with the original GeoPref test. Results: ASD toddlers spent a significantly greater amount of time viewing geometric images than any other diagnostic group. Fixation patterns from ASD toddlers who participated in both tests revealed a significant correlation, supporting the idea that these tests identify a phenotypically meaningful ASD subgroup. Combined use of both original and Complex Social GeoPref tests identified a subgroup of about 1 in 3 ASD toddlers from the "GeoPref" subtype (sensitivity 35%, specificity 94%, AUC 0.75.) Replicating our previous studies, more time looking at geometric images was associated with significantly greater ADOS symptom severity. Conclusions: Regardless of the complexity of the social images used (low in the original GeoPref test vs high in the new Complex Social GeoPref test), eye tracking of toddlers can accurately identify a specific ASD "GeoPref" subtype with elevated symptom severity. The GeoPref tests are predictive of ASD at the individual subject level and thus potentially useful for various clinical applications (e.g., early identification, prognosis, or development of subtype-specific treatments).

The 30-second rule: the effects of prolonged intubation attempts on oxygen saturation and heart rate in preterm infants in the delivery room.

BACKGROUND: A duration of 30 seconds has been shown to improve the success rate of intubation attempts without any decompensation. There is limited data regarding the detrimental effects of prolonged intubation attempts in preterm infants. The aim was to determine the effect of prolonged intubation attempts on heart rate and oxygen saturation in preterm infants. METHODS: We retrospectively reviewed videos and physiologic data collected during delivery room (DR) resuscitations. Infants who had a functioning pulse oximeter at the time of intubation in the delivery room were analyzed using video and analog recordings. The duration of the intubation attempt was defined as the time the laryngoscope blade was in the infant's mouth. Prolonged intubations were defined as intubations over 30 seconds. Baseline heart rate and saturations were defined as the heart rate and saturation immediately prior to the intubation attempt. Video recording was used to determine time laryngoscope was in the mouth, what other procedures were performed, and whether there was recovery between attempts. Analog data including heart rate, airway pressure and saturation was also recorded. RESULTS: There were 52 intubation attempts in 28 infants. The median (IQR) birth weight and gestational age were 795 (705, 972) grams and 25 (25, 27) weeks. The duration of an intubation attempt was 35 (27, 46) seconds with number of attempts 2 (1, 2). There were 34 intubation attempts greater than 30 seconds (prolonged group) and 18 attempts less than or equal to 30 seconds (short group). Longer attempts did not affect intubation success (successful 34 [25,37] seconds vs. unsuccessful 41[29, 53] seconds; P=0.05). Infants in the prolonged group had a greater decrease in oxygen saturation percentage from baseline (5±8 percent, short intubation group and 13±27 prolonged intubation group; P=0.004). There was also a significant decrease in heart rate beats per minute between the two groups (6±9 in the short intubation group and 23±29 prolonged group; P=0.004). CONCLUSIONS: The currently recommended guideline by the Neonatal Resuscitation Program limiting intubation attempts to less than 30 seconds is supported by stable oxygen saturations and heart rate. Prolonging the intubation more than 30 seconds leads to greater hypoxia and may contribute to increased neonatal morbidity, with no effect on success rate.

Resistance of Colorimetric Carbon Dioxide Detectors Commonly Utilized in Neonates.

BACKGROUND: Colorimetric end-tidal carbon dioxide (ETCO2) detectors can identify airway obstruction during noninvasive ventilation and successful intubation during newborn resuscitation. The resistance of these devices is not well described, and the information provided by manufacturers is incomplete. METHODS: We compared the resistance of 3 colorimetric ETCO2 detectors (Neo-StatCO2, Pedi-Cap, and Mini StatCO2,) and 2 mainstream capnograph sensors (EMMA infant airway adapter 17449 and neonatal/infant airway adapter YG-213T). Endotracheal tubes, 2.5-4.0-mm inner diameter (Portex) were measured as a reference range. A differential pressure transducer was placed between the device and a T-piece resuscitator. The other side of the device was open to air. Resistance to flow was tested at 1-10 L/min. Resistance was calculated as the change in pressure over change in flow and expressed as cm H2O/L/s. RESULTS: There was a significantly higher mean resistance across all flows tested for the Neo-StatCO2 compared with the other ETCO2 devices (P < .001). There was a 6-fold difference between the least and most resistive colorimetric detectors. At the commonly utilized flow of 10 L/min, the resistance of the Neo-StatCO2 was 61.1 cm H2O/L/s, comparable with that of a 3.0 endotracheal tube, which we measured at 62.7 cm H2O/L/s. The resistance values of the Pedi-Cap and Mini StatCO2 were 9.9 and 8.4 cm H2O/L/s, respectively. Those of the EMMA and YG-213T were 7.1 and 2.6 cm H2O/L/s, respectively. CONCLUSIONS: We found significant differences in resistance between devices used to detect ETCO2 during resuscitation of premature infants. Future trials are needed to determine the effects of this resistance on work of breathing, particularly on very premature newborns receiving mask CPAP.

Measuring cardiac changes using electrical impedance during delayed cord clamping: a feasibility trial.

BACKGROUND: To date no study has attempted to continuously evaluate changes in hemodynamics during delayed cord clamping in humans. We aimed to demonstrate 1. the feasibility of measurements of hemodynamics during delayed cord clamping and 2. to describe the changes that occur over each minute. RESULTS: After vaginal delivery, term infants (37(0)-41(6) weeks) were placed on a Life Start® bed 10-20 cm below the placenta. Transcutaneous sensors were placed on the neck and chest to determine heart rate, stroke volume and cardiac output at each beat. Once a signal was obtained, first 5 values (taken every beat) were averaged and the percent change for each subject from baseline was calculated. 20 infants were enrolled and all had a reliable signal obtained from transcutaneous sensors and had a delay in cord clamping for about 5 minutes. Cardiac output increased from 2 to 5 minutes of life (p = 0.008). For every minute of life the cord was kept unclamped, the stroke volume increased 13.1% ± 12.3 (p = 0.0001) and cardiac output increased 12.6% ± 6.3 from baseline (p < 0.0001). While the majority of infants continued to have an increase in cardiac output at 5 minutes of life, 7/20 infants reached their peak cardiac output at 188 ± 41 seconds of life. CONCLUSIONS: This study demonstrates that hemodynamic measures could be successfully obtained during the first five minutes of birth and while a newborn was receiving delayed cord clamping. This study also provides reference values for changes in cardiac output and stroke volume in well term infants during delayed cord clamping. TRIAL REGISTRATION: Clinical Trials.gov NCT02195037 Registered 17 July 2014.