Patterns of Blood Pressure and Stress: A Descriptive Report among Anesthesiology Residents Institution.

BACKGROUND: There has been an increase in health problems among physicians due to low primary care maintenance, noncompliance with recommendations for physical activity and balanced eating practices, high levels of caffeine intake, and reduced amount of sleep. We hypothesize that physical health, specifically blood pressure (BP) control, is suboptimal among anesthesiology residents. METHODS: The purpose of this study is to investigate the prevalence of hypertension and stress among an anesthesiology resident population, and attempt to correlate possible hypertension and increased stress among residents with life and work environment factors. All University of Miami anesthesiology residents in the year 2016 were invited to participate. Blood pressures were taken and anonymous surveys, including demographic and lifestyle questions, were administered. RESULTS: Of 85 invited residents, 80 (92%) participated. 18 (22.50%) residents had blood pressures within the normal range. Twenty (25.00%) residents were hypertensive and 42 (52.50%) were pre-hypertensive. Males exhibited higher systolic blood pressures than females (p<0.0001). The mean Perceived Stress Scale (PSS) for all residents was 17.16 ± 7.2. Fifty-four (67.50%) residents scored a PSS above 13, indicating stress levels greater than the national average. Thirty-three (41.25%) residents scored above 20, indicating the presence of severe stress. Females were more likely than males to have stress (p=0.0314). Residents sleeping less than 6 hours per night were more likely to have stress (p=0.0158). Residents reporting more than one overnight call per week were also more likely to have stress (p=0.013). CONCLUSIONS: Our study showed 75% of residents have hypertensive disease and 68% of residents exhibit clinically significant stress. These findings emphasize the need for greater attention to personal health and well-being.

Aortoiliac Thrombosis Following Tranexamic Acid Administration During Urgent Cesarean Hysterectomy: A Case Report.

Postpartum hemorrhage (PPH) contributes to 25% of maternal deaths worldwide. Abnormal placentation is a well-known culprit of PPH. Although controversial, iliac artery balloon occlusion has been used in patients to decrease bleeding. The use of antifibrinolytic agents, such as tranexamic acid (TXA), have gained popularity in the management of PPH. We present a 35-year-old parturient with placenta percreta that was managed with internal iliac artery balloon occlusion with concomitant use of TXA during urgent cesarean hysterectomy with subsequent aortoiliac thrombosis formation. The role of both TXA and arterial balloons in PPH, along with their respective limitations, are discussed.

Quantification of bony pelvic exposure through the modified Stoppa approach.

OBJECTIVES: Authors previously have described anatomic structures commonly seen through the modified Stoppa approach; however, no study has formally quantified the areas and amount of visual bony exposure that is obtained. This information is important for proper preoperative planning of acetabulum fractures with regard to fracture reduction and fixation. The aim of this study was to quantify and describe the extent of bony pelvis exposed while identifying the limits of exposure from osseous landmarks within the dissection of the modified Stoppa approach. METHODS: Ten modified Stoppa approaches were performed on cadavers. Specific anatomic landmarks were identified, and the far boundaries of the exposed osseous structures from the surgeon's perspective were marked on each cadaver. All soft tissues were then stripped, and calibrated digital images of the demarcated area of exposure were taken and total viewable osseous surface area was calculated. Additionally, the boundaries of exposure based on various anatomic landmarks were determined. RESULTS: All neurovascular structures at potential risk (external iliac, obturator, corona mortis, and superior gluteal) were identified in each exposure. The entire pelvic brim from the pubic symphysis to beyond the sacroiliac joint was visualized in all exposures, with an average ± SD of 10 ± 5 mm of anterior sacrum exposed. On average, visualization above the pelvic brim was possible 15 ± 5 mm anteriorly over the acetabular roof and 19 ± 5 mm posteriorly above the greater sciatic notch. The viewable area included 51 ± 5 mm below the pelvic brim along the quadrilateral surface, with 41 ± 5 mm of the obturator foramen depth and 29 ± 9 mm of the greater sciatic notch seen on average. Approximately 32% ± 4% of the total surface area of the inner pelvis was able to be visualized, which included 79% ± 5% of the inner true pelvis below the brim and 80% ± 6% of the quadrilateral surface. CONCLUSIONS: The modified Stoppa approach allows for exposure of most (79%) of the inner true bony pelvis including the entire pelvic brim and 80% of the quadrilateral surface. On average, visualization is possible 2 cm above the pelvic brim and 5 cm below the pelvic brim along the quadrilateral surface, providing adequate anterior exposure for clamp and implant placement.

Tibia-based referencing for standard proximal tibial radiographs during intramedullary nailing.

Limited information exists to define standard tibial radiographs. The purpose of this study was to define new landmarks on the proximal tibia for standard anteroposterior and lateral radiographs. In 10 cadaveric knees, fibular head bisection was considered the anteroposterior image, and femoral condyle overlap the lateral image. In another 10 knees, a "twin peaks" anteroposterior view, showing the sharpest profile of the tibial spines, was used. The "flat plateau" lateral image was obtained by aligning the femoral condyles then applying a varus adjustment with overlap of the tibial plateaus. Medial peritendinous approaches were performed, and an entry reamer used to open the medullary canal. A priori analysis showed good to excellent intra-/inter-observer reliability with the new technique (intra-class correlation coefficient ICC 0.61-0.90). The "twin peaks" anteroposterior radiograph was externally rotated 2.7±2.1° compared to the standard radiograph with fibular head bisection. Portal position and incidence of damage to intra-articular structures did not significantly differ between groups (P>.05). The "twin peaks" anteroposterior view and "flat plateau" lateral view can safely be used for nail entry portal creation in the anatomic safe zone. Tibia-based radiographic referencing is useful for intramedullary nailing cases in which knee or proximal tibiofibular joint anatomy is altered.

Quantification of anterior cortical bone removal and intermeniscal ligament damage at the tibial nail entry zone using parapatellar and retropatellar approaches.

OBJECTIVES: Anterior cortical bone removal at the tibial nail entry zone has been shown to alter biomechanical properties of the proximal tibia. However, no study has quantified the amount of bone removed. The purpose of this study was to quantify the amount of anterior bone removed at the nail entry zone and assess damage to adjacent intra-articular structures using both parapatellar and retropatellar techniques. METHODS: The study was performed using 36 cadaveric knees (18 medial parapatellar and 18 retropatellar approaches). A guide pin was placed in the anatomic safe zone using fluoroscopic guidance and a 12.5-mm entry reamer used to open medullary canal. Soft tissues were removed, damage to intra-articular structures recorded, and size of osseous defect created in proximal tibia measured. RESULTS: The surface area of bone removed with portal creation was not significantly larger with retropatellar (228.4 ± 38.1 mm) versus parapatellar technique (207.9 ± 33.4 mm(2); P = 0.108). This was substantially different than if the entry hole was perfectly round (122.7 mm(2)). No knee went without some damage to intra-articular structures using the parapatellar technique, as opposed to 33% knees with retropatellar technique (P = 0.019). Intermeniscal (IM) ligament was damaged in 83% parapatellar and 56% retropatellar knees (P = 0.146). CONCLUSIONS: A substantial amount of anterior bone is removed during nail entry portal creation using both parapatellar and retropatellar techniques. Intra-articular structure damage, most commonly IM ligament disruption, was also found to occur at a lower rate with retropatellar technique. Avoidance of both anterior bone removal and IM ligament damage may not be possible because of size and geometrical constraints.

Analysis of retrograde femoral intramedullary nail placement through traumatic knee arthrotomies.

OBJECTIVES: To analyze the rate of postoperative infection after retrograde femoral nail placement in the setting of traumatic knee arthrotomy (KA). DESIGN: Retrospective. SETTING: Level-I trauma center. PATIENTS: A review of all adult femur fractures (N = 1748) treated with an intramedullary nail over a 10-year period identified 34 retrograde nails with traumatic KA as the study group and 23 antegrade nails with traumatic KA as a control group. The retrograde femoral traumatic KA group was also compared with a 4:1 matched control group of 136 patients with retrograde femoral nails without traumatic KA. INTERVENTION: Retrograde femoral nail placement with traumatic KA. MAIN OUTCOME MEASUREMENTS: Occurrence of postoperative infection. RESULTS: The traumatic KA groups treated with retrograde and antegrade femoral nails were similar across all recorded patient variables. No infections occurred in the retrograde traumatic KA group versus 1 infection (4.3%) in the antegrade traumatic KA group (P = 0.404). Four nonunions (11.8%) occurred in the retrograde traumatic KA group versus 1 nonunion (4.3%) in the antegrade traumatic KA group (P = 0.638). The matched control group of retrograde nails did not significantly differ when compared with the retrograde traumatic KA group for infection or nonunion (P = 1.000 and 0.261). CONCLUSIONS: This is the first study to investigate retrograde nail placement through traumatic KA with comparison to control groups, with no differences found in infection rates. Furthermore, no infections (knee or fracture) occurred in those patients who were treated using a retrograde femoral nail with traumatic KA. This study documents the relative safety associated with retrograde femoral nailing in the setting of a concurrent traumatic KA with surgical debridement.

Both surgical clipping and endovascular embolization of unruptured intracranial aneurysms are associated with long-term improvement in self-reported quantitative headache scores.

BACKGROUND: The most common presenting symptom for unruptured intracranial aneurysms (UIAs) is headache (HA). However, most experts believe that UIAs associated with HAs are unrelated and incidental. OBJECTIVE: To analyze the incidence and characterization of HAs in patients with UIAs before and after treatment with either surgical clipping or endovascular embolization. METHOD: We prospectively determined the presence, sidedness, and severity of HAs preoperatively in patients who presented to the senior author with a UIA. A validated, quantitative 11-point HA pain scale was used in all patients. The same HA assessments were performed again on these patients an average of 32.4 months postoperatively. RESULTS: In this study, 92.45% (n = 53) of patents for whom we were able to obtain both a preoperative and postoperative pain score had an improvement in their HAs. The average quantitative HA score was 5.87 preoperatively vs 1.39 postoperatively (P < .001). There was no relationship found between the following: (1) HA severity vs aneurysm size, (2) sidedness of aneurysm vs sidedness of HA, and (3) HA improvement after surgical vs endovascular treatment. CONCLUSION: This study suggests that surgical and endovascular treatment of a UIA is associated with dramatic improvement in self-reported HA score an average of 32.4 months postoperatively.