Association of Multimodal Pain Control with Patient-Reported Outcomes in Children Undergoing Surgery

IntroductionOur aim was to describe practices in multimodal pain management at US children's hospitals and evaluate the association between non-opioid pain management strategies and pediatric patient-reported outcomes (PROs).MethodsData were collected as part of the 18-hospital ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US) clinical trial. Non-opioid pain management strategies included use of preoperative and postoperative non-opioid analgesics, regional anesthetic blocks, and a biobehavioral intervention. PROs included perioperative nervousness, pain-related functional disability, health-related quality of life (HRQoL). Associations were analyzed using multinomial logistic regression models.ResultsAmong 186 patients, 62 (33%) received preoperative analgesics, 186 (100%) postoperative analgesics, 81 (44%) regional anesthetic block, and 135 (73%) used a biobehavioral intervention. Patients were less likely to report worsened as compared to stable nervousness following regional anesthetic block (relative risk ratio [RRR]:0.31, 95% confidence interval [CI]:0.11–0.85), use of a biobehavioral technique (RRR:0.26, 95% CI:0.10–0.70), and both in combination (RRR:0.08, 95% CI:0.02–0.34). There were no associations of non-opioid pain control modalities with pain-related functional disability or HRQoL.ConclusionUse of postoperative non-opioid analgesics have been largely adopted, while preoperative non-opioid analgesics and regional anesthetic blocks are used less frequently. Regional anesthetic blocks and biobehavioral interventions may mitigate postoperative nervousness in children.Level of evidenceIII.     

BIA-ALCL diagnosis on CytoLyt fixed ThinPrep,cell block and immunohistochemistry

Breast implant associated anaplastic large cell lymphoma (BIA-ALCL) is an emergent rare T cell non-Hodgkin lymphoma arising in association with a breast implant, particularly textured ones. Recent guidelines list cytopathological examination as the first essential step for diagnosis, routinely followed by CD30 immunohistochemistry (IHC) and flow cytometry (FC) for a T cell clone. The majority of BIA-ALCL literature regarding cytopathological evaluation describes morphology based on various preparation methods limited to cytospins and smears with the exception of at least one case report detailing cytomorphological and IHC findings on ThinPrep. This case report details initial diagnosis of BIA-ALCL rendered with CytoLyt prepared ThinPrep and cell block, including the specific antibodies used for IHC. The ThinPrep slide showed numerous singly dispersed large, atypical cells with abundant cytoplasm containing irregular nuclei with dispersed chromatin and prominent nucleoli in a background of macrophages, inflammatory cells and granular debris. TIA-1 and CD30 along with other T-cell markers, including specific antibodies, remains immunoreactive in tissue collected in CytoLyt solution. Cell size reduction, artifactual lymphoid cell aggregation and prominent nucleoli in benign and reactive conditions are among other ThinPrep cellular alterations pathologists should bear in mind.     

Transient left bundle branch block after posture change to the prone position during general anesthesia: A case report

Rationale:The prone position is commonly used in spinal surgery. There have been many studies on hemodynamic changes in the prone position during general anesthesia. We report a rare case of transient left bundle branch block (LBBB) in a prone position.Patient concern:Electrocardiogram (ECG) of a 64-year-old man scheduled for spinal surgery showed normal sinus rhythm change to LBBB after posture change to the prone position.Diagnosis:Twelve lead ECG revealed LBBB. His coronary angio-computed tomography results showed right coronary artery with 30% to 40% stenosis and left circumflex artery with 40% to 50% stenosis. The patient was diagnosed with stable angina and second-degree atrioventricular block of Mobitz type II.Intervention:Nitroglycerin was administered intravenously during surgery. Adequate oxygen was supplied to the patient. After surgery, the patient was prescribed clopidogrel, statins, angiotensin II receptor blocker, and a permanent pacemaker was inserted.Outcome:Surgery was completed without complications. After surgery, the transient LBBB changed to a normal sinus rhythm. The patient did not complain of chest pain or dyspnea.Lesson:The prone position causes significant hemodynamic changes. A high risk of cardiovascular disease may cause ischemic heart disease and ECG changes. Therefore, careful management is necessary.     

Influence of coronary stenosis location on diagnostic performance of machine learning-based fractional flow reserve from CT angiography

BackgroundCompared with invasive fractional flow reserve (FFR), coronary CT angiography (cCTA) is limited in detecting hemodynamically relevant lesions. cCTA-based FFR (CT-FFR) is an approach to overcome this insufficiency by use of computational fluid dynamics. Applying recent innovations in computer science, a machine learning (ML) method for CT-FFR derivation was introduced and showed improved diagnostic performance compared to cCTA alone. We sought to investigate the influence of stenosis location in the coronary artery system on the performance of ML-CT-FFR in a large, multicenter cohort.MethodsThree hundred and thirty patients (75.2% male, median age 63 years) with 502 coronary artery stenoses were included in this substudy of the MACHINE (Machine Learning Based CT Angiography Derived FFR: A Multi-Center Registry) registry. Correlation of ML-CT-FFR with the invasive reference standard FFR was assessed and pooled diagnostic performance of ML-CT-FFR and cCTA was determined separately for the following stenosis locations: RCA, LAD, LCX, proximal, middle, and distal vessel segments.ResultsML-CT-FFR correlated well with invasive FFR across the different stenosis locations. Per-lesion analysis revealed improved diagnostic accuracy of ML-CT-FFR compared with conventional cCTA for stenoses in the RCA (71.8% [95% confidence interval, 63.0%–79.5%] vs. 54.8% [45.7%–63.8%]), LAD (79.3 [73.9–84.0] vs. 59.6 [53.5–65.6]), LCX (84.1 [76.0–90.3] vs. 63.7 [54.1–72.6]), proximal (81.5 [74.6–87.1] vs. 63.8 [55.9–71.2]), middle (81.2 [75.7–85.9] vs. 59.4 [53.0–65.6]) and distal stenosis location (67.4 [57.0–76.6] vs. 51.6 [41.1–62.0]).ConclusionIn a multicenter cohort with high disease prevalence, ML-CT-FFR offered improved diagnostic performance over cCTA for detecting hemodynamically relevant stenoses regardless of their location.     

液晶数字显示角度仪在全髋关节置换术中的应用价值

目的:探讨在全髋关节置换术中使用液晶数字显示角度仪控制前倾角的应用价值。方法:回顾分析自2018年1月至2019年12月83例行初次全髋关节置换术的患者,其中男28例,女55例;年龄42~81(70.4±7.9)岁。股骨颈骨折63例,股骨头缺血性坏死20例。所有患者术中使用液晶数显角度仪控制髋臼杯假体的前倾角,术后采用CT扫描,测量髋臼杯的前倾角,两者进行比较,了解使用液晶数显角度仪的准确性。结果:术后CT测量提示患者的髋臼前倾角均位于Lewinnek提倡的安全区内,术中使用液晶数显角度仪测量髋臼杯的前倾角度中位数为14.20°(12.80~15.40)°,术后CT扫描测量的髋臼杯的前倾角中位数为14.20°(13.40~15.50)°,两者比较差异无统计学意义(Z=-1.725,P=0.085)。结论:应用液晶数显角仪器对术中控制髋臼杯的前倾角是一种准确可靠的方法,具有良好的辅助参考价值。     

Reliability and criterion validity of two-dimensional movement assessments in those with patellofemoral pain

ObjectivesDetermine criterion validity and intra/inter-rater reliability of 2-dimensional (2D) knee frontal plane projection angle (kFPPA), hip frontal plane projection angle (hFPPA), and dynamic valgus index (DVI) during forward step-downs in those with patellofemoral pain (PFP).DesignCross-sectional.SettingUniversity research laboratory.Participants39 participants with PFP (34.18 ± 7.41years, 170± .1 cm, 81.03 ± 19.36 kg, duration of pain: 68.67 ± 85.08months, anterior knee pain scale: 80.49 ± 7.87, visual analog scale:2.08 ± 2.02)Main outcome measuresAverage 3D hip and knee sagittal, frontal, and transverse joint angles and 2D kFPPA, hFPPA, and DVI at maximum knee flexion were variables of interest. 3D DVI was calculated as the sum of hip and knee frontal and transverse angles. 2D kFPPA, hFPPA, and DVI were calculated by two raters independently on two occasions.ResultsIntra- and inter-rater reliability of all 2D angles were excellent. kFPPA was moderately correlated to 3D knee transverse angles. hFPPA was moderately correlated to 3D hip frontal and transverse angles and largely correlated to 3D DVI. 2D DVI was moderately correlated to hip transverse angles.ConclusionkFPPA, hFPPA, and DVI are reliable. hFPPA may be reflective of 3D hip and knee frontal and transverse motion during forward step-downs in those with PFP.