The tower of Babel: Survey on concepts and terminology in electrical status epilepticus in sleep and continuous spikes and waves during sleep in North America

Purpose: The terms “electrical status epilepticus during sleep (ESES)” and “continuous spikes and waves during sleep (CSWS)” have been used interchangeably when referring to related but different concepts. In addition, the quantification of epileptiform activity has not been standardized, and different approaches to quantification have been used. The aim of this study was to evaluate the extent to which pediatric neurologists and epileptologists use a homogeneous terminology and conceptualization in CSWS and ESES and to characterize the current understanding of these conditions. Methods: A survey addressing the use of terminology in “ESES” and “CSWS” and the understanding of related concepts was distributed online to all members of the Child Neurology Society and the American Epilepsy Society mailing lists. Surveys were self‐administered and collected using an online survey website ( http://www.surveymonkey.com ). Key Findings: Two hundred nineteen surveys were completed, 137 from the Child Neurology Society mailing list and 82 from the American Epilepsy Society mailing list. ESES and CSWS were considered synonymous by 117 respondents, not synonymous by 61, 21 respondents did not know, and 20 did not respond. Most respondents (63.1%) considered CSWS as a devastating epileptic encephalopathy with severe sequelae even if treated correctly, but 25.1% of respondents indicated that it does not leave sequelae if epilepsy was treated early and another 11.8% noted that cognitive difficulties resolved with age. Cognitive and/or language regression were considered mandatory for the diagnosis of CSWS by only 27% of the respondents. The diagnosis of CSWS was based on electroencephalography (EEG) assessment alone by 31% of respondents. Respondents used different methods for calculation of the epileptiform activity, different EEG samples for calculation, and considered differently the lateralized epileptiform activity. The cut‐off values for percentage of the sleep record occupied by spike‐waves were variable depending on the respondent. There was no agreement on whether these cutoff values were mandatory for the diagnosis of ESES and CSWS. Significance: Our data show that the professionals caring for children with ESES and CSWS in North America use the terms, concepts, and defining features heterogeneously. The lack of a common language may complicate communication among clinicians and jeopardize research in this field. We anticipate that our data will fuel the development of much needed common terminology and conceptualization of ESES and CSWS.     

The general surgery workforce shortage is worse when assessed at county level

Background

Multiple studies have documented a significant decrease in the general surgery workforce in the United States, both rural and urban, for the past 3 decades. This 11-year study evaluates the Texas general surgery workforce at both the state and local level in 2002 and 2012.

Methods

Data were obtained from the Texas Medical Board, the United States Census Bureau/Texas State Library and Archives Commission, and the Texas Department of State Health Services for 2002 and 2012. A benchmark target of 7 general surgeons per 100,000 population was used.

Results

During the study period, the Texas population increased 21%, and actively practicing physicians increased 44%. All surgical specialists increased by 26%. General surgeons increased 4%; however, the number of general surgeons per 100,000 population decreased 14% (from 6.7 to 5.8/10⁵). Using the total Texas population for 2012, an additional 329 general surgeons are needed by benchmark standards. However, when analyzed by individual county population, 449 additional general surgeons are needed in the individual counties. These effects were greater in the nonmetropolitan areas of Texas where per capita general surgeons decreased by 21%.

Conclusions

The absolute increase in Texas general surgeons over the past decade has not kept pace with an increase in the Texas population. The general surgery workforce deficit based on the Texas state population underestimates the local workforce shortage, particularly in the nonmetropolitan areas of Texas.     

Anatomic guide and sonography for surgical repair of leg muscle lacerations

Background

There were over 110,000 leg laceration cases reported in the United States in 2011. Currently, muscle laceration is repaired by suturing epimysium to epimysium. Tendon-to-tendon repair is stronger, restores the muscle's resting length, and leads to a better functional recovery. Tendons retract into the muscle belly following laceration and surgeons have a difficult time finding them. Many surgeons are unfamiliar with leg muscle anatomy and the fact that the leg muscles have long intramuscular tendons that are not visible in situ. A surgical anatomic guide exists to help surgeons locate forearm tendons; no such guide exists for tendons in the leg.

Materials and methods

The leg tendon ends of 11 cadavers were dissected, measured, and recorded as percentages of leg length. High-frequency ultrasound was used to locate tendon ends in three additional cadavers. These locations were compared with the actual tendon ends located via dissection.

Results

There was little variation in tendon end position within the cadaver group, between men and women or right and left legs. The data are presented as an anatomic guide to inform surgeons of the tendon ends' likely locations in the leg.

Conclusion

The location of leg intramuscular tendon ends is predictable and the anatomic guide will help surgeons locate tendon ends and perform tendon-to-tendon repairs. Ultrasound is a potentially effective tool for detection of accurate location of repairable tendon ends in leg muscle lacerations.     

Testosterone Levels Following Decreases in Serum Osteocalcin

Recent preclinical studies suggest that osteoblasts are able to induce testosterone production by the testis, a process mediated by osteocalcin. Bisphosphonates substantially reduce osteocalcin levels. If osteocalcin is an important regulator of testosterone levels in adult men, it would be expected that the substantial reductions in osteocalcin induced by zoledronate would impact negatively on testosterone levels. Previously, we carried out a 2-year randomized, controlled trial of annual 4 mg zoledronate in 43 HIV-infected men. To explore the relationship between osteocalcin and testosterone further, we measured serum testosterone at baseline, 3 months, and 2 years; luteinizing hormone at 3 months and 2 years; and total osteocalcin at 2 years in 28 trial participants with available blood samples. At 2 years, total osteocalcin was 39 % lower in the zoledronate group than the placebo group (zoledronate mean 10.1 [SD 3.0] μg/L, placebo 16.5 [SD 4.9] μg/L, P = 0.003). Despite these substantial differences in osteocalcin levels, testosterone levels did not change over time in either group and there were no between-group differences over time, P = 0.4 (mean change at 2 years [adjusted for baseline levels] in zoledronate group ?0.4 nmol/L, 95 % CI ?2.5 to 1.6; placebo group 0.4 nmol/L, 95 % CI ?1.6 to 2.5). Luteinizing hormone was within the normal range and did not differ between the groups at either 3 months or 2 years. Thus, the absence of a change in testosterone despite a substantial reduction in osteocalcin following zoledronate treatment argues against a biologically significant role for osteocalcin in the regulation of testosterone in adult men. This provides reassurance that men receiving potent antiresorptive drugs are not at risk of iatrogenic hypogonadism.     

Improving Participant Feedback to Continuing Medical Education Presenters in Internal Medicine: A Mixed-Methods Study

BACKGROUND  

Feedback is essential for improving the skills of continuing medical education (CME) presenters. However, there has been little research on improving the quality of feedback to CME presenters.     

Provision of Contraceptive Services to Women with Diabetes Mellitus

BACKGROUND  

Women with diabetes mellitus who delay pregnancy until glycemic control is achieved experience lower rates of adverse pregnancy outcomes.