Motor unit potential induced repetitive discharges (MIRDs): Description of an unusual iterative discharge

Introduction: Repetitive discharges may be recorded during nerve conduction studies (NCS) or during needle electromyography in a muscle at rest. Repetitive discharges that occur during voluntary activation and are time‐locked to voluntary motor unit potentials (MUP) have not been described. Methods: Retrospective review of motor unit potential induced repetitive discharges (MIRDs) identified in the EMG laboratory. Characteristics of each MIRD, patient demographics, other EMG findings in the same muscle, and electrophysiological diagnosis were analyzed. Results: MIRDs were observed in 15 patients. The morphology and number of spikes and duration of MIRDs varied. The discharges fired at rates of 50–200 Hz . All but 2 patients had EMG findings of a chronic neurogenic disorder. Conclusions: MIRDs are rare iterative discharges time‐locked to a voluntary MUP. The pathophysiology of MIRDs is unclear, but their presence may indicate a chronic neurogenic process. Muscle Nerve 48 : 977–979, 2013     

A Circuit for Safe Diagnostic Electrical Stimulation of the Human Brain

Abstract

An electronic circuit for controlled electrical stimulation of the human brain has been designed to optimize safety in charge transfer from electrodes to brain and to eliminate the likelihood of unwanted currents from the neurostimulator resulting from component failure. The circuit schematics feature the following designs: (1) a highly accurate and versatile rate generator 0.5 p.p.s. to 99 in increments of 0.5 p.p.s., (2) symmetrically-biphasic lead and lag pulses of 100 μsec duration, (3) photo-isolated driver amplifiers with accurate waveform, reproduction, (4) true biphasic passive-current regulators driven by an isolated battery supply voltage for switch-selectable currents of 0.25 to 5 ma or variable current regulation, (5) accurate current and voltage waveform monitors that isolate the stimulating electrodes from the monitors, and (6) capacity-coupled outputs to guarantee no net D.C. component at the end of each biphasic pulse. Relay-switching circuits are also shown that allow sequential stimulation and recording from one or several electrodes. This neurostimulator has been in use for over two years without evidence of electrolytic damage at identifiable electrode tips. The utility of simultaneous stimulation of several different electrodes at safe charge levels is described.     

Now how do we get them home? Outpatient care of pediatric patients on mechanical circulatory support

The last five yr have been monumental for the pediatric heart failure community. In the US, the most notable has been the FDA approval of the first pediatric specific device (Berlin Heart EXCOR^®; Berlin Heart, Inc., Berlin, Germany). Subsequently, the field of heart failure has gained a great deal of knowledge regarding the nuances of MCS in children. Despite FDA approval in the US, the Berlin EXCOR^® is only currently indicated for in‐hospital use. Due to the limitations with discharge and the positive in‐ hospital experiences with the Berlin EXCOR^®, there has been an increased interest in the implantation of adult durable devices into children. While many institutions have focused their intial efforts on the first phase of care within the hospital, they are now ready to tackle the challenge of how to safely transition children to the community setting.     

Targeted postoperative care improves discharge outcome after hip or knee arthroplasty

OBJECTIVE: To determine whether targeted postoperative care, based on preoperative risk assessment, can increase the number of patients who are discharged home directly from acute care after elective hip or knee arthroplasty. DESIGN: Quasiexperimental with historical control. SETTING: A public university teaching hospital. PARTICIPANTS: One hundred patients who had an elective hip or knee arthroplasty. INTERVENTIONS: Between January and July 2001, 50 patients had their risk of discharge to extended inpatient rehabilitation assessed preoperatively with a newly developed Risk Assessment and Prediction Tool (RAPT). Postoperative management was targeted on the basis of the identified level of risk. Results were compared with those of a similar group of 50 patients treated between January and July 2000. MAIN OUTCOME MEASURES: Discharge destination, length of stay (LOS), and readmission rates. RESULTS: The percentage of patients discharged directly home increased significantly, from 34% during 2000 to 64% in 2001 (P=.002), with no increase in readmission rates in the 12 months postdischarge. In addition, the mean acute hospital LOS decreased by 1.1 days to 7.5 days in 2001 (P=.02). CONCLUSIONS: Use of the RAPT and targeted postoperative care resulted in more patients being discharged directly home after hip or knee arthroplasty while hospital LOS further decreased.     

Diagnosis and surgical treatment of pathologic nipple discharge using ultrasound‐guided wire localization of focal ductal dilatation

Nipple discharge is the third breast complaint after pain and lumps. The modern high‐resolution ultrasound techniques are becoming more sensitive for the visualization of intraductal changes especially focal ductal dilatation (FDD), hypothesized as a radiographic manifestation of the lesion itself and that ultrasound‐guided wire localization of this finding would enable identification and excision of the causative lesion. The aim of this study was to evaluate the safety, feasibility, efficiency and outcome of ultrasound‐guided wire localization of FDD as possible cause of pathological nipple discharge (PND). The present study was conducted on 56 patients with PND presented to Surgical Oncology Unit at General Surgery Department, Tanta University Hospital from January 2018 to January 2019. The patients subjected to ultrasound‐guided wire localization of FDD on the day of surgery, the involved duct was cannulated with a lacrimal duct probe, the targeted tissue was excised, and the specimen was sent for histopathological examination. The patients' age ranged between 26 and 71 years with a mean age of 48 years. The bloody nipple discharge was the commonest presenting symptom in 44 out of 56 patients (78.5%). The duct dilatation on study ultrasound ranged from 2.1 to 3.7 mm with a mean of 2.6 mm. Preoperative ultrasound‐guided wire localization of the site of FDD was successfully performed in all cases. Papilloma alone founded in 40 out of 56 patients (71.4%), papilloma + ductal carcinoma in situ (DCIS) in six patients (10.7%), papilloma + invasive ductal carcinoma in six patients (10.7%), DCIS in two patients (3.6%) and duct ectasia in two patients (3.6%). Ultrasound‐guided wire localization of FDD is an easy and safe technique for evaluation, precise localization, and targeted excision of the underlying lesions of PND.     

Composite score for prediction of 30-day orthopedic surgery outcomes

The LACE+ (Length of stay, Acuity of admission, Charlson Comorbidity Index score, and Emergency department visits in the past 6 months) risk-prediction tool has never been tested in an orthopedic surgery population. LACE+ may help physicians more effectively identify and support high-risk orthopedics patients after hospital discharge. LACE+ scores were retrospectively calculated for all consecutive orthopedic surgery patients (n = 18 893) at a multi-center health system over 3 years (2016-2018). Coarsened exact matching was employed to create “matched” study groups with different LACE+ score quartiles (Q1, Q2, Q3, Q4). Outcomes were compared between quartiles. In all, 1444 patients were matched between Q1 and Q4 (n = 2888); 2079 patients between Q2 and Q4 (n = 4158); 3032 patients between Q3 and Q4 (n = 6064). Higher LACE+ scores significantly predicted 30D readmission risk for Q4 vs Q1 and Q4 vs Q3 (P < .001). Larger LACE+ scores also significantly predicted 30D risk of ED visits for Q4 vs Q1, Q4 vs Q2, and Q4 vs Q3 (P < .001). Increased LACE+ score also significantly predicted 30D risk of reoperation for Q4 vs Q1 (P = .018), Q4 vs Q2 (P < .001), and Q4 vs Q3 (P < .001).     

Clinical Features of Bacterial Conjunctivitis in Children

Objectives
Conjunctivitis is a common cause of primary care and emergency department (ED) visits. There is a paucity of data in recent literature on the prevalence of pediatric bacterial conjunctivitis, and there are no evidence-based clinical guidelines for empirical treatment. The study objective was to describe clinical features most predictive of bacterial conjunctivitis.
Methods
This was a prospective study in a children's hospital ED. Conjunctival swabs for bacterial culture were obtained from patients aged 1 month to 18 years presenting with red or pink eye and/or the diagnosis of conjunctivitis.
Results
A total of 111 patients were enrolled over one year. Patients had a mean (±SD) age of 33.2 (±37.5) months, and 55% were male. Eighty-seven patients (78%) had positive bacterial cultures. Nontypeable Haemophilus influenzae accounted for 82% (71/87), Streptococcus pneumoniae for 16% (14/87), and Staphylococcus aureus for 2.2% (2/87). Five clinical variables were significantly associated with a positive bacterial culture. Regression analysis revealed that the combination of a history of gluey or sticky eyelids and the physical finding of mucoid or purulent discharge had a posttest probability of 96% (95% confidence interval = 90% to 99%). Subjective scoring by physicians for a positive culture was 50.6%.
Conclusions
Conjunctivitis in children is predominantly bacterial, with nontypeable H. influenzae being the most common organism. A history of gluey or sticky eyelids and physical findings of mucoid or purulent discharge are highly predictive of bacterial infection. Based on the above data, empirical ophthalmic antibiotic therapy may be appropriate in children presenting with conjunctivitis.