Publications by authors named "Kara G Fields"

53 Publications

Fewer Wrong-Site Peripheral Nerve Blocks Following Updates to Anesthesia Time-Out Policy.

HSS J 2021 Jul 22;17(2):180-184. Epub 2021 Feb 22.

Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA.

Peripheral nerve block (PNB) has been shown to be safe and effective, and its use has continued to increase, but it is not without risks. One potentially preventable risk is wrong-site blocks (WSBs). Our institution mandated a time-out process before PNB in 2003, and then in 2007 made two more changes to our policy to mitigate risk: (1) the circulating/block nurse was the only person permitted to access the block needles; after a time-out period was complete, the nurse gave the needles to the anesthesiologist; and (2) the nurse remained at the patient's bedside until the PNB was initiated. We sought to compare the incidence of WSBs before and after this time-out process was implemented in 2003 and the enhanced form of it was implemented in 2007. We hypothesized that the enhanced process would decrease the incidence of WSBs. We retrospectively analyzed data, from January 2003 to December 2016, taken from the quality assurance and performance improvement (QA/PI) division of the anesthesiology department at our institution, which maintained daily statistics on anesthetic types using quality audits from paper or electronic anesthesia records. All WSBs from this period were reported to the QA/PI division and root cause analyses performed. The incidence of WSB was compared pre- and post-implementation of the enhanced time-out policy for upper extremity, lower extremity, and all blocks by calculating relative risks with 95% score confidence intervals and performing Fisher's exact tests. The incidence of WSBs decreased from 1.10/10,000 before changes to the policy were initiated to 0.24/10,000 afterward. We observed an association between the implementation of a dynamic, team-focused time-out process and a reduction in the incidence of WSBs at our institution. A causal effect of the enhanced time-out cannot be determined given the risk of bias associated with before-after study designs and our lack of adjustment for potential confounders. Further research is therefore warranted.
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http://dx.doi.org/10.1177/1556331621993079DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8361586PMC
July 2021

A forecast of maternal deaths with and without vaccination of pregnant women against COVID-19 in Mexico.

Int J Gynaecol Obstet 2021 09 30;154(3):566-567. Epub 2021 Jun 30.

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1002/ijgo.13788DOI Listing
September 2021

Characterization of version in the dysplastic hip and the need for subsequent femoral derotational osteotomy after periacetabular osteotomy.

J Hip Preserv Surg 2020 Aug 20;7(3):575-582. Epub 2020 Dec 20.

Department of Orthopedic Surgery, Hospital for Special Surgery, 535 E. 70th St, New York, NY 10021, USA.

Hip dysplasia is a three-dimensional pathomechanical condition that is often more complex than the standard method of measuring lateral center edge angle (CEA) can quantify. Yet there is a paucity of literature examining the differences in version seen between dysplastic and non-dysplastic femoroacetabular impingement (FAI) hips, the relationship of acetabular and femoral version (FV) within dysplastic hips and the contribution of each of these factors to symptoms and outcomes of dysplasia treatment. We sought to describe the acetabular version (AcetV) and FV in dysplastic hips and quantify how these measurements compared with non-dysplastic FAI hips. We also sought to analyze the association of these factors with patient-reported outcomes (PROs) after periacetabular osteotomy (PAO) and determine the need for subsequent femoral derotational osteotomy after PAO. A total of 113 dysplastic patients who underwent PAO (92% female, mean age 24) were compared with 1332 (45% female, mean age 25) non-dysplastic FAI (CEA > 25°) patients. We found that dysplastic hips had a statistically higher AcetV and FV than non-dysplastic FAI hips. There was a very weak correlation between AcetV and FV in dysplastic hips, suggesting that patients with higher AcetV did not necessarily have higher FV. There was no association with AcetV or FV and patient outcomes in our very limited analysis of PROs after PAO, and only 5% of patients with excessive FV (>20°) required subsequent femoral derotational osteotomy, suggesting that in a majority of patients with hip dysplasia, FV may not impact the post-operative clinical course.
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http://dx.doi.org/10.1093/jhps/hnaa045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8081430PMC
August 2020

The interrater reliability and agreement of a 0 to 10 uterine tone score in cesarean delivery.

Am J Obstet Gynecol MFM 2021 05 27;3(3):100342. Epub 2021 Feb 27.

Department of Anesthesiology, Perioperative and Pain Medicine (Drs Cole and Abushoshah, Ms Fields, and Drs Bateman and Farber).

Background: Postpartum hemorrhage is a leading source of maternal morbidity and mortality worldwide with uterine atony identified as the underlying cause in up to 80% of cases. Several measures have been utilized to report uterine tone. The most commonly reported measure is a 0 to 10 numeric rating scale, but this scale has not been tested for reliability or agreement between different raters.

Objective: The primary purpose of this study was to evaluate the interrater reliability and agreement of the 0 to 10 visual numeric rating scale of uterine tone during cesarean delivery. A secondary purpose was to obtain estimates of scale responsiveness and minimal clinically important difference.

Study Design: Between August and November of 2018, obstetricians used a 0 to 10 numeric rating score to independently rate uterine tone at 3 and 10 minutes after cesarean delivery by palpation of the uterus. Of note, "0" represented "no tone" and "10" represented excellent tone. Each obstetrician independently and blinded to the other's score pointed to a numeric rating scale held by the anesthesiologist through a clear sterile drape. Intraclass correlation coefficients and Bland-Altman analysis were used to assess interrater reliability and agreement, respectively. Standardized response mean and standard error of measurement were used to obtain estimates of responsiveness and minimal clinically important difference, respectively.

Results: A total of 82 and 84 pairs of scores were collected at 3 and 10 minutes, respectively, from pairs of 62 unique obstetricians. The mean±standard deviation difference in scores between rater 1 and rater 2 was 0.4±1.4 at 3 minutes and 0.1±1.1 at 10 minutes. Intraclass correlation coefficients for a future single rater (intraclass correlation coefficient [1, 1]) at 3 and 10 minutes were 0.67 (95% confidence interval, 0.53-0.77) and 0.61 (95% confidence interval, 0.46-0.73), and for the average between 2 future raters (intraclass correlation coefficient [1, 2]), they were 0.80 (95% confidence interval, 0.71-0.87) and 0.76 (95% confidence interval, 0.63-0.84), indicating good and excellent reliability, respectively. Bland-Altman analysis estimated 95% limit of agreement between raters of -2.4 (95% confidence interval, -3.0 to -1.9) to 3.1 (95% confidence interval, 2.6-3.7) at 3 minutes and -2.1 (95% confidence interval, -2.5 to -1.7) to 2.4 (95% confidence interval, 2.0-2.8) at 10 minutes, consistent with good interrater agreement at both time points. The standardized response mean from 3 to 10 minutes after delivery was 1.1 (n=81). Standard error of measurement was 1.0 (95% confidence interval, 0.9-1.1) at 3 minutes and 0.8 (95% confidence interval, 0.7-0.9) at 10 minutes.

Conclusion: The 0 to 10 numeric rating scale for uterine tone demonstrated good to excellent interrater reliability with 1 and 2 raters, respectively, and good interrater agreement. The scale was responsive to within-parturient change in tone, and preliminary estimates of the minimal clinically important difference were obtained. The 0 to 10 numeric rating scale for uterine tone may be a reliable, standardized tool for future research in reporting degree of uterotonic contraction during cesarean delivery.
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http://dx.doi.org/10.1016/j.ajogmf.2021.100342DOI Listing
May 2021

Patient characteristics associated with SARS-CoV-2 infection in parturients admitted for labour and delivery in Massachusetts during the spring 2020 surge: A prospective cohort study.

Paediatr Perinat Epidemiol 2021 01;35(1):24-33

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Background: While studies from large cities affected by coronavirus disease 2019 (COVID-19) have reported on the prevalence of SARS-CoV-2 in the context of universal testing during admission for delivery, the patient demographic, social and clinical factors associated with SARS-CoV-2 infection in pregnant women are not fully understood.

Objective: To evaluate the epidemiological factors associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in women admitted for labour and delivery, in the context of universal screening at four Boston-area hospitals.

Methods: In this prospective cohort study, we reviewed the health records of all women admitted for labour and delivery at four hospitals from the largest health system in Massachusetts between 19 April 2020 and 27 June 2020. We calculated the risk of SARS-CoV-2 infection, including asymptomatic infection. We calculated associations between SARS-CoV-2 infection and demographic and clinical characteristics.

Results: A total of 93 patients (3.2%, 95% confidence interval 2.5, 3.8) tested positive for SARS-CoV-2 infection on admission for labour and delivery out of 2945 patients included in the analysis; 80 (86.0%) of the patients who tested positive were asymptomatic at the time of testing. Factors associated with SARS-CoV-2 infection included the following: younger age, obesity, African American or Hispanic race/ethnicity, residence in heavily affected communities (as measured in cases reported per capita), presence of a household member with known SARS-CoV-2 infection, non-health care essential worker occupation and MassHealth or Medicaid insurance compared to commercial insurance. 93.8% of patients testing positive for SARS-CoV-2 on admission had one or more identifiable factors associated with disease acquisition.

Conclusions: In this large sample of deliveries during the height of the surge in infections during the spring of 2020, SARS-CoV-2 infection was largely concentrated in patients with distinct demographic characteristics, those largely from disadvantaged communities. Racial disparities seen in pregnancy persist with respect to SARS-CoV-2 infection.
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http://dx.doi.org/10.1111/ppe.12743DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8014491PMC
January 2021

Prediction of Persistent Pain Severity and Impact 12 Months After Breast Surgery Using Comprehensive Preoperative Assessment of Biopsychosocial Pain Modulators.

Ann Surg Oncol 2021 Sep 15;28(9):5015-5038. Epub 2021 Jan 15.

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Background: Persistent post-mastectomy pain (PPMP) is a significant negative outcome occurring after breast surgery, and understanding which individual women are most at risk is essential to targeting of preventive efforts. The biopsychosocial model of pain suggests that factors from many domains may importantly modulate pain processing and predict the progression to pain persistence.

Methods: This prospective longitudinal observational cohort study used detailed and comprehensive psychosocial and psychophysical assessment to characterize individual pain-processing phenotypes in 259 women preoperatively. Pain severity and functional impact then were longitudinally assessed using both validated surgery-specific and general pain questionnaires to survey patients who underwent lumpectomy, mastectomy, or mastectomy with reconstruction in the first postsurgical year. An agnostic, multivariable modeling strategy identified consistent predictors of several pain outcomes at 12 months.

Results: The preoperative characteristics most consistently associated with PPMP outcomes were preexisting surgical area pain, less education, increased somatization, and baseline sleep disturbance, with axillary dissection emerging as the only consistent surgical variable to predict worse pain. Greater pain catastrophizing, negative affect, younger age, higher body mass index (BMI), and chemotherapy also were independently predictive of pain impact, but not severity. Sensory disturbance in the surgical area was predicted by a slightly different subset of factors, including higher preoperative temporal summation of pain.

Conclusions: This comprehensive approach assessing consistent predictors of pain severity, functional impact, and sensory disturbance may inform personalized prevention of PPMP and also may allow stratification and enrichment in future preventive studies of women at higher risk of this outcome, including pharmacologic and behavioral interventions and regional anesthesia.
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http://dx.doi.org/10.1245/s10434-020-09479-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8280248PMC
September 2021

Conditioned open-label placebo for opioid reduction after spine surgery: a randomized controlled trial.

Pain 2021 06;162(6):1828-1839

Departments of Anesthesiology, Perioperative, and Pain Medicine and.

Abstract: Placebo effects have traditionally involved concealment or deception. However, recent evidence suggests that placebo effects can also be elicited when prescribed transparently as "open-label placebos" (OLPs), and that the pairing of an unconditioned stimulus (eg, opioid analgesic) with a conditioned stimulus (eg, placebo pill) can lead to the conditioned stimulus alone reducing pain. In this randomized control trial, we investigated whether combining conditioning with an OLP (COLP) in the immediate postoperative period could reduce daily opioid use and postsurgical pain among patients recovering from spine surgery. Patients were randomized to COLP or treatment as usual, with both groups receiving unrestricted access to a typical opioid-based postoperative analgesic regimen. The generalized estimating equations method was used to assess the treatment effect of COLP on daily opioid consumption and pain during postoperative period from postoperative day (POD) 1 to POD 17. Patients in the COLP group consumed approximately 30% less daily morphine milligram equivalents compared with patients in the treatment as usual group during POD 1 to 17 (-14.5 daily morphine milligram equivalents; 95% CI: [-26.8, -2.2]). Daily worst pain scores were also lower in the COLP group (-1.0 point on the 10-point scale; 95% CI: [-2.0, -0.1]), although a significant difference was not detected in average daily pain between the groups (-0.8 point; 95% CI: [-1.7, 0.2]). These findings suggest that COLP may serve as a potential adjuvant analgesic therapy to decrease opioid consumption in the early postoperative period, without increasing pain.
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http://dx.doi.org/10.1097/j.pain.0000000000002185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8378225PMC
June 2021

In Response.

Anesth Analg 2020 09;131(3):e163-e164

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts

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http://dx.doi.org/10.1213/ANE.0000000000005027DOI Listing
September 2020

The effect of emergency manuals on team performance during two different simulated perioperative crises: A prospective, randomized controlled trial.

J Clin Anesth 2021 Feb 6;68:110080. Epub 2020 Oct 6.

Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States of America.

Study Objective: Whether having an emergency manual (EM) available for use during perioperative crises enhances or detracts from team performance, especially for multi-factorial diagnostic situations that do not explicitly match a chapter of the EM.

Design: A simulation-based, prospective randomized trial based upon two perioperative crises, one involving a patient with a transfusion reaction for which the EM contains a specific chapter, and the other involving a patient with refractory hypotension progressing into septic shock for which the EM does not have a specific chapter.

Setting: 52 regularly scheduled 6-h courses at the Center for Medical Simulation in Boston, Massachusetts, USA.

Study Group: 304 US-trained practicing anesthesiologists.

Interventions: The absence or presence of the EM during the simulation case.

Measurements: Teams were rated in the following categories: primary underlying diagnosis, fluid resuscitation, treatment of primary diagnosis, cardiac arrest management, overall crisis management, and (if applicable) EM usage. Also, raters recorded free-text 'field notes' about the usage-patterns and perceived utility of the EM. Using these 'field notes' and a two-stage, inductively revised procedure, two independent reviewers examined a subset of case videos for action analysis.

Main Results: Performance ratings for a total of 51 teams and 95 simulations were included in the final analysis. No effect on performance was demonstrated with providing the EM in either the refractory hypotension/septic shock case or the transfusion reaction case, with the exception of the PEA arrest category. In the subset of simulations in which resuscitation from PEA arrest performance could be evaluated, EM availability was associated with an adjusted mean 1.3 point (99% confidence interval [CI]: 0.2, 2.4) improvement in performance in the transfusion reaction case (p = 0.004), but only an adjusted mean 0.2 point (99% CI, -0.7, 1.1) improvement in the refractory hypotension/septic shock case (p = 0.530) (p for interaction = 0.069). Analysis of actions found that when available, the EM was usually used, but often not until after cardiac arrest had occurred. In some cases, teams persisted with incorrect diagnoses and treatments irrespective of the presence or absence of an EM.

Conclusions: Providing an EM did not affect team performance in areas like diagnosis, treatment, fluid resuscitation, communication, and teamwork in management of perioperative crises such as transfusion reaction where an explicit chapter in the EM exists and refractory hypotension / septic shock where an explicit chapter does not exist. A suggestion of improved cardiac arrest resuscitation with the availability of an EM was found, but should be interpreted with caution given a limited sample size. Observed actions using the EM demonstrated that only about half of the teams used the EM to any substantive degree and most used it relatively late in the crisis. By observation, the EM appeared to be helpful in about half of the cases and did not, by itself, deter from appropriate management.
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http://dx.doi.org/10.1016/j.jclinane.2020.110080DOI Listing
February 2021

Implementation of a Self-guided Focused Cardiac Ultrasound Curriculum for Anesthesiology Residents.

J Educ Perioper Med 2020 Apr-Jun;22(2):E642. Epub 2020 Apr 1.

Background: Focused cardiac ultrasound (FoCUS) is an increasingly used diagnostic modality for anesthesiologists and intensivists. However, training residents in its use can be resource intensive. We investigated the feasibility of implementing a self-guided FoCUS curriculum for anesthesiology residents rotating in the postanesthesia care unit (PACU).

Methods: We created a FoCUS curriculum with the aim of providing a consistent largely self-guided experience that would improve FoCUS knowledge and skills while minimizing ongoing time commitment from faculty. To achieve this, we used several methods: (1) developed video didactics and quizzes; (2) used an online educational delivery platform to automate delivery of educational content, monitor resident progress, and elicit feedback; (3) used the transthoracic echocardiography simulator for aided hands-on learning; (4) dedicated educational time that integrated into PACU workflow; (5) worked with a cardiac sonographer; and (6) used image storage software to facilitate remote feedback by ultrasound faculty. The response to the curriculum was evaluated using Kirkpatrick levels 1-3.

Results: Forty-one anesthesiology residents rotated through the PACU over a 1-year period and completed this weeklong self-guided FoCUS curriculum. Interesting findings include: (1) favorable evaluation from the residents and (2) improvement in image acquisition skills by objective measures. Once the curriculum was established, ongoing faculty time commitment was approximately 1 hour 20 minutes per week.

Conclusions: The implementation of a FoCUS curriculum in the PACU resulted in favorable resident evaluation and improved FoCUS skills. The curriculum was feasible and self-sustainable because of the novel educational approach employed.
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http://dx.doi.org/10.46374/volxxii-issue2-swansonDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489477PMC
April 2020

Excess Maternal Deaths Associated With Coronavirus Disease 2019 (COVID-19) in Mexico.

Obstet Gynecol 2020 12;136(6):1114-1116

Departments of Obstetrics and Gynecology and Anesthesiology, Perioperative and Pain Medicine, Brigham & Women's Hospital, Harvard Medical School, and the Department of Postgraduate Medical Education, Harvard Medical School, Boston, Massachusetts; and Hospital Central "Dr. Ignacio Morones Prieto," San Luis Potosí, and Hospital General 450, Durango, Durango, Mexico.

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http://dx.doi.org/10.1097/AOG.0000000000004140DOI Listing
December 2020

A comparison of difficult intubation documentation practices with existing guidelines in the advent of video laryngoscopy.

J Clin Anesth 2020 Oct 12;65:109807. Epub 2020 May 12.

Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA; Department of Anesthesiology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles St, Boston, MA 02114, USA. Electronic address:

Study Objective: To assess whether anesthesia providers' interpretations of a difficult intubation are consistent with current guidelines and explore possible explanations for any observed discrepancy including video laryngoscopy usage.

Design: A retrospective data analysis of tracheal intubation records from the electronic health record of a large healthcare system in the United States from January to June 2018.

Setting: General anesthesia encounters that involved a tracheal intubation in the operating rooms and non-operating room areas, including procedural areas, medical/surgical floors, and intensive care units.

Patients: Records for 30,072 adult patients (33,142 cases) were identified for analysis. Patient age ranged from 18 to 100 and ASA physical status from I to V.

Interventions: None.

Measurements: The magnitude and direction of disagreement regarding intubation difficulty was estimated by examining anesthesiologist documentation vs. the American Society of Anesthesiologists guideline definitions. Any explanations for disagreement provided by clinicians were also analyzed. Furthermore, the association between video laryngoscopy and odds of disagreement was assessed.

Main Results: While documentation of intubation difficulty in over 95% of records was consistent with current definitions, disagreement occurred in 1.6% of cases using the number of attempts definition (N = 31,964) and in 4.6% of cases using the Cormack-Lehane grade definition (N = 25,407). Some of the most frequently identified explanations clinicians gave in these cases of disagreement included the use of video laryngoscopy (used to explain documented difficult and easy intubations), clinician experience level, and the use of airway assist devices. Video laryngoscopy use was associated with greater odds of disagreement between anesthesiologist documentation and guideline definitions.

Conclusions: A review of electronic anesthesia records suggests that clinicians inconsistently interpret and document difficult intubations in light of current guideline definitions and that video laryngoscopy usage appears to be associated, albeit not necessarily independently, with a greater discrepancy between anesthesiologist documentation and guideline definitions.
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http://dx.doi.org/10.1016/j.jclinane.2020.109807DOI Listing
October 2020

Risk of Postdural Puncture Headache in Adolescents and Adults.

Anesth Analg 2020 07;131(1):273-279

From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York.

Background: Spinal anesthesia is known to have numerous benefits, including reductions in nausea and opioid consumption; however, postdural puncture headache (PDPH) remains a significant risk associated with this technique. The literature specifically examining this complication in adolescents is scarce. Our primary objective was therefore (1) to estimate the incidence of PDPH with a 27G pencil-point needle in patients between the ages of 12 and 19 undergoing ambulatory lower extremity procedures and (2) to compare it to the incidence in adults aged 20-45 years.

Methods: After institutional review board (IRB) approval, patients aged 12-45 years undergoing ambulatory lower extremity surgery were approached. Patients undergoing the procedure under combined spinal-epidural (CSE) or spinal anesthesia with a 27G pencil-point needle were eligible for enrollment. Patients were consented before surgery and received a survey via e-mail on postoperative day (POD) 4 inquiring about the presence of a headache. Each headache was described by the participant and assessed for severity, time of onset, duration, location, and whether it was of a postural nature. All patients reporting a postural headache were contacted by a physician author to confirm a diagnosis of PDPH using the International Headache Society diagnostic criteria.

Results: A total of 656 patients were included in the analysis. Overall, 3.4% of patients developed PDPH. The percentage developing PDPH was 4.9% (3.0-7.8) among those aged 12-19 years and 1.8% (0.8-3.9) in the 20- to 45-year-old group. After adjusting for covariates, the age group between 12 and 19 years was associated with an almost 3-fold increase in the odds (2.8 [95% confidence interval {CI}, 1.1-7.3]) for the development of PDPH compared to that in the 20-45 age group. One patient in the adult group required an epidural blood patch.

Conclusions: The overall incidence for the development of PDPH in ambulatory patients <45 years of age is low. However, the odds for developing PDPH is significantly higher in teenagers compared to those aged 20-45 years. This increase was not associated with an increase in the need for an epidural blood patch. Providers may incorporate these data in their consent process and have a higher index of suspicion for PDPH in teenagers who report headaches after neuraxial anesthesia.
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http://dx.doi.org/10.1213/ANE.0000000000004691DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8335938PMC
July 2020

Introduction of a Novel System for Quantitating Blood Loss After Vaginal Delivery: A Retrospective Interrupted Time Series Analysis With Concurrent Control Group.

Anesth Analg 2020 04;130(4):857-868

Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Background: Postpartum hemorrhage (PPH) is a leading cause of maternal mortality worldwide. While volumetric and gravimetric blood loss measurement techniques have been shown to increase PPH detection compared to visual estimation of blood loss (vBL), a combination of these methods has not been evaluated. The primary aim of this study was to compare the change in odds of PPH detection after vaginal delivery (VD; the intervention series) versus cesarean delivery (CD; the control series) before versus after implementation of a device (Triton L&D, Gauss Surgical, Inc, Los Altos, CA) that combines gravimetric and volumetric estimation of blood loss (tBL).

Methods: After institutional review board (IRB) approval, patients were identified who had a VD or CD at our institution 3 months before and 3 months after the implementation of a tBL device for VD. The levels and trends in odds of PPH detection (the primary outcome, defined as blood loss ≥500 mL for VD and ≥1000 mL for CD) were compared within and between delivery methods before and after implementation of the device. Secondary outcomes were blood loss ≥1000 mL, total blood loss, secondary uterotonic use, and a composite outcome related to PPH management (transfusion, vasopressor administration, and/or surgical procedures). A post hoc subgroup analysis compared nadir hematocrit, hematocrit reduction ≥10%, and difference between vBL or tBL and calculated blood loss (cBL) between VDs before and after introduction of the device. All outcome comparisons were performed using segmented regression with inverse probability of treatment weighting.

Results: The weighted odds ratio (wOR) of PPH detection post- versus preimplementation of the device was 2.74 (95% confidence interval [CI], 1.39-5.41; P = .004) for VDs versus 1.43 (95% CI, 0.72-2.85; P = .304) for CDs (P for interaction .190). No difference was detected in the secondary outcomes for VDs between time periods. In the subgroup of VD patients who had postdelivery hematocrits measured, the mean difference between vBL or tBL and cBL was smaller in the tBL (mean ± standard deviation [SD]: -237 ± 522 mL) versus vBL group (-600 ± 596 mL; weighted difference in means [95% CI]: 349 mL [13-684]; P = .042).

Conclusions: In this interrupted time series analysis, the odds of PPH detection after VD increased after implementation of the tBL device. However, a statistical difference was not detected between the increase in PPH detection post- versus preimplementation of the device in VDs versus CDs.
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http://dx.doi.org/10.1213/ANE.0000000000004560DOI Listing
April 2020

Comparison of Topical and Intravenous Tranexamic Acid for Total Knee Replacement: A Randomized Double-Blinded Controlled Study of Effects on Tranexamic Acid Levels and Thrombogenic and Inflammatory Marker Levels.

J Bone Joint Surg Am 2019 Dec;101(23):2120-2128

Department of Anesthesiology, Critical Care & Pain Management (K.M.J.-E., A.T., and L.R.B.), Department of Orthopedic Surgery (T.P.S., A.S.M., E.P.S., and D.J.M.), and Biostatistics Core (K.G.F.), Hospital for Special Surgery, New York, NY.

Background: Tranexamic acid (TXA) is an antifibrinolytic drug. Topical administration of TXA during total knee arthroplasty (TKA) is favored for certain patients because of concerns about thrombotic complications, despite a lack of supporting literature. We compared local and systemic levels of thrombogenic markers, interleukin (IL)-6, and TXA between patients who received intravenous (IV) TXA and those who received topical TXA.

Methods: Seventy-six patients scheduled for TKA were enrolled in this randomized double-blinded study. The IV group received 1.0 g of IV TXA before tourniquet inflation and again 3 hours later; a topical placebo was administered 5 minutes before final tourniquet release. The topical group received an IV placebo before tourniquet inflation and again 3 hours later; 3.0 g of TXA was administered topically 5 minutes before final tourniquet release. Peripheral and wound blood samples were collected to measure levels of plasmin-anti-plasmin (PAP, a measure of fibrinolysis), prothrombin fragment 1.2 (PF1.2, a marker of thrombin generation), IL-6, and TXA.

Results: At 1 hour after tourniquet release, systemic PAP levels were comparable between the IV group (after a single dose of IV TXA) and the topical group. At 4 hours after tourniquet release, the IV group had lower systemic PAP levels than the topical group (mean and standard deviation, 1,117.8 ± 478.9 µg/L versus 1,280.7 ± 646.5 µg/L; p = 0.049), indicative of higher antifibrinolytic activity after the second dose. There was no difference in PF1.2 levels between groups, indicating that there was no increase in thrombin generation. The IV group had higher TXA levels at all time points (p < 0.001). Four hours after tourniquet release, wound blood IL-6 and TXA levels were higher than systemic levels in both groups (p < 0.001). Therapeutic systemic TXA levels (mean, 7.2 ± 7.4 mg/L) were noted in the topical group. Calculated blood loss and the length of the hospital stay were lower in the IV group (p = 0.026 and p = 0.025).

Conclusions: Given that therapeutic levels were reached with topical TXA and the lack of a major difference in the mechanism of action, coagulation, and fibrinolytic profile between topical TXA and a single dose of IV TXA, it may be a simpler protocol for institutions to adopt the use of a single dose of IV TXA when safety is a concern.

Level Of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.19.00258DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7406146PMC
December 2019

Addition of Adductor Canal Block to Periarticular Injection for Total Knee Replacement: A Randomized Trial.

J Bone Joint Surg Am 2019 May;101(9):812-820

Departments of Anesthesiology (E.A.G., Y.L., D.H.K., P.D.M., and J.T.Y.), Orthopedic Surgery (A.S.R., G.H.W., D.J.M., E.P.S., D.E.P., and M.M.A.), and Rehabilitation (R.S.), Hospital for Special Surgery (K.F.), New York, NY.

Background: Periarticular injection is a popular method to control postoperative pain after total knee replacement. An adductor canal block is a sensory block that can also help to alleviate pain after total knee replacement. We hypothesized that the combination of adductor canal block and periarticular injection would allow patients to reach discharge criteria 0.5 day faster than with periarticular injection alone.

Methods: This prospective trial enrolled 56 patients to receive a periarticular injection and 55 patients to receive an adductor canal block and periarticular injection. Both groups received intraoperative neuraxial anesthesia and multiple different types of pharmaceutical analgesics. The primary outcome was time to reach discharge criteria. Secondary outcomes, collected on postoperative days 1 and 2, included numeric rating scale pain scores, the PAIN OUT questionnaire, opioid consumption, and opioid-related side effects.

Results: There was no difference in time to reach discharge criteria between the groups with and without an adductor canal block. The Wilcoxon-Mann-Whitney odds ratio was 0.87 (95% confidence interval [CI], 0.55 to 1.33; p = 0.518). The median time to achieve discharge criteria (and interquartile range) was 25.8 hours (23.4 hours, 44.3 hours) in the adductor canal block and periarticular injection group compared with 26.4 hours (22.9 hours, 46.2 hours) in the periarticular injection group. Patients who received an adductor canal block and periarticular injection reported lower worst pain (difference in means, -1.4 [99% CI, -2.7 to 0]; adjusted p = 0.041) and more pain relief (difference in means, 12% [99% CI, 0% to 24%]; adjusted p = 0.048) at 24 hours after anesthesia. There was no difference in any other secondary outcome measure (e.g., opioid consumption, opioid-related side effects, numeric rating scale pain scores).

Conclusions: The time to meet the discharge criteria was not significantly different between the groups. In the adductor canal block and periarticular injection group, the patients had lower worst pain and greater pain relief at 24 hours after anesthesia. No difference was noted in any other secondary outcome measure (e.g., opioid consumption, opioid-related side effects, numeric rating scale pain scores).

Level Of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.18.00195DOI Listing
May 2019

What Pain Levels Do TSA Patients Experience When Given a Long-acting Nerve Block and Multimodal Analgesia?

Clin Orthop Relat Res 2019 03;477(3):622-632

J. T. YaDeau, S. S. Liu, M. A. Gordon, E. A. Goytizolo, Y. Lin, A. A. Schweitzer, Department of Anesthesiology, Critical Care and Pain Management Hospital for Special Surgery, New York, NY, USA D. M. Dines, L. V. Gulotta, Department of Orthopedic Surgery, Sports Medicine, Hospital for Special Surgery, New York, NY, USA K. G. Fields, Healthcare Research Institute, Hospital for Special Surgery, New York, NY, USA.

Background: The pain experience for total shoulder arthroplasty (TSA) patients in the first 2 weeks after surgery has not been well described. Many approaches to pain management have been used, with none emerging as clearly superior; it is important that any approach minimizes postoperative opioid use.

Questions/purposes: (1) With a long-acting nerve block and comprehensive multimodal analgesia, what are the pain levels after TSA from day of surgery until postoperative day (POD) 14? (2) How many opioids do TSA patients take from the day of surgery until POD 14? (3) What are the PainOUT responses at POD 1 and POD 14, focusing on side effects from opioids usage?

Methods: From January 27, 2017 to December 6, 2017, 154 TSA patients were identified as potentially eligible for this prospective, institutional review board-approved observational study. Of those, 46 patients (30%) were excluded (either because they were deemed not appropriate for the study, research staff were not available, patients were not eligible, or they declined to participate), and another six (4%) had incomplete followup data and could not be studied, leaving 102 patients (66%) for analysis here. Median preoperative pain with movement was 7 (interquartile range [IQR], 5-9) and 13 of 102 patients used preoperative opioids. All patients received a single-injection bupivacaine interscalene block with adjuvant clonidine, dexamethasone, and buprenorphine. Multimodal analgesia included acetaminophen, NSAIDs, and opioids. The primary outcome was the Numerical Rating Scale (NRS) pain score with movement on POD 14. The NRS pain score ranges from 0 (no pain) to 10 (worst pain possible). Secondary outcomes included NRS pain scores at rest and with movement (day of surgery, and PODs 1, 3, 7 and 14), daily analgesic use from day of surgery to POD 14 (both oral and intravenous), Opioid-Related Symptom Distress Scale (which assesses 12 symptoms ranging from 0 to 4, with 4 being the most distressing; the composite score is the mean of the 12 symptom-specific scores) on POD 1, and the PainOut questionnaire on POD 1 and POD 14. The PainOut questionnaire includes questions rating nausea, drowsiness, itching from 0 (none) to 10 (severe), as well as rating difficulty staying asleep from 0 (does not interfere) to 10 (completely interferes).

Results: The median NRS pain scores with movement were 2 (IQR, 0-5) on POD 1, 5 (IQR, 3-6) on POD 3, and the pain score was 3 (IQR, 1-5) on POD 14. Median total opioid use (converted to oral morphine equivalents) was 16 mg (4-50 mg) for the first 24 hours, 30 mg (8-63 mg) for the third, and 0 mg (0-20 mg) by the eighth 24-hour period, while the most frequent number of activations of the intravenous patient-controlled analgesia device was 0. Median PainOut scores on POD 1 and POD 14 for sleep interference, nausea, drowsiness and itching were 0, and the median composite Opioid-Related Symptom Distress Scale score on day 1 was 0.3 (IQR, 0.1-0.5).

Conclusions: Clinicians using this protocol, which combines a long-acting, single-injection nerve block with multimodal analgesia, can inform TSA patients that their postoperative pain will likely be less than their preoperative pain, and that on average they will stop using opioids after 7 days. Future research could investigate what the individual components of this protocol contribute. Larger cohort studies or registries would document the incidence of rare complications. Randomized controlled trials could directly compare analgesic effectiveness and cost-benefits for this protocol versus alternative strategies, such as perineural catheters or liposomal bupivacaine. Perhaps most importantly, future studies could seek ways to further reduce peak pain and opioid usage on POD 2 and POD 3.

Level Of Evidence: Level IV, therapeutic study.
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http://dx.doi.org/10.1097/CORR.0000000000000597DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6382177PMC
March 2019

Teaching a Point-of-Care Ultrasound Curriculum to Anesthesiology Trainees With Traditional Didactic Lectures or an Online E-Learning Platform: A Pilot Study.

J Educ Perioper Med 2018 Jul-Sep;20(3):E624. Epub 2018 Jul 1.

Background: Point-of-care ultrasonography (PoCUS) provides real-time, dynamic clinical evidence for providers to make potentially lifesaving medical decisions; however, these tools cannot be used effectively without appropriate training. Although there is always the option of traditional didactic methods, there has been a recent trend toward a "reverse classroom" web-based model using online e-learning modules. Our objective was to collect pilot data that would justify a future randomized controlled trial, comparing traditional didactics to an e-learning PoCUS curriculum for lung ultrasonography (LUS) and the focused assessment with sonography in trauma (FAST) exam.

Methods: Anesthesiology interns, residents (CA 1-3), and fellow trainees enrolled in a LUS and FAST exam course and were randomized to receive didactic lectures or e-learning. Trainees completed knowledge pre- and posttests. Surveys were administered to gauge learning satisfaction. All trainees completed a hands-on-training (HOT) workshop. Image acquisition was assessed through practical tests before HOT, immediately after HOT, and 5 months later.

Results: Eighteen trainees completed the study. There was no evidence of a difference in change in LUS knowledge test score from baseline to posttest between the e-learning and didactic groups (difference in median percentage point change [95 % CI]: 6.6 [-10.0, 23.2]; = .411). There was no evidence of a difference in LUS knowledge posttest scores (difference in median percentage points [95% CI]: -0.9 [-4.8, 3.0]; = .629), FAST knowledge posttest score (0 [incalculable]; = .999), or post-HOT practical test score (-4.2 [-24.6, 16.3]; = .672) between groups. There was no evidence of a difference in degree of satisfaction with learning experience between groups (odds ratios [95% CI]: 1.75 [0.31, 9.94]; = .528).

Conclusions: There was no evidence of a difference between the e-learning and traditional didactic groups in learning or satisfaction outcomes. These results justify establishing an adequately powered, randomized controlled trial assessing the noninferiority of e-learning to traditional didactics for teaching LUS and FAST.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6257000PMC
July 2018

The Incidence of Complications Is Low Following Foot and Ankle Surgery for Which Peripheral Nerve Blocks Are Used for Postoperative Pain Management.

HSS J 2018 Jul 7;14(2):134-142. Epub 2017 Dec 7.

1Department of Anesthesiology, Hospital for Special Surgery, 535 E. 70th Street, New York, NY 10021 USA.

Background: The incidence of neurologic complications from foot and ankle surgery utilizing regional anesthesia is not well established.

Questions/purposes: The purpose of this study was to prospectively determine the incidence of neurologic and peripheral nerve block (PNB) site complications on a busy foot and ankle service that utilizes ankle blocks (ABs) and popliteal blocks (POPs).

Patients And Methods: This prospective observational study included patients undergoing foot and ankle surgery with ABs or POPs. Block choice was determined by surgeon's preference. Patients were assessed for complications during postoperative visits at 2, 6, and 12 weeks. The relation of each complication to the block was scored by a surgeon and anesthesiologist.

Results: From October 2012 to October 2014, 2516 patients underwent 2704 surgeries. There were 195 complications (7.2%) considered neurologic or at the PNB site. The incidence of serious complications was 0.7%. A higher complication rate was reported for POPs (8.8%) than for ABs (2.5%). However, when analysis was limited to forefoot surgery, this difference was not significant. Dexamethasone use was associated with increased complications for POPs. Only 5 of the 195 total complications, and 2 of 20 serious complications, were deemed to have been likely caused by the block by both the surgeon and anesthesiologist reviewer.

Conclusions: The incidences of neurologic or block-related complications and serious complications were 7.2 and 0.7%, respectively, most without a clear surgical vs. nerve block etiology. The higher complication rate for POPs using perineural dexamethasone should be interpreted cautiously in light of the lack of randomization and likely confounders.
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http://dx.doi.org/10.1007/s11420-017-9588-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6031533PMC
July 2018

Perineural Low-Dose Dexamethasone Prolongs Interscalene Block Analgesia With Bupivacaine Compared With Systemic Dexamethasone: A Randomized Trial.

Reg Anesth Pain Med 2018 Aug;43(6):572-579

Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY.

Background And Objectives: Perineural dexamethasone and intravenous (IV) dexamethasone have been shown to prolong peripheral nerve block duration. The effects of perineural and IV dexamethasone have only been compared at doses of 4 mg or greater. This triple-blind, randomized trial examined the effect of 1 mg IV versus perineural dexamethasone on interscalene block (ISB) analgesia duration.

Methods: Patients undergoing ambulatory shoulder arthroscopy received an ultrasound-guided ISB with 15 mL bupivacaine 0.5% and 1 mg preservative-free dexamethasone that was administered perineurally (PeriD) or IV (IVDex). All patients received IV ketorolac and were discharged on naproxen 500 mg 2 times a day plus oxycodone/acetaminophen as needed. Peripheral nerve block duration, pain, opioid consumption, and block satisfaction were assessed via telephone follow-ups.

Results: There were 63 PeriD patients and 62 IVDex patients who completed the primary outcome follow-up. The median time until analgesia from the ISB completely wore off was 3.5 hours (95% confidence interval, 1.0-6.0 hours) longer in the PeriD versus IVDex groups; P = 0.007). Time until the pain relief from the ISB began to wear off was also longer in the PeriD versus IVDex group (5.5 hours [95% confidence interval, 2.1-9.0 hours]; P = 0.002). Other secondary outcomes, including opioid consumption, satisfaction, and pain scores, were not different between groups.

Conclusions: In patients undergoing shoulder arthroscopy, low-dose perineural dexamethasone (1 mg) in combination with 15 mL of 0.5% bupivacaine prolonged the median time until pain relief from the ISB completely wore off compared with 1 mg IV dexamethasone. However, the degree of prolongation was smaller than the a priori-defined minimal clinically meaningful difference of 5 hours.

Clinical Trial Registration: This study was registered at Clinicaltrials.gov, identifier NCT02506660.
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http://dx.doi.org/10.1097/AAP.0000000000000817DOI Listing
August 2018

Readiness for Discharge After Foot and Ankle Surgery Using Peripheral Nerve Blocks: A Randomized Controlled Trial Comparing Spinal and General Anesthesia as Supplements to Nerve Blocks.

Anesth Analg 2018 09;127(3):759-766

Department of Orthopaedic Surgery, Foot and Ankle Service, Hospital for Special Surgery, New York, New York.

Background: Neuraxial anesthesia is often viewed as superior to general anesthesia but may delay discharge. Comparisons do not typically use multimodal analgesics and nerve blockade. Combining nerve blockade with general anesthesia may reduce pain, opioid consumption, and nausea. We hypothesized that general anesthesia (with nerve blocks) would lead to earlier readiness for discharge, compared to spinal anesthesia (with nerve blocks).

Methods: All patients underwent ambulatory foot and ankle surgery, with a predicted case duration of 1-3 hours. All patients received popliteal and adductor canal nerve blocks using bupivacaine and dexamethasone. No intraoperative opioids were administered. All patients received ondansetron, dexamethasone, ketamine, and ketorolac. Patients, data collectors, and the data analyst were not informed of group assignment. Patients were randomized to spinal or general anesthesia with concealed allocation. Spinal anesthesia was performed with mepivacaine and accompanied with propofol sedation. After general anesthesia was induced with propofol, a laryngeal mask airway was inserted, followed by sevoflurane and propofol. Time until ready for discharge, the primary outcome, was compared between groups after adjusting for age and surgery time using multivariable unconditional quantile regression. Secondary outcomes compared at multiple timepoints were adjusted for multiple comparisons using the Holm-Bonferroni step-down procedure.

Results: General anesthesia patients were ready for discharge at a median of 39 minutes earlier (95% confidence interval, 2-75; P = .038) versus spinal anesthesia patients. Patients in both groups met readiness criteria for discharge substantially before actual discharge. Pain scores at rest were higher among general anesthesia patients 1 hour after leaving the operating room (adjusted difference in means, 2.1 [95% confidence interval, 1.0-3.2]; P < .001). Other secondary outcomes (including opioid use, opioid side effects, nausea, headache, sore throat, and back pain) were not different.

Conclusions: General anesthesia was associated with earlier readiness for discharge, but the difference may not be clinically significant and did not lead to earlier actual discharge. Most secondary outcomes were not different between groups. The choice of spinal or general anesthesia as an adjunct to peripheral nerve blockade can reflect patient, clinician, and institutional preferences.
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http://dx.doi.org/10.1213/ANE.0000000000003456DOI Listing
September 2018

Clinical Decision Rules for Pulmonary Embolism in Hospitalized Patients: A Systematic Literature Review and Meta-analysis.

Thromb Haemost 2017 11 30;117(11):2176-2185. Epub 2017 Nov 30.

Department of Medicine, Hospital for Special Surgery, New York, United States.

 Clinical decision rules (CDRs) for pulmonary embolism (PE) have been validated in outpatients, but their performance in hospitalized patients is not well characterized.  The goal of this systematic literature review was to assess the performance of CDRs for PE in hospitalized patients.  We performed a structured literature search using Medline, EMBASE and the Cochrane library for articles published on or before January 18, 2017. Two authors reviewed all titles, abstracts and full texts. We selected prospective studies of symptomatic hospitalized patients in which a CDR was used to estimate the likelihood of PE. The diagnosis of PE had to be confirmed using an accepted reference standard. Data on hospitalized patients were solicited from authors of studies in mixed populations of outpatients and hospitalized patients. Study characteristics, PE prevalence and CDR performance were extracted. The methodological quality of the studies was assessed using the QUADAS instrument.  Twelve studies encompassing 3,942 hospitalized patients were included. Studies varied in methodology (randomized controlled trials and observational studies) and reference standards used. The pooled sensitivity of the modified Wells rule (cut-off ≤ 4) in hospitalized patients was 72.1% (95% confidence interval [CI], 63.7-79.2) and the pooled specificity was 62.2% (95% CI, 52.6-70.9). The modified Wells rule (cut-off ≤ 4) plus D-dimer testing had a pooled sensitivity 99.7% (95% CI, 96.7-100) and pooled specificity 10.8% (95% CI, 6.7-16.9). The efficiency (proportion of patients stratified into the 'PE unlikely' group) was 8.4% (95% CI, 4.1-16.5), and the failure rate (proportion of low likelihood patients who were diagnosed with PE during follow-up) was 0.1% (95% CI, 0-5.3).  In symptomatic hospitalized patients, use of the Wells rule plus D-dimer to rule out PE is safe, but allows very few patients to forgo imaging.
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http://dx.doi.org/10.1160/TH17-06-0395DOI Listing
November 2017

Using Mobile Tracking Technology to Visualize the Trajectory of Recovery After Hip Arthroscopy: a Case Report.

HSS J 2017 Jul 17;13(2):194-200. Epub 2017 Apr 17.

Healthcare Research Institute, Hospital for Special Surgery, 525 East 71st Street, Belaire Suite 9-10A, New York, NY 10021 USA.

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http://dx.doi.org/10.1007/s11420-017-9544-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5481265PMC
July 2017

Post-Dural Puncture Headache is Uncommon in Young Ambulatory Surgery Patients.

HSS J 2017 Jul 16;13(2):146-151. Epub 2017 Mar 16.

Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA.

Background: The incidence of post-dural puncture headache (PDPH) arising from spinal anesthesia in the general population is low. However, patients under 45 years have been shown to exhibit a higher incidence of PDPH, even with small needles.

Questions/purposes: This study aimed to estimate the incidence of PDPH from a 27G pencil-point needle in ambulatory surgery patients between the ages of 15-45 years and compare incidence of PDPH by age group, sex, and history of headache.

Methods: In this prospective cohort study, 300 patients (15-45 years old) who underwent simple knee arthroscopy under spinal anesthesia with a 27G pencil-point needle were enrolled. Verbal consent was obtained during the initial phone conversation between post-operative days (PODs) 2-5. A PDPH questionnaire was administered during this conversation and between PODs 7-10. Patients who reported a positional headache were contacted by a physician co-investigator, who determined PDPH diagnosis.

Results: Five patients were excluded from analysis due to complicated operative procedures or spinal needle size. The overall PDPH incidence was 2.0% (95% CI 0.9-4.4; 6/295). PDPH incidence in 15-19-year-old patients was 16.7% (95% CI 4.7-44.8; 2/12). The crude relative risk of PDPH was 15.4 (95% CI 2.8-114.4) for patients with and without history of headache and 2.5 (95% CI 0.5-14.8) for females vs. males. Overall, 16.3% (95% CI 12.5-20.9) of patients reported post-operative, non-positional headaches.

Conclusions: There was a low overall incidence of PDPH among patients aged 15-45. Pre-planned subgroup analyses of PDPH incidence by age group revealed a high risk of PDPH among a small sample of 15-19-year-olds.
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http://dx.doi.org/10.1007/s11420-017-9541-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5481263PMC
July 2017

Early Functional Outcomes of Periacetabular Osteotomy After Failed Hip Arthroscopic Surgery for Symptomatic Acetabular Dysplasia.

Am J Sports Med 2017 Sep 15;45(11):2460-2467. Epub 2017 Jun 15.

Center for Hip Pain and Preservation, Hospital for Special Surgery, New York, New York, USA.

Background: Persistent acetabular dysplasia is a common reason for the failure of hip arthroscopic surgery; however, the effect of prior hip arthroscopic surgery on functional outcomes after subsequent periacetabular osteotomy (PAO) is unknown. Hypothesis/Purpose: The purpose of this study was to (1) compare demographic and radiological findings in patients who had and had not undergone previous hip arthroscopic surgery before PAO for symptomatic acetabular dysplasia and (2) compare the short-term, hip-specific patient-reported outcomes in these same patient populations. It was hypothesized that prior hip arthroscopic surgery is associated with worse early functional outcomes in PAO.

Study Design: Cohort study; Level of evidence, 3.

Methods: A retrospective cohort study design was utilized. Patients undergoing PAO were enrolled from a single-center, prospective hip preservation registry from March 2011 to April 2015. Patients with a minimum of 1-year clinical follow-up with preoperative and postoperative outcome scores undergoing PAO were eligible for inclusion (n = 93 patients; mean clinical follow-up, 24 months [range, 11-58 months]). The study group consisted of patients undergoing PAO for symptomatic hip dysplasia after prior hip arthroscopic surgery (PREVSCOPE group; 22 patients, 25 hips). Patients undergoing PAO without prior hip arthroscopic surgery (PAOALONE group; 71 patients, 85 hips) were included as a comparison group. Demographic and radiological variables were recorded. Postoperative functional outcome scores (modified Harris Hip Score [mHHS], Hip Outcome Score [HOS], and International Hip Outcome Tool [iHOT-33]) were recorded at 6 months and annually postoperatively.

Results: There were no demographic differences between the 2 groups at baseline. Acetabular version, femoral version, Tönnis grade, preoperative lateral center edge angle, and intraoperative procedures were not different between the 2 groups. At 1-year follow-up from the last hip surgical procedure, the mean (±SD) mHHS (73 ± 14 vs 86 ± 14, respectively; P < .001), HOS-Activities of Daily Living (84 ± 12 vs 93 ± 11, respectively; P = .007), HOS-Sport (62 ± 25 vs 85 ± 18, respectively; P < .001), and iHOT-33 (62 ± 21 vs 79 ± 20, respectively; P = .004) were decreased in the PREVSCOPE group versus the PAOALONE group. At last follow-up (mean, 18 months from the last hip surgical procedure), the mHHS and HOS-Sport were lower in the PREVSCOPE group versus the PAOALONE group. There was no difference in complication or reoperation rates between the 2 groups.

Conclusion: Failed hip arthroscopic surgery before PAO for symptomatic hip dysplasia is associated with lower hip-specific functional outcomes within the first 1 year of follow-up despite similar baseline demographic and radiological characteristics. These differences persisted in certain outcome scores (mHHS, HOS-Sport) at last follow-up but were less pronounced than at 1 year.
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http://dx.doi.org/10.1177/0363546517710011DOI Listing
September 2017

Short-term outcomes of open hip preservation surgery for symptomatic extraarticular femoroacetabular impingement.

Hip Int 2017 Nov 7;27(6):599-607. Epub 2017 Jun 7.

Center for Hip Pain and Preservation, Hospital for Special Surgery, New York - USA.

Introduction: The purposes of this study were to describe: (i) short-term disease-specific patient-reported outcome scores (PROMs); and (ii) factors associated with reoperation or treatment failure in patients undergoing open hip preservation surgery for symptomatic extraarticular FAI.

Methods: Patients undergoing open hip preservation surgery for symptomatic extraarticular FAI were identified from a prospective, single-centre hip preservation registry (n = 51 patients; median clinical follow-up 24 [range 11-49] months). Hip-specific PROMs were assessed preoperatively, 6 months, and each year subsequently. Patients undergoing reoperation or treatment failure (<10 point improvement in iHOT-33 postoperatively) over the study period were identified. Preoperative associated factors were explored on a univariate basis.

Results: International Hip Outcome Tool-33 (iHOT-33) improved from 33 (standard deviation [SD] 18) to 62 (26) at most recent follow-up and 76% of patients improved by minimum clinically important difference (MCID). Harris Hip Score improved from 53 (15) to 75 (17) at most recent follow-up and 79% of patients improved by MCID. Hip Outcome Score (HOS) Sport improved from 45 (26) to 66 (28) at most recent follow-up and 60% of patients improved by MCID. Continued improvements in mean follow-up scores were seen from 1 year to 2 years. Overall, 7 patients underwent reoperation and 9 patients failed to improve by MCID. Preoperative HOS Sport was higher in patients experiencing reoperation or treatment failure (58 [SD 19] vs. 40 [SD 27] respectively; p = 0.03). No other associated demographic, physical examination, or radiographic factors were found.

Conclusions: Open treatment of extraarticular FAI results in short-term improvements in hip-specific PROMs in most patients. Higher HOS Sport scores were associated with reoperation or treatment failure. Longer-term follow-up is necessary to define maximum improvements in this challenging patient population.
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http://dx.doi.org/10.5301/hipint.5000506DOI Listing
November 2017

Pyrimethamine significantly lowers cerebrospinal fluid Cu/Zn superoxide dismutase in amyotrophic lateral sclerosis patients with SOD1 mutations.

Ann Neurol 2017 Jun 9;81(6):837-848. Epub 2017 Jun 9.

Department of Neurology, Ulm University, Ulm, Germany.

Objective: Cu/Zn superoxide dismutase (SOD1) reduction prolongs survival in SOD1-transgenic animal models. Pyrimethamine produces dose-dependent SOD1 reduction in cell culture systems. A previous phase 1 trial showed pyrimethamine lowers SOD1 levels in leukocytes in patients with SOD1 mutations. This study investigated whether pyrimethamine lowered SOD1 levels in the cerebrospinal fluid (CSF) in patients carrying SOD1 mutations linked to familial amyotrophic lateral sclerosis (fALS/SOD1).

Methods: A multicenter (5 sites), open-label, 9-month-duration, dose-ranging study was undertaken to determine the safety and efficacy of pyrimethamine to lower SOD1 levels in the CSF in fALS/SOD1. All participants underwent 3 lumbar punctures, blood draw, clinical assessment of strength, motor function, quality of life, and adverse effect assessments. SOD1 levels were measured in erythrocytes and CSF. Pyrimethamine was measured in plasma and CSF. Appel ALS score, ALS Functional Rating Scale-Revised, and McGill Quality of Life Single-Item Scale were measured at screening, visit 6, and visit 9.

Results: We enrolled 32 patients; 24 completed 6 visits (18 weeks), and 21 completed all study visits. A linear mixed effects model showed a significant reduction in CSF SOD1 at visit 6 (p < 0.001) with a mean reduction of 13.5% (95% confidence interval [CI] = 8.4-18.5) and at visit 9 (p < 0.001) with a mean reduction of 10.5% (95% CI = 5.2-15.8).

Interpretation: Pyrimethamine is safe and well tolerated in ALS. Pyrimethamine is capable of producing a significant reduction in total CSF SOD1 protein content in patients with ALS caused by different SOD1 mutations. Further long-term studies are warranted to assess clinical efficacy. Ann Neurol 2017;81:837-848.
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http://dx.doi.org/10.1002/ana.24950DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5518287PMC
June 2017

Functional Outcomes and Cam Recurrence After Arthroscopic Treatment of Femoroacetabular Impingement in Adolescents.

Arthroscopy 2017 Jul 12;33(7):1361-1369. Epub 2017 Apr 12.

Center for Hip Preservation, Hospital for Special Surgery, New York, New York, U.S.A.

Purpose: To compare the functional outcomes after arthroscopic treatment of femoroacetabular impingement (FAI) in adolescent patients and non-adolescent patients, and to report on the rate of cam recurrence within 2 years after femoral osteoplasty in a limited sample of the adolescent group.

Methods: From 2010 to 2014, patients younger than 18 years with symptomatic FAI (alpha angle >50°) who underwent hip arthroscopy with minimum 2-year follow-up or reoperation were identified. A group of non-adolescent patients with identical inclusion criteria, except age of 18 years or older, was also identified for comparison. In addition, a separate group of adolescent patients with 2-year postoperative radiographs was reviewed for cam recurrence. Demographic data, operative data, and radiographic and clinical outcomes (modified Harris Hip Score [mHHS], Hip Outcome Score-Activities of Daily Living [HOS-ADL], Hip Outcome Score-Sport-Specific Subscale [HOS-SSS], and International Hip Outcome Tool 33 [iHOT-33] score) were collected.

Results: We identified 34 adolescent patients (38 hips) with an average age of 16 years (range, 13-17 years). The mean clinical follow-up period was 36.1 ± 11.6 months (range, 24.1-71.7 months) and 29.6 ± 2.4 months (range, 27.9-31.3 months) without and with reoperation, respectively. A control group of 296 non-adolescent patients (306 hips), with a mean age of 31 years (range, 18-59 years), was identified as our non-adolescent group. The mean clinical follow-up period was 34.1 ± 11 months (range, 24.0-77.4 months) and 15.1 ± 9.1 months (range, 3.6-34.6 months) without and with reoperation, respectively. Significant improvement was noted in adolescents in the changes in outcome scores (mHHS, 22.2 [95% confidence interval (CI), 15.4-29.0]; HOS-ADL, 18.6 [95% CI, 11.9-25.2]; HOS-SSS, 33.5 [95% CI, 24.5-42.5]; and iHOT-33 score, 30.5 [95% CI, 21.8-39.2]; P < .001). Similar improvements were observed in non-adolescents (mHHS, 21.0 [95% CI, 19.0-23.0]; HOS-ADL, 16.6 [95% CI, 14.6-18.6]; HOS-SSS, 30.1 [95% CI, 26.6-33.6]; and iHOT-33 score, 34.9 [95% CI, 31.5-38.3]; P < .001). There was no evidence of a difference in follow-up survey scores between groups (P > .203). Revision surgery was required in 2 adolescent hips (5.3% [95% CI, 1.5%-17.3%]) and 19 non-adolescent hips (6.2% [95% CI, 4.0%-9.5%]). Minimum 2-year radiographs were available for review in 24 adolescent patients (30 hips). The alpha angle (mean ± standard deviation) was reduced from 55.4° ± 12.1° preoperatively to 38.7° ± 4.9° at 6 weeks postoperatively (mean difference, -16.4° [95% CI, -19.8° to -12.9°]; P < .001). At 2 years, the alpha angle remained at 39.2° ± 11.2°, which did not differ from 6-week measurements (mean difference, 0.5° [95% CI, -2.9° to 3.9°]; P = .784). There were no cases of cam recurrence (0% [95% CI, 0%-11.4%]).

Conclusions: Significant improvement in clinical outcomes can be anticipated after arthroscopic treatment of FAI in adolescents. From a limited sample of our adolescent population, the risk of cam recurrence appears low; however, further follow-up is needed to ensure this does not represent a biased sample of the initial population.

Level Of Evidence: Level III, retrospective comparative study.
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http://dx.doi.org/10.1016/j.arthro.2017.01.044DOI Listing
July 2017
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