Publications by authors named "Matthew Ellison"

38 Publications

Results from a Blind Comparison of Chloride Measurements by Accredited Laboratories and the Implications for Enforcing Increasingly Stringent HCl Emission Limits in EU Legislation.

J Air Waste Manag Assoc 2021 Nov 21. Epub 2021 Nov 21.

National Physical Laboratory, Hampton Road, Teddington, Middlesex, TW11 0LW, UK.

We report results from a blind comparison of six analytical laboratories ISO/IEC 17025 accredited for the implementation of the analytical element of EN 1911, which involves the quantification of chloride in deionised water collected from HCl emitting industrial processes regulated under the EU's Industrial Emissions Directive (IED). Both "synthetic" (sodium chloride dissolved in deionised water) and "real" (extracted and collected from a stack simulator facility) samples were prepared across ranges which were equivalent to concentrations in the stack of 0 - 10 mg.m and 0 - 60 mg.m, respectively. Laboratory measurements of the real samples showed significantly poorer performance than the synthetic, implying that the use of synthetic samples in national proficiency testing schemes may be leading to an overly optimistic view of the uncertainties that can routinely be achieved in measurements of real industrial processes. In addition, at the applicable emission limits (10 mg.m and 3 mg.m) and measurement ranges (0 - 15 mg.m and 0 - 4.5 mg.m) under the IED and more recent BAT Conclusions legislation it was found that of the real samples 22 out of 102 (21.6%) and 28 out of 51 (54.9%), respectively, of the measurements would not comply with the overall uncertainty that at least one national regulator considers as necessary for EN 1911 to be an "effective tool" for the calibration of automated measuring systems (AMSs - process plant operator analysers providing continuous monitoring of emissions). Hence, it is proposed that at the next revision of EN 1911 the standard should be revised to give the same degree of consideration to the analytical element of the method as the sampling element. Key analytical laboratory uncertainty sources should be identified, numerical uncertainty requirements should be placed on key analytical uncertainty sources, and there should be an overall uncertainty requirement for the analytical element.
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http://dx.doi.org/10.1080/10962247.2021.2002465DOI Listing
November 2021

Anesthetic choice for arteriovenous access creation: A National Anesthesia Clinical Outcomes Registry analysis.

J Vasc Access 2021 Sep 21:11297298211045495. Epub 2021 Sep 21.

Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology, West Virginia University, Morgantown, WV, USA.

Background: We sought to evaluate differences in primary anesthetic type used in arteriovenous access creation with the hypothesis that administration of regional anesthesia and monitored anesthesia care (MAC) with local anesthesia as the primary anesthetic has increased over time.

Methods: National Anesthesia Clinical Outcomes Registry data were retrospectively evaluated. Covariates were selected a priori within multivariate models to determine predictors of anesthetic type in adults who underwent elective arteriovenous access creation between 2010 and 2018.

Results: A total of 144,392 patients met criteria; 90,741 (62.8%) received general anesthesia. The use of regional anesthesia and MAC decreased over time (8.0%-6.8%, 36.8%-27.8%, respectively; both  < 0.0001). Patients who underwent regional anesthesia were more likely to have ASA physical status >III and to reside in rural areas (52.3% and 12.9%, respectively; both  < 0.0001). Patients who underwent MAC were more likely to be older, male, receive care outside the South, and reside in urban areas (median age 65, 56.8%, 68.1%, and 70.8%, respectively; all  < 0.0001). Multivariate analysis revealed that being male, having an ASA physical status >III, and each 5-year increase in age resulted in increased odds of receiving alternatives to general anesthesia (regional anesthesia adjusted odds ratios (AORs) 1.06, 1.12, and 1.26, MAC AORs 1.09, 1.2, and 1.1, respectively; all  < 0.0001). Treatment in the Midwest, South, or West was associated with decreased odds of receiving alternatives to general anesthesia compared to the Northeast (regional anesthesia AORs 0.28, 0.38, and 0.03, all  < 0.0001; MAC 0.76, 0.13, and 0.43, respectively; all  < 0.05).

Conclusions: Use of regional anesthesia and MAC with local anesthesia for arteriovenous access creation has decreased over time with general anesthesia remaining the primary anesthetic type. Anesthetic choice, however, varies with patient characteristics and geography.
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http://dx.doi.org/10.1177/11297298211045495DOI Listing
September 2021

Healthcare Leadership in the COVID-19 Pandemic: From Innovative Preparation to Evolutionary Transformation.

J Healthc Leadersh 2021 7;13:199-207. Epub 2021 Sep 7.

Department of Anesthesiology, West Virginia University Medicine, Morgantown, WV, USA.

Purpose: In pandemics, centralized healthcare leadership is a critical requirement. The objective of this study was to analyze the early development, operation, and effectiveness of a COVID-19 organizational leadership team and transformation of healthcare services at West Virginia University Hospitals and Health System (WVUHS). The analysis focused on how Kotter's Leading Change eight-stage paradigm could contribute to an understanding of the determinants of successful organizational change in response to the COVID-19 pandemic.

Methods: The fifteen core leaders of WVUHS COVID-19 strategic system were interviewed. A qualitative thematic analysis of the interviews was used to evaluate key aspects of leadership dynamics and system-wide changes in healthcare policies and protocols to contain the pandemic. Outcome measures included the degree to which WVUHS could handle and contain COVID-19 cases as well as COVID-19 death and vaccination rates in West Virginia compared with other states.

Results: The leadership team radically and rapidly revamped nearly all healthcare policies, procedures, and protocols for WVUHS hospitals and clinics, and launched a Hospital Incident Command System. As a result of this effective leadership team and strategic plan, WVUHS surge capacity was adequate for COVID-19 cases. In addition, West Virginia was an early frontrunner in COVID-19 vaccination rates as well as lower death rates.

Conclusion: WVUHS's leadership response to the COVID-19 pandemic followed Kotter's eight-stage paradigm for Leading Change in organizations, including the establishment of a sense of urgency, formation of a powerful guiding coalition, creation of a vision, communication of the vision, empowerment of others to act on the vision, plan for and creation of short-term wins, consolidation of improvements and production of more changes, and institutionalization of new approaches. This approach was effective in limiting the spread and impact of COVID-19 within the hospital network and across the state, with many lessons learned along the way.
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http://dx.doi.org/10.2147/JHL.S319829DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8434849PMC
September 2021

Patients should be extubated in the operating room after routine cardiac surgery: An inconvenient truth.

JTCVS Tech 2021 Aug 24;8:95-99. Epub 2021 Apr 24.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa.

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http://dx.doi.org/10.1016/j.xjtc.2021.03.038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8350799PMC
August 2021

Erratum: A 34-Year-Old Male Intravenous Drug User with a Third Episode of Tricuspid Valve Endocarditis Treated with Repeat Valve Surgery.

Am J Case Rep 2021 Aug 17;22:e934383. Epub 2021 Aug 17.

Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology, West Virginia University, Morgantown, WV, USA.

Figure Legends Corrected: Figure 1. Intraoperative transesophageal echocardiogram, midesophageal right ventricular infow-outflow view, initial operation September 2018. Figure 2. Intraoperative transesophageal echocardiogram, midesophageal right ventricular inflow-outflow view, second operation January 2019. Figure 3. Intraoperative transesophageal echocardiogram, midesophageal right ventricular inflow-outflow view, third operation March 2019. Reference: Jeffrey W. Cannon, J.W. Awori Hayanga, Thomas B. Drvar, Matthew Ellison, Christopher Cook, Muhammad Salman, Harold Roberts, Vinay Badhwar, Heather K. Hayanga. A 34-Year-Old Male Intravenous Drug User with a Third Episode of Tricuspid Valve Endocarditis Treated with Repeat Valve Surgery. Am J Case Rep. 2021; 22: e927385, 10.12659/AJCR.927385.
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http://dx.doi.org/10.12659/AJCR.934383DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8380853PMC
August 2021

Unexpected Evolution After Multivessel Coronary Artery Bypass Grafting in a Patient With Kawasaki Disease.

Cureus 2021 Jun 25;13(6):e15927. Epub 2021 Jun 25.

Anesthesiology, West Virginia University, Morgantown, USA.

Kawasaki disease (KD), also known as mucocutaneous lymph node syndrome, is an acute vasculitis that frequently affects medium-sized blood vessels. The disease is usually self-limiting and most commonly affects children under five years of age. It often affects the coronary arteries and is the leading cause of acquired heart disease in developed countries. We report the case of a teenage boy who had a long-standing diagnosis of Kawasaki disease, underwent coronary artery bypass grafting surgery, and had a complicated medical course following the surgery.
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http://dx.doi.org/10.7759/cureus.15927DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8310738PMC
June 2021

Quadricuspid Aortic Valve Repair Facilitated by Geometric Ring Annuloplasty.

Innovations (Phila) 2021 Jul-Aug;16(4):390-392. Epub 2021 Apr 20.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA.

Quadricuspid aortic valve (QAV) is a rare congenital anomaly often associated with aortic insufficiency. The exact anatomy of QAV is variable, and most cases have undergone aortic valve replacement. With the recognition that aortic valve repair achieves superior patient outcomes as compared to replacement, a systematic approach to autologous reconstruction of QAV is needed. This article reports 2 cases having successful repair utilizing geometric aortic annuloplasty rings, and describes a proposed scheme for repairing most QAV defects, based on relative leaflet and commissural characteristics. Using either tri-leaflet or bicuspid ring annuloplasty, the normal sub-commissural triangles can be remodeled into a 120° or 180° configuration, respectively, and then the leaflets can be sutured and plicated to fit annular geometry. With this approach, most quadricuspid valves potentially could undergo autologous reconstruction.
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http://dx.doi.org/10.1177/15569845211003095DOI Listing
November 2021

Incidence, Prevalence, and Outcomes of Pediatric Trauma in Rural Appalachia (West Virginia) From 2017 to 2019.

Cureus 2021 Apr 1;13(4):e14245. Epub 2021 Apr 1.

Surgical Trauma and Critical Care, West Virginia University School of Medicine, Morgantown, USA.

Background Appalachian rural pediatric trauma has its unique incidence, presentation, and distribution due to the mechanisms of injury, geographic location, access to care, and social issues.  Purpose To review, analyze, and understand pediatric trauma in West Virginia during the period 2017-2019. Materials and methods After institutional review board approval, the statewide trauma database was queried and analyzed in a retrospective cohort study for all pediatric trauma ages zero to 18 from 2017-2019 in the Appalachian regions one through four in West Virginia. The following were analyzed: gender, injury mechanism, Glasgow Coma Scale Score (GCS) at admission, injury severity score (ISS), toxicology screen results, hospital length of stay, duration of ventilatory support, number of procedures performed during admission, presence of non-accidental trauma, cardiac arrest, patient discharge disposition, and mortality. Results One-thousand eighty-two (1182) patients between the ages of zero to 18 were admitted to the trauma center. An average of 37% was female and 63% male. In the 11-18 age group, 24% were female and 76% were male. Most injuries were due to blunt force (89%), followed by penetrating injuries (7.2%) and burns (1.4%). The majority had minor or moderate injuries with 95% receiving a Glasgow Coma Scale (GCS) >13 and 72% listed as minor on the injury severity score (ISS). Children in ages 0-2 years had the highest proportion of poor (0-8) GCS scores, high ISS (>14) scores, most hospital admission days, most days on a ventilator, highest mortality, most pre-hospital cardiac arrests, child abuse, burns, and placement with child protective services. An average of 31% of children tested, and 17% in the age group of 0-2 had a positive toxicology screen. There were 3670 procedures done in total and the most common procedure performed was an ultrasound of the abdomen. Procedures were performed in 90% of the patients. Conclusions and relevance Based on our study, the zero to two-year-old pediatric trauma patients are most vulnerable to poor outcomes and may need targeted preventative interventions. Toxicology screens may need to be more widely implemented in pediatric trauma in the Appalachian region. Rural trauma in Appalachia has endemic issues related to substance abuse, poverty, and a lower degree of social support as compared to urban areas. Although the distribution of injury may follow a national distribution, mechanism, management, and outcomes can vary.
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http://dx.doi.org/10.7759/cureus.14245DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8016142PMC
April 2021

A 34-Year-Old Male Intravenous Drug User with a Third Episode of Tricuspid Valve Endocarditis Treated with Repeat Valve Surgery.

Am J Case Rep 2021 03 29;22:e927385. Epub 2021 Mar 29.

Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology, West Virginia University, Morgantown, WV, USA.

BACKGROUND Intravenous drug use is an epidemic in the United States. One of the complications of intravenous drug use can be infective endocarditis. The treatment for this disease is a combination of intravenous antibiotics, cardiac surgery consultation, and multidisciplinary psychiatric care. Despite surgical intervention, recurrence of disease is common. In the setting of recurrent infective endocarditis in the setting of intravenous drug use, the ethics of redo cardiac surgery has not been well-established. CASE REPORT A 34-year-old man with history of intravenous drug use presented on 3 separate occasions with infective endocarditis resulting in 3 tricuspid valve surgeries within fewer than 7 months. He said he had not injected drugs since before his first operation, he was considered to have a strong social support system, and he completed his postoperative antibiotic regimens each time. However, prior to his last operation, the patient had a urine drug screen positive for opiates without recorded prescribed opioids. Pathology reports from the 3 intraoperative specimens showed different pathogens each time. An extensive interprofessional discussion ensued. CONCLUSIONS Infective endocarditis in the setting of intravenous drug use and its treatments continue to be a point of ethical and medical discussion for all professionals involved with the care of these patients. This case could be used as an example of individualized decision-making, with rigorous ethical and medical discussion factoring into each decision for cardiac surgery. The ongoing treatment for patients with recurrent endocarditis in the setting of intravenous drug use requires more research and guidelines to help medical professionals better care for this patient population.
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http://dx.doi.org/10.12659/AJCR.927385DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8021270PMC
March 2021

Transesophageal echocardiography probe cover: implementation of a cross-contamination containment strategy during the COVID-19 pandemic.

Braz J Anesthesiol 2021 Mar-Apr;71(2):200-201. Epub 2021 Feb 19.

West Virginia University, Department of Anesthesiology, Division of Cardiovascular and Thoracic Anesthesiology, Morgantown, United States.

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http://dx.doi.org/10.1016/j.bjane.2020.12.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7893245PMC
May 2021

Will Protective Innovations Like the "Airway Box" Become Routine Practice After the Pandemic?: An Opinion Survey.

Cureus 2021 Feb 10;13(2):e13258. Epub 2021 Feb 10.

Anesthesiology, West Virginia University School of Medicine, Morgantown, USA.

Background Tracheal intubation carries an elevated risk of exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) due to the generation of aerosols containing high concentrations of the virus. An airway box was designed to mitigate the exposure of healthcare professionals performing intubations. Aim We evaluated usability and sustainability in the routine practice of the "airway box" as a protective device during high-risk airway procedures.  Materials and methods After institutional review board approval, clinicians were educated on using the device through simulation, intranet learning modules, and emailed resources. The airway box was made available in the emergency department, critical care units, perioperative area, and operating rooms. QR codes affixed to the box, emailed, and displayed in common areas provided easy access to complete a REDcap survey (Vanderbilt University Nashville, USA) eliciting providers' experience. Data was collected and analyzed between April 1 and July 31, 2020, on REDcap, and the results were analyzed. Results 687 emergent intubations took place. 232 were performed by anesthesiologists, 315 by emergency department providers, and 140 by critical care specialists. 39 surveys were completed, 29 from intubations in the operating room, three from the critical care units, five from interventional radiology suites, and two perioperatively. Providers found the device to be readily available, with a score of 4.51/5, and the majority of providers, 60%, found the device easy to use, rating it either a 4 or 5 out of 5. Providers acquired a mean Mallampati score of 1.75 and 1.40 mean laryngoscopic grade view. Conclusion Intubation boxes may effectively mitigate high-risk viral exposure during airway procedures. Survey responses show that devices were easy to use and did not significantly affect visualization of the airway. Similar to mask use, enclosure devices in clinical practice could become a vital part of medical protective equipment even after the SARS-CoV-2 pandemic if they are effectively implemented.
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http://dx.doi.org/10.7759/cureus.13258DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7877255PMC
February 2021

Anesthetic Choice for Atrial Fibrillation Ablation: A National Anesthesia Clinical Outcomes Registry Analysis.

J Cardiothorac Vasc Anesth 2021 09 5;35(9):2600-2606. Epub 2021 Jan 5.

Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology, West Virginia University, Morgantown, WV. Electronic address:

Objective: The authors evaluated the type of anesthesia administered in atrial fibrillation ablation, hypothesizing that monitored anesthesia care is used less frequently than general anesthesia.

Design: A retrospective study.

Setting: National Anesthesia Clinical Outcomes Registry data, which are multi-institutional from across the United States.

Participants: Adult patients who underwent elective atrial fibrillation ablation between 2013 and 2018.

Interventions: None.

Measurements And Main Results: National Anesthesia Clinical Outcomes Registry data were evaluated, and covariates were selected a priori within multivariate models to assess for predictors of anesthetic type. A total of 54,321 patients underwent atrial fibrillation ablation; 3,251 (6.0%) received monitored anesthesia care. Patients who received monitored anesthesia care were more likely to be >80 years old (12.4% v 4.9%; p < 0.0001), female (36.1% v 34.3%; p < 0.0001), have American Society of Anesthesiologists physical status >III (17.28% v 10.48%; p < 0.0001), and reside in urban areas (62.23% v 53.37%; p < 0.0001). They received care in the Northeast (17.6% v 10.1%; p < 0.0001) at low-volume centers (median 224 v 284 procedures; p < 0.0001). Multivariate analysis revealed that each five-year increase in age, being female, and having an American Society of Anesthesiologists physical status >III resulted in a 7% (p < 0.0001), 9% (p = 0.032), and 200% (p < 0.0001) increased odds of receiving monitored anesthesia care, respectively. Requiring additional ablation of atria or of a second arrhythmia and residing outside the Northeast resulted in a decreased odds of monitored anesthesia care (adjusted odds ratio 0.24 [p=0.002] and < 0.5 [p < 0.03], respectively). For each 50 cases performed annually at a center, the odds decreased by 5% (p = 0.005).

Conclusions: General anesthesia is the most common type of anesthesia administered for atrial fibrillation ablation. The type of anesthesia administered, however, varies with patient, procedural, and hospital characteristics.
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http://dx.doi.org/10.1053/j.jvca.2020.12.046DOI Listing
September 2021

Aortic Cannulation around Grade 5 Aortic Arch Atheroma Utilizing Transesophageal Echocardiography.

Case Rep Anesthesiol 2020 5;2020:8820948. Epub 2020 Nov 5.

Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology, West Virginia University, Morgantown, WV, USA.

A 61-year-old male with severe aortic valve stenosis was scheduled for a minimally invasive bioprosthetic aortic valve replacement. Intraoperative transesophageal echocardiography (TEE) showed a unicuspid aortic valve and extensive aortic atheromatous disease. A large atheroma with mobile components existed near the distal aortic arch. A 17-French aortic cannula was successfully placed using TEE guidance with the tip proximal to the mobile atheroma to avoid inadvertent disruption and subsequent embolic sequelae. The patient had no evidence of perioperative stroke or other complications postoperatively. This case demonstrates one strategy to manage severe atheromatous disease intraoperatively. We also review additional management options.
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http://dx.doi.org/10.1155/2020/8820948DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7661110PMC
November 2020

Corrigendum to "Iatrogenic Superior Vena Cava Syndrome after Cardiopulmonary Bypass Diagnosed by Intraoperative Echocardiography".

Case Rep Anesthesiol 2020 13;2020:8179176. Epub 2020 Oct 13.

Department of Anesthesiology, West Virginia University School of Medicine, P.O. Box 8255, 1 Medical Center Drive, Morgantown, WV 26506, USA.

[This corrects the article DOI: 10.1155/2020/8813065.].
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http://dx.doi.org/10.1155/2020/8179176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7585671PMC
October 2020

Iatrogenic Superior Vena Cava Syndrome after Cardiopulmonary Bypass Diagnosed by Intraoperative Echocardiography.

Case Rep Anesthesiol 2020 18;2020:8813065. Epub 2020 Aug 18.

Department of Anesthesiology, West Virginia University School of Medicine, P.O. Box 8255, 1 Medical Center Drive, Morgantown, WV 26506, USA.

A 73-year-old female patient presented for mitral valve replacement and coronary artery bypass grafting secondary to multivessel coronary disease and severe mitral valve regurgitation with moderate stenosis. After bypass, the patient developed refractory hypotension with decreased biventricular volume and elevated central venous pressure (CVP). Transesophageal echocardiography (TEE) was utilized to make the diagnosis of acute intraoperative superior vena cava (SVC) syndrome. The SVC cannulation site was revised, resulting in resolution of the hypotension and a decrease in the CVP. Intraoperative TEE was vital in recognizing, managing, and ultimately repairing the acute intraoperative SVC stenosis.
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http://dx.doi.org/10.1155/2020/8813065DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7450329PMC
August 2020

Tibial stress during running following a repeated calf-raise protocol.

Scand J Med Sci Sports 2020 Dec 24;30(12):2382-2389. Epub 2020 Aug 24.

Department of Kinesiology, University of Massachusetts, Amherst, MA, USA.

Tibial stress fractures are a problematic injury among runners. Increased loading of the tibia has been observed following prolonged weight-bearing activity and is suggested to be the result of reduced activity of the plantar flexor muscles. The musculature that spans the tibia contributes to bending of the bone and influences the magnitude of stress on the tibia during running. Participant-specific models of the tibia can be used as a non-invasive estimate of tibial stress. This study aimed to quantify tibial stress during running using participant-specific bone geometry and to compare tibial stress before and after a protocol of repeated muscular contractions of the plantar flexor muscle group. Fourteen participants who run recreationally were included in the final analysis of the study. Synchronized force and kinematic data were collected during overground running before and after an exhaustive, weighted calf-raise protocol. Bending moments and stress at the distal third of the tibia were estimated using beam theory combined with inverse dynamics and musculoskeletal modeling. Bone geometry was obtained from magnetic resonance images. There was no difference in stress at the anterior, posterior, medial, or lateral peripheries of the tibia after the calf-raise protocol compared with before. These findings suggest that an exhaustive, repeated calf-raise protocol did not alter tibial stress during running.
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http://dx.doi.org/10.1111/sms.13794DOI Listing
December 2020

A Novel Approach to Postoperative Ear Pain-Greater Auricular Nerve Block Catheter: A Case Report.

A A Pract 2020 Jan;14(1):21-24

From the Department of Anesthesiology, West Virginia University School of Medicine, Morgantown, West Virginia.

A 70-year-old man presented for repair of an ear avulsion injury sustained from an all-terrain vehicle accident. A continuous technique using a catheter for a greater auricular nerve (GAN) block was performed in the preoperative area followed by general anesthesia in the operating room. No opioids were administered during the surgical procedure or in the immediate postoperative period. The GAN catheter was kept in place for 3 days with near-complete pain relief per the patient. To our knowledge, there are no case reports that describe a continuous GAN technique for surgery and postoperative pain.
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http://dx.doi.org/10.1213/XAA.0000000000001134DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7453958PMC
January 2020

Uncertainty requirements of the European Union's Industrial Emissions Directive for monitoring sulfur dioxide emissions: Implications from a blind comparison of sulfate measurements by accredited laboratories.

J Air Waste Manag Assoc 2019 09 6;69(9):1070-1078. Epub 2019 Aug 6.

Emissions and Atmospheric Metrology Group, National Physical Laboratory , Teddington , UK.

We report results from a blind comparison of five analytical laboratories ISO/IEC 17025 (International Organization for Standardization/International Electrotechnical Commission) accredited for the analysis of sulfate collected in HO from industrial stacks in accordance with the European Standard Reference Method (SRM) for sulfur dioxide (SO) (EN 14791): the method produced under European Commission mandate to support the enforcement of the Industrial Emissions Directive (IED). Both "synthetic" (sodium sulfate dissolved in aqueous hydrogen peroxide [HO]) and "real" (extracted and collected from a stack simulator facility in accordance with EN 14791) samples were prepared across 2-10 and 10-290 mg·m emission equivalent concentration ranges, respectively. From the measurements returned by the laboratories, it was found that in 35% of the former and 28% of the latter the stated expanded uncertainty limits did not intersect with the mean. It was also found with the real samples that in 30% of the 46 different concentration test levels the stated expanded uncertainty of at least two of the laboratories did not intersect. With respect to compliance monitoring, it was found that EN 14791 was capable of enforcing emission limits under the IED associated with waste incinerators (i.e., 50 mg·m), as only 3% of the deviations were in excess of the required uncertainty (commensurate with a 95% level of confidence). However, with respect to the use of EN 14791 for calibration of automated measuring systems (AMSs), it was found that 38.5% of the deviations were in excess of the uncertainty recommended by at least one national regulator as being necessary for EN 14791 to be an "effective tool" for the calibration of AMSs. With emission limits under the IED and the Best Available Technique Reference (BREF) documents it adopts becoming increasingly stringent, it is clear that more work is needed to determine the capability of the SRM and also alternative methods based on portable instruments. : The deviations observed between laboratories ISO/IEC 17025 accredited for sulfate analysis bring into question the monitoring communities' ability to routinely meet the uncertainty requirements associated with increasingly stringent SO emission limits under the European Union's Industrial Emissions Directive. Furthermore, with even further reductions in the near future due to legislative adoption of BREF documents, such issues are only likely to be exacerbated. If the European monitoring community is to have confidence in the capability of the existing Standard Reference Method described in EN 14791 for enforcing increasingly stringent limits, work is needed to validate this method at these lower emission levels.
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http://dx.doi.org/10.1080/10962247.2019.1604449DOI Listing
September 2019

A randomized control trial using intraoperative dexmedetomidine during Roux-en-Y gastric bypass surgery to reduce postoperative pain and narcotic use.

Surg Obes Relat Dis 2019 Apr 31;15(4):588-594. Epub 2019 Jan 31.

Department of Surgery, West Virginia University - School of Medicine, Morgantown, West Virginia. Electronic address:

Background: Dexmedetomidine (DMET), a selective a2-adrenergic agonist, is an opioid-sparing adjuvant sedative that avoids respiratory depression and has been shown to be beneficial in bariatric surgery patients. Although benefit has been shown, prior studies have not evaluated the pain control effects of a single intraoperative bolus.

Objectives: To evaluate the postoperative effects of a single intraoperative dose of DMET.

Settings: University Hospital, United States.

Methods: This is a prospective, randomized, double-blinded study registered with clinicaltrials.gov (#NCT02604940). Patients undergoing laparoscopic Roux-en-Y gastric bypass surgery were randomized and given either a placebo or an intraoperative DMET bolus, where 1 mg/kg was delivered over 10 minutes at the time of surgical closure. Measured outcomes included the following: postoperative pain scores, patient-controlled analgesia (PCA) opioid consumption, PCA demand bolus attempts, duration of postanesthesia care unit (PACU) stay, and vital signs. Descriptive statistics were recorded as frequencies and compared using Χ analysis, and a Welch's 2-sample t test was used to compare continuous variables.

Results: Forty-six participants undergoing laparoscopic Roux-en-Y gastric bypass surgery were randomized into placebo (n = 20) or DMET (n = 26) groups. There were no statistical differences in age (45.1 versus 43.2 yr, P = .522), sex (80% versus 81% female, P = .948), and body mass index (46.1 versus 45.6 kg/m, P = .818) between the 2 groups. There were no statistically significant differences in vital signs (heart rate, blood pressure, oxygen saturation, and respiration rate) between DMET and placebo groups in the preoperative and intraoperative period. During the initial 4 hours in the PACU postoperatively, mean heart rate (70 ± 12 versus 86 ± 14, P < .001), systolic blood pressure (107 ± 17 versus 148 ± 16, P < .001), and diastolic blood pressure (56 ± 15 versus 79 ± 13, P < .001) were significantly lower in the DMET-treated group compared with placebo. During the initial 4 hours in the PACU, mean self-reported pain scores were significantly lower in the DMET-treated group (3.6 ± 2.8) compared with the placebo group (6.7 ± 3; P = .005). The lower pain scores occurred with no significant difference in the mean opioid dosage received in the PACU between DMET-treated (2.66 ± 2.02 mg) and placebo (3.7 ± 2.3 mg; P = .09) groups. Also, there was no statistically significant difference in the total number of PCA attempts for opioids between the DMET-treated and placebo groups (P = .49).

Conclusions: A single bolus of DMET (1 mg/kg delivered over 10 min) administered at the time of surgical closure did not reduce immediate PACU usage of opioids but significantly reduced reported pain scores and caused a significant decrease in the number of attempts made by patients; this is a trend of decreased attempts over time (P = .04) in the DMET group. The trend of the mean total medication used over time indicates that there is neither an increasing nor decreasing trend for the DMET group, but there is an increasing trend in the total used over time for the placebo group. There was no statistically or clinically significant bradycardia, hypotension, hypoxia, respiratory depression intraoperative duration, or PACU stay. Reduced single bolus dosing of DMET required for analgesia in bariatric surgery patients is optimal from physiologic, level of care, and cost perspectives.
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http://dx.doi.org/10.1016/j.soard.2019.01.021DOI Listing
April 2019

Otolaryngologist adherence to the AAO-HNSF Allergic Rhinitis Clinical Practice Guideline.

Int Forum Allergy Rhinol 2018 06 7;8(6):741-750. Epub 2018 Feb 7.

Division of Head and Neck Surgery & Communication Sciences, Duke University Health System, Durham, NC.

Background: In February 2015, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNSF) published the Allergic Rhinitis Clinical Practice Guideline (AR-CPG). The objective of this study was to assess otolaryngologists' perception of the accuracy and adherence to the AR-CPG.

Methods: A survey was distributed to fellows of the American Academy of Otolaryngic Allergy and members of the American Academy of Otolaryngology-Head and Neck Surgery Foundation. A total of 601 otolaryngologists responded. The survey evaluated otolaryngologists' demographic data, perception of the accuracy of the guideline, and adherence to the guideline action statements.

Results: The majority of respondents were actively practicing (544 [90.5%]), for a duration of 11-30 years (308 [51.2%]), in a private practice setting (387 [64.4%]). The cohort was largely fellowship trained (348 [57.9%]) and had reviewed the guideline (428 [71.2%]). Most respondents perceived the guideline as being correct "a great deal" (295 [69.7%]) and deviated from the guideline "only a little" (302 [71.6%]). High rates of adherence to the strong guideline recommendations were observed. Respondents "always/most of the time" recommended intranasal steroids (581 [97.6%]), and oral antihistamines (439 [74%]) as primary therapy. Otolaryngologists in practice for longer were more likely to deviate from the guideline recommendations by obtaining sinonasal imaging (p = 0.007) and recommending oral leukotriene receptor antagonists as primary therapy (p = 0.0001).

Conclusion: Overall perception of the correctness of and adherence to the AR-CPG was high in this cohort. Targeted education resources should be provided to otolaryngologists in practice for longer in efforts to reduce harmful or unnecessary variations in care.
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http://dx.doi.org/10.1002/alr.22096DOI Listing
June 2018

Influence of Pressure on the Composition of Gaseous Reference Materials.

Anal Chem 2018 03 9;90(5):3490-3495. Epub 2018 Feb 9.

National Physical Laboratory , Hampton Road , Teddington , Middlesex TW11 0LW , United Kingdom.

We have shown that the amount fraction of carbon dioxide in a nitrogen or synthetic air matrix stored in cylinders increases as the pressure of the gas mixture reduces, while the amount fraction of methane remains unchanged. Our measurements show the initial amount fraction of carbon dioxide to be lower than the gravimetric value after preparation, which we attribute to the adsorption of a proportion of the molecules to active sites on the internal surface of the cylinder and the valve. As the mixture is consumed, the pressure in the cylinder reduces and the amount fraction of the component is observed to increase. The effect is less pronounced in the presence of water vapor. More dramatic effects have been observed for hydrogen chloride. These findings have significant implications for the preparation of high accuracy gaseous reference materials with unprecedented uncertainties which underpin a broad range of requirements, in particular atmospheric monitoring of high impact greenhouse gases.
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http://dx.doi.org/10.1021/acs.analchem.7b05309DOI Listing
March 2018

The impact of Huntington disease on young people.

Authors:
Matthew Ellison

Handb Clin Neurol 2017 ;144:179-182

Huntington's Disease Youth Organization, United Kingdom. Electronic address:

This chapter covers the challenges young people impacted by Huntington's disease (HD) experience on a daily basis. Research suggests young people in HD families are twice as likely to struggle with issues such as self-harm, depression, anxiety etc. Yet support for young people in HD families is generally lacking. Young people in HD families have to face their own genetic risk for HD, caregiving responsibilities, social isolation, financial woes, educational impact on top of witnessing their family member progressing with HD and gradually losing one ability after another until they are unable to do anything. There are plenty of challenges when you're a young person impacted by HD. This chapter covers most.
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http://dx.doi.org/10.1016/B978-0-12-801893-4.00015-8DOI Listing
March 2018

Ultrasound-Guided Greater Auricular Nerve Block as Sole Anesthetic for Ear Surgery.

Clin Pract 2016 Apr 23;6(2):856. Epub 2016 May 23.

Department of Anesthesiology, West Virginia University School of Medicine , Morgantown, WV, USA.

A greater auricular nerve (GAN) block was used as the sole anesthetic for facial surgery in an 80-year-old male patient with multiple comorbidities which would have made general anesthesia challenging. The GAN provides sensation to the ear, mastoid process, parotid gland, and angle of the mandible. In addition to anesthesia for operating room surgery, the GAN block can be used for outpatient or emergency department procedures without the need for a separate anesthesia team. Although this nerve block has been performed using landmark-based techniques, the ultrasound-guided version offers several potential advantages. These advantages include increased reliability of the nerve block, as well as prevention of inadvertent vascular puncture or blockade of the phrenic nerve, brachial plexus, or deep cervical plexus. The increasing access to ultrasound technology for medical care providers outside the operating room makes this ultrasound guided block an increasingly viable alternative.
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http://dx.doi.org/10.4081/cp.2016.856DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4943106PMC
April 2016

Prolonged Paralysis Following Emergent Cesarean Section with Succinylcholine Despite Normal Dibucaine Number.

W V Med J 2016 Mar-Apr;112(2):44-6

Prolonged paralysis due to a quantitative or qualitative deficiency of pseudocholinesterase activity is an uncommon but known side effect of succinylcholine. We describe a patient who experienced prolonged paralysis following administration of succinylcholine for general anesthesia and endotracheal intubation for an emergent cesarean section despite laboratory evidence of normal enzyme function. The patient required mechanical ventilation in the intensive care unit for several hours following surgery. The patient was extubated following return of full muscle strength and had a good outcome. The enzyme responsible for the metabolism of succinylcholine, pseudocholinesterase, was determined to be low in quantity in this patient but was functionally normal. This low level, by itself, was unlikely to be solely responsible for the prolonged paralysis. The patient likely had an abnormal pseudocholinesterase enzyme variant that is undetectable by standard laboratory tests.
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April 2016

Characterizing airflow profile in the postoperative maxillary sinus by using computational fluid dynamics modeling: A pilot study.

Am J Rhinol Allergy 2016 Jan-Feb;30(1):29-36

Department of Surgery, Division of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA.

Background: Maxillary antrostomy is commonly performed during endoscopic sinus surgery. Little is known about the association surrounding recalcitrant maxillary sinusitis, antrostomy size, and intranasal airflow changes. Furthermore, the interaction between sinus mucosa and airflow is poorly understood. This study used computational fluid dynamics (CFD) modeling to investigate postoperative airflow characteristics between diseased and nondiseased maxillary sinuses in subjects with recurrent disease.

Methods: A retrospective review of patients from a tertiary-level academic rhinology practice was performed. Seven subjects with endoscopic evidence of postoperative maxillary sinus disease that presented as chronic unilateral crusting at least 1 year after bilateral maxillary antrostomies were selected. A three-dimensional model of each subject's sinonasal cavity was created from postoperative computed tomographies and used for CFD analysis.

Results: Although the variables investigated between diseased and nondiseased sides were not statistically significant, the diseased side in six subjects had a smaller antrostomy, and five of these subjects had both reduced nasal unilateral airflow and increased unilateral nasal resistance on the diseased side. The ratio of posterior wall shear stress (WSS) of the maxillary sinus to the total WSS was higher on the diseased side in six subjects. Results also showed strong correlations between antrostomy and CFD variables on the diseased side than on the nondiseased side.

Conclusion: This pilot study showed that the majority of the simulated sinonasal models exhibited common characteristics on the side with persistent disease, such as smaller antrostomy, reduced nasal airflow, increased nasal resistance, and increased posterior WSS. Although statistical significance was not established, this study provided preliminary insight into variables to consider in a larger cohort study.
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http://dx.doi.org/10.2500/ajra.2016.30.4266DOI Listing
December 2016

Effect of Head Position on Intraocular Pressure During Lumbar Spine Fusion: A Randomized, Prospective Study.

J Bone Joint Surg Am 2015 Nov;97(22):1817-23

Department of Orthopaedics, West Virginia University, P.O. Box 9196, Morgantown, WV 26506-9196. E-mail address for S.E. Emery:

Background: Ischemic optic neuropathy resulting in visual loss is a rare but devastating complication of spine surgery. Elevated intraocular pressure (IOP) results in decreased perfusion and possibly ischemic optic neuropathy. We performed a randomized, prospective trial to evaluate the effect of head positioning on IOP during lumbar spine fusion.

Methods: The study included fifty-two patients treated at one institution. Inclusion criteria were a lumbar spine fusion and an age of eighteen to eighty years. Exclusion criteria were a diagnosis of tumor, infection, or traumatic injury or a history of eye disease, ocular surgery, cervical spine surgery, chronic neck pain, or cervical stenosis. The control group underwent the surgery with the head in neutral and the face parallel to the level operating room table whereas, in the experimental group, the neck was extended so that the face had a 10° angle of inclination in relation to the table. IOP measurements were recorded along with the corresponding blood pressure and PCO2 values at the same time points. The primary outcome measure was the change in intraocular pressure (ΔIOP, defined as the maximum IOP minus the initial IOP).

Results: Analysis of covariance (ANCOVA) was used for categorical risk factors, and regression analysis was used for continuous risk factors. The mean ΔIOP, corrected for duration of surgery, was significantly (p = 0.0074) lower in the group treated with the head elevated than it was in the group treated with the head in neutral (difference between the two groups, 4.53 mm Hg [95% confidence interval, 1.29 to 7.79 mm Hg]). No patient sustained visual loss or any cervical-spine-related complications.

Conclusions: Head elevation for adult lumbar spine fusion performed with the patient prone resulted in significantly lower IOP measurements than those seen when the operation was done with the patient's head in neutral. As lower IOP correlates with increased optic nerve perfusion, this intervention could mitigate the risk of perioperative blindness after spine surgery done with the patient prone.
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http://dx.doi.org/10.2106/JBJS.O.00091DOI Listing
November 2015
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