Background: There remains controversy surrounding the treatment of pediatric medial epicondyle fractures. This systematic review examines the existing literature with the aim to elucidate optimal management strategies. Methods: A systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was executed. All data collection was completed by August 01, 2018. Functional outcomes, diagnostic imaging, athlete management, union rates, ulnar nerve symptoms, surgical methods, surgical positioning, and posttreatment protocols were categorized and recorded. Frequency-weighted mean values were calculated with associated SDs. Results: Thirty-seven studies with 1022 patients met the inclusion criteria. Functional outcomes for patients were mostly good following operative and nonoperative management. The most common complication was a slight loss of elbow extension (7.6±5.9 degrees) and flexion (13.3±5.8 degrees). Operative treatment was associated with higher union rates than nonoperative management (700/725, 96% vs. 69/250, 28%; P<0.001). Standard diagnostic imaging techniques to measure displacement were unreliable with a newly proposed axial view having high inter-rater and intrarater reliability. The most common surgical method used was open reduction and internal fixation with Kirschner wires. Whereas surgical management of patients with associated ulnar nerve symptoms led to symptom resolution, nonoperative management occasionally led to the development of these symptoms. Elbow range of motion was initiated at ~2.8±1.4 (range, 0 to 8 wk) weeks after surgery and 3.4±1.2 (range, 3 to 5 wk) weeks without surgery (P<0.001). Conclusions: Although there is still no consensus on treatment of pediatric medial epicondyle fractures, both operative and nonoperative approaches result in good outcomes. Level of Evidence: Level IV—therapeutic
The role of radiology and the radiologist have evolved throughout the coronavirus disease-2019 (COVID-19) pandemic. Early on, chest computed tomography was used for screening and diagnosis of COVID-19; however, it is now indicated for high-risk patients, those with severe disease, or in areas where polymerase chain reaction testing is sparsely available. Chest radiography is now utilized mainly for monitoring disease progression in hospitalized patients showing signs of worsening clinical status. Additionally, many challenges at the operational level have been overcome within the field of radiology throughout the COVID-19 pandemic. The use of teleradiology and virtual care clinics greatly enhanced our ability to socially distance and both are likely to remain important mediums for diagnostic imaging delivery and patient care. Opportunities to better utilize of imaging for detection of extrapulmonary manifestations and complications of COVID-19 disease will continue to arise as a more detailed understanding of the pathophysiology of the virus continues to be uncovered and identification of predisposing risk factors for complication development continue to be better understood. Furthermore, unidentified advancements in areas such as standardized imaging reporting, point-of-care ultrasound, and artificial intelligence offer exciting discovery pathways that will inevitably lead to improved care for patients with COVID-19.
Graphical abstract Additive manufacturing, or 3-Dimensional (3-D) Printing, is built with technology that utilizes layering techniques to build 3-D structures. Today, its use in medicine includes tissue and organ engineering, creation of prosthetics, the manufacturing of anatomical models for preoperative planning, education with high-fidelity simulations, and the production of surgical guides. Traditionally, these 3-D prints have been manufactured by commercial vendors. However, there are various limitations in the adaptability of these vendors to program-specific needs. Therefore, the implementation of a point-of-care in-house 3-D modeling and printing workflow that allows for customization of 3-D model production is desired. In this manuscript, we detail the process of additive manufacturing within the scope of medicine, focusing on the individual components to create a centralized in-house point-of-care manufacturing workflow. Finally, we highlight a myriad of clinical examples to demonstrate the impact that additive manufacturing brings to the field of medicine.
INTRODUCTION There is an unprecedented opioid epidemic in the United States with the rate of drug overdose deaths tripling between 2000 and 2014. The literature suggests that preoperative opioid exposure prior to any surgery independently predicts poorer surgical outcomes. There is a paucity of research on preoperative opioid use and craniotomies. This study proposes to characterize the effects of opioid use on craniotomy outcomes, and triangulate epidemiological sources that predispose patients to adverse outcomes. METHODS From January 1, 2013 to October 1, 2018, 861 craniotomy patients were identified by CPT codes. Relevant medical and surgical information was extracted from the electronic medical record. Adverse outcomes and readmissions were recorded within 90 d of discharge. Opioid use was recorded by converting dosage into a milligram morphine equivalent (MME) using the Oregon Health Authority online calculator. Regression analysis determined significant factors impacting postoperative outcomes. RESULTS Patients receiving opioids preoperatively were more likely to be prescribed higher MMEs postoperatively (beta = 0.445, 95% CI 0.320-0.569; P < .001) and at discharge (beta = 0.151, 95% CI 0.069-0.232; P < .001). Preoperative MME significantly impacted postoperative respiratory failure (OR 1.004, 95% CI 1.002-1.006; P < .001) and pneumonia (OR 1.005, 95% CI 1.002-1.007; P < .001). Preoperative MME positively correlated with an increased length of stay (LOS) (beta = 0.024, 95% CI 0.014-0.034, P < .001). Preoperative MME did not correlate with other adverse outcomes. Employment and insurance status lacked correlation with preoperative MME. CONCLUSION Craniotomy patients with higher preoperative MMEs are more likely to suffer from respiratory failure, pneumonia, and have a longer LOS compared to the no-opioids group. Our findings show that these patients should be more closely monitored for these negative events postoperatively. The lack of significance with other outcomes suggests that other factors impact negative outcomes in the opioid-exposed craniotomy population. Future work should further elucidate the mechanisms behind adverse events in this patient population.
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