Citations

Records of 34 hyperventilating children aged 18 years or younger seen at the Mayo Clinic over a 25-year period were reviewed. Five different clinical subtypes were identified. Evaluation and treatment varied considerably. At follow-up, 40% were still hyperventilating as adults, and many had signs and symptoms of chronic anxiety. Hyperventilation in childhood can be a signal that the child is experiencing severe anxiety, which may persist into adulthood.

ObjectiveThe relative risk of SARS–CoV‐2 infection and COVID‐19 disease severity among people with rheumatic and musculoskeletal diseases (RMDs) compared to those without RMDs is unclear. This study was undertaken to quantify the risk of SARS–CoV‐2 infection in those with RMDs and describe clinical outcomes of COVID‐19 in these patients.MethodsWe conducted a systematic literature review using 14 databases from January 1, 2019 to February 13, 2021. We included observational studies and experimental trials in RMD patients that described comparative rates of SARS–CoV‐2 infection, hospitalization, oxygen supplementation/intensive care unit (ICU) admission/mechanical ventilation, or death attributed to COVID‐19. Methodologic quality was evaluated using the Joanna Briggs Institute critical appraisal tools or the Newcastle‐Ottawa scale. Risk ratios (RRs) and odds ratios (ORs) with 95% confidence intervals (95% CIs) were calculated, as applicable for each outcome, using the Mantel‐Haenszel formula with random effects models.ResultsOf the 5,799 abstracts screened, 100 studies met the criteria for inclusion in the systematic review, and 54 of 100 had a low risk of bias. Among the studies included in the meta‐analyses, we identified an increased prevalence of SARS–CoV‐2 infection in patients with an RMD (RR 1.53 [95% CI 1.16–2.01]) compared to the general population. The odds of hospitalization, ICU admission, and mechanical ventilation were similar in patients with and those without an RMD, whereas the mortality rate was increased in patients with RMDs (OR 1.74 [95% CI 1.08–2.80]). In a smaller number of studies, the adjusted risk of outcomes related to COVID‐19 was assessed, and the results varied; some studies demonstrated an increased risk while other studies showed no difference in risk in patients with an RMD compared to those without an RMD.ConclusionPatients with RMDs have higher rates of SARS–CoV‐2 infection and an increased mortality rate.

Abstract: Many sports medicine physicians are currently considering introducing regenerative medicine into their practice. Regenerative medicine and the subclassification of orthobiologics are a complicated topic and have produced widely varying opinions. Although there is concern by government regulators, clinicians, scientists, patient advocacy organizations, and the media regarding the use of regenerative medicine products, there is also excitement about the potential benefits with growing evidence that certain regenerative medicine products are safe and potentially efficacious in treating musculoskeletal conditions. Sports medicine physicians would benefit from decision-making guidance about whether to introduce orthobiologics into their practice and how to do it responsibly. The purpose of this position statement is to provide sports medicine physicians with information regarding regenerative medicine terminology, a brief review of basic science and clinical studies within the subclassification of orthobiologics, regulatory considerations, and best practices for introducing regenerative medicine into clinical practice. This information will help sports medicine physicians make informed and responsible decisions about the role of regenerative medicine and orthobiologics in their practice.

Abstract Deep brain stimulation of the anterior nuclei of thalamus (ANT‐DBS) is effective for reduction of seizures, but little evidence is available to guide practitioners in the practical use of this therapy. In an attempt to fill this gap, a questionnaire with 37 questions was circulated to 578 clinicians who were either engaged in clinical trials of or known users of DBS for epilepsy, with responses from 141, of whom 58.2% were epileptologists and 28.4% neurosurgeons. Multiple regions of the world were represented. The survey found that the best candidates for DBS were considered those with temporal or frontal seizures, refractory to at least two medicines. Motivations for renewing therapy upon battery depletion were reduced convulsive, impaired awareness, and severe seizures and improved quality of life. Targeting of leads mainly was by magnetic resonance imaging, sometimes with intraoperative imaging or microelectrode recording. The majority used transventricular approaches. Stimulation parameters mostly imitated the SANTE study parameters, except for initial stimulation amplitudes in the 2–3‐V or ‐mA range, versus 5 V in the SANTE study. Stimulation intensity was most often increased or reduced, respectively, for lack of efficacy or side effects, but changes in active contacts, cycle time, and pulse duration were also employed. Mood or memory problems or paresthesias were the side effects most responsible for adjustments. Off‐label sites stimulated included centromedian thalamus, hippocampus, neocortex, and a few others. Several physicians used DBS in conjunction with vagus nerve stimulation or responsive neurostimulation, although our study did not track efficacy for combined use. Experienced users varied more from published parameters than did inexperienced users. In conclusion, surveys of experts can provide Class IV evidence for the most prevalent practical use of ANT‐DBS. We present a flowchart for one protocol combining common practices. Controlled comparisons will be needed to choose the best approach.

AbstractPurposeEye plaques are widely used for ocular melanoma and provide an effective alternative to enucleation with adequate tumor control. A COMS plaque utilizes a Silastic insert for precise positioning of the radioactive seeds with respect to the scleral surface of the eye; however, due to manufacturing variability, the insert may unintentionally increase or decrease the distance between the sources and tumor. The purpose of this work is to provide guidance in measuring and identifying outliers in Silastic inserts. The importance of regular quality assurance (QA) is illustrated in an experience where a systematic problem was detected and the manufacturer's 22‐mm mold was corrected.MethodsA detailed description of the molds and manufacturing process used to produce Silastic inserts is provided, including photographs of the process steps. The variability in Silastic insert production was evaluated by measuring the thickness of 124 Silastic inserts. An estimate of how the observed Silastic thickness discrepancies impact the dose to the tumor and critical eye structures was performed using homogeneous dose calculations. A standard QA protocol was developed to guide the clinical user.ResultsThickness of the measured Silastic inserts ranged from 1.22 to 2.67 mm, demonstrating variation from the 2.25 mm standard. Six of the 22‐mm inserts were outliers (Δthickness >3 standard deviations) and were excluded from the statistics. The outliers were investigated with the help of the manufacturer, who discovered that a systematic error was accidentally introduced into the 22‐mm mold.ConclusionsDue to manufacturing errors or variability, the Silastic inserts used in COMS eye plaques may be thicker or thinner than the design standard. Such variations may impact tumor control or increase the risk of normal tissue side effects. A standardized QA program is recommended to detect variations and communicate unusual findings to the manufacturer.

Introduction: The relative performance of carotid artery stenting (CAS) and carotid endarterectomy (CEA) among Medicare beneficiaries in routine clinical practice has not been established. Objective: To compare the performance of CAS relative to CEA among Medicare beneficiaries. Methods: We linked Medicare data (2000-2009) to the Society for Vascular Surgery’s Vascular Registry (SVS-VR; 2005-2008) and to the NCDR® Carotid Artery Revascularization and Endarterectomy Registry (CARE; 2006-2008/9). Medicare patients aged ≥66 years undergoing CAS or CEA were followed from the procedure date for the outcomes of death, stroke/transient ischemic attack (TIA), peri-procedural myocardial infarction (MI) or a composite endpoint for these outcomes. We derived high-dimensional propensity scores using registry and Medicare data to control for patient-level factors and adjusted for provider-level factors including past-year CAS/CEA physician and hospital volume, hospital ownership, teaching affiliation, and hospital size in a Cox regression model comparing CAS to CEA. Results: Among 5,254 SVS-VR (1,999 CAS and 3,255 CEA) and 4,055 CARE (2,824 CAS and 1,231 CEA) patients, CAS patients were more often at higher surgical risk (SVS-VR: 96.7% vs. 44.5%; CARE: 71.3% vs. 44.7%) and had a higher comorbidity burden. Crude outcome risks for death and stroke/TIA were lower for CEA. Adjusting for patient-level factors drove estimates downwards for CAS relative to CEA but only after further adjustment for provider-level factors did the performance of CAS and CEA become comparable on all outcomes (figure 1). Conclusion: Performance of CAS and CEA among Medicare beneficiaries was comparable after accounting for patient- and provider-level factors, which is consistent with landmark trials. Further studies are needed to understand the role of heterogeneity in provider-level characteristics.

Objective To identify novel genes and pathways associated with acute mountain sickness (AMS). Background The uniform, rapid transfer of adults from McMurdo Station (sea level, SL) in Antarctica to the South Pole (SP, 2835m) provides a unique opportunity to study changes in gene expression related to the body's adaptation to hypobaric hypoxia. Methods Venous blood was drawn at SL and after 2 d at SP in 98 subjects (age 37±9 y, 70% male). Peripheral blood mononuclear cells (PBMCs) were isolated and microarray analysis of the mRNA isolated from these cells was performed (Affymetrix HG U133 Plus 2 microarray chip). Analysis and the computation of expression fold changes and phenotypic regression were performed using the Bioconductor package in R. Pathway analysis was performed using MetaCore™. Results ~3200 probe sets with sig. p‐values (p<0.05) and fold changes for each subject were used in a binary logistic regression with the presence or absence of AMS during the 2 d at altitude. Corresponding p‐values and z‐values were entered into MetaCore™ for pathways analysis. Identified pathways included smooth muscle contraction, calcium signaling, and acetylcholine regulation of nerve impulses. Conclusions Probe sets associated with the presence of AMS had a significant representation in pathways involving aspects of the autonomic nervous system including smooth muscle contraction and nerve signaling. NSF B‐179‐M.

Background It is documented that cognitive performance can diminish with altitude, but the sensitivity of specific tests have not been investigated. Our objective was to assess and compare cognitive performance from several tests and relate this to quality of sleep and acute mountain sickness (AMS). Methods During an Everest expedition, 3 cognitive tests (Stroop, Trail Making, and a proprietary motor accuracy test) were used along with a questionnaire to assess sleep and AMS. Six athlete climbers and 9 core team members were assessed pre and post‐expedition and at several time points during the expedition (up to 17,500 ft). Results To normalize for individual differences, scores were assessed as % change from baseline. There was no difference in the variation between repeated attempts in a single testing session (0.19<p<0.87), demonstrating that each test was reproducible. There was no decrement in test scores with altitude, nor was there an association with reported sleep quality. The Stroop performance was associated with AMS (p<0.05) and trending with headache (p< 0.15). The in‐house motor test trended towards an association with AMS and headache (p<0.15). However, the trail making test was not associated with AMS/headache. Conclusion With appropriate acclimatization, cognitive performance is maintained at altitude but is linked to presence of headache and AMS. Mayo Clinic and TNF.