Citations

Objectives While methods of endovascular carotid artery stenting have improved over time, concerns surrounding the safety and efficacy of stenting for blunt carotid injury (BCI) remain. This study aims to present our approach to carotid artery stenting (CAS) by incorporating new technologies such as flow-diverting stents and circuits. Methods There is no robust evidence to support routine carotid artery stenting; however, there are several therapeutic options and approaches for treating BCI that currently require an individualized approach. Endovascular stenting and specific stent selection are largely dictated by the disease process the surgeon intends to treat. We will discuss patient selection, medical management, and the most common revascularization techniques, including transfemoral stenting, trans-carotid arterial revascularization using flow reversal, and stent-assisting coiling. Results It must be stressed that endovascular intervention is not an alternative to or preclusive of antithrombotic or anticoagulant therapy. In the setting of BCI, transfemoral CAS is most appropriate in patients who are symptomatic, have a rapidly progressing or large lesion, and do not have a soft thrombus present due to risk of embolism. Unlike transfemoral CAS, TCAR offers an elegant solution for embolic protection when patients have a soft thrombus present. In the case of a large pseudoaneurysm, we perform stent-assisted coiling. Conclusions We practice selective endovascular intervention, stenting lesions that are flow-limiting or have large or rapidly expanding pseudoaneurysms, and only in patients for whom anticoagulation and antiplatelet agents are not contraindicated. As technology and investigation progress, the concerns regarding the safety and the role of endovascular intervention in the treatment of BCI will be more clearly defined.

Abstract Purpose In 2019, the National Comprehensive Cancer Network (NCCN) recommended genetic testing for all patients with pancreatic ductal adenocarcinoma (PDAC). To evaluate the status of implementation of these guidelines in a loco-regional setting, we performed a retrospective, observational study among patients with newly diagnosed PDAC who received oncologic care at Northeast Georgia Medical Center in Georgia. Methods Chart abstraction of patients with newly diagnosed PDAC from January 1, 2020 to December 31, 2021, was performed to include information on genetic testing recommendation and completion, and time from diagnosis to testing. The deidentified dataset was then analyzed using appropriate descriptive and associative statistical testing. Results Of the cohort of 109 patients, 32 (29.4%) completed genetic screening; 16 (14.7%) were screened within 10 days of diagnosis. Among the 77 (70.6%) patients who did not receive genetic screening, 45 (41.3%) were not recommended genetic screening despite treatment intent with standard of care therapy. However, 32 (29.4%) were not recommended genetic screening in conjunction with a desire to pursue palliative care/hospice/or due to terminal illness. Conclusions The study highlighted the gap in implementation of NCCN guideline-directed genetic testing in PDAC patients as only a third underwent testing suggesting the need for systematic processes to facilitate testing. The test was more likely to be completed if done early in the course, especially soon after the diagnosis. Research is needed to explore discussing genetic testing for the large proportion of patients who are terminally ill at diagnosis where genetic screening would potentially benefit the family members.

Abstract Background Mechanical ventilation (MV) management is an essential skill for pulmonary and critical care medicine (PCCM) fellows to master during training. The unprecedented emergence of the coronavirus disease (COVID-19) pandemic highlighted the need for advanced operator competency in MV to improve patients’ outcomes. Objective We aimed to create a standardized case-based curriculum using a blended approach of high-fidelity simulation, rapid-cycle deliberate practice, video didactics, and hands-on small group sessions for rapid accumulation of knowledge and hands-on skills for PCCM fellows before caring for critically ill patients during the COVID-19 pandemic. Methods The MV curriculum consisted of the following steps: 1) baseline written knowledge test with 15 multiple-choice questions covering MV, the latest evidence-based practices, and pathophysiology of COVID-19; 2) baseline confidence survey using a 5-point Likert scale; 3) a one-on-one session using a high-fidelity simulation manikin, a lung simulator, and a mechanical ventilator to test baseline competencies; 4) a structured debriefing tailored per fellow’s 50-point competency assessment checklist from the simulation using rapid-cycle deliberate practice; 5) video didactics; 6) a hands-on session in small groups for basic knobology, waveforms, and modes of MV; 7) a one-on-one simulation reassessment session; 8) a written knowledge posttest; and 9) a post-training confidence survey using a 5-point Likert scale. Results Eight PCCM fellows completed the training. The mean multiple-choice question score increased from 7.4 ± 2.9 to 10.4 ± 2.4 (P < 0.05), and the simulation scores increased from 17.1 ± 4.4 to 30.8 ± 3.7 (P < 0.05). Comparing the simulation reassessment to the baseline, fellows showed significant improvement (P < 0.05) in assessing indications for MV; implementing rapid sequence intubation for patients with COVID-19; initiating MV and ventilator bundle per best practices; recognizing and managing mucous plugging, ventilator dyssynchrony, and evidence-based treatments for acute respiratory distress syndrome; and developing a care plan for proning. The post-training survey revealed improved learner confidence in all competencies. Conclusion This pilot MV curriculum using a blended approach was feasible and allowed PCCM fellows to significantly improve their knowledge and hands-on skills, allowing for the appropriate use of MV during the pandemic. Self-reported improvement scores further reinforced this. The emergent need for novice learners may again be necessary for future pandemic settings where standard training models requiring extensive training time are limited.

Background Balloon guide catheters (BGCs) can be used adjunctively during mechanical thrombectomy (MT) for acute ischemic stroke (AIS). Evaluating the potential economic impact associated with adjunctive BGC use is an important consideration for resource allocation. Methods Decision tree models were used to estimate the economic value of BGC use in MT through its impact on functional outcomes. Healthcare utilization cost estimates in the short- and long-term for patients with different 90-day mRS scores were analyzed for MT-only and MT + BGC scenarios. Deterministic (one-way) and probabilistic sensitivity analyses were performed to evaluate the robustness and uncertainty of model parameters. Results Per-patient index hospitalization cost was estimated at $65,260 for MT-only and $62,883 for MT + BGC scenarios. Per-patient one-year post-index hospitalization cost was estimated at $27,569 for MT-only and $24,830 for MT + BGC. MT + BGC had a total cost savings of $5117 compared with MT-only. Deterministic (one-way) sensitivity analysis demonstrated that cost saving per patient was most sensitive to the proportion of patients in the mRS 0–2 category in both MT + BGC and MT-only. In a probabilistic sensitivity analysis, mean per-patient costs for the index hospitalization were estimated at $63,737 for MT-only and $61,425 for MT + BGC. Mean per-patient cost estimates one-year post-index hospitalization was $27,445 for MT-only and $24,715 for MT + BGC. MT + BGC had a total cost savings of $5043 compared with MT-only. Conclusion Mechanical thrombectomy with adjunctive BGC use may reduce short-term and long-term patient costs due to improved functional outcomes when compared to MT treatment alone for AIS.

Purpose The purposes of this study were to determine the incidence and key characteristics of meniscus injuries in professional baseball players, assess current treatment strategies, determine the return to play rates at any level (RTP) and at the same level (RSL), and identify prognostic factors that predict injury severity. Methods After approval from the Major League Baseball (MLB) Research Committee and our institutional review board, the MLB Health and Injury Tracking System was used to identify meniscus injuries occurring across MLB and Minor League Baseball (MiLB) from 2011 to 2017. Analyzed injuries occurred during normal baseball activity in a player who was active on an MLB or MiLB roster and resulted in at least 1 day missed. Results A total of 293 professional baseball players sustained 314 meniscus injuries from 2011 to 2017 (7 years) for a mean of 44.9 injuries/y. Pitchers were the most injured position (31.8%), followed by infielders (26.4%). Catchers and infielders missed the most median number of days (50 days). When comparing injuries to landing leg vs push‐off leg in pitchers, injury to the push‐off leg resulted in significantly more days missed per injury compared to the lead leg (59.6 vs 39.9 days, P = .048). Overall, RTP was 93.0%, while RSL was 84.4%. Conclusions Over 7 professional baseball seasons, 314 meniscus injuries occurred in 293 players. Pitchers and catchers were most injured, and overall, the number of meniscal injuries per year declined while the percentage of injuries that required surgery increased over time. High rates of RTP were observed. Level of Evidence Level IV, therapeutic case series.

Background: Ankle injuries are more common in the National Basketball Association (NBA) compared with other professional sports. Purpose/Hypothesis: The purpose of this study was to report the incidence and associated risk factors of ankle injuries in NBA athletes. It was hypothesized that factors associated with an increased physiologic burden, such as minutes per game (MPG), usage rate, and associated lower extremity injury, would be associated with increased ankle injury risk and time loss. Study Design: Descriptive epidemiology study. Methods: Ankle injury data from the 2015-2016 through 2020-2021 NBA seasons were evaluated. The truncated 2019-2020 season due to the COVID-19 pandemic was omitted. The primary outcome was the incidence of ankle injuries, reported per 1000 game-exposures (GEs). Secondary analysis was performed to identify risk factors for ankle injuries through bivariate analysis and multivariable logistic regression of player demographic characteristics, performance statistics, injury characteristics, and previous lower extremity injuries. Factors influencing the time loss after injury were assessed via a negative binomial regression analysis. Results: A total of 554 ankle injuries (4.06 injuries per 1000 GEs) were sustained by NBA players over 5 NBA seasons, with sprain/strain the most common injury type (3.71 injuries per 1000 GEs). The majority of ankle injury events (55%) resulted in 2 to 10 game absences. The likelihood of sustaining an ankle injury was significantly associated with a greater number of games played ( P = .029) and previous injury to the hip, hamstring, or quadriceps ( P = .004). Increased length of absence due to ankle injury was associated with greater height ( P = .019), MPG ( P < .001), usage rate ( P = .025), points per game ( P = .011), and a prior history of foot ( P = .003), ankle ( P < .001), and knee injuries ( P < .001). Conclusion: The incidence of ankle injuries was 4.06 per 1000 GEs in professional basketball players. Games played and prior history of hip, hamstring, or quadriceps injuries were found to be risk factors for ankle injuries. Factors associated with physiologic burden such as MPG and usage rate were associated with an increased time loss after injury.