40 results on '"Joshua J. Murphy"'
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2. Determination of the Frequency of Right and Left Internal Mammary Artery Embolization in Single Ventricle Patients: A Two-Center Study
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Bassel Mohammad Nijres, Anas S. Taqatqa, Lamya Mubayed, Gregory J. Jutzy, Ra-id Abdulla, Karim A. Diab, Hoang H. Nguyen, Brieann A. Muller, Cyndi R. Sosnowski, Joshua J. Murphy, Joseph Vettukattil, Vishal R. Kaley, Darcy N. Marckini, Bennett P. Samuel, Khaled Abdelhady, and Sawsan Awad
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Heart Defects, Congenital ,Male ,Cardiac Catheterization ,Heart Ventricles ,Infant ,Coronary Artery Disease ,030204 cardiovascular system & hematology ,Fontan Procedure ,Embolization, Therapeutic ,03 medical and health sciences ,Treatment Outcome ,0302 clinical medicine ,Child, Preschool ,Pediatrics, Perinatology and Child Health ,Humans ,Female ,030212 general & internal medicine ,Mammary Arteries ,Cardiology and Cardiovascular Medicine ,Retrospective Studies - Abstract
Embolization of systemic to pulmonary artery collaterals to regulate pulmonary arterial flow or pressure of the cavopulmonary circulation in patients with single ventricle is a common practice. The relative incidence and impact of this practice on future interventions like coronary artery bypass grafting is poorly understood. This study aims to evaluate the frequency and implications of internal mammary artery (IMA) embolization in the single ventricle (SV) population. A retrospective chart review was performed of SV patients who underwent cardiac catheterization before and after Fontan procedure between February 2007 and 2017. Data were collected from two tertiary care centers in the Midwest. Of the 304 SV patients, 62 (20.4%) underwent embolization of one or more IMAs, whereas 242 (79.6%) did not. The rate of embolization of IMA was 40.5% in one center and 14.5% in the second center. Among patients who received IMA embolization, left internal mammary artery (LIMA) embolization was seen in 6 (9.7%) patients. Majority of patients underwent either right internal mammary artery (RIMA) embolization (n = 25; 40.3%) or RIMA and LIMA embolization (n = 27; 43.5%). IMA embolization in SV patients is common. Embolizing IMAs early in life will likely eliminate a valuable graft option for coronary artery bypass grafting should it be required in the future care of these patients. Multi-center, prospective, nation-wide studies are warranted to examine coronary artery disease in the SV population and true frequency of IMA embolization. Delineation of which IMAs were embolized is a necessary in surgical and cardiac intervention national data, such as Society of Thoracic Surgeons (STS) database. All measures should be taken to preserve IMAs patency, if deemed feasible and safe.
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- 2018
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3. Acute and midterm results following perventricular device closure of muscular ventricular septal defects: A multicenter PICES investigation
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Robert G, Gray, Shaji C, Menon, Joyce T, Johnson, Aimee K, Armstrong, Michael A, Bingler, John P, Breinholt, Damien, Kenny, John, Lozier, Joshua J, Murphy, Shyam K, Sathanandam, Nathaniel W, Taggart, Sara M, Trucco, Bryan H, Goldstein, and Brent M, Gordon
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Heart Septal Defects, Ventricular ,Male ,Time Factors ,Septal Occluder Device ,Infant ,Length of Stay ,Prosthesis Design ,United States ,Percutaneous Coronary Intervention ,Treatment Outcome ,Risk Factors ,Child, Preschool ,Humans ,Female ,Cardiac Surgical Procedures ,Child ,Echocardiography, Transesophageal ,Retrospective Studies - Abstract
To describe acute and mid-term results of hybrid perventricular device closure of muscular ventricular septal defects (mVSDs).Perventricular device closure of mVSDs can mitigate technical limitations of percutaneous closure and need for cardiopulmonary bypass or ventriculotomy with a surgical approach.This is a multicenter retrospective cohort study of patients undergoing hybrid perventricular mVSD device closure from 1/2004 to 1/2014. Procedural details, adverse events, outcomes, and follow-up data were collected. Patients were divided into two groups: (1) simple (mVSD closure alone) and (2) complex (mVSD closure with concomitant cardiac surgery).Forty-seven patients (60% female) underwent perventricular mVSD device closure at a median age of 5.2 months (IQR 1.8-8.9) and weight of 5.1 kg (IQR 4.0-6.9). Procedural success was 91% [100% (n = 22) simple and 84% (n = 21/25) complex]. Adverse events occurred in 19% (9/47) [9% (2/22) simple and 28% (7/25) complex]. Hospital length of stay (LOS) was shorter in the simple vs. complex group (4 vs. 14 days, P 0.01). At mid-term follow-up of 19.2 months (IQR 2.3-43) 90% of pts had complete mVSD closure; none developed late heart block, increased atrioventricular (AV) valve insufficiency or ventricular dysfunction.Perventricular device closure of simple mVSD was associated with a high rate of procedural success, few adverse events, and short hospital LOS. Procedural adverse events were associated with the presence of concomitant complex surgery. Residual mVSD, AV valve insufficiency, or ventricular dysfunction were uncommon at mid-term follow-up. © 2017 Wiley Periodicals, Inc.
- Published
- 2017
4. Abstract 18106: 2d Strain is a More Accurate Measure of Systolic Function Than Shortening Fraction and Ejection Fraction in Pediatric Patients Following Orthotopic Heart Transplant
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Meghna D Patel, Georgeann K Groh, Justin Varughese, Craig Myers, Tim Sekarski, Diana Hartman, Joshua J Murphy, Gautam K Singh, and Shafkat Anwar
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Physiology (medical) ,Cardiology and Cardiovascular Medicine - Abstract
Introduction: 2D strain by echocardiography is a sensitive technique for assessing LV systolic function in pediatric heart transplant patients, although it is under-utilized clinically. Methods: We prospectively compared 2D LV 4-chamber Lagrangian longitudinal strain (LS) in 34 echo studies against cardiac output indexed to body surface area (cardiac index, Ci) via cardiac catheterization to assess accuracy of LS. Of those echos, 31/34 were simultaneous with cath, and 3/34 were within 10 days of catheterization. Ci was also compared to LV shortening fraction (SF) and single plane ejection fraction (EF). FS via M-mode in parasternal short-axis and EF via 4 chamber were measured. Strain was obtained in the 4 chamber apical view as an average of 6 segments. Right heart catheterization was performed and evaluated by a cardiac interventionalist blinded to echo data. Pearson’s correlation coefficient was used to assess relationships. Results: Mean age was 10.2 years (0.3 - 19 years), 11 males. Mean HR was 99 bpm (64-155) for catheterization, and 97 bpm (66-148) for echocardiography, mean frame rate 72 f/sec (47-109). Mean Ci was 3.8 L/min/m2 (95% CI 1.9 to 5.73). LS was diminished for this cohort, mean -13.7 (95% CI - 4 to -23.3), however, EF and SF were normal (mean EF 59.1% (95% CI 32.58%- 85.6%), mean FS 35.6% (95% CI 24%- 47%)). There was moderate positive correlation between LS and Ci, (r = 0.48, p = 0.002). FS and EF did not correlate with Ci (r = 0.34, p = 0.03, and r = 0.15, p = 0.39 respectively). There was fair positive correlation between LS and EF and LS and SF (r = 0.36, p = 0.03 and r = 0.38, p = 0.02 respectively). Conclusion: 4 chamber LV LS may be a more sensitive and reliable non-invasive method to assess systolic function in pediatric heart transplant patients. Further investigation in a larger sample using global (18 segment) strain is warranted.
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- 2015
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5. Differential vertebral body growth is maintained after vertebral body tethering surgery for idiopathic scoliosis: 4-year follow-up on 888 peri-apical vertebrae and 592 intervertebral discs.
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Photopoulos G, Hurry J, Bansal A, Miyanji F, Parent S, Murphy J, and El-Hawary R
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- Humans, Female, Follow-Up Studies, Male, Child, Adolescent, Prospective Studies, Vertebral Body surgery, Vertebral Body diagnostic imaging, Thoracic Vertebrae surgery, Thoracic Vertebrae diagnostic imaging, Thoracic Vertebrae growth & development, Radiography, Treatment Outcome, Scoliosis surgery, Scoliosis diagnostic imaging, Intervertebral Disc surgery, Intervertebral Disc diagnostic imaging, Intervertebral Disc growth & development
- Abstract
Purpose: To radiographically evaluate if vertebral body tethering (VBT) can maintain differential peri-apical vertebral growth at medium-term follow-up of 4 years., Methods: A prospective, international, multicenter database was queried to identify idiopathic scoliosis patients treated with thoracic VBT. Concave vs. convex vertebral body height, vertebral wedging, and disc wedging of the 3 peri-apical vertebrae were measured by two independent observers at 5 timepoints (pre-operative to 4-year follow-up)., Results: 65 skeletally immature patients (60 female, mean 12.8 years old, 21 with open triradiate cartilages) met inclusion criteria. Mean pre-operative maximum scoliosis of 50 ± 8° decreased significantly post-operatively to 27 ± 9° (p < 0.001), which remained stable at 4-year follow-up 30 ± 17° (p = 0.38 vs. post-operative). Mean instrumented scoliosis was 21 ± 14° at 4-year follow-up, which was significantly different than 4-year maximum scoliosis (p < 0.001). Mean pre-operative kyphosis of 30 ± 12° did not significantly change post-operatively (p = 1.0) and remained stable at 4-year follow-up (35 ± 18°; p = 0.05). Mean individual convex vertebral height increased from 17.7 ± 1.9 mm to 19.8 ± 1.5 mm (p < 0.001), while mean individual concave height increased from 14.8 ± 1.9 mm to 17.6 ± 1.6 mm (p < 0.001). Summing the peri-apical heights, the difference in height from pre-operative to 4-year follow-up was greater on the concave (8.3 ± 4.7 mm) than on the convex side (6.2 ± 4.7 mm) (p < 0.001). Mean individual vertebral wedging decreased from 6 ± 2° at pre-operative to 4 ± 2° at 4-year follow-up (p < 0.001). Mean total vertebral and disc wedging started at 29 ± 7° pre-operatively, decreased to 16 ± 6° at post-operative (p < 0.001), then further decreased to 14 ± 8° at 4-year follow-up (p < 0.001). Patients with open triradiate cartilages at the time of surgery had a larger height change over the 4 years compared to those with closed triradiate cartilages (p < 0.001)., Conclusion: Patients with idiopathic scoliosis treated with VBT demonstrated differential vertebral growth which was maintained at minimum 4-year follow-up. This effect was more pronounced in patients whose triradiate cartilages were open at the time of surgery., Level of Evidence: III., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)
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- 2024
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6. Regional Anesthesia as an Alternative to Procedural Sedation for Forearm Fracture Reductions in the Pediatric Emergency Department.
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Sulton CD, Fletcher N, Murphy J, Gillespie S, and Burger RK
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- Humans, Child, Forearm, Fracture Fixation methods, Emergency Service, Hospital, Hematoma, Retrospective Studies, Conscious Sedation methods, Forearm Injuries therapy, Anesthesia, Conduction methods, Radius Fractures therapy
- Abstract
Background: Pediatric forearm fractures are common injuries in the pediatric emergency department (PED). Pediatric procedural sedation (PPS) is often required for forearm fracture reductions and pain control for casting. Bier blocks and hematoma blocks are types of regional anesthesia (RA) procedures that can be performed as a potential alternative to PPS., Objective: The objective of this study is to compare the safety of RA with that of PPS. We hypothesized that RA has a safety profile that is equal or superior to PPS as well as a shorter duration of treatment in the PED., Methods: Pediatric emergency department encounters in patients presenting with a diagnosis of radius fracture, ulna fracture, distal "both-bone" fracture, Monteggia fracture, and/or Galeazzi fracture were included. Outcomes of interest included patient adverse events (AEs), sedation medications used, PED duration of treatment (arrival time to disposition time), sedation failures, and reduction failures., Results: Propensity matching was performed resulting in 632 well-matched RA-PPS pairs. The PPS cohort had 13% of encounters with at least 1 AE compared with 0.2% in the RA cohort, P < 0.001. The most common AE in the PPS group was hypoxia (9.8%), and the only AE in the RA group was an intravenous infiltrate (0.16%). Within the matched cohorts, PPS required more medications than RA (100% vs 60%, P < 0.001). Ketamine alone was more commonly used in the PPS group than the RA group (86% vs 0.2%, P < 0.001). Propofol was used only in the PPS group. The average duration of treatment was 205 (SD, 81) minutes in the PPS group and 178 (SD, 75) minutes in the RA group ( P < 0.001). There were no reduction failures in either group., Conclusions: Bier blocks and hematoma blocks are an acceptable alternative to PPS for children requiring forearm reductions. The AE rate is low and the reduction success rate is high. Duration of treatment in the PED is shorter for patients receiving RA compared with PPS., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)
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- 2024
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7. Chronic Morel-Lavallée Lesion in a Pediatric Patient: An Underrecognized Sequela after Trauma.
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Kamson AO, Lazzari B, and Murphy J
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Morel-Lavallée lesions are serious internal degloving injuries associated with trauma. Its diagnosis and treatment can be challenging. We describe the surgical treatment of a case of a chronic Morel-Lavallée lesion in a pediatric patient who sustained an injury to her left thigh during an all-terrain vehicle accident more than a year ago., Competing Interests: The authors declare that there are no conflicts of interest regarding the publication of this article., (Copyright © 2023 Anthony O. Kamson et al.)
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- 2023
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8. Effects of distraction-based distal fixation on pelvic parameter development in early onset scoliosis.
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Shaw KA, Fletcher N, West J, Sachwani N, Romine M, El-Hawary R, and Murphy J
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- Child, Humans, Female, Male, Retrospective Studies, Follow-Up Studies, Sacrum surgery, Pelvis diagnostic imaging, Pelvis surgery, Scoliosis diagnostic imaging, Scoliosis surgery
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Purpose: Prior studies have suggested that distraction-based treatment for early onset scoliosis (EOS) may impede the natural development of the sagittal spinal alignment and pelvic parameters. However, to date no study has investigated the effect of distal fixation on pelvic development., Methods: Ambulatory children with EOS undergoing index distraction-based treatment with distal fixation below T11 were retrospectively reviewed. Patients with distal fixation to the pelvis were identified and compared to children with Spine-based fixation at T12-L5. Radiographic measurements were performed for coronal and sagittal alignment in addition to pelvic parameters (pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) and compared at initial presentation, first erect radiograph, and at 2 years following instrumentation., Results: 33 ambulatory children were identified with a minimum of 2-year follow-up (25 female, average 6.59 ± 2.6 years), with 33% (N = 11) instrumented to the pelvis (54.4% female, average 4.42 ± 2.2 years, initial Cobb 76.1°). Children in the pelvis cohort were significantly younger at treatment initiation (P < 0.001). There was no significant difference in PI at the study time periods, however, there was a significant change in PI between presentation and 2-year follow-up with the pelvic fixation demonstrating a mean 12.3° decrease in PI vs a 3.8° increase in the spine-based cohort (P = 0.027)., Discussion: Distal fixation to the pelvis in ambulatory children with EOS treated with growth-friendly instrumentation was associated with a mean decrease in PI of 12.3° that developed over the 2-year treatment duration. Further research is needed to investigate the long-term implications of these findings on pelvic and spinal development., (© 2022. The Author(s), under exclusive licence to Scoliosis Research Society.)
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- 2023
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9. Reliability of radiographic assessment of growth modulation from anterior vertebral body tethering surgery in pediatric scoliosis.
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Photopoulos G, Hurry J, Murphy J, Brooks J, Fitzgerald R, Louer C, Shaw K, Smit K, Miyanji F, Parent S, and El-Hawary R
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- Humans, Child, Thoracic Vertebrae diagnostic imaging, Thoracic Vertebrae surgery, Vertebral Body, Reproducibility of Results, Radiography, Scoliosis diagnostic imaging, Scoliosis surgery
- Abstract
Purpose: To assess the reliability of vertebral height and angular measurements for anterior vertebral body tethering (AVBT)., Methods: Eight observers measured PA radiographs of 15 idiopathic scoliosis patients treated with AVBT, pre-operative and 4-year follow-up. Vertebral wedging, disc wedging, convex vertebral body heights, and concave vertebral body heights of the 3 apical vertebrae were measured. For each observer, there were a total of 90 measurements for vertebral body height and 75 measurements for all wedging types At least 14 days elapsed between first and second round measurements., Results: From the pre-operative to the 4-year follow-up time-point, the total wedging angle over the 3 peri-apical levels fell from 30 ± 7° to 16 ± 6° (p < 0.001) and the difference between the convex and concave vertebral heights decreased from 9 ± 4 to 6 ± 3 mm (p < 0.001). Interobserver agreement for pre-operative vertebral body heights was good [ICC = 0.80; 95% CI (0.74-0.85)]. At 4-year follow-up there was a moderate agreement [ICC = 0.67 (0.59-0.74)]. There was a poor interobserver agreement for pre-operative wedging angle measurements [ICC = 0.41 (0.32-0.52)] and 4-year follow-up [ICC = 0.45 (0.36-0.56)]. The Limits of Agreement with the Mean (LOAM) for pre-op heights was ± 2.4 mm, similar to the follow-up ± 2.6 mm. When raters are averaged in random groups of two the agreement limits decrease to ± 1.8 mm pre-op and ± 1.6 mm at follow-up. Similarly for wedging angles, LOAM values among the 8 observers of ± 4.6° pre-op and ± 4.2° dropped to ± 2.7° for both pre-op and follow-up when random groups of two raters were averaged together. Intraobserver agreement ranged from good to excellent per individual (ICC = 0.84-0.94) for pre-operative vertebral body heights, but this decreased at 4-year follow-up (ICC = 0.52-0.88). Intraobserver agreement was low overall for wedging (pre-operative ICC = 0.41-0.71; 4-year follow-up ICC = 0.41-0.76)., Conclusion: Based on 8 individual observers, interobserver agreement ranged from good (pre-operative vertebral body heights) to moderate (4-year follow-up vertebral body heights) to poor (all wedging angles). To improve the reliability of the measurement of wedging angles, we recommend averaging the measurements of at least two observers., (© 2022. The Author(s), under exclusive licence to Scoliosis Research Society.)
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- 2023
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10. Pericardial Effusion Causing Cardiac Tamponade in a 10-Year-Old Male.
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Hall J, Rosado M, Wohrley JD, Bandi S, Kent PM, Jandeska SE, Murphy J, and Wilkerson MK
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- Male, Child, Humans, Pericardiocentesis adverse effects, Echocardiography adverse effects, Pericardial Effusion diagnostic imaging, Pericardial Effusion etiology, Pericardial Effusion surgery, Cardiac Tamponade diagnostic imaging, Cardiac Tamponade etiology, Cardiac Tamponade surgery, Hypertension complications
- Abstract
A 10-year-old male with a past medical history of premature pubarche, mild persistent asthma, and eczema presented to the emergency department with progressive dyspnea and chest pain. On examination, he was found to be tachycardic and tachypneic. Chest radiograph demonstrated cardiomegaly, bilateral pleural effusions, and scattered atelectasis. Echocardiogram revealed a large pericardial effusion with right atrial collapse. The patient was admitted to the pediatric ICU for pericardiocentesis and drain placement. As he later became hypertensive and febrile, we will discuss how our patient's hospital course guided our differential diagnosis and how we arrived at a definitive diagnosis using a multidisciplinary approach., (Copyright © 2023 by the American Academy of Pediatrics.)
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- 2023
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11. Body mass index affects outcomes after vertebral body tethering surgery.
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Mishreky A, Parent S, Miyanji F, Smit K, Murphy J, Bowker R, Al Khatib N, and El-Hawary R
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- Adolescent, Body Mass Index, Child, Humans, Overweight complications, Retrospective Studies, Thinness complications, Thoracic Vertebrae surgery, Treatment Outcome, Vertebral Body, Scoliosis surgery
- Abstract
Purpose: To compare the outcomes of anterior Vertebral Body Tethering (AVBT) surgery between overweight and non-overweight patients., Methods: AIS/JIS patients with AVBT with 2-year follow-up from a multi-center pediatric spine database were evaluated pre-operatively, 1st post-operative erect, and 2 years post-operatively. ANOVA was used to compare 3 categories of BMI with significance as per Tukey-Kramer HSD post hoc test. Risk of scoliosis progression was analysed with Mid-P exact test., Results: 121 patients (51 underweight, 58 normal, 12 overweight; mean age 12.5 ± 1.6 yr; BMI 18.8 ± 4.6 kg/m
2 ) were identified. Comparing underweight, normal, and overweight groups: mean pre-operative age (13 yr, 13 yr, 12 yr), scoliosis (52°, 50°, 52°), pre-operative kyphosis (29°, 28°, 33°), peri-operative scoliosis correction (44%, 42%, 46%), and complications by 2-year follow-up (23%, 24%, 17%) were similar between groups. There was one broken tether in each of the underweight and normal weight groups. Change in percent scoliosis correction from 1st erect to 2-year post-operative (i.e., growth modulation phase) was not significantly different between groups; however, the risk ratio for scoliosis progression during this period was 4.74 (1.02-22.02; p = 0.04) for overweight patients., Conclusion: Our findings demonstrate that, as compared to normal weight and underweight patients, overweight patients did not have a statistically significant difference in intra-operative scoliosis correction or in risk of experiencing complication; however, overweight patients had a risk ratio of 4.74 for progression of scoliosis during the growth modulation phase of treatment from first erect radiographs to minimum 2-year follow-up., Level of Evidence: III., (© 2021. The Author(s), under exclusive licence to Scoliosis Research Society.)- Published
- 2022
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12. A Novel Patent Ductus Arteriosus Severity Score to Predict Clinical Outcomes in Premature Neonates.
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Umapathi KK, Muller B, Sosnowski C, Thavamani A, Murphy J, Awad S, and Bokowski JW
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Background: Patent Ductus Arteriosus (PDA) in premature neonates has been associated with comorbidities including chronic lung disease (CLD), and death. However, the treatment of PDA remains controversial. There have been several echocardiographic variables previously used to determine the hemodynamic significance of PDA but their utility in early prediction of clinical outcomes is not well studied. Objective: The objective of our study was to evaluate the use of a severity scoring system incorporating markers of systemic under perfusion, pulmonary over perfusion and left ventricular (LV) function in predicting clinical outcomes in premature neonates. Methods: It is a single center prospective observational study involving newborns < 32 weeks’ gestation. An echocardiogram was done within seven days of life to measure variables previously known to predict severity of shunting in PDA including pulmonary perfusion index (PPI). Predictors of CLD/death were identified using multivariate logistic regression. A severity score was derived and its ability to predict clinical outcomes was tested using a receiver operating characteristic curve. Results: We studied 98 infants with a mean (SD) gestation of 28.9 ± 1.91 weeks and birth weight of 1228.06 ± 318.94 g, respectively. We identified five echocardiographic variables along with gestational age that was independently associated with the outcome variable (PPI, LV output, Superior Mesenteric Artery [SMA] Velocity Time Integral [VTI], Peak diastolic flow velocity in Pulmonary Vein [PV Vd], and reversal of flow in diastole in descending aorta [DFR]). The range of severity score was 0 (low risk) to 12 (high risk). A higher score was associated with the primary outcome variable of CLD/death (7.5 [1.2] vs. 3.6 [1.5], p < 0.001). Our severity score had an area under the curve of 0.97 (95% CI 0.93−0.99, p < 0.001) for predicting CLD/death. Conclusion: Our new PDA severity score of 5.5 has a sensitivity and specificity of 94% and 93%, and positive and negative predictive values of 94% and 93%, respectively.
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- 2022
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13. Surgical Outcomes of Obese Patients With Adolescent Idiopathic Scoliosis From Endemic Areas of Obesity in the United States.
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McDonald TC, Heffernan MJ, Ramo B, Haber L, Sheffer B, Murphy J, Murphy R, Fletcher N, Coyne K, Lubicky J, Bumpass DB, Crawford C 3rd, Carreon L, Toner S, Stafford WH, Poppino K, Adams T, Song BM, Gidwani S, Taillac H, Cornaghie M, Sukkarieh H, Wright PB, Conklin M, Gilbert S, Thimothee J, Bhanat E, and Brooks JT
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- Adolescent, Body Mass Index, Child, Humans, Retrospective Studies, Treatment Outcome, United States epidemiology, Kyphosis, Pediatric Obesity complications, Pediatric Obesity epidemiology, Scoliosis epidemiology, Scoliosis surgery
- Abstract
Background: Obesity rates continue to rise among children and adolescents across the globe. A multicenter research consortium composed of institutions in the Southern US, located in states endemic for childhood obesity, was formed to evaluate the effect of obesity on pediatric musculoskeletal disorders. This study evaluates the effect of body mass index (BMI) percentile and socioeconomic status (SES) on surgical site infections (SSIs) and perioperative complications in patients with adolescent idiopathic scoliosis (AIS) treated with posterior spinal fusion (PSF)., Methods: Eleven centers in the Southern US retrospectively reviewed postoperative AIS patients after PSF between 2011 and 2017. Each center contributed data to a centralized database from patients in the following BMI-for-age groups: normal weight (NW, 5th to <85th percentile), overweight (OW, 85th to <95th percentile), and obese (OB, ≥95th percentile). The primary outcome variable was the occurrence of an SSI. SES was measured by the Area Deprivation Index (ADI), with higher scores indicating a lower SES., Results: Seven hundred fifty-one patients were included in this study (256 NW, 235 OW, and 260 OB). OB and OW patients presented with significantly higher ADIs indicating a lower SES (P<0.001). In addition, SSI rates were significantly different between BMI groups (0.8% NW, 4.3% OW, and 5.4% OB, P=0.012). Further analysis showed that superficial and not deep SSIs were significantly different between BMI groups. These differences in SSI rates persisted even while controlling for ADI. Wound dehiscence and readmission rates were significantly different between groups (P=0.004 and 0.03, respectively), with OB patients demonstrating the highest rates. EBL and cell saver return were significantly higher in overweight patients (P=0.007 and 0.002, respectively)., Conclusion: OB and OW AIS patients have significantly greater superficial SSI rates than NW patients, even after controlling for SES., Level of Evidence: Level III., Competing Interests: J.T.B. is a paid consultant for Depuy-Synthes, A Johnson & Johnson Company, and OrthoPediatrics; is a paid presenter or speaker at Medtronic Spine. The remaining authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)
- Published
- 2021
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14. Shoulder balance in patients with Lenke type 1 and 2 idiopathic scoliosis appears satisfactory at 2 years following anterior vertebral body tethering of the spine.
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Miyanji F, Fields MW, Murphy J, Matsumoto H, Fano AN, Roye BD, Skaggs D, El-Hawary R, Vitale MG, and Parent S
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- Adolescent, Canada, Child, Female, Follow-Up Studies, Humans, Male, Postural Balance, Retrospective Studies, Shoulder diagnostic imaging, Shoulder surgery, Thoracic Vertebrae diagnostic imaging, Thoracic Vertebrae surgery, Vertebral Body, Scoliosis diagnostic imaging, Scoliosis surgery, Spinal Fusion adverse effects
- Abstract
Background: Shoulder balance is an important factor for patient satisfaction following surgery for idiopathic scoliosis (IS). There is no literature reporting the effect of anterior vertebral body tethering (AVBT) on shoulder balance. The purpose of this study was to report the prevalence of postoperative shoulder imbalance in patients undergoing AVBT for IS., Methods: In this retrospective case series, patients enrolled in a multicenter scoliosis registry who underwent AVBT from 2013 to 2017 in two Canadian centers were identified. The primary outcome was shoulder imbalance, defined as an absolute radiographic shoulder height of > 2 cm, at 2 years postoperatively (follow-up range: 22-30 months). Clavicular angle and T1 tilt angle were also investigated., Results: Of the 50 patients identified (92% female; preoperative age: 11.9 ± 1.4 years), there were 43 (86%) patients with Lenke 1 and 7 (14%) patients with Lenke 2 curves. The mean Cobb angles of the proximal thoracic and main thoracic curves were 22.8° ± 8.8° and 49.4° ± 8.5° preoperatively and 13.1° ± 7.5° and 24.9° ± 9.5° at a mean follow-up time of 2.1 years. Absolute clavicular angle and T1 tilt angle were 2.8° ± 2.2° and 4.8° ± 3.5° preoperatively and 2.2° ± 1.7° and 4.7° ± 4.2° at 2-year follow-up. Preoperatively, absolute shoulder height averaged 15.6 ± 10.4 mm, and 15 (30%) patients had shoulder imbalance. At 2-year follow-up, absolute shoulder height averaged 11.2 ± 8.3 mm, and 8 (16%) patients had shoulder imbalance. Of the patients who had acceptable shoulder balance preoperatively, 4 (11.4%) became imbalanced at 2 years postoperatively., Conclusion: Postoperative shoulder imbalance in this early group of patients with IS undergoing AVBT was seen in 16% of patients, a reduction from 30% preoperatively. These results likely reflect the potential of the proximal thoracic curve to correct spontaneously following AVBT., Level of Evidence: Level III., (© 2021. Scoliosis Research Society.)
- Published
- 2021
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15. Risk of early complication following anterior vertebral body tethering for idiopathic scoliosis.
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Abdullah A, Parent S, Miyanji F, Smit K, Murphy J, Skaggs D, Gupta P, Vitale M, Ouellet J, Saran N, Cho RH, Group PSS, and El-Hawary R
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- Humans, Retrospective Studies, Thoracic Vertebrae diagnostic imaging, Thoracic Vertebrae surgery, Treatment Outcome, Vertebral Body, Scoliosis diagnostic imaging, Scoliosis surgery, Spinal Fusion adverse effects
- Abstract
Purpose: The purpose of this study was to determine peri-operative morbidity associated with anterior vertebral body tethering (aVBT) for idiopathic scoliosis., Method: Of 175 patients treated with aVBT, 120 patients had 2 year follow up and were included in this study. Prospectively collected clinical and radiographic data was analyzed retrospectively., Results: Pre-operatively, the mean patient age was 12.6 year (8.2-15.7 year), Risser 0-3, with main thoracic scoliosis 51.2° (40-70°). Immediately post-operative, scoliosis improved to 26.9° (6-53°; p < 0.05), at 1-year post-operative was 23.0° (- 11 to 50°; p < 0.01 vs immediate post-op) and at 2-year post-operative was 27.5° (- 5 to 52; p = 0.64 vs immediate post-op). Pre-operative T5-T12 kyphosis was 16.0° (- 23 to 52°), post-operative was 16.9° (- 7 to 44°), at 1-year was 17.5° (- 14 to 61°) and at 2-year was 17.0° (- 10 to 50°; p = 0.72 vs pre-op). All patients underwent thoracoscopic approach, EBL 200 ml (20-900 ml), surgical time 215.3 min (111-472 min), anesthesia time 303.5 min (207-480 min), ICU stay of 0.2 day (0-2 days), and post-operative hospital stay 4.5 days (2-9 days). During the in-hospital peri-operative period, there were no unplanned return to the operating room (UPROR) and there was a 0.8% rate of complication: one pneumothorax requiring reinsertion of chest tube. By 90 days post-operative, there was no UPROR and a 5% rate of complication. Five additional patients developed complications after discharge: one CSF leak treated with blood patch injection in the clinic and resolved, two pleural effusions requiring chest tubes, one superficial wound infection and one pneumonia treated with outpatient antibiotics. By 1-year post-op, there was a 1.7% rate of UPROR and 8.3% rate of complication. Four additional patients developed complications beyond 90 days: two upper limb paresthesia required outpatient medical management, one CSF leak which initially treated blood patch injection in the clinic initially which then required UPROR, and one compensatory lumbar curve add on that was treated with extension of the tether. By 2-years post-op, there was a 6.7% rate of UPROR and 15.8% rate of complication. 9 additional complications developed after 1 year. One curve progression, one keloid scar, one right leg weakness, 4 cable failures and 2 curve overcorrections., Conclusion: This large, multicenter series of aVBT demonstrated a 15.8% complication rate and a 6.7% UPROR rate at 2 year post-operatively. This early study during the learning curve of aVBT found higher rates of CSF leaks and overall complications than would be expected for PSFI at 1 year post-operatively and a higher rate of overall complications and of UPROR than would be expected for PSFI at 2 year post-operatively. As is common with new procedures, the complication rate may fall with further experience., (© 2021. Scoliosis Research Society.)
- Published
- 2021
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16. The pivotal role of PFO in paradoxical embolism following venous sclerotherapy: a unique case report with pathological correlations.
- Author
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Gajo EC, Kavinsky CJ, Murphy J, and Suradi HS
- Abstract
Background: Vein sclerosing therapy for varicose veins remains an extremely popular procedure. Cerebrovascular accidents can be a serious complication. A patent foramen ovale (PFO) can act as a conduit to the arterial circulation, which could explain the adverse neurologic consequence of this procedure. This case provides pathologic evidence of this concept., Case Summary: A 66-year-old female presented with syncope after undergoing varicose vein sclerotherapy. A computed tomography angiography of the head and neck in the emergency room revealed an occluded right distal M1 middle cerebral artery. Clot retrieval was performed with final pathology revealing amorphous material consistent with an exogenous agent, polidocanol foam, which was used for the patient's vein sclerotherapy. A transthoracic echocardiogram and transoesophageal echocardiogram showed a PFO, which was ultimately closed percutaneously., Discussion: In a quarter of the population, lack of closure of the intrauterine interatrial shunt leads to the existence of a PFO. This direct communication between the atria provides an anatomical conduit for paradoxical emboli and eventually infarction of affected tissues. While a paradoxical embolism is an uncommon cause of acute arterial occlusion, it can have catastrophic sequelae. Historically, the presence of an arterial thrombus from the venous circulation has been difficult to establish unless the thrombus is visualized in transit through a PFO. Complications from vein sclerotherapy have been reported in the literature and include transient ischaemic attacks and strokes, however, this is the first case to provide pathological proof of a paradoxical embolism, which ultimately resulted in percutaneous closure of the PFO., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)
- Published
- 2021
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17. Fast-track treatment initiation counselling in South Africa: A cost-outcomes analysis.
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Larson BA, Pascoe SJS, Huber A, Long LC, Murphy J, Miot J, Fraser-Hurt N, Fox MP, and Rosen S
- Subjects
- Adolescent, Adult, Aftercare economics, Aftercare organization & administration, Aftercare standards, Aftercare statistics & numerical data, Counseling organization & administration, Counseling standards, Female, Guideline Adherence statistics & numerical data, HIV Infections economics, Health Care Costs statistics & numerical data, Humans, Male, Middle Aged, Practice Guidelines as Topic, Practice Patterns, Physicians' economics, Practice Patterns, Physicians' organization & administration, Practice Patterns, Physicians' standards, Practice Patterns, Physicians' statistics & numerical data, South Africa, Time-to-Treatment economics, Time-to-Treatment organization & administration, Time-to-Treatment statistics & numerical data, Young Adult, Anti-HIV Agents therapeutic use, Cost-Benefit Analysis, Counseling economics, Guideline Adherence economics, HIV Infections drug therapy
- Abstract
Introduction: In 2016, under its new National Adherence Guidelines (AGL), South Africa formalized an existing model of fast-track HIV treatment initiation counselling (FTIC). Rollout of the AGL included an evaluation study at 24 clinics, with staggered AGL implementation. Using routinely collected data extracted as part of the evaluation study, we estimated and compared the costs of HIV care and treatment from the provider's perspective at the 12 clinics implementing the new, formalized model (AGL-FTIC) to costs at the 12 clinics continuing to implement some earlier, less formalized, model that likely varied across clinics (denoted here as early-FTIC)., Methods: This was a cost-outcome analysis using standard methods and a composite outcome defined as initiated antiretroviral therapy (ART) within 30 days of treatment eligibility and retained in care at 9 months. Using patient-level, bottom-up resource-utilization data and local unit costs, we estimated patient-level costs of care and treatment in 2017 U.S. dollars over the 9-month evaluation follow-up period for the two models of care. Resource use and costs, disaggregated by antiretroviral medications, laboratory tests, and clinic visits, are reported by model of care and stratified by the composite outcome., Results: A total of 350/343 patients in the early-FTIC/AGL-FTIC models of care are included in this analysis. Mean/median costs were similar for both models of care ($135/$153 for early-FTIC, $130/$151 for AGL-FTIC). For the subset achieving the composite outcome, resource use and therefore mean/median costs were similar but slightly higher, reflecting care consistent with treatment guidelines ($163/$166 for early-FTIC, $168/$170 for AGL-FTIC). Not surprisingly, costs for patients not achieving the composite outcome were substantially less, mainly because they only had two or fewer follow-up visits and, therefore, received substantially less ART than patients who achieved the composite outcome., Conclusion: The 2016 adherence guidelines clarified expectations for the content and timing of adherence counseling sessions in relation to ART initiation. Because clinics were already initiating patients on ART quickly by 2016, little room existed for the new model of fast-track initiation counseling to reduce the number of pre-ART clinic visits at the study sites and therefore to reduce costs of care and treatment., Trial Registration: Clinical Trial Number: NCT02536768., Competing Interests: The authors have declared that no competing interests exist.
- Published
- 2021
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18. Elastic Stable Intramedullary Nailing of Pediatric Tibial Fractures.
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Egger A, Murphy J, Johnson M, Hosseinzadeh P, and Louer C
- Abstract
Background: Most pediatric tibial shaft fractures (75%)
1 can be treated nonoperatively; however, unstable and open fractures require surgical intervention. Titanium elastic nails have become a popular technique for fixation of pediatric tibial shaft fractures. They act as internal splints that impart relative stability to the fracture, promoting callus formation at the fracture site2 ., Description: After the patient is placed in the supine position, the proximal tibial physis is marked using fluoroscopy. An anteromedial and anterolateral incision are made distal to the physis. Entry holes are created in the proximal part of the tibia, and appropriately sized titanium nails are introduced into the bone. Nail size should be 40% of the width of the canal, yielding 80% canal fill when 2 nails are used. The nails are prebent into a gentle C-shape to increase cortical contact at the apex so that 3-point fixation is achieved. The nails are passed to the fracture site, and the fracture is then reduced. The nails are then passed across the fracture site and stopped proximal to the distal tibial physis. The nails are then cut and tamped distally until there is just a short portion of nail left out of the proximal part of the tibia so that the nails can be removed once the fracture is healed. The wounds are then closed, and postoperative immobilization is applied., Alternatives: Many pediatric tibial shaft fractures can be treated with closed reduction and cast immobilization. Open fractures, or fractures that fail nonoperative management, can be treated with external fixation, open reduction and internal fixation (ORIF), or intramedullary stabilization3 ., Rationale: Anatomic reduction and fracture compression can be achieved with ORIF; however, a drawback to this technique is the lack of soft-tissue coverage in the diaphyseal area of the tibia, which can lead to infection and wound-healing problems4 . External fixation has traditionally been the technique of choice for open tibial fractures; however, with the ability to use flexible tibial nails in both open and closed tibial fractures, external fixation is now reserved for open fractures with large soft-tissue defects or in fractures with segmental bone loss. Intramedullary flexible nailing can be used in both open and closed tibial fractures, provides excellent fracture fixation, and utilizes incisions that are more cosmetically appealing to patients5,6 ., Expected Outcomes: Outcomes following flexible nailing for pediatric tibial fractures are excellent. In a study of 19 patients undergoing flexible nailing for tibial shaft fractures, 18 had excellent or satisfactory results7 . Compared with patients who had external fixation, those treated with flexible nails had less pain, shorter time to union, and better functional outcomes2 . Compared with patients treated with ORIF, those who underwent flexible intramedullary nailing spent less time in the operating room and had lower rates of wound complications4 . In the immediate postoperative period, clinicians should be aware of the risk of compartment syndrome, particularly in patients with high-energy injuries, older patients (>14 years old), and heavier patients (>50 kg)8 . There is also an increased risk of soft-tissue irritation and fracture malunion in heavier patients treated with flexible nails9,10 ., Important Tips: Nail size should be 80% of the canal diameter (e.g., two 4.0-mm nails should be chosen for a canal that measures 10 mm).Nails should be properly contoured to avoid corticotomy of the far cortex during insertion; apex of the bend should be positioned at the level of the fracture.During insertion, leave room to advance nails further after they are cut proximally.Do not bury the proximal nail tips beneath the cortex as extraction will be difficult.Ensure that the ends of the nails are not lying up against the proximal tibial physis as this may cause premature growth arrest., Competing Interests: Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJSEST/A309)., (Copyright © 2020 by The Journal of Bone and Joint Surgery, Incorporated.)- Published
- 2020
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19. Effects of race on blood loss in spinal fusions for adolescent idiopathic scoliosis.
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Kaushal N, Orland KJ, Schwartz AM, Wilson JM, Fletcher ND, Patel A, Menapace B, Ramirez M, Wetzel M, Devito D, and Murphy J
- Subjects
- Adolescent, Black or African American, Blood Transfusion statistics & numerical data, Child, Ethnicity, Female, Hematocrit, Hemoglobins analysis, Humans, Kyphosis, Male, Retrospective Studies, Treatment Outcome, United States, White People, Blood Loss, Surgical statistics & numerical data, Scoliosis surgery, Spinal Fusion adverse effects, Spinal Fusion methods
- Abstract
Objective: Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) can be associated with significant blood loss. It has been suggested that blood loss is greater in different racial groups. The purpose of this study was to evaluate differences in blood loss between African American and Caucasian patients undergoing PSF for AIS., Methods: A retrospective review was performed of patients aged 10-18 years with AIS who were treated with PSF from 2014 to 2017 at a single children's healthcare system. Patient demographic, radiographic, and operative data were obtained from medical records. Intraoperative blood loss was calculated using the formula described by Waters et al. Patients who declined reporting their race or had prior spinal surgery, neuromuscular or syndromic diagnoses, a history of cardiac or thoracic surgery, or a bleeding disorder were excluded. Blood loss variables were log-transformed for normality and modeled using multivariable linear regression., Results: A total of 433 PSFs for AIS qualified for the analysis. The average age was 14.1 years, and 73.7% of the patients were female. With respect to race, 44.6% identified themselves as African American. There was no significant difference in blood loss (p = 0.31) or blood loss per level fused (p = 0.36) in African American patients. African American patients, however, did have significantly lower preoperative hemoglobin and hematocrit levels and greater operating room time than Caucasian patients (p < 0.001). There was no difference between race and transfusion rate., Conclusions: There appears to be no relationship between race and blood loss during PSF for AIS. Standardized protocols for minimizing perioperative blood loss can be applied to both Caucasian and African American patients.
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- 2020
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20. A Rare Report of Hypoplastic Coronary Arteries and Pulmonary Veins: A Case Report and Review of the Literature.
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Morales R, Bokowski J, Aljemmali S, Murphy J, Bharati S, and Abdulla RI
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- Angiography, Coronary Artery Disease diagnosis, Coronary Vessel Anomalies diagnosis, Fatal Outcome, Female, Humans, Infant, Stenosis, Pulmonary Vein complications, Stenosis, Pulmonary Vein surgery, Coronary Artery Disease complications, Coronary Vessel Anomalies complications, Pulmonary Veins pathology
- Abstract
Congenital coronary artery anomalies are estimated to affect about 1% of the general population. Hypoplastic coronary artery disease is an uncommon subset associated with significant mortality regardless whether another major cardiac anomaly is present. In this case report, we present an extremely rare case of an infant with hypoplastic coronary artery disease and hypoplastic pulmonary veins. A literature review pertinent to the clinical findings is also contained herein.
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- 2020
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21. Will differentiated care for stable HIV patients reduce healthcare systems costs?
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Larson BA, Pascoe SJ, Huber A, Long LC, Murphy J, Miot J, Fox MP, Fraser-Hurt N, and Rosen S
- Subjects
- Ambulatory Care, Ambulatory Care Facilities, Anti-HIV Agents therapeutic use, Delivery of Health Care economics, HIV Infections drug therapy, Health Personnel, Humans, South Africa, HIV Infections economics, HIV Infections therapy, Health Care Costs
- Abstract
Introduction: South Africa's National Department of Health launched the National Adherence Guidelines for Chronic Diseases in 2015. These guidelines include adherence clubs (AC) and decentralized medication delivery (DMD) as two differentiated models of care for stable HIV patients on antiretroviral therapy. While the adherence guidelines do not suggest that provider costs (costs to the healthcare system for medications, laboratory tests and visits to clinics or alternative locations) for stable patients in these differentiated models of care will be lower than conventional, clinic-based care, recent modelling exercises suggest that such differentiated models could substantially reduce provider costs. In the context of continued implementation of the guidelines, we discuss the conditions under which provider costs of care for stable HIV patients could fall, or rise, with AC and DMD models of care in South Africa., Discussion: In prior studies of HIV care and treatment costs, three main cost categories are antiretroviral medications, laboratory tests and general interaction costs based on encounters with health workers. Stable patients are likely to be on the national first-line regimen (Tenofovir/Entricitabine/Efavarinz (TDF/FTC/EFV)), so no difference in the costs of medications is expected. Laboratory testing guidelines for stable patients are the same regardless of the model of care, so no difference in laboratory costs is expected as well. Based on existing information regarding the costs of clinic visits, AC visits and DMD drug pickups, we expect that for some clinics, visit costs for DMD or AC models of care could be less, but modestly so, than for conventional, clinic-based care. For other clinics, however, DMD or AC models could have higher visit costs (see Table 2)., Conclusions: The standard of care for stable patients has already been "differentiated" for years in South Africa, prior to the roll out of the new adherence guidelines. AC and DMD models of care, when implemented as envisioned in the guidelines, are unlikely to generate substantive reductions or increases in provider costs of care., (© 2020 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)
- Published
- 2020
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22. "Patients are not the same, so we cannot treat them the same" - A qualitative content analysis of provider, patient and implementer perspectives on differentiated service delivery models for HIV treatment in South Africa.
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Pascoe SJS, Scott NA, Fong RM, Murphy J, Huber AN, Moolla A, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fox MP, and Fraser-Hurt N
- Subjects
- Adolescent, Adult, Attitude of Health Personnel, Counseling, Female, Focus Groups, HIV Infections drug therapy, Health Personnel, Humans, Male, Middle Aged, Patient Care Management, Qualitative Research, Sexual Partners, South Africa, Young Adult, Delivery of Health Care, HIV Infections therapy
- Abstract
Introduction: In 2014, the South African government adopted a differentiated service delivery (DSD) model in its "National Adherence Guidelines for Chronic Diseases (HIV, TB and NCDs)" (AGL) to strengthen the HIV care cascade. We describe the barriers and facilitators of the AGL implementation as experienced by various stakeholders in eight intervention and control sites across four districts., Methods: Embedded within a cluster-randomized evaluation of the AGL, we conducted 48 in-depth interviews (IDIs) with healthcare providers, 16 IDIs with Department of Health and implementing partners and 24 focus group discussions (FGDs) with three HIV patient groups: new, stable and those not stable on treatment or not adhering to care. IDIs were conducted from August 2016 to August 2017; FGDs were conducted in January to February 2017. Content analysis was guided by the Consolidated Framework for Implementation Research. Findings were triangulated among respondent types to elicit barriers and facilitators to implementation., Results: New HIV patients found counselling helpful but intervention respondents reported sub-optimal counselling and privacy concerns as barriers to initiation. Providers felt insufficiently trained for this intervention and were confused by the simultaneous rollout of the Universal Test and Treat strategy. For stable patients, repeat prescription collection strategies (RPCS) were generally well received. Patients and providers concurred that RPCS reduced congestion and waiting times at clinics. There was confusion though, among providers and implementers, around implementation of RPCS interventions. For patients not stable on treatment, enhanced counselling and tracing patients lost-to-follow-up were perceived as beneficial to adherence behaviours but faced logistical challenges. All providers faced difficulties accessing data and identifying patients in need of tracing. Congestion at clinics and staff attitude were perceived as barriers preventing patients returning to care., Conclusions: Implementation of DSD models at scale is complex but this evaluation identified several positive aspects of AGL implementation. The positive perception of RPCS interventions and challenges managing patients not stable on treatment aligned with results from the larger evaluation. While some implementation challenges may resolve with experience, ensuring providers and implementers have the necessary training, tools and resources to operationalize AGL effectively is critical to the overall success of South Africa's HIV control strategy., (© 2020 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)
- Published
- 2020
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23. Differentiated HIV care in South Africa: the effect of fast-track treatment initiation counselling on ART initiation and viral suppression as partial results of an impact evaluation on the impact of a package of services to improve HIV treatment adherence.
- Author
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Pascoe SJ, Fox MP, Huber AN, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, and Fraser-Hurt N
- Subjects
- Adult, Female, HIV Infections epidemiology, Humans, Male, Medication Adherence, Middle Aged, South Africa epidemiology, Anti-HIV Agents therapeutic use, Counseling, HIV Infections drug therapy, Treatment Adherence and Compliance, Viral Load drug effects
- Abstract
Introduction: In response to suboptimal adherence and retention, South Africa's National Department of Health developed and implemented National Adherence Guidelines for Chronic Diseases. We evaluated the effect of a package of adherence interventions beginning in January 2016 and report on the impact of Fast-Track Treatment Initiation Counselling (FTIC) on ART initiation, adherence and retention., Methods: We conducted a cluster-randomized mixed-methods evaluation in 4 provinces at 12 intervention sites which implemented FTIC and 12 control facilities providing standard of care. Follow-up was by passive surveillance using clinical records. We included data on subjects eligible for FTIC between 08 Jan 2016 and 07 December 2016. We adjusted for pre-intervention differences using difference-in-differences (DiD) analyses controlling for site-level clustering., Results: We enrolled 362 intervention and 368 control arm patients. Thirty-day ART initiation was 83% in the intervention and 82% in the control arm (RD 0.5%; 95% CI: -5.0% to 6.0%). After adjusting for baseline ART initiation differences and covariates using DiD we found a 6% increase in ART initiation associated with FTIC (RD 6.3%; 95% CI: -0.6% to 13.3%). We found a small decrease in viral suppression within 18 months (RD -2.8%; 95% CI: -9.8% to 4.2%) with no difference after adjustment (RD: -1.9%; 95% CI: -9.1% to 5.4%) or when considering only those with a viral load recorded (84% intervention vs. 86% control). We found reduced crude 6-month retention in intervention sites (RD -7.2%; 95% CI: -14.0% to -0.4%). However, differences attenuated by 12 months (RD: -3.6%; 95% CI: -11.1% to 3.9%). Qualitative data showed FTIC counselling was perceived as beneficial by patients and providers., Conclusions: We saw a short-term ART-initiation benefit to FTIC (particularly in districts where initiation prior to intervention was lower), with no reductions but also no improvement in longer-term retention and viral suppression. This may be due to lack of fidelity to implementation and delivery of those components that support retention and adherence. FTIC must continue to be implemented alongside other interventions to achieve the 90-90-90 cascade and fidelity to post-initiation counselling sessions must be monitored to determine impact on longer-term outcomes. Understanding the cost-benefit and role of FTIC may then be warranted., (© 2019 Health Economics and Epidemiology Research Office. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)
- Published
- 2019
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24. Adherence clubs and decentralized medication delivery to support patient retention and sustained viral suppression in care: Results from a cluster-randomized evaluation of differentiated ART delivery models in South Africa.
- Author
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Fox MP, Pascoe S, Huber AN, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, and Fraser-Hurt N
- Subjects
- Adolescent, Adult, Anti-HIV Agents adverse effects, Anti-HIV Agents supply & distribution, Female, HIV Infections diagnosis, HIV Infections psychology, HIV Infections virology, Health Knowledge, Attitudes, Practice, Humans, Male, Middle Aged, Patient Dropouts, Retention in Care, South Africa, Time Factors, Treatment Outcome, Viral Load, Young Adult, Anti-HIV Agents therapeutic use, HIV Infections drug therapy, Health Services Accessibility, Medication Adherence, Peer Influence, Sustained Virologic Response
- Abstract
Background: Differentiated antiretroviral therapy (ART) delivery models, in which patients are provided with care relevant to their current status (e.g., newly initiating, stable on treatment, or unstable on treatment) has become an essential part of patient-centered health systems. In 2015, the South African government implemented Chronic Disease Adherence Guidelines (AGLs), which involved five interventions: Fast Track Initiation Counseling for newly initiating patients, Enhanced Adherence Counseling for patients with an unsuppressed viral load, Early Tracing of patients who miss visits, and Adherence Clubs (ACs) and Decentralized Medication Delivery (DMD) for stable patients. We evaluated two of these interventions in 24 South African facilities: ACs, in which patients meet in groups outside usual clinic procedures and receive medication; and DMD, in which patients pick up their medication outside usual pharmacy queues., Methods and Findings: We compared those participating in ACs or receiving DMD at intervention sites to those eligible for ACs or DMD at control sites. Outcomes were retention and sustained viral suppression (<400 copies/mL) 12 months after AC or DMD enrollment (or comparable time for controls). 12 facilities were randomly allocated to intervention and 12 to control arms in four provinces (Gauteng, North West, Limpopo, and KwaZulu Natal). We calculated adjusted risk differences (aRDs) with cluster adjustment using generalized estimating equations (GEEs) using difference in differences (DiD) with patients eligible for ACs/DMD prior to implementation (Jan 1, 2015) for comparison. For DMD, randomization was not preserved, and the analysis was treated as observational. For ACs, 275 intervention and 294 control patients were enrolled; 72% of patients were female, 61% were aged 30-49 years, and median CD4 count at ART initiation was 268 cells/μL. AC patients had higher 1-year retention (89.5% versus 81.6%, aRD: 8.3%; 95% CI: 1.1% to 15.6%) and comparable sustained 1-year viral suppression (<400 copies/mL any time ≤ 18 months) (80.0% versus 79.6%, aRD: 3.8%; 95% CI: -6.9% to 14.4%). Retention associations were apparently stronger for men than women (men RD: 13.1%, 95% CI: 0.3% to 23.5%; women RD: 6.0%, 95% CI: -0.9% to 12.9%). For DMD, 232 intervention and 346 control patients were enrolled; 71% of patients were female, 65% were aged 30-49 years, and median CD4 count at ART initiation was 270 cells/μL. DMD patients had apparently lower retention (81.5% versus 87.2%, aRD: -5.9%; 95% CI: -12.5% to 0.8%) and comparable viral suppression versus standard of care (77.2% versus 74.3%, aRD: -1.0%; 95% CI: -12.2% to 10.1%), though in both cases, our findings were imprecise. We also noted apparently increased viral suppression among men (RD: 11.1%; 95% CI: -3.4% to 25.5%). The main study limitations were missing data and lack of randomization in the DMD analysis., Conclusions: In this study, we found comparable DMD outcomes versus standard of care at facilities, a benefit for retention of patients in care with ACs, and apparent benefits in terms of retention (for AC patients) and sustained viral suppression (for DMD patients) among men. This suggests the importance of alternative service delivery models for men and of community-based strategies to decongest primary healthcare facilities. Because these strategies also reduce patient inconvenience and decongest clinics, comparable outcomes are a potential success. The cost of all five AGL interventions and possible effects on reducing clinic congestion should be investigated., Clinical Trial Registration: NCT02536768., Competing Interests: SR is a member of the Editorial Board of PLOS Medicine. The authors have declared that no other competing interests exist.
- Published
- 2019
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25. Effectiveness of interventions for unstable patients on antiretroviral therapy in South Africa: results of a cluster-randomised evaluation.
- Author
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Fox MP, Pascoe SJS, Huber AN, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, and Fraser-Hurt N
- Subjects
- Adolescent, Adult, Cluster Analysis, Female, Humans, Male, Middle Aged, Patient Compliance statistics & numerical data, South Africa, Treatment Outcome, Young Adult, Anti-HIV Agents therapeutic use, Attitude to Health, Counseling methods, HIV Infections drug therapy, HIV Infections psychology, Patient Compliance psychology
- Abstract
Background: As loss from HIV care is an ongoing challenge globally, interventions are needed for patients who don't achieve or maintain ART stability. The 2015 South African National Adherence Guidelines (AGL) for Chronic Diseases include two interventions targeted at unstable patients: early tracing of patients who miss visits (TRIC) and enhanced adherence counselling (EAC)., Methods: As part of a cluster-randomised evaluation at 12 intervention and 12 control clinics in four provinces, intervention sites implemented the AGL interventions, while control sites retained standard care. We report on outcomes of EAC for patients with an elevated viral load (>400 copies/ml) and for TRIC patients who missed a visit by >5 days. We estimated risk differences (RD) of 3 and 12-month viral resuppression (<400 copies/ml) and 12-month retention with cluster adjustment using generalised estimating equations and controlled for imbalances using difference-in-differences compared to all eligible in 2015, prior to intervention roll-out., Results: For EAC, we had 358 intervention and 505 control site patients (61% female, median ART initiation CD4 count 154 cells/μl). We found no difference between arms in 3-month resuppression (RD: -1.7%; 95%CI: -4.3% to 0.9%), but <20% of patients had a repeat viral load within 3 months (19.8% intervention, 13.5% control). Including the entire clinic population eligible for EAC with a repeat viral load at all evaluation sites (n = 934), intervention sites showed a small increase in 3-month resuppression (28% vs. 25%, RD 3.0%; 95%CI: -2.7% to 8.8%). Adjusting for baseline differences increased the RD to 8.1% (95% CI: -0.1% to 17.2%). However, we found no differences in 12-month suppression (RD: 1.5%; 95% CI: -14.1% to 17.1% but suppression was low overall at 40%) or retention (RD: 2.8%; 95% CI: -7.5% to 13.2%). For TRIC, we enrolled 155 at intervention sites and 248 at control sites (44% >40 years, 67% female, median CD4 count 212 cells/μl). We found no difference between groups in return to care by 12 months (RD: -6.8%; 95% CI: -17.7% to 4.8%). During the study period, control sites continued to use tracing within standard care, however, potentially masking intervention effects., Conclusions: Enhanced adherence counselling showed no benefit over 12 months. Implementation of the tracing intervention under the new guidelines was similar to the standard of care. Interventions that aim to return unstable patients to care should incorporate active monitoring to determine if the interventions are effective., (© 2018 John Wiley & Sons Ltd.)
- Published
- 2018
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26. Understanding health worker data use in a South African antiretroviral therapy register.
- Author
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Jobson G, Murphy J, van Huyssteen M, Myburgh H, Hurter T, Grobbelaar CJ, Struthers HE, McIntyre JA, and Peters RPH
- Subjects
- Adult, Black People, Female, Humans, Male, Middle Aged, Qualitative Research, South Africa, Anti-HIV Agents therapeutic use, Data Accuracy, HIV Infections diagnosis, HIV Infections drug therapy, Health Personnel statistics & numerical data, Information Literacy, Registries
- Abstract
Objective: To evaluate how electronic data management systems affect data use practices in antiretroviral therapy (ART) programs within local health districts, and individual health facilities., Methods: We used a data quality audit to establish a baseline of the quality of data in the electronic register alongside in-depth interviews with health workers and managers, to understand perceptions of data quality, data use by facility staff and challenges affecting data use., Results: The findings provide a four-level continuum of data use that can be applied to other settings and recommendations for optimising facility-level data use., Conclusion: By defining four levels of data use our findings suggest the potential to encourage a structured process of moving from passive data use, to more active and engaged data use, where data could be used to anticipate patient behaviour and link that behaviour to differentiated care plans., (© 2018 John Wiley & Sons Ltd.)
- Published
- 2018
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27. Coronary sinus morphology in pediatric patients with supraventricular tachycardia.
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Ambrose MB, Avari Silva JN, Rudokas M, Bowman TM, Murphy J, and Van Hare GF
- Subjects
- Academic Medical Centers, Adolescent, Age Factors, Catheter Ablation mortality, Chi-Square Distribution, Child, Cohort Studies, Coronary Sinus diagnostic imaging, Coronary Sinus surgery, Electrophysiology, Female, Follow-Up Studies, Heart Conduction System pathology, Humans, Male, Pediatrics, Prospective Studies, Recurrence, Risk Assessment, Sex Factors, Survival Rate, Tachycardia, Atrioventricular Nodal Reentry diagnostic imaging, Tachycardia, Supraventricular diagnostic imaging, Tachycardia, Supraventricular surgery, Treatment Outcome, Catheter Ablation methods, Coronary Sinus anatomy & histology, Heart Conduction System surgery, Tachycardia, Atrioventricular Nodal Reentry surgery
- Abstract
Purpose: The anatomic basis of atrioventricular node reentrant tachycardia (AVNRT) remains incompletely characterized in children. Differences in coronary sinus (CS) size and morphology have been observed in adults with AVNRT but have not been well characterized in children., Methods: Children (< 18 years) brought to the EP lab with supraventricular tachycardia for ablation underwent CS venography. A blinded pediatric interventional cardiologist performed CS measurements, which were indexed to body surface area. Patients were excluded if they were < 25 kg or had significant congenital heart disease., Results: Forty-six patients (age 14.2 ± 3.3 years) met inclusion criteria, 17 with AVNRT and 32 with an accessory pathway (AP). CS ostium (LAO projection, end-systole) was 7.8 ± 2.9 mm/m
2 for the AVNRT group versus 6.0 ± 2.5 mm/m2 for the AP group (p = 0.04). CS "windsock" morphology was more prevalent in the AVNRT group (16/17, 94.1%) than the AP group (11/32, 34.3%) (p < 0.001). Within the AVNRT group, there was no correlation between CS ostium size and tachycardia cycle length (R = 0.01, p = 0.96), fast-pathway ERP (FPERP) (R = 0.42, p = 0.12), or A2-H2 at the FPERP (R = 0.25, p = 0.39)., Conclusions: Children with AVNRT have larger CS ostia and more prevalent windsock morphology. CS size/morphology did not correlate with EP properties of the AVNRT substrate. These features may explain the basis for the development of the electrophysiologic substrate for dual AV node physiology in children.- Published
- 2018
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28. Assessing the impact of the National Department of Health's National Adherence Guidelines for Chronic Diseases in South Africa using routinely collected data: a cluster-randomised evaluation.
- Author
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Fox MP, Pascoe SJ, Huber AN, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, and Fraser-Hurt N
- Subjects
- Chronic Disease therapy, Data Collection methods, Humans, Research Design, South Africa, Anti-HIV Agents therapeutic use, Guideline Adherence, HIV Infections drug therapy
- Abstract
Introduction: In 2016, South Africa's National Department of Health (NDOH) launched the National Adherence Guidelines for Chronic Diseases for phased implementation throughout South Africa. Early implementation of a 'minimum package' of eight interventions in the Adherence Guidelines for patients with HIV is being undertaken at 12 primary health clinics and community health centres in four provinces. NDOH and its partners are evaluating the impact of five of the interventions in four provinces in South Africa., Methods and Analysis: The minimum package is being delivered at the 12 health facilities under NDOH guidance and through local health authorities. The five evaluation interventions are: (1) fast track initiation counselling for patients eligible for antiretroviral therapy (ART); (2) adherence clubs for stable ART patients; (3) decentralised medication delivery for stable ART patients; (4) enhanced adherence counselling for unstable ART patients; and (5) early tracing of patients who miss an appointment by ≥5 days. For evaluation, NDOH matched the 12 intervention clinics with 12 comparison clinics and randomly allocated one member of each pair to intervention or comparison (standard of care) status within pairs, allowing evaluation of the interventions using a matched cluster-randomised design. The evaluation uses data routinely collected by the clinics, with no study interaction with subjects to prevent influencing the primary outcomes. Enrolment began on 20 June 2016 and was completed on 16 December 2016. A total of 3456 patients were enrolled and will now be followed for 14 months to estimate effects on short-term and final outcomes. Primary outcomes include viral suppression, retention and medication pickups, evaluated at two time points during follow-up., Ethics and Dissemination: The study received approval from the University of Witwatersrand Human Research Ethics Committee and Boston University Institutional Review Board. Results will be presented to key stakeholders and at international conferences and published in peer-reviewed journals., Trial Registration Number: NCT02536768; Pre-results., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)
- Published
- 2018
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29. Can the Pulmonary Artery Wedge Pressure be Used Reliably as a Surrogate for the Left Atrial Mean Pressure in Pre-Fontan Evaluation?
- Author
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Mohammad Nijres B, Abdulla RI, Awad S, and Murphy J
- Subjects
- Adolescent, Biomarkers, Cardiac Catheterization methods, Child, Child, Preschool, Female, Heart Ventricles physiopathology, Humans, Hypoplastic Left Heart Syndrome surgery, Infant, Male, Pulmonary Artery physiopathology, Pulmonary Artery surgery, Retrospective Studies, Young Adult, Atrial Pressure physiology, Heart Atria physiopathology, Hypoplastic Left Heart Syndrome physiopathology, Pulmonary Wedge Pressure physiology, Vascular Resistance physiology
- Abstract
The correlation between mean pulmonary artery wedge pressure (PAWP) and left atrial mean pressure (LAMP) has been poorly studied in patients with single ventricle (SV) physiology (Bernstein et al. in Pediatr Cardiol 33: 15-20 2012). The aim of this study is to determine if the PAWP can be used safely as a surrogate to the LAMP to calculate the pulmonary vascular resistance (PVR) during the pre-Fontan evaluation. Also, we aimed to understand if the presence of significant systemic-to-pulmonary collaterals (SPCs) is a confounding factor for accurate estimation of the LAMP. From February 2007 to February 2017, forty-one patients were eligible for inclusion in the study. These patients were varied in terms of underlying cardiac malformation. Sex distribution was equal with 20 males and 21 females. Median weight was 11.8 kg, median body surface area was 0.51 m
2 , median age at catheterization was 2 years, and the median age at Glenn surgery was 5 months. We found the left and right PAWP and LAMP correlated strongly and the differences in the measurements were negligible. Similar findings were observed when calculating PVRs using PAWP and LAMP. These findings were more pronounced in the absence of significant SPCs. PAWP and LAMP correlation was still valid in the presence of significant SPCs; however, the correlation among the calculated PVRs was more attenuated.- Published
- 2017
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30. Pulmonary Artery Acceleration Time Provides a Reliable Estimate of Invasive Pulmonary Hemodynamics in Children.
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Levy PT, Patel MD, Groh G, Choudhry S, Murphy J, Holland MR, Hamvas A, Grady MR, and Singh GK
- Subjects
- Acceleration, Child, Child, Preschool, Female, Humans, Image Interpretation, Computer-Assisted methods, Infant, Male, Reproducibility of Results, Sensitivity and Specificity, Vascular Resistance physiology, Blood Flow Velocity physiology, Blood Pressure Determination methods, Echocardiography, Doppler methods, Pulmonary Artery diagnostic imaging, Pulmonary Artery physiology, Pulmonary Circulation physiology, Pulmonary Wedge Pressure physiology
- Abstract
Background: Pulmonary artery acceleration time (PAAT) is a noninvasive method to assess pulmonary hemodynamics, but it lacks validity in children. The aim of this study was to evaluate the accuracy of Doppler echocardiography-derived PAAT in predicting right heart catheterization (RHC)-derived pulmonary artery pressure (PAP), pulmonary vascular resistance (PVR), and compliance in children., Methods: Prospectively acquired and retrospectively measured Doppler echocardiography-derived PAAT and RHC-derived systolic PAP, mean PAP (mPAP), indexed PVR (PVRi), and compliance were compared using regression analysis in a derivation cohort of 75 children (median age, 5.3 years; interquartile range, 1.3-12.6 years) with wide ranges of pulmonary hemodynamics. To account for heart rate variability, PAAT was adjusted for right ventricular ejection time and corrected by the RR interval. Regression equations incorporating PAAT and PAAT/right ventricular ejection time from the derivation cohort were then evaluated for the accuracy of their predictive values for invasive pulmonary hemodynamics in a validation cohort of 50 age- and weight-matched children with elevated PAP and PVR., Results: There were significant inverse correlations between PAAT and RHC-derived mPAP (r = -0.82) and PVRi (r = -0.78) and a direct correlation (r = 0.78) between PAAT and pulmonary compliance in the derivation cohort. For detection of pulmonary hypertension (PRVi > 3 Wood units · m
2 and mPAP > 25 mm Hg), PAAT < 90 msec and PAAT/right ventricular ejection time < 0.31 resulted in sensitivity of 97% and specificity of 95%. In the derivation cohort, the regression equations relating PAAT with mPAP and PVRi were mPAP = 48 - 0.28 × PAAT and PVRi = 9 - 0.07 × PAAT. These PAAT-integrated equations predicted RHC-measured pulmonary hemodynamics in the validation cohort with good correlations (r = 0.88 and r = 0.83, respectively), small biases (<10%), and minimal coefficients of variation (<8%)., Conclusions: PAAT inversely correlates with RHC-measured pulmonary hemodynamics and directly correlates with pulmonary arterial compliance in children. The study established PAAT-based regression equations in children to accurately predict RHC-derived PAP and PVR., (Copyright © 2016 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)- Published
- 2016
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31. Percutaneous carotid artery access in infants < 3 months of age.
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Choudhry S, Balzer D, Murphy J, Nicolas R, and Shahanavaz S
- Subjects
- Age Factors, Angioplasty, Balloon, Balloon Valvuloplasty, Blalock-Taussig Procedure, Cardiac Catheterization adverse effects, Cardiac Catheterization instrumentation, Cardiac Catheters, Catheterization, Peripheral adverse effects, Catheterization, Peripheral instrumentation, Female, Heart Defects, Congenital diagnosis, Humans, Infant, Infant, Newborn, Male, Punctures, Retrospective Studies, Stents, Treatment Outcome, Vascular Patency, Cardiac Catheterization methods, Carotid Arteries diagnostic imaging, Carotid Arteries physiopathology, Catheterization, Peripheral methods, Heart Defects, Congenital therapy
- Abstract
Background: Carotid artery access in infants with congenital heart disease undergoing cardiac catheterization via a surgical cut down has been well described. There is a paucity of information regarding percutaneous carotid artery (CA) access in infants <3 months., Methods: A retrospective review of infants <3 months of age undergoing cardiac catheterization via percutaneous CA approach was performed after IRB approval. Between January 2012 and May 2015, 18 patients underwent 20 procedures; median age 13 days (2-77); median weight 3.3 kg (1.6-5). Procedures performed were patent ductus arteriosus (PDA) stenting (8), modified blalock taussig (BT) shunt stenting (3), balloon aortic valvuloplasty (6), and balloon angioplasty of coarctation (3)., Results: Percutaneous access was obtained with a Doppler needle under ultrasound guidance into the right (16) and left CA (4). Sheath size used was 4 Fr (17), 5 Fr (2), and 6 Fr (1). Median time to sheath insertion was 6.5 min (2-20). Percutaneous access was obtained successfully in all cases. There were no major procedural complications. There were two minor complications; hypotension, and ductal spasm. Hemostasis was achieved by manual compression; median time was 14.5 min (8-36). There were two post-procedural complications involving development of CA pseudo aneurysms that were repaired surgically. Post-procedure CA patency was documented by angiography (3), MRA (3), or vascular ultrasound (14). There were no documented arterial occlusions., Conclusion: Our experience suggests that percutaneous CA access in infants <3 months of age is safe and feasible with preserved vascular patency and no neurological adverse events., (© 2015 Wiley Periodicals, Inc.)
- Published
- 2016
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32. Practice Variation in Single-Ventricle Patients Undergoing Elective Cardiac Catheterization: A Report from the Congenital Cardiac Catheterization Project on Outcomes (C3PO).
- Author
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Goldstein BH, Holzer RJ, Trucco SM, Porras D, Murphy J, Foerster SR, El-Said HG, Beekman RH 3rd, and Bergersen L
- Subjects
- Adolescent, Child, Child, Preschool, Female, Follow-Up Studies, Heart Defects, Congenital physiopathology, Heart Defects, Congenital surgery, Heart Ventricles surgery, Humans, Infant, Male, Prospective Studies, Time Factors, Treatment Outcome, Cardiac Catheterization methods, Elective Surgical Procedures methods, Fontan Procedure methods, Heart Defects, Congenital diagnosis, Heart Ventricles abnormalities, Hemodynamics physiology, Registries
- Abstract
Objective: The objective of this study was to investigate variation in practice surrounding elective cardiac catheterization in patients with single-ventricle (SV) congenital heart disease., Design: Patient and procedural characteristics and outcomes during SV catheterization were collected prospectively from eight centers using a web-based registry (Congenital Cardiac Catheterization Project on Outcomes). We attempted to identify a population of elective procedures by limiting the cohort in case type and timing. Cases were then stratified by stage of SV palliation (pre-bidirectional cavopulmonary anastomosis [pre-BCPA], pre-Fontan and post-Fontan) and limited by age. Subcohort analysis was performed by mode of airway management (assisted vs. spontaneous ventilation). Institutional variation was assessed., Results: Between 2/2007 and 6/2010, 1459 (10.1%) of 14 467 cases in the registry met the inclusion and exclusion criteria, including 326 pre-BCPA, 571 pre-Fontan and 562 post-Fontan procedures. Median patient age was 0.4 (interquartile range 0.3, 0.5), 2.6 (1.0, 3.4) and 9.6 (5.2, 15.4) years and weight was 5.6 (4.8, 6.4), 12.2 (10.5, 14), and 26.3 (16.6, 51.8) kg in the pre-BCPA, pre-Fontan and post-Fontan cohorts, respectively. Cases were more commonly diagnostic in the pre-BCPA cohort (57%) whereas they were more commonly interventional in the pre-Fontan (69%) and post-Fontan (77%) cohorts. At least one adverse event (AE) occurred in 210 cases (14.4%) overall, including 20% of pre-BCPA, 11% of pre-Fontan and 14% of post-Fontan catheterizations. Mode of airway management was associated with statistically significant, but clinically small differences in hemodynamic measures in the pre- and post-Fontan cohorts, but not in the pre-BCPA group. Considerable practice variation exists across centers with variability in airway management, AE rate, case type, interventions performed and fluoroscopy time, in all SV cohorts., Conclusions: Elective catheterization in SV patients, frequently performed with intervention, is common among US congenital cardiac centers. However, important variation in practice exists during these procedures in SV patients, at all stages of palliation., (© 2015 Wiley Periodicals, Inc.)
- Published
- 2016
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33. Balloon valvuloplasty for congenital aortic stenosis: Multi-center safety and efficacy outcome assessment.
- Author
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Torres A, Vincent JA, Everett A, Lim S, Foerster SR, Marshall AC, Beekman RH 3rd, Murphy J, Trucco SM, Gauvreau K, Holzer R, Bergersen L, and Porras D
- Subjects
- Adolescent, Adult, Aortic Valve Stenosis congenital, Aortic Valve Stenosis diagnosis, Aortic Valve Stenosis physiopathology, Chi-Square Distribution, Child, Child, Preschool, Female, Hemodynamics, Humans, Infant, Infant, Newborn, Logistic Models, Male, Odds Ratio, Prospective Studies, Recovery of Function, Registries, Risk Factors, Severity of Illness Index, Time Factors, Treatment Outcome, United States, Young Adult, Aortic Valve physiopathology, Aortic Valve Stenosis therapy, Balloon Valvuloplasty adverse effects
- Abstract
Objective: To describe contemporary outcomes of balloon aortic valvuloplasty (BAVP) performed in 22 US centers., Background: BAVP constitutes first-line therapy for congenital aortic stenosis (cAS) in many centers., Methods: We used prospectively-collected data from two active, multi-institutional, pediatric cardiac catheterization registries. Acute procedural success was defined, for purposes of this review, as a residual peak systolic gradient≤35 mm Hg and no more than mild aortic regurgitation (AR) for patients with isolated cAS. For patients with mixed aortic valve disease, a residual peak systolic gradient≤35 mm Hg without worsening of AR was considered successful outcome., Results: In 373 patients with a median age of 8 months (1 day to 40 years of age) peak systolic gradient had a median of 59 [50, 71] mm Hg pre-BAVP and 22 [15, 30] mm Hg post-BAVP (P<0.001). Procedural success was achieved in 160 patients (71%). The factors independently associated with procedural success were: first time intervention (OR=2.0 (1.0, 4.0) P=0.04), not-prostaglandin dependent, (OR=3.5 (1.5, 8.1); P=0.003), and isolated cAS (absence of AR) (OR=2.1 (1.1-3.9); P=0.03). Twenty percent of patients experienced adverse events, half of which were of high severity. There was no procedural mortality. Neonatal status was the only factor associated with increased risk of high severity adverse events (OR 3.7; 95% CI 1.5-9.0)., Conclusion: In the current era, BAVP results in procedural success (gradient reduction with minimal increase in AR) in 71% of patients treated at US centers where BAVP is considered first-line therapy relative to surgery., (© 2015 Wiley Periodicals, Inc.)
- Published
- 2015
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34. Case Report: Percutaneous Closure of an Ascending Aortic Pseudoaneurysm by 3D Angiography Guidance.
- Author
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Lin CH, Murphy J, and Balzer DT
- Subjects
- Aneurysm, False diagnostic imaging, Aortic Aneurysm diagnostic imaging, Child, Female, Humans, Prosthesis Design, Septal Occluder Device, Treatment Outcome, Aneurysm, False therapy, Aortic Aneurysm therapy, Aortography methods, Endovascular Procedures instrumentation, Imaging, Three-Dimensional, Radiographic Image Interpretation, Computer-Assisted, Radiography, Interventional methods
- Published
- 2015
- Full Text
- View/download PDF
35. Patient factors to target for elimination of mother-to-child transmission of HIV.
- Author
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Mnyani CN, Simango A, Murphy J, Chersich M, and McIntyre JA
- Subjects
- Adult, Case-Control Studies, Female, Health Knowledge, Attitudes, Practice, Humans, Infant, Maternal Health Services, Mothers, Pre-Exposure Prophylaxis, Pregnancy, Pregnancy, Unplanned, Risk Factors, Socioeconomic Factors, South Africa, Anti-Retroviral Agents administration & dosage, HIV Infections transmission, Infectious Disease Transmission, Vertical prevention & control, Pregnancy Complications, Infectious prevention & control, Prenatal Care
- Abstract
Background: There is great impetus to achieve elimination of mother-to-child transmission of HIV (eMTCT) by 2015, and part of this is to identify factors to target to achieve the goal. This study thus identified key patient factors for MTCT in a high HIV prevalence setting in Johannesburg, South Africa. Between November 2010 and May 2012, we conducted a case-control study among HIV-infected women with HIV-infected (cases) and uninfected (controls) infants diagnosed around six weeks of age as part of routine, early infant diagnosis. Mothers and infants were identified through registers in six healthcare facilities that provide antenatal, postpartum and HIV care. Structured interviews were conducted with a focus on history of HIV infection, antenatal, intrapartum and immediate postpartum management of the mother-infant pair. Patient-related risk factors for MTCT were identified., Results: A total of 77 women with HIV-infected infants and 154 with -uninfected infants were interviewed. Among HIV-infected cases, 13.0% of the women knew their HIV status prior to conception, and 83.1% reported their pregnancies as unplanned. Antenatal antiretroviral coverage was high in the control group - only 1/154 (0.7%) reported receiving no prophylaxis or treatment compared with 17/74 (22.9%) of cases. In multivariate analysis, key patient-related risks for HIV transmission were: unknown HIV status prior to conception (adjusted odds ratio [AOR] = 6.6; 95% CI = 2.4 - 18.4; p < 0.001); accessing antenatal care after 20 weeks gestation (AOR = 4.3; 95% CI = 2.0 - 9.3; p < 0.001); less than 12 years of formal education (AOR = 3.4; 95% CI = 1.6 - 7.5; p = 0.002); and unplanned pregnancy (AOR = 2.7; 95% CI = 1.2 to 6.3; p = 0.022). Mean age at first HIV test was 6.6 weeks (SD = 3.5) for infants who were diagnosed as HIV-infected, and the mean age at antiretroviral treatment initiation was 10.8 weeks (SD = 4.4). HIV-uninfected infants were diagnosed at a mean age of 6.0 weeks (SD = 0.2)., Conclusions: Undiagnosed maternal HIV infection prior to conception, unplanned pregnancies, delays in accessing antenatal care, and low levels of education were the most significant patient risk factors associated with MTCT. While the emphasis has been on increasing availability and coverage of efficacious antiretroviral regimens, and strengthening health systems within eMTCT initiatives, there is a need to also address patient-related factors if we are to achieve eMTCT goals.
- Published
- 2014
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36. Balloon angioplasty and stenting of branch pulmonary arteries: adverse events and procedural characteristics: results of a multi-institutional registry.
- Author
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Holzer RJ, Gauvreau K, Kreutzer J, Leahy R, Murphy J, Lock JE, Cheatham JP, and Bergersen L
- Subjects
- Adolescent, Adult, Aged, Angioplasty, Balloon methods, Cardiac Catheterization, Child, Child, Preschool, Humans, Infant, Infant, Newborn, Middle Aged, Prospective Studies, Registries, Angioplasty, Balloon adverse effects, Heart Defects, Congenital therapy, Pulmonary Artery, Stents adverse effects
- Abstract
Background: Pulmonary artery (PA) balloon angioplasty and/or stenting (PA rehabilitation) is one of the most common procedures performed in the cardiac catheterization laboratory, but comprehensive and consistently reported data on procedure-related adverse events (AE) are scarce., Methods and Results: Data were prospectively collected using a multicenter registry (Congenital Cardiac Catheterization Project on Outcomes). All cases that included balloon angioplasty and/or stent implantation in a proximal or lobar PA position were included. Multivariate analysis was used to evaluate for independent predictors of AE and need for early reintervention. Between February 2007 and December 2009, 8 institutions submitted details on 1315 procedures with a PA intervention. An AE was documented in 22% with a high severity (level 3 to 5) AE in 10% of cases. Types of AE included vascular/cardiac trauma (19%), technical AE (15%), arrhythmias (15%), hemodynamic AE (14%), bleeding via endotracheal tube/reperfusion injury (12%), and other AE (24%). AE were classified as not preventable in 50%, possibly preventable in 41%, and preventable in 9%. By multivariate analysis, independent risk factors for level 3 to 5 AE were presence of ≥2 indicators of hemodynamic vulnerability, age below 1 month, use of cutting balloons, and operator experience of <10 years. Reintervention during the study period occurred in 22% of patients undergoing PA rehabilitation., Conclusions: PA rehabilitation is associated with a 10% incidence of high-level severity AE. Hemodynamic vulnerability, young age, use of cutting balloons, and lower operator experience were significant independent risk factors for procedure-related AE.
- Published
- 2011
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37. Motorcyclist "biker couples": a descriptive analysis of orthopaedic and non-orthopaedic injuries.
- Author
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Murphy J, Nyland J, Lantry J, and Roberts C
- Subjects
- Accidents, Traffic mortality, Adolescent, Adult, Alcohol Drinking blood, Family Characteristics, Female, Fractures, Bone epidemiology, Head Protective Devices statistics & numerical data, Humans, Length of Stay, Male, Middle Aged, Multiple Trauma epidemiology, Retrospective Studies, Trauma Severity Indices, Young Adult, Accidents, Traffic statistics & numerical data, Motorcycles statistics & numerical data, Registries, Wounds and Injuries epidemiology
- Abstract
The term "biker couple" is becoming an increasingly common site in emergency departments. The purpose of this study was to identify orthopaedic and non-orthopaedic injury patterns among this unique patient group. A 14-year (1993-2006) retrospective review of a Level I Trauma Institute Registry was performed. Patient demographic and injury data were obtained from 21 confirmed biker couples (n=42). Nineteen of 21 biker couple pairs (90.5%) included a male driver and a female passenger. Drivers were more likely to have a positive blood alcohol concentration/toxicology test. Drivers had a greater incidence of scapular and rib fractures than passengers. Both drivers and passengers who sustained scapular fractures had a greater incidence of clavicle, rib, pelvis, and fibula fractures. Drivers with scapular fractures had a greater incidence of thoracic spine fractures, while passengers with scapular fractures had a greater incidence of arm-forearm-wrist-hand, femur, tibia, and foot-ankle fractures. Overall, biker couple drivers and passengers did not differ for head injury, pulmonary system, road rash, aortic injury or visceral injury. Both drivers and passengers with scapular fractures had a greater incidence of head injuries, and passengers had a greater incidence of pulmonary system, visceral injury and road rash. Both drivers and passengers who were not wearing a helmet had a greater incidence of head injuries. Unhelmeted drivers were more likely to sustain head injury than passengers. When a scapular fracture was present both drivers and passengers had a greater incidence of head injuries. Prospective investigations are needed to better delineate the precise mechanisms for these injury patterns.
- Published
- 2009
- Full Text
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38. Results of exercise stress testing in patients with diffuse pulmonary arteriovenous malformations.
- Author
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Murphy J, Pierucci P, Chyun D, Henderson KJ, Pollak J, White RI Jr, and Fahey J
- Subjects
- Adolescent, Adult, Analysis of Variance, Angiography, Arteriovenous Malformations diagnostic imaging, Child, Child, Preschool, Female, Humans, Male, Middle Aged, Oxygen blood, Pulmonary Artery diagnostic imaging, Pulmonary Veins diagnostic imaging, Retrospective Studies, Tomography, X-Ray Computed, Arteriovenous Malformations physiopathology, Exercise Test methods, Pulmonary Artery abnormalities, Pulmonary Veins abnormalities
- Abstract
Patients with diffuse pulmonary arteriovenous malformations (PAVMs) are subject to frequent complications and need to be followed closely. As part of this follow-up, we have employed exercise stress testing (EST) as an aid to assess their status. Twenty patients from a cohort of 35 with diffuse PAVMs have undergone EST using a standard cycle ergometer test. All patients had previously undergone pulmonary angiography, noncontrast chest computed tomography (CT), and repair of large focal PAVMs, prior to EST. Mean room air oxygen saturation at baseline and at maximum exercise (85% of maximum heart rate) were tabulated. Serial studies in six children and young adults were plotted by year and compared using the patient as their own control. Fourteen females and six males ranging in age from 4 to 50 years (mean 22 years) were studied. Baseline mean oxygen saturation was 84% and fell to 73% at maximum exercise. There was no significant difference between those with unilateral and bilateral involvement (P = 0.09). In four of the six patients with serial EST, the baseline and exercise oxygen saturations were quite stable. In the two patients who became symptomatic, with age, growth, and more activity, complete embolization of one or more segments of the lung improved their EST and functionality. Based on our previous work in patients with diffuse PAVMs, EST appears to offer a relatively safe and noninvasive method for assessing these patients. Our limited experience with serial EST suggests a good correlation with decreased functionality in these patients.
- Published
- 2009
- Full Text
- View/download PDF
39. Anterior transposition of the radial nerve--a cadaveric study.
- Author
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Yakkanti MR, Roberts CS, Murphy J, and Acland RD
- Subjects
- Aged, Aged, 80 and over, Cadaver, Female, Humans, In Vitro Techniques, Male, Bone Plates, Fracture Fixation, Internal instrumentation, Fracture Fixation, Internal methods, Humeral Fractures surgery, Radial Nerve surgery
- Abstract
Objective: The radial nerve is at risk during the posterior plating of the humerus. The purpose of this anatomic study was to assess the extent of radial nerve dissection required for anterior transposition through the fracture site (transfracture anterior transposition)., Methods: A cadaver study was conducted approaching the humerus by a posterior midline incision. The extent of dissection of the nerve necessary for plate fixation of the humerus fracture was measured. An osteotomy was created to model a humeral shaft fracture at the spiral groove (OTA classification 12-A2, 12-A3). The radial nerve was then transposed anterior to the humeral shaft through the fracture site. The additional dissection of the radial nerve and the extent of release of soft tissue from the humerus shaft to achieve the transposition were measured., Results: Plating required a dissection of the radial nerve 1.78 cm proximal and 2.13 cm distal to the spiral groove. Transfracture anterior transposition of the radial nerve required an average dissection of 2.24 cm proximal and 2.68 cm distal to the spiral groove. The lateral intermuscular septum had to be released for 2.21 cm on the distal fragment to maintain laxity of the transposed nerve., Conclusions: Transfracture anterior transposition of the radial nerve before plating is feasible with dissection proximal and distal to the spiral groove and elevation of the lateral intermuscular septum. Potential clinical advantages of this technique include enhanced fracture site visualization, application of broader plates, and protection of the radial nerve during the internal fixation.
- Published
- 2008
- Full Text
- View/download PDF
40. New definition and natural history of patients with diffuse pulmonary arteriovenous malformations: twenty-seven-year experience.
- Author
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Pierucci P, Murphy J, Henderson KJ, Chyun DA, and White RI Jr
- Subjects
- Adolescent, Adult, Aged, Angiography, Arteriovenous Malformations diagnosis, Arteriovenous Malformations therapy, Cardiac Catheterization, Child, Child, Preschool, Female, Follow-Up Studies, Humans, Infant, Male, Middle Aged, Morbidity trends, Prognosis, Pulmonary Artery diagnostic imaging, Pulmonary Veins diagnostic imaging, Retrospective Studies, Survival Rate trends, Arteriovenous Malformations epidemiology, Embolization, Therapeutic methods, Pulmonary Artery abnormalities, Pulmonary Veins abnormalities
- Abstract
Background: Patients with diffuse pulmonary arteriovenous malformations (PAVM), a small but important subset of the PAVM population, have significant morbidity and mortality rates., Methods: Thirty-six patients (21 female and 15 male) with diffuse PAVM from a cohort of 821 consecutive patients with PAVM were evaluated. Diffuse PAVM were categorized angiographically: involvement of one or more segmental pulmonary arteries in one or both lungs. Hereditary hemorrhagic telangiectasia (HHT) status, gender, presence or absence of large (> or = 3-mm diameter artery) focal PAVM, oxygen saturations, complications including hemoptysis, years of follow-up, and survival were tabulated., Results: HHT was present in 29 of 36 patients (81%), and diffuse PAVM were more commonly bilateral (26 of 36 patients, 72%) than unilateral (10 of 36 patients, 28%) [p = 0.02]. Female gender was associated with bilateral diffuse PAVM (19 of 26 patients, 73%) [p = 0.01]. Focal PAVM were present in both groups but more commonly in patients with bilateral involvement (16 of 26 patients, 62%) [p = 0.02]. Initial oxygen saturations (pulse oximetry, standing) of patients with unilateral and bilateral diffuse PAVM were 87 +/- 7% and 79 +/- 8% (mean +/- SD), respectively (p = 0.02). The last or current values for patients with unilateral and bilateral involvement are 95 +/- 3% and 85 +/- 7%, respectively (p < 0.0001). Nine deaths occurred, and all were in patients with bilateral involvement. Deaths were due to hemoptysis of bronchial artery origin (n = 2), hemorrhage from duodenal ulcer (n = 1), spontaneous liver necrosis (n = 3), brain hemorrhage (n = 1), brain abscess (n = 1), and operative death during attempted lung transplant (n = 1)., Conclusions: Patients with diffuse PAVM are a high-risk group, and yearly follow-up is recommended.
- Published
- 2008
- Full Text
- View/download PDF
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