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BACKGROUND: In colorectal surgery, indications for incisional negative pressure wound therapy (iVAC) remain unclear. We sought to compare rates of surgical site infection (SSI) in patients who received iVAC or standard sterile dressing (SSD). METHODS: Institutional colorectal NSQIP data between 2014 and 2018 was reviewed. SSI rates were compared between iVAC and SSD cohorts using the NSQIP surgical risk calculator (NSQIP SRC) for risk-adjusted analysis. Secondary outcomes included other wound complications, morbidity, mortality, disposition destination and overall length of stay. RESULTS: 145 patients received iVAC while 544 received SSD. SSI was greater in iVAC than SSD (17% vs 9%, p = 0.009). iVAC was independently associated with SSI (OR 2.3, 95% CI 1.3-3.9). The presence of a colostomy strengthened this relationship. There was no difference in secondary outcomes. CONCLUSION: iVAC was independently associated with SSI with risk-adjusted analysis. This relationship was stronger in patients with a colostomy.

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[This corrects the article DOI: 10.1186/s13223-016-0110-8.].

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BACKGROUND: Food allergy is the most common cause of anaphylaxis in children. Intramuscular delivery of epinephrine auto-injectors (EAI) is the standard of care for the treatment of anaphylaxis. We examined if children and adolescents at risk of anaphylaxis weighing 15-30 kg and >30 kg would receive epinephrine into the intramuscular space with the currently available EAI in North America and Europe. METHODS: The distance from skin to muscle (STMD) and skin to bone (STBD) on the mid third anterolateral area of the right thigh was measured by ultrasound applying either high pressure (max) or slight pressure (min) in 102 children weighing 15-30 kg (group 1) and 100 children and adolescents, weighing more than 30 kg (group 2). RESULTS: Using a high pressure EAI (HPEAI), Epipen Jr(®) and Auvi-Q(®)/Allerject(®) 0.15 mg, 11/102 (11 %) children in group 1 and 38/102 (38 %) using another HPEAI, Jext(®), had a STMDmax that showed a risk of intraosseous injection. There was a 1 % risk of subcutaneous injection with these devices. There was no risk of intraosseous injection using a low pressure EAI (LPEAI), Emerade(®). In group 2, the risk of intraosseous injection using a HPEAI was 3 % and no risk using a LPEAI. However, the risk of subcutaneous injection using HPEAI was 9 % and using LPEAI was 2 %. CONCLUSION: There is a risk of intraosseous injection using HPEAI (Epipen(®)/Epipen Jr(®), Auvi-Q(®)/Allerject(®) and especially Jext(®)) in children at risk of anaphylaxis. There was also a risk of subcutaneous injection using the currently available HPEAI in children and adolescents.

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PURPOSE: To determine the efficacy of compressed sensing (CS) reconstructions for specific clinical magnetic resonance neuroimaging applications beyond more conventional acceleration techniques such as parallel imaging (PI) and low-resolution acquisitions. MATERIALS AND METHODS: Raw k-space data were acquired from five healthy volunteers on a 3T scanner using a 32-channel head coil using T2 -FLAIR, FIESTA-C, time of flight (TOF), and spoiled gradient echo (SPGR) sequences. In a series of blinded studies, three radiologists independently evaluated CS, PI (GRAPPA), and low-resolution images at up to 5× accelerations. Synthetic T2 -FLAIR images with artificial lesions were used to assess diagnostic accuracy for CS reconstructions. RESULTS: CS reconstructions were of diagnostically acceptable quality at up to 4× acceleration for T2 -FLAIR and FIESTA-C (average qualitative scores 3.7 and 4.3, respectively, on a 5-point scale at 4× acceleration), and at up to 3× acceleration for TOF and SPGR (average scores 4.0 and 3.7, respectively, at 3× acceleration). The qualitative scores for CS reconstructions were significantly better than low-resolution images for T2 -FLAIR, FIESTA-C, and TOF and significantly better than GRAPPA for TOF and SPGR (Wilcoxon signed rank test, P < 0.05) with no significant difference found otherwise. Diagnostic accuracy was acceptable for both CS and low-resolution images at up to 3× acceleration (area under the ROC curve 0.97 and 0.96, respectively.) CONCLUSION: Mild to moderate accelerations are possible for those sequences by a combined CS and PI reconstruction. Nevertheless, for certain sequences/applications one might mildly reduce the acquisition time by appropriately reducing the imaging resolution rather than the more complicated CS reconstruction. J. Magn. Reson. Imaging 2016;44:433-444.

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Published data on earthquake-associated peripheral nerve injury is very limited. Ultrasonography has been proven to be efficient in the clinic to diagnose peripheral nerve injury. The aim of this study was to assess the role of ultrasound in the evaluation of persistent peripheral nerve injuries 1 year after the Wenchuan earthquake. Thirty-four patients with persistent clinical symptoms and neurologic signs of impaired nerve function were evaluated with sonography prior to surgical repair. Among 34 patients, ultrasonography showed that 48 peripheral nerves were entrapped, and 11 peripheral nerves were disrupted. There was one case of misdiagnosis on ultrasonography. The concordance rate of ultrasonographic findings with those of surgical findings was 98%. A total of 48 involved nerves underwent neurolysis and the symptoms resolved. Only five nerves had scar tissue entrapment. Preoperative and postoperative clinical and ultrasonographic results were concordant, which verified that ultrasonography is useful for preoperative diagnosis and postoperative evaluation of injured peripheral nerves.

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BACKGROUND: The Epipen® Jr and Allerject® 0.15 mg are currently the most commonly prescribed epinephrine auto-injectors (EAIs) for the management of anaphylaxis in pediatric patients in North America and Canada. To ensure rapid absorption, it should be administered intramuscularly into the anterolateral aspect of the thigh. We examined whether the 12.7-mm needle length of the Epipen® Jr and Allerject® 0.15 mg is adequate for delivering epinephrine intramuscularly in pediatric patients who weighed <15 kg. METHODS: Consecutive pediatric patients with food allergy weighing <15 kg who required an EAI were included. Ultrasounds of the mid-anterolateral thigh were performed under minimal (min) and maximal (max) pressure. Skin-to-muscle depth (STMD) and skin-to-bone depth (STBD) measurements were completed. Baseline characteristics were compared between patients with a STBDmax <12.7 mm vs. ≥12.7 mm. Linear regression including variables such as age, sex, body mass index (BMI) and race was performed. The proportion of patients with a STBDmax <12.7 mm was compared in those weighing <10 kg vs. 10-14.9 kg. RESULTS: One hundred patients were included; 29 (29%) had STBDmax <12.7 mm. Height (p = 0.02) and weight (p = 0.0002) differed significantly between the two groups. Approximately 19% of those weighing 10-14.9 kg and 60% of those <10 kg had a STBDmax <12.7 mm. In the multivariable regression analysis, BMI was found to be a significant predictor of STBDmax. CONCLUSIONS: A large proportion of children <15 kg prescribed an EAI is at risk of having the auto-injector administered into bone. Since alternative EAIs with shorter needle lengths are not currently available, EAIs should be prescribed with appropriate counselling in this population.

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BACKGROUND: Epinephrine auto-injectors are the standard first aid treatment for anaphylaxis. Intramuscular delivery into the anterolateral aspect of the thigh is recommended for optimal onset of action of epinephrine. The most frequently prescribed auto-injector in North America and Canada is the EpiPen(®), which has a needle length of 15.2 mm. Currently, it is unknown whether this needle length is adequate for intramuscular delivery of epinephrine in adult patients at risk of anaphylaxis. METHODS: One hundred consecutive adult patients with confirmed food allergy requiring an epinephrine auto-injector were recruited. Skin to muscle depth (STMD) at the right mid-anterolateral thigh was measured using ultrasound under minimal (min) and maximum (max) pressure. The EpiPen(®) needle length was considered adequate if STMDmax was ≤15.2 mm. Baseline characteristics including age, gender, ethnicity, and body mass index (BMI) were compared in patients with STMDmax ≤15.2 mm vs. >15.2 mm. RESULTS: The EpiPen(®) needle length of 15.2 mm was inadequate for intramuscular delivery in 19 of the 100 enrolled patients (19%), all of whom were female; 28% of women had a STMDmax >15.2 mm. The mean STMDmax in the ≤15.2-mm and >15.2-mm groups were 9 ± 4 mm and 20 ± 4 mm, respectively (p = 0.0001). Linear regression analysis found BMI to be significantly associated with STMDmax after adjusting for age (p < 0.001). CONCLUSIONS: The needle length of the epinephrine auto-injectors may not be adequate for intramuscular delivery of epinephrine in a large proportion of women with food allergy; this may impact morbidity and mortality from anaphylaxis in this patient population.

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OBJECTIVE: We developed a semi-automated tool to quantify emphysema from thoracic X-ray multi-detector (64-slice) computed tomography (CT) for training purposes and multi-reader studies. MATERIALS AND METHODS: Thoracic X-ray CT was acquired in 93 ex-smokers, who were evaluated by six trainees with little or no expertise (trainees) and a single experienced thoracic radiologist (expert). A graphic user interface (GUI) was developed for emphysema quantification based on the percentile of lung where a score of 0=no abnormalities, 1=1-25%, 2=26-50%, 3=51-75% and 4=76-100% for each lung side/slice. Trainees blinded to subject characteristics scored randomized images twice; accuracy was determined by comparison to expert scores, density histogram 15th percentile (HU 15), relative area at -950 HU (RA(950)), low attenuation clusters at -950 HU (LAC(950)), -856 HU (LAC(856)) and the diffusing capacity for carbon monoxide (DL(CO%pred)). Intra- and inter-observer reproducibility was evaluated using coefficients-of-variation (COV), intra-class (ICC) and Pearson correlations. RESULTS: Trainee-expert correlations were significant (r=0.85-0.97, p<0.0001) and a significant trainee bias (0.15 ± 0.22) was observed. Emphysema score was correlated with RA(950) (r=0.88, p<0.0001), HU 15 (r=-0.77, p<0.0001), LAC(950) (r=0.76, p<0.0001), LAC(856) (r=0.74, p=0.0001) and DLCO%pred (r=-0.71, p<0.0001). Intra-observer reproducibility (COV=4-27%; ICC=0.75-0.94) was moderate to high for trainees; intra- and inter-observer COV were negatively and non-linearly correlated with emphysema score. CONCLUSION: We developed a GUI for rapid and interactive emphysema scoring that allows for comparison of multiple readers with clinical and radiological standards.

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PURPOSE: To evaluate the relationship between orbital bony geometry and the volume of the intraorbital structures in predicting compressive dysthyroid optic neuropathy (DON). DESIGN: Retrospective, consecutive case series. PARTICIPANTS: Images of 198 orbits from 99 patients suffering from thyroid-related orbitopathy were reviewed. METHODS: Clinical examination and computed tomography of the orbits, including volumetric analysis, were performed on all patients. MAIN OUTCOME MEASURES: Clinical and radiologic predictors of DON. RESULTS: Significant volumetric univariate predictors of compressive optic neuropathy included medial rectus volume (P = 0.005), lateral rectus volume (P = 0.011), superior muscle group volume (P = 0.04), and total rectus muscle volume (P = 0.015). Inferior rectus muscle volume, orbital volume, bony orbital apex angle, globe diameter, and bony medial wall contour were not associated with optic neuropathy. Multivariate modeling found medial rectus volume the only independently significant predictor. Univariate modeling of simple rectus diameter measurements found medial rectus axial diameter (P = 0.003) and total recti diameter (P = 0.016) predictive of optic neuropathy. Lateral rectus, superior rectus, and inferior rectus diameters were not predictive. Multivariate modeling found only medial rectus diameter to be a significant independent predictor of optic neuropathy. The area under the receiver operating characteristic curve was not different between the volumetric and rectus diameter curves. CONCLUSIONS: Medial rectus size was found to be the most important quantifiable predictor of compressive optic neuropathy in patients with optic neuropathy. In this study, simple maximum medial rectus diameter, as measured on axial scans, was equally predictive of compressive optic neuropathy as the more involved volumetric calculation. Assessment of orbital geometry, including bowing of the medial wall, orbital apex angle, globe diameter, and orbital volume, were not found to be predictive of DON.

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OBJECTIVE: To evaluate the ability to predict the presence of dysthyroid optic neuropathy (DON) using computed tomography assessment of soft-tissue and clinical features. STUDY DESIGN: A retrospective consecutive case series of patients with thyroid-related orbitopathy. RESULTS: One hundred eighty-nine orbits from 99 patients were evaluated. Statistically significant clinical predictors of DON on univariate analysis included a difference in intraocular pressure from primary gaze to upgaze (P = .02), the presence of lagophthalmos (P = .04), and inflammation as measured by the VISA (vision, inflammation, strabismus, appearance/exposure) inflammatory scale (P = .004). Dysthyroid optic neuropathy was inversely related to the marginal reflex distance (P = .01), levator function (P = .02), total ductions (P = .003), and interpalpebral fissure (P = .04). Statistically significant radiologic predictors determined on univariate analysis included apical crowding (P < .001), presence of enlarged tendons (P = .004), increasing total rectus diameter (P = .02), and presence of small, low densities within the recti muscles (P = .04). Multivariate analysis found only total ductions (P = .02) and marginal reflex distance (P = .04) determined on clinical examination and apical crowding shown on computed tomography (P = .003) to be significantly associated with DON. Receiver operating characteristic curves were used to evaluate the ability of the clinical and radiologic assessment, as well as the combination of these assessments, to predict DON. All 3 models were strong predictors of DON, with no statistically significant differences in the area under the receiver operating characteristic curve among them (P = .14). CONCLUSIONS: Total ductions, marginal reflex distance, and apical crowding observed on computed tomography scans are able to predict the presence of DON with high sensitivity, specificity, positive predictive value, and negative predictive value. Eyelid ptosis is a novel predictor of DON.

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