Megan S. Orlando

A Decade of Excellent Outcomes after Surgical Intervention in 538 Patients with Thoracic Outlet Syndrome

BACKGROUND Our aim was to evaluate the outcomes of patients who underwent first rib resection (FRR) for all 3 forms of thoracic outlet syndrome (TOS) during a period of 10 years. STUDY DESIGN Patients treated with FRR from August 2003 through July 2013 were retrospectively reviewed using a prospectively maintained database. RESULTS Five hundred and thirty-eight patients underwent 594 FRRs for indications of neurogenic (n = 308 [52%]), venous (n = 261 [44%]), and arterial (n = 25 [4%]) TOS. Fifty-six (9.4%) patients had bilateral FRR. Fifty-two (8.8%) patients had cervical ribs. Three hundred and ninety-eight (67%) FRRs were performed on female patients, with a mean age of 33 years (range 10 to 71 years). Three hundred and forty (57%) were right-sided procedures. Seventy-five children (aged 18 years or younger) underwent FRRs; 25 during the first 5 years and 50 during the second 5 years. When comparing the second 5-year period with the first 5-year period, more patients had venous TOS (48% vs 37%; p < 0.02); fewer patients had neurogenic TOS (48% vs 58%; p < 0.05), and improved or fully resolved symptoms increased from 93% to 96%. Complications included 2 vein injuries, 2 hemothoraces, 4 hematomas, 138 pneumothoraces (23%), and 8 (1.3%) wound infections. Mean length of stay was 1 day. CONCLUSIONS Excellent results were seen in this surgical series of neurogenic, venous, and arterial TOS due to appropriate selection of neurogenic patients, use of a standard protocol for venous patients, and expedient intervention in arterial patients. There is an increasing role for surgical intervention in children.

The Student Curriculum Review Team: How we catalyze curricular changes through a student-centered approach.

Abstract Student feedback is a valuable asset in curriculum evaluation and improvement, but many institutions have faced challenges implementing it in a meaningful way. In this article, we report the rationale, process and impact of the Student Curriculum Review Team (SCRT), a student-led and faculty-supported organization at the Johns Hopkins University School of Medicine. SCRT’s evaluation of each pre-clinical course is composed of a comprehensive three-step process: a review of course evaluation data, a Town Hall Meeting and online survey to generate and assess potential solutions, and a thoughtful discussion with course directors. Over the past two years, SCRT has demonstrated the strength of its approach by playing a substantial role in improving medical education, as reported by students and faculty. Furthermore, SCRT’s uniquely student-centered, collaborative model has strengthened relationships between students and faculty and is one that could be readily adapted to other medical schools or academic institutions.

Lessons Learned in the Surgical Treatment of Neurogenic Thoracic Outlet Syndrome Over 10 Years

Objective: To evaluate our extensive experience over a decade in the treatment of patients with neurogenic thoracic outlet syndrome (NTOS) who underwent first rib resection and scalenectomy (FRRS). Methods: Patients treated with FRRS for NTOS from 2003 to 2013 were retrospectively reviewed using a prospectively maintained database. Results: Over 10 years, 286 patients underwent 308 FRRS. During the first 5-year period, 127 FRRS were performed (96 F, 31 M), with an average age of 36.9 years. During the second 5-year period, 181 FRRS were performed (143 F, 38 M), with an average age of 33 years. A total of 24 children (age ≤18years) underwent FRRS, 9 during the first 5 years and 15 during the second 5 years. When comparing the second 5-year period to the first 5-year period, patients were younger (P = .066), reported a significantly shorter length of preoperative symptoms (35.4 vs 52.1 months, P < .01), prior narcotic use decreased from 31.5% to 23.8% (P < .05), and a history of prior surgical intervention on the ipsilateral side (head, neck, and shoulder) increased from 30.1% to 51.9% (P < .01). Use of lidocaine blocks as a diagnostic tool (57%-35.4%, P = .06) and Botox blocks as a therapeutic tool (29.1%-12.7%, P < .01) decreased in the second 5 years with similar positive results. Improved or fully resolved symptoms following FRRS increased from 89% in the first 5 years to 92.8% in the second 5 years. Average length of follow-up over the 10-year period was 13.4 months. Conclusion: Excellent results were seen in this surgical series reported for NTOS. Younger patients with shorter duration of symptoms with less narcotic use led to even better FRRS results in the second 5 years of surgical intervention. An established vascular practice for referrals for NTOS resulted in an increased number of appropriate patients for surgical intervention, requiring fewer lidocaine and/or Botox injections preoperatively.

Preoperative Duplex Scanning is a Helpful Diagnostic Tool in Neurogenic Thoracic Outlet Syndrome

Objective: To evaluate the diagnostic role of venous and arterial duplex scanning in neurogenic thoracic outlet syndrome (NTOS). Methods: Retrospective review of patients who underwent duplex ultrasonography prior to first rib resection and scalenectomy (FRRS) for NTOS from 2005 to 2013. Abnormal scans included ipsilateral compression (IC) with abduction of the symptomatic extremity (>50% change in subclavian vessel flow), contralateral (asymptomatic side) compression (CC) or bilateral compression (BC). Results: A total of 143 patients (76% female, average age 34, range 13-59) underwent bilateral preoperative duplex scanning. Ipsilateral compression was seen in 44 (31%), CC in 12 (8%), and BC in 14 (10%). Seventy-three (51%) patients demonstrated no compression. Patients with IC more often experienced intraoperative pneumothoraces (49% vs. 25%, P < .05) and had positive Adson tests (86% vs. 61%, P < .02). Conclusion: Compression of the subclavian vein or artery on duplex ultrasonography can assist in NTOS diagnosis. Ipsilateral compression on abduction often correlates with Adson testing.

A predictive model and risk score for unplanned cardiac surgery intensive care unit readmissions

Readmissions or “bounce back” to the intensive care unit (ICU) following cardiac surgery is associated with an increased risk of morbidity and mortality. We sought to identify clinical and system‐based factors associated with ICU bounce backs in order to generate a Bounce Back After Transfer (BATS) prediction score.

Kiosks as tools for health information sharing: exploratory analysis of a novel ED program

It is widely recognized that the demand for emergency services is rising. Emergency Department (ED) utilization increased from 36.9 visits per 100 persons per year in 1995 to 42.8 in 2010.1,2 With increasingly time- and personnel-constrained EDs, self-service kiosks have emerged as one potential solution to perform simple tasks such as registration and information distribution. This process-oriented solution may free up health care providers for more complex duties and is particularly relevant to EDs, whose core mission is to provide emergency care for potentially life-threatening conditions. A non-targeted opt-in rapid oral fluid HIV testing program has been part of standard of care in this ED since 2005.3,4 Recently, we evaluated the feasibility and outcomes of a kiosk approach to testing in order to improve efficiency and reach a greater proportion of patients.5 As part of that quality insurance program evaluation, we included a structured questionnaire on the kiosk to determine patient comfort level with using kiosks to share and update personal health information with ED staff. This report presents a secondary analysis of data.5 Kiosk-facilitated screening involved two stages, a front-end registration kiosk to engage those interested in HIV testing, and a back-end testing kiosk that collected demographic data and provided a single location for testing.5 The front-end kiosk surveyed patients about comfort level with using kiosk technology, measured via a 5-point Likert scale (Figure 1). Level 1 Emergency Severity Index (ESI) patients who were sent directly to treatment rooms and non-ambulatory patients were excluded from the program evaluation, due to inability to use the free-standing kiosks.6 The study was approved by the Johns Hopkins University School of Medicine Institutional Review Board. Figure 1 Between December 2011 and April 2012, 4,351 patients completed the kiosk module. Table 1 summarizes patient demographic and clinical information collected from the electronic medical record. The majority of patients (57%) responded positively to using the kiosk, indicating that they felt either “very comfortable” (32%) or “somewhat comfortable” (25%) with using it to update their information. 15% rated “neutral”, while 6% answered “not very comfortable” and 16% “not at all comfortable” (Table 2). We performed a multivariate regression analysis to determine whether patient characteristics were associated with kiosk comfort level (Table 3). Men were less confident than women with using kiosks to enter information (OR: 0.8) and patients age 65 and older were less likely to express comfort utilizing kiosks for this purpose relative to those 18–24 years old (OR: 0.6). Table 1 Baseline Characteristics of All Study Patients (N = 4351) Table 2 Patient Comfort with Reviewing and Making Corrections to Medical and Surgical History and Medication Lists on a Kiosk (N = 4351) Table 3 Regression Results on Patient Comfort with Using Kiosks To the best of our knowledge, our analysis is one of the first to examine patient preferences surrounding kiosk utilization for personal data entry. Porter, et al. (2004) reported the use of a kiosk in ED pediatric asthma cases. Parents entered information about their child’s illness experience and the kiosk provided parent-child needs and recommended actions to improve the child’s care. Parents’ responses to the asthma kiosk were extremely positive as most found it easy to navigate, characterizing the kiosk interaction as a valuable use of time, and appreciating the action item outputs.7 Our study revealed age and gender discrepancies in level of comfort with using kiosks as men and elderly patients were less comfortable using kiosks to enter and update personal information. Although we did not specifically assess logistical challenges associated with the module, we have reported previously that higher education levels and prior experience with kiosks are associated with less time spent on specific kiosk modules and higher patient-reported ratings of ease of use.8 The 2008 U.S. Census Bureau reports that 14.5% of men over age 18 in Baltimore City do not graduate from high school, as compared to 12.7% of women.9 This may pose an intrinsic challenge to kiosk usage if men in certain locations on the whole are less educated and less comfortable with new technologies. In regards to elderly patients, it is likely that a certain amount of the discrepancy will disappear as self-service kiosks become more common in settings outside the hospital such as airports, grocery stores, banks, retail stores, etc. In order to be widely implemented as a tool for data entry and information disbursement, kiosks must be easy to understand and navigate for most patients. Our findings suggest promise for use of kiosks in the ED as a supportive communication tool with the majority of patients expressing comfort with using the kiosk to share health information with providers. Self-service kiosks have the potential to speed up ED visits because patients can fill in medical and surgical history and medication lists during wait times. This study provides an excellent foundation upon which to introduce kiosk interventions into an urban ED setting with the goals of optimizing ED throughput and improving information sharing.

Physical Therapy in the Management of Patients with Neurogenic Thoracic Outlet Syndrome: In Reply to Gambhir and colleagues.

We must congratulate the John Hopkins team for their excellent outcomes after transaxillary surgical decompression of thoracic outlet syndrome (TOS). We note that surgery was offered to patients with neurogenic TOS (NTOS) after failure to respond to 8 weeks of physical therapy (PT). Can you tell us what PT protocol was followed for these 8 weeks? In our own practice, we normally ask patients to commit to 3 to 6 months of PT before proceeding to surgical decompression, and our preferred approach is supraclavicular. One of the most neglected areas of TOS management is the role of PT, and we would be grateful if you could share your PT protocol. A set of 6 exercises described by Peet and colleagues are now no longer popular, and most TOS surgeons leave it to the physiotherapists to decide what they think is the best. In our practice, we give patients a typed list of exercises to do beginning preoperatively and continuing for 6 weeks postoperatively. In their recent publication, the Stanford group has actually been offering surgery to patients who respond to PT, which seems counterintuitive. But the logic is understandable because compliance with PT is always an issue. Regarding your investigation protocol, do you routinely do nerve conduction studies and MRI scans of brachial plexus for your NTOS patients?

Utilization of venous duplex scanning and postoperative venography in patients with subclavian vein thrombosis

OBJECTIVE The purpose of this study was to review preoperative and postoperative duplex scans and postoperative venograms in patients with subclavian vein thrombosis who underwent first rib resection and scalenectomy (FRRS) during 2005 to 2013. METHODS Preoperative venous duplex scans revealed no compression (NC), venous compression (VC, ≥ 50% decrease in velocity on abduction), venous ablation (VA, 0 velocity on abduction), and acute thrombus (AT, 0 velocity on abduction and adduction). Correlation with 2-week postoperative venograms (open, stenosis requiring dilation, or occluded) and postoperative (2- to 4-month, 6- to 8-month, and 12-month) duplex scans was performed. RESULTS Of 215 patients treated with FRRS for effort thrombosis, 140 had an ipsilateral preoperative duplex scan and postoperative venogram. Twenty-nine patients (21%) had VC, 70 (50%) had VA, 8 (5.7%) had AT, and 33 (24%) had NC. Patients with preoperative NC or VC were more likely to have an open vein on venography (P = .014). Six to 8 months after FRRS, patients with preoperative VA were more likely to have compression or ablation (P = .009); no difference was seen at 1 year. Patency rates at last follow-up were 100% in the preoperative VC and AT groups, 96% in those with VA, and 94% in patients with no preoperative compression. The 128 preoperative scans of the asymptomatic side revealed that 67 patients (52%) had NC, 29 (23%) had VC, 32 (25%) had VA, and 0 had AT. Patients with NC (P = .027), VC (P = .017), or VA (P = .008) were significantly more likely to have the same result on the opposite side. CONCLUSIONS Postoperative duplex scans reveal that VC and VA resolve during the year after FRRS, obviating the need for repeated venography or intervention. Patency rates are excellent in all patients when postoperative venography directs intervention. Patients with NC, VC, or VA on preoperative scans often show the same result on the opposite side.