Michelle A. Holman

Cochlear implantation in children 12 months of age and younger.

Objective To investigate surgical, anesthetic, and device-related complications as well as auditory and speech-language development outcomes associated with cochlear implantation (CI) in children 12 months of age and younger. Study Design Retrospective chart review. Setting Tertiary academic referral center. Patients All children with severe-to-profound sensorineural hearing loss who underwent cochlear implantation at 12 months of age or younger and an audiometric control group implanted between 13 and 24 months of age. Main Outcome Measures Anesthetic and surgical course; major and minor surgical, anesthetic and device-related complications; postoperative disposition; postoperative auditory receptive and expressive language development. Results Twenty-six patients (41 ears) met criteria. The median duration of follow-up was 58 months. No major surgical or anesthetic complications occurred. One patient (4%) experienced device failure, which required revision surgery and implant exchange. Two other patients (8%) had individual electrode anomalies that were treated with map exclusion. At the last recorded follow-up, 73% of patients were performing at or above the level of normal-hearing age-matched peers. Patients that were implanted at 12 months of age or younger reached age-appropriate speech and language skills by 24 months of age compared with 40 months for the older pediatric control group. Conclusion The current study demonstrates that CI provides substantial benefit among infant recipients. Furthermore, when performed by an experienced cochlear implant and pediatric anesthesia team, the surgical and anesthetic risks are similar to that expected with both older pediatric and adult patients.

Cigarette smoke enhances proliferation and extracellular matrix deposition by human fetal airway smooth muscle

Cigarette smoke is a common environmental insult associated with increased risk of developing airway diseases such as wheezing and asthma in neonates and children. In adults, asthma involves airway remodeling characterized by increased airway smooth muscle (ASM) cell proliferation and increased extracellular matrix (ECM) deposition, as well as airway hyperreactivity. The effects of cigarette smoke on remodeling and contractility in the developing airway are not well-elucidated. In this study, we used canalicular-stage (18-20 wk gestational age) human fetal airway smooth muscle (fASM) cells as an in vitro model of the immature airway. fASM cells were exposed to cigarette smoke extract (CSE; 0.5-1.5% for 24-72 h), and cell proliferation, ECM deposition, and intracellular calcium ([Ca(2+)]i) responses to agonist (histamine 10 μM) were used to evaluate effects on remodeling and hyperreactivity. CSE significantly increased cell proliferation and deposition of ECM molecules collagen I, collagen III, and fibronectin. In contrast, [Ca(2+)]i responses were not significantly affected by CSE. Analysis of key signaling pathways demonstrated significant increase in extracellular signal-related kinase (ERK) and p38 activation with CSE. Inhibition of ERK or p38 signaling prevented CSE-mediated changes in proliferation, whereas only ERK inhibition attenuated the CSE-mediated increase in ECM deposition. Overall, these results demonstrate that cigarette smoke may enhance remodeling in developing human ASM through hyperplasia and ECM production, thus contributing to development of neonatal and pediatric airway disease.

Pediatric cerebellopontine angle and internal auditory canal tumors

OBJECT The aim in this study was to describe the clinical presentation, differential diagnosis, and risk for neurofibromatosis Type 2 (NF2) in pediatric patients presenting with cerebellopontine angle (CPA) and internal auditory canal (IAC) tumors. METHODS The authors conducted a retrospective study at a tertiary care academic referral center. All patients with an age ≤ 18 years who had presented with an extraaxial CPA or IAC tumor between 1987 and 2012 were included in the study cohort. Data regarding symptoms, diagnosis, tumor characteristics, and NF2 status were collected and analyzed. RESULTS Sixty patients (55% female, 45% male) harboring 87 tumors were identified. The mean age at diagnosis was 12.8 years (median 14.0 years, range 0.9-18.9 years). Schwannomas were the most commonly identified lesions (57 of 87 tumors, including 52 vestibular, 3 facial, and 2 trigeminal schwannomas), followed by meningiomas (5 of 87) and epidermoid cysts (4 of 87). Six malignant tumors were diagnosed, including small-cell sarcoma, squamous cell carcinoma, malignant meningioma, atypical rhabdoid-teratoid tumor, endolymphatic sac tumor, and malignant ganglioglioma. Headache, followed by hearing loss and imbalance, was the most common presenting symptom, whereas dysphagia, otalgia, and facial pain were uncommon. Neurofibromatosis Type 2 was diagnosed in 20 (61%) of 33 patients with vestibular schwannoma (VS), while the other 13 patients (39%) had sporadic tumors. Nineteen of the 20 patients with NF2 met the diagnostic criteria for that disorder on initial presentation, and 15 of them presented with bilateral VS. At the last follow-up, 19 of the 20 patients subsequently diagnosed with NF2 demonstrated bilateral VSs, whereas 1 patient with a unilateral VS and multiple other NF2-associated tumors has yet to demonstrate a contralateral VS to date. Only 1 patient presenting with an isolated unilateral VS and no family history of NF2 demonstrated a contralateral VS on subsequent radiological screening. CONCLUSIONS Cerebellopontine angle and IAC tumors in the pediatric population are rare. There are several noteworthy differences between the adult and pediatric populations harboring these lesions. While VS is the most common pathology in both age groups, the lesion was found in only 60% of the pediatric patients in the present study. Unlike in adults, VSs in the pediatric population were associated with NF2 in over one-half of all cases. The majority of pediatric patients with NF2 fulfilled the diagnostic criteria at initial presentation; however, approximately 7% of patients presenting with a seemingly sporadic (no family history of NF2) unilateral VS will meet the criteria for NF2 later in life. Finally, malignancies account for a significantly higher percentage (10%) of cases among pediatric patients. These findings underscore the importance of early screening and close radiological follow-up and may be helpful in patient counseling.

Does emotional intelligence change during medical school gross anatomy course? Correlations with students' performance and team cohesion.

Emotional intelligence (EI) has been associated with increased academic achievement, but its impact on medical education is relatively unexplored. This study sought to evaluate change in EI, performance outcomes, and team cohesion within a team‐based medical school anatomy course. Forty‐two medical students completed a pre‐course and post‐course Schutte Self‐Report Emotional Intelligence Test (SSEIT). Individual EI scores were then compared with composite course performance grade and team cohesion survey results. Mean pre‐course EI score was 140.3 out of a possible 160. During the course, mean individual EI scores did not change significantly (P = 0.17) and no correlation between EI scores and academic performance was noted (P = 0.31). In addition, EI did not correlate with team cohesion (P = 0.16). While business has found significant utility for EI in increasing performance and productivity, its role in medical education is still uncertain. Anat Sci Educ 9: 143–149.

Use of Genetic Testing after Abnormal Screening Ultrasound: A Descriptive Cohort Study

Background/Aims: The study aimed to characterize the use of genetic testing after abnormal screening ultrasound. Methods: We performed a retrospective review of patients undergoing genetic testing after abnormal ultrasound. Genetic evaluation consisted of noninvasive prenatal screening (NIPS) or amniocentesis. Classification of ultrasound findings, type of genetic testing, and results were collected. Results: A total of 139 subjects underwent genetic evaluation after abnormal screening ultrasound. Screening via NIPS was pursued by 61 (44%) patients while 78 (56%) proceeded directly to amniocentesis. Patients electing for amniocentesis had more cardiac, neurologic, and gastrointestinal malformations while soft markers for aneuploidy prompted more NIPS screening. Results were negative in 85% of the NIPS group compared to 60% of the amniocentesis group. Only 8% of patients who underwent NIPS proceeded to diagnostic testing. Conclusion: Patients pursuing NIPS after abnormal ultrasound had more soft markers of aneuploidy. Patients pursuing diagnostic testing were more likely to have major structural malformations and more total abnormalities identified. Patients who proceeded directly to amniocentesis were more likely to have abnormal genetic testing.

Lessons learned from a single institution’s retrospective analysis of emergent cesarean delivery following external cephalic version with and without neuraxial anesthesia

OBJECTIVES To evaluate the risk of emergent cesarean delivery with the use of neuraxial anesthesia for external cephalic version in a single practice. BACKGROUND Randomized trials have shown increased external cephalic version success when neuraxial anesthesia is used, without additional risk. We hypothesized that in our actual clinical practice, outside the confines of randomized trials, neuraxial anesthesia could be associated with an increased risk of emergent cesarean delivery. METHODS This retrospective cohort study included all women who underwent external cephalic version at a single institution with and without neuraxial anesthesia. The primary outcome was the incidence of emergent cesarean delivery (defined as delivery within 4hours of version). Secondary outcomes were version success and ultimate mode of delivery. RESULTS A total of 135 women underwent external cephalic version procedures; 58 with neuraxial anesthesia (43.0%) and 77 without (57.0%). Location of the procedure, tocolytic therapy, and gestational age were different between groups. An increased rate of emergent cesarean delivery was found in procedures with neuraxial anesthesia compared to procedures without (5/58 (8.6%) compared to 0/77 (0.0%); 95% CI for difference, 1.4 to 15.8%; P=0.013). CONCLUSION In this single hospitals practice, patients who may be at higher risk of complications and have a lesser likelihood of success were provided NA for ECV. As a result, the use of neuraxial anesthesia for external cephalic version was associated with a higher rate of emergent cesarean delivery. Obstetric and anesthetic practices should evaluate their patient selection and procedure protocol for external cephalic version under neuraxial anesthesia.

Does Regional Anesthesia for External Cephalic Version Increase the Risk of Emergent Cesarean Delivery? [8C]

INTRODUCTION: Previous studies have shown improved success without additional complications when external cephalic version (ECV) is performed with neuraxial anesthesia (NA). The purpose of this study was to evaluate the effect of NA at the time of ECV on emergent cesarean delivery (CD), procedure success, and subsequent vaginal delivery. METHODS: Women who underwent ECV at Mayo Clinic between January 1, 2010 and December 31, 2014 with and without NA were retrospectively studied. The primary outcome was the rate of emergency CD (delivery within 4 hours of ECV). Secondary outcomes were ECV success and ultimate mode of delivery. Outcomes were compared using the chi-square test. RESULTS: A total of 135 patients underwent 144 ECV procedures with NA use in 65 (45.1%) procedures. Increased rates of emergent CD were found with NA compared to procedures without NA (6 [9.2%] versus 0 [0%], P=.006). ECV success was unaffected by NA (36 [55.4%] successful ECV with NA versus 38 [48.1%] without NA, P=.38). Successful ECV led to subsequent vaginal delivery in only 55 (38.2%) women. CONCLUSION: NA for ECV increased the risk of emergent CD without impacting ECV success. These findings differ from previous randomized controlled trials (RCTs). The increased risk and decreased success of our ECVs compared to ECVs performed in the context of RCTs could be explained by patient selection, variation in operator experience or technique, or variation in anesthetic management. Future studies should further evaluate the risk of NA for ECV in true practice scenarios outside of RCTs.

Does Maternal Body Mass Index or Weight Gain Affect External Cephalic Version Success? [19H]

INTRODUCTION: External cephalic version (ECV) has been demonstrated to reduce the number of cesarean deliveries for fetal malpresentation. Numerous factors have been identified that affect the success rate; however, the effect of maternal weight parameters (body mass index [BMI] and weight gain) remains unclear. The purpose of this retrospective study is to evaluate the impact of maternal weight parameters on ECV success. METHODS: This is a retrospective cohort study including all women who underwent an attempted ECV at our academic, tertiary care institution from January 1, 2010 through December 31, 2014. Data were manually abstracted from the electronic medical record and included baseline maternal characteristics and ECV success. BMI was categorized as normal (less than 25), overweight (25–29), or obese (greater than 30). RESULTS: During the study period, 135 women underwent a total of 137 procedures (2 women had ECV attempts in 2 different pregnancies). One patient was excluded from analysis as data for pre-pregnancy BMI was unavailable. ECV was successful in 71 cases (52%). Pre-pregnancy BMI and BMI at the time of ECV showed a non-significant trend toward higher success rates with lower BMI (P=.87, 0.32, respectively). Additionally, mean maternal weight gain was not significantly different among successful and unsuccessful ECV (P=.56). CONCLUSION: Maternal BMI or weight gain do not appear to significantly impact ECV success. These results can be used when counseling women about the chance of successful ECV, and weight parameters should not be considered a contraindication to the procedure.