York Hospital

Background Stable slipped capital femoral epiphysis (SCFE) is often considered semi-urgent, prompting admission for in situ screw fixation (ISF), which may increase the cost/burden of care. Avascular necrosis (AVN) affects 25% to 50% of patients with unstable SCFE, yet it is uncommon after stable SCFE. Among patients presenting with stable SCFE, little is known about the relationship between diagnosis and surgical timing with regard to slip progression or complications. Methods This retrospective observational study included all patients younger than 18 years with stable SCFE at initial diagnosis treated with ISF between 2000 and 2020 at 4 centers. Patients with Loder unstable SCFE at the time of initial SCFE diagnosis were excluded. Timing data included time from (1) symptom onset to diagnosis, (2) symptom onset to surgical team evaluation, (3) symptom onset to surgery, (4) diagnosis to surgical team evaluation, (5) surgical team evaluation to surgery, and (6) diagnosis to surgery. Regression analyses explored relationships between timing and slip progression to unstable, subsequent procedures, and complications as graded by the modified Clavien-Dindo-Sink system. Results A total of 298 patients with 362 stable SCFEs were included. The mean time from symptom onset to diagnosis was 134 days, from diagnosis to surgical team evaluation was 3.2 days, and from surgical team evaluation to surgery was 2.1 days. The mean follow-up was 2.4 years. Eighteen percent of hips were affected by a complication. Two patients initially diagnosed with stable SCFE progressed to unstable SCFE, having experienced falls after diagnosis and before orthopaedic evaluation; one of these went on to develop AVN. Time elapsed between symptom onset, diagnosis, surgical team evaluation, and surgery was not associated with the incidence or severity of complications or subsequent procedure. Conclusions The urgency of surgical treatment of stable SCFE does not appear to affect mid-term outcomes. If surgical management of stable SCFE is not performed urgently, it is critical to avoid weight bearing and falls to reduce progression to an unstable SCFE. Level of Evidence Level III, therapeutic.

The AAP Task Force on SIDS (now the AAP Subcommittee on SUID) Policy Statement outlines the many components required for minimizing the risk of SUID for the healthy term infant. There are scenarios where the infant is not perfectly healthy. Some medical conditions present dilemmas for family and clinician because interventions thought to be beneficial may be at odds with safe sleep recommendations. In this chapter, we will review common health conditions and misconceptions about treatment that may lead families to deviate from safe sleep behaviors and how the clinician can discuss overcoming barriers to maintaining a safe sleep environment.

Loneliness has been identified as an important psychosocial factor associated with cardiovascular disease, but the relationship has been underexplored using validated measures. This cross-sectional study analyzed 92 patients from 2018 to 2019 using the Revised UCLA Loneliness Scale to evaluate associations between loneliness and coronary artery disease (CAD). Statistical analysis was performed using R v4.4.0. A multivariate logistic regression model assessed the relationship between loneliness scores and CAD, adjusting for age and race/ethnicity. A one-sided Wilcoxon rank-sum test compared loneliness scores between CAD and non-CAD patients. Age was significantly associated with CAD (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.01–1.08, p = 0.0084), whereas loneliness score showed a trend toward significance (OR: 1.03, 95% CI: 0.99–1.07, p = 0.140). No significant associations were found between race/ethnicity or sex and loneliness. In a subgroup analysis of patients ≥ 55 years, loneliness was significantly associated with CAD (OR: 1.06, 95% CI: 1.00–1.12, p = 0.04), whereas age was not (p = 0.378). Patients aged ≥ 55 years with CAD had significantly higher loneliness scores than those without CAD (p = 0.044), whereas no significant difference was observed in patients < 55 years (p = 0.87). While loneliness was not independently associated with CAD in the overall cohort, it was significantly associated with CAD in patients aged ≥ 55 years. This suggests that loneliness may be a relevant factor in cardiovascular health among older adults. This emphasizes the need for health care providers to consider loneliness as a potential risk factor for CAD, alongside traditional risk factors.

Recurrent meningitis, although rare, poses a significant clinical challenge due to its potential for severe complications and profound impact on patient quality of life. This case report details a 33-year-old male with a family history of meningitis who presented with recurrent bacterial meningitis. Initial diagnostic evaluations, including CT and MRI, identified a defect in the bony cribriform plate, creating an abnormal pathway for bacterial invasion. Despite appropriate management with intravenous antibiotics, the patient’s recurrent episodes necessitated surgical intervention. A multidisciplinary approach involving neurosurgical resection of the mass and repair of the skull base defect successfully resolved the issue, with the patient remaining asymptomatic postoperatively. This report emphasises the importance of thorough anatomical evaluation in cases of recurrent meningitis, particularly in identifying subtle skull base defects that may not be apparent on initial imaging. The discussion reviews the relevant literature on the aetiologies of recurrent bacterial meningitis, highlighting the significant role of anatomical abnormalities and the necessity for advanced imaging techniques in diagnosis. Further research into the potential familial links and unrecognised aetiologies of recurrent meningitis is warranted to better understand and manage this complex condition.

Background The effectiveness and safety of traditional versus dual lumen microcatheter (DLMC)‐assisted parallel wiring in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. Aims To compare traditional versus dual lumen microcatheter (DLMC)‐assisted parallel wiring. Methods We compared the clinical and angiographic characteristics and outcomes of traditional versus DLMC‐assisted parallel wiring after failed antegrade wiring (AW) in a large, multicenter CTO PCI registry. Results Among 1353 CTO PCIs with failed AW with a single wire, traditional parallel wiring ( n = 1081) or DLMC‐assisted parallel wiring ( n = 272) were utilized at the operator's discretion. The baseline characteristics of patients were similar in both groups except for higher prevalence of diabetes mellitus, and lower prevalence of hypertension, prior heart failure, prior MI and cerebrovascular disease in DLMC patients. Lesions in the DLMC group were more likely to have proximal cap ambiguity, side branch at the proximal cap, blunt/no stump, moderate/severe calcification, and had higher J‐CTO score (2.6 ± 1.0 vs. 2.1 ± 1.3, p < 0.001). Technical (87.1% vs. 74.3%, p < 0.001) and procedural (83.8% vs. 75.5%, p = 0.001) success and the incidence of in‐hospital major cardiac adverse events (MACE) (4.8% vs. 2.0%, p = 0.020) were higher in the DLMC group. In propensity score matching analysis, DLMC‐assisted wiring was associated with higher technical success (odds ratio [OR] 2.17, 95% confidence interval [CI] 1.33−3.54, p = 0.002) and no significant difference in MACE (OR 2.00, 95% CI 0.89−4.50, p = 0.093). Conclusions In lesions that could not be crossed with AW, DLMC‐assisted parallel wiring was associated with a higher likelihood of technical success, without an increased risk of MACE, compared with traditional parallel wiring.

Objective To identify risk factors for tracheostomy among infants born < 33 week gestational age. Methods We conducted a retrospective matched case‐control study of infants < 33 week gestation who underwent tracheostomy between 2000 and 2018 at a single level IV NICU. For each case, we identified two controls matched for gestational age ± 1 week and birthweight ± 100 g who were admitted during the same year. Records were reviewed for IMV duration, number of intubations/extubations, postnatal steroid exposure, BPD severity and other clinical factors. Odds ratios and 95% CI were calculated by a conditional logistic regression. Results The mean (SD) gestation of the cohort (30 tracheostomy cases; 60 controls) was 26.2 (2.2) week. Tracheostomies were performed at 158 d (127–183) of age and 48 week (44.6–55) post‐menstrual age (PMA) following 92 d (64–134) IMV; median (IQR). Tracheostomy was indicated for severe BPD [N = 19(68%)], acquired airway obstruction [ N = 4(14%)], or severe BPD with airway obstruction [ N = 5(18%)]. Additional risk factors included male sex, outborn birth, intrauterine growth retardation, pulmonary hypertension, and sepsis. IMV duration and length of stay were longer, postnatal steroid exposure was more common and PMA at discharge was later for tracheostomy cases than controls. The number of intubations, extubations (planned and unplanned) and extubations adjusted for IMV duration were significantly higher in cases than controls. In the final logistic model, the number of unplanned extubations and steroid courses were independently associated with tracheostomy. Conclusion Strategies to minimize tracheostomy risk should target modifiable risk factors such as reducing unplanned extubations and limiting postnatal steroids in high‐risk infants.

Background Despite women comprising 52% of full-time equivalent general practitioners (GPs) in England, a significant gender pay gap persists (15% after adjustments). Further understanding of the barriers and facilitators impacting women GPs’ careers is needed. Aim To identify and synthesise research evidence exploring barriers to and facilitators of women GPs’ careers. Design & setting Systematic review of qualitative and quantitative studies. Studies were included of general practitioners conducted in the UK NHS general practice setting. Method Review methods followed Cochrane and PRISMA guidelines to systematically search MEDLINE, Embase, HMIC and Google Scholar to identify studies that explored gendered barriers and facilitators to GP careers. An inductive thematic analysis was used to synthesise the evidence. Results 21 articles were included in this review, with varied study designs. No relevant intervention studies were identified. There was a lack of recent research evidence; over half of the studies were conducted over 20 years ago. Most met quality criteria, though there were some problems with reporting and adjustment for potential confounders. Studies found barriers at personal, socio-cultural and system levels that inhibit women GPs’ careers. While some positive changes have been documented across studies that span some thirty years, many challenges remain. Conclusion Despite general practice being a medical specialty where women outnumber men, barriers at personal, socio-cultural and system levels continue to inhibit women GPs’ careers.

Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and human coronavirus HKU1 (HCoV-HKU1) are two forms of human coronaviruses known to cause respiratory tract symptoms. A co-infection with both viruses is rare, particularly in the United States. Case description An 85-year-old male presented to the Emergency Department with recurrent falls, diarrhoea and cough, and whose viral panel was positive for both SARS-COV-2 and HCoV-HKU1. The patient developed bacterial pneumonia and was treated with antibacterial agents and glucocorticoids. His past medical history of atrial fibrillation required careful monitoring and subsequent discontinuation of remdesivir, a medication known to cause adverse cardiovascular effects in COVID-19 patients. The length of stay was also prolonged due to delirium and deconditioning. Ultimately, the patient required an urgent ablation followed by the placement of a permanent pacemaker, and anticoagulation therapy was initiated before discharge. The patient had a favourable outcome given the rarity of this case. Discussion COVID-19 patients co-infected with other human coronaviruses should be monitored for disease progression and superimposed bacterial infections. Providers should be cautious with the use of remdesivir in cases of co-infection and in severely ill COVID-19 patients who have a history of atrial fibrillation. LEARNING POINTS This is a rare clinical case of a patient co-infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and human coronavirus HKU1 (HCoV-HKU1), two forms of coronaviruses; the report presents an epidemiological anomaly and a treatment framework. The importance of close monitoring of bacterial infections in coronavirus co-infections is reinforced. The cautious use of remdesivir in patients with a history of atrial fibrillation in severe or unique COVID-19 disease is recommended.

A short cut review of the literature was carried out to examine whether a decision rule in conjunction with a D-dimer can be used to rule out aortic dissection. 117 unique papers were found of which three systematic reviews included data on patients relevant to the clinical question; these are discussed in the paper. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the best papers are tabulated. The clinical bottom line is that in low-risk patients (aortic dissection detection risk score 0 or 1) who present to the Emergency Department with chest pain, a negative D-dimer level makes aortic dissection unlikely. However, further prospective validation studies are needed to optimally define the patient group that warrants investigation, the threshold for investigation and the clinical effectiveness of such a diagnostic strategy before it can be widely adopted.

Background: The use of the Ostial Flash balloon (Ostial Corporation) has received limited study in aorto-ostial chronic total occlusion (CTO) percutaneous coronary artery intervention (PCI). Methods: The authors evaluated the outcomes of Ostial Flash balloon use in a large CTO-PCI registry (PROGRESS-CTO, NCT02061436). Results: The Ostial Flash balloon was used in 54 of 907 aorto-ostial CTO PCIs in 905 patients (6.0%). The mean patient age was 65.1 ± 10.7 and 80.6% were men, with a high prevalence of diabetes mellitus, hypertension, prior PCI, and prior myocardial infarction. The mean occlusion length was 40.5 ± 25.1 mm, 52.2% had moderate to severe calcification, and the mean Japanese-CTO score was 2.8 ± 1.1. Lesions treated with the Ostial Flash balloon were more frequently located in the right aorto-ostium (79.6% vs 66.0%, P = .002). In the Ostial Flash group, the most common successful CTO crossing technique was antegrade wiring (46.3%), followed by the retrograde approach (40.7%); intravascular imaging was used in 61.1% of cases. Technical success (92.6% vs 87.9%, P = .300) and the incidence of major adverse cardiac events (MACE) (5.6% vs 3.6%, P = .450) was similar in the Ostial Flash vs non-Ostial Flash patients, respectively. In multivariable analysis, PCI of proximal right coronary artery CTOs was independently associated with use of the Ostial Flash balloon (odds ratio 2.2; 95% CI, 1.1-4.8; P = .036). Conclusions: The Ostial Flash balloon is infrequently used in aorto-ostial CTO PCI. Although there were no differences in MACE with use of the balloon, randomized controlled trials are needed to determine its effectiveness.

Clinicians continue to seek out ways to decrease antibiotic usage and its sequelae for infants with risk factors for Early Onset Sepsis (EOS). We carried out a large system intervention (LSI) to decrease antibiotic usage, decrease the proportion of infants exposed to any antibiotics and evaluate the financial impact of this intervention. Antibiotic use was monitored from January 2018 through June 2020 for infants born at York Hospital ≥ 35 weeks gestation and discharged from Newborn Nursery. LSIs, including the Kaiser Sepsis Calculator, were implemented January–June 2019. Quality metrics were compared 12-months before and after the intervention. Overall, 5021 infants were discharged from the nursery. Antibiotic usage decreased 68% and infant exposure to antibiotics decreased 64%. There was a savings of $697 per at risk newborn and there were no readmissions for EOS. A Systemic LSI can safely reduce newborn antibiotic exposure and create significant cost saving.

Background ROS1 tyrosine kinase inhibitors are one of the primary immunotherapies for ROS1 fusion-positive cancers. Tyrosine Kinase inhibitors have markedly improved outcomes for advanced cancers previously with poor prognosis. Entrectinib is an example of a ROS1 inhibitor that can be used for lung adenocarcinoma. There are numerous adverse effects with rare cardiac side effects reported such as heart failure and myocarditis.1,2 Case Summary A 27-year-old male being treated for lung adenocarcinoma who presented new congestive heart failure (CHF) 2 weeks after starting Entrectinib. He developed refractory ventricular tachycardia, cardiogenic shock with an endomyocardial biopsy that showed active lymphohistiocytic myocarditis. With antiarrhythmic therapy, heavy sedation, mechanical circulatory support, and high dose steroids the patient had complete resolution of symptoms and return to baseline status. Discussion This is a rare case with a severe complication after starting Entrectinib for lung adenocarcinoma. In the literature this is the first case of its kind presenting with myocarditis and severe heart failure after treatment with Entrectinib. This case highlights not only using cardiac imaging, and biopsy to help guide the diagnosis but also describe the appropriate management.