Intraoperative Radiation Exposure to U.S. Podiatric and Medicine Surgery Residents Annually: How Much Are We Really Getting?

As the number and complexity of operative techniques taught at U.S. podiatric medicine and surgical residencies (PMSR) with the added credential in reconstructive rearfoot and ankle (RRA) surgery has continued to increase, so to has the use of intraoperative fluoroscopy. The purpose of the present prospective observational pilot study was to quantify and compare the shallow dose equivalent (SDE), deep dose equivalent (DDE), and lens of the eye dose equivalent (LDE) exposures for podiatric medicine and surgery residents at a single PMSR-RRA over 12 consecutive months. Shallow-dose equivalent, DDE, and LDE exposures (in millirems) were measured using Landauer Luxel dosimeters from July of 2018 to July of 2019. Dosimeters were exchanged monthly, and mean monthly/annual SDE, DDE, and LDE exposures were calculated and compared. Overall, residents averaged 19 operative cases per month and 222 per year. More than half (53%) required intraoperative fluoroscopy, for which a mini C-arm was used in most cases. Monthly SDE, DDE, and LDE exposures averaged 7.3, 9.3, and 7.0 mrem, respectively; whereas annual SDE, DDE, and LDE exposures averaged 87.3, 112, and 84 mrem, respectively. No significant monthly (P = 1.0, P = .70, and P = .74) or annual (P = .67, P = .67, and P = .33) differences were identified between residents. The annual SDE, DDE, and LDE for residents at a single PMSR-RRA were well below the recommended dose limits of 50,000 mrem/year (SDE), 5,000 mrem/year (DDE), and 15,000 mrem/year (LDE) set by the National Council on Radiation Protection. However, given that the stochastic effects from low levels of ionizing radiation are cumulative, not well studied long-term, and relate both to the degree and duration of exposure, mini-C arm fluoroscopy, radiation tracking, and use of personal protective equipment provide simple means for residents to reduce any long-term potential for risk.

An Innovative Application of a Computer Aided Design and Manufacture Implant for First Metatarsal Phalangeal Joint Arthrodesis: A Case Report.

The definitive treatment to correct the deformity of hallux abducto valgus involves surgical fixation. This pathological condition focuses on combined abnormalities of the first metatarsal phalangeal joint (MPJ), medial progression of the first metatarsal, and lateral deviation of the hallux. In most known literature described to date, a computer aided design/manufacture implant has not yet been reported as a viable salvage tool used as an inter-positional structural implant for a first MPJ arthrodesis. The fundamentals of this salvage procedure are to restore anatomical length of the first ray, furnish continuity to the forefoot parabola, administer a robust inter-positional implantTM (Additive Orthopaedics, Little Silver, NJ) of optimal strength, and provide biomechanical reclamation of the tripod foot. This case study describes a procedural technique that required a 2-stage surgical approach consisting of primary external fixation with a SideKickTMCoreTrackTM (Wright Medical, Memphis, TN) tube fixator monorail to expand soft tissues for approximately 1 month.  Followed by a secondary procedure utilizing BioCUE® (Biomet Orthopaedics, Warsaw, Indiana) Bone Marrow Aspiration Concentration system, Augment® Injectable (Wright Medical, Memphis, TN), and custom GAME PLANTM (Additive Orthopaedics, Little Silver, NJ) Technology with computer assisted design/manufacture first MPJ inter-positional caged implantTM arthrodesis.  We present the case of a 46-y-old active female who suffered avascular necrosis of her left foot first metatarsal head from a previous Austin bunionectomy correctional procedure.

Patient-Perceived Recovery and Outcomes after Bipolar Radiofrequency Controlled Ablation with Platelet-Rich Plasma Injection for Refractory Plantar Fasciosis.

Previous studies have documented persistent postoperative symptoms and limitations following plantar fasciotomy using patient-reported outcome measures (PROMs). The incomplete recovery (resolution) has been theorized to occur from altered foot biomechanics, and alternative treatment methods have continued to gained popularity for addressing refractory plantar fasciosis (RPF). The purpose of the present study was to assess patient-perceived recovery (PPR) and outcomes after bipolar radiofrequency controlled ablation (BRC) with platelet-rich plasma (PRP) injection for RPF. From July 2006 to July 2016, 43 patients (52 procedures) were enrolled. PROMS were prospectively obtained and compared between patients who perceived themselves as recovered without/residual deficits (recovered-resolved, recovered-not resolved) and those not recovered. Holistic satisfaction, procedure-specific satisfaction, complications, reoperations, and failure were recorded. Overall, 67.4% perceived themselves as recovered-resolved, 23.3% as recovered-not resolved, and 9.3% as not recovered. Holistic and procedure specific satisfaction were high (90.7% and 88.4%), with a mean modified Foot Function Index of 11.65, visual analog scale for pain 1.5, and failure rate of 9.3% at a median of 53 months (interquartile range 33 to 83). In the present study, outcomes with BRC with PRP injection compared favorably to the long-term outcomes reported for partial and complete plantar fasciotomy. Although 14 patients (32.6%) continued to have some postoperative symptoms, 71% indicated that they were satisfied with their symptoms, and 64% would undergo a similar procedure again. Therefore, despite the study's shortcomings, a patient's ability to cope appears to have a role in recovery from RPF.

Patient-Perceived Recovery and Outcomes After Silastic Implant Arthroplasty.

In some chronic musculoskeletal conditions, patients with persistent pain and disability have still achieved recovery through behavioral adaptations (readjustment) or cognitive coping (redefinition). Although the pendulum shift from physician-reported clinical indicators to patient-reported outcomes measures (PROMs) has recently focused on quantifying residual pain and disability to determine recovery (resolution), whether patients are capable of coping with any ongoing deficits and achieving other forms of recovery has not been considered. We performed a retrospective case series to assess patient-perceived recovery and outcomes after silastic implant arthroplasty for hallux rigidus. From July 2006 to July 2016, 28 patients at a single institution were enrolled. PROMs were prospectively obtained and compared between patients considering themselves recovered without or with residual deficits (recovered-resolved, recovered-not resolved) and those not recovered. Holistic satisfaction, procedure-specific satisfaction, complications, reoperations, and failure rates were recorded. Overall, 50.0% perceived themselves as recovered-resolved, 43% as recovered-not resolved, and 7% as not recovered. The mean modified Foot Function Index was 17.26, the verbal analog scale for pain score was 2.03, and implant survivorship 100% at a median of 67 (interquartile range 28.4 to 103.5) months. Although only 50% of patients reported complete symptom resolution, satisfaction was high, and most perceived themselves as recovered, suggesting recovery in hallux rigidus might not always be predicated by the complete resolution of all symptomatology. Although PROMs relying on pain inference and functional disability will continue to be utilized with increasing frequency, foot and ankle surgeons should be cognizant of their inherent limitations in assessing other forms of recovery.

Publication Rates for Oral Manuscript and Poster Presentations From the American College of Foot and Ankle Surgeons: 2010 to 2014.

The American College of Foot and Ankle Surgeons (ACFAS) annual conference has served as a premiere platform to disseminate the latest innovations and research in the field of foot and ankle surgery. The quality of national society conferences is often assessed indirectly by analyzing the the journal publication rate of the abstracts presented. The purpose of this retrospective study was to assess the journal publication rate for abstracts (oral manuscripts and posters) accepted for presentation at the ACFAS conference from 2010 to 2014. All accepted abstracts from this period were compiled by the ACFAS office. PubMed, Google Scholar, and Scopus searches were performed using abstract titles and author names. Overall, the journal publication rate was 76.9% (83 of 108) for oral manuscripts and 23.2% (258 of 1113) for poster abstracts. The mean time to publication was 9.6 (range 0 to 44) months and 19.8 (range 0 to 66) months for oral and poster abstracts, respectively. The most common journal for abstract publication was The Journal of Foot and Ankle Surgery. Notably, the ACFAS oral manuscript publication rate from 2010 to 2014 (76.9%) exceeded its previously reported rate from 1999 to 2008 (67.5%) and the American Orthopaedic Foot and Ankle Society podium publication rate from 2008 to 2012 (73.7%). To the best of our knowledge, the publication incidence for oral abstracts presented at the ACFAS conference is now the highest reported of any national foot and ankle society conference to date.

The HIVToolbox 2 web system integrates sequence, structure, function and mutation analysis.

There is enormous interest in studying HIV pathogenesis for improving the treatment of patients with HIV infection. HIV infection has become one of the best-studied systems for understanding how a virus can hijack a cell. To help facilitate discovery, we previously built HIVToolbox, a web system for visual data mining. The original HIVToolbox integrated information for HIV protein sequence, structure, functional sites, and sequence conservation. This web system has been used for almost 40,000 searches. We report improvements to HIVToolbox including new functions and workflows, data updates, and updates for ease of use. HIVToolbox2, is an improvement over HIVToolbox with new functions. HIVToolbox2 has new functionalities focused on HIV pathogenesis including drug-binding sites, drug-resistance mutations, and immune epitopes. The integrated, interactive view enables visual mining to generate hypotheses that are not readily revealed by other approaches. Most HIV proteins form multimers, and there are posttranslational modification and protein-protein interaction sites at many of these multimerization interfaces. Analysis of protease drug binding sites reveals an anatomy of drug resistance with different types of drug-resistance mutations regionally localized on the surface of protease. Some of these drug-resistance mutations have a high prevalence in specific HIV-1 M subtypes. Finally, consolidation of Tat functional sites reveals a hotspot region where there appear to be 30 interactions or posttranslational modifications. A cursory analysis with HIVToolbox2 has helped to identify several global patterns for HIV proteins. An initial analysis with this tool identifies homomultimerization of almost all HIV proteins, functional sites that overlap with multimerization sites, a global drug resistance anatomy for HIV protease, and specific distributions of some DRMs in specific HIV M subtypes. HIVToolbox2 is an open-access web application available at [http://hivtoolbox2.bio-toolkit.com].

The Geogenomic Mutational Atlas of Pathogens (GoMAP) web system.

We present a new approach for pathogen surveillance we call Geogenomics. Geogenomics examines the geographic distribution of the genomes of pathogens, with a particular emphasis on those mutations that give rise to drug resistance. We engineered a new web system called Geogenomic Mutational Atlas of Pathogens (GoMAP) that enables investigation of the global distribution of individual drug resistance mutations. As a test case we examined mutations associated with HIV resistance to FDA-approved antiretroviral drugs. GoMAP-HIV makes use of existing public drug resistance and HIV protein sequence data to examine the distribution of 872 drug resistance mutations in ∼ 502,000 sequences for many countries in the world. We also implemented a broadened classification scheme for HIV drug resistance mutations. Several patterns for geographic distributions of resistance mutations were identified by visual mining using this web tool. GoMAP-HIV is an open access web application available at http://www.bio-toolkit.com/GoMap/project/

Minimotif Miner 3.0: database expansion and significantly improved reduction of false-positive predictions from consensus sequences.

Minimotif Miner (MnM available at http://minimotifminer.org or http://mnm.engr.uconn.edu) is an online database for identifying new minimotifs in protein queries. Minimotifs are short contiguous peptide sequences that have a known function in at least one protein. Here we report the third release of the MnM database which has now grown 60-fold to approximately 300,000 minimotifs. Since short minimotifs are by their nature not very complex we also summarize a new set of false-positive filters and linear regression scoring that vastly enhance minimotif prediction accuracy on a test data set. This online database can be used to predict new functions in proteins and causes of disease.

HIVToolbox, an integrated web application for investigating HIV.

Many bioinformatic databases and applications focus on a limited domain of knowledge federating links to information in other databases. This segregated data structure likely limits our ability to investigate and understand complex biological systems. To facilitate research, therefore, we have built HIVToolbox, which integrates much of the knowledge about HIV proteins and allows virologists and structural biologists to access sequence, structure, and functional relationships in an intuitive web application. HIV-1 integrase protein was used as a case study to show the utility of this application. We show how data integration facilitates identification of new questions and hypotheses much more rapid and convenient than current approaches using isolated repositories. Several new hypotheses for integrase were created as an example, and we experimentally confirmed a predicted CK2 phosphorylation site. Weblink: [http://hivtoolbox.bio-toolkit.com].

A computational tool for identifying minimotifs in protein-protein interactions and improving the accuracy of minimotif predictions.

Protein-protein interactions are important to understanding cell functions; however, our theoretical understanding is limited. There is a general discontinuity between the well-accepted physical and chemical forces that drive protein-protein interactions and the large collections of identified protein-protein interactions in various databases. Minimotifs are short functional peptide sequences that provide a basis to bridge this gap in knowledge. However, there is no systematic way to study minimotifs in the context of protein-protein interactions or vice versa. Here we have engineered a set of algorithms that can be used to identify minimotifs in known protein-protein interactions and implemented this for use by scientists in Minimotif Miner. By globally testing these algorithms on verified data and on 100 individual proteins as test cases, we demonstrate the utility of these new computation tools. This tool also can be used to reduce false-positive predictions in the discovery of novel minimotifs. The statistical significance of these algorithms is demonstrated by an ROC analysis (P = 0.001).