Clinical Evaluation of the Knee Arthritis Patient.

The evaluation of a patient with knee osteoarthritis (OA) has 3 main components: clinical history, physical examination, and radiographic imaging. The clinician should assess for inciting and aggravating factors for the knee pain as well as for the presence of any mechanical symptoms. A history of prior knee injury or surgery can suggest the development of early osteoarthritis. A thorough physical examination of the knee should be performed. Some features of OA include limited range of motion, crepitus in the patellofemoral compartment, and joint line tenderness. Depending on the severity of OA varus or valgus alignment can develop. Special tests such as the McMurray for meniscal tears may cause increased pain as patients with OA will often have degenerative meniscal tears. Weight bearing radiographs can confirm the diagnosis of OA. Several scales exist to grade the severity of OA with the Kellgren-Lawrence being one that is often used. Radiographic features of OA include joint space narrowing, osteophytes, sclerosis of bone and bone end deformities. If after the above evaluation the diagnosis is still unclear, advanced imaging or laboratory testing can be performed to evaluate for alternative diagnoses.

Implementation of Multimodal Pain Protocol Associated With Opioid Use Reduction in Trauma Patients.

INTRODUCTION: Many trauma centers have adopted multimodal pain protocols (MMPPs) to provide safe and effective pain control. The objective was to evaluate the association of a protocol on opioid use in trauma patients and patient-reported pain scores. METHODS: This was a retrospective review of adult trauma patients admitted from 7/1-9/30/2018 to 7/1-9/30/2019 at an urban academic level 1 trauma center. The MMPP consisted of scheduled nonopioid medications implemented on July 1, 2019. Patients were stratified by level of care upon admission, intensive care unit (ICU) or floor, and by injury severity score (ISS) (ISS < 16 or ISS ≥ 16). Pain scores, opioid, and nonopioid analgesic medication use were compared for the hospital stay or first 30 d. RESULTS: Seven hundred ninety eight patients were included with a mean age of 54 ± 22 y and 511 (64.0%) were men. Demographic and clinical characteristics between those in the pre-MMP (n = 404) and post-MMPP (n = 394) groups were not different. The average pain scores were not different between the two groups (3.7 versus 3.8, P = 0.44), but patients in the post-MMPP group received 36% less morphine milliequivalents (109.6 versus 70; P < 0.0001). The MMPP had the largest effect on patients admitted to the ICU regardless of injury severity. ICU patients with ISS ≥ 16 had the greatest reduction in morphine milliequivalents (174.6 versus 84.4; P < 0.0001). The use of nonopioid analgesics was significantly increased in all groups. CONCLUSIONS: A MMPP is associated with a reduction of opioids and increase in nonopioid analgesics with no difference in patient-reported pain scores.

Association between Receipt of Intrapartum Magnesium Sulfate and Postpartum Hemorrhage.

Objective The aim of the study is to investigate the association between intrapartum administration of magnesium sulfate in women with hypertensive disorders of pregnancy and postpartum hemorrhage. Study Design This was a retrospective cohort study of women diagnosed with a hypertensive disorder of pregnancy who delivered singleton gestations >32 weeks at a single, large volume tertiary care center between January 2006 and February 2015. Women who received intrapartum magnesium sulfate for seizure prophylaxis were compared with women who did not receive intrapartum magnesium sulfate. The primary outcome was frequency of postpartum hemorrhage. Secondary outcomes included estimated blood loss, uterine atony, and transfusion of packed red blood cells. Bivariable analyses were used to compare the frequencies of each outcome. Multivariable logistic regression models examined the independent associations of magnesium sulfate with outcomes. Results Of 2,970 women who met inclusion criteria, 1,072 (36%) received intrapartum magnesium sulfate. Women who received magnesium sulfate were more likely to be nulliparous, publicly insured, of minority race or ethnicity, earlier gestational age at delivery, and undergo labor induction. The frequency of postpartum hemorrhage was significantly higher among women who received magnesium sulfate compared with those who did not (12.4 vs. 9.3%, p = 0.008), which persisted after controlling for potential confounders. Of secondary outcomes, there was no difference in estimated blood loss between women who did and did not receive magnesium sulfate (250 mL [interquartile range 250-750] vs. 250 mL [interquartile range 250-750], p = 0.446). However, compared with women who did not receive magnesium sulfate, women who received magnesium sulfate had a greater frequency of uterine atony (8.9 vs 4.9%, p < 0.001) and transfusion of packed red blood cells (2.0 vs. 0.8%, p = 0.008). These differences persisted after controlling for potential confounders. Conclusion Intrapartum magnesium sulfate administration to women with hypertensive disorders of pregnancy is associated with increased odds of postpartum hemorrhage, uterine atony, and red blood cell transfusion.

Nanoparticle delivery systems to combat drug resistance in ovarian cancer.

Due to the lack of early symptoms and difficulty of accurate diagnosis, ovarian cancer is the most lethal gynecological cancer faced by women. First-line therapy includes a combination of tumor resection surgery and chemotherapy regimen. However, treatment becomes more complex upon recurrence due to development of drug resistance. Drug resistance has been linked to many mechanisms, including efflux transporters, apoptosis dysregulation, autophagy, cancer stem cells, epigenetics, and the epithelial-mesenchymal transition. Thus, developing and choosing effective therapies is exceptionally complex. There is a need for increased specificity and efficacy in therapies for drug-resistant ovarian cancer, and research in targeted nanoparticle delivery systems aims to fulfill this challenge. Although recent research has focused on targeted nanoparticle-based therapies, few of these therapies have been clinically translated. In this review, non-viral nanoparticle delivery systems developed to overcome drug-resistance in ovarian cancer were analyzed, including their structural components, surface modifications, and drug-resistance targeted mechanisms.

Suggested Curricular Guidelines for Musculoskeletal and Sports Medicine in Family Medicine Residency Training.

Patients often seek care from a family physician when they have a musculoskeletal injury or sport-related ailment. Family physicians must be adequately trained to provide this care. While general guidance is provided by the Accreditation Counsel for Graduate Medical Education (ACGME) it is left up to the individual programs to develop, implement, and execute their orthopedic and sports medicine curriculums. The American Academy of Family Physicians' (AAFP) Recommended Curriculum Guideline for Family Medicine Residents - Musculoskeletal and Sports Medicine provides a basic outline format for curriculum content and reference resources. The aim of this article is to elaborate on those training requirements and help programs to develop a curriculum implementation plan that will deliver a baseline level of competence for family medicine trainees.

Biosimilars for breast cancer: a review of HER2-targeted antibodies in the United States.

The utilization of trastuzumab biosimilar medications is of particular interest in HER2-positive breast cancer as these drugs have the potential for cost savings and increased utilization/access to HER2 targeted therapy in both early stage and metastatic HER2-positive breast cancers. Five trastuzumab biosimilars: MYL-1401O (Ogivri), CT-P6 (Herzuma), SB3 (Ontruzant), PF-05280014 (Trazimera), and ABP980 (Kanjinti), have now been approved by the US Food and Drug Administration (FDA) for use in HER2-positive breast cancers. This review provides an overview of these agents with special consideration of the development and approval process, including available clinical data results for these trastuzumab biosimilars. Adoption in the clinic will depend on the degree of comfort with the overall evidence.

The Utility of Rivaroxaban as Primary Venous Thromboprophylaxis in an Adult Trauma Population.

BACKGROUND: Venous thromboembolism (VTE) is a frequent and morbid complication after injury. Despite utilization of twice-daily enoxaparin, a significant proportion of patients still develop VTE. The purpose of this study was to compare the safety and efficacy of rivaroxaban to enoxaparin for the prevention of VTE in patients with multisystem injuries. MATERIALS AND METHODS: This retrospective cohort analysis evaluated VTE rate in multiply injured patients at a level I trauma Center. Propensity matching was used to compare patients receiving rivaroxaban or enoxaparin. The primary outcome was incidence of VTE during or up to 6 mo after admission. Secondary outcomes included major and minor bleeding, hospital mortality, and hospital length of stay. RESULTS: A total of 2106 patients were randomly selected from the entire cohort for inclusion. Patients who developed a VTE with no significant difference between groups (14 [1.3%] in the rivaroxaban group and 14 [1.3%] in the enoxaparin group, P = 1) was 1.3%. In addition, there was no difference in deep venous thrombosis (10 [0.9%] in the rivaroxaban group and 12 [1.1%] in the enoxaparin group) or pulmonary embolism (6 [0.6%] in the rivaroxaban group and 2 [0.2%] in the enoxaparin group). Incidence of bleeding, minor or major, was equivalent between groups (P > 0.05). Hospital length of stay and mortality were significantly higher in the enoxaparin group compared with rivaroxaban (11 [1.0%] versus 0 [0%] respectively, P < 0.001). CONCLUSIONS: Rivaroxaban demonstrated a similar incidence of VTE and bleeding complications as enoxaparin. Rivaroxaban may be a safe and effective alternative for VTE prophylaxis in this high-risk population.

Effects of exercise-induced low back pain on intrinsic trunk stiffness and paraspinal muscle reflexes.

The purpose of this study was to (1) compare trunk neuromuscular behavior between individuals with no history of low back pain (LBP) and individuals who experience exercise-induced LBP (eiLBP) when pain free, and (2) investigate changes in trunk neuromuscular behavior with eiLBP. Seventeen young adult males participated including eight reporting recurrent, acute eiLBP and nine control participants reporting no history of LBP. Intrinsic trunk stiffness and paraspinal muscle reflex delay were determined in both groups using sudden trunk flexion position perturbations 1-2 days following exercise when the eiLBP participants were experiencing an episode of LBP (termed post-exercise) and 4-5 days following exercise when eiLBP had subsided (termed post-recovery). Post-recovery, when the eiLBP group was experiencing minimal LBP, trunk stiffness was 26% higher in the eiLBP group compared to the control group (p=0.033) and reflex delay was not different (p=0.969) between groups. Trunk stiffness did not change (p=0.826) within the eiLBP group from post-exercise to post-recovery, but decreased 22% within the control group (p=0.002). Reflex delay decreased 11% within the eiLBP group from post-exercise to post-recovery (p=0.013), and increased 15% within the control group (p=0.006). Although the neuromuscular mechanisms associated with eiLBP and chronic LBP may differ, these results suggest that previously-reported differences in trunk neuromuscular behavior between individuals with chronic LBP and healthy controls reflect a combination of inherent differences in neuromuscular behavior between these individuals as well as changes in neuromuscular behavior elicited by pain.

Females exhibit shorter paraspinal reflex latencies than males in response to sudden trunk flexion perturbations.

BACKGROUND: Females have a higher risk of experiencing low back pain or injury than males. One possible reason for this might be altered reflexes since longer paraspinal reflex latencies exist in injured patients versus healthy controls. Gender differences have been reported in paraspinal reflex latency, yet findings are inconsistent. The goal here was to investigate gender differences in paraspinal reflex latency, avoiding and accounting for potentially gender-confounding experimental factors. METHODS: Ten males and ten females underwent repeated trunk flexion perturbations. Paraspinal muscle activity and trunk kinematics were recorded to calculate reflex latency and maximum trunk flexion velocity. Two-way mixed model analyses of variance were used to determine the effects of gender on reflex latency and maximum trunk flexion velocity. FINDINGS: Reflex latency was 18.7% shorter in females than in males (P=0.02) when exposed to identical trunk perturbations, and did not vary by impulse (P=0.38). However, maximum trunk flexion velocity was 35.3% faster in females than males (P=0.01) when exposed to identical trunk perturbations, and increased with impulse (P<0.01). While controlling for differences in maximum trunk flexion velocity, reflex latency was 16.4% shorter in females than males (P=0.04). INTERPRETATION: The higher prevalence of low back pain and injury among females does not appear to result from slower paraspinal reflexes.