Ketorolac and bone healing: a review of the basic science and clinical literature.

Although the efficacy of ketorolac in pain management and the short duration of use align well with current clinical practice guidelines, few studies have specifically evaluated the impact of ketorolac on bony union after fracture or surgery. The purpose of this study was to review the current basic science and clinical literature on the use of ketorolac for pain management after fracture and surgery and the subsequent risk of delayed union or nonunion. Animal studies demonstrate a dose-dependent risk of delayed union in rodents treated with high doses of ketorolac for 4 weeks or greater; however, with treatment for 7 days or low doses, there is no evidence of risk of delayed union or nonunion. Current clinical evidence has also shown a dose-dependent increased risk of pseudoarthrosis and nonunion after post-operative ketorolac administration in orthopedic spine surgery. However, other orthopedic subspecialities have not demonstrated increased risk of delayed union or nonunion with the use of peri-operative ketorolac administration. While evidence exists that long-term ketorolac use may represent risks with regard to fracture healing, insufficient evidence currently exists to recommend against short-term ketorolac use that is limited to the peri-operative period. LEVEL OF EVIDENCE V: Narrative Review.

Venous thromboembolism prophylaxis in shoulder surgery: a break-even cost-effectiveness study.

BACKGROUND: Venous thromboembolism (VTE) is a serious complication following orthopedic shoulder surgery; however, research is limited involving the break-even cost-effectiveness of VTE prophylaxis. The purpose of this study was to determine whether the cost of aspirin and enoxaparin would break even for VTE prevention in patients following shoulder surgery. METHODS: A drug retail database was used to obtain the lowest price for a course of aspirin (81 mg) and enoxaparin (40 mg) to perform a break-even cost analysis. Our institutional purchasing records were then searched to estimate the cost of treating a symptomatic VTE. The TriNetX national database was queried to establish a rate of VTE after shoulder surgery. A break-even cost analysis was performed by determining the absolute risk reduction (ARR). This value was used to calculate the number of patients who are treated to prevent a single VTE while breaking even on cost. Sensitivity analyses were performed for drugs that did not break even at the database-derived VTE rates. RESULTS: Full medication courses of aspirin and enoxaparin were found to cost $1.18 and $125.37, respectively. The cost of treating a symptomatic VTE was determined to be $9407.00. Data from the TriNetX database showed rates of symptomatic VTE following shoulder arthroplasty, hemiarthroplasty, and arthroscopic rotator cuff repair of 1.60%, 1.50%, and 0.68%, respectively. Aspirin broke even on cost for all procedures if the initial rate decreased by an ARR of 0.01% (number needed to treat, 7972). Similarly, enoxaparin broke even for shoulder arthroplasty and hemiarthroplasty if the initial rate of VTE decreased by an ARR of 1.33% (number needed to treat, 75). Enoxaparin did not break even at the initial VTE rate for arthroscopic rotator cuff repair; however, sensitivity analysis found enoxaparin would break even if the drug could be obtained at a cost of ≤$60.00. Enoxaparin broke even if the cost of treating a symptomatic VTE was ≥$20,000.00. CONCLUSIONS: The cost of a 3-week course of twice-daily aspirin or once-daily enoxaparin breaks even for VTE prophylaxis following shoulder arthroplasty and hemiarthroplasty if these drugs reduce the VTE rate by a calculated ARR. Given the lower rate of VTE observed for patients undergoing arthroscopic rotator cuff repair, only the 3-week course of aspirin broke even under these conditions. Once-daily enoxaparin did not break even at current market rate. Further research is needed to help determine optimal VTE prophylaxis after shoulder surgery.

Uniportal thoracoscopic sympathicotomy for hyperhidrosis.

Video-assisted thoracoscopic sympathicotomy is the most widely used technique in the modern era for the treatment of primary hyperhidrosis. Primary hyperhidrosis is characterized by excessive sweating and significantly affects the quality of life in those who suffer from it. This video tutorial details a uniportal, drainless sympathicotomy performed by the cardiothoracic surgical team at St George Hospital, Sydney, Australia.

Hammer Toe Correction with Proximal Interphalangeal Joint Arthrodesis.

Background: First described by Soule in 1910, arthrodesis of the proximal interphalangeal joint is a common operative method of treatment of hammer toe, or fixed-flexion deformity of the proximal interphalangeal joint of the lesser toes1. The deformity is often caused by imbalance in intrinsic and extrinsic muscle function across the interphalangeal joint and metatarsophalangeal joint2,3, which can be effectively addressed through proximal interphalangeal joint straightening and arthrodesis in conjunction with soft-tissue balancing of the metatarsophalangeal joint. Description: Following longitudinal skin incision over the joint, a transverse extensor tenotomy and capsulotomy reveal the proximal interphalangeal joint and provide appropriate exposure of the head of the proximal phalanx. With the soft tissues protected, the proximal and middle phalanges undergo resection of the articular surfaces to allow osseous apposition. This step can be performed with a rongeur sagittal saw or with osteotomes4,5. The head of the proximal phalanx is resected proximal to the head-neck junction, and the proximal portion of the middle phalanx is removed to expose the subchondral bone. Often, there is a dorsal contracture of the metatarsophalangeal joint that is elevating the toe, which is addressed with use of a longitudinal incision over the metatarsophalangeal joint, a Z-lengthening of the long extensor tendon to the toe, and a subsequent capsulectomy. If there is an angular component to the deformity, the collateral ligaments are released from the metatarsal neck, and the toe can be balanced. If there is residual subluxation of the joint that is incompletely corrected by soft-tissue procedures, a metatarsal osteotomy should be considered. Fixation is then performed with use of a smooth Kirschner wire. The wire is inserted from the middle phalanx out the tip of the toe and subsequently inserted retrograde across the proximal interphalangeal joint, often into the metatarsal head and neck, holding the metatarsophalangeal joint in appropriate position. This step can also be completed with use of novel methods including screws, bioabsorbable pins, or intramedullary implants6-8. Alternatives: Nonoperative treatments for hammer toe deformity are generally pursued prior to surgery and include shoe modifications such as a wide toe-box, soft uppers, and padding of osseous prominences3,9,10. Alternative surgical treatments include proximal interphalangeal arthroplasty, soft-tissue capsulotomy, extensor tendon lengthening, and amputation11. Rationale: Although nonoperative treatment can alleviate symptoms temporarily, surgical treatment is often necessary for definitive treatment of hammer toe. Soft-tissue procedures such as tendon lengthening can provide a stabilizing benefit, but the degenerative bone changes associated with hammer toe are better addressed with use of resection of the proximal interphalangeal joint3. Arthroplasty allows for some retained motion; however, this motion may lead to deformity and pain over time2. Arthrodesis provides less painful and more reliable fixation as well as equal outcomes compared with other operative techniques. Patient satisfaction rates after this procedure are high, with pain relief in up to 92% of patients and rare complications7-12. Expected Outcomes: Outcomes of this procedure are favorable, with rates of osseous fusion ranging from 83% to 98%2,4,11,13. Patient satisfaction rates range from 83% to 100%4,11. Historically, patients have expressed dissatisfaction with pain and the appearance of exposed hardware, but novel internal fixative devices provide a more natural appearance to the toe without the need for secondary surgical procedures for pin removal8,14. Patients are often able to return to regular activity at 6 weeks postoperatively; however, there may be persistent pain or swelling in the toe. Wide shoes and activity modifications are frequently continued for several more weeks postoperatively, and some patients may benefit from formal physical therapy and at-home rehabilitation. Important Tips: Avoid vascular compromise by ensuring adequate resection of bone at the proximal interphalangeal joint.A longitudinal incision across the joint provides greater exposure but can lead to scar contracture that elevates the toe. One alternative is the use of an elliptically shaped incision over the proximal interphalangeal joint, which can improve cosmesis but does restrict exposure.Excessive osseous resection can lead to a cosmetically undesirable short toe.If using an implant for the arthrodesis, ensure the implant is not too big for the toe. Most implants are too big for fifth-toe arthrodesis.In toes with severe deformity, fixation with a Kirschner wire is often preferred because excessive stretching of the neurovascular bundle can lead to toe compromise and if Kirschner wire is used the pin can easily be removed at bedside.For flexible deformities, a nonoperative approach is recommended, such as stretching exercises, shoe-wear modifications, and metatarsal pads. A tenotomy of the flexor digitorum brevis is a soft-tissue procedure that can be considered if nonoperative treatment is insufficient to correct the deformity. If flexor digitorum brevis tenotomy does not adequately treat proximal interphalangeal joint deformity, a proximal interphalangeal joint arthrodesis should be the next step. Acronyms and Abbreviations: MTP = metatarsophalangealPIP = proximal interphalangeal.

Animal model detects early pathologic changes of Charcot neuropathic arthropathy.

Charcot neuropathic arthropathy is a degenerative, debilitating disease that affects the foot and ankle in patients with diabetes and peripheral neuropathy, often resulting in destruction, amputation. Proposed etiologies include neurotraumatic, inflammatory, and neurovascular. There has been no previous animal model for Charcot. This study proposes a novel rodent model of induced neuropathic arthropathy to understand the earliest progressive pathologic changes of human Charcot. High-fat-diet-induced obese (DIO) Wild-type C57BL/6J mice (n = 8, diabetic) and age-matched low-fat-diet controls (n = 6) were run on an inclined high-intensity treadmill protocol four times per week for 7 weeks to induce mechanical neurotrauma to the hind-paw, creating Charcot neuropathic arthropathy. Sensory function and radiologic correlation were assessed; animals were sacrificed to evaluate hindpaw soft tissue and joint pathology. With this model, Charcot-DIO mice reveals early pathologic features of Charcot neuropathic arthropathy, a distinctive subchondral microfracture callus, perichondral/subchondral osseous hypertrophy/osteosclerosis, that precedes fragmentation/destruction observed in human surgical pathology specimens. There is intraneural vacuolar-myxoid change and arteriolosclerosis. The DIO mice demonstrated significant hot plate sensory neuropathy compared (P < 0.01), radiographic collapse of the longitudinal arch in DIO mice (P < 0.001), and diminished bone density in DIO, compared with normal controls. Despite exercise, high-fat-DIO mice increased body weight and percentage of body fat (P < 0.001). This murine model of diet-induced obesity and peripheral neuropathy, combined with repetitive mechanical trauma, simulates the earliest changes observed in human Charcot neuropathic arthropathy, of vasculopathic-neuropathic etiology. An understanding of early pathophysiology may assist early diagnosis and intervention and reduce patient morbidity and mortality in Charcot neuropathic arthropathy.

Comparing the Efficacy of True-Volume Analysis Using Magnetic Resonance Imaging With Computerized Tomography and Conventional Methods of Evaluation in Cystic Osteochondral Lesions of the Talus: A Pilot Study.

Background: Osteochondral lesions of the talus (OLT) often require advanced imaging if they prove to be refractory to preliminary microfracture. Orthopedic surgeons may misinterpret the size and morphology of the OLT when evaluating through conventional methods. The purpose of this study was to evaluate MRI as a modality for calculating true-volumes and compare its utility to that of CT true-volume and conventional methods of measuring lesion size. METHODS: With IRB approval, an institutional radiology database was queried for patients with cystic OLT that had undergone and failed microfracture and had compatible CT and MR scans between 2011 and 2016. Five lesions, previously analyzed and described in the literature using CT true-volume, were selected. 10 orthopedic surgeons independently estimated the volume of these 5 OLT via standard MRI. Next, 3D reconstructions were created and morphometric true-volume (MTV) analysis measurements of each OLT were generated. The percent change in volumes from CT and MR was compared based upon MTVs determined from 3D reconstructive analysis. RESULTS: The volume calculated using conventional methods in CT and MR scans grossly overestimated the size by of the OLT by 285-864% and 56-374% respectively when compared to 3D true-volume analysis of those CT and MR scans. CONCLUSIONS: This study demonstrates that true-volume is more accurate for calculating lesion size than conventional methods. Additionally, when comparing MRI and CT, thin slice CT true-volume is superior to MRI true-volume. True-volume calculation improves accuracy with CT and MRI and should be recommended for use in revision OLT cases.Levels of Evidence: Level III: Case control study.

Natural History of 321 Flatfoot Reconstructions in Adult Acquired Flatfoot Deformity Over a 14-Year Period.

The purpose of this study was to report the natural history, demographics, and mechanisms of requirement for additional surgery in patients undergoing flatfoot reconstruction for adult acquired flatfoot. A total of 321 consecutive patients undergoing flatfoot reconstruction over a 14-year period were included (2002-2016). All procedures were performed by a senior orthopaedic foot and ankle surgeon at our institution. Demographic data, operative reports, clinic notes, and radiographs were available for review. Statistical analysis included calculation of relative risk (RR) ratios. The majority of patients were female (83.2%,) and most patients were overweight with a body mass index greater than 25 kg/m2 (56.4%). Patient comorbidities included diabetes (13.7%) and rheumatoid arthritis (3.7%). Additional surgery was required for 54 patients (16.8%). The most common reasons for additional surgery were the following: painful calcaneal hardware (57.4%), conversion to triple arthrodesis (16.7%), and wound healing complications (9.1%). An increased risk of need for additional surgery was associated with female gender (RR = 3.4; P = .0005), smoking status (RR = 1.9; P = .0081), and age (<60 years of age; RR = 1.8; P = .042). Although retrospective, the results provide insight into the natural history of this procedure. Clinicians may use these data to appropriately counsel patients who are at increased risk of requirement for additional surgery, such as smokers, women, and patients <60 years old, regarding treatment options.Levels of Evidence: Level IV.

Novel FEMASK-score, a histopathologic assessment for destructive Charcot neuropathic arthropathy, reveals intraneural vasculopathy and correlates with progression and best treatment.

BACKGROUND: Charcot neuropathic arthropathy is a debilitating, rapidly destructive degenerative joint disease that occurs in diabetic, neuropathic midfoot. Clinicoradiologic assessment for Charcot neuropathic arthropathy previously relied on Eichenholtz stage. There is limited histopathologic data on this entity. We wanted to independently develop a histopathologic scoring system for Charcot neuropathic arthropathy. DESIGN: Retrieval of surgical pathology midfoot specimens from Charcot patients (2012-2019) were analyzed to evaluate joint soft tissue and bone. Considering progression from large (≥half 40× hpf) to small (

Outcomes of NCAA Defensive Football Players Following Achilles Tendon Repair.

BACKGROUND: The incidence of Achilles ruptures has been on the rise in National Collegiate Athletic Association (NCAA) football players, but the career impact of this injury is not fully understood. In this study, we analyzed a large series of Achilles tendon injuries in NCAA Football Bowl Subdivision (FBS) defensive football players who required repair in order to determine their return to play, performance, and career outcomes afterward. METHODS: FBS defensive football players who required Achilles repair from 2010 to 2016 were identified. The return to play of the eligible underclassmen athletes was then determined and the preinjury and postoperative performances of players who met criteria were compared with matched controls. The number of underclassmen who went on to participate in the National Football League (NFL) Combine or play in at least 1 NFL game was also determined and compared with controls. RESULTS: Fifty-seven total Achilles ruptures were identified, 40 of which occurred in underclassmen, who returned at a rate of 92.5%. Of the players who met performance criteria, only defensive backs differed from matched controls in terms of solo tackling (P = .025) and total tackling (P = .038), while still increasing compared with preoperative performance. Only 5.0% of underclassmen performed at NFL Combine and only 7.5% competed in at least 1 NFL game (20.0% and 21.3%, respectively, for matched controls). CONCLUSION: Defensive FBS players returned at a high rate following Achilles rupture and did not seem to experience a significant drop-off in performance upon return. An Achilles rupture did appear to impact their chances of playing professionally in the future, however. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Cost Comparison of Synthetic Hydrogel Implant and First Metatarsophalangeal Joint Arthrodesis.

Background. First metatarsophalangeal (MTP) arthrodesis is the "gold standard" treatment for hallux rigidus. Recently, there has been increased interest in new synthetic cartilage implants to preserve joint motion while eradicating pain. With current health care economics, the cost of a treatment is gaining particular importance. This study set out to perform a cost comparison between MTP arthrodesis and synthetic hydrogel implant to determine which treatment modality is more cost-effective based on direct aggregate costs. Study design. Economic and decision analysis. Methods. Studies in the available literature were analyzed to estimate hardware removal rates for MTP fusion and failure rates for a synthetic hydrogel implant and MTP fusion. Costs were determined by examining direct costs at a single institution for implants and data reported in the literature for operating room time. Sensitivity analysis and Monte Carlo simulation were performed to examine cost and measurement uncertainty. Results. Assuming a 4.76% MTP arthrodesis revision rate and 7.06% hardware removal rate, the total direct cost of MTP joint arthrodesis was $3632. Using a 9.2% failure rate with subsequent conversion to MTP arthrodesis, the total cost of synthetic hydrogel implant was $4565. Sensitivity analysis revealed that MTP fusion was more cost-effective even if the failure rate increased to 15% and synthetic hydrogel implant failure rate was 0%. The synthetic cartilage implant cost would have to be reduced 28% or approximately 200% the cost of MTP fusion implants to be comparable to MTP arthrodesis. Conclusion. Hallux rigidus treatment with a synthetic hydrogel implant resulted in a higher direct aggregate cost than MTP arthrodesis.Level of Evidence: Level II: Cost analysis.

A Preliminary Computational Investigation Into the Flow of PEG in Rat Myocardial Tissue for Regenerative Therapy.

Myocardial infarction (MI), a type of cardiovascular disease, affects a significant proportion of people around the world. Traditionally, non-communicable chronic diseases were largely associated with aging populations in higher income countries. It is now evident that low- to middle-income countries are also affected and in these settings, younger individuals are at high risk. Currently, interventions for MI prolong the time to heart failure. Regenerative medicine and stem cell therapy have the potential to mitigate the effects of MI and to significantly improve the quality of life for patients. The main drawback with these therapies is that many of the injected cells are lost due to the vigorous motion of the heart. Great effort has been directed toward the development of scaffolds which can be injected alongside stem cells, in an attempt to improve retention and cell engraftment. In some cases, the scaffold alone has been seen to improve heart function. This study focuses on a synthetic polyethylene glycol (PEG) based hydrogel which is injected into the heart to improve left ventricular function following MI. Many studies in literature characterize PEG as a Newtonian fluid within a specified shear rate range, on the macroscale. The aim of the study is to characterize the flow of a 20 kDa PEG on the microscale, where the behavior is likely to deviate from macroscale flow patterns. Micro particle image velocimetry (µPIV) is used to observe flow behavior in microchannels, representing the gaps in myocardial tissue. The fluid exhibits non-Newtonian, shear-thinning behavior at this scale. Idealized two-dimensional computational fluid dynamics (CFD) models of PEG flow in microchannels are then developed and validated using the µPIV study. The validated computational model is applied to a realistic, microscopy-derived myocardial tissue model. From the realistic tissue reconstruction, it is evident that the myocardial flow region plays an important role in the distribution of PEG, and therefore, in the retention of material.

Three-Dimensional Morphometric Modeling Measurements of the Calcaneus in Adults with Stage IIB Posterior Tibial Tendon Dysfunction: A Pilot Study.

Background: The pathophysiology of adult-acquired flatfoot deformity (AAFD) is not fully explained by degeneration of the posterior tibial tendon alone. While a shortened or dysplastic lateral column has been implicated in flatfoot deformity in pediatrics, there is no study that has quantified the degree of dysplasia in adults with a stage IIb flatfoot deformity, or if any exists at all. Methods: An institutional radiology database was queried for patients with posterior tibial tendon dysfunction (PTTD) who had computed tomography (CT) performed. Controls were patients receiving CT scan for an intra-articular distal tibia fracture without preexisting foot or calcaneal pathology. Clinical notes, physical examination, and weightbearing radiographs were used to find patients that met clinical criteria for stage IIb PTTD. Morphometric measurements of the calcanei were performed involving the length of the calcaneal axis (LCA), height of the anterior process (HAP), and length of the anterior process (LAP). All measurements were performed independently by separate observers, with observers blinded to group assignment. We considered a difference of ±4 mm as our threshold. Results: 7 patients and 7 controls were available for reconstruction and analysis. On average, the LCA was 3.1 mm shorter in patients with stage IIb PTTD compared with controls (P < .05). The LAP was shorter in PTTD patients compared with controls 3.4 mm (P < .001). Conclusions: Our results support the hypothesis that the calcaneus of adult patients with stage IIb AAFD is dysplastic when compared with healthy controls, which further supports the utility of lateral column lengthening. Levels of Evidence: Level III: Case-control study.

Neighborhood Socioeconomic Status and Cognitive Trajectories in a Diverse Longitudinal Cohort.

OBJECTIVES: Although individual-level socioeconomic status is associated with poor outcomes, less is known regarding how the social context might affect cognitive outcomes. We examined the effect of neighborhood socioeconomic status (NSES) on baseline cognitive function and trajectories of decline. METHODS: The sample (N = 480) came from a longitudinal cohort recruited to study cognitive function. Mixed effects models examined the influence of NSES on baseline and rate of change in executive function, semantic memory, and episodic memory. RESULTS: NSES was positively associated with semantic memory scores at baseline, but not with executive function or episodic memory in adjusted models, nor was it associated with cognitive change in longitudinal analyses. In exploratory analyses, for individuals with dementia, those with higher NSES declined faster in executive function and semantic memory than did those with lower NSES. CONCLUSIONS: Results suggest that NSES has limited effects independent of personal characteristics; however, findings showed a complex relation of NSES and decline, with NSES effects observed only for individuals with dementia. Results are discussed in the context of cognitive reserve. CLINICAL IMPLICATIONS: Clinical assessments of individuals who present with cognitive impairment might benefit from an understanding of the neighborhood context from which patients come.

Does Attorney Advertising Influence Patient Perceptions of Pelvic Mesh?

OBJECTIVE: To measure the relative influence of attorney advertising on patient perceptions of pelvic mesh compared with a history of surgery and a first urology visit. MATERIALS AND METHODS: A 52-item survey was administered to 170 female patients in 2 urology offices between 2014 and 2016. Multiple survey items were combined to form scales for benefit and risk perceptions of pelvic mesh, perceptions of the advertising, attitudes toward pelvic mesh, and knowledge of pelvic mesh and underlying medical conditions. Data were analyzed using hierarchical linear regression models. RESULTS: Exposure to attorney advertising was quite high; 88% reported seeing a mesh-related attorney advertisement in the last 6 months. Over half of patients reported seeing attorney advertisements more than once per week. A history of prior mesh implant surgery was the strongest predictor of benefit and risk perceptions of pelvic mesh. Exposure to attorney advertising was associated with higher risk perceptions but did not significantly affect perceptions of benefits. Past urologist visits increased perceptions of benefits but had no effect on risk perceptions. CONCLUSION: Attorney advertising appears to have some influence on risk perceptions, but personal experience and discussions with a urogynecologist or urologist also influence patient perceptions. Implications, limitations, and future research are discussed.

Impact of a University-Based Outpatient Telemedicine Program on Time Savings, Travel Costs, and Environmental Pollutants.

OBJECTIVE: The objective of this study was to estimate travel-related and environmental savings resulting from the use of telemedicine for outpatient specialty consultations with a university telemedicine program. METHODS: The study was designed to retrospectively analyze the telemedicine consultation database at the University of California Davis Health System (UCDHS) between July 1996 and December 2013. Travel distances and travel times were calculated between the patient home, the telemedicine clinic, and the UCDHS in-person clinic. Travel cost savings and environmental impact were calculated by determining differences in mileage reimbursement rate and emissions between those incurred in attending telemedicine appointments and those that would have been incurred if a visit to the hub site had been necessary. RESULTS: There were 19,246 consultations identified among 11,281 unique patients. Telemedicine visits resulted in a total travel distance savings of 5,345,602 miles, a total travel time savings of 4,708,891 minutes or 8.96 years, and a total direct travel cost savings of $2,882,056. The mean per-consultation round-trip distance savings were 278 miles, average travel time savings were 245 minutes, and average cost savings were $156. Telemedicine consultations resulted in a total emissions savings of 1969 metric tons of CO2, 50 metric tons of CO, 3.7 metric tons of NOx, and 5.5 metric tons of volatile organic compounds. CONCLUSIONS: This study demonstrates the positive impact of a health system's outpatient telemedicine program on patient travel time, patient travel costs, and environmental pollutants.

Geospatial Information System Analysis of Healthcare Need and Telemedicine Delivery in California.

BACKGROUND: Geospatial Information Systems (GIS) superimpose data on geographical maps to provide visual representations of data by region. Few studies have used GIS data to investigate if telemedicine services are preferentially provided to communities of greatest need. INTRODUCTION: This study compared the healthcare needs of communities with and without telemedicine services from a university-based telemedicine program. METHODS: Originating sites for all telemedicine consultations between July 1996 and December 2013 were geocoded using ArcGIS software. ZIP Code Tabulation Areas (ZCTAs) were extracted from the 2010 U.S. Census Bureau's Topologically Integrated Geographic Encoding and Referencing file and assigned a community needs index (CNI) score to reflect the ZCTA community's healthcare needs based on evidence-based barriers to healthcare access. CNI scores were compared across communities with and without active telemedicine services. RESULTS: One hundred ninety-four originating telemedicine clinic sites in California were evaluated. The mean CNI score for ZCTAs with at least one telemedicine clinic was significantly higher (3.32 ± 0.84) than those without a telemedicine site (2.95 ± 0.99) and higher than the mean ZCTAs for all of California (2.99 ± 1.01). Of the 194 telemedicine clinics, 71.4% were located in communities with above average need and 33.2% were located in communities with very high needs. DISCUSSION: Originating sites receiving telemedicine services from a university-based telemedicine program were located in regions with significantly higher community healthcare needs. Leveraging a geospatial information system to understand community healthcare needs provides an opportunity for payers, hospitals, and patients to be strategic in the allocation of telemedicine services.

Transcriptomic analysis of tail regeneration in the lizard Anolis carolinensis reveals activation of conserved vertebrate developmental and repair mechanisms.

Lizards, which are amniote vertebrates like humans, are able to lose and regenerate a functional tail. Understanding the molecular basis of this process would advance regenerative approaches in amniotes, including humans. We have carried out the first transcriptomic analysis of tail regeneration in a lizard, the green anole Anolis carolinensis, which revealed 326 differentially expressed genes activating multiple developmental and repair mechanisms. Specifically, genes involved in wound response, hormonal regulation, musculoskeletal development, and the Wnt and MAPK/FGF pathways were differentially expressed along the regenerating tail axis. Furthermore, we identified 2 microRNA precursor families, 22 unclassified non-coding RNAs, and 3 novel protein-coding genes significantly enriched in the regenerating tail. However, high levels of progenitor/stem cell markers were not observed in any region of the regenerating tail. Furthermore, we observed multiple tissue-type specific clusters of proliferating cells along the regenerating tail, not localized to the tail tip. These findings predict a different mechanism of regeneration in the lizard than the blastema model described in the salamander and the zebrafish, which are anamniote vertebrates. Thus, lizard tail regrowth involves the activation of conserved developmental and wound response pathways, which are potential targets for regenerative medical therapies.