Intra-articular steroid injection at the time of knee arthroscopy increases risk of post-operative infection.

PURPOSE: To evaluate the risk of post-operative infection after intra-articular steroid injection at the time of knee arthroscopy at a single institution high-volume sports medicine practice. METHODS: The electronic medical record at a single institution was queried for all patients who underwent knee arthroscopy from 2011 to 2019. Patients were included if they underwent more simple arthroscopic procedures: diagnostic arthroscopy, meniscectomy, loose body removal, synovectomy, or microfracture. Patients were excluded if they underwent more complex procedures, such as ligament reconstruction, meniscus repair, or any open procedures. These patients' medical records were then queried for current procedural terminology and international classification of disease codes indicating post-operative infection. Individual chart review was performed on this group of patients to determine if a true postoperative infection occurred within 6 months of the index arthroscopy. Patients were then categorized into "intra-operative steroid injection" versus "no steroid" based on each surgeon's preferred intra-operative analgesic injection cocktail. RESULTS: A total of 6889 patients were identified, including 2416 (35.1%) who were given intra-articular steroid at the time of knee arthroscopy. Post-operative infection occurred in 10 patients (0.15%) at a median of 18 days (range 9-42 days), 7 who received intra-operative steroid injection (0.29%) and 3 who did not (0.067%), p = 0.040. The relative risk of infection for those who received intra-operative steroid injection was 4.32 times higher than those who did not, with a number needed to harm of 448. There were no significant differences in age, body mass index, smoking status, or the prevalence of diabetes between those who got infected and those who did not. CONCLUSIONS: Knee infection following arthroscopic surgery is rare. Intra-operative steroid injection during arthroscopic knee surgery is associated with a 4.3-fold increased risk of subsequent knee infection. While the overall risk remains low, the use of intra-operative steroids is expected to result in one additional knee infection for every 448 arthroscopic procedures performed. LEVEL OF EVIDENCE: IV.

Treatment of Chronic Proximal Hamstring Tendinopathy with Surgical Debridement and Suture Anchor Repair.

We evaluated outcomes following surgical debridement and suture anchor repair of chronic proximal hamstring tendinopathy without sciatic nerve decompression. Chart review identified eight patients (one bilateral) who met study requirements. All eight patients were available for follow-up at a mean of 6.7 years and none underwent re-operation on the index hip during the follow-up period. Seven patients completed patient-reported outcome scores. The mean LEFS score was 81.1, and the mean SANE score was 74.9. The mean Marx activity score was 2.8, and the mean Custom Marx score was 23.3. Pain relief was excellent. The mean numeric pain score at rest was 0.6, while the mean numeric pain score with activity was 4.0. Treatment of chronic, recalcitrant proximal hamstring tendinopathy with surgical debridement and suture anchor repair without exploration of the sciatic nerve results in excellent pain relief, good function, and low re-operation risk. (Journal of Surgical Orthopaedic Advances 31(1):061-064, 2022).

Organ donation video messaging in motor vehicle offices: results of a randomized trial.

CONTEXT: Since nearly all registered organ donors in the United States signed up via a driver's license transaction, motor vehicle (MV) offices represent an important venue for organ donation education. OBJECTIVE: To evaluate the impact of organ donation video messaging in MV offices. DESIGN: A 2-group (usual care vs usual care+video messaging) randomized trial with baseline, intervention, and follow-up assessment phases. SETTING: Twenty-eight MV offices in Massachusetts. INTERVENTION: Usual care comprised education of MV clerks, display of organ donation print materials (ie, posters, brochures, signing mats), and a volunteer ambassador program. The intervention included video messaging with silent (subtitled) segments highlighting individuals affected by donation, playing on a recursive loop on monitors in MV waiting rooms. MAIN OUTCOME MEASURES: Aggregate monthly donor designation rates at MV offices (primary) and percentage of MV customers who registered as donors after viewing the video (secondary). RESULTS: Controlling for baseline donor designation rate, analysis of covariance showed a significant group effect for intervention phase (F=7.3, P=.01). The usual-care group had a significantly higher aggregate monthly donor designation rate than the intervention group had. In the logistic regression model of customer surveys (n=912), prior donor designation (ß=-1.29, odds ratio [OR]=0.27 [95% CI=0.20-0.37], P<.001), white race (ß=0.57 OR=1.77 [95% CI=1.23-2.54], P=.002), and viewing the intervention video (ß=0.73, OR=1.54 [95% CI=1.24-2.60], P=.01) were statistically significant predictors of donor registration on the day of the survey. CONCLUSION: The relatively low uptake of the video intervention by customers most likely contributed to the negative trial finding.

Smartphone medical applications useful for the rural practitioner.

Like other similarly situated rural states, West Virginia's patients and practitioners often experience access barriers to current medical expertise for multiple disciplines. This article was generated to help bridge this gap and highlights the best-rated mobile medical applications (Apps) for smartphone use. From finding drug interactions and dosing schedules to discussing patients in HIPAA-compliant formats, Apps are becoming integral to the practice of 21st Century medicine. The increased use of these Apps by physicians-in-training and established practitioners highlights the shift from reliance upon the medical library to the easy to use mobile-based technology platforms. This article provides our practitioners, physician extenders, medical trainees, and office staff a guide to access and assess the utility of some of the best rated medical and HIPAA compliant Apps.

Too smart to fail: guide for the struggling medical student.

Medicine is a vocation of perpetual independent learning; long-term success is critically dependent on finding the right resources and establishing effective study methods and test-taking strategies. Students who struggle with the academic transition in medical school have common risk factors and characteristics. We highlight key resources that are available for struggling medical students with an emphasis on West Virginia's HELP, ASPIRE, and STAT programs.

Predictors of clinically significant weight loss and participant retention in an insurance-sponsored community-based weight management program.

Health insurance providers are a logical partner in providing third-party payment for behavioral weight loss programming, but little evidence of predictors of improved outcomes or retention in large, insurance-sponsored lifestyle programming is available. The purpose was to determine predictors of weight loss and retention in an insurance-sponsored, community-based weight management program. Current and former participants (N = 2,106) were recruited to complete a program evaluation survey. Respondents' survey and objective outcome data (n = 766) were analyzed using logistic regression procedures to understand the factors predictive of clinically-significant (5%) weight loss and program retention (>6 months). Clinically significant weight loss was predicted by completing more than 6 months of the program, positive ratings of staff interaction, and social support from friends on success. Ratings of positive impact of site hours of operation, nurse calls, and availability of safe places to be active and feeling comfortable at the site were predictive of program retention. Modifiable intervention, social factors, and site-level factors were predictive of clinically significant weight loss and program retention, providing fodder for further study and dissemination to current providers and to a broader network of health promotion professionals.

Evidence-based review: Screening body dysmorphic disorder in aesthetic clinical settings.

BACKGROUND: Body dysmorphic disorder (BDD) is a psychiatric disturbance with high incidence in aesthetic clinical settings. Early recognition may avoid unnecessary elective procedures with ethical and medicolegal consequences. AIMS: To identify validated BDD screening tools and critically appraise current literature regarding its implementation and efficacy in aesthetic medicine and surgery scenarios, with the purpose of transposing the findings to the broad clinical settings in the field. METHODS: Data was collected using advanced search from PubMed (MEDLINE). Having satisfied the search parameters, 12 studies referring BDD definition according to Diagnostic and Statistical Manual of Mental Disorder (DSM-5) criteria and including a BDD screening tool in clinical aesthetic settings were selected. RESULTS: While BDD screening enables the recognition of at-risk individuals, further work is required to uncover the best screening tool for general aesthetic clinical practice. Level III evidence favored BDD Questionnaire (BDDQ)/BDDQ-Dermatology Version (DV), and The Dysmorphic Concern Questionnaire (DCQ) among the limited available validated screening instruments to be used outside the psychiatric environment. Based on level II self-classification, one study selected BDDQ-Aesthetic Surgery (AS) version for rhinoplasty patients. The validation process of both BDDQ-AS and Cosmetic Procedure Screening Questionnaire (COPS) had limitations. For BDD screening potential in avoiding postoperative complications, the limited studies found evaluating the outcomes following aesthetic treatments using validated BDD screening measures showed a trend toward less satisfaction with aesthetic treatment outcome among positive screening population against non-BDD counterparts. CONCLUSION: Further research is necessary to establish more effective methods to identify BDD and evaluate the impact of positive findings on aesthetic intervention outcomes. Future studies may elucidate which BDD characteristics best predict a favorable outcome and provide high-quality evidence for standardized protocols in research and clinical practice.

Qualitative visual assessment of the J-sign demonstrates high inter-rater reliability.

OBJECTIVES: To assess the inter- and intra-rater reliability of the classification of the J-sign as "large" versus "small or none" as compared to another two-level system ("present" versus "absent") and a three-level system ("large," "small," or "none") and to identify anatomical and patient factors associated with the presence of a large J-sign. METHODS: Forty patients (40 knees) with recurrent patellar instability were prospectively enrolled and recorded on video actively extending their knee while seating. Four raters classified patellar tracking on two separate occasions using three systems: 1) two groups: J-sign versus no J-sign; 2) three groups: large J-sign, small J-sign, or no J-sign; and 3) two groups: large J-sign versus small or no J-sign. The intra- and inter-rater reliability of each system was assessed using kappa statistics. Anatomical (trochlear dysplasia, tibial tubercle-trochlear groove (TT-TG) distance, patellar height) and patient (Beighton score) factors as well as Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales were compared between patients with a large J-sign and patients with a small or no J-sign. RESULTS: Inter- and intra-rater reliability were found to be highest with the two-level classification system of a large J-sign versus a small or no J-sign (inter-rater kappa â€‹= â€‹0.76, intra-rater kappa â€‹= â€‹0.75). Patients with a large J-sign had more severe trochlear dysplasia as assessed with the sulcus angle (p â€‹= â€‹0.042) and were more likely to have a tight lateral retinaculum (p â€‹= â€‹0.032) and an elevated Beighton score (p â€‹= â€‹0.009). No significant differences in KOOS subscales were noted based on the presence of a large J-sign versus a small J-sign or no J-sign. CONCLUSION: Qualitative visual assessment of patellar tracking with the J-sign demonstrates substantial inter- and intra-rater reliability, particularly when utilizing a two-group classification system to identify knees with a large J-sign. Patients with a large J-sign demonstrate an increased incidence of a tight lateral retinaculum, generalized ligamentous laxity, and trochlear dysplasia. LEVEL OF EVIDENCE: Level III - cross-sectional study.

Larger Prior Tibial Tunnel Size Is Associated with Increased Failure Risk following Revision Anterior Cruciate Ligament Reconstruction.

We hypothesize that larger prior tunnel size is associated with an increased risk of failure of single-stage revision anterior cruciate ligament reconstruction (ACLR) as defined by the performance of a re-revision (third) ACLR on the index knee. Retrospective review identified 244 patients who underwent single-stage revision ACLR at a single center with available preoperative radiographs. Patient and surgical factors were extracted by chart review. The maximum diameter of the tibial tunnel was measured on lateral radiographs and the maximum diameter of the femoral tunnel was measured on anteroposterior radiographs. Record review and follow-up phone calls were used to identify failure of the revision surgery as defined by re-revision ACLR on the index knee. One hundred and seventy-one patients (70%) were reviewed with a mean of 3.9 years follow-up. Overall, 23 patients (13.4%) underwent re-revision surgery. Mean tibial tunnel size was 12.6 ± 2.8 mm (range: 5.7-26.9 mm) and mean femoral tunnel size was 11.7 ± 2.8 mm (range: 6.0-23.0 mm). Re-revision risk increased with tibial tunnel size. Tibial tunnels 11 mm and under had a re-revision risk of 4.2%, while tunnels > 11 mm had a risk of 17.1% (relative risk: 4.1, p = 0.025). No significant association between femoral tunnel size and re-revision risk was noted. Patients with prior tibial tunnels > 11mm in diameter at revision surgery had significantly increased risk of re-revision ACLR. Further studies are needed to explore the relationship between prior tunnel size and outcomes of revision ACLR.

Arthroscopic Bone Graft Technique for Two-Stage Revision Anterior Cruciate Ligament Reconstruction.

Revision anterior cruciate ligament reconstruction is an increasingly common procedure, with 2-stage surgery often required to address large bone defects and malpositioned tunnels. The arthroscopic bone grafting technique described herein uses morselized allograft bone to provide reproducible fill of asymmetrical bone defects without autograft harvest or additional loss of native bone. The second stage of the anterior cruciate ligament reconstruction can typically proceed 6 months following bone grafting.

Shark virgin birth produces multiple, viable offspring.

Facultative automictic parthenogenesis has only recently been confirmed in the most ancient jawed vertebrates, the chondrichthyan fishes (sharks, batoids, and chimeras). To date, however, in both documented cases, the females have only produced a single parthenogen offspring, and none of these have lived for more than 3 days. We present a genetically verified case of automictic parthenogenesis by a white-spotted bamboo shark (Chiloscyllium plagiosum), in which at least 2 parthenogens were produced and survived for 5 years or more. These findings demonstrate that some female sharks are capable of producing, multiple, viable offspring through parthenogenesis.

Inferior Vena Cava Filter Strut Penetration into the Vertebral Column: A Case of 10-Year Clinical Follow Up.

BACKGROUND: The rate of vena cava (IVC) filter placement has increased over the past decade, especially in the orthopaedic trauma patient population. With the increasing use of IVC filters, radiologists and referring clinicians must be familiar with potential complications. CLINICAL CASE: This case report presents an 18-year-old polytraumatized patient who had an IVC filter placed and required T8-L2 posterior spinal fusion. At 4.5 years of follow-up, a computed tomography (CT) scan for painful spinal hardware incidentally found that the IVC filter had migrated into the L3 vertebral body. The patient eventually underwent removal of her spinal hardware, but the IVC filter migration was managed conservatively with routine surveillance. At 10 years follow-up, the patient continued to remain asymptomatic despite of filter penetration into the vertebral body. CONCLUSION: This case demonstrates, long term follow-up for an asymptomatic patient with IVC migration and vertebral body penetration. This case may suggest that attempt at complex IR filter retrieval is not necessarily warranted in scenarios of strut penetration.

Integrative genomic analysis implicates ERCC6 and its interaction with ERCC8 in susceptibility to breast cancer.

Up to 30% of all breast cancer cases may be inherited and up to 85% of those may be due to segregation of susceptibility genes with low and moderate risk [odds ratios (OR) ≤ 3] for (mostly peri- and post-menopausal) breast cancer. The majority of low/moderate-risk genes, particularly those with minor allele frequencies (MAF) of < 30%, have not been identified and/or validated due to limitations of conventional association testing approaches, which include the agnostic nature of Genome Wide Association Studies (GWAS). To overcome these limitations, we used a hypothesis-driven integrative genomics approach to test the association of breast cancer with candidate genes by analyzing multi-omics data. Our candidate-gene association analyses of GWAS datasets suggested an increased risk of breast cancer with ERCC6 (main effect: 1.29 ≤ OR ≤ 2.91, 0.005 ≤ p ≤ 0.04, 11.8 ≤ MAF ≤ 40.9%), and implicated its interaction with ERCC8 (joint effect: 3.03 ≤ OR ≤ 5.31, 0.01 ≤ pinteraction ≤ 0.03). We found significant upregulation of ERCC6 (p = 7.95 × 10-6) and ERCC8 (p = 4.67 × 10-6) in breast cancer and similar frequencies of ERCC6 (1.8%) and ERCC8 (0.3%) mutations in breast tumors to known breast cancer susceptibility genes such as BLM (1.9%) and LSP1 (0.3%). Our integrative genomics approach suggests that ERCC6 may be a previously unreported low- to moderate-risk breast cancer susceptibility gene, which may also interact with ERCC8.

Biomechanical Testing of a Transmetatarsal Base Screw in Lisfranc Injuries.

OBJECTIVES: To compare displacement between the cuneiforms and metatarsals for a typical Lisfranc screw and a transmetatarsal base screw under biomechanical loading. METHODS: Eight pairs of cadaveric feet (16 total) were evaluated. The Lisfranc ligamentous structures were transected in all specimens. All feet were repaired with screws traversing the first and second tarsometatarsal joints. A Lisfranc screw was placed from the first cuneiform to the second metatarsal in 8 specimens. A transmetatarsal base screw from the first metatarsal to the second metatarsal was placed in the remaining 8 corresponding feet. The repairs were randomized by side. Markers were placed on the dorsum of the midfoot for optical tracking. The feet were mounted into a load frame and loaded on the plantar forefoot to 100, 400, 800, and 1100 N. Displacement was measured and recorded using 3D camera tracking. RESULTS: Displacement between the first cuneiform and second metatarsal base was found to be significantly less (P = 0.02) with the transmetatarsal screw than the Lisfranc screw. There were no significant differences between displacements at any other articulations. CONCLUSIONS: This study demonstrates biomechanical superiority using a modified transmetatarsal base screw compared with the highly used Lisfranc screw for fixation of ligamentous Lisfranc injuries.

Arthroscopic Repair of an Isolated Infraspinatus Tear in a Contact Athlete: A Case Report.

INTRODUCTION: Young, athletic patients who suffer a traumatic rotator cuff tear often have high expectations for returning to their pre-injury level of physical ability. Rotator cuff injuries in adolescent and young adults are rare injuries. Isolated tears of the infraspinatus tendon are ever more rare with only one other case being previously reported in literature. CASE REPORT: We present the case of a full-thickness rotator cuff tear isolated to the infraspinatus tendon in an 18-year-old quarterback. The patient underwent arthroscopic fixation and has returned to pre-injury level of function. CONCLUSION: This case presents the rare injury of an isolated infraspinatus tear and demonstrates that with subsequent treatment the patient was able to return to pre-injury level of function. General arthroscopic techniques and rehabilitation protocols used for rotator cuff tears in young patients can be applied to successfully manage traumatic tears of the infraspinatus.

Points to Consider: Best Practices to Identify Particle Entry Routes along the Manufacturing Process for Parenteral Formulations.

During the processes involved in pharmaceutical manufacturing, particulate matter may be introduced into a product from a variety of sources and at different points in the manufacturing process. Companies design quality at the beginning of the process to ensure against defects and strive to manufacture products that meet the pharmacopeial standard of being "practically/essentially free" of particles, which can be challenging, though necessary. As particulate matter recalls are predominantly associated with parenteral products, most companies employ a quality risk management program to identify critical parameters or conditions that could affect product quality or patient safety and incorporate systemic and procedural controls to mitigate or reduce the probability of their occurrence. Yet, determining where particulates are most likely to enter the process, what types of materials are most vulnerable, and how the size and number of particles might affect product quality can be very complex. Visual inspection and sampling of the manufactured drug product are designed to control the risk of particulate contamination; building prevention controls will ensure sustainability. This concept paper highlights the necessity of a more thorough understanding of the failure mechanisms that result in particle contamination across a range of products, such as elastomeric components and glass, and processes, such as the formulation and filling of injectables. The goal is to identify process steps within the end-to-end manufacturing process that are most critical to particle generation and entering of visible particles into the final drug product.LAY ABSTRACT: This concept paper highlights the necessity of a more thorough understanding of the failure mechanisms that result in particle contamination across a range of products, such as elastomeric components and glass, and processes, such as the formulation and filling of injectables. The goal is to identify process steps within the end-to-end manufacturing process that are most critical to particle generation and entering of visible particles into the final drug product.

A statewide public health approach to improving organ donation: the Massachusetts Organ Donation Initiative.

Despite the growing disparity between organ supply and demand in the United States, few initiatives have attempted to close the gap through systematic population-based public health endeavors. We examined the evolution, implementation, and outcomes of the Massachusetts Organ Donation Initiative, a statewide effort that included a unique partnership among organ procurement organizations, major teaching hospitals, and the state's department of public health. Lessons from this initiative have contributed to growing national efforts for increasing organ supply and have provided insights for addressing this continuing public health challenge.

Using Double-Contrast CT Arthrography to Confirm Suspected Dissociation of a Cemented Polyethylene Liner in the Setting of Revision Total Hip Arthroplasty: A Case Report.

CASE: A 67-year-old woman who underwent a re-revision of a total hip arthroplasty with a cemented polyethylene liner fell 14 months after surgery. The patient had symptoms of pain and weakness; however, clinical, laboratory, and radiographic evaluation did not disclose fracture, infection, osteolysis, or component migration. Liner dissociation was suspected, and a double-contrast computed tomography (CT) arthrogram confirmed failure at the cement-liner interface. She underwent additional revision surgery and was doing well at the 3-year follow-up. CONCLUSION: Double-contrast CT arthrography confirmed failure at the cement-liner interface and is an effective diagnostic tool in identifying suspected dissociations of cemented polyethylene liners.

Genetic differentiation and phylogeography of Mediterranean-North Eastern Atlantic blue shark (Prionace glauca, L. 1758) using mitochondrial DNA: panmixia or complex stock structure?

BACKGROUND: The blue shark (Prionace glauca, Linnaeus 1758) is one of the most abundant epipelagic shark inhabiting all the oceans except the poles, including the Mediterranean Sea, but its genetic structure has not been confirmed at basin and interoceanic distances. Past tagging programs in the Atlantic Ocean failed to find evidence of migration of blue sharks between the Mediterranean and the adjacent Atlantic, despite the extreme vagility of the species. Although the high rate of by-catch in the Mediterranean basin, to date no genetic study on Mediterranean blue shark was carried out, which constitutes a significant knowledge gap, considering that this population is classified as "Critically Endangered", unlike its open-ocean counterpart. METHODS: Blue shark phylogeography and demography in the Mediterranean Sea and North-Eastern Atlantic Ocean were inferred using two mitochondrial genes (Cytb and control region) amplified from 207 and 170 individuals respectively, collected from six localities across the Mediterranean and two from the North-Eastern Atlantic. RESULTS: Although no obvious pattern of geographical differentiation was apparent from the haplotype network, Φst analyses indicated significant genetic structure among four geographical groups. Demographic analyses suggest that these populations have experienced a constant population expansion in the last 0.4-0.1 million of years. DISCUSSION: The weak, but significant, differences in Mediterranean and adjacent North-eastern Atlantic blue sharks revealed a complex phylogeographic structure, which appears to reject the assumption of panmixia across the study area, but also supports a certain degree of population connectivity across the Strait of Gibraltar, despite the lack of evidence of migratory movements observed by tagging data. Analyses of spatial genetic structure in relation to sex-ratio and size could indicate some level of sex/stage biased migratory behaviour.

Ultrapressure liquid chromatography-tandem mass spectrometry assay using atmospheric pressure photoionization (UPLC-APPI-MS/MS) for quantification of 4-methoxydiphenylmethane in pharmacokinetic evaluation.

4-Methoxydiphenylmethane (4-MDM), a selective augmenter of Leukotriene A4 Hydrolase (LTA4H), is a new anti-inflammatory compound for potential treatment of chronic obstructive pulmonary disease (COPD). Currently, there is no liquid chromatography tandem mass spectrometric (LC-MS/MS) method for the quantification of 4-MDM. A major barrier for developing the LC-MS/MS method is the inability of electrospray ionization (ESI) and atmospheric pressure chemical ionization (APCI) to ionize 4-MDM due to its hydrophobicity and lack of any functional group for ionization. With the advent of atmospheric pressure photoionization (APPI) technique, many hydrophobic compounds have been demonstrated to ionize by charge transfer reactions. In this study, a highly sensitive ultrapressure liquid chromatography tandem mass spectrometry assay using atmospheric pressure photoionization (UPLC-APPI-MS/MS) for the quantifications of 4-MDM in rat plasma has been developed and validated. 4-MDM was extracted from the plasma by solid phase extraction (SPE) and separated chromatographically using a reverse phase C8 column. The photoionization (PI) was achieved by introducing anisole as a dopant to promote the reaction of charge transfer. The assay with a linear range of 5 (LLOQ)-400ngmL(-1) met the regulatory requirements for accuracy, precision and stability. The validated assay was employed to quantify the plasma concentrations of 4-MDM after an oral dosing in Sprague Dawley (SD) rats.