Pre-Operative Rank of Expectations for Shoulder Surgery (PRESS): A Novel Survey.

BACKGROUND: Patient expectations for orthopedic surgeries, and elective shoulder surgery in particular, have been shown to be important for patient outcomes and satisfaction. Current surveys assessing patient expectations lack clinical applicability and allow patients to list multiple expectations at the highest level of importance. The purpose of this study was to develop and evaluate the use of a novel, rank-based survey assessing the relative importance of patient expectations for shoulder surgery. METHODS: The Preoperative Rank of Expectations for Shoulder Surgery (PRESS) survey was developed by polling 100 patients regarding their expectations for surgery. The PRESS survey consisted of eight common expectations for elective shoulder surgery by importance and a 0-100% scale of expected pain relief and range of motion improvement. After initial development of the PRESS survey, it was administered preoperatively to 316 patients undergoing surgery for shoulder arthritis, rotator cuff tear, subacromial pain syndrome, or glenohumeral instability between August 2020 and April 2021. Patients also completed preoperative outcome measures such as ASES, PROMIS PF, and PROMIS PI surveys. PROM surveys were administered six months postoperatively. RESULTS: Improvement in range of motion was the expectation most often ranked first for the entire study group (18%), arthritis subgroup (23%), and rotator cuff tear subgroup (19%). Subacromial pain syndrome patients most often ranked improving ability to complete ADL's and relieving daytime pain first (19%). Shoulder instability patients most often ranked improving ability to participate in sports first (31%). Patients that ranked improving range of motion or sports highly had better PROMs. Those who ranked relieving pain highly had worse PROMs. Patients with high (>90%) expectations of pain relief had better PROMIS PI scores. Patients with high pain relief expectations in the arthritis and subacromial pain syndrome groups had better PROMs, while patients with instability were less satisfied. CONCLUSION: The novel PRESS survey assesses patient expectations for shoulder surgery in a new, more clinically applicable rank-based format. The responses provided by patients provide actionable information to clinicians and are related to postoperative outcomes. Therefore the PRESS survey represents a useful tool for guiding discussions between patients and surgeons, as well as aiding in overall patient-centered clinical decision making.

A comparison of quantitative and qualitative shoulder range of motion with patient-reported outcomes.

BACKGROUND: The evaluation of shoulder function requires a combination of physical examination of shoulder range of motion and measures of functional outcome measures. Although efforts have been made to define range of motion for clinical evaluation with respect to functional outcomes, a disconnect still exists when defining a successful outcome. We aim to compare quantitative and qualitative measures of shoulder range of motion with patient-reported outcome measures. METHODS: Data from 100 patients who presented to the office of a single surgeon with a chief complaint of shoulder pain were evaluated for this study. Evaluation included American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Single Assessment Numeric Evaluation relative to the shoulder of interest, demographic information, and range of motion in the shoulder of interest. RESULTS: Internal rotation angle did not correlate with patient-reported outcomes, whereas external rotation and forward flexion angles did. Qualitative internal rotation as measured by hand-behind-back reach demonstrated a weak to moderate correlation with patient-reported outcomes, and a significant difference in global range of motion and functional outcome measures were identified in patients who can or cannot reach above the belt line or to the thoracic spine. Qualitative assessment of forward flexion demonstrated that patients who can reach specific anatomic landmarks have significantly improved functional outcome measures, and the same is true when comparing patients who can externally rotate past neutral. CONCLUSIONS: Hand-behind-back reach can be used as a clinical marker of global range of motion and functional outcome measures for patients with shoulder pain. Goniometer measurement of internal rotation has no relationship with patient-reported outcomes. Forward flexion and external rotation assessment with qualitative cutoffs can additionally be used clinically to determine functional outcome for patients with shoulder pain.

Clinical and radiological outcomes in lateralized versus nonlateralized and distalized glenospheres in reverse total shoulder arthroplasty: a randomized control trial.

BACKGROUND: Lateralization in reverse total shoulder arthroplasty (RTSA) has been used to theoretically offer the potential benefits of reduced scapular notching rates and improved stability and range of motion (ROM), particularly external rotation. The aim of this study was to compare ROM and clinical and radiographic outcomes between patients who underwent RTSA with a lateralized vs. a nonlateralized and distalized glenosphere. METHODS: A single-surgeon randomized control trial was conducted comparing 27 patients with a lateralized glenosphere and 26 patients with a nonlateralized and distalized glenosphere. A total of 66 patients were enrolled, 2 patients died before 2-year follow-up, 4 patients withdrew from the study, and 7 patients were lost to follow-up. All patients in the lateralized group received 6 mm of lateralization through the glenosphere. Participants represented a population presenting to an orthopedics sports medicine clinic with any indication for RTSA including revision arthroplasty. Patients completed preoperative and routine postoperative functional outcome measures 3, 6, 12, and a minimum of 24 months postoperatively, including American Shoulder and Elbow Surgeons, Patient-Reported Outcomes Measurement Information System Physical Function Upper Extremity, and Activities of Daily Living Requiring Active External and Internal Rotation assessments. Patients were also evaluated with ROM and radiographic measurements. The primary outcome of interest in this study was ROM, particularly external rotation. RESULTS: At 2-year follow-up, both groups had significant improvement in their American Shoulder and Elbow Surgeons, Patient-Reported Outcomes Measurement Information System Physical Function Upper Extremity, and Activities of Daily Living Requiring Active External and Internal Rotation scores with no significant difference observed between the groups. There were no statistically significant differences in incidence of scapular notching or acromial stress fractures. ROM in both groups improved significantly at their 2-year assessment with the only exception to this being external rotation at 90° of abduction in the nonlateralized and distalized group (39° ± 31° vs. 48° ± 24°, P = .379). CONCLUSIONS: Regardless of glenosphere lateralization status, patients in both groups had significant improvement in functional outcome scores and ROM, and there were no significant differences observed between the groups at 2-year follow-up. Longer follow-up is needed to determine the effect of implant design on late complications, long-term outcomes, and implant retention.

Molecular characterization of methicillin-susceptible Staphylococcus aureus clinical isolates in the United States, 2004 to 2010.

While much is known about the geographic distribution of different clonal types of methicillin-resistant Staphylococcus aureus (MRSA), few studies have assessed the molecular epidemiology of methicillin-susceptible S. aureus (MSSA), despite its continued clinical importance. In each U.S. Census region, reference laboratories collected successive MSSA isolates from patients with invasive or superficial staphylococcal infections for use in the Tigecycline Evaluation and Surveillance Trial. All isolates from the periods of 2004 to 2005 and 2009 to 2010 underwent antimicrobial susceptibility testing and characterization of their staphylococcal protein A (spa) type. Of the 708 isolates analyzed, 274 spa types were identified and divided into 15 genetic clusters. The most common clones were spa t002 (n = 63, 8.9%) and t008 (n = 56, 7.9%). While the distribution of the predominant spa types did not differ by U.S. Census region or time period, spa t008 was nearly twice as common in community skin and soft tissue infections than in nosocomial bloodstream infections (11.1% versus 5.6%, respectively; P = 0.008). Despite such differences, both community and nosocomial settings had diverse staphylococcal clonal types representing all major spa clusters. In contrast to those of MRSA, MSSA infectious isolates show wide genetic diversity without clear geographical or temporal clustering. Notably, the prevalent MSSA strains (spa t002 and spa t008) are analogous to the predominant MRSA clones, further demonstrating the importance of both lineages.

Pectoralis Major Muscle Belly Rupture in a 17-Year-Old Female Softball Player: A Case Report.

CASE: We report the case of a healthy 17-year-old female softball player with a subacute full-thickness intramuscular tear of the pectoralis major (PM) muscle. A successful muscle repair was obtained using a modified Kessler technique. CONCLUSIONS: Despite initially being a rare injury pattern, the incidence of PM muscle rupture is likely to increase as interest in sports and weight training increases, and although this injury pattern is more common in men, it is becoming more common in women as well. Furthermore, this case presentation provides support for operative treatment of intramuscular ruptures of the PM muscle.

Implementation of a Multidisciplinary Preoperative Protocol for Geriatric Hip Fractures Improves Time to Surgery at a Level III Trauma Center.

Introduction: Hip fractures are common among the elderly, and delays in time to surgery (TTS) and length of stay (LOS) are known to increase mortality risk in these patients. Preoperative multidisciplinary protocols for hip fracture management are effective at larger trauma hospitals. The purpose of this study is to evaluate the effect of a similar multidisciplinary preoperative protocol for geriatric hip fracture patients at our Level III trauma center. Materials and Methods: In this single-center retrospective study, patients aged 65 and older who were admitted from March 2016 to December 2018 (pre-protocol group, Cohort #1, n = 247) and from August 2021 to September 2022 (post-protocol group, Cohort #2, n = 169) were included. Demographic information, TTS, and LOS were obtained and compared using Student's t-test and Chi-square testing. Results: There was a significant decrease in TTS in Cohort #2 compared to Cohort #1 (P < .001). There was a significant increase in LOS in Cohort #2 compared to Cohort #1 (P < .05), but when comparing a subset of Cohort #2 (Subgroup 2B, patients admitted from May to September 2022 when the effects of COVID-19 were likely dissipated) to Cohort #1, there was no significant difference in LOS (P = .13). For patients admitted to skilled nursing facilities (SNF), LOS in Cohort #2 was significantly longer than in Cohort #1 (P = .001). Discussion: In general, Level III hospitals have fewer perioperative resources compared to larger Level I hospitals. Despite this fact, this multidisciplinary preoperative protocol effectively reduced TTS which improves mortality risk in elderly patients. LOS is a multifactorial variable, and we believe the COVID-19 pandemic was a significant confounder that reduced available SNF beds in our area which prolonged the average LOS in Cohort #2. Conclusion: A multidisciplinary preoperative protocol for geriatric hip fracture management can improve efficiency of getting patients to surgery at Level III trauma centers.

Team Approach: Treatment of Traumatic Dislocations of the Knee.

¼: Traumatic knee dislocations are complex injuries that can be associated with compromise of the neurovascular structures about the knee. ¼: Various classification systems for knee dislocations exist in the literature but should be used with caution as a prognostic tool because many knee dislocations fit into more than 1 category. ¼: Special populations of knee dislocations, such as obese patients and high-velocity mechanism injuries, require additional caution during the initial evaluation for possible vascular injuries.

What are the risk factors associated with limited musculoskeletal health literacy in shoulder arthroplasty patients?

OBJECTIVES: Low health literacy is both pervasive in the United States and a substantial barrier to satisfactory patient care and the appropriate utilization of healthcare resources. This prospective study aims to evaluate the factors that contribute to limited musculoskeletal literacy in patients who undergo shoulder arthroplasty. METHODS: Ninety patients undergoing shoulder replacement surgery completed demographics and Literacy in Musculoskeletal Problems (LiMP) surveys. Scores of less than six were considered indicative of limited musculoskeletal literacy. RESULTS: The overall percentage of participants with limited musculoskeletal literacy was 38.8%. Multivariable logistic regression analysis with multiple imputation modeling demonstrated a significant positive relationship between patient income and adequate LiMP scores (p = 0.009) with an odds ratio of 1.15 (CI: 1.04; 1.28) while level of education (p = 0.173) and patient ethnicity (p = 0.830) among other patient characteristics did not have a significant relationship with LiMP scores. CONCLUSION: In patients undergoing shoulder replacement surgery, low income was the only variable found to be predictive of limited musculoskeletal health literacy scores. Therefore, when discussing the risks and benefits of shoulder arthroplasty, orthopaedic surgeons should be cognizant of the possibility that any given patient may not meet the threshold of adequate musculoskeletal literacy.

Campsites, forest fires, and entry point distance affect earthworm abundance in the Boundary Waters Canoe Area Wilderness.

Factors controlling the spread of invasive earthworms in Minnesota's Boundary Waters Canoe Area Wilderness are poorly known. Believed to have been introduced by anglers who use them as bait, invasive earthworms can alter the physical and chemical properties of soil and modify forest plant communities. To examine factors influencing earthworm distribution and abundance, we sampled 38 islands across five lakes to assess the effects of campsites, fire and entry point distance on earthworm density, biomass and species richness. We hypothesized that all three parameters would be greater on islands with campsites, lower on burned islands and would decrease with distance from the wilderness entry point. In addition to sampling earthworms, we collected soil cores to examine soil organic matter and recorded ground and vegetation cover. Campsite presence was the single most important factor affecting sampled earthworm communities; density, biomass and species richness were all higher on islands having campsites. Fire was associated with reduced earthworm density, but had no direct effects on earthworm biomass or species richness. Fire influenced earthworm biomass primarily through its negative relationship to groundcover and through an interaction with entry point distance. Entry point distance itself affected earthworm density and biomass. For islands with campsites, earthworm biomass increased with distance from the entry point.

In vitro activity of tigecycline against 3989 Gram-negative and Gram-positive clinical isolates from the United States Tigecycline Evaluation and Surveillance Trial (TEST Program; 2004).

The Tigecycline Evaluation and Surveillance Trial (TEST Program) determined the in vitro activity of tigecycline over a large population of organisms from geographically diverse sites. Tigecycline was compared to amikacin, ampicillin, amoxicillin/clavulanic acid, imipenem, cefepime, ceftazidime, ceftriaxone, levofloxacin, minocycline, piperacillin/tazobactam, linezolid, penicillin, and vancomycin against 3989 commonly encountered clinical Gram-negative and Gram-positive pathogens collected from sites in the United States during 2004. The tigecycline activity was equivalent to imipenem against Enterobacteriaceae. Tigecycline inhibited extended-spectrum beta-lactamase and AmpC phenotypes at MIC90 values (minimum inhibitory concentration) of < or =2 microg/mL. In vitro results for tigecycline were similar to other broad-spectrum antimicrobial agents against nonfermenters with MIC90 results of 2 microg/mL against Acinetobacter spp. and >16 microg/mL against Pseudomonas aeruginosa. Tigecycline demonstrated potent activity against Staphylococcus aureus (MIC90, 0.25 microg/mL) and enterococci (MIC90, 0.12 microg/mL) regardless of methicillin or vancomycin susceptibility. Tigecycline MIC values were unaffected by penicillin nonsusceptibility and beta-lactamase production among fastidious respiratory pathogens (Streptococcus pneumoniae [MIC90, 0.5 microg/mL] and Haemophilus influenzae [MIC90, 0.25 microg/mL]). Tigecycline offers excellent activity against most of the commonly encountered nosocomial and community-acquired bacterial pathogens.

In vitro activity of tigecycline against 6792 Gram-negative and Gram-positive clinical isolates from the global Tigecycline Evaluation and Surveillance Trial (TEST Program, 2004).

Tigecycline, a new glycylcycline antibiotic, has shown promising in vitro activity against many common pathogens, including multidrug-resistant strains. To determine the activity of tigecycline against a broad range of pathogens from diverse populations and geographic areas, the Tigecycline Evaluation and Surveillance Trial (TEST Program) commenced in 2003. This study evaluated the activity of tigecycline and commonly used antimicrobials against 6792 clinical isolates from 40 study centers in 11 countries. Tigecycline was the most active agent tested against Gram-positive facultative species including multidrug-resistant strains. MIC90 results (microg/mL) for tigecycline against Enterococcus faecalis, Enterococcus faecium, Staphylococcus aureus, Streptococcus agalactiae, and Streptococcus pneumoniae were 0.12, 0.12, 0.25, and 0.25 microg/mL, respectively. Tigecycline was active against Enterobacteriaceae with an MIC90 of 1 microg/mL. Haemophilus influenzae was very susceptible to tigecycline with an MIC90 of only 0.25 microg/mL. Pseudomonas aeruginosa was the least susceptible organism tested against tigecycline. Tigecycline appears to be a promising new glycylcycline agent for the treatment of many types of pathogens with varying resistance phenotypes.

In vitro evaluation of tigecycline and comparative agents in 3049 clinical isolates: 2001 to 2002.

Tigecycline is the first glycylcycline antimicrobial in phase III clinical trials. This study compares the in vitro activity of tigecycline to 12 other predominately broad-spectrum antimicrobials against 3049 recent inpatient isolates from 38 clinical centers in 17 countries. The minimum concentration at which tigecycline inhibited 90% of the isolates for the entire collection, excluding Pseudomonas aeruginosa, was 1 microg/mL, including vancomycin-resistant enterococci-, extended-spectrum beta-lactamase-, and methicillin-resistant Staphylococcus aureus-resistant phenotypes.

Sulfate addition increases methylmercury production in an experimental wetland.

Atmospheric mercury is the dominant Hg source to fish in northern Minnesota and elsewhere. However, atmospherically derived Hg must be methylated prior to accumulating in fish. Sulfate-reducing bacteria are thought to be the primary methylators of Hg in the environment. Previous laboratory and field mesocosm studies have demonstrated an increase in methylmercury (MeHg) levels in sediment and peatland porewaters following additions of sulfate. In the current ecosystem-scale study, sulfate was added to half of an experimental wetland at the Marcell Experimental Forest located in northeastern Minnesota, increasing annual sulfate load by approximately four times relative to the control half of the wetland. Sulfate was added on four separate occasions during 2002 and delivered via a sprinkler system constructed on the southeast half (1.0 ha) of the S6 experimental wetland. MeHg levels were monitored in porewater and in outflow from the wetland. Prior to the first sulfate addition, MeHg concentrations (filtered, 0.7 microm) were not statistically different between the control (0.47 +/- 0.10 ng L(-1), n = 12; mean +/- one standard error) and experimental 0.52 +/- 0.05 ng L(-1), n = 18) halves. Following the first addition in May 2002, MeHg porewater concentrations increased to 1.63 +/- 0.27 ng L(-1) two weeks after the addition, a 3-fold increase. Subsequent additions in July and September 2002 did not raise porewater MeHg, but the applied sulfate was not observed in porewaters 24 h after addition. MeHg concentrations in outflow from the wetland also increased leading to an estimated 2.4x increase of MeHg flux from the wetland. Our results demonstrate enhanced methylation and increased MeHg concentrations within the wetland and in outflow from the wetland suggesting that decreasing sulfate deposition rates would lower MeHg export from wetlands.

Impact of carbon dioxide on the susceptibility of key respiratory tract pathogens to telithromycin and azithromycin.

OBJECTIVES: To determine the quantitative differences in telithromycin and azithromycin MIC values against Streptococcus pneumoniae, Haemophilus influenzae and Streptococcus pyogenes obtained using two recommended and commonly used methodologies: CLSI reference standard broth microdilution in ambient air and Etest((R)) concentration gradient in CO(2). METHODS: Four hundred clinical isolates (S. pneumoniae, n = 200; H. influenzae, n = 100; S. pyogenes, n = 100) were evaluated in seven independent laboratories. Telithromycin and azithromycin MICs were determined using CLSI broth microdilution panels incubated in ambient air and Etest strips incubated in CO(2). Standard quality control reference strains-S. pneumoniae ATCC 49619 (n = 10) and H. influenzae ATCC 49247 (n = 10)-were also tested. RESULTS: Telithromycin and azithromycin Etest MICs in CO(2) were elevated for all organisms when compared with values obtained using broth microdilution in ambient air. Telithromycin geometric mean MIC values increased in CO(2) by 2.05, 1.00 and 1.78 log(2) dilutions for S. pneumoniae, H. influenzae and S. pyogenes, respectively. The corresponding values for azithromycin were 2.54, 1.21 and 3.0 log(2) dilutions, respectively. CONCLUSIONS: Telithromycin MICs measured using Etest in CO(2) are consistently elevated compared with those generated by CLSI broth microdilution measured in ambient air. These findings indicate that Etest should not be routinely used for the determination of telithromycin MICs against S. pneumoniae, H. influenzae and S. pyogenes, unless appropriate corrective factors are applied before reporting MICs or applying interpretive susceptibilities. Based on results from this study, Etest MIC breakpoints and quality control ranges are proposed.