An Atypical Manifestation of Necrotizing Fasciitis in a Patient With Type II Diabetes.

In this case report, we discuss a 32-year-old diabetic male patient who presented with right foot pain three days following a spider bite. The foot progressively became swollen, preventing the patient from bearing weight on it. After admission to the emergency department, the examination showed discoloration of the dorsum of the proximal phalanx of the first toe with an open wound and pus. The patient received fluid resuscitation along with a course of metronidazole and levofloxacin. Subsequently, the patient was referred to an orthopedic and podiatric team where he underwent a complete foot fasciotomy. The procedure was successful, and the patient recovered well. This case showcases a rare manifestation of necrotizing fasciitis (NF) and highlights the importance of future research regarding NF and its association with diabetes mellitus.

Does the Chief Executive Officer (CEO)'s Educational Background Have an Impact on the Academic Hospital Leapfrog Safety Grades?

Background This study aims to investigate the potential association of the Chief Executive Officer (CEO)'s educational background on hospital safety metrics, specifically the Leapfrog safety grades. Methods A total of 172 academic and university-affiliated hospitals across the United States were included in the study. Information regarding a CEO's background was obtained through hospital websites, while the Leapfrog safety scores were found through the Leapfrog safety grade website. Hospital sizes were also noted. Results A total of 67 hospitals were led by Doctors of Medicine (MDs), 16 were led by Masters in Business Administration (MBAs), 14 were led by Masters in Healthcare Administration (MHAs), and 62 were led by CEOs with various other degree types. Of the 42 A-rated hospitals included, 17 were led by physicians and 25 by nonphysicians. The average Leapfrog grade point average was similar regardless of the CEO's background, ranging from 2.6 to 3.1. Conclusion The findings suggest that a CEO's educational background has less of an impact on the overall hospital safety performance than what may have previously been hypothesized.

Postoperative Infection Following Hip Arthroscopy in Patients Receiving Preoperative Intra-articular Injections: A Systematic Review and Meta-Analysis.

Intra-articular injections prior to hip arthroscopy are often used to diagnose and conservatively manage hip pathologies, such as femoroacetabular impingement, labral tears, and chondral lesions. As a diagnostic tool, the relief of hip pain following an intra-articular injection helps pinpoint the primary source of pain and assists surgeons in recommending arthroscopic intervention for underlying intra-articular pathologies. However, when injections are not sufficiently spaced apart in time prior to hip arthroscopy, there is an elevated risk of postoperative infection. This systematic review aims to assess whether preoperative intra-articular injections prior to hip arthroscopy are associated with an increased risk of postoperative infection and to determine the safety timeframe for administering such injections prior to the procedure. A comprehensive search was conducted in the PubMed, Embase, and Cochrane Library databases to identify studies examining the relationship between preoperative intra-articular injections and postoperative infection following hip arthroscopy. A meta-analysis was conducted to compare the risk of infection between patients who received injections prior to hip arthroscopy at varying intervals and those who did not receive any preoperative injections. Five studies were included (four level III and one level IV), which consisted of 58,576 patients (58.4% female). Injections administered anytime prior to hip arthroscopy posed a significantly higher risk of infection compared to no history of prior injections (risk ratio: 1.45, 95% confidence interval: 1.14-1.85, P = 0.003). However, upon subanalysis, the risk of infection was significantly higher among patients who received injections within three months prior to hip arthroscopy compared to those who did not receive injections (risk ratio: 1.55, 95% confidence interval: 1.19-2.01, P = 0.001). Additionally, no significant difference in infection risk was observed when injections were administered more than three months before hip arthroscopy compared to no injections (risk ratio: 1.05, 95% confidence interval: 0.56-1.99, P = 0.87). The findings suggest that patients undergoing hip arthroscopy who have previously received intra-articular injections may face a statistically higher risk of postoperative infection, particularly when the injection is administered within three months prior to hip arthroscopy. Consequently, surgeons should exercise caution and avoid administering intra-articular injections to patients scheduled for hip arthroscopy within the subsequent three months to mitigate the increased risk of infection.

Association of Preoperative Patient Resilience With Postoperative Patient-Reported Outcomes and Sleep Quality Following Arthroscopic Rotator Cuff Repair: A Systematic Review.

Recent studies have shown that low preoperative resilience may lead to inferior outcomes following arthroscopic rotator cuff repair. Therefore, the purpose of this systematic review is to evaluate whether preoperative patient resilience is associated with outcome measures, including patient-reported outcome measurements (PROMs) and sleep quality, following arthroscopic rotator cuff repair. To perform the review, a literature search was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the PubMed and Embase databases to gather studies related to the influence of preoperative resilience on postoperative outcomes of rotator cuff repair. Methodological quality and risk of bias were assessed using the Methodological Index for Non-randomized Studies (MINORS). Seven studies with 584 patients were included. Of 36 total reported postoperative outcomes, including PROMs and sleep quality, 14 had a significant positive correlation with higher preoperative resilience. One study reported that higher resilience was significantly correlated with worse sleep quality at a two-week follow-up but not at further follow-ups of up to 24 weeks. Significant differences in outcomes between patients with varying levels of resilience were assessed in five studies, all of which found that patients with higher resilience had significantly better outcomes or no significant differences in outcomes between patients with varying levels of preoperative resilience. In no study was it reported that patients with low resilience had better outcomes. Overall, approximately half of all reported postoperative outcome data was found to be significantly associated with preoperative resilience. Therefore, clinicians should preemptively identify those with low resilience and administer psychological interventions to limit inferior outcomes following arthroscopic rotator cuff repair.

Orphan Applicants in Orthopedic Surgery: Where Do Allopathic Applicants Without an Affiliated Residency Program Match?

Background  Orthopedic surgery is one of the most competitive specialties to match into a residency. With a plethora of qualified applicants and the subjective nature of matching into any residency program, it can be difficult to accurately assess the chances of successfully matching into orthopedic surgery and the types of programs an applicant will match into. The purpose of this study is to compare the types of programs that students from medical schools with and without home programs match. Methods This was a five-year retrospective study (2019 to 2023) analyzing 155 United States Doctor of Medicine (M.D.) programs and their orthopedic residency-matched students. Of the 155 programs, 40 were excluded from the study due to the lack of obtainable data. For each medical school, we analyzed several variables: the presence of a home program, the total number of orthopedic residency matches, residency program matches, and residency program affiliation (academic, community, university-affiliated community-based, military). Results Of the 2066 total matched applicants from institutions with home programs, 1508 (73%) matched into academic centers, 315 (15.3%) into university-affiliated community programs, 172 (8.3%) into community programs, and 71 (3.4%) into military programs. In contrast, of the 219 total matched applicants from institutions without home programs (orphan applicants), 144 (67.8%) matched into academic programs, 36 (16.4%) into university-affiliated community programs, 28 (12.8%) into community programs, and 11 (5%) into military programs. Conclusion A greater proportion of students from institutions with home programs matched into academic centers compared to orphan applicants (73% vs. 65.8%). A greater proportion of orphan applicants matched into community programs (12.8% vs. 8.3%).

Culture-Negative Fibrinous Peritonitis in a Postpartum Female.

Peritonitis is inflammation of the peritoneum that can arise from a number of complications affecting the lining of the abdominal wall and organs. Acute abdomen and peritonitis is a rare complication in a previously healthy woman following a seemingly uncomplicated normal full-term vaginal delivery. We report such a case in a 20-year-old gravida 2 para 2 (G2P2) woman of Guatemalan descent, who presented nine days postpartum following an uncomplicated delivery, to the emergency room with acute abdomen and associated systemic inflammatory reaction. Interventional radiology paracentesis was performed, yielding a milky, purulent peritoneal fluid with no visible organisms and negative cultures. Antibiotics and paracentesis were insufficient in managing her condition, which continued to worsen over the course of several days. Given her continued deterioration despite clinical intervention, she underwent an exploratory laparotomy and peritoneal lavage along with continued broad-spectrum antibiotics. Cultures continued to be negative but operative findings included diffuse fibrinous peritonitis with no obvious abscess or perforated abdominal viscus. Following surgical laparotomy, she recovered fully without any complications. We review the available literature regarding peritonitis, discuss its management, and speculate as to its cause in this case.

A Rare Case of Varicella-Zoster Virus Encephalitis Presenting With Lost Ability to Play the Piano in an Immunocompetent Pediatric Patient.

Varicella-zoster virus (VZV) is a member of the alpha-herpesvirus family, which can occasionally cause severe neurological complications such as encephalitis. In this case report, we discuss a rare finding of VZV encephalitis in which an immunocompetent pediatric patient, vaccinated against varicella, presented with altered mental status and no vesicular rash. A 15-year-old male presented to the Emergency Department with progressively worsening altered mental status over the past three days. The patient's mother stated that he was exhibiting frequent memory lapses as well as the sudden loss of the ability to play the piano. After admission to the pediatric general floor, lumbar puncture was performed and cerebrospinal fluid analysis returned positive for VZV, confirmed by polymerase chain reaction. The patient was then started on intravenous (IV) acyclovir at a dose of 650 mg every 8 hours to treat VZV-induced encephalitis. While the patient continued to have intermittent episodes of confusion and headaches, his overall condition improved, and by day 4, he was able to resume playing the piano and ukulele. The patient was discharged on day 8 with no home medications, and a follow-up with this primary care physician was scheduled. This patient is one of only four recorded cases of VZV encephalitis in immunocompetent children. It is extremely rare to encounter pediatric patients with this diagnosis and, as such, can elude physicians when developing differential diagnoses. If VZV is suspected, a lumbar puncture should be performed promptly, and, if confirmed, IV acyclovir should be started. Furthermore, this case highlights the need for future research with regard to VZV and potential predisposing factors in immunocompetent patients.

Is Intravascular Lithotripsy (IVL) Alone a Therapy for the Treatment of Aortoiliac Occlusive Disease (AIOD)?

We present a rare case in which a 63-year-old male with a history of hypertension, diabetes mellitus, hyperlipidemia, and previous coronary artery bypass graft (CABG) presented with bilateral external iliac artery near occlusion. We describe the utilization of lithotripsy balloon angioplasty as opposed to the traditional double-barrel stenting method or modified endovascular repair (EVAR) to treat the occlusion. Pre-operative computed tomography (CT) angiography demonstrated a 90 percent occlusion of both the distal aorta and right external iliac artery, and 99 percent occlusion of the left external iliac. The patient remains symptom-free three years post-intervention with normal right and left ankle-brachial indices, 1.34 and 1.32 respectively. We review the available literature regarding aortoiliac occlusive disease (AIOD) and discuss the advantages and disadvantages of novel and traditional treatment modalities. Understanding all treatment options is crucial for physicians who are presented with similar cases.

Hydropneumothorax as a Presentation of Birt-Hogg-Dubé Syndrome.

Birt-Hogg-Dubé syndrome (BHDS) is a rare genetic disorder characterized by cutaneous, pulmonary, and renal manifestations. We present a unique case in which a combination of multiple chronic illnesses, genetic testing, and significant family history led to a diagnosis of BHDS. A 72-year-old male patient presented to their primary care physician with a persistent cough of four months and was admitted to the emergency department after the discovery of a left hydropneumothorax. The patient's medical history was significant for recurrent spontaneous bilateral pneumothoraces diagnosed over 20 years ago, chronic obstructive pulmonary disease (COPD), and many other systemic illnesses. A combination of the patient's significant past medical and family history led to a diagnosis of BHDS. Genetic testing was also done to confirm the diagnosis. Despite benign skin lesions being the most common finding, they are not always present, as seen in our case, which can result in missed diagnosis. Due to the autosomal dominant nature of BHDS, it is vital to make an accurate diagnosis to allow for proper genetic counseling, as the development of renal cancer is the leading cause of mortality.

Current Surgical Techniques in the Treatment of Adult Developmental Dysplasia of the Hip.

The surgical protocols currently used for the treatment of developmental dysplasia of the hip (DDH) are varied, with sufficient differences in clinical outcomes that warrant a review of the role of practicing orthopedic surgeons. This paper aims to summarize the current novel techniques within the realm of surgical treatment for adult DDH, thus serving as a guide to surgeons looking to quickly familiarize themselves with available techniques. We performed computer systematic literature searches of the Embase and PubMed databases from 2010 to 2 April 2022. Study parameters as well as their respective patient reported outcomes (PROMs) were described in detail and compiled into diagrams. Two novel techniques were identified for the treatment of borderline or low-grade DDH. Six techniques which included modifications to the Bernese periacetabular osteotomy (PAO) were identified for the treatment of symptomatic DDH. Three techniques which include combinations of arthroscopy and osteotomy were identified for the treatment of DDH with concomitant hip pathologies such as cam deformities. Finally, six techniques, all of which are modifications to total hip arthroplasty (THA), were identified for the treatment of high-grade DDH. The techniques detailed in this review therefore equip surgeons with the necessary knowledge to improve outcomes in patients with varying degrees of DDH.

Complications and Outcomes of the Nuss Procedure in Adult Patients: A Systematic Review.

Pectus excavatum is a congenital chest wall deformity, commonly identified in early childhood, creating a "sunken chest" appearance. Over time, the deformity can worsen, thus impacting cardiopulmonary function and creating significant body image disturbance in patients. The Nuss procedure is a minimally invasive technique in which a curved steel bar is introduced underneath the sternum through small bilateral thoracic incisions to correct the deformity. Most studies regarding the procedure to date focus on outcomes and complications in pediatric patients, however, few studies discuss these results in adult patients. This systematic review aims to analyze common complications and outcomes in patients over the age of 18 who have not undergone any prior intervention for pectus excavatum. The most common complications experienced in adult patients were displacement of the implanted steel bar, infection of the surgical site, pneumothorax, pleural effusion, and chronic postoperative pain. Reoperation was common in patients with a displacement of the bar, chronic pain, and bleeding. Additionally, adult patients routinely required a higher number of steel bars to be placed to correct the deformity. Despite evidence that the rate of complications increases with age, the majority of adult patients in our included studies were satisfied with the outcome of the procedure with indications of improved self-image and reduced preoperative symptoms such as dyspnea on exertion, palpitations, chest pain, and depression.

Patient-Reported Outcomes and Factors Impacting Success of the Periacetabular Osteotomy.

Hip dysplasia is a condition affecting both infants and adults, characterized by a shallow acetabulum that does not sufficiently cover the head of the femur. This leads to instability of the hip and elevated levels of mechanical stress around the acetabular rim. A popular procedure for the correction of hip dysplasia is the periacetabular osteotomy (PAO), in which fluoroscopically guided osteotomies around the pelvis are made to allow for repositioning of the acetabulum to fit properly on the femoral head. This systematic review aims to analyze patient factors that impact outcomes, as well as patient-reported outcomes such as the Harris Hip Score (HHS) and the Western Ontario and McMaster Universities Arthritis Index (WOMAC). The patients in this review did not undergo any prior intervention for acetabular hip dysplasia, allowing for an unbiased reporting of outcomes from all included studies. Of studies reporting HHS, the mean preoperative HHS was 68.92 and the mean postoperative HHS was 89.1. Of the study that reported mHHS, the mean preoperative mHHS was 70, and the mean postoperative mHHS was 91. Of the studies reporting WOMAC, the mean preoperative WOMAC was 66, and the mean postoperative WOMAC was 63. Key findings of this review are that of the seven included studies, six achieved a minimally important clinical difference (MCID) based on patient-reported outcomes, and factors impacting outcome are preoperative Tönnis osteoarthritis (OA) grade, pre and postoperative lateral-center edge angle (LCEA), preoperative hip joint congruency, postoperative Tönnis angle, and age. In patients with no prior intervention for hip dysplasia, the PAO is a successful procedure with significant improvement in postoperative patient-reported outcomes. Despite the reported success of the PAO, proper patient selection is vital to avoid early conversions to total hip arthroplasty (THA) and prolonged pain. However, further investigation is prompted regarding the long-term survivorship of the PAO in patients with no prior intervention for hip dysplasia.

The Role of Sirtuin 1 (SIRT1) in Neurodegeneration.

Sirtuins (SIRT) are a class of histone deacetylases that regulate important metabolic pathways and play a role in several disease processes. Of the seven mammalian homologs currently identified, sirtuin 1 (SIRT1) is the best understood and most studied. It has been associated with several neurodegenerative diseases and cancers. As such, it has been further investigated as a therapeutic target in the treatment of disorders such as Parkinson's disease (PD), Huntington's disease (HD), and Alzheimer's disease (AD). SIRT1 deacetylates histones such as H1 lysine 26, H3 lysine 9, H3 lysine 56, and H4 lysine 16 to regulate chromatin remodeling and gene transcription. The homolog has also been observed to express contradictory responses to tumor suppression and tumor promotion. Studies have shown that SIRT1 may have anti-inflammatory properties by inhibiting the effects of NF-κB, as well as stimulating upregulation of autophagy. The SIRT1 activators resveratrol and cilostazol have been shown to improve Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog) scores in AD patients. In this review, we aim to explore the various roles of SIRT1 with regard to neuroprotection and neurodegeneration.