Patient reported outcomes and ankle plantarflexor muscle performance following gastrocnemius recession for Achilles tendinopathy: A prospective case-control study.

BACKGROUND: Prospective studies to guide the application of a gastrocnemius recession for Achilles tendinopathy are limited. Our aim was to prospectively evaluate patient reported outcomes and muscle performance. METHODS: Patients with unilateral recalcitrant Achilles tendinopathy who received an isolated gastrocnemius recession (n=8) and a healthy control group (n=8) were included. Patient reported outcomes, ankle power during walking and stair ascent, and the heel rise limb symmetry index (total work) were collected. RESULTS: Improvements in pain and self-reported function were observed (six months and two years). Sport participation scores reached 92% by two years. Patients demonstrated lower ankle power during stair ascent and decreased limb symmetry during heel rise six months following treatment (p≤.02). CONCLUSIONS: Study findings regarding long-term improvements in patient pain, self-reported function and sport participation, and early preservation of ankle function during walking, can help refine patient selection, anticipated outcomes, and rehabilitation strategies.

Continuous local anaesthetic wound infusion for postoperative pain after midline laparotomy for colorectal resection in adults.

BACKGROUND: Colorectal resection through a midline laparotomy is a commonly performed surgical procedure to treat various bowel conditions. The typical postoperative hospital stay after this operation is 6 to 10 days. The main factors hindering early recovery and discharge are thought to include postoperative pain and delayed return of bowel function.Continuous infusion of a local anaesthetic into tissues surrounding the surgical incision via a multi-lumen indwelling wound catheter placed by the surgeon prior to wound closure may reduce postoperative pain, opioid consumption, the time to return of bowel function, and the length of hospital stay. OBJECTIVES: To evaluate the efficacy and adverse events of continuous local anaesthetic wound infusion for postoperative pain after midline laparotomy for colorectal resection in adults. SEARCH METHODS: We searched the CENTRAL, MEDLINE and Embase databases to January 2019 to identify trials relevant to this review. We also searched reference lists of relevant trials and reviews for eligible trials. Additionally, we searched two clinical trials registers for ongoing trials. SELECTION CRITERIA: We considered randomised controlled trials (including non-standard designs) or quasi-randomised controlled trials comparing continuous wound infusion of a local anaesthetic versus a placebo or a sham after midline laparotomy for colorectal resection in adults. We did not compare continuous local anaesthetic wound infusion to other techniques, such as transverse abdominis plane block or thoracic epidural analgesia. We allowed non-randomised analgesic co-interventions carried out equally in the intervention and control groups. DATA COLLECTION AND ANALYSIS: Two review authors independently identified trials for inclusion and assessed their quality using the Cochrane 'Risk of bias' tool. We extracted data using standardised forms, including pain at rest and on movement (10-point scale), opioid consumption via a patient-controlled analgesia (PCA) system (mg morphine equivalent), postoperative opioid-related adverse events, the time to rescue analgesia, the time to first flatus and to first bowel movement, the time to ambulation, the length of hospital stay, serious postoperative adverse events, and patient satisfaction. We quantitatively synthesised the data by meta-analysis. We summarised and graded the certainty of the evidence for critical outcomes using the GRADEpro tool and created a 'Summary of findings' table. MAIN RESULTS: This review included six randomised controlled trials that enrolled a total of 564 adults undergoing elective midline laparotomy for colorectal resection comparing continuous wound infusion of a local anaesthetic to a normal saline placebo. Due to 23 post-randomisation exclusions, a total of 541 participants contributed data to the analysis of at least one outcome (local anaesthetic 268; control 273). Most participants were aged 55 to 65 years, with normal body mass index and low to moderate anaesthetic risk (American Society of Anesthesiologists class I-III). Random sequence generation, allocation concealment, and blinding were appropriately carried out in most trials. However, we had to downgrade the certainty of the evidence for most outcomes due to serious study limitations (risk of bias), inconsistency, indirectness, imprecision and reporting bias.Primary outcomesOn postoperative day 1, pain at rest (mean difference (MD) -0.59 (from 3.1), 95% confidence interval (CI) -1.12 to -0.07; 5 studies, 511 participants; high-certainty evidence), pain on movement (MD -1.1 (from 6.1), 95% CI -2.3 to -0.01; 3 studies, 407 participants; low-certainty evidence) and opioid consumption via PCA (MD -12 mg (from 41 mg), 95% CI -20 to -4; 6 studies, 528 participants; moderate-certainty evidence) were reduced in the local anaesthetic group compared to the control group.Secondary outcomesThere was a reduction in the time to first bowel movement (MD -0.67 from 4.4 days, 95% CI -1.17 to -0.17; 4 studies, 197 participants; moderate-certainty evidence) and the length of hospital stay (MD -1.2 from 7.4 days, 95% CI -2.0 to -0.3; 4 studies, 456 participants; high-certainty evidence) in the local anaesthetic group compared to the control group.There was no evidence of a difference in any serious postoperative adverse events until hospital discharge (RR 1.04, 95% CI 0.68 to 1.58; 6 studies, 541 participants; low-certainty evidence) between the two study groups. AUTHORS' CONCLUSIONS: After elective midline laparotomy for colorectal resection, continuous wound infusion of a local anaesthetic compared to a normal saline placebo reduces postoperative pain at rest and the length of hospital stay, on the basis of high-certainty evidence. This means we are very confident that the effect estimates for these outcomes lie close to the true effects. There is moderate-certainty evidence to indicate that the intervention probably reduces opioid consumption via PCA and the time to first bowel movement. This means we are moderately confident that effect estimates for these outcomes are likely to be close to the true effects, but there is a possibility that they are substantially different. The intervention may reduce postoperative pain on movement, however, this conclusion is based on low-certainty evidence. This means our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect. There is low-certainty evidence to indicate that the intervention may have little or no effect on the rates of any serious postoperative adverse events until hospital discharge. High-quality randomised controlled trials to evaluate the intervention with a focus on important clinical and patient-centred outcomes are needed.

Musculoskeletal Medicine Is Underrepresented in the American Medical School Clinical Curriculum.

BACKGROUND: Musculoskeletal (MSK) conditions are common, and their burden on the healthcare system is increasing as the general population ages. It is essential that medical students be well prepared to evaluate and treat MSK disorders in a confident manner as they enter the workforce. Recent studies and the American Association of Medical Colleges have raised concern that medical schools may not give sufficient instruction on this topic. Other authors have shown that preclinical instruction has increased over the past decade; however, it is unclear if required clinical instruction also has followed that trend. QUESTIONS/PURPOSES: The purposes of this study were: (1) to assess the presence and duration of required or selective instruction in a MSK medicine specialty within the clinical years of undergraduate medical education; and (2) to assess the current state of requirements of clinical clerkships or rotations in other surgical and nonsurgical fields for comparison with the initial findings. METHODS: The web sites of all 141 US medical schools were assessed to determine the content of their clinical curricula for the 2014-2015 academic year; five were excluded because they had not yet had a graduating class by the conclusion of the 2014-2015 academic year. Complete information on required rotations was obtained through the schools' web sites for all 136 (100%) medical schools. For selective experience during the surgery clerkships, complete information was available for 130 of the remaining 136 (96%) web sites. RESULTS: Mean (in weeks, ± SD) duration of core clerkships were as follows: internal medicine (10 ± 2), surgery (8 ± 2), pediatrics (7 ± 1), obstetrics/gynecology (6 ± 1), and psychiatry (5 ± 1). Other common required clerkships were: family medicine (required in 96% [131 of 136] of schools, mean duration of 6 ± 2 weeks), neurology (81% [110], 4 ± 1), and emergency medicine (55% [75], 3 ± 1). Required MSK instruction, at a mean of 2 ± 1 weeks, was only present in 15% (20 of 136) of medical schools. In addition, clinical MSK instruction was offered as a selective (eg, students pick from a selection of subspecialties such as orthopaedics, plastics, or urology during a general surgery clerkship) in 34% (44 of 130) of all medical schools. This is less than other non-core specialties: geriatrics/ambulatory care (required in 40% [54 of 136] of schools, mean duration of 3 ± 1 weeks), critical care (30% [41], mean of 3 ± 1 weeks), radiology (26% [35], mean of 3 ± 1 weeks), anesthesiology (23% [31], mean of 2 ± 1 weeks), and other surgical subspecialties (19% [26], mean of 3 ± 1weeks). CONCLUSIONS: Traditional core clerkships continue to be well represented in the clinical years, whereas three newer specialties have gained a larger presence: family medicine, neurology, and emergency medicine; these comprise the "big eight" of clinical clerkships. Given the high prevalence and burden of MSK disorders, required experience in MSK medicine continues to be underrepresented. Further discussion at a national level is needed to determine appropriate representation of MSK medicine specialties during the clinical years.

Achilles Allograft Fiber Track Graft Preparation Technique for Anterior Cruciate Ligament Reconstruction.

Anterior cruciate ligament rupture is a common orthopaedic injury, with reconstruction the treatment of choice for active individuals. Graft selection is an important consideration for surgical planning. Achilles tendon allograft is a graft choice most likely used in cases of revision anterior cruciate ligament reconstruction. This technical note discusses an approach to Achilles tendon allograft preparation that respects and follows the rotation of the fibers of the Achilles tendon. Key considerations in the use of this technique include (1) identifying the rotational fiber tracks, (2) performing careful dissection along the identified tracks of the fibers, and (3) ensuring an appropriate graft width based on patient size, all of which are crucial for the success of this unique technique. The preservation of the rotational fibers provided by this technique may have the potential to result in increased tensile strength and better clinical outcomes.

Heat Transfer Enhancement by Hybrid Nano Additives-Graphene Nanoplatelets/Cellulose Nanocrystal for the Automobile Cooling System (Radiator).

A radiator is used to remove a portion of the heat generated by a vehicle engine. It is challenging to efficiently maintain the heat transfer in an automotive cooling system even though both internal and external systems need enough time to keep pace with catching up with evolving engine technology advancements. The effectiveness of a unique hybrid's heat transfer nanofluid was investigated in this study. The hybrid nanofluid was mainly composed of graphene nanoplatelets (GnP), and cellulose nanocrystals (CNC) nanoparticles suspended in a 40:60 ratio of distilled water and ethylene glycol. A counterflow radiator equipped with a test rig setup was used to evaluate the hybrid nano fluid's thermal performance. According to the findings, the proposed GNP/CNC hybrid nanofluid performs better in relation to improving the efficiency of heat transfer of a vehicle radiator. The suggested hybrid nanofluid enhanced convective heat transfer coefficient by 51.91%, overall heat transfer coefficient by 46.72%, and pressure drop by 34.06% with respect to distilled water base fluid. Additionally, the radiator could reach a better CHTC with 0.01% hybrid nanofluid in the optimized radiator tube by the size reduction assessment using computational fluid analysis. In addition to downsizing the radiator tube and increasing cooling capacity over typical coolants, the radiator takes up less space and helps to lower the weight of a vehicle engine. As a result, the suggested unique hybrid graphene nanoplatelets/cellulose nanocrystal-based nanofluids perform better in heat transfer enhancement in automobiles.

Does Patient-Reported Outcome Measures Use at New Foot and Ankle Patient Clinic Visits Improve Patient Activation, Experience, and Satisfaction?

BACKGROUND: Patient-reported outcome measures (PROMs) can help predict clinical outcomes and improve shared clinical decision-making discussions. There remains a paucity of research assessing how the use of PROMs may drive improved patient experience and patient activation. METHODS: New foot and ankle patients completed PROMIS physical function (PF), pain interference (PI), and depression assessments. Patients were then randomized to viewing and discussing their PROMIS scores with their surgeon or not. Following the clinic visit, patients completed a series of Clinician & Group Survey-Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) questions and the Patient Activation Measure (PAM). Responses to the CG-CAHPS questions and PAM were compared between the 2 groups and after clustering on surgeon. Potential interaction effects by social deprivation were also explored. RESULTS: After enrolling patients but removing those lost to follow-up or with missing data, 97 and 116 patients remained in the intervention control cohorts, respectively. No difference was found in CG-CAHPS responses nor PAM scores between the 2 groups (P > .05). All surgeons were highly rated by all patients. When clustered by surgeon, intervention subjects were less likely to indicate "top box" scores for the understanding domain of the CG-CAHPS question (OR 0.51, P < .001) and had decreased odds of high patient activation compared to control subjects (OR 0.67; P = .005). Among the most socially disadvantaged patients, there was no difference in control and intervention subjects in their likelihood of having high patient activation (P = .09). CONCLUSION: Highly rated foot and ankle surgeons who show and discuss PROM results may not improve patient experience or activation and may, in fact, decrease understanding or patient activation in select populations. Future work is needed to determine when PROM discussions are most beneficial and how best to present PROMs data, as we suspect that how the information was presented-and not the use of PROMs-resulted in our findings. Health literacy tools and/or communication training may better engage different patient groups regarding PROMs. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Advancing renewable fuel integration: A comprehensive response surface methodology approach for internal combustion engine performance and emissions optimization.

In the realm of internal combustion engines, there is a growing utilization of alternative renewable fuels as substitutes for traditional diesel and gasoline. This surge in demand is driven by the imperative to diminish fuel consumption and adhere to stringent regulations concerning engine emissions. Sole reliance on experimental analysis is inadequate to effectively address combustion, performance, and emission issues in engines. Consequently, the integration of engine modelling, grounded in machine learning methodologies and statistical data through the response surface method (RSM), has become increasingly significant for enhanced analytical outcomes. This study aims to explore the contemporary applications of RSM in assessing the feasibility of a wide range of renewable alternative fuels for internal combustion engines. Initially, the study outlines the fundamental principles and procedural steps of RSM, offering readers an introduction to this multifaceted statistical technique. Subsequently, the study delves into a comprehensive examination of the recent applications of alternative renewable fuels, focusing on their impact on combustion, performance, and emissions in the domain of internal combustion engines. Furthermore, the study sheds light on the advantages and limitations of employing RSM, and discusses the potential of combining RSM with other modelling techniques to optimise results. The overarching objective is to provide a thorough insight into the role and efficacy of RSM in the evaluation of renewable alternative fuels, thereby contributing to the ongoing discourse in the field of internal combustion engines.

Antibody titers of individuals vaccinated for COVID-19: A systematic review.

An important preventive measure to mitigate the COVID-19 pandemic is vaccine implementation. In creating vaccines, evoking neutralizing antibody (NAb) production is the main objective. This review determines and compares the NAb titers produced by COVID-19 vaccine recipients based on the vaccine type and the manner of administration. This review includes published articles on studies with healthy participants with a minimum age of 18 years, without previous infections, and those who were given Emergency Use License (EUL) vaccines from WHO. Bias assessment was performed using the Cochrane Risk of Bias and the Newcastle- Ottawa Scale. In all the studies, 40.82% of the primary doses were viral vector platforms. For booster doses, 50% were mRNA platforms. Messenger RNA (mRNA) vaccines have higher titers as homologous than as heterologous vaccines. However, inactivated vaccines and viral vector vaccines have lower titers as homologous than as heterologous vaccines. Meanwhile, subunit vaccines lack data for their titers. Based on the antibody titers, homologous mRNA vaccines are more viral-protective than their heterologous counterparts. Heterologous inactivated and viral vector vaccines are more protective than homologous combinations, mainly when mRNA is the other type in those heterologous combinations. This is because mRNA vaccines elicit higher immunogenicity compared to other types.

Preferred management of recalcitrant plantar fasciitis among orthopaedic foot and ankle surgeons.

BACKGROUND: There are a number of different treatment options available for recalcitrant plantar fasciitis, with limited high-level evidence to guide nonoperative and operative treatment methods. The purpose of this study was to determine the current preferred nonoperative and operative treatment methods for recalcitrant plantar fasciitis by a group of experienced orthopaedic foot and ankle surgeons. METHODS: A hypothetical patient with recalcitrant plantar fasciitis was developed as the basis for a survey comprised of seven questions. The questions related to the surgeon's preferred treatment after 4~months of failed nonoperative management and then after 10 months of recalcitrant symptoms. The survey was sent to committee members of the American Orthopaedic Foot and Ankle Society (AOFAS). RESULTS: Eighty-four orthopaedic surgeons completed the survey (84 out of 116; response rate=72%). At the 4-month visit, when questioned regarding their most preferred next step in management, 37 (44%) respondents favored initiation of plantar fascia-specific stretching (PFSS), 20 (24%) supervised physical therapy, 17 (20%) night splinting, five (6%) steroid injection, three (4%) custom orthotics, and two (2%) cast or boot immobilization. With ongoing symptoms at 10~months, 62 (74%) respondents chose surgery or ECSWT (extracorporeal shock wave therapy) as their next step in management. Some form of surgery (alone or in combination) was chosen by 46 (55%) respondents. The most popular operative interventions were gastrocnemius recession (alone or in combination with another procedure) and open partial plantar fascia release with nerve decompression. CONCLUSIONS: For shorter duration symptoms, tissue-specific stretching and conditioning methods were favored over anti-inflammatory or structural support modalities which is consistent with available high-level evidence studies. Heterogeneity of operative preferences for chronic symptoms highlighted the need for further high-quality studies.

Scapular winging: an update.

Scapular winging is a rare disorder often caused by neuromuscular imbalance in the scapulothoracic stabilizer muscles. Lesions of the long thoracic nerve and spinal accessory nerves are the most common cause. Numerous underlying etiologies have been described. Patients report diffuse neck, shoulder girdle, and upper back pain, which may be debilitating, associated with abduction and overhead activities. Accurate diagnosis and detection depend on appreciation of the scapulothoracic anatomy and a comprehensive physical examination. Although most cases resolve nonsurgically, surgical treatment of scapular winging has been met with success.

Implementation and Evaluation of a Formal Virtual Medical Student Away Rotation in Orthopaedic Surgery During the COVID-19 Pandemic: A Single Institution Pilot Experience.

Away rotations are a valuable experience for medical students when applying for residency. In light of the coronavirus disease 2019 pandemic, there has been significant interest in the development of virtually based substitutes. This study evaluates the utility of a formal virtual fourth-year medical student away rotation in orthopaedic surgery by surveying participants and provides recommendations for success. METHODS: A 2-week virtual orthopaedic elective was offered to fourth-year medical students in lieu of traditional in-person away rotations. The course consisted of multiple components such as subspecialty case-based didactics, "happy hours" with residents, assigned resident mentors, student case presentations, and observation of resident lectures. After course completion, anonymous surveys were administered to participants to evaluate the rotation. RESULTS: Twenty-three of 24 participating students (96%) completed the student survey, and 22 of 24 participating faculty and residents (82%) completed the resident/faculty survey. Most students were very (87%) or somewhat (9%) satisfied with their experience and found the rotation to be a very (35%) or somewhat useful (61%) substitute for an in-person rotation. Students indicated that the rotation very (91%) or somewhat positively (9%) influenced their perception of the program. All students indicated that the rotation was very educational. Most students (91%) reported that the rotation was very useful for learning about the program and culture, with subspecialty didactics and happy hours most useful. Faculty and residents indicated that the rotation was useful for getting to know the students (17% "very useful" and 83% "somewhat useful") and for assessing student characteristics, such as knowledge base and communication skills. CONCLUSIONS: A formal virtual orthopaedic surgery away rotation can be a valuable experience for medical students which provides educational value, insight into program culture, and an opportunity to demonstrate interest in the program. The curriculum and recommendations presented in this study can be used as a preliminary template for others interested in creating successful virtual rotations.

Increasing the Educational Value of the Orthopaedic Subinternship: The Design and Implementation of a Fourth-Year Medical Student Curriculum.

INTRODUCTION: Most orthopaedic subinternships function as month-long interviews. These rotations remain relatively unstructured and lack standardization, and their overall educational value has been called into question. The goals of this educational initiative were to create a structured subinternship curriculum for orthopaedic applicants and to shift the focus of the subinternship from a month-long interview to an organized educational experience. METHODS: After review of knowledge and skills expected for early orthopaedic residency under the structure of the Accreditation Council for Graduate Medical Education Milestones, a curriculum dedicated to orthopaedic subinternships was created. Students who completed the curriculum filled out anonymous Likert scale evaluations (rating their comfort/knowledge from 0 to 10 before and after their rotation) and answered open-ended qualitative questions. RESULTS: Forty-six subinterns participated in the program over 3 years. Four weekly learning modules were designed and taught by orthopaedic residents, with faculty oversight of content and structure. Each monthly rotation began with an orthopaedic surgical skills laboratory and concluded with a case-based oral presentation. Weeks two and three covered different milestone-based topics and included didactic and skills development. Data analysis revealed that students reported notable improvement in knowledge and familiarity with each of the topics. The greatest improvements were in tibia intramedullary nailing and applying a tension band to an olecranon fracture. When asked which surgical skills station was the most helpful, 70% chose lag screw insertion and basic plating techniques. All students felt that creating their case presentation was productive. CONCLUSION: This educational initiative resulted in the successful design and implementation of a milestone-based orthopaedic surgery subinternship curriculum. The program was well received by students, contributed to learning and competency, and provided teaching opportunities for residents. The format and content of this subinternship curriculum can easily be adapted to regional and national teaching programs.

Physical Function and Pain Interference Levels of Hallux Rigidus Patients Before and After Synthetic Cartilage Implant vs Arthrodesis Surgery.

BACKGROUND: Hallux rigidus is a common and painful degenerative condition of the great toe limiting a patient's physical function and quality of life. The purpose of this study was to investigate pre- and postoperative physical function (PF) and pain interference (PI) levels of patients undergoing synthetic cartilage implant hemiarthroplasty (SCI) vs arthrodesis (AD) for treatment of hallux rigidus using the Patient-Reported Outcomes Measurement Information System (PROMIS). METHODS: PROMIS PF and PI t scores were analyzed for patients who underwent either SCI or AD. Postoperative final PROMIS t scores were obtained via phone survey. Linear mixed model analysis was used to assess differences in PF and PI at each follow-up point. Final follow-up scores were analyzed using independent sample t tests. RESULTS: Total 181 (59 SCI, 122 AD) operatively managed patients were included for analysis of PROMIS scores. Final phone survey was performed at a minimum of 14 (mean 33, range, 14-59) months postoperatively, with 101 patients (40 SCI, 61 AD) successfully contacted. The mean final follow-up was significantly different for SCI and AD: 27 vs 38 months, respectively (P < .01). The mean age of the SCI cohort was lower than the AD cohort (57.5 vs 61.5 years old, P = .01). Average PF t scores were higher in the SCI cohort at baseline (47.1 and 43.9, respectively, P = .01) and at final follow-up (51.4 vs 45.9, respectively, P < .01). A main effect of superior improvement in PF was noted in the SCI group (+4.3) vs the AD group (+2) across time intervals (P < .01). PI t scores were similar between the 2 procedures across time points. CONCLUSION: The SCI cohort reported slightly superior PF t scores preoperatively and at most follow-up time points compared with the arthrodesis group. No differences were found for PI or complication rates between the 2 treatment groups during this study time frame. LEVEL OF EVIDENCE: Level IV, case series.

Foot and ankle experience in orthopedic residency: an update.

BACKGROUND: In 2003, a limited survey regarding the number of dedicated foot and ankle faculty and foot and ankle rotations at orthopaedic surgery residency programs was published. The purpose of this paper was to update the results of that previous survey and provide additional, more in-depth information. MATERIALS AND METHODS: A survey questionnaire was emailed to the program directors and chairpersons of the 150 ACGME-accredited orthopaedic residency training programs in the United States. RESULTS: Responses were obtained from all programs. One hundred thirty-seven (91.3%) programs had one or more orthopaedic surgeon faculty members with a predominantly foot and ankle practice (at least 50%), an increase of 5.5 percentage points from the survey performed 6 years previously. One hundred forty three (95.3%) programs had one or more orthopaedic surgeon faculty members with a practice consisting of at least 25% foot and ankle. One hundred twenty programs (80%) had one or more dedicated foot and ankle rotations, an increase of 15.1% from 6 years prior. Orthopaedic surgery residents were felt to spend a mean of 30.4% and a median of 20% of their time with board-certified/ board-eligible orthopaedic surgeons in rotations that include treatment of foot and ankle pathology but were not considered ;;dedicated'' foot and ankle rotations. CONCLUSIONS: The number of orthopaedic surgery residency programs with rotations and faculty members dedicated to foot and ankle education has increased over the 6 years between surveys. Orthopaedic surgery residents' experience and skill development in foot and ankle surgery during their 5 years of residency training are not limited to their time spent in dedicated foot and ankle rotations.

Thermal Performance of Hybrid-Inspired Coolant for Radiator Application.

Due to the increasing demand in industrial application, nanofluids have attracted the considerable attention of researchers in recent decades. The addition of nanocellulose (CNC) with water (W) and ethylene glycol (EG) to a coolant for a radiator application exhibits beneficial properties to improve the efficiency of the radiator. The focus of the present work was to investigate the performance of mono or hybrid metal oxide such as Al2O3 and TiO2 with or without plant base-extracted CNC with varying concentrations as a better heat transfer nanofluid in comparison to distilled water as a radiator coolant. The CNC is dispersed in the base fluid of EG and W with a 60:40 ratio. The highest absorption peak was noticed at 0.9% volume concentration of TiO2, Al2O3, CNC, Al2O3/TiO2, and Al2O3/CNC nanofluids which indicates a better stability of the nanofluids' suspension. Better thermal conductivity improvement was observed for the Al2O3 nanofluids in all mono nanofluids followed by the CNC and TiO2 nanofluids, respectively. The thermal conductivity of the Al2O3/CNC hybrid nanofluids with 0.9% volume concentration was found to be superior than that of the Al2O3/TiO2 hybrid nanofluids. Al2O3/CNC hybrid nanofluid dominates over other mono and hybrid nanofluids in terms of viscosity at all volume concentrations. CNC nanofluids (all volume concentrations) exhibited the highest specific heat capacity than other mono nanofluids. Additionally, in both hybrid nanofluids, Al2O3/CNC showed the lowest specific heat capacity. The optimized volume concentration from the statistical analytical tool was found to be 0.5%. The experimental results show that the heat transfer coefficient, convective heat transfer, Reynolds number and the Nusselt number have a proportional relationship with the volumetric flow rate. Hybrid nanofluids exhibit better thermal conductivity than mono nanofluids. For instance, a better thermal conductivity improvement was shown by the mono Al2O3 nanofluids than the CNC and TiO2 nanofluids. On the other hand, superior thermal conductivity was observed for the Al2O3/CNC hybrid nanofluids compared to the other mono and hybrid ones (Al2O3/TiO2).

Changes in Muscle Morphology Following Gastrocnemius Recession for Achilles Tendinopathy: A Prospective Cohort Imaging Study.

Background. The purpose of this study was to evaluate changes in posterior compartment muscle volume and intramuscular fat content following gastrocnemius recession in people with Achilles tendinopathy (AT). Methods. Eight patients diagnosed with unilateral recalcitrant AT and an isolated gastrocnemius contracture participated in this prospective cohort study. Magnetic resonance imaging was performed on both limbs of each participant before and 6 months following an isolated gastrocnemius recession. Involved limb muscle volumes and fat fractions (FFs) of the medial gastrocnemius, lateral gastrocnemius, and soleus muscle were normalized to the uninvolved limb. Preoperative to postoperative comparisons were made with Wilcoxon signed-rank tests. Results. Soleus or lateral gastrocnemius muscle volumes or FFs were not significantly different between study time points. A significant difference was found in medial gastrocnemius muscle volume (decrease; P = .012) and FF (increase; P = .017). Conclusion. A major goal of the Strayer gastrocnemius recession, selective lengthening of the posterior compartment while preserving soleus muscle morphology, was supported. The observed changes isolated to the medial gastrocnemius muscle may reduce ankle plantarflexion torque capacity. Study findings may help inform selection of surgical candidates, refine anticipated outcomes, and better direct postoperative rehabilitation following gastrocnemius recession for AT.Levels of Evidence: Level IV: Prospective cohort study.

A Comparative Analysis of Clinical Outcomes in Noninsertional Versus Insertional Tendinopathy Using PROMIS.

Background. Achilles tendinopathy is a common clinical disorder. Utilizing the Patient-Reported Outcomes Measurement Information System, we aim to determine clinical response to nonoperative achilles tendinopathy rehabilitative care of insertional achilles tendinopathy compared to non-insertional achilles tendinopathy. Methods. Prospective Patient-Reported Outcomes Measurement Information System Physical Function, Pain Interference, and Depression scores were collected for patients with achilles tendinopathy at presentation and following a standard course of nonoperative care. A distribution-based method was used to determine the minimal clinically important difference. Descriptive statistics were reported and bivariate analysis was used to compare insertional achilles tendinopathy and non-insertional achilles tendinopathy. Receiver operating characteristic curve analysis was used to predict clinical improvement. Results. A total of 102 patients with an average follow-up of 68 days were included. For the non-insertional achilles tendinopathy group: Fifteen (46%), 12 (36%) and 9 (27%) patients reached clinical improvement for Physical Function, Pain Interference and Depression, respectively. For the insertional achilles tendinopathy group: Seventeen (25%), 20 (29%) and 22 (32%) patients reached clinical improvement for Physical Function, Pain Interference and Depression, respectively. Physical Function scores improved more in non-insertional achilles tendinopathy patients (4.0 vs. -0.046; p = 0.035) and more patients clinically improved (45.5% vs. 24.6%; p = 0.034). Patients with non-insertional and insertional achilles tendinopathy clinically improved functionally when initial Physical Function scores were equal to or lower than 40.25 and 38.08, respectively. Conclusions. Nonoperative care in achilles tendinopathy is often successful. The Patient-Reported Outcomes Measurement Information System can be used to evaluate and help determine clinical success. Levels of Evidence: Level II: Prospective comparative study.

PROMIS Pain Interference Is Superior vs Numeric Pain Rating Scale for Pain Assessment in Foot and Ankle Patients.

BACKGROUND:: The Numeric Pain Rating Scale (NPRS) is a popular method to assess pain. Recently, the Patient-Reported Outcomes Measurement Information System (PROMIS) has been suggested to be more accurate in measuring pain. This study aimed to compare NPRS and PROMIS Pain Interference (PI) scores in a population of foot and ankle patients to determine which method demonstrated a stronger correlation with preoperative and postoperative function, as measured by PROMIS Physical Function (PF). METHODS:: Prospective PROMIS PF and PI and NPRS data were obtained for 8 common elective foot and ankle surgical procedures. Data were collected preoperatively and postoperatively at a follow-up visit at least 6 months after surgery. Spearman correlation coefficients were calculated to determine the relationship among NPRS (0-10) and PROMIS domains (PI, PF) pre- and postoperatively. A total of 500 patients fit our inclusion criteria. RESULTS:: PROMIS PF demonstrated a stronger correlation to PROMIS PI in both the pre- and postoperative settings (preoperative: ρ = -0.66; postoperative: ρ = -0.69) compared with the NPRS (preoperative: ρ = -0.32; postoperative:ρ = -0.33). Similar results were found when data were grouped by Current Procedural Terminology (CPT) code. CONCLUSION:: PROMIS PI was a superior tool to gauge a patient's preoperative level of pain and functional ability. This information may assist surgeons and patients in setting postoperative functional expectations and pain management. LEVEL OF EVIDENCE:: Level II, prognostic.

Depressive and Anxiety Symptoms among Pediatric In-Patients with Dengue Fever: A Case-Control Study.

BACKGROUND: Psychiatric symptoms have been reported in adult patients with dengue fever (DF); however, information on pediatric patients remains inadequate. We sought to identify the prevalence and predictors of depressive and anxiety symptoms and identify other psychiatric symptoms among pediatric patients with DF. This case-control study involved pediatric in-patients (n = 225) who had clinical or serologic-confirmed DF and healthy school-based controls (n = 260). Participants completed the Revised Child Anxiety and Depression Scale (RCADS). RESULTS: The prevalence of depressive (13.3%) and anxiety (34.2%) symptoms among pediatric patients with DF was significantly (p < 0.001) higher than that among controls (3.5% and 16.2%, respectively). Multiple linear regression analysis found that age, family history of DF, ≤2 days of hospitalization, myalgia, and arthralgia were predictors of increased depressive and anxiety symptoms among the patients. Further, 26.7% of pediatric patients reported irritability, agitation, visual hallucinations, and aggressiveness. CONCLUSION: Pediatric patients present depressive and anxiety symptoms whose levels were associated with social and clinical factors. However, whether these symptoms are present only during the infection or may still persist after recovery or are brought by children's adverse reactions to hospitalization are unknown, and thus, further studies are needed.

Knowledge, Attitude, and Practices Regarding Dengue Fever among Pediatric and Adult In-Patients in Metro Manila, Philippines.

BACKGROUND: Knowledge, attitude, and practice (KAP) of in-patients with dengue fever (DF) through hospital-based surveillance has not been done. This study aimed to assess and compare the KAP, identify its predictors, correlation, and protective factors among pediatric and adult patients with DF and community-based controls to structure proactive community-wide DF prevention and control programs. METHODS: This case-control study involved clinically or serologically confirmed patients (pediatrics n = 233; adults n = 17) with DF admitted in three public hospitals and community-based controls in Metro Manila, Philippines. A pretested structured KAP questionnaire was administered to participants to assess their KAP. RESULTS: Pediatric and adult patients had significantly lower mean scores in the practice (p < 0.001) domain compared with the pediatric and adult controls. Being in senior high school, having had days in hospital, and rash were predictors of KAP among pediatric patients. Knowledge and attitude of patients with DF did not correlate with their practices against DF. Use of mosquito-eating fish, screen windows, and dengue vaccine were protective factors against DF. CONCLUSION: The study highlights the importance of behavioral change for knowledge and attitude to have significant effect to practices against DF. Thus, we recommend two comprehensive health programs, Communication for Behavioral Impact (COMBI) and Health Belief Model (HBM).