Quadriceps tendon autograft ACL reconstruction has less pivot shift laxity and lower failure rates than hamstring tendon autografts.

PURPOSE: Quadriceps tendon (QT) autograft ACL reconstruction was hypothesized to possess less anterior knee laxity, pivot shift laxity, and lower failure rates than hamstring tendon (HT) autografts. METHODS: Terms "hamstring tendon autograft" and "ACL reconstruction" or "quadriceps tendon autograft" and "ACL reconstruction" were searched in Embase and PubMed. Inclusion criteria required that studies included patients treated for primary ACL injury with reconstruction using either a QT autograft (Group 1) or a HT autograft (Group 2) and instrumented anterior knee laxity assessment. Extracted information included surgical fixation method, graft type, graft thickness or diameter, single vs. double bundle surgical method, publication year, time between the index knee injury and surgery, % women, initial and final subject number, subject age, follow-up length, side-to-side anterior knee laxity difference, Lysholm Score, Subjective IKDC score, anterior knee laxity side-to-side difference grade, ipsilateral pivot shift laxity grade, and failure rate. The Methodological Index for Nonrandomized Studies was used to evaluate study methodological quality. RESULTS: The QT group (Group 1) had 17 studies and the HT group (Group 2) had 61 studies. Overall, Group 2 had greater pivot shift laxity (OR 1.29, 95% CI 1.05-1.59, p = 0.005). Group 2 suspensory femoral fixation had greater pivot shift laxity (OR 1.26, 95% CI 1.01-1.58, p = 0.02) than Group 1 compression femoral fixation. Group 2 compression femoral fixation also had more anterior knee laxity (OR 1.25, 95% CI 1.03-1.52, p = 0.01) than Group 1 compression femoral fixation and higher failure rates based on initial (OR 1.69, 95% CI 1.18-2.4, p = 0.002) and final (OR 1.89, 95% CI 1.32-2.71, p = 0.0003) subject number. Failure rate for HT compression femoral fixation was greater than suspensory femoral fixation based on initial (OR 2.08, 95% CI 1.52-2.84, p < 0.0001) and final (OR 2.26, 95% CI 1.63-3.16, p < 0.0001) subject number. CONCLUSIONS: Overall, QT autografts had less pivot shift laxity and lower failure rates based on final subject number than HT autografts. Compression QT autograft femoral fixation had lower pivot shift laxity than suspensory HT autograft femoral fixation. Compression QT autograft femoral fixation had less anterior knee laxity and lower failure rates than compression HT autograft femoral fixation. Suspensory HT autograft femoral fixation had lower failure rates than compression HT autograft femoral fixation. Greater knee laxity and failure rates may be related to a combination of HT autograft diameter and configuration (tissue quality and dimensions, strands, bundles, and suturing method) variability and fixation mode. LEVEL OF EVIDENCE: Level IV.

Cementless Tapered Femoral Stems for Total Hip Arthroplasty in Octogenarians.

BACKGROUND: The use of cementless femoral components has become the standard in younger patients due to increased implant survivorship and decreased loosening. However, it remains controversial whether these femoral stems can provide comparable results in elderly patients. Therefore, our purpose was to compare the (1) incidence of revisions; (2) clinical outcomes; (3) incidence of postoperative blood transfusions; and (4) differences in complications between the 2 cohorts. METHODS: Seventy-four consecutive patients (78 hips) aged 80 years or older, who underwent primary total hip arthroplasty using a cementless, tapered, femoral stem were retrospectively compared with a matched cohort of 76 patients (78 hips) who were less than 80 years. Mean age was 83 years (range, 80-91 years) vs 59 years (range, 17-79 years) for the matched group. Minimum follow-up was 2 years. Revision rates, clinical outcomes using the Harris Hip Score, incidences of complications, and postoperative transfusion rates were evaluated. RESULTS: In the octogenarian cohort, the aseptic survivorship was 99%, compared with 95% in the matched group. There were 2 aseptic loosenings (2.6%): 1 femoral implant loosening (1.3%) and 1 acetabular loosening, but only 1 revision was performed, as one of the patients declined revision surgery. In the matched cohort, there were 6 revisions (7.7%). There were no significant differences in revision rates between the 2 cohorts, and no significant differences in final Harris Hip Score scores. The incidence of blood transfusion in the study group was 42% vs 19% in control group (P < .01). CONCLUSION: The use of cementless, tapered, femoral stems yielded excellent results in the octogenarian group, although adequate patient preoperative optimization is necessary given the significantly higher transfusion incidence.

Embracing 21st Century Information Sharing: Defining a New Paradigm for the Food and Drug Administration's Regulation of Biopharmaceutical Company Communications with Healthcare Professionals.

The Food and Drug Administration (FDA) plays a unique role in protecting the public health and minimizing the risk of the distribution of unsafe or ineffective medicines in the United States. Perhaps equally as important for public health, however, is the need for healthcare professionals to be well informed about the benefits and risks of the medicines they prescribe. In this way, information sharing is critical to healthcare delivery. FDA's current interpretation of laws and regulations governing healthcare communications prohibits biopharmaceutical companies from sharing certain accurate, data-driven information about FDA-approved uses and medically accepted alternative uses of FDA-approved drugs with healthcare professionals. Often, these uses are the standard of care for good medical practice and are, accordingly, reimbursed under the federal healthcare programs. FDA has failed to describe adequately how manufacturers can share truthful and non-misleading information about such uses with healthcare professionals and formulary decision makers. This failure could impede medical innovation, negatively impact patient care, and increase healthcare costs. To improve public health, FDA should reform its current approach and provide manufacturers with a clear safe harbor on how to share data and information on both approved uses and medically accepted alternative uses of FDA-approved drugs with healthcare professionals. This Article describes key principles for a new regulatory paradigm.

A rare case of fatal multi-organ polymer graft material and cholesterol embolization following aortic repair.

Ischemia is a common complication of various endovascular procedures including endovascular aortic aneurysm repair. Multiple mechanisms can contribute to the pathogenesis of ischemia: thrombosis, arterial dissection, graft malpositioning, cholesterol embolization, and polymer graft embolization which is an underrecognized complication. To the best of our knowledge, only 38 cases of polymer graft embolization have been reported in the literature. The phenomenon has been reported in different organs including brain, heart, lungs, kidneys, bowel, liver, and skin. We report a unique case of fatal simultaneous cholesterol and polymer graft embolization with subsequent ischemic infarction of multiple organs (liver, kidneys, spleen, pancreas, duodenum, and stomach) in a 76-year-old woman following endovascular repair for an enlarging thoracic aortic aneurysm.

National Trends of Tobacco, Alcohol, and Drug Use in Patients Admitted With Acute Myocardial Infarction.

BACKGROUND: Acute myocardial infarction (AMI) is a significant health and economic burden in the US. Tobacco, alcohol, and drug use are established risk factors. We sought to evaluate the national trend of use of each substance in patients admitted with AMI. METHODS: We used the National Inpatient Sample between 2005 and 2017. We included adult patients hospitalized with AMI. International Classification of Diseases, Ninth and Tenth Revisions codes were used to define tobacco, alcohol, cocaine, opioid, cannabis and other drug use. Trends of each substance use were assessed using multivariable Poisson regression, and were expressed as annual percent change (APC) with their 95% confidence intervals (CIs). RESULTS: A total of 10,796,844 hospitalizations with AMI were included. Among all substances used, tobacco was the most common (32.7%), followed by alcohol (3.2%). Between 2005 and 2017, the prevalence ratio of tobacco use increased from 21.5% to 44.5% with an APC +6.2% (95%CI 6.2%-6.2%). Tobacco users had more percutaneous coronary intervention (41%vs25%) and coronary artery bypass surgery (6.9%vs4.9%), p < 0.001. Further, there were positive trends in alcohol (APC +3.1%; 95%CI 3.0%-3.2%), opioid (APC +9.0%; 95%CI 8.7%-9.2%), cannabis (APC + 7.2; 95% CI 7%-7.4%), and combined all drug use (+7.1%; 95%CI 7%-7.2%). Meanwhile, there was a slight negative trend in cocaine use. CONCLUSIONS: This analysis outlines the national trends of substance use in patients admitted with AMI and reveals an increasing prevalence of tobacco use, alcohol and drug use. More effective cessation measures are necessary to reduce the risk for AMI and its burden on the healthcare system and economy.

The Columbia-Harlem Homeless Medical Partnership: a new model for learning in the service of those in medical need.

Though altruism and patient advocacy are promoted in medical education curricula, students are given few opportunities to develop these skills. Student-run clinics focusing on the health needs of the underserved can provide important health services to needy patients while providing students with career-influencing primary care experiences. The Columbia-Harlem Homeless Medical Partnership (CHHMP)-a project initiated by medical students to provide primary care to Northern Manhattan's homeless population-serves as a new model of service learning in medical education. Unlike many other student-run clinics, CHHMP has developed direct patient outreach, continuous care (stable "student-patient teams" and a weekly commitment for all volunteers), and regular internal data review. Chart review data presented demonstrate the project's success in providing care to the clinic's target population of homeless and unstably housed patients. Targeted outreach efforts among clients have increased rates of patient follow-up at each subsequent review period. Additionally, CHHMP has used review data to develop services concordant with identified patient needs (psychiatric care and social services). CHHMP has recruited a committed group of volunteers and continues to engender an interest in the health needs of the underserved among students. Not only does CHHMP provide a "medical home" for homeless patients, it also provides a space in which students can develop skills unaddressed in large teaching hospitals. This project, a "win-win" for patients and students, serves as a unique model for community health-based service learning in medical education.

Reperfusion Microvascular Ischemia After Prolonged Coronary Occlusion: Implications And Treatment With Local Supersaturated Oxygen Delivery.

Following a prolonged coronary arterial occlusion, heterogeneously scattered, focal regions of low erythrocyte flow are commonly found throughout the reperfused myocardium. Experimental studies have also demonstrated the presence of widespread, focally patchy regions of microvascular ischemia during reperfusion (RMI). However, the potential contribution of RMI to tissue viability and function has received little attention in the absence of practical clinical methods for its detection. In this review, the anatomic/functional basis of RMI is summarized, along with the evidence for its presence in reperfused myocardium. Advances in microcirculation research related to obstructive responses of vascular endothelial cells and blood elements to the effects of hypoxia and low shear stress are discussed, and a potential cycle of intensification of RMI from such responses and progressive loss of functional capillary density is presented. In capillaries with impaired erythrocyte flow, compensatory increases in the delivery of oxygen, because of its low solubility in plasma, are effective only at high partial pressures. As discussed herein, attenuation of the cycle with oxygen at hyperbaric levels in plasma is, very likely, responsible for improved tissue level perfusion noted experimentally. Observed clinical benefits from intracoronary SuperSaturated oxygen (SSO2) delivery, including infarct size reduction, can be attributed to attenuation of RMI with improvement in microvascular blood flow.

Case report: recurrent heart failure with preserved ejection fraction but markedly elevated BNP in a 51-year-old female on hemodialysis with oversized AV fistula.

We hereby report a case that appeared to have had recurrent clinical heart failure secondary to high-output state due to oversized arteriovenous fistula. Patient started to have dyspnea on exertion approximately 4 months after the creation of the fistula, and subsequently had two episodes of heart failure exacerbation. On both occasions, she had normal left ventricular systolic function as demonstrated by echocardiogram. The shunt was estimated to be as large as 1.9 L/min. B-type natriuretic peptide (BNP) levels were markedly elevated. To our knowledge, this is the first case in which BNP level was reported and used in the diagnosis of high-output heart failure.

Payer type has little effect on operative rate and surgeons' work intensity.

Does health-care payer type affect the rate of operative treatment and surgeons' work intensity for patients with orthopaedic conditions? We analyzed the clinical and financial data collected during 6 consecutive years (1999-2004) for a group practice of 40 orthopaedic surgeons. We examined the rate of operative treatment and surgeons' work intensity (total physician's work Resource-based Relative Value System units) by diagnosis, patient age, and payer type. The eight payer types were: capitation health maintenance organization, health maintenance organization, preferred provider organization, indemnity, self-pay, Workers' Compensation, Medicaid, and Medicare. There were 230,306 patients with 526 unique primary diagnoses. Diagnosis accounted for most of the variability in operative rates and surgeons' work intensity. After adjusting for differences attributable to diagnosis, payer type had little effect on the rate of operative treatment and surgeons' work intensity.