The Evolution of the Human Hand From an Anthropologic Perspective.

Coupled with the developing brain and freed from ambulatory responsibilities, the human hand has experienced osteologic and myologic changes throughout evolutionary time that have permitted manipulative capacities of social, functional, and cultural importance in modern-day human life. Hand cupping, precision gripping, and power gripping are at the root of these evolutionary developments. It is in appreciation of the evolutionary trajectory that we can truly understand how 'form is function.' The structure of the human hand is distinct in many ways from that of even our closest relatives in the primate order (ie, chimpanzees). We present some of the key anatomic changes and evolutionary anatomic remnants of the human hand. The human hand is truly an amazing organ-the product of millions of years of selective changes.

Resilience as a Predictor of Patient Satisfaction With Nonopioid Pain Management and Patient-Reported Outcome Measures After Knee Arthroscopy.

PURPOSE: The purpose of this study was to evaluate the Brief Resilience Score (BRS) as a predictor for patient satisfaction with nonopioid pain management and patient-reported outcome measures (PROMs) after arthroscopic partial meniscectomy or chondroplasty. METHODS: One hundred seventy-five patients undergoing arthroscopic partial meniscectomy and/or chondroplasty were recruited from a single clinic and were preoperatively stratified into low-to-normal resilience or high resilience groups as measured by the BRS. Satisfaction with nonopioid pain control was assessed at a 2-week follow-up visit using the Hospital Consumer Assessment of Healthcare Provider and Systems questionnaire, and various PROMs were measured at 3 and 6 months postoperatively. Statistical analysis was performed to assess for differences in satisfaction with pain control or PROMs between resilience groups. RESULTS: Analysis revealed no statistically significant differences between the low-to-normal resilience group and the high resilience group with regard to satisfaction with nonopioid pain control or PROMs assessed at 3- or 6-month follow-ups. Outcome measures [visual analog scale pain, Knee Injury and Osteoarthritis Outcome Score (KOOS) Pain, KOOS Activities of Daily Living, KOOS Quality of Life, Single Assessment Numerical Evaluation (SANE) Knee, and Veterans Rand 12-Item Health Survey Physical and Mental Component Scores] all followed expected trajectories after surgery, without a statistically significant difference between resilience groups. CONCLUSION: This study provides evidence that preoperative resilience score, as measured by the BRS, does not correlate with postoperative patient-reported functional outcome or satisfaction with a nonopioid pain regimen after knee arthroscopy. LEVEL OF EVIDENCE: II.

Patient feedback and early outcome data with a novel tiered-binned model for multiplex breast cancer susceptibility testing.

PURPOSE: The risks, benefits, and utilities of multiplex panels for breast cancer susceptibility are unknown, and new counseling and informed consent models are needed. We sought to obtain patient feedback and early outcome data with a novel tiered-binned model for multiplex testing. METHODS: BRCA1/2-negative and untested patients completed pre- and posttest counseling and surveys evaluating testing experiences and cognitive and affective responses to multiplex testing. RESULTS: Of 73 patients, 49 (67%) completed pretest counseling. BRCA1/2-negative patients were more likely to proceed with multiplex testing (86%) than those untested for BRCA1/2 (43%; P < 0.01). Many patients declining testing reported concern for uncertainty and distress. Most patients would not change anything about their pre- (76%) or posttest (89%) counseling sessions. Thirty-three patients (72%) were classified as making an informed choice, including 81% of those who proceeded with multiplex testing. Knowledge increased significantly. Anxiety, depression, uncertainty, and cancer worry did not significantly increase with multiplex testing. CONCLUSION: Some patients, particularly those without prior BRCA1/2 testing, decline multiplex testing. Most patients who proceeded with testing did not experience negative psychological responses, but larger studies are needed. The tiered-binned approach is an innovative genetic counseling and informed consent model for further study in the era of multiplex testing.Genet Med 18 1, 25-33.

Time-Resolved Infrared (TRIR) Studies of Oxycarbonylnitrenes.

N-Ethyloxycarbonyl-S,S-dibenzothiphene sulfilimine and N-t-butyloxycarbonyl-S,S-dibenzothiphene sulfilimine have been utilized as precursors to ethoxycarbonylnitrene and t-butyloxycarbonylnitrene. B3LYP/6-31G(d) calculations predict triplet ground states for both oxycarbonylnitrenes, albeit by small margins. Triplet ethoxycarbonylnitrene and triplet t-butyloxycarbonylnitrene have been observed following photolysis of these sulfilimine precursors by time-resolved infrared (TRIR) spectroscopy. Kinetic studies show that ethoxycarbonylnitrene reacts with solvents such as acetonitrile and cyclohexane, while t-butyloxycarbonylnitrene undergoes an intramolecular insertion reaction to produce 5,5-dimethyl oxazolidinone. Product analysis following photolysis of N-t-butyloxycarbonyl-S,S-dibenzothiphene sulfilimine confirms that the oxazolidinone is the major product with an estimated yield of 90%. The products from these two nitrenes are derived from the corresponding singlet nitrene, either directly or via thermal repopulation of the singlet from the lower-energy triplet nitrene.

Handoffs and transitions in critical care (HATRICC): protocol for a mixed methods study of operating room to intensive care unit handoffs.

BACKGROUND: Operating room to intensive care unit handoffs are high-risk events for critically ill patients. Studies in selected patient populations show that standardizing operating room to intensive care unit handoffs improves information exchange and decreases errors. To adapt these findings to mixed surgical populations, we propose to study the implementation of a standardized operating room to intensive care unit handoff process in two intensive care units currently without an existing standard process. METHODS/DESIGN: The Handoffs and Transitions in Critical Care (HATRICC) study is a hybrid effectiveness- implementation trial of operating room to intensive care unit handoffs. We will use mixed methods to conduct a needs assessment of the current handoff process, adapt published handoff processes, and implement a new standardized handoff process in two academic intensive care units. Needs assessment: We will use non-participant observation to observe the current handoff process. Focus groups, interviews, and surveys of clinicians will elicit participants' impressions about the current process. Adaptation and implementation: We will adapt published standardized handoff processes using the needs assessment findings. We will use small group simulation to test the new process' feasibility. After simulation, we will incorporate the new handoff process into the clinical work of all providers in the study units. EVALUATION: Using the same methods employed in the needs assessment phase, we will evaluate use of the new handoff process. DATA ANALYSIS: The primary effectiveness outcome is the number of information omissions per handoff episode as compared to the pre-intervention period. Additional intervention outcomes include patient intensive care unit length of stay and intensive care unit mortality. The primary implementation outcome is acceptability of the new process. Additional implementation outcomes include feasibility, fidelity and sustainability. DISCUSSION: The HATRICC study will examine the effectiveness and implementation of a standardized operating room to intensive care unit handoff process. Findings from this study have the potential to improve healthcare communication and outcomes for critically ill patients. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02267174. Date of registration October 16, 2014.

Challenges of perioperative pain control in opioid use disorder patients following intramedullary nail fixation.

BACKGROUND: Outcomes of patients with opioid use disorder undergoing elective procedures have been well studied, but research is lacking in the orthopaedic trauma population. AIM: The aim was to compare perioperative pain and morphine equivalents required by patients with versus without opioid use disorder following intramedullary nail fixation of femoral or tibial fractures. METHODS: We conducted a retrospective review of all patients with isolated femoral or tibial diaphyseal fractures treated with intramedullary nail fixation. Outcomes were compared between patients with diagnosed opioid use disorder and controls without, including daily morphine equivalents and patient-reported pain scores. RESULTS: Patients with opioid use disorder (n = 42) required greater morphine equivalents and reported higher pain than controls (n = 42) at all time points but did not differ in change of morphine equivalents over the perioperative period. CONCLUSION: This highlights the challenge of perioperative pain control in this population and need for improved specific pain management protocols.

The Use of Knotless Suture Tape Construct vs Screw Fixation for Lisfranc Injuries: A Cadaveric Biomechanical Study.

BACKGROUND: Lisfranc injuries are often treated with open reduction and internal fixation using rigid fixation techniques. The use of flexible fixation to stabilize the Lisfranc joint is a newer technique. The purpose of this cadaveric study is to compare the amount of diastasis at the Lisfranc interval under diminished physiologic loads when treated with a knotless suture tape construct and a solid screw. METHODS: Ten cadavers (20 feet) had native motion at the intact Lisfranc interval assessed at multiple increasing loads (69, 138, and 207 N). The Lisfranc ligamentous complex was then disrupted, and testing repeated to evaluate the amount of diastasis. Randomization was performed to determine the type of fixation for each cadaver: solid screw or knotless suture tape construct. Once fixation was completed, specimens were cyclically loaded for 10 000 cycles at loads, and diastasis was quantified after each load cycle to compare the interventions. Diastasis was measured using motion tracking cameras and retroreflective marker sets. A non-inferiority statistical analysis was performed. RESULTS: Diastasis mean values were confirmed to be >2 mm for all load bearing conditions in the injury model. Posttreatment, diastasis was significantly reduced when compared to the sectioned conditions (P < .01) for both treatment options. Non-inferiority analyses showed that the knotless suture tape construct did not perform inferior to screw fixation for diastasis at the Lisfranc interval at any of the compared load states. CONCLUSION: Under the loads tested, there is no significant difference in diastasis at the Lisfranc interval when treating ligamentous Lisfranc injuries with a knotless suture tape construct or solid screws. Both reduced diastasis from the injured state and were not different from the intact state. CLINICAL RELEVANCE: In this cadaveric model with ligamentous Lisfranc injury, diastasis of a knotless suture tape construct is compared to solid screw fixation as tested.

Disparities in psychological distress and access to mental health services among immigrants with rheumatologic disease.

INTRODUCTION: Patients with rheumatologic disease experience higher rates of comorbid mental health diseases than those without. Although mental health services (MHS) can improve musculoskeletal functional outcomes, access to MHS has been limited among vulnerable populations in the United States (US). The purpose of this study was to investigate contemporary patterns of severe psychological distress and receipt of MHS among immigrant populations with rheumatologic disease in the US. METHODS: The National Health Interview Survey was queried for patients with rheumatologic disease from 2009 to 2018. Patient demographics, severe psychological distress, and receipt of MHS were collected and/or calculated. Multivariable logistic regressions assessed for factors associated with decreased receipt of MHS and severe psychological distress. RESULTS: Immigrant patients with rheumatologic disease had higher rates of severe psychological distress than US-born patients (7.7% vs. 6.5%, p < 0.001), but were less likely to access MHS (8.3% vs. 11.0%, p < 0.001). Among immigrant patients, factors associated with lower MHS receipt included being Black (AOR 0.50, 95% CI 0.32-0.77, p = 0.002), Hispanic (AOR 0.80, 95% CI 0.30-1.00, p = 0.050), Asian (AOR 0.44, 95% CI 0.31-0.63, p < 0.001), older (p < 0.001), uninsured (p < 0.001), and having self-reported poor health (p < 0.001). DISCUSSION: Immigrant patients with rheumatologic disease in the US had higher rates of severe psychological distress yet were less likely to receive MHS compared to US-born patients. Immigrants with rheumatologic illness were less likely to receive MHS if they were male, Black, Hispanic, Asian, older, lower income, or uninsured. This lack of MHS receipt may contribute to disparities in functional outcomes seen in immigrant minorities with musculoskeletal disease. Key Points • Immigrant patients with rheumatologic disease in the US had higher rates of severe psychological distress yet were less likely to receive MHS compared to US-born patients between 2009 and 2018 • Immigrants with rheumatologic illness were less likely to receive MHS if they were Black, Hispanic, Asian, older, lower income, or uninsured • Future efforts to carefully screen for mental health diseases in these vulnerable patient populations should be made while exploring patient-specific cultural considerations of MHS receipt.

Nudging Emergency Department-Initiated Addiction Treatment.

OBJECTIVES: When initiated in the Emergency Department (ED), medication for addiction treatment (MAT) with buprenorphine improves outcomes, increases engagement in addiction treatment and decreases the use of inpatient addiction treatment services. Unfortunately, initiating MAT in the ED is not yet standard practice. We assessed the impact of the addition of a multipart behavioral science-based intervention to increase opioid use disorder (OUD)-related treatments prescribed in the ED. METHODS: Our ED initiated a campaign to help ED faculty obtain their DEA-X waiver required to prescribe buprenorphine. In parallel, we implemented 2 ED-initiated buprenorphine treatment pathways. We then conducted a two-stage qualitative process informed by behavioral science to identify key barriers to physician use of the MAT protocol. Using these insights, we developed 4 behavioral science-based interventions. To assess the impact of the interventions on the number of OUD-related treatments per day among patients meeting the inclusion criteria we compared the number of OUD-related treatments per day before versus after the interventions began using t tests. Then, in our primary model, we estimated the causal effect of the behavioral interventions using a regression discontinuity in time approach. RESULTS: Across the entire year study period, there is an increase in OUD-related treatment after the interventions begin, driven by greater use of ambulatory referral orders. The unadjusted mean difference in any OUD treatments per day pre- versus post-intervention increased by 0.80 (95% confidence interval [CI]: 0.04, 1.56; P = 0.039) whereas the number of ambulatory referral orders placed increased by 0.82 (95% CI: 0.48,1.16; P < 0.001). Using the 120-day study window and an ordinary least squares regression discontinuity in time model, the 4-part intervention increased the number of patients receiving any opioid treatment in the ED by 1.6 additional treatments per day (95% CI: 0.04, 3.19; P = 0.045). CONCLUSIONS: To support our protocol and increase the provision of ED-MAT, we implemented 1 patient-facing and 3 provider-facing interventions rooted in behavioral science principles. Our results show that this pack of behavioral science interventions increased the likelihood that ED providers offer MAT to patients with OUD.

Beyond Buprenorphine: Models of Follow-up Care for Opioid Use Disorder in the Emergeny Department.

Recent evidence shows that emergency physicians (EP) can help patients obtain evidence-based treatment for Opioid Use Disorder by starting medication for addiction treatment (MAT) directly in the Emergency Department (ED). Many EDs struggle to provide options for maintenance treatment once patients are discharged from the ED. Health systems around the country are in need of a care delivery structure to link ED patients with OUD to care following initiation of buprenorphine. This paper reviews the three most common approaches to form effective partnerships between EDs and primary care/addiction medicine services: the Project Alcohol and Substance Abuse Services and Referral to Treatment (ASSERT) model, Bridge model, and ED-Bridge model.The ASSERT Model is characterized by peer educators or community workers in the ED directly referring patients suffering from OUD in the ED to local addiction treatment services. The Bridge model encourages prescribing physicians in an ED to screen patients for OUD, provide a short-term prescription for buprenorphine, and then refer the patient directly to an outpatient Bridge Clinic that is co-located in the same hospital but is a separate from the ED. This Bridge Clinic is staffed by addiction trained physicians and mid-level clinicians. The ED-Bridge model employs physicians trained in both emergency medicine and addiction medicine to serve within the ED as well as in the follow up addiction clinic.Distinct from the Bridge Clinic model above, EPs in the ED-Bridge model are both able to screen at-risk patients in the ED, often starting treatment, and to longitudinally follow patients in a regularly scheduled addiction clinic. This paper provides examples of these three models as well as implementation and logistical details to support a health system to better address OUD in their communities.

Entrapment of the urinary bladder: A rare mechanism of bladder injury in pelvic trauma.

A pelvic fracture with entrapment of the urinary bladder in the fracture site is a rare pattern of injury. As the "team captains" in the trauma bay and in the care of polytraumatized patients, trauma surgeons must be aware of this entity and its implications. We report a case of acute bladder entrapment in the fracture site of a lateral compression pelvic fracture. A review of the English literature yielded four previous reports, including two patients with delayed diagnosis (Ghuman et al., 2014; Kumar et al., 1980; Wright and Taitsman, 1996; Min et al., 2010 [1-4]). Kumar and colleagues first documented bladder entrapment by a pelvic fracture in 1980 (Kumar et al., 1980 [2]). Ghuman et al. described a similar case treated with fixation of the pelvic fracture (Ghuman et al., 2014 [1]). Wright and colleagues treated a patient with bladder perforation due to entrapment diagnosed two weeks after a pelvic ring fracture (Wright and Taitsman, 1996 [3]). In this case the bladder injury was repaired, but internal fixation of the pelvis fracture was avoided due to fear of contamination. Finally, Min et al. documented a case of bladder entrapment and perforation presenting six months after non-operative management of a pelvic ring fracture. The female patient developed recurrent UTIs and dyspareunia, and imaging revealed fracture malunion with the bladder entrapped in the fracture site (Min et al., 2010 [4]). This collection of case reports demonstrates the potential for acute or delayed bladder injury even in seemingly benign pelvic fractures. A high index of suspicion is required to intervene and prevent morbidity from bladder injuries in pelvic trauma. Entrapment of the bladder may require surgical intervention even when the injury pattern would not normally dictate surgery for the pelvis or bladder alone (Bryk and Zhao, 2016 [5]). We describe the diagnosis and surgical management of bladder entrapment and present a brief review of bladder injuries associated with pelvic fractures.

The chemical biology of the persulfide (RSSH)/perthiyl (RSS·) redox couple and possible role in biological redox signaling.

The recent finding that hydropersulfides (RSSH) are biologically prevalent in mammalian systems has prompted further investigation of their chemical properties in order to provide a basis for understanding their potential functions, if any. Hydropersulfides have been touted as hyper-reactive thiol-like species that possess increased nucleophilicity and reducing capabilities compared to their thiol counterparts. Herein, using persulfide generating model systems, the ability of RSSH species to act as one-electron reductants has been examined. Not unexpectedly, RSSH is relatively easily oxidized, compared to thiols, by weak oxidants to generate the perthiyl radical (RSS·). Somewhat surprisingly, however, RSS· was found to be stable in the presence of both O2 and NO and only appears to dimerize. Thus, the RSSH/RSS· redox couple is readily accessible under biological conditions and since dimerization of RSS· may be a rare event due to low concentrations and/or sequestration within a protein, it is speculated that the general lack of reactivity of individual RSS· species may allow this couple to be utilized as a redox component in biological systems.

Oxidation of N-hydroxy-l-arginine by hypochlorous acid to form nitroxyl (HNO).

Recent research has shown that nitroxyl (HNO) has important and unique biological activity, especially as a potential alternative to current treatments of cardiac failure. HNO is a reactive molecule that undergoes efficient dimerization and subsequent dehydration to form nitrous oxide (N(2)O), making its detection in solution or biologically relevant preparations difficult. Due to this limitation, HNO has not yet been observed in vivo, though several pathways for its endogenous generation have been postulated. Here, we investigate the oxidation of N-hydroxy-l-arginine (NOHA) by hypochlorous acid (HOCl), which is generated in vivo from hydrogen peroxide and chloride by the heme enzyme, myeloperoxidase. NOHA is an intermediate in the enzymatic production of nitric oxide (NO) by NO synthases, and has been shown previously to be chemically oxidized to either HNO or NO, depending on the oxidant employed. Using membrane inlet mass spectrometry and standard N(2)O analysis by gas chromatography, we find that NOHA is oxidized by excess HOCl to form HNO-derived N(2)O. In addition, we also observe the analogous production of HNO from the HOCl oxidation of hydroxylamine, hydroxyurea, and (to a lesser extent) acetohydroxamic acid.

Nitroxyl (HNO) signaling.

Nitroxyl (HNO) has become a nitrogen oxide of significant interest due to its reported biological activity. The actions of HNO in the cardiovascular system appear to make it a good candidate for therapeutic applications for cardiovascular disorders and other potentially important effects have been noted as well. Although the chemistry associated with this activity has not been firmly established, the propensity for HNO to react with thiols and metals are likely mechanisms. Herein, are described the biological activity of HNO and some of the chemistry of HNO that may be responsible for its biological effects.