Ethnic Differences in Clinical Presentations and Esophageal High-Resolution Manometry Findings in Patients with Achalasia.

BACKGROUND: Ethnic differences in achalasia presentations have scarcely been described. The association between achalasia and immunologic HLA haplotypes suggests that there may be a genetic predisposition. We aimed to evaluate differences in demographic, clinical, endoscopic, and manometric findings between two distinct ethnic groups with achalasia-Israeli Arabs (IA) and Israeli Jews (IJ). METHODS: A retrospective study was performed at two medical centers. High-resolution manometry (HRM) reports were reviewed for newly-diagnosed achalasia patients. Demographic data, clinical presentations, endoscopy reports, and HRM metrics including the integrated relaxation pressure (IRP) were all reviewed. RESULTS: Overall, 94 achalasia patients were included (53.2% male; mean age 54.5 ± 18.0). 43 patients were IA (45.7%). Body mass index (BMI) was similar in both groups. Compared to IJ, the IA patients had more esophageal dysphagia (100% vs. 88.2%; P = 0.022), chest pain (46.5% vs. 25.5%; P = 0.033), and a tortuous esophagus on endoscopy (23.3% vs. 3.9%; p = 0.005). IA patients were also diagnosed at a younger age than IJ patients (50.9 ± 17.5 vs. 57.5 ± 18.0; p = 0.039). Furthermore, IRP values were higher among IA patients than IJ patients (32.2 ± 13.8 vs. 23.3 ± 8.4; p < 0.001). A regression model analysis found that ethnicity significantly predicted IRP (ß = - 10, p < .001). CONCLUSION: Ethnicity appears to affect achalasia clinical presentation and HRM findings. IA achalasia patients are diagnosed at a younger age, present with more severe esophageal symptoms, and have a higher IRP compared to IJ patients. Additional studies of diverse, multiethnic populations, especially with genetic evaluations, are required to further assess the role of ethnicity in achalasia.

Perspectives of clinical pharmacists on the provision of pharmaceutical care through telepharmacy services during COVID-19 pandemic in Qatar: A focus group.

BACKGROUND: Coronavirus disease 2019 (COVID-19) pandemic created unprecedented pressures on healthcare systems and led to the widespread adoption of telepharmacy services, a practice that was not previously established in the state of Qatar. OBJECTIVE: The -study aimed to explore clinical pharmacists' (CPs) perspectives and experiences in utilizing telepharmacy for the provision of pharmaceutical care during the COVID-19 pandemic. METHODS: A descriptive, qualitative approach using face-to-face focus group (FG) discussions was used. CPs across Hamad Medical Corporation (HMC) were purposively invited to participate in the study. FG discussions were audio-recorded, transcribed verbatim, and validated. Transcripts were analyzed using inductive thematic analysis. Recruitment continued until a saturation point was achieved. RESULTS: We conducted five focus groups that included 23 CPs and led to seven themes. Overall, CPs reported inadequate preparedness for the practice of telepharmacy, which they perceived as challenging. The primary perceived benefits of telepharmacy were decreased infection exposure risk, improved quality of care, improved patients' satisfaction, and enhanced workplace efficiency and productivity. The main highlighted risks of telepharmacy were related to threatened patient confidentiality, missed pharmaceutical care opportunities, and negatively impacted professional rapport with other healthcare providers; and the major perceived challenges were low digital health literacy, complex illnesses and medication regimens, lack of standardized protocols, and inadequacy of resources and cultural resistance for virtual care. Participants recommended standardization and training, resource allocation, and proper service promotion as potential facilitators of telepharmacy practice. CONCLUSION: The current study revealed that despite perceived barriers, pharmacists identified several benefits of telepharmacy and recommended potential facilitators that should be used to integrate and sustain the practice of telepharmacy in the future. Future studies should investigate the impact of telepharmacy on clinical pharmacy interventions and patient outcomes.

Characteristics of Elderly Hip Fracture Patients in Jordan: A Multicenter Epidemiological Study.

Background: Elderly hip fractures represent a global health care burden. Several reports expected a massive increase in the incidence of hip fractures by the next few decades. Knowing the epidemiology of hip fractures is crucial for planning health care policies. The purpose of this study is to provide a nationwide epidemiological overview of hip fractures in Jordan and to report the perioperative outcomes that may help to improve the delivered healthcare. . Methods: We conducted a retrospective study at 2 university hospitals and 2 major governmental hospitals in Jordan. We reviewed the records for all patients (age >55 years) who were diagnosed with hip fractures over a 3 years duration (2019-2021). We documented the patient's characteristics and the perioperative data (including preoperative, intraoperative, and postoperative details including the 1-year mortality). . Results: The total number of included patients was 1268; more than half (53.7%) were females. The mean age is 75 years (SD 9.7). The most common fracture type was trochanteric (66.2%) . 7% of patients had a prior contralateral hip fracture . The average time from admission to surgery was 2.96 days (SD 2.63). The surgery was done within 48 hours for 56.7% of patients. Approximately, one-third of all patients (34.5%) received a blood transfusion. The average length of hospital stay is 7.44 days (SD 5). The overall rate of postoperative thromboembolic events, readmission within 1 month, and revision for the same surgery are 2.4% , 10.7% , and 3% respectively. The 1-month, 6-month, and 12-month mortality rates are 4.5%, 9.1%, and 12.8% respectively. Conclusion: The annual incidence of elderly hip fractures in Jordan is approximately 96 per 100,000 individuals. The 1-year mortality rate of hip fractures in Jordan is 12.8% . Both findings are in the lower range of nearby Arab countries.

Translation and cross-cultural adaptation of the low back pain treatment belief questionnaire and its clinimetric properties.

BACKGROUND: The Low Back Pain Treatment Beliefs Questionnaire (LBP-TBQ) was developed to systematically measure patients' preferences about common treatments for low back pain (LBP). However, the questionnaire is not available in the Arabic language. OBJECTIVE: To translate and cross-culturally adapt the LBP-TBQ to the Arabic language and assess its clinimetric properties. METHODS: The LBP-TBQ was translated into Arabic version according to published guidelines. In pilot testing, the face and content validity of the translated questionnaire was assessed. Two hundred and fifty patients with LBP completed the translated LBP-TBQ for five common LBP treatments. In addition, a subgroup of 51 participants completed the questionnaire on two consecutive occasions to examine the test-retest reliability. RESULTS: Confirmatory factor analysis results showed that the Arabic version of LBP-TBQ has three factors: (1) "credibility", (2) "effectiveness and fitness", and (3) "concerns", and this 3-factors model had the best fit for the data for all the five treatments. Cronbach's α of the total items ranged from 0.812 to 0.899, while the sub-scores ranged from 0.557 to 0.837, indicating moderate to high internal consistency. The ICC(2,1) ranged from 0.626 to 0.909, which shows acceptable to good test-retest reliability. Correlation with other LBP questionnaires was < 0.3, demonstrating acceptable discriminant validity. Finally, the questionnaire showed acceptable criterion validity for all the subscales and the general questionnaire. CONCLUSIONS: The Arabic version of LBP-TBQ is reliable, valid, and appropriate to use in clinical and research settings.

Description and Validation of the Anterior Glenoid Angle: A Novel MRI-Based Measure of Glenoid Morphologic Features and Version.

The goal of this study was to establish a normal value for, and evaluate the reliability of, a new measurement of glenoid morphologic features using magnetic resonance imaging: the anterior glenoid angle. A total of 90 magnetic resonance imaging scans of patients without shoulder arthritis were reviewed. The anterior glenoid angle of each glenoid was measured by 4 blinded physicians. The images were randomized and measured again. Finally, the Friedman angle was measured on the same images for reference. Descriptive statistics and inter- and intraclass correlation coefficients were calculated. The mean anterior glenoid angle was 60.4°±3.6°. Of the measured values, 77% were between 56° and 64°. Intraobserver reliability was very good to excellent in single measure (range, 0.763-0.901) and mean measure (range, 0.865-0.948) comparisons. Interobserver reliability was very good to excellent in both single measure (0.769) and mean measure (0.964) comparisons. The mean Friedman angle was 10.2°. Correlation between the anterior glenoid angle and Friedman angle ranged from a moderate negative (-0.496) to a strong negative correlation (-0.711) among the observers. The mean anterior glenoid angle measured via magnetic resonance imaging scan was 60.4° in normal shoulders, and more than 75% of the values were within 4° of the mean. The anterior glenoid angle has excellent inter- and intrarater reliability without using computed tomography scan or including the entire scapula in the field of view. The anterior glenoid angle has a good to very good negative correlation with the Friedman angle because decreasing anterior glenoid angles indicate increasing retroversion. [Orthopedics. 2022;45(6):361-366.].

Effect of COVID-19 on Injury Rates and Timing in the National Football League.

Background: The coronavirus 2019 (COVID-19) pandemic resulted in the cancellation of the 2020 National Football League (NFL) preseason and a decreased preseason roster size. The effect of this disruption on athlete injury rates is unknown. Purpose/Hypothesis: The purpose was to quantify the rates of anterior cruciate ligament (ACL), Achilles tendon, and hamstring tendon injuries in NFL players before and after the COVID-19 pandemic. We hypothesized that injury rates in the 2020 season would be higher than those seen prepandemic. Study Design: Descriptive epidemiology study. Level of evidence, 4. Methods: An online search using publicly available data was carried out to identify all NFL players who sustained an ACL, Achilles tendon, or hamstring tendon injury between April 1, 2017, and March 31, 2021. Data collected included player characteristics as well as career and season of injury workloads. Results: The number of Achilles tendon (27 vs 20; P = .024) and hamstring tendon (186 vs 149; P < .001) injuries, respectively, in the 2020 NFL season were significantly higher than the average of the 2017 to 2019 seasons. However, the number of ACL injuries sustained remained constant (43 vs 46; P = .175). More than half (52.9%) of ACL injuries in the 2017 to 2019 seasons occurred in the preseason, while most of the injuries (34.9%) in the 2020 season occurred in weeks 1 to 4. There was no player characteristic or career workload variable collected that was significantly different for players who sustained an ACL, Achilles tendon, or hamstring tendon injury in the 2020 NFL season compared with the 2017 to 2019 seasons. Conclusion: In the 2020 NFL season, the number of Achilles tendon and hamstring tendon injuries rose while the number of ACL injuries remained constant compared with the 2017 to 2019 seasons. Injuries that occurred during the first 4 games of the 2020 NFL season were consistent, with higher rates of injuries seen in the preseason in previous years.

Professional Baseball Pitchers Drafted at a Younger Age Pitch More Innings During Their Professional Baseball Careers Than Pitchers Drafted at an Older Age.

Purpose: To evaluate and describe the differences in characteristics between the Major League Baseball (MLB) pitchers with greater workload and career longevity in terms of innings pitched (IP) and performance-matched controls who have not experienced similar length careers. Methods: Using publicly available data, we identified the top 100 MLB pitchers in terms of career IP. Controls were matched to the top 100 pitchers by draft year and round. Pitchers with fewer than 400 IP were excluded. Demographic information, performance statistics, and injury history were reviewed. Logistic regression analysis and Mann-Whitney U tests were used to compare data. Results: Compared with controls, the top 100 pitchers in terms of IP were drafted at a younger age (19.35 vs 19.83, P < .001) and in later rounds (6.16 vs 2.45, P < .001). They made their MLB debut at a younger age (21.77 vs 23.12, P < .001). They also pitched fewer innings before debut (470.59 vs 632.07, P = .007), were older at their first (30.72 vs 27.50 years, P < .001) and second (32.42 vs 29.43 years, P < .001) designations to the injured list (IL), and had a significantly longer time from debut to first (3063.50 vs 1565.59 days, P < .001) and second (3712.10 vs 2202.03 days, P < .001) IL trips. The top 100 pitchers were 7.45 times less likely to have made a trip to the IL within 8 seasons from their debut and were 4.04 times more likely to be younger than 24 years at their major league debut. Conclusions: Pitchers with the greatest number of IP in their MLB careers were significantly younger when drafted and when they made their major league debut, although this age difference is likely clinically insignificant. Pitchers who were drafted or debuted at a later age accumulate more pre-debut innings and this may contribute to fewer total IP in the MLB. Similarly, later trips to the injured list and longer duration from debut to first or second trip to the IL, but not total IL trips, are predictive of longer careers compared to age and draft class matched controls. Level of Evidence: III, retrospective cohort study.

Evaluating the Academic Influence of Orthopedic Surgeons in Spinal Literature Through Relative Citation Ratio.

INTRODUCTION:  The innovative iCite tool applies the relative citation ratio (RCR) to gauge the time and field-adjusted scientific influence of a publication. This study examines scholarly effects on spine surgery to distinguish the impact made by orthopedic surgeons, neurosurgeons, and several other specialists. MATERIALS AND METHODS:  From 2013 to 2017, 100 of the highest RCR-rated articles were gathered for each of the following terms: cervical disc herniation (CDH), lumbar disc herniation (LDH), lumbar spinal stenosis (LSS), neurogenic claudication (NC), radiculopathy (RAD), and sciatica (SC). The first, second, and last authors were queried for background and academic qualifications and placed into the following specialty categories: orthopedic surgery, neurosurgery, pain management, medicine, and others. To provide an alternative degree of influence, the Scopus database was employed to classify the h-index associated with each author. RESULTS:  Across the six search terms, there were 526 orthopedic surgeons among 1,730 authors (30.4%), with the highest representation in LSS (118/290, 40.7%), and the lowest in SC (45/286, 15.7%). Orthopedics was the most influential specialty across all six research terms by median RCR (p = 0.012). Compared to their neurosurgical counterparts, orthopedic authors had a greater influence in CDH (3.93 vs. 2.63, p = 0.0492), LDH (5.10 vs. 4.99, p = 1.0000), NC (2.16 vs. 1.40, p = 0.2370), and SC (3.35 vs. 3.04, p = 0.5285), but had a lower influence in LSS (5.13 vs. 5.32, p = 0.7736) and RAD (5.03 vs. 6.05, p = 0.3938). CONCLUSION:  Orthopedic surgeons lead other specialties when determining scholarly influence through RCR across six of the pre-designated research domains within spine surgery. For orthopedics, a modest influence in LSS and RAD may suggest potential areas of future focus. The use of bibliometrics to analyze available literature enables us to identify other specialties that have contributed to our field and promote interdisciplinary collaboration.

Physiotherapists' knowledge, perception, and attitude regarding COVID-19 and infection control: An online cross-sectional survey in Jordan.

BACKGROUND: The COVID-19 pandemic highlighted the importance of knowledge and awareness of healthcare practitioners regarding infection control. OBJECTIVE: To explore Jordanian physiotherapists' knowledge and perception of COVID-19, awareness about protection measures, and attitude towards infection prevention. METHODS: A cross-sectional online survey was used. Data were collected from licensed physiotherapists currently living in Jordan. A structured survey was used to collect the data consisting of five parts: 1) General information about the physiotherapists including sociodemographic, academic training, and employment setting, 2) General knowledge about COVID-19, 3) Infection protection in the workplace, 4) Perception of COVID-19, and 5) Attitude towards COVID-19 in daily life and during work. RESULTS: A total of 147 physiotherapists completed the survey with a mean age of 30.56 (7.70) and years of experience of 7.28 (7.21). The mean of the total knowledge score was 17.18 (2.32)/ 26. There was a significant difference in the total knowledge score between COVID-19 trained physiotherapists and untrained (t = 2.895, p = 0.004). About 70.8% of the physiotherapists perceived COVID-19 as a very dangerous disease, 69.4% considered physiotherapy a high-risk profession, and 41% perceived COVID-19 does not require any special treatment. Approximately 85% of physiotherapists avoided going to crowded places and wore a mask when leaving home. 75-86.6% of physiotherapists would consider appropriate protective measures during their work. CONCLUSIONS: Physiotherapists showed suboptimal knowledge, perception, and attitude towards COVID-19. There is a need for training courses to increase physiotherapists' knowledge about COVID-19 and improve their perception and attitude towards COVID-19.

The Influence of Orthopedic Journals in Knee Arthritis Treatment Research: Evaluation Using Relative Citation Ratio.

Introduction The iCite database, developed by the National Institute of Health (NIH), utilizes a bibliometric known as the relative citation ratio (RCR) to gauge scholarly impact. The goal of this study was to use the RCR to evaluate the influence of orthopedic journals in regard to knee arthritis treatment literature, as no such studies exist to date. Materials and methods The 100 highest RCR-rated articles published between 2007 and 2017 were obtained in the following categories: physical therapy (PT), viscosupplementation (VS), nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid injection (CSI), results of total knee arthroplasty (TKA), platelet-rich plasma (PRP), and meniscectomy (MS). Journals were categorized with respect to the following specialties: general orthopedics (GO), orthopedic subspecialty (OSS), nonsurgical musculoskeletal (NSMSK), general medicine (GM), and basic science/nonclinical (BS/NC). Results Across the seven domains, GO journals held the highest median RCR, while OSS ranked fourth (RCR, 6.60 versus 3.95; p=0.0027). GO journals were considered the most influential specialty in CSI (RCR, 2.99), while OSS journals held the highest median RCR in PRP (RCR, 4.10). OSS and GO journals ranked third (RCR, 4.79) and fourth (RCR, 4.21), respectively, in NSAIDs, lagging behind NSMSK and GM journals. Conclusions Bibliometric tools, such as the RCR, can inform the orthopedic field of current and future research trends and help guide further research efforts. Currently, publications in GO journals hold a strong influence in CSI but less so in PT and NSAIDs. The use of bibliometrics allows the identification of highly influential non-orthopedic articles and journals to read while identifying influential non-orthopedic researchers to promote interdisciplinary collaboration.

The yield of solid swallows in high resolution esophageal manometry among patients with dysphagia and gastro-esophageal reflux symptoms.

BACKGROUND: Swallowing disorders are frequently reported esophageal symptoms and represent a common cause for referrals to gastroenterology consultations. Esophageal high-resolution manometry (HRM) is considered the gold standard modality for the evaluation of esophageal peristalsis and esophageal sphincter. The standard protocol of HRM includes water swallows only, that may not assess appropriately esophageal function and symptoms. Hence, we investigated the diagnostic yield of combining solid food swallows (SFS) to standard HRM. METHODS: We conducted a retrospective study at the Gastroenterology unit of EMMS Nazareth Hospital, Israel. Patients who underwent manometry mainly due to dysphagia or reflux symptoms between November 2019 and November 2020 were enrolled. All patients underwent routine HRM and completed ten 5 ml water swallows and 5 bread swallows. Analysis and reports were done by an expert gastroenterologist, based on the Chicago Classification version 3. RESULTS: Overall, 99 patients (45.5% men, mean age 52.1±16 years) who underwent HRM were included. The addition of solid swallows to the test changed manometry results in 43 patients (43.4%) (P<0.005). Furthermore, SFS improved the contractility in 26/42 cases of ineffective and/or absent motility (61%) (P< 0.005). Finally, SFS aggravated symptoms in 44 patients (44.6% more aggravation than in liquid only) (P<0.005). CONCLUSIONS: Combining SFS to HRM can improve the diagnostic yield of the study. Adding solid swallows is of special value in cases of ineffective esophageal motility but induces a high rate of symptoms aggravation.

Femoral Condyle Insufficiency Fracture After Total Knee Arthroplasty Using a Stemless Femoral Component With a Midlevel Constraint Articular Surface.

Midlevel constraint prostheses have provided increased varus/valgus and rotational stability for patients with severe deformity or ligamentous instability undergoing total knee arthroplasty (TKA). Here we present a series of 5 patients, 2 in detail, who underwent a primary TKA with a midlevel constraint articular surface and a primary femoral component without stem extension who all suffered isolated medial femoral condyle insufficiency fractures. All 5 TKAs were performed in females with both preoperative valgus deformity and flexion contractures. Patients had an average age of 74.4 years, height 62.4 in, and weight 156.2 lbs. Revision TKA was performed in 4 of 5 cases. As a result of these cases, we now routinely consider implanting a stemmed femoral component in this population with osteoporotic medial femoral condyles.

Patient Satisfaction with Orthopedic Telemedicine Health Visits During the COVID-19 Pandemic.

Background:Telemedicine usage in orthopedic surgery has seen a dramatic increase as a result of the severe acute respiratory syndrome coronavirus 2 pandemic. The purpose of this study was to examine patient perceptions with telemedicine at a large orthopedic practice.Materials and Methods:An anonymous online survey was distributed to all patients who received a telemedicine health visit at our institution for musculoskeletal complaints from March 17 to June 1, 2020. Responses were scored on a 5-point Likert scale (strongly disagree, disagree, neutral, agree, and strongly agree, 1-5) and analyzed by average score and percent reaching top box.Results:A majority of patients (76.5%) were satisfied with their visit, and only 19.2% did not want telemedicine as a future option. Patients who presented for follow-up visits (4.11 vs. 3.94, p = 0.0053; 48% vs. 41%, p = 0.02) and utilized video (4.21 vs. 3.88, p < 0.001; 51% vs. 39%, p < 0.001) were more satisfied. Average satisfaction between older (>65 years) and younger patients was similar (4.06 vs. 4.06, p = 0.97), however, younger patients were more likely to reach top box (42% vs. 51%, p < 0.001). Confidence that the physician came to the correct diagnosis (r = 0.78, p < 0.001) and receiving the same information and care as an in-office visit (r = 0.60, p < 0.001) demonstrated the strongest correlation with satisfaction and desire for future telemedicine visits, respectively. Interestingly, 31.1% of patients would have sought treatment elsewhere had telemedicine not been an option.Conclusions:Overall, satisfaction rates are high for orthopedic patients undergoing telemedicine visits. Patients are more confident in telemedicine when presenting for a follow-up visit and with the use of video.

The Yield of Endoscopy and Histology in the Evaluation of Esophageal Dysphagia: Two Referral Centers' Experiences.

Background and Objectives: The initial diagnostic test required to evaluate esophageal dysphagia is upper endoscopy (EGD) to assess the structure of the esophagus and the esophageo-gastric junction (EGJ). Taking biopsies during EGD has become a common practice in patients with dysphagia to rule out eosinophilic esophagitis (EoE). The aims of this study were to evaluate the endoscopic findings of patients who underwent EGD for esophageal dysphagia, to assess the rate of biopsy taking from the esophagus to diagnose/exclude EoE, and to report histology outcomes of these biopsies. Materials and Methods: This was a retrospective multicenter study that included individuals ≥18 years who underwent EGD due to esophageal dysphagia between the years 2015 and2020, (with no other alarm signs, such as weight loss, new iron deficiency anemia, and lymphadenopathy). We obtained data from patients' electronic files. The endoscopy and histology findings were obtained from endoscopy reports saved in our electronic files. Results: A total of 209 patients were included in the study. The average age was 57.1 ± 17.1 years. The most common endoscopic findings were normal endoscopy in 76 patients (36.4%) and erosive esophagitis in 75 patients (35.9%). Barrett's esophagus and esophageal malignancy were encountered in 11 patients (5.3%) and 2 patients (0.95%), respectively. Esophageal biopsies were taken in 50.2% of patients, and one patient had histological evidence of EoE (0.5%). On univariate analysis, there was a trend for association between proton pump inhibitors (PPIs) use and a normal EGD, but it was not statistically significant (OR 0.28, 95% CI 0.07-1.11, p = 0.07). Conclusions: Endoscopic findings were prevalent in dysphagia patients even when no other alarm symptoms exist. Neoplastic lesions and EOE were rare in our study.

Success of Various Marketing Strategies for a New-to-the-Area Orthopedic Practice.

Background Competition for patients among orthopaedic private practices, multi-specialty groups, and hospital systems continues to persist. An effective marketing campaign is essential for a practice to succeed in this competitive environment. The purpose of this study was to investigate the cost-effectiveness and efficacy of each marketing campaign and the influence of patient demographics on efficacy. Methods The first 300 consecutive, new patients were prospectively surveyed on how they initially discovered and then selected the orthopaedic practice. Demographics and marketing costs were tabulated and categorized to analyze the effectiveness of each marketing strategy. Results A substantial portion of the marketing budget was allocated for traditional (67.0%) and online advertising (25.0%). However, only 56/300 (18.7%) patients surveyed were brought to the practice by these methods combined. In contrast, expenditure on a marketing liaison (8.0%) delivered 128 patients (42.7%) through referrals: 80 (26.7%) from physicians, 28 (9.3%) from urgent cares, 17 (5.7%) from physical therapists, and 3 (1.0%) from attorneys. Conclusion Marketing strategies were not proportionally beneficial during the first six months of the orthopaedic practice start-up period. During this early ramping up period, the most cost-effective marketing strategy was utilization of a liaison for direct in-person visits to various healthcare facilities.

Effect of COVID-19 on Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers.

BACKGROUND: The coronavirus disease of 2019 (COVID-19) pandemic led to the suspension and shortening of the 2020 Major League Baseball (MLB) season from 162 to 60 regular season games. The effect of this disruption on injury rates, specifically injury to the ulnar collateral ligament (UCL), has not been quantified. PURPOSE/HYPOTHESIS: The purpose of this study was to compare the rate of UCL reconstruction (UCLR), surgery timing, and pitching workload in MLB pitchers from before and after the COVID-19 pandemic lockdown. We hypothesized that UCLR rates relative to games played would be increased and pitching workload would be decreased in 2020 compared with previous seasons. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: An extensive online search using publicly available data was conducted to identify all MLB pitchers who underwent UCLR between January 1, 2017, and December 31, 2020. Only pitchers who were competing at the MLB level when undergoing reconstruction were included. Player characteristics and surgery date, as well as career and season of surgery pitching workload, were collected for all included pitchers. All data were compared as a pooled sample (2017-2019 vs 2020). RESULTS: A similar number of pitchers underwent UCLR during or after the 2020 regular season (n = 18) compared with the 2017-2019 seasons (n = 16, 20, and 16, respectively). However, after accounting for the decrease in games played during the 2020 regular season, an MLB pitcher was 2.9 times more likely to undergo surgery per game after the COVID-19 lockdown compared with the previous years (P < .001). MLB pitchers who underwent surgery in 2020 threw fewer preseason innings than did pitchers who underwent surgery between 2017 and 2019 (5.98 vs 9.39; P = .001). CONCLUSION: MLB pitchers were almost 3 times more likely to undergo UCLR per game after the COVID-19 lockdown. A decreased preseason pitching workload because of the COVID-19 lockdown may have had an effect on per game UCLR rates.

Differences in Patient and Physician Perceptions of Urgency for Musculoskeletal Conditions During the COVID-19 Pandemic.

In 2020, the coronavirus disease 2019 (COVID-19) pandemic limited musculoskeletal care to urgent or "nonelective" office visits and procedures. No guidelines exist to inform patients or physicians what meets these criteria. The purpose of this multi-institutional study was to describe the differences in perceptions of urgency for musculoskeletal complaints between patients and providers during the COVID-19 pandemic. An anonymous survey was distributed to patients who visited the authors' orthopedic clinics in January and February 2020 and practicing orthopedic surgeons. The surveys were administered in May 2020 after COVID-19 was officially labeled a pandemic and included questions regarding demographic information and perceptions of orthopedic urgency. A total of 1491 patients and 128 physicians completed the surveys. A significantly higher percentage of physicians considered the following diagnoses an appropriate indication for an urgent visit compared with patients: fracture (P<.001), acute dislocation (P<.001), infection (P<.001), neurologic compromise (P<.001), tumor (P<.001), acute tendon injury (P<.001), weakness (P<.001), inability to bear weight (P<.001), post-surgical problem (P<.001), and painful joint effusion (P<.001). There were no significant differences in the perception of urgency for the following conditions: bursitis/tendonitis (P=1.00), joint/extremity deformity without pain (P=.113), and loss of range of motion of a joint (P=.467). Younger patients and those with higher levels of education were significantly more likely to consider their conditions urgent. Patients may require additional education to prevent delay in treatment of urgent conditions-especially time-sensitive conditions such as neurologic compromise, tumors, and infections-when access to physicians is limited. [Orthopedics. 2021;44(4):e534-e538.].

Entrapped long head of biceps tendon in pediatric proximal humerus fracture dislocation: A case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Combined proximal humerus fracture and glenohumeral dislocation in the pediatric population is extremely rare, with only few reports of such cases been reported. We review all cases of combined proximal humerus fracture and glenohumeral dislocation in the pediatric population and present a case of left proximal humerus fracture dislocation in a healthy 5-year-old girl. CASE PRESENTATION: A 5-year-old girl fell from 2 m height and landed on her left shoulder where she started to complain from severe left shoulder pain, inability to move her left shoulder and bruising. She was diagnosed at our facility to have left proximal humerus fracture combined with glenohumeral dislocation and was treated with open reduction, K-wires fixation and immobilization in a shoulder cast. CLINICAL DISCUSSION: Traumatic proximal humeral fracture associated with glenohumeral dislocation is a rare presentation in pediatric age group. This type of fracture is usually managed by closed reduction and casting, with a minority being managed with open reduction. Indications for surgical intervention are open fractures, severely displaced fractures, fractures that are associated with neurovascular compromise, or irreducible fracture due to soft tissue obstacles. CONCLUSIONS: A high index of suspicion is required to diagnose such injuries along with appropriate radiographic evaluation. We recommend open reduction with K-wires fixation for irreducible combined proximal humeral fracture and glenohumeral dislocation.

Patient Perception of Physician Attire in the Outpatient Setting During the COVID-19 Pandemic.

INTRODUCTION: In response to the SARS-CoV-2 pandemic, physician attire has evolved to incorporate personal protective equipment (PPE). Although PPE is mandated for all healthcare workers, variability exists in choice and availability. The purpose of this study was to determine patient perception of physician attire during the COVID-19 pandemic in an outpatient setting. METHODS: Three hundred sixty-eight patients who presented to our outpatient orthopaedic clinics completed an anonymous survey. In addition to demographic characteristics, patient preferences for attire, PPE, and social distancing were obtained. RESULTS: Scrubs (81%, 298/368) were found to be the most acceptable physician attire. Eye protection (34.2%, 126/368) and gloves (32.6%, 120/368), however, were deemed much less acceptable; 93.5% (344/368) of patients reported that no mask was unacceptable, with 41.0% (151/368) preferring a surgical mask. Predilection for a surgical mask and N95 rose with increasing patient education level. Interestingly, 55.2% (203/368) responded that physicians should stop wearing PPE only when the Center for Disease Control recommends. CONCLUSION: During the COVID-19 pandemic, most of the patients found scrubs to be the most acceptable attire in an office-based outpatient setting. Patients also found physician mask-wearing to be important but are less accepting of providers wearing eye and hand protection.

2021 John N. Insall Award: Aspirin is effective in preventing propagation of infrapopliteal deep venous thrombosis following total knee arthroplasty.

AIMS: The optimal management of an infrapopliteal deep venous thrombosis (IDVT) following total knee arthroplasty (TKA) remains unknown. The risk of DVT propagation and symptom progression must be balanced against potential haemorrhagic complications associated with administration of anticoagulation therapy. The current study reports on a cohort of patients diagnosed with IDVT following TKA who were treated with aspirin, followed closely for development of symptoms, and scanned with ultrasound to determine resolution of IDVT. METHODS: Among a cohort of 5,078 patients undergoing TKA, 532 patients (695 TKAs, 12.6%) developed an IDVT between 1 January 2014 to 31 December 2019 at a single institution, as diagnosed using Doppler ultrasound at the first postoperative visit. Of the entire cohort of 532 patients with IDVT, 91.4% (486/532) were treated with aspirin (325 mg twice daily) and followed closely. Repeat lower limb ultrasound was performed four weeks later to evaluate the status of IDVT. RESULTS: Follow-up Doppler ultrasound was performed on 459/486 (94.4%) patients and demonstrated resolution of IDVT in 445/459 cases (96.9%). Doppler diagnosed propagation of IDVT to the popliteal vein had occurred in 10/459 (2.2%) cases. One patient with an IDVT developed a pulmonary embolus six weeks postoperatively. CONCLUSION: The results of this study demonstrate a low rate of IDVT propagation in patients managed with aspirin. Additionally, no significant bleeding episodes, wound-related complications, or other adverse events were noted from aspirin therapy. Cite this article: Bone Joint J 2021;103-B(6 Supple A):18-22.