Insights into the spatial ecology of severely injured free-living felids: Iberian lynx, bobcat, and snow leopard.

Severe musculoskeletal diseases, such as those associated with congenital or traumatic events, that result in missing limbs may compromise the fitness and survival of free-living felids. Here we report the space use of four amputee individuals from three felid species captured from 2017 to 2022 in Missouri (USA), Toledo and Badajoz (Spain), and Suitai Khairkhan Mountain (Mongolia). We describe home ranges and daily travel distances post-release of free-living felids that had either suffered a traumatic amputation or following a surgical amputation. We compared these data with those reported in the literature for felids without amputations. Forelimb or hindlimb amputation did not affect the hunting, mating, or territory patrolling behavior of any of the individuals. However, we recorded significant differences in the daily movement before and after the traumatic event of the Iberian lynx forelimb amputee. We attribute this difference to the physical impairment, although we consider other variables that may have played a role. Nevertheless, all animals appeared to cope well with their limb loss, showing home ranges and daily distances within those recorded for their sex and species. Unless amputee felids represent a threat to domestic livestock or humans, our data suggest these individuals may remain free-living as they contribute to local population persistence and appear to maintain good general health and welfare.

Ranavirus (Frog Virus 3) Infection in Free-Living Three-Toed Box Turtles (Terrapene mexicana triunguis) in Missouri, USA.

Frog virus 3 (FV3) and related ranaviruses are emerging infectious disease threats to ectothermic vertebrate species globally. Although the impact of these viruses on amphibian health is relatively well studied, less is understood about their effects on reptile health. We report two cases of FV3 infection, 11 mo apart, in three-toed box turtles (Terrapene mexicana triunguis) from a wildlife rehabilitation center. Case 1 had upper respiratory signs upon intake but had no clinical signs at the time of euthanasia 1 mo later. Case 2 presented for vehicular trauma, had ulcerative pharyngitis and glossitis, and died overnight. In case 1, we detected FV3 nucleic acid with qPCR in oral swabs, kidney, liver, spleen, and tongue. In case 2, we detected FV3 in an oral swab, an oral plaque, heart, kidney, lung, liver, spleen, and tongue. We also detected FV3 nucleic acid with in situ hybridization for case 2. For both cases, FV3 was isolated in cell culture and identified with DNA sequencing. Histopathologic examination of postmortem tissue from case 1 was unremarkable, whereas acute hemorrhagic pneumonia and splenic necrosis were noted in case 2. The difference in clinical signs between the two cases may have been due to differences in the temporal course of FV3 disease at the time of necropsy. Failure to detect this infection previously in Missouri reptiles may be due to lack of surveillance, although cases may also represent a novel spillover to box turtles in Missouri. Our findings reiterate previous suggestions that the range of FV3 infection may be greater than previously documented and that infection may occur in host species yet to be tested.

Arterial Monitoring in Hypertensive Emergencies: Significance for the Critical Care Resuscitation Unit.

INTRODUCTION: Blood pressure measurement is important for treating patients. It is known that there is a discrepancy between cuff blood pressure vs arterial blood pressure measurement. However few studies have explored the clinical significance of discrepancies between cuff (CPB) vs arterial blood pressure (ABP). Our study investigated whether differences in CBP and ABP led to change in management for patients with hypertensive emergencies and factors associated with this change. METHODS: This prospective observational study included adult patients admitted between January 2019-May 2021 to a resuscitation unit with hypertensive emergencies. We defined clinical significance of discrepancies as a discrepancy between CBP and ABP that resulted in change of clinical management. We used stepwise multivariable logistic regression to measure associations between clinical factors and outcomes. RESULTS: Of 212 patients we analyzed, 88 (42%) had change in management. Mean difference between CBP and ABP was 17 milligrams of mercury (SD 14). Increasing the existing rate of antihypertensive infusion occurred in 38 (44%) patients. Higher body mass index (odds ratio [OR] 1.04, 95% confidence Interval [CI] 1.0001-1.08, P-value <0.05) and history of peripheral arterial disease (OR 0.16, 95% CI 0.03-0.97, P-value <0.05) were factors associated with clinical significance of discrepancies. CONCLUSION: Approximately 40% of hypertensive emergencies had a clinical significance of discrepancy warranting management change when arterial blood pressure was initiated. Further studies are necessary to confirm our observations and to investigate the benefit-risk ratio of ABP monitoring.

HEMATOLOGY AND BLOOD CHEMISTRY VALUES IN CUBAN CROCODILES (CROCODYLUS RHOMBIFER) HOUSED AT THE ZAPATA SWAMP CROCODILE FARM, CUBA.

We report hematology and biochemistry reference intervals (RI) for the critically endangered Cuban crocodile (Crocodylus rhombifer). In November 2019, we sampled 43 adult crocodiles (6 male, 37 female) under human care at the Zapata Swamp Crocodile Farm in Matanzas, Cuba. These crocodiles are part of a breeding program for the species registered by the Convention on International Trade in Endangered Species (CITES). Visual health evaluations were performed immediately after manual restraint, and blood was collected from the postoccipital sinus. We performed packed cell volume (PCV), total solids (TS), complete blood counts (CBC), and biochemistry profiles for each crocodile on the day of sampling. Mean PCV (n = 42) was 21.1 ± 5.0% and TS (n = 42) 7.3 ± 1.2 mg/dl, respectively. Absolute white blood cell (WBC) (n = 40) was 9.6 ± 5.7 ｘ 109/L. Similar to other crocodilian species, the dominant leukocyte was lymphocytes (70.7 ± 10.4%), followed by heterophils (18.7 ± 9.7%). Two of the crocodiles had a high heterophil:lymphocyte ratio (0.87 and 0.74), although on visual exam they were both considered healthy. The range of creatine kinase was 41-1,482 U/L, and the higher values may be a reflection of muscle exertion at time of handling. Limitations to the study included skewed sex ratios and high lipemia and hemolysis in most samples collected. These are the first reference intervals reported for this species, including the first descriptions of WBC morphology. These data are valuable for the management of animals at the Zapata Swamp Crocodile Farm, for comparison with free-living Cuban crocodiles in Cuba, and for comparison with those managed under human care outside of Cuba.

Most patients with non-hypertensive diseases at a critical care resuscitation unit require arterial pressure monitoring: a prospective observational study.

BACKGROUND: Blood pressure (BP) monitoring is essential for patient care. Invasive arterial BP (IABP) is more accurate than non-invasive BP (NIBP), although the clinical significance of this difference is unknown. We hypothesized that IABP would result in a change of management (COM) among patients with non-hypertensive diseases in the acute phase of resuscitation. METHODS: This prospective study included adults admitted to the Critical Care Resuscitation Unit (CCRU) with non-hypertensive disease from February 1, 2019, to May 31, 2021. Management plans to maintain a mean arterial pressure >65 mmHg (1 mmHg=0.133 kPa) were recorded in real time for both NIBP and IABP measurements. A COM was defined as a discrepancy between IABP and NIBP that resulted in an increase/decrease or addition/discontinuation of a medication/infusion. Classification and regression tree analysis identified significant variables associated with a COM and assigned relative variable importance (RVI) values. RESULTS: Among the 206 patients analyzed, a COM occurred in 94 (45.6% [94/206]) patients. The most common COM was an increase in current infusion dosages (40 patients, 19.4%). Patients receiving norepinephrine at arterial cannulation were more likely to have a COM compared with those without (45 [47.9%] vs. 32 [28.6%], P=0.004). Receiving norepinephrine (relative variable importance [RVI] 100%) was the most significant factor associated with a COM. No complications were identified with IABP use. CONCLUSION: A COM occurred in 94 (45.6%) non-hypertensive patients in the CCRU. Receiving vasopressors was the greatest factor associated with COM. Clinicians should consider IABP monitoring more often in non-hypertensive patients requiring norepinephrine in the acute resuscitation phase. Further studies are necessary to confirm the risk-to-benefit ratios of IABP among these high-risk patients.

Quality assessment of polymer materials for human model eye development.

PURPOSE: We developed model eyes using six polymer materials to determine which materials were most appropriate in simulating real human sclera and extraocular muscle (EOM). METHODS: Five three-dimensional (3-D) printed polymers (FlexFill, PolyFlex, PCTPE, Soft PLA, and NinjaFlex) and one silicone material were systematically tested by board-certified ophthalmologists and senior ophthalmology residents. Material testing included scleral passes with 6-0 Vicryl sutures through each eye model. Participants completed a survey designed to collect demographic data, subjective assessment of each material's accuracy in simulating real human sclera and EOM, and a ranking for each polymer material to identify which would be most suitable for an ophthalmic surgery training tool. The Wilcoxon signed-rank test was conducted to determine if there was a statistically significant difference in the distribution of ranks between the polymer materials. RESULTS: The distribution of ranks for silicone material's "sclera" and "EOM" components were statistically significantly higher than that of all other polymer materials (all p < 0.05). Silicone material received the highest rank for both "sclera" and "EOM" components. Survey results indicated that the silicone material effectively simulated real human tissue. CONCLUSION: Silicone model eyes performed better than 3-D printed polymers as an educational tool for incorporation into a microsurgical training curriculum. Silicone models provide a low-cost teaching tool that allows for independent practice of microsurgical techniques without requiring a wet-laboratory facility.

Mobile integrated health-community paramedicine programs' effect on emergency department visits: An exploratory meta-analysis.

INTRODUCTION: Mobile Integrated Health Community Paramedicine (MIH-CP) programs are designed to increase access to care and reduce Emergency Department (ED) and Emergency Medical Services (EMS) usage. Previous MIH-CP systematic reviews reported varied interventions, effect sizes, and a high prevalence of biased methods. We aimed to perform a meta-analysis on MIH-CP effect on ED visits, and to evaluate study designs' effect on reported effect sizes. We hypothesized biased methods would produce larger reported effect sizes. METHODS: We searched Pubmed, Embase, CINAHL, and Scopus databases for peer-reviewed MIH-CP literature from January 1, 2000, to July 24, 2021. We included all full-text English studies whose program met the National Associations of Emergency Medical Technicians definition, reported ED visits, and had an MIH-CP related intervention and outcome. We established risk ratios for each included study through interpreting the reported data. We performed a random-effects and cumulative meta-analysis of ED visit data, tests of heterogeneity, and a moderator analysis to assess for factors influencing the magnitude of observed effect. RESULTS: We identified 16 studies that reported ED visit data and included 12 in our meta-analysis. All studies were observational; 3 used matched controls, 6 pre-post controls, and 3 without controls. 7 studies' intervention were diversion/triage while 5 studies intervened with health education/home primary care services. Pooled risk ratio for our data set was 0.56 (95% confidence interval 0.42-0.74). Cumulative meta-analysis revealed that as of 2018 MIH-CP programs began to show consistent reductions in ED visits. Significant heterogeneity was seen among studies, with I-squared >90%. Moderator analysis showed reduced heterogeneity for matched-control studies. CONCLUSION: Our data revealed MIH-CP programs were associated with a reduced risk of ED visits. Study design did not have a statistically significant influence on effect size, though it did influence heterogeneity. We would recommend future studies continue to use high levels of control to produce reliable data with lower heterogeneity.

Validating the Efficacy of a Stepwise Video Module for Conjunctival Closure.

Objective The aim of this study is to describe a cost-effective and portable surgical training module for ophthalmology trainees and demonstrate its effectiveness in building confidence and reducing stress with conjunctival closure. Methods A total of 29 trainees (fourth year medical students, postgraduate year (PGY) 1 ophthalmology residents, PGY2 ophthalmology residents) participated in the module during July 2022. They completed a Pre-Module and Post-Module Questionnaire, with some questions assessing their confidence level and other questions assessing their stress level with conjunctival closure. A Likert scale of 1 to 10 was used to evaluate their level of confidence or stress (with 1 indicating low confidence or low stress and 10 indicating high confidence or high stress). Results Prior to completing the module, participants had an average conjunctival suturing skills confidence level score of 2.6 ± 1.6, which increased significantly to 5.6 ± 1.6 after completing the module ( p < 0.001). Participant's stress level score with performing conjunctival closure on live patients significantly decreased from 7.5 ± 2.4 to 5.6 ± 1.5 ( p < 0.001) after completion of the module. When participants were separated into two groups, participants in the PGY1 residents/medical students group had an average conjunctival suturing skills confidence level score of 2.7 ± 1.8, which rose significantly to 5.1 ± 1.5 after completing the module ( p = 0.008), whereas PGY2 residents had an average conjunctival suturing skills confidence level score of 2.6 ± 1.6, which rose significantly to 5.8 ± 1.7 after completing the module ( p < 0.001). Participant's stress level scores with performing conjunctival closure on live patients did not show significant results in the PGY1 residents/medical students group but significantly decreased from 7.2 ± 2.2 to 5.2 ± 1.3 ( p < 0.001) in PGY2 residents. Participants agreed that the video presented was effective for learning the surgical skill and that the module was engaging and prepared them well to learn more advanced conjunctival suturing techniques. Conclusion Our surgical training module is an effective teaching tool for ophthalmology trainees to increase confidence and decrease stress about performing conjunctiva closure. It provides an opportunity for trainees to repetitively practice key surgical techniques on an inexpensive and reusable training model.

Advantages and limitations of experimental autoimmune encephalomyelitis in breaking down the role of the gut microbiome in multiple sclerosis.

Since the first model of experimental autoimmune encephalomyelitis (EAE) was introduced almost a century ago, there has been an ongoing scientific debate about the risks and benefits of using EAE as a model of multiple sclerosis (MS). While there are notable limitations of translating EAE studies directly to human patients, EAE continues to be the most widely used model of MS, and EAE studies have contributed to multiple key breakthroughs in our understanding of MS pathogenesis and discovery of MS therapeutics. In addition, insights from EAE have led to a better understanding of modifiable environmental factors that can influence MS initiation and progression. In this review, we discuss how MS patient and EAE studies compare in our learning about the role of gut microbiome, diet, alcohol, probiotics, antibiotics, and fecal microbiome transplant in neuroinflammation. Ultimately, the combination of rigorous EAE animal studies, novel bioinformatic approaches, use of human cell lines, and implementation of well-powered, age- and sex-matched randomized controlled MS patient trials will be essential for improving MS patient outcomes and developing novel MS therapeutics to prevent and revert MS disease progression.

A Systematic Review of Methodologies and Outcome Measures of Mobile Integrated Health-Community Paramedicine Programs.

INTRODUCTION: Mobile integrated health-community paramedicine (MIH-CP) uses patient-centered, mobile resources in the out-of-hospital environment to increase access to care and reduce unnecessary emergency department (ED) usage. The objective of this systematic review is to characterize the outcomes and methodologies used by MIH-CP programs around the world and assess the validity of the ways programs evaluate their effectiveness. METHODS: The PubMed, Embase, CINAHL, and Scopus databases were searched for peer-reviewed literature related to MIH-CP programs. We included all full-length studies whose programs met the National Association of Emergency Medical Technicians definition, had MIH-CP-related interventions, and measured outcomes. We excluded all non-English papers, abstract-only, and incomplete studies. RESULTS: Our initial literature review identified 6434 titles. We screened 178 full-text studies to assess for eligibility and identified 33 studies to include in this review. These 33 include four randomized controlled trials, 17 cohort studies, eight 8 case series, and four 4 cross-sectional studies. Of the 29 non-randomized trials, five used matched controls, 13 used pre-post, and 11 used no controls. Outcomes measured were hospital usage (24 studies), ED visits (15), EMS usage (23), patient satisfaction (8), health-related outcomes (8), and cost (9). Studies that evaluated hospital usage reported one of several outcome measures: hospital admissions (11), ED length of stay (3), and hospital readmission rate (2). EMS usage was measured by ambulance transports (12) and EMS calls (10). Cost outcomes observed were ambulance transport savings (7), ED visit savings (4), hospital admission savings (3), and cost per quality-adjusted life year (2). CONCLUSION: Most studies assessing MIH-CP programs reported success of their interventions. However, significant heterogeneity of outcome measures and varying quality of study methodologies exist among studies. Future studies designed with adequately matched controls and applying uniform core metrics for cost savings and health care usage are needed to better evaluate the effectiveness of MIH-CP programs.

Invasive arterial blood pressure monitoring may aid in the medical management of hypertensive patients with acute aortic disease.

INTRODUCTION: Blood pressure (BP) monitoring and management is essential in the treatment of acute aortic disease (AoD). Previous studies had shown differences between invasive arterial BP monitoring (ABPM) and non-invasive cuff BP monitoring (CBPM), but not whether ABPM would result in patients' change of clinical management. We hypothesized that ABPM would change BP management in AoD patients. METHODS: This was a prospective observational study of adult patients with AoD admitted to the Critical Care Resuscitation Unit from January 2019 to February 2021. Patients with AoD and both ABPM and CBPM measurements were included. Clinician's BP management goals were assessed in real time before and after arterial catheter placement according to current guidelines. We defined change of management as change of current antihypertensive infusion rate or adding a new agent. We used multivariable logistic and ordinal regressions to determine relevant predictors. RESULTS: We analyzed 117 patients, and 56 (47%) had type A dissection. ABPM was frequently ≥10 mmHg higher than CBPM values. Among 40 (34%) patients with changes in management, 58% (23/40) had [ABPM-CBPM] differences ≥20 mmHg. ABPM prompted increasing current antihypertensive infusion in 68% (27/40) of patients. Peripheral artery disease (OR 13, 95% CI 1.18-50+) was associated with changes in clinical management, and ordinal regression showed hypertension and serum lactate to be associated with differences between ABPM and CBPM. CONCLUSIONS: ABPM was frequently higher than CBPM, resulting in 34% of changes of management, most commonly increasing anti-hypertensive infusion rates.

Discrepancy Between Invasive and Noninvasive Blood Pressure Measurements in Patients with Sepsis by Vasopressor Status.

INTRODUCTION: Blood pressure (BP) monitoring is an essential component of sepsis management. The Surviving Sepsis Guidelines recommend invasive arterial BP (IABP) monitoring, although the benefits over non-invasive BP (NIBP) monitoring are unclear. This study investigated discrepancies between IABP and NIBP measurement and their clinical significance. We hypothesized that IABP monitoring would be associated with changes in management among patients with sepsis requiring vasopressors. METHODS: We performed a retrospective study of adult patients admitted to the critical care resuscitation unit at a quaternary medical center between January 1-December 31, 2017. We included patients with sepsis conditions AND IABP monitoring. We defined a clinically significant BP discrepancy (BPD) between NIBP and IABP measurement as a difference of > 10 millimeters of mercury (mm Hg) AND change of BP management to maintain mean arterial pressure ≥ 65 mm Hg. RESULTS: We analyzed 127 patients. Among 57 (45%) requiring vasopressors, 9 (16%) patients had a clinically significant BPD vs 2 patients (3% odds ratio [OR] 6.4; 95% CI: 1.2-30; P = 0.01) without vasopressors. In multivariable logistic regression, higher Sequential Organ Failure Assessment (SOFA) score (OR 1.33; 95% CI: 1.02-1.73; P = 0.03) and serum lactate (OR 1.27; 95% CI: 1.003-1.60, P = 0.04) were associated with increased likelihood of clinically significant BPD. There were no complications (95% CI: 0-0.02) from arterial catheter insertions. CONCLUSION: Among our population of septic patients, the use of vasopressors was associated with increased odds of a clinically significant blood pressure discrepancy between IABP and NIBP measurement. Additionally, higher SOFA score and serum lactate were associated with higher likelihood of clinically significant blood pressure discrepancy. Further studies are needed to confirm our observations and investigate the benefits vs the risk of harm of IABP monitoring in patients with sepsis.

A novel method for strabismus surgery education using an asynchronous video module.

Conjunctival closure is an important step in strabismus surgery and a fundamental surgical skill that requires dexterity and understanding of general surgical principles. Traditionally, ophthalmology residents have improved their surgical technique in supervised wet labs. Social distancing guidelines during the COVID-19 pandemic may have limited the ability for direct supervised surgical teaching. We developed a safe, reusable, low-cost teaching module that allows residents to train independently to develop skills necessary for conjunctival closure. This module uses stepwise teaching and video instruction to improve resident confidence and preparedness in conjunctival suturing.

A novel herpesvirus detected in 3 species of chelonians.

Herpesviruses are found in free-living and captive chelonian populations, often in association with morbidity and mortality. To date, all known chelonian herpesviruses fall within the subfamily Alphaherpesvirinae. We detected a novel herpesvirus in 3 species of chelonians: a captive leopard tortoise (Stigmochelys pardalis) in western TX, USA; a steppe tortoise (Testudo [Agrionemys] horsfieldii) found near Fort Irwin, CA, USA; and 2 free-living, three-toed box turtles (Terrapene mexicana triunguis) found in Forest Park, St. Louis, MO. The leopard tortoise was coinfected with the tortoise intranuclear coccidian and had clinical signs of upper respiratory tract disease. The steppe tortoise had mucopurulent nasal discharge and lethargy. One of the three-toed box turtles had no clinical signs; the other was found dead with signs of trauma after being observed with blepharedema, tympanic membrane swelling, cervical edema, and other clinical signs several weeks prior to death. Generally, the branching order of the turtle herpesviruses mirrors the divergence patterns of their hosts, consistent with codivergence. Based on phylogenetic analysis, this novel herpesvirus clusters with a clade of viruses that infect emydid hosts and is likely of box turtle origin. Therefore, we suggest the name terrapene alphaherpesvirus 3 (TerAHV3) for the novel virus. This virus also has the ability to host-jump to tortoises, and previously documented herpesviral morbidity tends to be more common in aberrant hosts. The relationship between clinical signs and infection with TerAHV3 in these animals is unclear, and further investigation is merited.

Predicting Outcomes for Interhospital Transferred Patients of Emergency General Surgery.

Background: Interhospital transferred (IHT) emergency general surgery (EGS) patients are associated with high care intensity and mortality. However, prior studies do not focus on patient-level data. Our study, using each IHT patient's data, aimed to understand the underlying cause for IHT EGS patients' outcomes. We hypothesized that transfer origin of EGS patients impacts outcomes due to critical illness as indicated by higher Sequential Organ Failure Assessment (SOFA) score and disease severity. Materials and Methods: We conducted a retrospective analysis of all adult patients transferred to our quaternary academic center's EGS service from 01/2014 to 12/2016. Only patients transferred to our hospital with EGS service as the primary service were eligible. We used multivariable logistic regression and probit analysis to measure the association of patients' clinical factors and their outcomes (mortality and survivors' hospital length of stay [HLOS]). Results: We analyzed 708 patients, 280 (39%) from an ICU, 175 (25%) from an ED, and 253 (36%) from a surgical ward. Compared to ED patients, patients transferred from the ICU had higher mean (SD) SOFA score (5.7 (4.5) vs. 2.39 (2), P < 0.001), longer HLOS, and higher mortality. Transferring from ICU (OR 2.95, 95% CI 1.36-6.41, P=0.006), requiring laparotomy (OR 1.96, 95% CI 1.04-3.70, P=0.039), and SOFA score (OR 1.22, 95% CI 1.13-1.32, P < 0.001) were associated with higher mortality. Conclusions: At our academic center, patients transferred from an ICU were more critically ill and had longer HLOS and higher mortality. We identified SOFA score and a few conditions and diagnoses as associated with patients' outcomes. Further studies are needed to confirm our observation.

Effects of early life adversity on male reproductive behavior and the medial preoptic area transcriptome.

Early life adversity can alter reproductive development in humans, changing the timing of pubertal onset and sexual activity. One common form of early adversity is limited access to resources. This adversity can be modeled in rats using the limited bedding/nesting model (LBN), in which dams and pups are placed in a low resource environment from pups' postnatal days 2-9. Our laboratory previously found that adult male rats raised in LBN conditions have elevated levels of plasma estradiol compared to control males. In females, LBN had no effect on plasma hormone levels, pubertal timing, or estrous cycle duration. Estradiol mediates male reproductive behaviors. Thus, here we compared reproductive behaviors in adult males exposed to LBN vs. control housing. LBN males acquired the suite of reproductive behaviors (mounts, intromissions, and ejaculations) more quickly than their control counterparts over 3 weeks of testing. However, there was no effect of LBN in males on puberty onset or masculinization of certain brain regions, suggesting LBN effects on estradiol and reproductive behaviors manifest after puberty. In male and female rats, we next used RNA sequencing to characterize LBN-induced transcriptional changes in the medial preoptic area (mPOA), which underlies male reproductive behaviors. LBN produced sex-specific alterations in gene expression, with many transcripts showing changes in opposite directions. Numerous transcripts altered by LBN in males are regulated by estradiol, linking hormonal changes to molecular changes in the mPOA. Pathway analysis revealed that LBN induced changes in neurosignaling and immune signaling in males and females, respectively. Collectively, these studies reveal novel neurobiological mechanisms by which early life adversity can alter reproductive strategies.

Postoperative Rehabilitation and Return to Sport Following Multiligament Knee Reconstruction.

Multiligament knee injuries (MLKIs) are debilitating injuries that increasingly occur in young athletes. Return to sport (RTS) has historically been considered unlikely due to the severity of these injuries. Reporting in the literature regarding objective outcomes following MLKI, including RTS, is lacking, as are clear protocols for both rehabilitation progressions and RTS testing. RTS following MLKI is a complex process that requires an extended recovery duration compared to other surgery types. Progressions through postoperative rehabilitation and RTS should be thoughtful, gradual, and criterion based. After effective anatomic reconstruction to restore joint stability, objective measures of recovery including range of motion, strength, movement quality, power, and overall conditioning guide decision-making throughout the recovery process. It is important to frame the recovery process of the athlete in the context of the severity of their injury, as it is typically slower and less linear. Improved reporting on objective outcomes will enhance our understanding of recovery expectations within this population by highlighting persistent deficits that may interfere with a full recovery, including RTS.

A Novel Method for Teaching Laser Peripheral Iridotomy and Selective Laser Trabeculoplasty Using Video Instruction and Model Eyes.

Objective The aim of the study is to describe an inexpensive and easily-constructed model eye for the purpose of teaching laser peripheral iridotomy (LPI) and selective laser trabeculoplasty (SLT) to ophthalmology residents. Methods Easily constructed, inexpensive model eyes were utilized to teach residents SLT and LPI utilizing a remote self-study module. A teaching microscope attachment allowed for video-based instruction and feedback. Results This model eye, used in conjunction with video modules is an effective low-cost teaching tool for laser surgery among ophthalmology residents. Attending ophthalmologists rated the use of these model eyes using surveys and found them to be appropriate teaching tools that could lead to improved knowledge and translate to better patient care. Conclusion Our novel method for teaching glaucoma laser surgery allows residents to learn the principles and theory behind common laser procedures while having the opportunity to practice repetitive procedures on low-cost model eyes.

Prevalence of myocardial infarction among patients with chest pain and cocaine use: A systematic review and meta-analysis.

BACKGROUND: Cocaine abuse is a public health burden. Cocaine is known to cause vasospasm and acute myocardial infarction (AMI). The prevalence of AMI in patients presenting with chest pain and concurrent cocaine use (CPCC) varies among studies. We performed a systemic review and meta-analysis to assess the current literature for the prevalence of AMI in patients with CPCC. METHODS: We performed a literature search of PubMed, EMBASE, and Scopus from its beginning to May 18, 2020 and updated this search on February 18, 2021. Full-text studies that assessed the primary outcome (AMI) specifically among patients with CPCC who presented to the emergency department (ED) were included. We excluded studies that were not in English, did not take place in the ED, and case reports, which only reported positive cases and not incidence of AMI. Random effect meta-analysis was performed to assess the prevalence of primary outcome and to examine correlations between risk factors and AMI. Heterogeneity was assessed by I-square value. We also performed subgroup analysis to identify potential sources of heterogeneity. RESULTS: We identified 2178 studies and screened 102 full-text studies to include 16 studies (3269 patients) in our final analysis. The pooled prevalence of AMI was 4.7% (95% CI 0.8-23), I-square of 84%. However, rates among studies of low risk patients were lower (1.1% 95% CI 0.2-5) compared to studies of mixed risk patients (7.7%, 95% 5-11). A meta-regression was used to look at correlation between risk factors and AMI and found that AMI was positively correlated in patients with a history of CAD (correlation coefficient [Corr. Coeff.] 5.6, 96% CI 2.3-8.7), HTN (Corr. Coeff. 2.9, 95% CI 0.9-4.9), DM (Corr. Coeff. 8.0, 95% CI 2.4-14), HLD (Corr. Coeff. 5.9, 95% CI 2.4, 9). Sources of potential heterogeneity included patients' risk as defined by the authors, study designs, publication year, and study sample size. CONCLUSION: The overall prevalence of AMI and death among patients with cocaine-associated chest pain was relatively low, although high risk patients were still associated with high prevalence of AMI. Clinicians should consider risk-stratify these patients and treat them accordingly.

Safety Matters: A Meta-analysis of Interhospital Transport Adverse Events in Critically Ill Patients.

OBJECTIVE: Interhospital transport (IHT) is common among critically ill patients. Our meta-analysis investigated the prevalence and possible factors associated with adverse events (AEs) during IHT. METHODS: Searching PubMed, Embase, and Scopus databases until February 12, 2021, we included studies that a priori defined AEs for adult medical patients. We excluded case reports, non-full-text, and non-English language studies. We performed a random effects meta-analysis and moderator analyses. RESULTS: We identified 554 studies and included 19 studies (14,969 patients) in our final analysis. The mean patients' (standard deviation) age was 60 (13.7). The pooled medical AEs for IHT was 1,059 (11%, 95% confidence interval, 7.5%-16%). The most common AE (n, %) was hypotension (424, 2.8%). Moderator analyses and meta-regressions suggested that conditions (P < .001) such as respiratory failure from coronavirus infection (88%), stroke (19%), and the need for extracorporeal membrane oxygenation (40%) were associated with higher AE prevalence. Transport by nurses (31%) and physicians (11%) was associated with a higher AE prevalence, whereas transport type did not influence AE prevalence. CONCLUSION: Our study suggests the prevalence of AEs of critically ill patients during IHT is low and likely due to patients' disease severity. Further studies should focus on interventions to mitigate AEs to improve patients' outcomes.