Top No-Nonsense Tips: The Dos and Don'ts of Managing Flexor Tendon Injuries.

Flexor tendon injury surgical repairs can be challenging for surgeons, where the timing of surgery and precision of repair matter the most. The latest evidence and basic science discoveries in flexor tendon management are provided. It is important to review how wide-awake local anesthesia no tourniquet surgery has been a paradigm shift in surgical management and pearls learned from incorporating this into practice.

Total Wrist Arthroplasty: An International Perspective.

Concerns about implant durability and technical difficulty continue to make total wrist arthroplasties a specialized procedure with a narrow scope of indications. As a result, more routinely performed total or partial wrist arthrodesis continues to maintain popularity over arthroplasty. However, wrist motion preservation is undoubtedly preferable for patients and current literature is trending to more favorable outcomes for total wrist arthroplasties. In the setting of the evolving role of wrist arthroplasties in clinical practice, it is important to focus on providing hand surgeons a practical approach to incorporating total wrist arthroplasty into the treatment toolbox available to them when treating patients with painful wrist arthritis.

Investigation Into the Effects of Intra-Articular Steroid on Post-Traumatic Osteoarthritis in Distal Radius Fractures: A Randomized Controlled Pilot Study.

PURPOSE: The aim of this prospective, randomized, controlled, double-blinded pilot study was to determine the rates of post-traumatic osteoarthritis and assess joint space width in the presence or absence of a single intra-articular injection of corticosteroid after an acute, intra-articular distal radius fracture (DRF). METHODS: Forty patients received a single, intra-articular, radiocarpal joint injection of 4 mg of dexamethasone (DEX) (n = 19) or normal saline placebo (n = 21) within 2 weeks of a surgically or nonsurgically treated intra-articular DRF. The primary outcome measure was minimum radiocarpal joint space width (mJSW) on noncontrast computed tomography scans at 2 years postinjection. Secondary outcomes were obtained at 3 months, 6 months, 1 year, and 2 years postinjection and included Disabilities of the Arm, Shoulder, and Hand; Michigan Hand Questionnaire; Patient-Rated Wrist Evaluation; wrist range of motion; and grip strength. RESULTS: At 2-year follow-up, there was no difference in mean mJSW between the DEX group (2.2 mm; standard deviation, 0.6; range, 1.4-3.2) and the placebo group (2.3 mm; standard deviation, 0.7; range, 0.9-3.9). Further, there were no differences in any secondary outcome measures at any postinjection follow-up interval. CONCLUSIONS: Radiocarpal joint injection of corticosteroid within 2 weeks of an intra-articular DRF does not appear to affect the development of post-traumatic osteoarthritis within 2 years follow-up in a small pilot cohort. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Psychosocial dimensions of vaccine hesitancy: A systematic review.

Despite widely recognised effectiveness against the spread of COVID-19, vaccine hesitancy persists. This systematic literature review aimed to clarify the definition and the operationalisation of the term 'vaccine hesitancy' and disclose the various psychosocial factors underlying this phenomenon. The results of studies conducted in European countries and in the United States after the vaccines became available were taken into account. The review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses statement. Twelve studies met the inclusion criteria and were reviewed. efinitions and measures of vaccine hesitancy differed across the studies, limiting their comparison. Nonetheless, by drawing on theoretical frameworks, we were able to identify several psychosocial variables in determining vaccine hesitancy. Our findings point to the need for a transdisciplinary approach to understanding the antecedents of vaccine hesitancy. A better understanding of the phenomenon may help to develop interventions and social policies to address a complex challenge such as vaccination hesitancy.

Twenty-Year Experience With Primary Distal Radioulnar Joint Arthroplasty From a Single Institution.

PURPOSE: The use of implant arthroplasty in the distal radioulnar joint is increasing. Two main types of implants are commonly used, ulnar head prosthesis (UHP) and hemi or semi-constrained total distal radioulnar joint arthroplasty. The literature consists mainly of small patient series. The purpose of this study was to examine our long-term outcomes of distal radioulnar joint arthroplasty. METHODS: Patient data were collected in a patient registry from 2000 to 2019. The follow-up included radiographic examination, physical examination, Mayo Wrist Scores, pain level, range of motion, and grip strength. Reoperations were recorded. The implants were a semi-constrained prosthesis and a metallic UHP. The mean age at surgery was 50 years. Patient demographics were similar, but the semi-constrained group had a higher preoperative percentage of instability (85 vs 52 percent). The median follow-up time was 30 months for the semi-constrained implants group and 102 months for the UHP group. RESULTS: A total of 53 primary semi-constrained total joint arthroplasties and 102 UHPs were included. The grip strength and Mayo Wrist Score improved for both the implant groups. Pain reduced in 76% of the patients. Supination improved for the semi-constrained total joint arthroplasty group. Lifting capacity was better in the semi-constrained total joint arthroplasty patients. The unadjusted reoperation rate was 23% for the semi-constrained implants group and 34% for the UHP group. Twenty-two implants were bilateral; these had comparable results to unilateral implants. Kaplan-Meier survival curves demonstrated 94% survival rate for the semi-constrained implants group and 87% survival for the UHP group after 5 years. The risk factors associated with reoperation for the combined implant group included younger age at surgery, previous wrist surgery, ulnar shortening, and wrist fusion. CONCLUSIONS: Distal radioulnar joint arthroplasty improved functional outcomes in both the implant groups, but reoperations were frequent. The semi-constrained implants group had better lifting capacity. The bilateral implants had comparable outcomes to the unilateral implants. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Treatment of giant cell tumors of the distal radius: A long-term patient-reported outcomes study.

INTRODUCTION: The distal radius is a common location for giant cell tumors (GCTs) of bone. Management includes intralesional curettage or wide excision, however, long-term comparisons of treatment options are limited. The purpose of the current study was to evaluate our institutions' outcomes of treatment of these tumors. METHODS: We reviewed 24 GCT of the distal radius in 23 patients (12 males: 11 females) with a mean age of 42 years at the time of surgery. Functional outcomes were collected including the Musculoskeletal Tumor Society Score (MSTS), QuickDash, the Visual Analog Scale (VAS), and the Patient Rated Wrist Evaluation (PRWE). The mean follow-up was 13 years. RESULTS: Tumor grade included Campanacci Grade II (n = 14) and Grade III (n = 10). Treatment included extended intralesional curettage (n = 16) and wide excision (n = 8). Reconstruction mainly included bone grafting/cement (n = 16) or free vascularized fibula radiocarpal arthrodesis (n = 5). At most recent follow-up, there was no difference in MSTS, VAS, and PRWE (p > 0.05) between patients undergoing a joint sparing or arthrodesis. Patients undergoing arthrodesis had a lower QuickDASH score (13.7 vs. 20.8, p = 0.04) CONCLUSIONS: Treatment for GCT of the distal radius is individualized however in the setting of articular surface involvement, arthrodesis can lead to superior functional results at long-term follow-up.

Managing Challenges in Thumb Carpometacarpal Arthritis.

Thumb carpometacarpal osteoarthritis is commonly encountered and multifactorial in etiology, and its management is based on the radiographic stage and surgeon preference. A variety of management strategies exist including ligament reconstruction, arthroscopic débridement, extension osteotomy, open versus arthroscopic total and partial trapeziectomy with or without interposition and/or suspensionplasty, arthrodesis, and total or hemi implant arthroplasty. A review of the literature shows each of these management strategies to be effective in pain relief, but no one procedure has been shown to be superior despite theoretic benefits to preserving trapezial height. The one common denominator is removal of the arthritic contact between the thumb metacarpal and trapezial surfaces.

Outcomes of Secondary Trapeziectomy Following Carpometacarpal Pyrocarbon Prosthetic Arthroplasty.

PURPOSE: Pyrocarbon implant hemiarthroplasty is a treatment option for select patients with trapeziometacarpal joint arthritis. The long-term revision rates after implant arthroplasty can be as high as 30%. Revision to trapeziectomy has been described for patients who require implant removal; however, few studies have assessed outcomes in patients in this subgroup. METHODS: This was a retrospective review of patients who underwent the conversion of a pyrocarbon carpometacarpal implant to trapeziectomy and suspensionplasty from 2003 to 2019. Patients who met the criteria were then compared with a matched cohort who underwent primary trapeziectomy and suspensionplasty. Patients were matched based on the revision procedure, age, and duration of follow-up. Data regarding demographic information, range of motion, grip and pinch strengths, and the need for subsequent procedures were collected. RESULTS: Twenty-five patients underwent the removal of their pyrocarbon carpometacarpal implant. The patients underwent revision to Thompson suspensionplasty (n = 14), the Weilby procedure (n = 5), ligament reconstruction tendon interposition (n = 2), or a suture-based suspension procedure (n = 4). The age, sex, and preoperative range of motion and strength measures were similar between the 2 groups. All the patients complained of moderate-to-severe pain prior to surgery, which improved in both groups after surgery. Patients who underwent the removal of a pyrocarbon arthroplasty implant lost 6.4° of palmar abduction after surgery. The postoperative grip, opposition strength, apposition pinch strength, and radial and palmar abduction were similar between the 2 groups. CONCLUSIONS: The removal of a pyrocarbon carpometacarpal implant using subsequent trapeziectomy successfully relieves pain in patients in whom pyrocarbon arthroplasty has failed. After revision, patients may lose abduction motion but have similar strength compared with those who undergo primary trapeziectomy. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Salvage of Painful Porous Coated Stem Ulnar Head Prosthesis With Semiconstrained Distal Radioulnar Joint Arthroplasty.

PURPOSE: To determine the functional outcome and complications after conversion from a painful and unstable ulnar head prosthesis to a semiconstrained distal radioulnar joint arthroplasty. METHODS: We conducted a retrospective review of 11 ulnar head prostheses in 10 patients with porous coated stems that were revised to semiconstrained prostheses. The median age of the patients was 47 years. The median number of wrist surgeries prior to conversion was 4 (range, 1-9). The median time from the ulnar head implant to the revision surgery was 47 months. Pre- and postoperative pain levels were recorded. Mayo Wrist Scores were calculated. Grip strength, range of motion, and complications and reoperations were recorded. RESULTS: All patients reported moderate or severe pain before surgery, whereas 3 patients reported moderate pain after surgery. The Mayo Wrist Score improved considerably from a median of 50 before surgery to 65 after surgery. The grip strength and forearm pronation-supination showed no change following surgery. The median wrist flexion-extension range improved considerably. Follow-up was a median of 64 (range, 15-132) months after revision surgery. Removal of the ulnar head implant was described as difficult by the surgeons, except in 1 case where the implant was loose. Resection of bone from the distal ulna was often necessary. One patient needed a reoperation requiring prosthesis removal for aseptic loosening of the stem 5 years after revision. There were 2 nondisplaced periprosthetic fractures successfully treated with cast immobilization and 2 additional minor complications, 1 postoperative stitch abscess, and 1 extensor carpi ulnaris tendinitis. CONCLUSIONS: Conversion from an ulnar head implant to a semiconstrained prosthesis provided improved pain scores and function with a low reoperation rate in this patient series. Removal of an ulnar head prosthesis can be technically challenging, but it can be performed leaving enough bone stock for immediate implantation of a semiconstrained implant. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Metacarpophalangeal Joint Pyrocarbon Arthroplasty for Osteoarthritis: An Analysis of 44 Arthroplasties.

PURPOSE: The objective of this study was to analyze postoperative outcomes in a group of patients who underwent metacarpophalangeal (MCP) arthroplasty using a pyrocarbon prosthesis for noninflammatory arthritis. METHODS: An analysis of 44 MCP joint arthroplasties in 30 patients with >2 years of follow-up over a 12-year period was reviewed. The mean age was 63 years. The primary operative indication was pain and stiffness from osteoarthritis refractory to nonsurgical management. RESULTS: At a mean follow-up of 6 ± 3 years, 8 (18%) joints underwent reoperation, including 5 (11%) that underwent revision arthroplasty. The 2- and 5-year rates for survival free of revision arthroplasty were 95% and 93%, respectively. One (2%) operation was complicated by intraoperative fracture. Postoperative complications occurred in 8 (18%) fingers and included ligament/tendon rupture (n = 3) and instability (n = 2). There was significant postoperative improvement in pain levels, MCP arc of motion, pinch strength, and grip strength. At a mean 5 years of radiographic follow-up, 7% had progressive implant instability because of grade 3 or greater loosening. No joints experienced implant instability from progressive subsidence. CONCLUSIONS: Metacarpophalangeal arthroplasty using a pyrocarbon implant for osteoarthritis demonstrates an 7% revision rate at 5 years after surgery. Complications lead to reoperation in 1 of 5 arthroplasties. Radiographic evidence of implant instability was uncommon. Overall, patients experienced predictable pain relief and improvements in their range of motion and pinch strength. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The potential of psychological connectedness: Mitigating the impacts of COVID-19 through sense of community and community resilience.

The purpose of this study was to identify patterns of relationships connecting sense of community (SOC) and community resilience with psychological wellbeing, via the mediation of coronavirus disease 2019 (COVID-19) impacts on life domains. Survey data were collected from an international sample of adults (n = 824) during the COVID-19 outbreak (June-September 2020). Using a structural equation model, we tested a mediation model to identify the associations between SOC and community resilience with the perceived impacts of the emergency situation and with psychological wellbeing. Results revealed that SOC mitigated the impacts of COVID-19 on multiple life domains, and it was also positively associated with wellbeing. Community resilience was correlated with SOC and wellbeing but showed no significant relationship with COVID-19 impacts. The findings support that SOC has a protective function and can contribute to mitigating the impacts of difficult life situations. SOC can also be leveraged as an intervention aimed at protecting the wellbeing of people and communities, particularly in times of crisiss.

COVID-19 in our lives: Sense of community, sense of community responsibility, and reflexivity in present concerns and perception of the future.

The aim of this study is to examine the association between citizens' perceptions of the effectiveness of the institutional response, their connection and responsibility to their community (Sense of Community-SoC; Sense of Community Responsibility-SoC-R), and their personal and social concerns about the current emergency and their perceptions of a postpandemic future during the first COVID-19 pandemic lockdown. Another variable considered was the personal reflexivity about the COVID-19 pandemic. 3925 Italian adults completed an online questionnaire during the first COVID-19 lockdown. A structural equation model with mediation was tested. Institutional effectiveness was associated with SoC, SoC-R, current social concerns, and perceptions of a postpandemic future. SoC and SoC-R were associated with current personal and social concerns, and perceptions of a postpandemic future. Reflexivity was negatively associated with SoC and positively associated with SoC-R, mediating the relationships between SoC, SoC-R and current personal and social concerns and perceptions of a postpandemic future. Findings indicate the need to adopt a perspective that considers individual and socio-political levels and their interaction to better understand the impact of the pandemic during a national lockdown.

Anterior elbow release for post-traumatic flexion contractures in patients 21 years or younger.

HYPOTHESIS AND BACKGROUND: An elbow contracture in a young person can be a devastating problem. Significant contractures will lead to functional loss of the extremity. Appropriately performed contracture release can have profound implications on the overall well-being of the patient. The purpose of this study was to report improvements in sagittal-plane range of motion and the complication rate following an anterior elbow release for flexion contractures in patients 21 years or younger. METHODS: We performed a retrospective review of 27 patients with a median age of 16.8 years who were treated surgically for elbow flexion contracture with an anterior approach. Follow-up was possible in 18 of these patients at an average of 31 months. An anterior approach was performed in all 18 patients, with 4 patients undergoing an additional posterior incision to address posterior structures limiting extension. RESULTS: Elbow extension improved by an average of 35°, from -54° to -19°. The mean total arc of elbow motion improved by 37°, from 65° to 102°. Two complications occurred: traction-related neurapraxia of the lateral antebrachial cutaneous nerve and transient neurapraxia of the posterior interosseous nerve. DISCUSSION AND CONCLUSION: Elbow contracture release through an anterior approach is an acceptable surgical option. Significant improvement is obtained with a low risk of complications.

Examining the role of value congruence, professional identity, and managerial job engagement in the budgetary participation-performance link.

BACKGROUND: In health care, important phenomena of perceived incompatibility between professional and managerial values have emerged as consequences of New Public Management reforms. Although there is a growing evidence on the variation in the enactment of hybrid roles by medical managers, existing research in health care management is mostly descriptive with little emphasis on the conditions under which hybrid roles are enacted and, importantly, on the effects of this variation on performance. PURPOSE: In this article, we seek to fill this research gap by empirically examining (a) whether budgetary participation aligns professional and organizational values, (b) the impact of this alignment on employees' work-related feelings and managerial performance, and (c) the effect of professional identity on value congruence. METHODOLOGY: Data were collected by a survey conducted in an Italian hospital, and partial least square was used to test the relationships among variables. RESULTS: Overall, results show that (a) high involvement in budgeting is instrumental in facilitating medical managers' value congruence, and this, in turn, positively effects managerial job engagement; (b) the effect of budgetary participation on value congruence depends on the extent of professional identity; and (c) as a result of enhanced value congruence and managerial job engagement, employees tend to deliver superior role performance. PRACTICE IMPLICATION: Findings of this study provide some guidance for managers on how organizations can take steps to guarantee effective support to hybrid professionals.

Understanding calcinosis cutis.

Calcinosis cutis is the aberrant deposition of insoluble calcified salts in cutaneous tissue that occurs in association with a variety of diseases. A relatively uncommon disorder, it can range in severity from mild to debilitating. This article describes a patient with a long history of dermatomyositis who developed multiple calcific lesions in the extremities that did not respond to conservative therapies and eventually required multiple surgical interventions.

Outcomes and Direct Costs of Needle Aponeurotomy, Collagenase Injection, and Fasciectomy in the Treatment of Dupuytren Contracture.

PURPOSE: The aims of our study were to evaluate the rates and predictors of reinterventions and direct costs of 3 common treatments of Dupuytren contractures-needle aponeurotomy, collagenase injection, and surgical fasciectomy. METHODS: A retrospective review identified 848 interventions for Dupuytren contracture in 350 patients treated by a single surgeon from 2005 to 2016. The treatments included needle aponeurotomy (NA) (n = 444), collagenase injection (n = 272), and open fasciectomy (n = 132). We collected information on demographics, contracture details, and comorbidities. Outcomes included reintervention rates, time to reintervention, and direct cost of treatments. Standardized costs were calculated by applying 2017 Medicare reimbursement to professional services and cost-to-charge ratios to hospital charges. RESULTS: Demographics were similar among the 3 treatment groups. The fifth finger was the most commonly affected digit including 43% of the NA, 60% of the collagenase, and 45% of the fasciectomy groups. The 2-year rates of reintervention following NA, collagenase, and fasciectomy were 24%, 41%, and 4%, respectively, and the 5-year rates were 61%, 55%, and 4%, respectively. Younger age and severity of preintervention proximal interphalangeal (PIP) joint contracture were predictive of reintervention in the NA and collagenase groups. The standardized direct costs for NA, collagenase, and fasciectomy were $624, $4,189, and $5,291, respectively. Including all reinterventions, the cumulative costs per digit following NA, collagenase, and surgery at 5 years were $1,540, $5,952, and $5,507, respectively. CONCLUSIONS: Treatment with collagenase resulted in the highest rate of reintervention at 2 years, comparable reintervention rates to NA at 5 years, and the highest cumulative costs. The NA was the least expensive and resulted in longer duration before reintervention compared with collagenase. More severe PIP joint contractures and younger age at time of initial intervention were predictive of reintervention after collagenase and NA. Fasciectomy has a high initial cost but the lowest reintervention rate. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Does DRG funding encourage hospital specialization? Evidence from the Italian National Health Service.

The impact of diagnosis-related group (DRG)-based funding has been analyzed along a wide range of dimensions. Its effects on hospital specialization, however, have been investigated only sparsely. This paper examines such effects in the context of the Italian National Health Service, where decentralization has produced a significant degree of variation in funding arrangements. To this end, a 9-year panel data set covering 762 Italian public and private hospitals was analyzed using a finite mixture model approach. Hospital specialization was measured by the internal Herfindahl-Hirschman Index. Three variables were introduced as proxies for the choices made by Italian Regions with respect to the development and use of their DRG systems. The best finite mixture model identified three groups of hospitals, two of which sizeable. Of these, one included nearly all public hospitals, while the other was composed almost exclusively of small and medium-sized investor-owned hospitals. Averagely, private and smaller hospitals showed a stronger tendency to specialize over time. The positive impact of DRG funding on the hospitals' propensity to specialize found only limited empirical support. Moreover, it emerged as comparatively much smaller for public hospitals vis à vis private ones.

Role of First Metacarpal Osteotomy in the Management of Basilar Thumb Arthritis.

This study reviews outcomes of patients undergoing Wilson extension osteotomy of the first metacarpal for treatment of carpometacarpal (CMC) joint pain and deformity. The study reviews varied indications for Wilson osteotomy outlining technique and functional outcomes. Twelve patients (11 female, 1 male) with an average age at surgery of 50 (range, 25-67) underwent osteotomy during the study period. Diagnoses included seven patients with early degenerative changes of the CMC joint with painful subluxation or instability. The remaining patients had symptomatic adduction contracture in either end-stage arthritis (three) or following prior trapeziectomy (two). Average motion improved modestly among all groups with considerable improvement of metacarpophalangeal hyperextension in late deformity patients. Wilson osteotomy is a motion-preserving alternative procedure that may be indicated for patients with early CMC arthrosis and instability as well as for patients with adduction contractures in end-stage arthritis or posttrapeziectomy (Journal of Surgical Orthopaedic Advances 28(1):63-67, 2019).

Dreaded Ulnar Wrist Pain: Long-Term Results of Pisiformectomy for Painful Pisotriquetral Arthrosis.

Pisiform pathology may be a source of ulnar-sided wrist pain. This study reviews the long-term outcomes of patients treated with pisiformectomy. A retrospective study approved by the institutional review board was performed over a 27-year period of patients undergoing pisiformectomy. Range of motion, grip strength, complications, and need for revision surgery were recorded. The series includes 61 wrists (60 patients) with an average age at surgery of 46 years. Two complications were noted (3%): a postoperative ulnar nerve palsy and symptomatic retained suture. At final follow-up, average flexion-extension arc was 81% (expressed as percent of contralateral), radioulnar deviation arc was 88%, and average grip strength was 89%. Pisiformectomy is a reliable, motion-preserving procedure with low complication rates for patients with chronic ulnar-sided wrist pain. In this series, 93% of patients did not require further procedures at an average of 8.2 years follow-up. (Journal of Surgical Orthopaedic Advances 28(3):196-200, 2019).

Outcomes Following Acute Metacarpophalangeal Joint Arthroplasty Dislocation: An Analysis of 37 Cases.

PURPOSE: There remains a paucity of information regarding the treatment outcomes of dislocation after metacarpophalangeal (MCP) joint arthroplasty. The purpose of this study was to assess the outcomes of surgical and nonsurgical treatment modalities of MCP arthroplasty dislocations. METHODS: Of 816 MCP joint arthroplasties over a 14-year period, there were 37 (4%) acute MCP joint dislocations that required intervention by a health care professional. Implants involved included 28 nonconstrained implants including pyrocarbon (n = 17) and surface replacement arthroplasty (n = 11), and 9 silicone implants. The analysis included the treatment of dislocations after primary (n = 30) and revision (n = 7) MCP joint arthroplasty. Dislocation was defined as clinical and radiographic evidence of MCP joint prosthetic acute dislocation diagnosed and treated by a fellowship trained hand surgeon. RESULTS: Etiologies underlying the dislocations included implant fracture (n = 6), component loosening (n = 2), and soft tissue deficiency (n = 29). Of the 37 dislocations, treatments included 14 nonsurgical (closed reduction, orthosis fabrication) all of which ultimately failed. Surgically, including some of the failed prior procedures, 18 soft tissue stabilization procedures and 21 revision arthroplasties were performed, with 6 that had failed soft tissue stabilization. The soft tissue stabilization procedures had a 28% success rate in achieving a stable MCP joint. Revision arthroplasty had a 71% success rate. Subgroup analysis showed an 86% success rate for silicone revisions and a 43% success rate with nonconstrained revisions, with 80% and 36% 5-year survival free of instability, for the 2 types of implants, respectively. CONCLUSIONS: The treatment of MCP joint arthroplasty dislocation with revision to silicone implant appears to hold the most promise in achieving a stable MCP joint after an acute prosthetic dislocation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.