The impact of self-efficacy on nonoperative treatment of atraumatic shoulder pain.

CONTEXT: Atraumatic shoulder pain is frequently encountered in primary care and surgical clinics. With increased recognition of the biopsychosocial model, there has been an increased emphasis on identifying patient factors associated with less effective coping strategies such as pain catastrophizing. It remains uncertain what impact self-efficacy has on the response to nonoperative treatment of shoulder pain. OBJECTIVES: Our purpose is to determine the influence of patient coping strategies (self-efficacy) on the outcome of nonoperative treatment of atraumatic shoulder pain. We hypothesize that higher levels of self-efficacy are associated with increased self-reported function after nonoperative treatment. METHODS: We conducted a retrospective case-control study for a consecutive series of patients seen in our clinic with nonoperatively managed atraumatic shoulder pain. Baseline demographics and range of motion were recorded. Patients completed the Simple Shoulder Test (SST), PROMIS Pain Interference (PI), and PROMIS Self-Efficacy for Managing Symptoms (SE). After 3 months of nonoperative treatment, patients were placed into two groups: patients who clinically improved (Group 1) and those that did not (Group 2), with clinical improvement defined as an increase of 2 or greater on the SST. RESULTS: Seventy-eight patients returned for follow-up and completed all questionnaires. There were no statistically significant differences for age, sex, or tobacco use between the two groups. Half of the patients in our series had symptoms for >12 months, with rotator cuff syndrome being the most frequent diagnosis (40.0%). Patients in Group 1 had significantly higher PROMIS SE scores (42 vs. 39, p=0.0094) at initial evaluation. At 3-month follow-up, patients in Group 1 also had significantly lower Numeric Pain Rating Scale (NPRS) scores (4.5 vs. 6.5, p=0.0067), compared to Group 2. CONCLUSIONS: Patients who experience clinical improvement with nonoperative treatment of atraumatic shoulder conditions demonstrate higher self-efficacy than patients who fail to improve. Guiding patients with atraumatic shoulder pain and low self-efficacy toward interventions aimed at improving coping strategies, rather than addressing musculoskeletal factors alone, may contribute to the goal of improving outcomes.

A Comparison of Histologic and Intraoperative Visual Assessments of Transverse Carpal Ligament During Revision Carpal Tunnel Release.

PURPOSE: We sought to determine surgeon-pathologist agreement with respect to distinguishing between a previously undivided transverse carpal ligament (TCL) and scar during revision carpal tunnel release (CTR). Additionally, we aimed to describe the histologic findings of the TCL and flexor tenosynovium during revision CTR. METHODS: All patients undergoing revision CTR for persistent or recurrent CTS by a single surgeon between 2013 and 2019 were included. An intraoperative assessment was made as to the presence of scar versus a previously undivided TCL by the surgeon. Two pathology specimens (1 consisting of flexor retinaculum and 1 consisting of tenosynovium) were sent for histopathological analysis with hematoxylin-eosin staining. The pathologist's assessment of the flexor retinaculum specimen was categorized as either "ligamentous" if a previously undivided TCL was identified or "nonligamentous" if scar or any other tissue was identified. The surgeon's intraoperative assessment served as the reference standard when comparing the histologic assessment. RESULTS: A total of 40 patients underwent 46 revision CTRs. The histologic assessment agreed with the surgeon's intraoperative assessment of a previously undivided TCL versus a scar in 30 of 46 (65%) cases. In 12 of 46 (26%) revision cases, the surgeon determined that there was a previously undivided TCL. In these 12 cases, the pathologist identified a ligament 17% of the time. CONCLUSIONS: Surgeon-pathologist agreement is low with respect to determining previously undivided TCLs versus nonligamentous tissue in the setting of revision CTR. The results of this investigation suggest that pathologists (with limited clinical information) have difficulty confirming the clinical diagnosis of persistent CTS with previously unreleased TCL when using routine hematoxylin-eosin staining. Routine biopsy of the TCL during revision CTR may be of limited clinical utility, as it does not alter the diagnosis or management in these cases. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

West Nile virus neuroinvasive disease associated with rituximab therapy.

West Nile virus neuroinvasive disease (WNVND) manifests with meningitis, encephalitis, and/or acute flaccid paralysis. It represents less than 1% of the clinical syndromes associated with West Nile virus (WNV) infection in immunocompetent patients. Immunosuppressive therapy is associated with increased risk of WNVND and worse prognosis. We present a patient with WNVND during therapy with rituximab, and a review of the literature for previous similar cases with the goal to describe the clinical spectrum of WNVND in patients treated specifically with rituximab. Our review indicates that the most common initial complaints are fever and altered mental status, brain magnetic resonance imaging often shows bilateral thalamic hyperintensities, and cerebrospinal analysis consistently reveals mild lymphocytic pleocytosis with elevated protein, positive WNV polymerase chain reaction, and negative WNV antibodies. Treatment is usually supportive care, with intravenous immunoglobulins (IVIG) plus corticosteroids and WNV-specific IVIG also used. The disease is usually fatal despite intervention. Our patient's presentation was very similar to prior reports, however demonstrated spontaneous improvement with supportive management only. WNVND is a rare and serious infection with poor prognosis when associated with rituximab therapy. Diagnosis is complicated by absent or delayed development of antibodies. The presence of bilateral thalamic involvement is a diagnostic clue for WNVND. There is insufficient evidence to recommend the use of corticosteroids or IVIG.

Experimental investigation of structural steel beams subjected to localized fire.

This paper presents an experimental behavior of unprotected W16 × 26 steel beams subjected to localized fire. Beam specimens were either simply supported or connected to steel columns via all bolted double angle connections. Two test fires, steady or transient heating, were produced using a natural gas fueled burner located below the center of the beams. Thermal and structural responses of the steel beams as well as the heat release rate and applied forces were measured. The tests showed that all specimens failed by lateral-torsional buckling regardless of fire loading and end support conditions. The results highlight that the heating conditions and end restraints influence the behavior of steel beams under localized fire. The experimental results presented can be used for validation of predictive models in order to improve deign methods for localized fire conditions.

INFLUENCE OF MATERIAL MODELS ON PREDICTING THE FIRE BEHAVIOR OF STEEL COLUMNS.

Finite-element (FE) analysis was used to compare the high-temperature responses of steel columns with two different stress-strain models: the Eurocode 3 model and the model proposed by National Institute of Standards and Technology (NIST). The comparisons were made in three different phases. The first phase compared the critical buckling temperatures predicted using forty seven column data from five different laboratories. The slenderness ratios varied from 34 to 137, and the applied axial load was 20-60 % of the room-temperature capacity. The results showed that the NIST model predicted the buckling temperature as or more accurately than the Eurocode 3 model for four of the five data sets. In the second phase, thirty unique FE models were developed to analyze the W8×35 and W14×53 column specimens with the slenderness ratio about 70. The column specimens were tested under steady-heating conditions with a target temperature in the range of 300-600 °C. The models were developed by combining the material model, temperature distributions in the specimens, and numerical scheme for non-linear analyses. Overall, the models with the NIST material properties and the measured temperature variations showed the results comparable to the test data. The deviations in the results from two different numerical approaches (modified Newton Raphson vs. arc-length) were negligible. The Eurocode 3 model made conservative predictions on the behavior of the column specimens since its retained elastic moduli are smaller than those of the NIST model at elevated temperatures. In the third phase, the column curves calibrated using the NIST model was compared with those prescribed in the ANSI/AISC-360 Appendix 4. The calibrated curve significantly deviated from the current design equation with increasing temperature, especially for the slenderness ratio from 50 to 100.