Electrocardiographic markers in patients with type 2 diabetes and the role of diabetes duration.

BACKGROUND: The association between type 2 diabetes and electrocardiographic (ECG) markers are incompletely explored and the dependence on diabetes duration is largely unknown. We aimed to investigate the electrocardiographic (ECG) changes associated with type 2 diabetes over time. METHODS: In this cross-sectional study, we matched people with type 2 diabetes 1:1 on sex, age, and body mass index with people without diabetes from the general population. We regressed ECG markers with the presence of diabetes and the duration of clinical diabetes, respectively, adjusted for sex, age, body mass index, smoking, heart rate, diabetes medication, renal function, hypertension, and myocardial infarction. RESULTS: We matched 988 people with type 2 diabetes (332, 34% females) with as many controls. Heart rate was 8 bpm higher (p < 0.001) in people with vs. without type 2 diabetes, but the difference declined with increasing diabetes duration. For most depolarization markers, the difference between people with and without type 2 diabetes increased progressively with diabetes duration. On average, R-wave amplitude was 6 mm lower in lead V5 (p < 0.001), P-wave duration was 5 ms shorter (p < 0.001) and QRS duration was 3 ms (p = 0.03). Among repolarization markers, T-wave amplitude (measured in V5) was lower in patients with type 2 diabetes (1 mm lower, p < 0.001) and the QRS-T angle was 10 degrees wider (p = 0.002). We observed no association between diabetes duration and repolarization markers. CONCLUSIONS: Type 2 diabetes was independently associated with electrocardiographic depolarization and repolarization changes. Differences in depolarization markers, but not repolarization markers, increased with increasing diabetes duration.

Lineage-tracing hematopoietic stem cell origins in vivo to efficiently make human HLF+ HOXA+ hematopoietic progenitors from pluripotent stem cells.

The developmental origin of blood-forming hematopoietic stem cells (HSCs) is a longstanding question. Here, our non-invasive genetic lineage tracing in mouse embryos pinpoints that artery endothelial cells generate HSCs. Arteries are transiently competent to generate HSCs for 2.5 days (∼E8.5-E11) but subsequently cease, delimiting a narrow time frame for HSC formation in vivo. Guided by the arterial origins of blood, we efficiently and rapidly differentiate human pluripotent stem cells (hPSCs) into posterior primitive streak, lateral mesoderm, artery endothelium, hemogenic endothelium, and >90% pure hematopoietic progenitors within 10 days. hPSC-derived hematopoietic progenitors generate T, B, NK, erythroid, and myeloid cells in vitro and, critically, express hallmark HSC transcription factors HLF and HOXA5-HOXA10, which were previously challenging to upregulate. We differentiated hPSCs into highly enriched HLF+ HOXA+ hematopoietic progenitors with near-stoichiometric efficiency by blocking formation of unwanted lineages at each differentiation step. hPSC-derived HLF+ HOXA+ hematopoietic progenitors could avail both basic research and cellular therapies.

Trigger Finger Release: Are Sutures Requiring Removal Necessary?

Purpose: There is no consensus regarding optimal closure for trigger finger release (TFR) surgery. The purpose of this study was to compare the number of postoperative visits and complications following TFR closure with nonabsorbable sutures versus those following TFR closure with absorbable sutures and skin glue. The hypothesis was that wound closure with absorbable sutures and glue will result in fewer postoperative visits, while having similar complication rates as that with nonabsorbable sutures. Methods: A retrospective review identified all patients undergoing open TFR over a 3-year period performed by two hand surgery fellowship-trained hand surgeons who adhered to an identical surgical protocol except for incisional closure. Patients were divided into two groups: a control group with nonabsorbable 4-0 monofilament sutures requiring removal ("suture" group) and a study group with buried absorbable 4-0 monofilament sutures not requiring removal as well as skin glue ("glue" group). The data collected included age, sex, number of postoperative visits, wound complications, infections, antibiotic use, prescribed hand therapy, hospital admission, and reoperation. Results: A total of 305 open TFR surgeries in 278 patients were included in the study, with 155 digits in the "suture" group and 150 in the "glue" group. Both groups were similar in age and sex. The "suture" group had significantly more total postoperative visits (185 vs 42, respectively, P < .001) and postoperative visits within the first 2 weeks (155 vs 10, respectively, P < .001) than the "glue" group. Additional postoperative visits beyond 2 weeks of surgery were similar between the two groups. Three (1.9%) patients in the "suture" group and two (1.3%) patients in the "glue" group developed a superficial surgical site infection within 30 days after surgery. Neither had deep infections requiring hospitalization or reoperation. Both groups required similar rates of postoperative hand therapy. Conclusions: Absorbable sutures afford fewer postoperative visits while having a similar complication rate as nonabsorbable sutures requiring removal. Type of study/level of evidence: Therapeutic IV.

Proximity of the Ulnar Neurovascular Structures in Endoscopic Carpal Tunnel Release Surgery: A Cadaveric Study.

PURPOSE: To evaluate the proximity of the ulnar neurovascular structures to the endoscopic blade during endoscopic carpal tunnel release (CTR). METHODS: Ten fresh-frozen cadaver hands were used to perform endoscopic CTR using devices from two manufacturers. The skin was excised from the palm, and the endoscopic carpal tunnel blade was deployed at the distal edge of the transverse carpal ligament (TCL). The blade's proximity to the ulnar neurovascular bundle, deep ulnar motor branch, superficial palmar arch, and median nerve was recorded. Following release of the TCL, the device was turned ulnar to the maximal extent to determine if direct injury to the ulnar neurovascular bundle was possible. RESULTS: The average longitudinal distance from the end of the TCL to the superficial palmar arch was 13.3 mm (range, 8.4-20.9) and to the ulnar motor branch was 10.8 mm (range, 4.0-15.0). The average transverse distance from the end of the TCL to the ulnar neurovascular bundle was 5.9 mm (range, 3.1-7.8) and to the median nerve was 3.3 mm (range, 0-6.5). In two of our specimens, the median nerve subluxated volarly over the cutting device. When placing the blade at the distal edge of the TCL, injury to the deep motor branch of the ulnar nerve, ulnar neurovascular bundle, or superficial palmar arch was not possible in any specimens using the tested devices, even when turning the blade directly toward these structures. CONCLUSIONS: There is a low likelihood of direct injury to the ulnar neurovascular bundle during endoscopic CTR. CLINICAL RELEVANCE: These results suggest that injury to the ulnar neurovascular bundle is unlikely during endoscopic CTR if the distal aspect of the transverse carpal ligament can be clearly identified prior to release. Control of the median nerve is also important to prevent subluxation over the cutting device.

Perioperative Management of Oral Anticoagulants and Antiplatelet Therapy in Hand and Wrist Surgery.

There is wide variability in the management of patients on antithrombotic therapy requiring surgery of the hand and wrist. There are no specific guidelines regarding whether to temporarily cease or continue oral anticoagulants and antiplatelet agents. Discontinuation of these medications before surgery can lead to perioperative thromboembolic or ischemic events. On the other hand, continuation can lead to intraoperative or postoperative bleeding complications. This review discusses various anticoagulants and antiplatelet agents with special considerations for their management, analyzes the current literature, summarizes current recommendations, and provides direction for additional research.

Early Revision Rate Following Primary Carpal Tunnel Release.

Purpose: The published revision rates after carpal tunnel release (CTR) vary from 0.3% to 7%. The explanation for this variation may not be fully apparent. The purpose of this study was to determine the rate of surgical revision within 1-5 years following primary CTR at a single academic institution, compare it with rates reported in the literature, and attempt to provide explanations for these differences. Methods: We identified all patients who underwent primary CTR at a single orthopedic practice by 18 fellowship-trained orthopedic hand surgeons from October 1, 2015, through October 1, 2020, using a combination of Current Procedural Terminology (CPT) and International Classification of Diseases (ICD), 10th Revision, codes. Patients who underwent CTR because of a diagnosis other than primary carpal tunnel syndrome were excluded. Patients who required revision CTR were identified using a practice-wide database query using a combination of CPT and ICD-10 codes. Operative reports and outpatient clinic notes were reviewed to determine the cause of revision. Data on patient demographics, surgical technique (open vs single-portal endoscopic), and medical comorbidities were collected. Results: A total of 11,847 primary CTR procedures were performed during the 5-year period on 9,310 patients. We found 24 revision CTR procedures among 23 patients, resulting in a revision rate of 0.2%. Of 9,422 open primary CTRs performed, 22 cases (0.23%) went on to undergo revision. Endoscopic CTR was performed in 2,425 cases, with 2 cases (0.08%) ultimately undergoing revision. The average length of time from primary CTR to revision was 436 days (range, 11-1,647 days). Conclusions: We noted a substantially lower rate of revision CTR within 1-5 years of primary release (0.2%) in our practice than that noted in previously published studies, although we accept that this does not account for out-of-area migration. There was no significant difference in the revision rates between open and single-portal endoscopic primary CTR. Type of study/level of evidence: Therapeutic III.

Swelling, Stiffness, and Dysfunction Following Proximal Interphalangeal Joint Sprains.

PURPOSE: Proximal interphalangeal (PIP) joint sprains are common injuries that often result in prolonged swelling, stiffness, and dysfunction; however, the duration of these sequelae is unknown. The purpose of this study was to determine the duration of time that patients experience finger swelling, stiffness, and dysfunction following a PIP joint sprain. METHODS: This was a prospective, longitudinal, survey-based study. To identify patients with PIP joint sprains, the electronic medical record was queried monthly using International Classification of Disease, Tenth Revision, codes for PIP joint sprain. A five-question survey was emailed monthly for 1 year or until their response indicated resolution of swelling, whichever occurred sooner. Two cohorts were established: patients with (resolution cohort) and patients without (no-resolution cohort) self-reported resolution of swelling of the involved finger within 1 year of a PIP joint sprain injury. The measured outcomes included self-reported resolution of swelling, self-reported limitations to range of motion, limitations to activities of daily living, Visual Analog Scale (VAS) pain score, and return to normalcy. RESULTS: Of 93 patients, 59 (63%) had complete resolution of swelling within 1 year of a PIP joint sprain. Of the patients in the resolution cohort, 42% reported return to subjective normalcy, with 47% having self-reported limitations in range of motion and 41% having limitations in activities of daily living. At the time of resolution of swelling, the average VAS pain score was 0.8 out of 10. In contrast, only 15% of patients in the no-resolution cohort reported return to subjective normalcy, with 82% having self-reported limitations in range of motion and 65% having limitations in activities of daily living. For this cohort, the average VAS pain score at 1 year was 2.6 out of 10. CONCLUSIONS: It is common for patients to experience a prolonged duration of swelling, stiffness, and dysfunction following PIP joint sprains. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Complications Following Intramedullary Screw Fixation for Metacarpal Fractures: A Systematic Review.

PURPOSE: There has been a recent increase in the use of intramedullary screws (IMS) for the surgical treatment of metacarpal fractures. While IMS fixation has been shown to produce excellent functional outcomes, postoperative complications have yet to be fully explored in a comprehensive way. This systematic review quantified the incidence, treatment, and results of complications following IMS fixation for metacarpal fractures. METHODS: A systematic review was performed using PubMed, Cochrane Central, EBSCO, and EMBASE databases. All clinical studies that documented IMS complications following metacarpal fracture fixation were included. Descriptive statistics were analyzed for all available data. RESULTS: Twenty-six studies were included: 2 randomized trials, 4 cohort studies, 19 case series, and 1 case report. Among the 1,014 fractures studied, 47 complications were reported across all studies (4.6%). Stiffness was the most common, followed by extension lag, loss of reduction, shortening, and complex regional pain syndrome. Other complications included screw fracture, bending, and migration; early-onset arthrosis; infection; tendon adhesion; hypertrophic scar; hematoma; and nickel allergy. Eighteen of the 47 (38%) patients with complications underwent revision surgery. CONCLUSIONS: Complications following IMS fixation of metacarpal fractures are relatively uncommon. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Correlation of Carpal Tunnel Syndrome 6 Score and Physical Exam Maneuvers With Electrodiagnostic Test Severity in Carpal Tunnel Syndrome: A Blinded Prospective Cohort Study.

PURPOSE: Although carpal tunnel syndrome (CTS) can be diagnosed clinically with the Carpal Tunnel Syndrome 6 (CTS-6) evaluation tool, the relationship between disease severity and CTS-6 score has not been elucidated. The purpose of our study was to determine the correlation of the CTS-6 score and other physical examination maneuvers with the carpal tunnel severity grade by electrodiagnostic testing (EDT). We hypothesized that the CTS-6 score, Durkan test, and Semmes Weinstein Monofilament Testing (SWMT) positively correlate with EDT severity. METHODS: We prospectively enrolled 105 consecutive patients who presented to the office with suspected CTS, excluding those with previous surgery, previous EDT from an outside facility, or concomitant neuropathy. Four fellowship-trained hand surgeons obtained the CTS-6 score, time to obtain a positive Durkan compression test, and SWMT of the thumb, index, and middle fingers. All patients were sent for EDT. Hand surgeons were blinded to the results of the EDT, and the electrodiagnosticians were blinded to the clinical data. We used the Bland criteria (0-6) to grade CTS severity on EDT. This grade was compared with the CTS-6 score, Durkan time, and SWMT results. RESULTS: Using Spearman correlation coefficients, we found a weakly positive correlation between a higher CTS-6 score and a higher severity grade on EDT. The mean CTS-6 score based on EDT grading were the following: (1) 14.8 (grade 0), (2) 16.0 (grade 1), (3) 14.8 (grade 2), (4) 16.7 (grade 3), (5) 18.7 (grade 4), (6) 18.3 (grade 5), and (7) 22.4 (grade 6). We also found a statistically significant association between the SWMT and a higher CTS-6 score as well as a higher severity grade on EDT. Durkan compression test did not appear to correlate with the EDT grade. CONCLUSIONS: The CTS-6 and SWMT show a positive correlation with EDT severity in CTS on the basis of the Bland criteria. The time to a positive Durkan test did not show any correlation. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Functional Outcomes of Cubital Tunnel Release in Patients with Negative Electrodiagnostic Studies.

BACKGROUND: Cubital tunnel syndrome (CuTS) is the second most common compression neuropathy of the upper extremity. Electrodiagnostic studies (EDSs) are often used to confirm diagnosis. However, negative EDSs can present a difficult clinical challenge. The purpose of this study was to determine the functional outcomes and symptom improvement for patients with a clinical diagnosis of CuTS, but with negative EDSs, who are treated surgically. METHODS: Patients who had EDSs before ulnar nerve surgery were identified by means of database search. Chart review was performed on 867 cases to identify those with negative EDSs. Twenty-five ulnar nerve operations in 23 patients were included in analysis. Chart review was performed to record preoperative and postoperative symptoms, physical examination findings, and outcome measures (ie, Disabilities of the Arm, Shoulder and Hand questionnaire and the Patient-Rated Ulnar Nerve Evaluation). RESULTS: At a mean follow-up period of 20.7 ± 14.9 months, 15 of 25 cases (60.0%) had complete resolution of all preoperative symptoms. All 10 patients who had residual symptoms endorsed improvement in their preoperative complaints. The median preoperative Disabilities of the Arm, Shoulder and Hand score was 40.0 [interquartile range (IQR), 23.9 to 58.0], which significantly decreased to a median of 6.8 (IQR, 0 to 22.7) at final follow-up ( P < 0.01). The median postoperative Patient-Rated Ulnar Nerve Evaluation score was 9.5 (IQR, 1.5 to 19.5). CONCLUSIONS: Patients with CuTS and normal EDSs treated surgically can be expected to have favorable outcomes with respect to symptoms and improvement in functional outcome scores. After ruling out confounding diagnoses, the authors continue to offer surgical intervention for these patients when nonoperative treatment has failed. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Outcomes After Surgically Managed Oblique Extra-Articular Proximal Phalanx Fractures: A Comparison of Closed-Reduction Percutaneous Pinning and Open-Reduction Internal Fixation With Lag Screws.

BACKGROUND: Long oblique extra-articular proximal phalanx fractures are common orthopedic injuries. When unstable and without substantial comminution, treatment options include closed-reduction percutaneous pinning (CRPP) and open-reduction internal fixation using lag screws (ORIF-screws). The aims of this study are primarily to compare the functional outcomes and complication rates between these techniques and secondarily to assess potential factors affecting outcomes after surgery. METHODS: All patients with long oblique extra-articular proximal phalanx fractures treated surgically within a single orthopedic institution from 2010 to 2017 were identified. Outcome measures and complications were assessed at the final follow-up. RESULTS: Sixty patients were included in the study with a mean time to the final follow-up of 41 weeks (range: 12-164 weeks). Thirty-four patients (57%) were treated with CRPP and 26 patients (43%) with ORIF-screws. The mean Disabilities of the Arm, Shoulder, and Hand score across both fixation types was 8 (range: 0-43) and did not differ significantly between the 2 groups. Mean proximal interphalangeal extension at the final follow-up was 9° short of full extension after CRPP and 13° short of full extension after ORIF-screws. The rates of flexion contracture and extensor lag were 15% and 41% in the CRPP group compared with 12% and 68% in the ORIF-screws group. Reoperation rates and complication rates did not differ significantly between fixation strategies. CONCLUSIONS: Acceptable outcomes can be achieved after surgical fixation of long oblique extra-articular proximal phalanx fractures using both CRPP and ORIF-screws. Extensor lag may be more common after ORIF-screws.

Side-hops challenge knee control in the frontal and transversal plane more than hops for distance or height among ACL-reconstructed individuals.

We compared knee landing mechanics with presumed relation to risk of anterior cruciate ligament (ACL) injury among three single-leg hop tests and between legs in individuals with unilateral ACL reconstruction. Thirty-four participants (>10 months' post-surgery, 23 females) performed the standardised rebound side hop (SRSH), maximal hop for distance (OLHD) and maximal vertical hop (OLVH). We calculated the following knee outcomes from motion capture and force plate data: finite helical axis inclination angles (approximates knee robustness), frontal and transversal plane angles at initial contact, peak angles of abduction and internal rotation during landing, and peak external moments of flexion, abduction and internal rotation during landing. Repeated-measures MANOVA analysis ('sex' as covariate) confirmed that SRSH induced greater angles and moments, particularly in the frontal plane, compared to OLHD and OLVH. There was between-leg asymmetry for peak knee flexion moment for males during OLHD and OLVH, and for females during SRSH. Our results advocate the SRSH over OLHD and OLVH for assessment of knee landing control to screen for movement patterns potentially related to ACL injury risk. However, clear differences in both knee kinematics and kinetics between OLHD and SRSH motivate the use of both tests to evaluate different aspects of landing control.

Wound Dehiscence Following Cubital Tunnel Surgery.

PURPOSE: Cubital tunnel syndrome is the second most common upper-extremity compressive neuropathy, and persistent symptoms can necessitate operative treatment. Surgical options include simple decompression and ulnar nerve transposition. The cause of wound dehiscence after surgery is not well known, and the factors leading to the development of these complications have not been previously described. METHODS: Patients undergoing ulnar nerve surgery from January 1, 2016, to December 31, 2019, were retrospectively evaluated for the development of wound dehiscence within 3 months of surgery. There were 295 patients identified who underwent transposition and 1,106 patients who underwent simple decompression. Patient demographics and past medical history were collected to evaluate the risk factors for the development of wound dehiscence. RESULTS: The overall rate of wound dehiscence following surgery was 2.5%. In the simple decompression group, the rate of wound dehiscence was 2.7% (30/1,106), which occurred a mean of 21 days (range, 2-57 days) following surgery. In the transposition group, the rate of wound dehiscence was 1.7% (5/295), which occurred a mean of 20 days (range, 12-32 days) following surgery. The difference in rates of dehiscence between the decompression and transposition groups was not significant. Five patients in the simple decompression group and 1 patient in the transposition group required a secondary surgery for closure of the wound. Age, body mass index, smoking status, and medical comorbidities were not found to contribute to the development of wound dehiscence. CONCLUSIONS: Wound dehiscence can occur following both simple decompression and transposition, even after postoperative evaluation demonstrates a healed wound. Surgeons should be aware of this possibility and specifically counsel patients about remaining cautious with, and protective of, their wound for several weeks after surgery. Dehiscence may be related to suboptimal vascularity in the soft tissue envelope in the posteromedial elbow. When it occurs, dehiscence can generally be treated by allowing healing by secondary intention. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Does Surgery Improve Healing After Isolated Diaphyseal Ulna Fractures?

PURPOSE: Isolated diaphyseal ulna fractures can be treated nonsurgically or with open reduction and internal fixation (ORIF). It is unclear whether ORIF provides quicker and/or more predictable healing. The purpose of this study was to compare the healing characteristics of isolated diaphyseal ulna fractures after surgical and nonsurgical treatment. METHODS: All patients treated for an isolated diaphyseal (distal- or middle-third) ulna fracture between 2010 and 2018, with a minimum of 3 months of follow-up, were identified. Electronic medical records were reviewed to record patient demographics, assess the treatments used, and compare outcomes. We determined healing and nonunion rates, complications, reoperations, and final radiographic fracture alignment. RESULTS: Ninety-five patients were included with a median follow-up of 20 weeks. Of these, 56 patients were treated nonsurgically and 39 patients were treated with ORIF. At the time of the final follow-up, 51 of the 56 (91.1%) nonsurgically treated fractures had healed and 38 of the 39 (97.4%) surgically managed fractures had healed. There were 5 nonunions after nonsurgical treatment (8.9%) and 1 nonunion after ORIF (2.6%). Eleven patients (19.6%) treated nonsurgically required conversion to ORIF, whereas 4 patients (10.3%) treated with ORIF required reoperation. Middle-third fractures treated nonsurgically had a higher rate of nonunion (30.8%) compared with distal-third fractures treated nonsurgically (2.3%). CONCLUSIONS: The healing characteristics of isolated ulnar shaft fractures do not appear to differ substantially between surgical and nonsurgical treatment. However, nearly 20% of the patients treated nonsurgically may require eventual ORIF. Distal-third fractures may be at a higher risk of conversion to ORIF, and middle-third fractures may be at a higher risk of nonunion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Effect of Perioperative Corticosteroid Administration on Early Postoperative Range of Motion and Functional Outcomes Following Dupuytren's Fasciectomy.

BACKGROUND: The purpose of the study was to evaluate whether perioperative corticosteroid (CS) administration improves early postoperative range of motion (ROM) and function in patients undergoing Dupuytren's fasciectomy. METHODS: We retrospectively identified 58 patients who underwent Dupuytren's fasciectomy by a single fellowship-trained orthopedic hand surgeon from 2016 to 2020. During this time period, 51 digits in 34 patients received a single intraoperative dose of 10 mg of intravenous dexamethasone followed by a 6-day oral methylprednisolone taper course (CS group), and 37 digits in 24 patients did not (control group). Postoperatively, all patients started hand therapy within 1 week of surgery. At 2 and 6 weeks, patients had ROM data and Disabilities of the Arm, Shoulder, and Hand (DASH) scores collected by a blinded hand therapist. Paired t tests were used to compare the change in ROM and DASH scores at weeks 2 and 6. RESULTS: The 2 cohorts had similar preoperative ROM. At 2 weeks postoperatively, the CS group had greater metacarpophalangeal (MP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) flexion. There was no difference in MP, PIP, or DIP extension. At 6 weeks postoperatively, the CS group had greater PIP flexion. There was no difference between the groups in MP extension, MP flexion, PIP extension, DIP extension, or DIP flexion. Mean DASH scores were significantly lower in the CS group at weeks 2 and 6. There were no postoperative deep infections or complications requiring surgery in either group. CONCLUSION: Perioperative CS administration appears to be safe and to improve early ROM and DASH scores following Dupuytren's fasciectomy.

The Impact of Intraoperative Nursing Care on Perioperative Complications During Wide-Awake Local Anesthesia Hand Surgery.

Purpose: The wide-awake local anesthesia technique in hand surgery is widely used, but there are currently no guidelines or protocols for the number of operating room personnel required to optimize patient safety intraoperatively. This study aimed to evaluate perioperative complication rates of wide-awake local anesthesia hand surgeries performed at surgery centers that used different numbers of operating room nurses. Methods: We conducted a retrospective review of patients who underwent wide-awake local anesthesia hand surgery at 4 surgical centers over a 30-month consecutive period. Two surgical centers used 3 operating room nurses, and 2 centers used 2 operating room nurses. The complications reported included intraoperative case abortion because of critical change in patient vitals, intraoperative medication delivery, intraoperative intravenous placement for medication delivery, intraoperative conversion to sedation, intraoperative medical complications, and postoperative transfer to the emergency department or a hospital. Results: A total of 1,771 wide-awake local anesthesia surgical procedures were identified, with 925 performed at a facility that used 2 operating room nurses and 846 performed at a facility that used 3 operating room nurses. There were no perioperative complications in either group during the study period. Conclusions: There was no difference in perioperative complications between the surgery centers that used 3 versus 2 intraoperative nurses during wide-awake local anesthesia hand surgery. This study supports that limiting the nursing personnel for wide-awake local anesthesia hand surgeries could be an efficient way to cut procedural costs without compromising patient safety. Type of study/level of evidence: Therapeutic IV.

The Attenuated Pseudorabies Virus Vaccine Strain Bartha Hyperactivates Plasmacytoid Dendritic Cells by Generating Large Amounts of Cell-Free Virus in Infected Epithelial Cells.

Pseudorabies virus (PRV) is a porcine alphaherpesvirus and the causative agent of Aujeszky's disease. Successful eradication campaigns against PRV have largely relied on the use of potent PRV vaccines. The live attenuated Bartha strain, which was produced by serial passaging in cell culture, represents one of the hallmark PRV vaccines. Despite the robust protection elicited by Bartha vaccination, very little is known about the immunogenicity of the Bartha strain. Previously, we showed that Bartha-infected epithelial cells trigger plasmacytoid dendritic cells (pDC) to produce much higher levels of type I interferons than cells infected with wild-type PRV. Here, we show that this Bartha-induced pDC hyperactivation extends to other important cytokines, including interleukin-12/23 (IL-12/23) and tumor necrosis factor alpha (TNF-α) but not IL-6. Moreover, Bartha-induced pDC hyperactivation was found to be due to the strongly increased production of extracellular infectious virus (heavy particles [H-particles]) early in infection of epithelial cells, which correlated with a reduced production of noninfectious light particles (L-particles). The Bartha genome is marked by a large deletion in the US region affecting the genes encoding US7 (gI), US8 (gE), US9, and US2. The deletion of the US2 and gE/gI genes was found to be responsible for the observed increase in extracellular virus production by infected epithelial cells and the resulting increased pDC activation. The deletion of gE/gI also suppressed L-particle production. In conclusion, the deletion of US2 and gE/gI in the genome of the PRV vaccine strain Bartha results in the enhanced production of extracellular infectious virus in infected epithelial cells and concomitantly leads to the hyperactivation of pDC. IMPORTANCE The pseudorabies virus (PRV) vaccine strain Bartha has been and still is critical in the eradication of PRV in numerous countries. However, little is known about how this vaccine strain interacts with host cells and the host immune system. Here, we report the surprising observation that Bartha-infected epithelial porcine cells rapidly produce increased amounts of extracellular infectious virus compared to wild-type PRV-infected cells, which in turn potently stimulate porcine plasmacytoid dendritic cells (pDC). We found that this phenotype depends on the deletion of the genes encoding US2 and gE/gI. We also found that Bartha-infected cells secrete fewer pDC-inhibiting light particles (L-particles), which appears to be caused mainly by the deletion of the genes encoding gE/gI. These data generate novel insights into the interaction of the successful Bartha vaccine with epithelial cells and pDC and may therefore contribute to the development of vaccines against other (alphaherpes)viruses.

Effectiveness of Corticosteroid Injections in Diabetic Patients With De Quervain Tenosynovitis.

PURPOSE: We sought to determine the effectiveness of corticosteroid injections (CSIs) for de Quervain tenosynovitis in patients with diabetes mellitus. METHODS: We retrospectively identified all patients with diabetes receiving a CSI for de Quervain tenosynovitis by 16 surgeons over a 2-year period. Data collected included demographic information, medical comorbidities, number and timing of CSIs, and first dorsal compartment release. Success was defined as not undergoing an additional CSI or surgical intervention. The mixture of a corticosteroid and local anesthetic provided in each injection was at the discretion of each individual surgeon. RESULTS: Corticosteroid injections were given to 169 wrists in 169 patients with diabetes. Out of 169 patients, 83 (49%) had success following the initial CSI, 44 (66%) following a second CSI, and 6 (67%) following a third CSI. A statistically significant difference was identified in the success rates between the first and second CSIs. Ultimately, 36 of 169 wrists (21%) underwent a first dorsal compartment release. CONCLUSIONS: Patients with diabetes mellitus have a decreased probability of success following a single CSI for de Quervain tenosynovitis in comparison to nondiabetic patients, as described in the literature. However, the effectiveness of each additional CSI does not appear to diminish. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.