Effects of Socioeconomic Burden on Opioid Use Following Total Shoulder Arthroplasty.

BACKGROUND: Preoperative opioid users (POU) experience worse outcomes and higher complication rates compared to opioid naïve patients (ONP) following shoulder arthroplasty. This study evaluates the effects of socioeconomic status (SES), as measured by the distressed communities index (DCI), on pre- and postoperative opioid use and its influence on clinical outcomes such as readmission and revision surgery. METHODS: A retrospective review of patients who underwent primary shoulder arthroplasty (CPT code 23472) from 2014-2022 at a single academic institution was performed. Exclusion criteria included arthroplasty for fracture, active malignancy, and revision arthroplasty. Demographics, Charlson Comorbidity Index (CCI), DCI, and clinical outcomes including 90-day readmission and revision surgery were collected. Patients were classified according to the DCI score of their zip code. Using the Prescription Drug Monitoring Program database, patient pre- and postoperative opioid use in morphine milligram equivalents (MME) was gathered. RESULTS: Individuals from distressed communities utilized more opioids within 90 days preoperatively compared to patients from prosperous, comfortable, mid-tier, and at-risk populations respectively. Patients from distressed communities also used significantly more opioids within 90 days postoperatively compared to prosperous, comfortable, and mid-tier respectively. Of patients from distressed communities, 35.1% developed prolonged opioid use (filling prescriptions >30 days after surgery), significantly more than all other cohorts. Among all patients, 3.5% were readmitted within 90 days and were more likely to be prolonged opioid users (38.9 vs 21.3%, p<0.001). Similarly, 1.5% of patients underwent revision surgery. Those who underwent revision were significantly more likely to be prolonged opioid users (38.2 vs 21.7%, p=0.002). CONCLUSIONS: Shoulder arthroplasty patients from distressed communities use more opioids within 90 days before and after their surgery and are more likely to become prolonged opioid users placing them at risk for readmission and revision surgery. Identifying patients at an increased risk for excess opioid use is essential to employ appropriate strategies that minimize the detrimental effects of prolonged use following surgery.

Diagnosis and Management of Early Complications After Reverse Shoulder Arthroplasty.

Reverse shoulder arthroplasty has become the predominant shoulder arthroplasty procedure. Despite newer design modifications, complications still occur after reverse shoulder arthroplasty. Early complications include instability, acromial and scapular spine stress fractures, periprosthetic fractures, periprosthetic joint infections, and neurologic injury. It is important to discuss the diagnosis and management of these early complications.

Management of proximal humerus bone loss with allograft prosthetic composite technique in shoulder arthroplasty.

BACKGROUND: Proximal humerus bone loss in shoulder arthroplasty is a difficult problem with limited treatment options. It most commonly occurs in the setting of a previously failed shoulder arthroplasty; however, it is occasionally encountered in cases of primary shoulder arthroplasty. Reconstruction of the proximal humerus is essential for soft tissue tension for implant stability and maximizing function. The purpose of this study was to analyze the clinical and functional outcomes of the allograft prosthetic composite (APC) technique for the management of proximal humeral bone loss in shoulder arthroplasty. METHODS: A retrospective review was performed of all patients who underwent primary or revision shoulder arthroplasty using an APC technique with a reverse shoulder arthroplasty prosthesis for the management of proximal humerus bone loss. Data collected included demographic variables, previous shoulder surgeries, indication for APC, type of allograft utilized, fixation technique, and reoperation and revision rates. Patients were contacted by phone and/or email survey to obtain the latest patient-reported functional outcome scores. RESULTS: We identified 14 patients who underwent shoulder arthroplasty using the APC technique with a reverse shoulder arthroplasty prosthesis. One (7.1%) was performed as a primary arthroplasty, and 13 (92.9%) were performed as revision arthroplasties. The indications for APC were instability (21.4%), periprosthetic fracture (21.4%), periprosthetic joint infection (14.3%), humeral component loosening (14.3%), rotator cuff failure (14.3%), fracture sequelae (7.1%), and failed hemiarthroplasty (7.1%). In terms of allograft type, 10 (71.4%) were performed with proximal femur allograft and 4 (28.6%) with proximal humerus allograft. There were 6 patients (42.9%) who sustained postoperative complications, 5 patients (35.7%) had instability, and 1 (7.1%) patient had postoperative wound drainage. All patients with a complication required a revision arthroplasty. CONCLUSION: The APC technique used to address proximal humerus bone loss in shoulder arthroplasty has a high complication rate with fair patient-reported functional outcome scores. Most of the postoperative complications and reoperations are related to implant instability.

Shoulder periprosthetic joint infection is associated with increased mortality.

BACKGROUND: Periprosthetic joint infections (PJIs) are a catastrophic complication after shoulder arthroplasty and may be associated with an increased mortality risk, as seen in hip and knee arthroplasty. Shoulder PJI organisms differ from hip and knee infections, as lower-virulence organisms, such as Cutibacterium acnes, are more commonly encountered. This study evaluated the association between shoulder PJI and mortality. METHODS: We retrospectively identified 411 patients who underwent revision shoulder arthroplasty from 2007 to 2020 at a single institution. 2018 International Consensus Meeting on Musculoskeletal Infection criteria were used to categorize each case as definite, probable, possible, or unlikely PJI. Mortality rate was assessed by performing chart reviews and an obituary search. Revision cases were grouped into a septic cohort (definite and probable PJI) and an aseptic cohort (possible and unlikely PJI). Kaplan-Meier analyses were performed to compare survival between septic and aseptic groups. The log-rank test was used to compare cumulative survival distributions and survival rates at 90 days, 6 months, 1 year, 2 years, and 5 years. Demographic information, Charlson Comorbidity Index (CCI), and culture data were collected. PJI organisms were categorized as virulent or nonvirulent per an infectious disease specialist, and predictors of mortality were determined by performing stepwise logistic regression analyses. RESULTS: The overall mortality rate was significantly greater (P < .001) in the septic group (20.5%) than in the aseptic group (6.6%). When evaluating time from revision surgery to death, patients with PJI had significantly greater mortality compared with those undergoing aseptic revision at 2 years (7.7% vs. 2.1%, P = .01) and 5 years (17% vs. 5.1%, P < .001). Body mass index, CCI, race, sex, and age were not significantly different between groups. Groups differed in utilization of 2-staged procedures (65% septic, 9% aseptic, P < .001). Multivariate regression analysis found that the variables most associated with mortality were septic revision, 2-staged procedures, and CCI. In the septic group, patients with C acnes PJI had a significantly lower mortality rate when compared to PJI from any other offending organism (3.1% vs. 48.4%, P = .001). CONCLUSION: Revision shoulder arthroplasty in the setting of PJI not only carries severe functional consequences for patients but is also associated with an increased mortality risk. Furthermore, C acnes infections are associated with a more favorable survival profile than PJI resulting from other organisms. Continued efforts to decrease shoulder arthroplasty infection rates are warranted and may influence long-term survival.

The impact of elective surgery restrictions during the COVID-19 (coronavirus disease 2019) pandemic on shoulder and elbow surgery: patient perceptions.

BACKGROUND: In late 2019 and early 2020, a novel coronavirus, COVID-19 (coronavirus disease 2019), spread across the world, creating a global pandemic. In the state of Pennsylvania, non-emergent, elective operations were temporarily delayed from proceeding with the normal standard of care. The primary purpose of this study was to determine the proportion of patients who required prescription pain medication during the surgical delay. Secondarily, we sought to determine the proportion of patients who perceived their surgical procedure as non-elective and to evaluate how symptoms were managed during the delay. MATERIALS AND METHODS: A single institutional database was used to retrospectively identify all shoulder and elbow surgical procedures scheduled between March 13 and May 6, 2020. Charts were manually reviewed. Patients who underwent non-shoulder and elbow-related procedures and patients treated by surgeons outside of Pennsylvania were excluded. Patients whose surgical procedures were postponed or canceled were administered a survey evaluating how symptoms were managed and perceptions regarding the delay. Preoperative functional scores were collected. Statistical analysis was performed to determine associations between procedure status, preoperative functional scores, perception of surgery, and requirement for prescription pain medication. RESULTS: A total of 338 patients were scheduled to undergo shoulder and elbow surgery in our practice in Pennsylvania. Surgery was performed as initially scheduled in 89 of these patients (26.3%), whereas surgery was postponed in 179 (71.9%) and canceled in 70 (28.1%). The average delay in surgery was 86.7 days (range, 13-299 days). Responses to the survey were received from 176 patients (70.7%) in whom surgery was postponed or canceled. During the delay, 39 patients (22.2%) required prescription pain medication. The surgical procedure was considered elective in nature by 73 patients (41%). One hundred thirty-seven patients (78%) would have moved forward with surgery if performed safely under appropriate medical guidelines. Lower preoperative American Shoulder and Elbow Surgeons scores (r = -0.36, P < .001) and Single Assessment Numeric Evaluation scores (r = -0.26, P = .016) and higher preoperative visual analog scale scores (r = 0.28, P = .009) were correlated with requiring prescription pain medication. Higher preoperative American Shoulder and Elbow Surgeons scores were positively correlated with perception of surgery as elective (r = 0.4, P < .001). CONCLUSION: Patients undergoing elective shoulder and elbow surgical procedures during the COVID-19 (coronavirus disease 2019) pandemic experienced a delay of nearly 3 months on average. Fewer than half of patients perceived their surgical procedures as elective procedures. Nearly one-quarter of patients surveyed required extra prescription pain medicine during the delay. This study elucidates the fact that although orthopedic shoulder and elbow surgery is generally considered "elective," it is more important to a majority of patients. These findings may also be applicable to future potential mandated surgical care delays by other third-party organizations.

Radiographic humeral head restoration after total shoulder arthroplasty: does the stem make a difference?

BACKGROUND: Humeral stem designs for total shoulder arthroplasty have varied over the years, with a recent trend toward shorter stems. The purpose of this study was to examine the impact of humeral component stem length on the ability to restore the native humeral head anatomy. METHODS: We performed a retrospective review including patients who underwent total shoulder arthroplasty for primary osteoarthritis between 2007 and 2017 with complete operative reports and adequate radiographs. Surgical data including stem design were collected. Preoperative and postoperative radiographic measurements of the center of rotation (COR), humeral head height (HH), and neck-shaft angle were performed. Restoration of the native humeral anatomy was deemed "acceptable" based on postoperative differences in the COR ≤ 3 mm, HH ≤ 5 mm, and neck-shaft angle > 130°. Deviations between preoperative and postoperative measurements were compared across stem types. All available 2-year stemless implant radiographs were also analyzed. RESULTS: In total, 261 patients were included, with 31 stemless, 43 short-stem, and 187 standard-stem implants. There was no significant difference in COR restoration in the x-axis direction (P = .060) or y-axis direction (P = .579). There was no significant difference in restoration of acceptable HH by stem type (P = .339). Stemless arthroplasty implants were more likely to be placed in varus (22.6%) compared with short-stem (7.0%) and standard-stem (3.7%) designs (P < .001). CONCLUSION: Restoration of humeral anatomic parameters occurred significantly less with stemless implants than with short- and standard-stem implants. The stem of a shoulder arthroplasty implant aids surgeons in accurately restoring patient-specific anatomy.

The effect of an orthopedic specialty hospital on operating room efficiency in shoulder arthroplasty.

BACKGROUND: Operating room (OR) time is a major cost to the health care system. Therefore, increasing OR efficiency to save time may be a cost-saving tool. This study analyzed OR efficiency in shoulder arthroplasty at an orthopedic specialty hospital (OSH) and a tertiary referral center (TRC). METHODS: All primary shoulder arthroplasties performed at our OSH and TRC were identified (2013-2015). Manually matched cohorts from the OSH and TRC were compared for OR times. Three times (minutes) were recorded: anesthesia preparation time (APT; patient in room to skin incision), surgical time (ST; skin incision to skin closed), conclusion time (CT; skin closed to patient out of room). RESULTS: There were 136 primary shoulder arthroplasties performed at the OSH and matched with 136 at the TRC. OSH and TRC patients were similar in age (P = .95), body mass index (P = .97), Charlson Comorbidity Index (P = 1.000), sex (P = 1.000), procedure (P = 1.000), insurance status (P = .714), discharge destination (P = .287), and diagnoses (P = .354). These matched populations had similar ST (OSH: 110.0 ± 26.6 minutes, TRC: 113.4 ± 28.7 minutes; P = .307). APT (39.2 ± 8.0 minutes) and CT (7.6 ± 3.8 minutes) were shorter in the OSH patients than APT (46.3 ± 8.8 minutes; P < .001) and CT (11.2 ± 4.7 minutes; P < .001) in TRC patients. Total nonoperative time (sum of APT and CT) at the OSH (46.8 ± 8.9 minutes) was shorter than at the TRC (57.5 ± 10.4 minutes; P < .001). CONCLUSIONS: Despite similar patient populations and case complexity, the OR efficiency at an OSH was superior to a TRC. Further analysis is needed to determine the financial implications of this superior OR efficiency.

Stemless Prosthesis for Total Shoulder Arthroplasty.

The fourth generation of humeral components currently are being used in anatomic shoulder arthroplasty. Anatomic shoulder arthroplasty implants have evolved to better re-create anatomy, improve fixation, preserve bone, and facilitate revision surgery. Most of the design changes for shoulder arthroplasty implants have centered on the humeral stem, with a transition to shorter, metaphyseal humeral stems. Many of these humeral component design changes may be beneficial; however, long-term studies are necessary to determine if the results of anatomic shoulder arthroplasty with the use of newer humeral components can match those of older humeral components.

Glenohumeral Arthritis in Young Patients: Scope, Arthroplasty, Interposition, Arthrodesis, and Resurfacing.

The management of glenohumeral arthritis in young patients is a challenge given the higher demand for use of the arms, need for longer implant survivorship, and higher postoperative expectations in this patient population. Shoulder arthroplasty is an excellent treatment option for elderly patients with glenohumeral arthritis because this patient population does not have demands as high as those of younger patients with glenohumeral arthritis. Common causes of glenohumeral arthritis in young patients include chondrolysis, inflammatory arthropathies, chronic instability, osteonecrosis, glenoid dysplasia, and early-onset osteoarthritis. Options for the surgical management of glenohumeral arthritis in young patients include arthroscopic débridement with or without capsular release, biceps tenodesis, chondroplasty, and/or subacromial decompression; soft-tissue resurfacing; humeral head resurfacing; anatomic total shoulder arthroplasty; reverse total shoulder arthroplasty; and glenohumeral arthrodesis. Shoulder arthroplasty is the preferred treatment for young patients with glenohumeral arthritis; however, surgeons must counsel patients on treatment options, surgical goals, postoperative functional expectations, and the potential for future surgery to increase the likelihood of good outcomes.

Management of Failed Rotator Cuff Repair in Young Patients.

Management of failed rotator cuff repair may be very difficult, especially in young patients. Various nonmodifiable and modifiable patient factors, including age, tendon quality, rotator cuff tear characteristics, acute or chronic rotator cuff tear, bone quality, tobacco use, and medications, affect rotator cuff repair healing. Surgical variables, such as the technique, timing, tension on the repair, the biomechanical construct, and fixation, as well as the postoperative rehabilitation strategy also affect rotator cuff repair healing. Variable outcomes have been reported in patients who undergo revision rotator cuff repair; however, a systematic surgical approach may increase the likelihood of a successful outcome. Numerous cellular and mechanical biologic augments, including platelet-rich plasma, platelet-rich fibrin matrix, mesenchymal stem cells, and acellular dermal matrix grafts, have been used in rotator cuff repair; however, conflicting or inconclusive outcomes have been reported in patients who undergo revision rotator cuff repair with the use of these augments. A variety of tendon transfer options, including latissimus dorsi, teres major, lower trapezius, pectoralis minor, pectoralis major, combined pectoralis major and latissimus dorsi, and combined latissimus dorsi and teres major, are available for the management of massive irreparable rotator cuff tears. Ultimately, the optimization of surgical techniques and the use of appropriate biologic/tendon transfer techniques, if indicated, is the best method for the management of failed rotator cuff repair.

Treatment of periprosthetic joint infection of the elbow: 15-year experience at a single institution.

BACKGROUND: Total elbow arthroplasty (TEA) can be complicated by periprosthetic joint infection (PJI) with potentially catastrophic failure. The purpose of this study was to describe the results of elbow PJI treatment at a tertiary-care referral center. METHODS: An institutional TEA database was queried for infection and reoperation after TEA. Patients who underwent irrigation and débridement (I&D) with component retention were compared with those who underwent component explantation, antibiotic spacer placement, and reimplantation of a revision TEA. RESULTS: A total of 26 patients (10 men; mean age, 64.3 years) were treated for PJI of TEA. There were 3 polymicrobial infections (11.5%) and 13 Staphylococcus aureus infections (50%) (4 methicillin resistant); 6 patients (23.1%) had negative culture results. Ten patients (38.5%) underwent I&D and component retention, with 5 of those patients (5 of 10, 50%) having recurrent infection at an average of 3.1 years (range, 0.25-7.8 years) after I&D. Of 16 patients who underwent antibiotic spacer placement, 12 (75%) underwent 2-stage reimplantation of a TEA. Among those with reimplantation, 4 of 12 (33.3%) required reoperation. In 3 of 12 (25.0%), reoperation was required for infection, whereas 1 of 12 (8.3%) required surgery for mechanical complications. CONCLUSION: Two-stage revision results in a decreased rate of recurrent PJI. Certain patients (those with poor health or well-fixed components) may be more suitable for I&D and component retention, with a demonstrated 50% success rate over a period of 3 years. Longer-term follow-up may result in higher reinfection rates in both groups.

The effectiveness of cerebral oxygenation monitoring during arthroscopic shoulder surgery in the beach chair position: a randomized blinded study.

BACKGROUND: Beach chair positioning for shoulder surgery is associated with measurable cerebral desaturation events (CDEs) in up to 80% of patients. Near-infrared spectroscopy (NIRS) technology allows real-time measurement of cerebral oxygenation and may minimize the frequency of CDEs. The purpose of this study was to investigate the incidence of CDEs when anesthetists were aware of and blinded to NIRS monitoring and to determine the short-term cognitive effects of surgery in the beach chair position. METHODS: NIRS was used to monitor cerebral oxygenation saturation in 41 consecutive patients undergoing arthroscopic shoulder surgery in the beach chair position. Patients were randomized to 2 groups, anesthetists aware of or blinded to NIRS data. The Montreal Cognitive Assessment (MoCA) was used to assess cognitive function preoperatively, immediately postoperatively, and at 2 and 6 weeks postoperatively. RESULTS: Overall, 7 (17.5%) patients experienced a CDE, 5 (25%) in the aware group and 2 (10%) in the blinded group. There was no significant difference in MoCA scores between the aware and blinded groups preoperatively (27.9.1 vs. 28.2; P = .436), immediately postoperatively (26.1 vs. 26.2; P = .778), 2 weeks postoperatively (28.0 vs. 28.1; P = .737), or 6 weeks postoperatively (28.5 vs. 28.4; P = .779). There was a correlation of NIRS with systolic blood pressure (r = 0.448), diastolic blood pressure (r = 0.708), and mean arterial pressure (r = 0.608). CONCLUSION: In our series, the incidence of CDEs was much lower than previously reported and was not lowered by use of NIRS. Patients did not have significant cognitive deficits after arthroscopic surgery in the beach chair position, and there was a correlation between NIRS and intraoperative brachial blood pressure.

Surgeons' experience and perceived barriers with outpatient shoulder arthroplasty.

BACKGROUND: Recently, outpatient total shoulder arthroplasty (TSA) has been proposed as a safe and cost-effective alternative to the inpatient setting. This study evaluated the expert shoulder surgeon's experience with and perceived barriers to outpatient TSA. METHODS: A secure web application was used to perform an online survey of 484 active American Shoulder and Elbow Surgeons members. The survey assessed surgeon practice demographics, experience with TSA/outpatient TSA, and perceived barriers to successful outpatient TSA. Simple descriptive statistics were performed to analyze the cohort. To identify differences between surgeons performing and not performing outpatient TSA, the Student t test and χ2 test were used in bivariate analysis. P < .05 was used for statistical significance. RESULTS: Of the 179 (37.0%) complete responses received, 20.7% perform outpatient TSA; of those, 78.4% reported an "excellent" experience. Outpatient surgeons were more likely to reside in the southern United States (P = .05) and performed a higher volume of TSAs annually (P = .03). Surgeons not performing outpatient TSA were more concerned with the potential of medical complications (P = .04). Perceived lack of experience (P = .002), low volume (P = .008), insurance contracts (P = .003), and reimbursement (P = .04) were less important barriers compared with outpatient TSA surgeons. CONCLUSIONS: Less than 25% of shoulder surgeons who completed survey are performing outpatient TSA, and those that do report an overall excellent experience. Volume of TSAs performed and practice location appear to play roles in the decision to perform outpatient TSA. As surgeons become more comfortable with outpatient TSA, there is a shift from concerns about medical complications to concerns about reimbursement.

Outcomes of an anatomic total shoulder arthroplasty with a contralateral reverse total shoulder arthroplasty.

BACKGROUND: It is common for patients to require staged bilateral shoulder arthroplasties. There is a unique cohort of patients who require an anatomic total shoulder arthroplasty (TSA) and a contralateral reverse shoulder arthroplasty (RSA). This study compared the outcomes of patients with a TSA in 1 shoulder and an RSA in the contralateral shoulder. METHODS: Our institutional database was queried to identify all patients with a TSA and a contralateral RSA. Data collection included patient demographics, preoperative and latest follow-up shoulder range of motion, radiographic analysis, and postoperative complications. Identified patients were assessed at follow-up visits or contacted by phone for functional outcome scores. RESULTS: Nineteen patients met our inclusion/exclusion criteria. There was statistically significant greater internal rotation in the TSA shoulder (P= .044) but no significant difference in forward elevation (P = .573) or external rotation (P= .368). There was no radiographic evidence of humeral or glenoid component loosening of any arthroplasty implants. There were no significant differences between TSA and RSA shoulders for the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment (P= .381), Simple Shoulder Test (P = .352), Single Assessment Numerical Evaluation (P = .709), and visual analog scale satisfaction (P= .448) or pain scores (P= .305). Thirteen patients (68.4%) preferred the RSA side, 1 patient (5.3%; z = 4.04, P < .001) patient preferred the TSA side, and 5 patients expressed no preference. CONCLUSION: Despite known limitations and differences between TSA and RSA designs, patients who have received both implants are highly satisfied with both. The only parameter in which the TSA had superior outcomes was internal rotation.

MicroRNAs are critical regulators of tuberous sclerosis complex and mTORC1 activity in the size control of the Xenopus kidney.

MicroRNAs (miRNAs) are major posttranscriptional regulators of a wide variety of biological processes. However, redundancy among most miRNAs has made it difficult to identify their in vivo functions. We previously demonstrated that global inhibition of miRNA biogenesis in Xenopus resulted in a dramatically smaller pronephric kidney. This suggested that microRNAs play a pivotal role in organ size control. Here we now provide a detailed mechanistic explanation for this phenotype. We identified that the activation of the mechanistic target of rapamycin complex 1 (mTORC1) by Insulin and insulin-like growth factor (Igf) 2 is an important regulator in kidney growth, which in turn is modulated by microRNAs. Molecular analyses demonstrate that microRNAs set a threshold for mTORC1 signaling by down-regulating one of its core negative regulators, tuberous sclerosis 1 (Tsc1). Most importantly, this rheostat can be reprogrammed experimentally. Whereas knockdown of miRNAs causes growth arrest, concomitant knockdown of Tsc1 restores mTORC1 activity and proximal tubular size. Together, these data establish a previously unidentified in vivo paradigm for the importance of posttranscriptional regulation in organ size control.

Survival of porcine reproductive and respiratory syndrome virus in fresh pork.

Porcine reproductive and respiratory syndrome virus (PRRSV) remains one of the most economically important diseases of pigs. Transmission of PRRS virus has been reported through many routes, with aerosol route being the most predominant. There may also be a potential risk of transmission through contami-nated pork, but this has never been investigated. The purpose of this study was to experimentally contaminate fresh pork with three different concentrations of PRRSV and to study virus survival at ambient (25 °C), refrigerated (4 °C), and frozen (-20 °C) temperatures. Concentrations of virus representing natural infectivity level and 'worst case scenario' were studied. The virus was detected in fresh pork at all three virus concentrations for up to 48 h at ambient temperature. At 4 °C, the virus survived for 6 days in pork inoculated with the higher virus concentration and for 3 days in pork inoculated at the lower concentration. At frozen temperature, PRRSV was detected for up to 60 days in pork inoculated at the higher concentration and for 7 days in pork inoculated at the lower concentration. These results suggest that fresh pork has the potential to be a vehicle for virus dissemination depending upon temperature and time of storage.

Perioperative and Anesthetic Considerations in Shone's Complex.

Shone's complex is a congenital cardiac disease consisting of the following four lesions: parachute mitral valve, supravalvar mitral ring, subaortic stenosis, and aortic coarctation. Though not all components are required for a diagnosis, the end result is both left ventricular inflow and outflow obstruction, which typically present in patients as congestive heart failure. The complex pathology requires careful management and surgical decision-making to ensure an optimal outcome. This review will focus on the anatomy, physiology, and perioperative anesthetic management of patients with Shone's complex.

Covid-19 patterns among adults with intellectual and developmental disability and the general population in New York state during the first year of the pandemic.

BACKGROUND: People with intellectual and developmental disabilities (IDD) in the US, especially those living in group homes, experienced comparatively higher Covid-19 case/case fatality rates than the general population during the first year of the pandemic. There is no information about the patterns of case/case fatality rates during this time. OBJECTIVE: This study compared Covid-19 case/case fatality rates among people with IDD living in residential group homes to the general population across the first year of the pandemic in New York State (NYS). METHODS: Covid-19 positive cases and deaths collected from New York Disability Advocates (NYDA), a coalition of organizations serving individuals with IDD, was compared to data for the NYS general population from the first pandemic year. Case rates/100,000 and case fatality rates were calculated for the study period. Joinpoint Trend Analysis Software was used to analyze patterns in weekly case/case fatality rates. RESULTS: Case fatality rates for people with IDD were higher than for the overall state population throughout the pandemic's first year. Case rates were higher among people with IDD across most of this year. Although the patterns in rates were similar, there was a sharp increase in cases for those with IDD during Fall 2020 beginning eight weeks before the general NYS population and a significant decrease in fatalities in late December 2020 into January 2021. CONCLUSIONS: Consistently higher case fatality rates and significant differences in case/case fatality rates for people with IDD living in group homes require further consideration. Planning for future emergencies will require an enhanced federal/state understanding of the needs of people with IDD and a responsive surveillance system.

Effect of pimenta essential oil against Salmonella Agona and Salmonella Saintpaul in ground turkey meat and nonprocessed turkey breast meat.

Salmonella enterica Agona (S. Agona) and Salmonella enterica Saintpaul (S. Saintpaul) are among the emerging drug-resistant Salmonella in turkey production and processing. Rapid solutions to control emerging and uncommon serotypes such as S. Agona and S. Saintpaul are needed. This study tested pimenta essential oil (PEO) as a processing antibacterial against S. Agona and S. Saintpaul in experiments representative of different stages of turkey processing. The compound effectively reduced S. Agona and S. Saintpaul in nutrient broth studies and with mature biofilm assays. PEO was tested against a combination of S. Agona and S. Saintpaul in ground turkey meat and nonprocessed breast meat. In the first experiment with ground turkey, samples were inoculated with a mixture of S. Agona and S. Saintpaul (∼3 log10 CFU/g) and treated with PEO at different concentrations (0% PEO, 0.25% PEO, 0.5% PEO, 1% PEO, 2% PEO, and 2.5% PEO). In the second experiment with turkey breast, samples inoculated with ∼3 log10 CFU/g (SA+SP) were dipped in different concentrations of PEO with chitosan (CN) for 2 min. In both these experiments, samples were stored at 4°C, and Salmonella recovery was carried out at 0, 1, 3, 5, and 7 d. All experiments followed a completely randomized design and were repeated 6 times (n = 6). Statistical analysis was done using the PROC-ANOVA procedure of SAS. In the ground turkey meat, PEO at or above 2% reduced 2 log10 CFU/g of Salmonella by day 1. PEO at 2.5% in ground turkey meat resulted in enrichment-negative samples by 1 min, indicative of the rapid killing effect of the compound at a high concentration of PEO (P ≤ 0.05). A maximum reduction of 1.7 log10 CFU Salmonella/g of turkey breast meat was obtained after 2 min of dip treatment containing CN and 2.5% PEO. Results indicate that PEO could be used as a plant-based processing antibacterial against S. Agona and S. Saintpaul in turkey processing. Upscaling to plant-level studies is necessary before recommending its usage.

Influence of Beef Hot Carcass Weight on Sensory Characteristics of Strip Loin, Eye of Round, and Denver Cut Steaks.

The objective of this research was to investigate the influence of beef hot carcass weight (HCW) on consumer sensory attributes. Beef carcasses (n = 116) were selected based on the USDA quality grade and HCW. Lightweight (LW; 296-341 kg), middleweight (MW; 386-432 kg), or heavyweight (HW; 466-524 kg) carcasses with USDA Choice (LC) or USDA Select (SEL) quality grades were used in this study. Carcasses were tracked through fabrication and the semitendinosus, chuck roll, and strip loin were collected and fabricated into eye of round, Denver cut, and strip loin steaks, respectively, for consumer sensory evaluation. USDA Select MW Denver cut steaks had increased overall liking and texture liking scores and were more tender and juicier than the SEL LW steaks (p ≤ 0.02). USDA Select MW strip loin steaks had increased overall and flavor liking scores and were more tender than the SEL LW steaks (p ≤ 0.02). USDA Choice MW eye of round steaks had increased overall, flavor, and texture liking scores and were juicier than the LW eye of round steaks (p ≤ 0.04). The steaks evaluated in this study were differentially impacted by HCW and little to no clear pattern of effects could be determined across cut or quality grade. Additional research is needed to determine the most acceptable HCW from a consumer perspective.