Delayed Digit Replantation: What is the Evidence?

A persistent challenge that has limited access and delivery of digit replantation surgery is timing, as ischemia time has traditionally been considered an important determinant of success. However, reports that the viability of amputated digits decreases after 6 hours of warm ischemia and 12 hours of cold ischemia are largely anecdotal. This review evaluates the quality and generalizability of available evidence regarding ischemia times after digit amputation and reported outcomes of "delayed" replantation. We identify substantial limitations in the literature supporting ischemia time cutoffs and recent evidence supporting the feasibility of delayed digit replantation. The current treatment approach for amputation injuries often necessitates transfers or overnight emergency procedures that increase costs and limit availability of digit replantation nationwide. Evidence-based changes to digit replantation protocols could lead to broader availability of this service, as well as improved care quality.

In utero exposure to valproic acid disrupts ascending projections to the central nucleus of the inferior colliculus from the auditory brainstem.

Prenatal exposure to the antiepileptic valproic acid (VPA) is associated with an increased risk of autism spectrum disorder (ASD) in humans. Accordingly, in utero exposure to VPA is a validated and biologically relevant animal model of ASD. The majority of individuals with ASD exhibit some degree of auditory dysfunction, ranging from deafness to hypersensitivity. Animals exposed to VPA in utero have abnormal tonotopic maps and responses in the cerebral cortex and hyperactivation, hypoplasia, abnormal neuronal morphology and reduced calcium binding protein expression throughout the auditory brainstem nuclei. Further, our previous work suggests that GABAergic neuronal populations may be more severely impacted by in utero VPA exposure. However, the axonal projection patterns of brainstem nuclei to the inferior colliculus (IC) have not been investigated in VPA-exposed animals. Herein, we use stereotaxic injections of the retrograde tracer Fast Blue into the central nucleus of the IC (CNIC) and examine the proportions of retrogradely labeled neurons in the nuclei of the lateral lemniscus, superior olivary complex and cochlear nuclei. Our results indicate that not only are there fewer neurons in the auditory brainstem after VPA exposure, but also that fewer neurons are retrogradely labeled from the CNIC. Together, our results indicate that in utero VPA exposure may result in altered patterns of input to the auditory midbrain.

The Effect of Skin Pigmentation on Determination of Limb Ischemia.

PURPOSE: Timely identification of tissue ischemia is critical, both in the traumatized limb and following free tissue transfer. The purpose of this study was to determine if skin pigmentation affects the ability to detect limb ischemia. METHODS: We conducted a study of healthy controls exposed to limb ischemia. The subjects were classified based on skin pigmentation using a defined skin type assessment tool, a visual color scale, and self-description of race. Participants were randomized by limb and tourniquet status; surgeons were blinded to both. Ischemia was induced by tourniquet insufflations, and board-certified orthopedic and plastic surgeons who had completed an accredited hand surgery fellowship conducted physical examinations. The surgeons monitored the forearms at 2, 6, and 10 minutes based on appearance of ischemia, capillary refill, and color in 3 locations on the limbs (posterior interosseous artery flap skin territory, radial forearm flap skin territory, and the digits). RESULTS: We found a significant decrease in the ability to detect ischemia in participants with increased skin pigmentation, as documented by all metrics, when evaluating the posterior interosseous artery and radial forearm flap skin territories at all time points. For example, when monitoring the posterior interosseous artery flap with the tourniquet insufflated at time 10 minutes, 92.9% of Caucasians were correctly identified as being ischemic whereas only 23.3% of African Americans were correctly identified. CONCLUSIONS: Skin pigmentation significantly affects the identification of an ischemic limb/skin flaps on physical examination. Whereas the standard treatment for monitoring of free tissue transfer is clinical examination, that may not be sufficient for patients with increased skin pigmentation. Surgeons should exercise particular vigilance during physical examination of a potentially ischemic limb/skin flaps with greater skin pigmentation. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

A long noncoding RNA maintains active chromatin to coordinate homeotic gene expression.

The genome is extensively transcribed into long intergenic noncoding RNAs (lincRNAs), many of which are implicated in gene silencing. Potential roles of lincRNAs in gene activation are much less understood. Development and homeostasis require coordinate regulation of neighbouring genes through a process termed locus control. Some locus control elements and enhancers transcribe lincRNAs, hinting at possible roles in long-range control. In vertebrates, 39 Hox genes, encoding homeodomain transcription factors critical for positional identity, are clustered in four chromosomal loci; the Hox genes are expressed in nested anterior-posterior and proximal-distal patterns colinear with their genomic position from 3' to 5'of the cluster. Here we identify HOTTIP, a lincRNA transcribed from the 5' tip of the HOXA locus that coordinates the activation of several 5' HOXA genes in vivo. Chromosomal looping brings HOTTIP into close proximity to its target genes. HOTTIP RNA binds the adaptor protein WDR5 directly and targets WDR5/MLL complexes across HOXA, driving histone H3 lysine 4 trimethylation and gene transcription. Induced proximity is necessary and sufficient for HOTTIP RNA activation of its target genes. Thus, by serving as key intermediates that transmit information from higher order chromosomal looping into chromatin modifications, lincRNAs may organize chromatin domains to coordinate long-range gene activation.

Perilunate Dislocations: Cadaveric Model K-Wire Versus Compression Staple Fixation.

Purpose: Repair of perilunate dislocations requires stabilization of the carpal bones, although there is limited research on the preferred method(s) of stabilization. We compared the biomechanical characteristics of K-wire versus staple fixation of scapholunate (SL) and lunotriquetral (LT) intervals in the wrist. Methods: After creating a grade IV instability model, 20 cadaver wrists were randomized into 2 stabilization model groups using K-wires or surgical staples across the SL and LT intervals. For each ligament, two K-wires or one surgical staple was used to stabilize the proximal carpal row. Each wrist was loaded with 15 N of force and cycled 5,000 times at an angular velocity of 10 rpm. Displacement between bones was measured at different cycles (10, 100, 500, 1,000, 2,000, 3,000, 4,000, and 5,000). A t test was used for comparisons. Results: For the LT K-wire group, the average displacement at 10 cycles was 0.08 mm, and at 5,000 cycles, 0.163 mm. For the SL K-wire group, the average displacement at 10 cycles was 0.025 mm, and at 5,000 cycles, 0.129 mm. For the LT and SL staple fixation models, the average shifts at 10 cycles were 0.029 and 0.063 mm, and at 5,000 cycles, 0.098 and 0.176 mm, respectively. No significant difference between the fixation models was found at any interval. Notably, in each group, a similar number of small outliers with higher amounts of displacement was observed. Conclusions: Either K-wire or surgical staple stabilization is suitable for perilunate dislocations. The surgical method should be selected based on patient-specific circumstances and the provider's judgment. Type of study/level of evidence: Therapeutic III.

Minimum 6-year follow-up after ulnar nerve decompression and submuscular transposition for primary entrapment.

PURPOSE: To retrospectively evaluate patients with 6-year minimum follow-up after submuscular transposition of the ulnar nerve for primary entrapment. METHODS: From 1992 to 2005, 142 patients were treated surgically for ulnar neuropathy at the elbow by 2 senior surgeons using a technique that preserved nerve vascularity. A total of 99 cases were eligible, and 82 elbows in 76 patients, average age 48 years, were followed for at least 6 years (average, 8.3 y). Thirty-two (42%) were male, and the dominant limb was involved in 49 (64%). The average duration of symptoms before surgery was 25 months. Clinical records were reviewed, and sensory (S0-2) and motor (M0-5) testing was performed. Dellon scores were determined, and visual analog scale and modified questionnaires from Novak et al and Kleinman and Bishop were completed. Preoperatively, 48 elbows were Dellon grade III, 33 were grade II, and one was grade I. RESULTS: There were clinically and statistically significant improvements in patient and surgeon-reported data regardless of the preoperative disease severity. Visual analog scale questionnaires, sensory scale, and motor strength all improved, with at least antigravity strength in all subjects. Dellon scores also improved, and 38 elbows had normalized to Dellon 0. Of the 33 preoperative elbows that were grade III, 15 improved to grade II, 13 to grade I, and 5 normalized. Of the 48 preoperative elbows that were grade II, 16 improved to grade I and 32 normalized. Preoperative Dellon III elbows had more residual symptoms than grade II elbows. A total of 73 elbows (89%) had a good or excellent outcome. There were no reoperations or infections. CONCLUSIONS: Submuscular transposition is a safe and durable option for primary ulnar neuropathy at the elbow. Overall, good or excellent results were achieved in 89% of patients with a low complication rate. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Open data for COVID-19 policy analysis and mapping.

As the COVID-19 pandemic unfolded in the spring of 2020, governments around the world began to implement policies to mitigate and manage the outbreak. Significant research efforts were deployed to track and analyse these policies in real-time to better inform the response. While much of the policy analysis focused narrowly on social distancing measures designed to slow the spread of disease, here, we present a dataset focused on capturing the breadth of policy types implemented by jurisdictions globally across the whole-of-government. COVID Analysis and Mapping of Policies (COVID AMP) includes nearly 50,000 policy measures from 150 countries, 124 intermediate areas, and 235 local areas between January 2020 and June 2022. With up to 40 structured and unstructured characteristics encoded per policy, as well as the original source and policy text, this dataset provides a uniquely broad capture of the governance strategies for pandemic response, serving as a critical data source for future work in legal epidemiology and political science.

EPR studies on hydroxyl radical-scavenging activities of pravastatin and fluvastatin.

Statins are known clinically by their cholesterol reduction properties through the inhibition of HMG-CoA reductase. There is mounting evidence suggesting a protective role of statins in certain types of cancer, cardiac, and vascular disease through a mechanism that extends beyond their lipid lowering ability. The root mechanism of damage likely involves the inflammatory cascade, specifically compounds known as reactive oxygen species such as the hydroxyl radical. However, direct evidence for the hydroxyl-scavenging capacity of pravastatin and fluvastatin, two forms of statins being widely used to lower LDL cholesterol, is still lacking in literature. In this study, electron paramagnetic resonance spectroscopy in combination with 5,5-dimethyl-1-pyrroline N-oxide (DMPO)-spin-trapping technique was utilized to determine the abilities of pravastatin and fluvastatin in scavenging hydroxyl radical generated from Fe(II) with H(2)O(2) system. In addition, we examined the effects of pravastatin and fluvastatin on oxidative-induced φX-174 RF I plasmid DNA damage. We have demonstrated here for the first time that pravastatin and fluvastatin at physiologically relevant concentrations significantly decreased formation of DMPO-OH adduct indicating that both compounds could directly scavenge hydroxyl radicals. However, pravastatin and fluvastatin were not able to directly protect against oxidative DNA plasmid damage. The hydroxyl radical sequestering ability of pravastatin and fluvastatin reported in this study may contribute to their beneficial use in certain types of cancer and in cardiovascular disease.

Arthritis of the distal radioulnar joint: from Darrach to total joint arthroplasty.

The distal radioulnar joint (DRUJ) is a complex structure that contributes to full, painless forearm rotation and weight bearing. Stability requires adequate bony architecture and robust soft-tissue support. Arthritis of the DRUJ between the sigmoid notch of the distal radius and the ulnar head can be caused by traumatic, inflammatory, congenital, and degenerative processes. Initial management of symptomatic DRUJ arthritis is nonsurgical. Surgery is reserved for patients with refractory pain. Although outcomes typically are positive following excision of the distal ulna, serious potential postoperative complications include instability and potentially painful impingement of the residual distal ulnar stump. Procedures used to manage the unstable residual ulna include soft-tissue stabilization techniques and DRUJ implant arthroplasty.

A 73-Year-Old Man with an Incidental Diagnosis of Deltoid Intramuscular Myxoma Following a History of Trauma.

BACKGROUND Intramuscular myxomas are rare and benign soft-tissue tumors of uncertain differentiation. Predisposing or precipitating factors have not yet been reported. Activating mutation in GNAS (exons 8 and 9) is detected in >90% of sporadic cases. The role of chronic myopathy, tendinopathy, or trauma to muscles in the etiology of these neoplasms is not known. We report an unusual case of a deltoid mass found following longstanding rotator cuff tendinopathy and a recent fall, later confirmed to be an intramuscular myxoma on biopsy. CASE REPORT A 73-year-old man with a 5-year history of left shoulder pain and rotator cuff tear presented with intractable pain in his left shoulder after a recent fall at home. Physical examination was suggestive of a rotator cuff injury and magnetic resonance imaging (MRI) of the left shoulder revealed a 2.7×2.5×3.7cm T1 hypo- and T2 hyperintense oblong mass-like signal abnormality with heterogeneous, predominantly peripheral enhancement within the deltoid muscle concerning for a malignant mass. Surgical resection was carried out along with left reverse total shoulder replacement, and histopathology revealed findings consistent with an intramuscular myxoma. CONCLUSIONS Intramuscular myxomas are rare, benign tumors. This case report presents one such myxoma incidentally found in a patient with longstanding rotator cuff tendinopathy and a recent fall. Although this co-occurrence is likely incidental, further research and case series review of similar presentations may influence postulations of the pathophysiology of myxomas.

An uncommon case of neurosarcoidosis presenting as trigeminal neuralgia.

Sarcoidosis is a systemic inflammatory condition causing increased immune system activity and manifesting as noncaseating granulomatous disease with the ability to affect multiple organ systems. Neurosarcoidosis is an uncommon presentation, with just 5-10% of patients with sarcoidosis experiencing intracranial disease. The diagnosis of neurosarcoidosis can be difficult, especially given the overlap of imaging findings with more common intracranial lesions. This case presents trigeminal neuralgia as the initial symptom of neurosarcoidosis and emphasizes the importance of a high clinical index of suspicion for neurosarcoidosis in patients with otherwise unexplained neurological symptoms.

Bell's Palsy as a Late Neurologic Manifestation of COVID-19 Infection.

Bell's palsy is acute peripheral facial nerve palsy; its cause is often unknown but it can be triggered by acute viral infection. Coronavirus disease 2019 (COVID-19) infection commonly presents with respiratory symptoms, but neurologic complications have been reported. A few studies have reported the occurrence of facial nerve palsy during the COVID-19 pandemic. We present a case of Bell's palsy in a 36-year-old man with COVID-19 infection and a past medical history of nephrolithiasis. He presented to the emergency room with a day history of sudden right facial weakness and difficulty closing his right eye four weeks following a diagnosis of COVID-19 infection. Physical examination revealed right lower motor neuron facial nerve palsy (House-Brackmann grade IV). Serologic screen for Lyme disease, human immunodeficiency virus (HIV), and herpes simplex virus (HSV) 1 and 2 were negative for acute infection; however, neuroimaging with MRI confirmed Bell's palsy. He made remarkable improvement following treatment with a course of valacyclovir and methylprednisolone. This case adds to the growing body of literature on neurological complications that should be considered when managing patients with COVID-19 infection.

Reassessment of Relative Value in Shoulder and Elbow Surgery: Do Payment and Relative Value Units Reflect Reality?

BACKGROUD: Many U.S. health care institutions have adopted compensation models based on work relative value units (wRVUs) to standardize payments and incentivize providers. A major determinant of payment and wRVU assignments is operative time. We sought to determine whether differences in estimated operative times between the Centers for Medicare & Medicaid Services (CMS) and the National Surgical Quality Improvement Program (NSQIP) contribute to payment and wRVU misvaluation for the most common shoulder/elbow procedures. METHODS: We collected data on wRVUs, payments, and operative times from CMS for 29 types of isolated arthroscopic and open shoulder/elbow procedures. Using regression analysis, we compared relationships between these variables, in addition to median operative times reported by NSQIP (2013-2016). We then determined the relative valuation of each procedure based on operative time. RESULTS: Seventy-nine percent of CMS operative time were longer than NSQIP time (R2 = 0.58), including, but not limited to, shoulder arthroplasty and arthroscopic shoulder surgery. The correlation between payments and operative times was stronger between CMS data (R2 = 0.61) than NSQIP data (R2 = 0.43). Similarly, the correlation between wRVUs and operative times was stronger when using CMS data (R2 = 0.87) than NSQIP data (R2 = 0.69). Nearly all arthroscopic shoulder procedures (aside from synovectomy, debridement, and decompression) were highly valued according to both datasets. Per NSQIP, compensation for revision total shoulder arthroplasty ($10.14/min; 0.26 wRVU/min) was higher than that for primary cases ($9.85, 0.23 wRVU/min) and nearly twice the CMS rate for revision cases ($5.84/min; 0.13 wRVU/min). CONCLUSIONS: CMS may overestimate operative times compared to actual operative times as recorded by NSQIP. Shorter operative times may render certain procedures more highly valued than others. Case examples show that this can potentially affect patient care and incentivize higher compensating procedures per operative time when less-involved, shorter operations have similar patient-reported outcomes.

Misvaluation of Hospital-Based Upper Extremity Surgery Across Payment, Relative Value Units, and Operative Time.

Background: Many US health care institutions have adopted compensation models based on work relative value units (wRVUs) to standardize payments and incentivize providers. Among other factors, a major determinant of payment and wRVU assignments is operative time. Our objective was to determine whether differences in estimated operative times between the Centers for Medicare & Medicaid Services (CMS) and the National Surgical Quality Improvement Program (NSQIP) contribute to payment and wRVU misvaluation for the most common hospital-based hand and upper extremity procedures. Methods: Data on wRVUs, surgeon payment, and estimated operative times were collected from CMS for 53 procedures. We used regression models to compare relationships between these variables, in addition to actual median operative times as reported in the NSQIP database, from 2011 to 2016. We then determined the relative valuation of each procedure based on operative time. Results: There was a wide discrepancy between CMS and NSQIP operative times (R2=0.49), with 60% of CMS times being longer than NSQIP times. Payment correlated more strongly with CMS operative times (R2=0.55) than with NSQIP operative times (R2=0.24). Similarly, wRVUs more strongly correlated with CMS operative times (R2=0.84) than with NSQIP operative times (R2=0.51). In general, for trauma-related procedures, any distal radius open reduction internal fixation (ORIF) had the highest valuation while any ORIF proximal to the distal radius had lower valuation in analysis of both databases. While 61% of trauma procedures were highly valued, 70% of elective procedures had a low valuation, including nearly all elective tendon procedures. Notable compensation differences were found between trapeziectomy versus ligament reconstruction and tendon interposition, epicondyle debridement with tendon repair versus denervation, proximal row carpectomy versus four corner fusion, and distal radius open versus percutaneous fixation. Conclusions: CMS may misvalue payment and wRVU rates of hospital-based hand procedures due to inaccurate operative time estimates. By identifying which procedures are misvalued in terms of payment and wRVU per operative time, providers and payors may be able to address these imbalances and maximize appropriate care delivery incentives.Level of Evidence: III.

Are standardized patient self-reporting instruments applicable to the evaluation of ulnar neuropathy at the elbow?

BACKGROUND: This study attempts to confirm that the Disabilities of Arm, Shoulder and Hand (DASH) Outcome Measure self-administered questionnaire is valid specifically for ulnar neuropathy at the elbow. Validity of the Levine-Katz questionnaire for ulnar neuropathology compared with DASH was also studied. MATERIALS AND METHODS: Forty-eight patients with isolated ulnar nerve surgery completed a 6-month evaluation. Patients were assigned a clinical stage. The DASH and Levine-Katz questionnaires were administered, and pinch and grip strength were measured preoperatively and postoperatively. Levine-Katz questionnaires were correlated with DASH to establish criterion validity. Construct validity was tested by determining a relationship between scores and clinical stages and by comparing scores preoperatively and postoperatively. RESULTS: There was a high correlation between DASH scores and symptom severity and functional status. Although correlations were significant between DASH and biomechanical measures, correlation coefficients were lower. Postoperatively, all measures improved significantly. CONCLUSION: This study confirms that scores on the DASH questionnaire reflect the clinical staging of ulnar neuropathy at the elbow.

Interventions to increase research publications in graduate medical education trainees: a systematic review.

INTRODUCTION: Competency-based educational models recommend trainee exposure to research, but the best methods for Graduate Medical Education (GME) programs to accomplish this have not been clarified. The objective of this study was to quantify published interventions to generate resident research and compare effectiveness among those interventions. MATERIAL AND METHODS: A systematic review of English-language articles of studies of GME programs was performed, describing resident research interventions and quantifying the number of publications as an outcome. RESULTS: The search produced 13,688 potentially relevant articles, and included 47 articles in the final synthesis. Publication effectiveness was calculated as publications per year. The top ten programs for publication effectiveness were compared to others for interventions chosen. Interventions were characterized as research director, protected time, research requirement, research mentor, curricula, research assistant, biostatistician, information technology support, research fund, pay-for-performance plans, and celebration of accomplishments. Total number of different interventions was not significantly associated with primary outcome (r = 0.20, p = 0.18). When comparing the top ten programs to the others, appointment of a research director was statistically more prevalent in those programs (70% vs. 30%, p = 0.02), while presence of a defined curriculum was more common (90% vs. 57%, p = 0.052) but not statistically significantly. CONCLUSIONS: Leadership interventions (directors, curricula) are associated with successful GME research efforts.

A review and meta-analysis of the nomological network of trainee reactions.

A review and meta-analysis of studies assessing trainee reactions are presented. Results suggest reactions primarily capture characteristics of the training course, but trainee characteristics (e.g., anxiety and pretraining motivation) and organizational support also have a moderate effect on reactions. Instructional style (rho = .66) followed by human interaction (rho = .56) were the best predictors of reactions. Reactions predicted pre-to-post changes in motivation (beta = .51) and self-efficacy (beta = .24) and were more sensitive than affective and cognitive learning outcomes to trainees' perceptions of characteristics of the training course. Moderator analyses revealed reactions- outcomes correlations tended to be stronger in courses that utilized a high level rather than a low level of technology, and affective and utility reactions did not differ in their relationships with learning outcomes. The current study clarifies the nomological network of reactions and specifies outcomes that are theoretically related to reactions.

Cross-sectional anatomy of the bicipital tuberosity and biceps brachii tendon insertion: relevance to anatomic tendon repair.

This study evaluated the insertional anatomy and orientation of the biceps tuberosity and tendon to assess the anatomic validity of repairs made with 1 incision vs 2 incisions. Computed axial tomography was used to image 30 cadaver radii, and each tendon insertion was measured with a digital micrometer. Specimens were sectioned and imaged with Faxitron radiography (Faxitron X-Ray Corp, Wheeling, IL) to determine the angular orientation of the biceps tendon insertion relative to the tuberosity apex. The tuberosity axis of orientation averaged 65 degrees (range, 15 degrees -120 degrees ) of pronation from anterior, with angular orientation encompassing a mean 59 degrees (range, 15 degrees -100 degrees ) arc with the midpoint of the insertion averaging 50 degrees (range, -5 degrees to 105 degrees ). Most biceps tendons inserted on the anterior aspect of the apex of the tuberosity, with an average width of 7 mm and length of 22 mm. The biceps tuberosity is oriented in more pronation than is typically described, prohibiting anatomic reinsertion of the tendon in 35% of specimens with current single-incision techniques.