YouTube provides poor information regarding anterior cruciate ligament injury and reconstruction.

PURPOSE: YouTube is a global medium used predominantly by young adults (aged 18-49 years). This study examined the quality of YouTube information regarding ACL injury and reconstruction. METHODS: YouTube was searched on the 13th of June 2015 for "ACL" and "anterior cruciate ligament" with/without associated terms of "injury", "reconstruction", and "surgery". Videos were evaluated by two independent reviewers [EF (Reviewer 1), (Reviewer 2)] using two recognized information scoring systems (Modified DISCERN (MD) 0-5 and JAMA Benchmark 0-4) and an adaptation of a score designed for written ACL information [ACL Specific Score (ASS) 0-25]. The ASS categorized scores as very good (21-25), good (16-20), moderate (11-15), poor (6-10), and very poor (0-5). Number of views/likes/dislikes, animation, and continent of origin and source (e.g., corporate/educational) were recorded. Correlation of video characteristics with number of views was examined using the analysis of variance (ANOVA) model. Agreement between reviewers was assessed by Interclass Correlation Co-efficient (ICC). RESULTS: Following a filtering process of the 964,770 identified videos, 39 videos were retained. The mean MD score was 2.3 (standard deviation (SD) ±0.9) for Reviewer 1 and 2.2 (SD ±0.9) for Reviewer 2 (ICC = 0.7). The mean JAMA score was 2.5(SD ±0.7) for Reviewer 1 and 2.3 (SD ±0.7) for Reviewer 2 (ICC = 0.8). The mean ASS was 6.3 (SD ±3.5) for Reviewer 1 and 4.6 (SD ±2.9) for Reviewer 2 (ICC = 0.9). Five videos achieved moderate score (13%), while 15 (38%) and 19 (49%) scored as poor and very poor, respectively. There was no correlation between number of views and video quality/video source for any scoring system. CONCLUSION: The majority of videos viewed on YouTube regarding ACL injury and treatment are of low quality.

Medical record weight (MRW): a new reliable predictor of hospital stay, morbidity and mortality in the hip fracture population?

We sought to compare the weight of patient's medical records (MRW) to that of standardised surgical risk scoring systems in predicting postoperative hospital stay, morbidity, and mortality in patients with hip fracture. Patients admitted for surgical treatment of a newly diagnosed hip fracture over a 3-month period were enrolled. Patients with documented morbidity or mortality had significantly heavier medical records. The MRW was equivalent to the age-adjusted Charlson co-morbidity index and better than the American Society of Anaesthesiologists physical status score (ASA), the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM,) and Portsmouth-POSSUM score (P-POSSUM) in correlation with length of hospital admission, p = .003, 95% CI [.15 to .65]. Using logistic regression analysis MRW was as good as, if not better, than the other scoring systems at predicting postoperative morbidity and 90-day mortality. Medical record weight is as good as, or better than, validated surgical risk scoring methods. Larger, multicentre studies are required to validate its use as a surgical risk prediction tool, and it may in future be supplanted by a digital measure of electronic record size. Given its ease of use and low cost, it could easily be used in trauma units globally.

Congenital-infantile fibrosarcoma of the foot--avoidance of amputation.

Congenital-infantile fibrosarcoma is a rare entity with a five year survival rate of over 90%. Surgery is still the most common treatment modality with amputation often necessary. There have been reports supporting the use of neoadjuvant chemotherapy to debulk the tumour in an effort to facilitate limb sparing surgery. We report a case of a newborn who presented with a life threatening haemorrhage from a fibrosarcoma of the foot, successfully treated with Vincristine, Actinomycin and Cyclophosphamide (VAC) chemotherapy alone.

In vitro assessment of human chondrocyte viability after treatment with local anaesthetic, magnesium sulphate or normal saline.

PURPOSE: Local anaesthetic agents are often used as an intra-articular analgesic following arthroscopic procedures. However, there is increasing evidence of a potential toxic effect to chondrocytes within the articular cartilage. The aim of this study was to compare the effect on human chondrocyte viability of treatment with bupivacaine, levobupivacaine and ropivacaine. The second aim was to compare the effect on chondrocyte viability of the local anaesthetics with magnesium, a potential alternative analgesic agent. METHODS: Chondrocytes were exposed to one of the local anaesthetic agents (levobupivacaine 0.13, 0.25, 0.5%; bupivacaine 0.13, 0.25, 0.5%; ropivacaine 0.19, 0.38, 0.75%), normal saline or 10% magnesium sulphate for 15 min. Cells exposed to cell culture media served as controls. Twenty-four hours after exposure, cell viability was assessed using the CellTiter 96® AQueous One Solution Cell Proliferation Assay. RESULTS: There was no significant difference in chondrocyte viability after treatment with either normal saline or magnesium sulphate. With the exception of 0.13% levobupivacine, all local anaesthetic treatment showed significantly greater toxic effects than either normal saline or magnesium sulphate. Statistically significant dose-dependent responses of decreasing cell viability were found with increasing local anaesthetic concentration. CONCLUSIONS: A dose-dependent reduction in chondrocyte viability after treatment with common local anaesthetic agents was confirmed. Local anaesthetic agents had a greater deleterious effect on chondrocytes than did 10% magnesium sulphate. These findings suggest the need for continuing caution with the use of intra-articular local anaesthetic. Magnesium sulphate is a potential alternative intra-articular analgesic agent.

Update on gout and hyperuricemia.

There have been recent advances in the understanding of underlying mechanisms and treatment of gout and chronic hyperuricemia, making this an important time to review the current state of the disease. The goal of this article is to provide a practical review of the current standard of care as well as discuss some new developments in the management. There is an increasing prevalence of gout and hyperuricemia worldwide. Gout confers a significant individual and societal burden and is often under-treated. Appropriate diagnosis and treatment of acute gout should be followed by aggressive and goal-oriented treatment of hyperuricemia and other risk factors. Allopurinol remains as a first-line treatment for chronic hyperuricemia, but uricosuric agents may also be considered in some patients. Febuxostat, a non-purine xanthine-oxidase inhibitor, is a new agent approved for the treatment of hyperuricemia in patients with gout, which may be used when allopurinol is contraindicated. Gout and hyperuricemia appear to be independent risk factors for incident hypertension, renal disease and cardiovascular disease. Physicians should consider cardiovascular risk factors in patients with gout and treat them appropriately and aggressively.

Femoro-acetabular impingement and hip pain with conventionally normal x-rays.

There has in recent years been a fundamental change in the understanding of hip pain in the young adult and hip pain without plain radiographic findings of arthritis. Pain in these groups has long represented a diagnostic and therapeutic challenge. With new appreciation of hip biomechanics, pathological processes and the arrival of modern imaging modalities we now have a greater understanding of non-arthritic hip pathology. One of the commonest yet least well recognized 'new' diagnoses around the hip is femoro-acetabular impingement (FAI). FAI is a developmental condition of the hip joint that is associated with abnormal anatomical configuration and thus joint mechanics on either the femoral or acetabular sides or both. It is hypothesized to have a variety of precipitants and may ultimately lead to labral and chondral injury and what has previously been referred to as 'primary' or 'idiopathic' hip osteoarthritis.

The management and outcome of lateral process fracture of the talus.

BACKGROUND: Lateral process fractures of the talus are a rare injury with significant associated morbidity when missed. Only a small number of case series' and reports are available and the appropriate management of these fractures is not really known. METHODS: We reviewed available English language literature for reports and series of lateral process fractures of talus. Only papers in which the classification of fracture, management and outcome were clear were included in our analyses. RESULTS: 109 Cases in total were identified including four cases from a personal series. 50 Type I, 17 type II and 29 type III fractures were analysed. A significant number of patients required late surgery when the diagnosis was initially missed. CONCLUSION: Type I fractures are best treated with ORIF, type II with excision and type III with casting. Fractures presenting late that are not united should be excised if small and internally fixed if large.

Coexistence of oligo-articular gout and Mycobacterium kansasii joint and bursal infection in a patient with an orthotopic heart transplant.

Mycobacterium kansasii septic arthritis is rare, most often occurring in immunosuppressed patients including those with organ transplants. We present a case of oligoarticular M. kansasii infection in bilateral ankles, knee, and bilateral olecranon bursae in coexistence with tophaceous gouty arthropathy in a heart transplant patient. There are no reports of M. kansasii infection occurring in joints also affected by tophaceous gout. We contend that gouty arthropathy may alter the joint in such a way as to increase the risk of development of this infection in patients already at risk. In transplant patients presenting with a history and pattern of arthritis consistent with gout, a sufficient level of suspicion should be maintained for this infectious complication, even if monosodium urate crystals are seen on joint aspiration.

The effect of body mass index on outcomes after total ankle replacement.

Total ankle replacement is an established alternative to ankle fusion in selected patients. One of the possible exclusions used is the presence of a high BMI. This is based on our experience with hip and knee replacements where poor outcomes have been associated with obesity, however little work has been done on this subject in the ankle. We report the first series solely focussing on the impact of BMI on TAR. Forty five consecutive patients were identified and followed up using the SF-36 and VAS-FA. All patients had their BMI collected prospectively and BMI at latest follow-up was calculated. There was an average 5-year follow-up with just 9 (20%) lost to follow-up. At final follow-up 8 (17.7%) patients were deceased, none of the deaths were attributable to their previous ankle surgery. We did not find an association between high BMI and reduced outcomes or need for secondary surgery. In addition there was no significant change in BMI after surgery.

Post-traumatic stress disorder and serum cytokine and chemokine concentrations in patients with rheumatoid arthritis✰.

OBJECTIVE: Although post-traumatic stress disorder (PTSD) is identified as a risk factor in the development of rheumatoid arthritis (RA), associations of PTSD with disease progression are less clear. To explore whether PTSD might influence disease-related measures of systemic inflammation in RA, we compared serum cytokine/chemokine (cytokine) concentrations in RA patients with and without PTSD. METHODS: Participants were U.S. Veterans with RA and were categorized as having PTSD, other forms of depression/anxiety, or neither based on administrative diagnostic codes. Multiplex cytokines were measured using banked serum. Associations of PTSD with cytokine parameters (including a weighted cytokine score) were assessed using multivariable regression, stratified by anti-CCP status and adjusted for age, sex, race, and smoking status. RESULTS: Among 1,460 RA subjects with mean (SD) age of 64 (11) years and disease duration of 11 (11) years, 91% were male, 77% anti-CCP positive, and 80% ever smokers. Of these, 11.6% had PTSD, 23.7% other depression/anxiety, and 64.7% had neither. PTSD, but not depression/anxiety, was associated with a higher cytokine score and number of high-concentration analytes in adjusted models, though this was limited to anti-CCP positive subjects. PTSD was associated with heightened expression of several individual cytokines including IL-1ß, IL-2, IL-4, IL-5, IL-6, IL-7, IL-10, IL-12, IL-17, IFN-γ, GM-CSF, MCP-1, and TNF-α. CONCLUSION: Anti-CCP positive RA patients with PTSD have higher serum cytokine concentrations than those without PTSD, demonstrating that systemic inflammation characteristic of RA is heightened in the context of this relatively common psychiatric comorbidity.

Diathermy awareness among surgeons-An analysis in Ireland.

INTRODUCTION: Diathermy is an integral part of many modern surgical procedures. While diathermy is generally accepted as 'safe', electrosurgery-induced injuries are among the more common causes for malpractice litigation. The purpose of this study was to evaluate the awareness among surgeons of the principles, risks, precautions and appropriate use of diathermy. METHODS: All surgeons employed from Senior House Officer (SHO) to Consultant grade in two teaching hospitals were surveyed. Sixty-three surgeons were asked to complete an anonymous questionnaire, which recorded level of training and addressed competence in principles, hazards, and precautions to be taken with diathermy. RESULTS: Eight Consultants, 5 Specialist Registrars, 19 Registrars and 13 SHO's responded (71% response). All but three subspecialties were represented. Eighty-two percent (37/45) had no formal diathermy training. Despite 89% (40/45) of surgeons regarding diathermy as a safe instrument, 56% felt they had inadequate understanding of the principles and failed to demonstrate an appropriate awareness of the potential risks. Fifty seven percent exhibited a dangerous lack of awareness in managing equipment not yielding the desired effect and 22% were unaware of any patient groups requiring special caution. Only 42% wanted formal training. CONCLUSION: Our results show a dearth of awareness among surgeons regarding diathermy. Given our findings, we urge a shift in attitude towards diathermy, with surgeons adopting a more cautious and safe approach to diathermy use. We recommend that formal training be introduced as a hospital based initiative.

Chronic recording of the vestibulo-ocular reflex in the restrained rat using a permanently implanted scleral search coil.

A technique is described which allows accurate long-term monitoring of eye movements in the rat using permanently implanted scleral search coils. Search coils permanently sutured around the sclera yield vestibulo-ocular reflex (VOR) gain and phase values which are comparable to those reported previously in the literature using acutely implanted coils or electrooculographic electrodes. Considerations related to strain, sex and surgical procedures which permit measurement of responses in the chronically restrained rat are described. VOR gain and phase show a time course to their recovery following the implant surgery, with asymptotic performance typically attained approximately 10 days post-surgically. This technique, with the ability to monitor eye movements over weeks to months, appears ideal for development of rodent models of reflex adaptation which require observation of reflex behavior over extended periods of time. Development of a chronic procedure for monitoring eye movement in rodents is especially important given their initial response to restraint (extensive struggling). Finally, adaptation of this technique to smaller species (e.g., mouse) appears technically feasible which should permit the application of transgenic and knockout techniques to the determination of various vestibular reflex functions requiring long-term monitoring.

Processing of spatial information by floccular and non-floccular target neurons in the alert cat.

In five alert chronically-prepared cats we studied the response to sinusoidal 3-D whole body rotation of well-isolated vestibular nucleus neurons which were tested for monosynaptic input from the vestibular labyrinth, direct projection to the oculomotor nucleus and, in some cases, inhibition from cerebellar flocculus stimulation. Neurons directly inhibited by flocculus stimulation had significantly greater horizontal-vertical semicircular canal signal convergence than did neurons not inhibited by flocculus stimulation.

Effects of optokinetic velocity and medial vestibulo-cerebellum lesions on vestibulo-ocular reflex direction adaptation in the cat.

Adaptive horizontal vestibulo-ocular reflex eye movements in response to vertical (pitch) rotations were produced by exposing three cats to synchronized horizontal optokinetic and vertical vestibular oscillations at 0.25 Hz. The effects of optokinetic stimulus velocity (6-80 degrees/s peak) and nodulo-uvular cerebellum lesions were studied. All optokinetic velocities elicited vestibulo-ocular reflex direction adaptation. though 6 degrees/s stimuli were somewhat less effective. Restricted aspirations of cerebellar vermis lobules IX and X in two cats resulted in reduced but still clearly evident adaptation.

Direction-specific adaptation in area MT of the owl monkey.

Single neurons were recorded in owl monkey middle temporal visual cortex (MT). Directional neurons showed direction-selective adaptation to pattern motion: responses to motion in the preferred direction were reduced by adaptation to motion in the preferred direction and enhanced by adaptation in the opposite direction. Non-directional neurons did not show significant adaptation.

Frequency dependence of cat vestibulo-ocular reflex direction adaptation: single frequency and multifrequency rotations.

Vertical and horizontal vestibulo-ocular reflex (VOR) eye movements were recorded in alert cats during horizontal rotation in total darkness before and after a 2 h vestibulo-ocular reflex direction adaptation procedure. Adaptation stimuli were whole body horizontal vestibular rotation coupled to synchronous vertical optokinetic motion. The waveform of the adaptation stimuli was either a sinusoid at 0.05, 0.1, 0.25, 0.5, or 1 Hz, or a sum of sinusoids containing 0.2, 0.3, 0.5, 0.7, 1.1, and 1.7 Hz. Exposure to single frequency stimuli produced adaptive vertical VOR with a gain that was greatest near the training frequency; adaptive VOR phases were advanced below, accurate at, and lagged above the training frequency. Exposure to the multifrequency waveform produced a uniform modest increase in gain across frequencies, with accurate adaptive VOR phase.

Dynamics of adaptive change in vestibulo-ocular reflex direction. I. Rotations in the horizontal plane.

Horizontal and vertical vestibulo-ocular reflex (VOR) eye movements were recorded in alert cats before and after adaptation to vertical optokinetic motion coupled with horizontal rotation at 0.05, 0.25 or 1.0 Hz. Within 15-30 min, the VOR measured in darkness acquired a vertical component; the maximal directional change in the VOR occurred at the frequency of the adapting stimulus. At other frequencies the gain was less and there were phase leads or lags for higher or lower frequencies, respectively. Adaptive VOR was stable for at least 14 h in unrestrained animals with no visual input and decayed within 30 min during rotation in a stationary visual world.

Changes in sensitivity of vestibular nucleus neurons induced by cross-axis adaptation of the vestibulo-ocular reflex in the cat.

In alert, chronically-prepared cats, we studied response characteristics of well-isolated vestibular nucleus neurons (n = 9) while pairing yaw rotation with a pitch optokinetic stimulus, resulting in cross-axis adaptation of the horizontal vestibulo-ocular reflex. Each neuron's sensitivity to whole body rotation in a variety of axes in three-dimensional space was determined. When tested in darkness following adaptation, neurons showed statistically significant increases in sensitivity to yaw but not vertical plane rotations, suggesting participation in reflex plasticity.

Preferred axis of rotation of floccular Purkinje cells in the decerebrate cat.

Responses of 35 Purkinje cells in decerebrate cats were recorded during 0.5 Hz rotations in 4-11 vertical planes and the horizontal plane to determine their semicircular canal input. Most neurons received convergent input from two canals (21 neurons) or 3 canals (5 neurons). Few Purkinje cells were maximally sensitive to rotations about an axis appropriate to their inferior olivary input as determined by Gerrits and Voogd [15,24,27,49].