Tumoral calcinosis of the knee treated with open, physeal sparing iliotibial band ACL reconstruction.

Tumoral calcinosis is a hereditary disease of calcium and phosphate metabolism causing peri-articular tumors of calcium deposits. We present a case of tumoral calcinosis in a 13-year-old male with a history of a 12q13.11 genetic deletion. Surgical resection of the tumor necessitated resection of the ACL in its entirety with curettage and adjuvant therapy to the lateral femoral notch, which resulted in ligamentous instability and bony structural incompetency at the femoral insertion. Given the patient's radiographically-apparent skeletal immaturity, and lack of reliable bony architecture to accommodate a femoral ACL tunnel, ACL reconstruction was performed using a physeal-sparing technique. This is a case of tumoral calcinosis treated with, to our knowledge, the first ACL reconstruction using this modified open technique.

Popular interventions to enhance sustained attention in children and adolescents: A critical systematic review.

There are a myriad of interventions promoting activities designed to help enhance sustained attention in children and adolescents. In this systematic review, we critically evaluate the evidence behind three popular sustained attention training approaches - cognitive attention training, meditation, and physical activity. Seven databases were searched in addition to secondary searches. Cognitive attention training, meditation training or physical activity intervention studies aimed at improving sustained attention (randomised-controlled or non-randomised-controlled designs) in samples of children and adolescents (3-18 years) were included. We screened 3437 unique articles. Thirty-seven studies satisfied inclusion criteria. In general, cognitive attention training (n = 14) did not reliably improve sustained attention. Physical activity (n = 15) and meditation interventions (n = 8) demonstrated somewhat more potential in enhancing sustained attention, but these effects should be considered preliminary and need to be replicated with greater methodological rigour. Cognitive attention training demonstrated very limited transfer to other aspects of attention. Notably, mindfulness training had rather consistent positive effects on selective attention. Across all three intervention types, there was very weak evidence for transfer to other aspects of cognition, behaviour, and academic achievement. The paper concludes with methodological recommendations for future studies to strengthen the evidence base.

Interorgan Metabolism of Amino Acids in Human Health and Disease.

Amino acids are integral for human health, influencing an array of physiological processes from gene expression to vasodilation to the immune response. In accordance with this expansive range of unique functions, the tissues of the body engage in a complex interplay of amino acid exchange and metabolism to respond to the organism's dynamic needs for a range of nitrogenous products. Interorgan amino acid metabolism is required for numerous metabolic pathways, including the synthesis of functional amino acids like arginine, glutamate, glutamine, and glycine. This physiological process requires the cooperative handling of amino acids by organs (e.g., the small intestine, skeletal muscle, kidneys, and liver), as well as the complete catabolism of nutritionally essential amino acids such as the BCAAs, with their α-ketoacids shuttled from muscle to liver. These exchanges are made possible by several mechanisms, including organ location, as well as the functional zonation of enzymes and the cell-specific expression of amino acid transporters. The cooperative handling of amino acids between the various organs does not appear to be under the control of any centralized regulation, but is instead influenced by factors such as fluctuations in nutrient availability, hormones, changes associated with development, and altered environmental factors. While the normal function of these pathways is associated with health and homeostasis, affected by physical activity, diet and body composition, dysregulation is observed in numerous disease states, including cardiovascular disease and cancer cachexia, presenting potential avenues for the manipulation of amino acid consumption as part of the therapeutic approach to these conditions in individuals.

Use of repurposed and adjuvant drugs in hospital patients with covid-19: multinational network cohort study.

OBJECTIVE: To investigate the use of repurposed and adjuvant drugs in patients admitted to hospital with covid-19 across three continents. DESIGN: Multinational network cohort study. SETTING: Hospital electronic health records from the United States, Spain, and China, and nationwide claims data from South Korea. PARTICIPANTS: 303 264 patients admitted to hospital with covid-19 from January 2020 to December 2020. MAIN OUTCOME MEASURES: Prescriptions or dispensations of any drug on or 30 days after the date of hospital admission for covid-19. RESULTS: Of the 303 264 patients included, 290 131 were from the US, 7599 from South Korea, 5230 from Spain, and 304 from China. 3455 drugs were identified. Common repurposed drugs were hydroxychloroquine (used in from <5 (<2%) patients in China to 2165 (85.1%) in Spain), azithromycin (from 15 (4.9%) in China to 1473 (57.9%) in Spain), combined lopinavir and ritonavir (from 156 (<2%) in the VA-OMOP US to 2,652 (34.9%) in South Korea and 1285 (50.5%) in Spain), and umifenovir (0% in the US, South Korea, and Spain and 238 (78.3%) in China). Use of adjunctive drugs varied greatly, with the five most used treatments being enoxaparin, fluoroquinolones, ceftriaxone, vitamin D, and corticosteroids. Hydroxychloroquine use increased rapidly from March to April 2020 but declined steeply in May to June and remained low for the rest of the year. The use of dexamethasone and corticosteroids increased steadily during 2020. CONCLUSIONS: Multiple drugs were used in the first few months of the covid-19 pandemic, with substantial geographical and temporal variation. Hydroxychloroquine, azithromycin, lopinavir-ritonavir, and umifenovir (in China only) were the most prescribed repurposed drugs. Antithrombotics, antibiotics, H2 receptor antagonists, and corticosteroids were often used as adjunctive treatments. Research is needed on the comparative risk and benefit of these treatments in the management of covid-19.

The potential of dietary treatment in patients with glycogen storage disease type IV.

There is paucity of literature on dietary treatment in glycogen storage disease (GSD) type IV and formal guidelines are not available. Traditionally, liver transplantation was considered the only treatment option for GSD IV. In light of the success of dietary treatment for the other hepatic forms of GSD, we have initiated this observational study to assess the outcomes of medical diets, which limit the accumulation of glycogen. Clinical, dietary, laboratory, and imaging data for 15 GSD IV patients from three centres are presented. Medical diets may have the potential to delay or prevent liver transplantation, improve growth and normalize serum aminotransferases. Individual care plans aim to avoid both hyperglycaemia, hypoglycaemia and/or hyperketosis, to minimize glycogen accumulation and catabolism, respectively. Multidisciplinary monitoring includes balancing between traditional markers of metabolic control (ie, growth, liver size, serum aminotransferases, glucose homeostasis, lactate, and ketones), liver function (ie, synthesis, bile flow and detoxification of protein), and symptoms and signs of portal hypertension.

The Society for Vascular Surgery Alternative Payment Model Task Force report on opportunities for value-based reimbursement in care for patients with peripheral artery disease.

The Society for Vascular Surgery Alternative Payment Model (APM) Taskforce document explores the drivers and implications for developing objective value-based reimbursement plans for the care of patients with peripheral arterial disease (PAD). The APM is a payment approach that highlights high-quality and cost-efficient care and is a financially incentivized pathway for participation in the Quality Payment Program, which aims to replace the traditional fee-for-service payment method. At present, the participation of vascular specialists in APMs is hampered owing to the absence of dedicated models. The increasing prevalence of PAD diagnosis, technological advances in therapeutic devices, and the increasing cost of care of the affected patients have financial consequences on care delivery models and population health. The document summarizes the existing measurement methods of cost, care processes, and outcomes using payor data, patient-reported outcomes, and registry participation. The document also evaluates the existing challenges in the evaluation of PAD care, including intervention overuse, treatment disparities, varied clinical presentations, and the effects of multiple comorbid conditions on the cost potentially attributable to the vascular interventionalist. Medicare reimbursement data analysis also confirmed the prolonged need for additional healthcare services after vascular interventions. The Society for Vascular Surgery proposes that a PAD APM should provide patients with comprehensive care using a longitudinal approach with integration of multiple key medical and surgical services. It should maintain appropriate access to diagnostic and therapeutic advancements and eliminate unnecessary interventions. It should also decrease the variability in care but must also consider the varying complexity of the presenting PAD conditions. Enhanced quality of care and physician innovation should be rewarded. In addition, provisions should be present within an APM for high-risk patients who carry the risk of exclusion from care because of the naturally associated high costs. Although the document demonstrates clear opportunities for quality improvement and cost savings in PAD care, continued PAD APM development requires the assessment of more granular data for accurate risk adjustment, in addition to largescale testing before public release. Collaboration between payors and physician specialty societies remains key.

Using high-resolution residential greenspace measures in an urban environment to assess risks of allergy outcomes in children.

Despite reported health benefits of urban greenspace (gs), the epidemiological evidence is less clear for allergic disease. To address a limitation of previous research, we examined the associations of medium- and high-resolution residential gs measures and tree and/or grass canopies with allergic outcomes for children enrolled in the longitudinal cincinnati childhood allergy and air pollution study (ccaaps). We estimated residential gs based on 400 m radial buffers around participant addresses (n = 478) using the normalized differential vegetation index (ndvi) and land cover-derived urban greenspace (ugs) (tree and grass coverage, combined and separate) at 30 m and 1.5-2.5 m resolution, respectively. Associations between outdoor aeroallergen sensitization and allergic rhinitis at age 7 and residential gs measures at different exposure windows were examined using multivariable logistic regression models. A 10% increase in ugs-derived grass coverage was associated with an increased risk of sensitization to grass pollens (adjusted odds ratio [aor]: 1.27; 95% confidence interval = 1.02-1.58). For each 10% increase in ugs-derived tree canopy coverage, nonstatistically significant decreased odds were found for grass pollen sensitization, tree pollen sensitization, and sensitization to either (aor range = 0.87-0.94). Results similar in magnitude to ugs-tree canopy coverage were detected for ndvi and allergic sensitizations. High-resolution (down to 1.5 m) gs measures of grass- and tree-covered areas showed associations in opposite directions for different allergy outcomes. These data suggest that measures strongly correlated with tree canopy (e.g., ndvi) may be insufficient to detect health effects associated with proximity to different types of vegetation or help elucidate mechanisms related to specific gs exposure pathways.

Proof of concept: Exposing the myth of urethral atrophy after artificial urinary sphincter via assessment of circumferential recovery after capsulotomy and intraoperative pressure profiling of the pressure regulating balloon.

Purpose: Rate of continence after artificial urinary sphincter (AUS) placement appears to decline with time. After appropriate workup to exclude inadvertent device deactivation, development of urge or overflow incontinence, and fluid loss, many assume recurrent stress urinary incontinence (rSUI) to be secondary to nonmechanical failure, asserting urethral atrophy as the etiology. We aimed to characterize the extent of circumferential urethral recovery following capsulotomy and that of pressure regulating balloon (PRB) material fatigue in men undergoing AUS revision for rSUI. Materials and Methods: Retrospective review of a single surgeon database was performed. Cases of AUS removal/replacement for rSUI involving ventral subcuff capsulotomy and intraoperative PRB pressure profile assessments were identified. Results: The described operative approach involving capsulotomy was applied in 7 patients from November 2015 to September 2017. Mean patient age was 75 years. Mean time between AUS placement and revision was 103 months. Urethral circumference increased in all patients after capsulotomy (mean increase 1.1 cm; range 0.5-2.5 cm). Cuff size increased, remained the same, and decreased in 2, 3, and 2 patients, respectively. Six of 7 patients underwent PRB interrogation. Four of these 6 PRBs (66.7%) demonstrated pressures in a category below the reported range of the original manufacturer rating. Conclusions: Despite visual appearance to suggest urethral atrophy, subcuff capsulotomy results in increased urethral circumference in all patients. Furthermore, intraoperative PRB profiling demonstrates material fatigue. Future multicenter efforts are warranted to determine if capsulotomy, with or without PRB replacement, may simplify surgical management of rSUI with reductions in cost and/or morbidity.

Retrograde autologous prime with shortened bypass circuits decreases blood transfusion in high-risk coronary artery surgery patients.

Previous studies have shown that minimizing the amount of hemodilution during open-heart surgery reduces the need for a blood transfusion. Transfusion increases a patient's medical risks and leads to increased costs. We used a shortened bypass circuit, primed with autologous blood in a retrograde fashion, to decrease red cell transfusion in high-risk patients. One hundred twenty-three patients having first-time, nonemergent coronary artery surgery were chosen for this trial, based on their low prebypass hematocrit and weight. In seventy-two cases, we used a shortened bypass circuit and retrograde autologous prime. A historical control group of fifty-one patients received a standard bypass circuit and prime method. The prebypass hematocrit was 35 +/- 2.62% and 34 +/- 2.99% in the control and study groups, respectively. Red blood cell transfusion was necessary in 70% of the control group during their hospital stay, whereas only 51.4% of the study group required transfusion (p = .006). Patients receiving no blood products were significantly higher in the study group, 48.6% vs. 30.0% (p = .005). The postbypass hematocrit was similar at 26.5 +/- 1.82% vs. 25.5 +/- 2.38%, and the discharge hematocrit was 30.8 +/- 3.33% and 31.2 +/- 3.04% in the control and study groups. respectively. Minimizing hemodilution by shortening the bypass circuit and performing retrograde autologous prime conserves the use of blood during routine coronary artery bypass surgery. These methods can be used for patients who are at greater risk for transfusion.