The Effect of Cautionary Versus Resiliency Spine Education on Maximum Deadlift Performance and Back Beliefs: A Randomized Control Trial.

ABSTRACT: Scott, KM, Kreisel, BR, Florkiewicz, EM, Crowell, MS, Morris, JB, McHenry, PA, and Benedict, TM. The effect of cautionary versus resiliency spine education on maximum deadlift performance and back beliefs: A randomized control trial. J Strength Cond Res 38(7): e341-e348, 2024-The purpose of this study was to determine the effect of cautionary information about the spine vs. a message of spine resiliency on maximum deadlift (MDL) performance and beliefs regarding the vulnerability of the spine. This cluster randomized control trial involved 903 military new cadets (n = 903) during their mandatory fitness test in cadet basic training (mean age 18.3 years, body mass index 23.8 kg·m-2, 22% female). Subjects were cluster randomized to 3 groups. The cautionary group received a message warning them to protect their backs while deadlifting, the resiliency group received a message encouraging confidence while deadlifting, and the control group received the standardized Army deadlift education only. The outcome measures were MDL weight lifted and perceived spine vulnerability. Significance was set at alpha ≤0.05. There were no between-group differences in weight lifted (p=0.40). Most subjects believed that the spine is vulnerable to injury. Three times as many subjects who received the resiliency education improved their beliefs about the vulnerability of their spines compared with those receiving the cautionary education (p<0.001). This study demonstrated the potential for brief resiliency education to positively influence beliefs about spine vulnerability, whereas cautionary education did not impair performance.

Mini All-Suture Anchors for Repairing the Central Slip of the Extensor Tendon at the Proximal Interphalangeal Joint: A Biomechanical Investigation.

PURPOSE: This study evaluated 1.0-mm mini suture anchors for repairing the central slip of the extensor mechanism at the proximal interphalangeal joint. Studies have reported a requirement for central slip fixation to withstand 15 N during postoperative rehabilitation exercises and 59 N during forceful contraction. METHODS: Index and middle fingers from 10 matched pairs of cadaveric hands were prepared with 1.0-mm mini suture anchors with 2-0 sutures or threaded with 2-0 sutures through a bone tunnel (BTP). In total, 10 index fingers from unmatched hands were prepared with suture anchors and fixed to the extensor tendons to evaluate the tendon/suture interface response. Each distal phalanx was secured to a servohydraulic testing machine, and ramped tensile loads were applied to suture or tendon until failure. RESULTS: All anchors for the all-suture bone tests failed because of pullout from the bone (Mean failure force = 52.5+/-17.3 N). Three anchors from the tendon-suture pull out test failed by pullout from the bone and seven failed at the tendon/suture interface (Mean failure force = 49.0+/-10.1 N). CONCLUSIONS: The 1.0-mm mini suture anchor provides enough strength for early short-arc motion, but it may not be adequate for forceful contraction in the early postoperative rehabilitation stage. CLINICAL RELEVANCE: The site of fixation, the type of anchor, and the type of suture used are key factors to consider for early range of motion, after surgery.

Nonmarinum, Nontuberculous Mycobacterial Infections of the Upper Extremity: A Multi-Institutional Descriptive Report.

PURPOSE: We analyzed patient demographic factors involved in the development of nonmarinum, nontuberculous mycobacterial infections (NTMI) involving the upper extremity, and assessed diagnostic and prognostic values of commonly used preoperative laboratory and imaging studies, as well as factors related to recurrence of disease and patient outcomes. METHODS: Patients from 2 academic, tertiary facilities with culture-proven, nonmarinum NTMI involving the upper extremity were reviewed. Patient-related factors and clinical outcomes were extracted. The analysis was based on pathogen identification (rapid- vs slow-growing subspecies) and immune status. RESULTS: Our 76 patients had a mean age of 59 years, and 65% were male. Forty-eight percent reported an injury, and hands were frequently involved (58%). Forty-one percent were immunosuppressed (19% organ transplant recipients). The mean symptom duration prior to presentation was 203 days. The culture identification took a mean of 33 days, with 25 different species identified (subcategorized as rapid or slow growers). Seventy-seven percent had solitary lesions, with a cutaneous or subcutaneous location most common. Immunosuppressed patients were treated longer with antibiotics (243 vs 155 days in immunocompetent patients) and experienced higher rates of side effects, complications, and recurrence. All patients underwent debridement to control infection, including 4 individuals who required amputations. One-third experienced complications and/or recurrence, regardless of the organism type. CONCLUSIONS: Upper-extremity nonmarinum NTMI is often misdiagnosed, causing management delays. Early consideration in differential diagnoses of chronic, painful swelling, nodular or inflammatory lesions, or septic arthritis is crucial. Tissue biopsy with specimens for histopathology and microbiological analysis (mycobacterial smear, cultures, and broad range polymerase chain reaction) and early involvement with an infectious disease specialist are recommended. Empiric antibiotic therapy is not standard. Debridement and prolonged, directed combination antimicrobial therapy is required; however, adverse reactions are commonly encountered. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Evaluating the impact of axillary dissection on recurrence-free survival by extent of nodal disease in invasive lobular carcinoma of the breast.

PURPOSE: Clinical trials have shown that axillary lymph node dissection (ALND) can be avoided for many breast cancer patients with limited nodal involvement. However, whether its omission is safe for those with invasive lobular carcinoma (ILC) is still questioned. We sought to evaluate the impact of ALND on recurrence-free survival (RFS) by extent of nodal disease in patients with ILC. METHODS: We performed a retrospective, cross-sectional analysis of ILC patients treated between 1990 and 2019 at our institution. Patients underwent either breast conservation surgery (BCS) or mastectomy. We used univariate and multivariate statistics in Stata 14.2 to evaluate associations between extent of axillary surgery and time to recurrence stratified by nodal burden. RESULTS: Of 520 cases, 387 (78.4%) were node negative, 74 (14.9%) had 1-2 positive nodes, and 59 (11.4%) had three or more positive nodes. Most patients (93.3%) had hormone receptor-positive disease, and 94.8% had low or intermediate-grade tumors. The rate of ALND significantly decreased over time (p < 0.002). Using a multivariate model, there was no significant difference in RFS estimates based on receipt of ALND (HR = 0.53, 95% CI 0.17-1.64, p = 0.27), which also held true for patients with 1-2 positive nodes using a test of interaction (HR = 0.91, 95% CI 0.12-6.76, p = 0.92). CONCLUSIONS: These findings support the safety of omitting ALND in selected patients with ILC. Further studies of axillary management in ILC and imaging tools to predict nodal involvement and therapeutic response are warranted.

Mitotic score and pleomorphic histology in invasive lobular carcinoma of the breast: impact on disease-free survival.

PURPOSE: Pleomorphic invasive lobular carcinoma (ILC) has long been thought to have worse outcomes than classic ILC and is therefore often treated with chemotherapy. However, recent data question the utility of the pleomorphic designation, as the poor outcomes seen may be related to other associated high-risk features. Importantly, mitotic count may better define a subset of ILC with high risk of recurrence. We sought to determine the impact of pleomorphic histology versus mitotic count on disease-free survival (DFS) in pure ILC. Additionally, we evaluated whether pleomorphic histology was associated with receipt of chemotherapy when adjusting for other factors. METHODS: We analyzed a cohort of 475 patients with stage I-III pure ILC. We used Kaplan-Meier estimates, and Cox proportional hazards and logistic regression for multivariate analyses. Pleomorphic histology was confirmed by central pathology review. RESULTS: In a multivariate model, pleomorphic histology was not associated with reduced DFS. Only mitotic score, receptor subtype, and pathologic stage were independently and significantly associated with DFS. Patients with pleomorphic ILC were significantly more likely to receive chemotherapy than patients with classic ILC (adjusted odds ratio 2.96, p = 0.026). CONCLUSIONS: The pleomorphic designation in ILC does not have clinical utility and should not be used to determine therapy. Rather, mitotic count identified clear prognostic groups in this cohort of pure ILC.

Role of MR Neurography in Groin and Genital Pain: Ilioinguinal, Iliohypogastric, and Genitofemoral Neuralgia.

OBJECTIVE: Chronic neuralgia of the border nerves (ilioinguinal, iliohypogastric, and genitofemoral) is difficult to diagnose and treat clinically. We examined the role of MR neurography (MRN) in the evaluation of border nerve abnormalities and the results of treatments directed at the MRN-detected nerve abnormalities. MATERIALS AND METHODS: This retrospective cross-sectional study included 106 subjects with groin or genital pain (mean [± SD] age, 50.7 ± 15.4 years) who showed mono- or multifocal neuropathy of the border nerves at 3-T MRN. Subjects who underwent CT-guided perineural injection were assessed for pain response. Injection responses were categorized as positive, possible positive, and negative. Subjects who received hyaluronidase, continuous radiofrequency ablation, or surgery were also evaluated for treatment outcomes. RESULTS: One hundred forty abnormal nerves were positive for neuropathy in 106 studies. Eighty of 106 subjects had single neuropathy, and 26 had multifocal neuropathy. Fifty-eight subjects underwent CT-guided perineural injections, with five receiving bilateral injections (63 injections). Improvement in subjective pain was seen in 53 of 63 cases (84.2%). A statistically significant improvement in pain response was noted in the isolated ilioinguinal nerve block group as compared with the isolated genitofemoral nerve block group (p = 0.0085). Thirteen of 58 subjects received multiple nerve injections at the same sitting. Both groups receiving single or multiple nerve injections had similar improvement in pain scores of 84% and 85%, respectively, although this difference was not statistically significant. CONCLUSION: Our retrospective analysis showed improved pain relief in subjects who underwent CT-guided nerve blocks on the basis of a positive MRN.

Remote Assessment of Wrist Range of Motion: Inter- and Intra-Observer Agreement of Provider Estimation and Direct Measurement With Photographs and Tracings.

PURPOSE: Information is limited regarding the validity and reliability of measurements made during remote assessment of wrist range of motion (ROM) motion. We sought to determine intra- and inter-observer agreement among visual estimation, direct goniometric measurement, and patients' self-taken digital photographs and line tracings by comparing the degree differences among measurements. We hypothesized that inter- and intra-observer differences would be less than 10° at least 90% of the time for all measurement modalities. METHODS: Thirty-seven patients were enrolled in this prospective cohort study. Visual estimation immediately followed by direct goniometry of maximal active wrist ROM (extension [E], flexion [F], radial deviation, and ulnar deviation) were independently and blindly assessed by 3 different providers: a hand surgeon, a hand therapist, and an orthopedic resident. Self-taken photographs and line tracings were blindly evaluated 3 weeks later. Intra- and inter-observer agreement was described using the Bland-Altman method. RESULTS: The surgeon and hand therapist observed intra-observer agreement within 10° for visual estimation of all 4 directions of motions greater than 90% of the time, but inter-observer agreement for E/F was lower (76% to 86%). Intra-observer agreement by the resident was within 10° 78% of the time for E/F. Intra-observer agreement for photographs and tracings were lower than visual estimation for all observers. Inter-observer agreement for photographs and tracings was higher than intra-observer agreement. The surgeon and hand therapist agreed within 10° at least 76% of the time, the surgeon and resident agreed within 10° at least 62% of the time, and the hand therapist and resident agreed within 10° at least 54% of the time. CONCLUSIONS: Visual estimation may be a valid method of remote assessment, but compared with goniometry, measurements may be susceptible to observer bias. Self-taken photographs and line tracings are unreliable, perhaps falsely lower owing to submaximal effort from task distraction, and we question their current use for remote assessment of wrist ROM. CLINICAL RELEVANCE: These results represent an initial step in evaluating potential methods of remote assessment of wrist ROM.

Breast Conservation and Negative Margins in Invasive Lobular Carcinoma: The Impact of Oncoplastic Surgery and Shave Margins in 358 Patients.

BACKGROUND: Invasive lobular carcinoma (ILC) of the breast grows in a diffuse pattern, making complete surgical excision difficult. This results in high rates of positive margins and low rates of successful breast-conserving surgery. We hypothesized that utilizing oncoplastic surgical techniques and selective shave margins would be associated with lower positive margin rates and increased breast conservation in women with ILC. METHODS: We performed a retrospective cross-sectional analysis in a large cohort of prospectively collected ILC cases who received surgical treatment at the University of California, San Francisco, between 1992 and 2017. We identified all patients with histologically proven, unilateral or bilateral, stage 1-3 ILC. The primary outcome was positive margin rates, defined as no ink on tumor. RESULTS: We identified 365 tumors in 358 women, with an average age of 61 years, who underwent breast-conserving surgery, and found that the use of oncoplastic techniques (odds ratio [OR] 0.4, 95% confidence interval [CI] 0.21-0.79, p = 0.008) and the selective use of shave margins (OR 0.393, 95% CI 0.22-0.7, p = 0.002) were significantly associated with lower positive margin rates, when adjusted for tumor size and multifocality. The success rate for breast-conservation surgery was 75%, with a 25% conversion rate to mastectomy. CONCLUSIONS: Surgeons should consider routine use of oncoplastic techniques and shave margins when performing breast-conservation surgery for women with ILC as these methods are associated with significantly lower odds of having positive margins and higher breast-conservation rates.

Sleep Loss and Affective Functioning: More Than Just Mood.

Empirical evidence supports an intimate link between sleep and affective functioning. While the bidirectional relationship between sleep duration and mood is well documented, limited research targets other aspects of affective functioning, such as emotion and emotion regulation, or considers their interrelationships. The present review summarizes research examining the relationship between sleep and emotion, emotion regulation, and mood, and presents a theoretical model representing the relationships between these constructs. Disruptions to sleep and mood may trigger and maintain a negative cascade, leading to more entrenched sleep problems and psychopathology. Given that insufficient sleep is a widespread phenomenon, understanding the interrelationships between sleep and affective functioning has implications for both public health and clinical practice.

Pudendal nerve and branch neuropathy: magnetic resonance neurography evaluation.

Pudendal neuralgia is being increasingly recognized as a cause of chronic pelvic pain, which may be related to nerve injury or entrapment. Due to its complex anatomy and branching patterns, the pudendal nerve abnormalities are challenging to illustrate. High resolution 3 T magnetic resonance neurography is a promising technique for the evaluation of peripheral neuropathies. In this article, the authors discuss the normal pudendal nerve anatomy and its variations, technical considerations of pudendal nerve imaging, and highlight the normal and abnormal appearances of the pudendal nerve and its branches with illustrative case examples.

Exercise Interventions to Reduce Cancer-Related Fatigue and Improve Health-Related Quality of Life in Cancer Patients.

Cancer-related fatigue (CRF) is the most common and debilitating side effect of patients receiving treatment of cancer. It is reported that 60% to 100% of patients will develop CRF as a result of the treatment or the cancer itself. The effects last for years posttreatment and lower overall quality of life. The purpose of this integrative review was to determine whether exercise interventions could reduce CRF and improve overall health-related quality of life (HRQOL) among selected cancer patients. Clinical Key, ProQuest Nursing and Allied Health Source, Cochrane Library, Mosby's Nursing Consult, and MEDLINE (Ovid) were the databases searched. Key terms searched were fatigue, exercise, cancer fatigue, holistic, spiritual, quality of life, and prevention. Findings from most studies suggest that exercise can decrease the effects of CRF among cancer patients, leading to an overall improved HRQOL. No negative results on the effects of exercise on CRF were reported. Nurses can be instrumental in developing holistic multidisciplinary exercise programs to assist in the management of CRF and improve HRQOL among cancer patients during and after cancer treatment. Recommendations for future research include the need for larger study sample sizes, a universal definition of fatigue, determination of the best exercise regimens, more consistent fatigue measures to facilitate better comparison across studies, and specifically assess patient improvements in overall mental and spiritual well-being within a holistic framework.

CT-guided Perineural Injections for Chronic Pelvic Pain.

Chronic pelvic pain is a disabling condition that affects a large number of men and women. It may occur after a known inciting event, or it could be idiopathic. A common cause of pelvic pain syndrome is neuropathy of the pelvic nerves, including the femoral and genitofemoral nerves, ilioinguinal and iliohypogastric nerves, pudendal nerve, obturator nerve, lateral and posterior femoral cutaneous nerves, inferior cluneal nerves, inferior rectal nerve, sciatic nerve, superior gluteal nerve, and the spinal nerve roots. Pelvic neuropathy may result from entrapment, trauma, inflammation, or compression or may be iatrogenic, secondary to surgical procedures. Imaging-guided nerve blocks can be used for diagnostic and therapeutic management of pelvic neuropathies. Ultrasonography (US)-guided injections are useful for superficial locations; however, there can be limitations with US, such as its operator dependence, the required skill, and the difficulty in depicting various superficial and deep pelvic nerves. Magnetic resonance (MR) imaging-guided injections are radiation free and lead to easy depiction of the nerve because of the superior soft-tissue contrast; although the expense, the required skill, and the limited availability of MR imaging are major hindrances to its widespread use for this purpose. Computed tomography (CT)-guided injections are becoming popular because of the wide availability of CT scanners, the lower cost, and the shorter amount of time required to perform these injections. This article outlines the technique of perineural injection of major pelvic nerves, illustrates the different target sites with representative case examples, and discusses the pitfalls. (©)RSNA, 2016.

Improving Rural Bone Health and Minimizing Fracture Risk in West Virginia: Validation of the World Health Organization FRAX Assessment Tool as a Phone Survey for Osteoporosis Detection.

West Virginia ranks second nationally in population ≥ 65 years old placing our state at greater risk for osteoporosis and fracture. The gold standard for detecting osteoporosis is dual X-ray absorptiometry (DXA), yet over half of West Virginia's counties do not have this machine. Due to access barriers, a validated phone-administered fracture prediction tool would be beneficial for osteoporosis screening. The World Health Organization's FRAX fracture prediction tool was administered as a phone survey to 45 patients; these results were compared to DXA bone mineral density determination. Results confirmed that the FRAX phone survey is as reliable as DXA in detecting osteoporosis or clinically significant osteopenia: 92% positive predictive value, 100% negative predictive value, 100% sensitivity and 91% specificity when compared to the gold standard. These promising results allow for the development of telephone-based protocols to improve osteoporosis detection, referral and treatment especially in areas with health care access barriers.

SHINKEI--a novel 3D isotropic MR neurography technique: technical advantages over 3DIRTSE-based imaging.

OBJECTIVES: Technical assessment of SHINKEI pulse sequence and conventional 3DIRTSE for LS plexus MR neurography. METHODS: Twenty-one MR neurography examinations of the LS plexus were performed at 3 T, using 1.5-mm isotropic 3DIRTSE and SHINKEI sequences. Images were evaluated for motion and pulsation artefacts, nerve signal-to-noise ratio, contrast-to-noise ratio, nerve-to-fat ratio, muscle-to-fat ratio, fat suppression homogeneity and depiction of LS plexus branches. Paired Student t test was used to assess differences in nerve conspicuity (p < 0.05 was considered statistically significant). ICC correlation was obtained for intraobserver performance. RESULTS: Four examinations were excluded due to prior spine surgery. Bowel motion artefacts, pulsation artefacts, heterogeneous fat saturation and patient motion were seen in 16/17, 0/17, 17/17, 2/17 on 3DIRTSE and 0/17, 0/17, 0/17, 1/17 on SHINKEI. SHINKEI performed better (p < 0.01) for nerve signal-to-noise, contrast-to-noise, nerve-to-fat and muscle-to-fat ratios. 3DIRTSE and SHINKEI showed all LS plexus nerve roots, sciatic and femoral nerves. Smaller branches including obturator, lateral femoral cutaneous and iliohypogastric nerves were seen in 10/17, 5/17, 1/17 on 3DIRTSE and 17/17, 16/17, 7/17 on SHINKEI. Intraobserver reliability was excellent. CONCLUSION: SHINKEI MRN demonstrates homogeneous and superior fat suppression with increased nerve signal- and contrast-to-noise ratios resulting in better conspicuity of smaller LS plexus branches. KEY POINTS: • SHINKEI provides homogeneous and superior fat suppression, shown by higher nerve and muscle-to-fat ratios. • SHINKEI shows better nerve signal-to-noise and contrast-to-noise ratios than 3DIRTSE. • SHINKEI enables nerve-selective images with increased conspicuity of smaller LS plexus branches. • SHINKEI should be considered in routine MR neurography of the LS plexus.

Three-dimensional MR neurography of the lumbosacral plexus.

The lumbosacral (LS) plexus is a complicated network of nerves, and the complex anatomy is resolvable using high-resolution three-dimensional (3D) magnetic resonance neurography. This article focuses on 3D imaging evaluation of the anatomy and the pathology of various LS plexus branch nerves.

Pelvic floor rehabilitation in the treatment of fecal incontinence.

Fecal incontinence (FI) is a prevalent problem that can drastically affect quality of life. Pelvic floor rehabilitation is an important first-line treatment for patients with FI, and many published case reports and a small number of randomized controlled trials (RCTs) provide limited evidence for its efficacy. Pelvic floor rehabilitation approaches to the treatment of FI include pelvic floor muscle training, biofeedback, and volumetric training with rectal balloon catheters. Various forms of external electrical stimulation have also been described and may be of added benefit. Behavioral bowel retraining is an important part of a good rehabilitative approach as well. Pelvic floor rehabilitation treatment for FI is thought to be effective and safe, with reported success rates in a majority of studies at 50 to 80%. Many more high-quality RCTs are needed to define optimal treatment protocols.

Electrical Stimulation Use in Upper Extremity Peripheral Nerve Injuries.

Peripheral nerve injuries can be debilitating and often have a variable course of recovery. Electrical stimulation (ES) has been used as an intervention to attempt to overcome the limits of peripheral nerve surgery and improve patient outcomes after peripheral nerve injury. Little has been written in the orthopaedic literature regarding the use of this technology. The purpose of this review was to provide a focused analysis of past and current literature surrounding the utilization of ES in the treatment of various upper extremity peripheral nerve pathologies including compression neuropathies and nerve transection. We aimed to provide clarity on the clinical benefits, appropriate timing for its employment, risks and limitations, and the need for future studies of ES.

Avoiding articular breakthrough in screw fixation of radial head fractures.

Background: The radial head is anatomically complex, making fracture fixation challenging because of the difficult visualization of the articular surface. As a result, screw penetration into the radiocapitellar joint can often occur. To facilitate safe placement of screws tangential to the joint surface, we define an approximate and reliable distance from the articular rim of the radial head that can minimize the risk of articular breach. Methods: A Kirschner wire for cannulated drilling was placed tangential to the articular surface in 15 cadaveric proximal radii. The distance from the wire to the articular rim was measured 3 times. After insertion of a 3.5-mm compression screw, the radial head was divided in the coronal plane, bisecting the screw track, to visualize the cross section of the screw's position. Headless compression screws of 3.5 mm were placed the distance from the most proximal edge of the screw track to the radial head's articular surface was measured 3 times. Results: The average distance from the articular rim to the distal surface of the Kirschner wire was 5.1 mm. The average distance from the articular rim to the proximal edge of the cavity was 1.7 mm. The screw placement was subchondral and extra-articular in all cases. Conclusion: When fixing Mason type 2 articular radial head fractures with 3.5-mm headless compression screws placed tangential to the articular surface, maintaining a screw entry point about 5 mm distal to the articular surface of the radial head will minimize the possibility of articular screw breach. This position also places the screw into subchondral bone, providing the best bone quality for mechanical support.