Resident Performance on the Fundamentals of Arthroscopic Surgery Training (FAST) Workstation Does Not Predictably Improve With Postgraduate Year.

Purpose: To identify differences in performance on the Fundamentals of Arthroscopic Surgery Training (FAST) workstation between residents across different postgraduate years and training sites. Methods: During the 2018-2019 academic year, 102 orthopaedic surgery residents from 4 training sites completed 6 FAST modules. Failure was defined as either completion time exceeding benchmark time or commission of task-specific errors. With the exception of knot tying, each module was completed by participants twice-once with each hand serving as the camera hand. Time to completion (except for knot tying) and errors were recorded for each of the modules. Completion times and failure rates were compared between postgraduate years, seniority groups, and training sites. Results: In all modules for which time was recorded, except for the suture-passage module, there was no significant difference in time to completion based on seniority (P < .01 for suture passage and P > .05 for all others). Significant differences in completion time were observed between sites for all modules except for the suture-passage module (P = .957 for suture passage and P < .05 for all others). Site predicted failure by at least 1 measure (time or technical error) for all modules (P < .05) except for number probing and suture passage. Failure rate across training years varied for each module. Conclusions: Time to completion and rate of failure did not predictably decrease with level of training. Training site proved to be a significant predictor of performance. Factors such as hand dominance and familiarity with the equipment proved to be important considerations for some modules. Clinical Relevance: Objective assessment of arthroscopic skills among orthopaedic trainees is difficult. Using reproducible methodology to assess trainees on specific skills at all postgraduate years and at multiple training sites may provide important information about orthopaedic training.

[Sleep disorders and fatigue in patients with different forms of myotonic dystrophy type 1]. / Narusheniya sna i utomlyaemost' u patsientov s raznymi formami miotonicheskoi distrofii 1-go tipa.

OBJECTIVE: To characterize sleep disorders in children and adults with different forms of myotonic dystrophy type 1 (DM1), to assess their impact on cognitive functions, excessive daytime sleepiness (EDS) and fatigue, to determine the relationship of EDS, fatigue, and sleep disorders with the quality of life of patients. MATERIAL AND METHODS: The study included 48 adults and 9 children with confirmed DM1. Patients underwent an assessment of clinical and anamnestic data, neurological, cognitive status, severity of EDS, fatigue, quality of life according to international scales and questionnaires. Polysomnography was performed to identify sleep disorders. RESULTS: Obstructive sleep apnea syndrome (OSAS) was found in 78% of children and 79.2% of adults. The severity of OSAS in adults, in contrast to children, was influenced by obesity (p<0.001), the severity of muscle weakness (p=0.033), especially the neck muscles (p=0.018). In patients with OSAS and nocturnal hypoxemia, an increase in the duration of the 1st stage of sleep (p=0.008) and in the microactivation index (p=0.005) was revealed. EDS and fatigue were present in 31 (64.6%) and 34 (70.8%) adults, respectively, in 9 (18.8%) they emerged at the onset of the disease. The greater severity of muscle symptoms, anxiety, depression contributed to increased fatigue in adults and the presence of obesity and type 2 diabetes mellitus contributed to EDS. Increased fatigue affects the quality of life to a greater extent than EDS and sleep disturbances. CONCLUSION: OSAS, the development of which is facilitated by the presence of muscle weakness and obesity, is the leading syndrome among the spectrum of sleep disorders in all age groups. Cognitive and emotional impairments are not the result of sleep apnea, but rather develop because of a primary CNS lesion. The presence of increased fatigue reduced the quality of life of patients.

Affinity purification of in vivo assembled whirlin-associated protein complexes from the zebrafish retina.

Mutations in WHRN lead to Usher syndrome type 2d or to non-syndromic hearing impairment. The WHRN-encoded gene product whirlin directly interacts with the intracellular regions of the other two Usher syndrome type 2-associated proteins, usherin and ADGRV1. In photoreceptor cells, this protein complex constitutes fibrous links between the periciliary membrane and the connecting cilium. However, the molecular mechanism(s) of retinal degeneration due to compromised formation and function of the USH2-associated protein complex remains elusive. To unravel this pathogenic mechanism, we isolated and characterized whirlin-associated protein complexes from zebrafish photoreceptor cells. We generated transgenic zebrafish that express Strep/FLAG-tagged Whrna, a zebrafish ortholog of human whirlin, under the control of a photoreceptor-specific promoter. Affinity purification of Strep/FLAG-tagged Whrna and associated proteins from adult transgenic zebrafish retinas followed by mass spectrometry identified 19 novel candidate associated proteins. Pull down experiments and dedicated yeast two-hybrid assays confirmed the association of Whrna with 7 of the co-purified proteins. Several of the co-purified proteins are part of the synaptic proteome, which indicates a role for whirlin in the photoreceptor synapse. Future studies will elucidate which of the newly identified protein-protein interactions contribute to the development of the retinal phenotype observed in USH2d patients. SIGNIFICANCE: Since protein-protein interactions identified using targeted in vitro studies do not always recapitulate interactions that are functionally relevant in vivo, we established a transgenic zebrafish line that stably expresses a Strep/FLAG-tagged ortholog of human whirlin (SF-Whrna) in photoreceptor cells. Affinity purification of in vivo-assembled SF-Whrna-associated protein complexes from retinal lysates followed by mass spectrometry, identified 19 novel candidate interaction partners, many of which are enriched in the synaptic proteome. Two human orthologs of the identified candidate interaction partners, FRMPD4 and Kir2.3, were validated as direct interaction partners of human whirlin using a yeast two-hybrid assay. The strong connection of whirlin with postsynaptic density proteins was not identified in previous in vitro protein-protein interaction assays, presumably due to the absence of a biologically relevant context. Isolation and identification of in vivo-assembled whirlin-associated protein complexes from the tissue of interest is therefore a powerful methodology to obtain novel insight into tissue specific protein-protein interactions and has the potential to improve significantly our understanding of the function of whirlin and the molecular pathogenesis underlying Usher syndrome type 2.

A Scoping Review of Injuries in Amateur and Professional Men's Ice Hockey.

Background: Orthopaedic injuries are common in ice hockey at all levels and can result in physical and psychological adverse effects on these athletes. Purpose: Primarily, to summarize published data on orthopaedic hockey injuries at the junior through professional level. Secondarily, to characterize the literature based on anatomic site injured, return-to-play rates, cause/mechanism of injury, time lost, and treatments used. Study Design: Scoping review; Level of evidence, 4. Methods: PubMed, EMBASE, Cochrane library, and SCOPUS were searched using the terms "hockey" and "injuries" using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, and 4163 studies involving orthopaedic injuries were identified. Our inclusion criteria consisted of accessible full-text articles that evaluated orthopaedic injuries in men's ice hockey athletes of all levels. We excluded case reports and articles evaluating women's ice hockey injuries, as well as those evaluating nonorthopaedic injuries, such as concussions; traumatic brain injuries; and facial, dental, and vascular injuries, among others. Studies were divided based on level of play and anatomic site of injury. Level of evidence, year published, country of corresponding author, method of data collection, incidence of injury per athlete-exposure, and time lost were extracted from each article. Results: A total of 92 articles met the inclusion criteria and were performed between 1975 and 2020, with the majority published between 2015 and 2020. These were divided into 8 anatomic sites: nonanatomic-specific (37%), intra-articular hip (20.7%), shoulder (9.8%), knee (8.7%), trunk/pelvis (7.6%), spine (7.6%), foot/ankle (6.5%), and hand/wrist (2.2%). Of these studies, 71% were level 4 evidence. Data were obtained mostly via surveillance programs and searches of publicly available information (eg, injury reports, player profiles, and press releases). Conclusion: This scoping review provides men's hockey players and physicians taking care of elite ice hockey athletes of all levels with a single source of the most current literature regarding orthopaedic injuries. Most research focused on nonanatomic-specific injuries, intra-articular hip injuries, knee injuries, and shoulder injuries, with the majority having level 4 evidence.

Adolescent Quadriceps Tendon Rupture, an Early Complication After ACL Reconstruction: A Case Report.

CASE: A healthy adolescent male patient initially presented with complete rupture of the anterior cruciate ligament (ACL) after a plant-twist injury during a high school football game. Four weeks after ACL reconstruction with autograft bone-patella tendon-bone, the patient slipped and fell, sustaining hyperflexion of the knee, resulting in rupture of the ipsilateral quadriceps tendon. CONCLUSION: Although this rare complication has previously been reported in the adult population, to the best of our knowledge, this is the first known report of an adolescent patient sustaining a quadriceps tendon rupture after ACL reconstruction.

Criteria for return to play after operative management of acromioclavicular joint separation: a systematic review.

Background: Acromioclavicular (AC) joint separation is a common cause of shoulder injury among athletes. High-grade injuries may require operative fixation, and comprehensive return-to-play guidelines have not yet been established. The purpose of this study was to summarize criteria for return to play after operative management of AC joint separation. Methods: A systematic review of the literature was performed from January 1999 to April 2020 to evaluate clinical evidence regarding criteria for return to play after operative management of isolated AC joint separation. Results: Sixty-three studies with at least 1 explicitly stated return-to-play criterion were identified out of an initial database search of 1253 published articles. Eight separate categories of return-to-play criteria were identified, the most common of which was time from surgery (95.2%). Return-to-play timelines ranged from 2 to 12 months, the most common timeline being 6 months (37.8%). Only 4 (6.3%) studies used conditional criteria to guide return to play, which included range of motion, strength, clinical stability, radiographic stability, functional assessment, safety assessment, and hardware removal. Conclusion: Most published studies use only time-based criteria for return to play after surgery for AC joint separation, and only a small number of studies use additional subjective or objective criteria. While this systematic review helps provide a foundation for developing a comprehensive return-to-play checklist, further investigation is needed to establish safe and effective guidelines that will enable athletes to safely return to sport and minimize the recurrence of injury.

Evolution of MET and NRAS gene amplification as acquired resistance mechanisms in EGFR mutant NSCLC.

EGFR mutant non-small cell lung cancer patients' disease demonstrates remarkable responses to EGFR-targeted therapy, but inevitably they succumb to acquired resistance, which can be complex and difficult to treat. Analyzing acquired resistance through broad molecular testing is crucial to understanding the resistance mechanisms and developing new treatment options. We performed diverse clinical testing on a patient with successive stages of acquired resistance, first to an EGFR inhibitor with MET gene amplification and then subsequently to a combination EGFR and MET targeted therapies. A patient-derived cell line obtained at the time of disease progression was used to identify NRAS gene amplification as an additional driver of drug resistance to combination EGFR/MET therapies. Analysis of downstream signaling revealed extracellular signal-related kinase activation that could only be eliminated by trametinib treatment, while Akt activation could be modulated by various combinations of MET, EGFR, and PI3K inhibitors. The combination of an EGFR inhibitor with a MEK inhibitor was identified as a possible treatment option to overcome drug resistance related to NRAS gene amplification.

Orthopaedic Resident Arthroscopic Knot-Tying Skills Are Improved Using a Training Program and Knot-Tying Workstation.

PURPOSE: To quantify an orthopaedic trainee's ability to tie arthroscopic knots before and after a short cadaveric-based arthroscopy training period using a commercially available knot-tying workstation. METHODS: During a weeklong cadaveric arthroscopic training camp, 15 third- and fourth-year orthopaedic residents were evaluated using a commercially available benchtop knot-tying workstation. At the beginning of the week (baseline), each participant was asked to tie 3 knots of his or her choice backed up by 3 half-hitches using nonabsorbable suture. Successful knots fit the sizer and elongated less than 3 mm after application of a 15-lb load. Afterward, residents watched a video demonstrating a sample knot and were encouraged to practice over the ensuing days. At the end of the week (post-training), residents were asked to tie 3 knots. The time to completion and success of each knot were recorded. To compare baseline and post-training knot success, t tests and χ2 analysis were performed. RESULTS: During baseline testing, residents successfully tied 26.7% of their knots (12 of 45 knots) in 352 ± 116 seconds (mean ± standard deviation). During post-training testing, residents successfully tied 66.7% of knots (30 of 45 knots, P = .00014) in 294 ± 63 seconds (P = .023), showing significant improvement in the time and ability to tie arthroscopic knots. CONCLUSIONS: With a short cadaveric-based training period, orthopaedic trainees showed a significant improvement in their ability to tie arthroscopic knots on a commercially available benchtop knot-tying workstation. Given the initial low percentage of successfully tied knots and the limited opportunities for trainees to improve, trainees should be encouraged to practice and improve their skills. CLINICAL RELEVANCE: With training, residents can improve arthroscopic knot-tying abilities, which may allow them to successfully perform this critical task in the operating room.

Radiologic Measurements in the Assessment of Patellar Instability: A Systematic Review and Meta-analysis.

BACKGROUND: Numerous diagnostic imaging measurements related to patellar instability have been evaluated in the literature; however, little has been done to compare these findings across multiple studies. PURPOSE: To review the different imaging measurements used to evaluate patellar instability and to assess the prevalence of each measure and its utility in predicting instability. We focused on reliability across imaging modalities and between patients with and without patellar instability. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: We performed a systematic review of the literature using the PubMed, SCOPUS, and Cochrane databases. Each database was searched for variations of the terms "patellar instability," "patellar dislocation," "trochlear dysplasia," "radiographic measures," "computed tomography," and "magnetic resonance imaging." Studies were included if they were published after May 1, 2009, and before May 1, 2019. A meta-analysis using a random effects model was performed on several measurements, comparing instability and control groups to generate pooled values. RESULTS: A total of 813 articles were identified, and 96 articles comprising 7912 patients and 106 unique metrics were included in the analysis. The mean patient age was 23.1 years (95% CI, 21.1-24.5), and 41% were male. The tibial tubercle-trochlear groove (TT-TG) distance was the most frequently included metric (59 studies), followed by the Insall-Salvati ratio and Caton-Deschamps index (both 26 studies). The interobserver intraclass correlation coefficients were excellent or good for the TT-TG distance and Insall-Salvati ratio in 100% of studies reporting them; however, for the Caton-Deschamps index and Blackburne-Peel ratio, they were excellent or good in only 43% and 40% of studies. Pooled magnetic resonance imaging values for TT-TG distance (P < .01), Insall-Salvati ratio (P = .01), and femoral sulcus angle (P = .02) were significantly different between the instability and control groups. Values for tibial tubercle-posterior cruciate ligament distance (P = .36) and Caton-Deschamps index (P = .09) were not significantly different between groups. CONCLUSION: The most commonly reported measurements for evaluating patellar instability assessed patellar tracking and trochlear morphology. The TT-TG distance was the most common measurement and was greater in the patellar instability group as compared with the control group. In addition, the TT-TG, tibial tubercle-posterior cruciate ligament, and patellar tendon-trochlear groove distances were highly reproducible measurements for patellar tracking, and the Insall-Salvati ratio had superior reproducibility for assessing patellar height.

Men's experiences of radiotherapy treatment for localized prostate cancer and its long-term treatment side effects: a longitudinal qualitative study.

PURPOSE: To investigate men's experiences of receiving external-beam radiotherapy (EBRT) with neoadjuvant Androgen Deprivation Therapy (ADT) for localized prostate cancer (LPCa) in the ProtecT trial. METHODS: A longitudinal qualitative interview study was embedded in the ProtecT RCT. Sixteen men with clinically LPCa who underwent EBRT in ProtecT were purposively sampled to include a range of socio-demographic and clinical characteristics. They participated in serial in-depth qualitative interviews for up to 8 years post-treatment, exploring experiences of treatment and its side effects over time. RESULTS: Men experienced bowel, sexual, and urinary side effects, mostly in the short term but some persisted and were bothersome. Most men downplayed the impacts, voicing expectations of age-related decline, and normalizing these changes. There was some reticence to seek help, with men prioritizing their relationships and overall health and well-being over returning to pretreatment levels of function. Some unmet needs with regard to information about treatment schedules and side effects were reported, particularly among men with continuing functional symptoms. CONCLUSIONS: These findings reinforce the importance of providing universal clear, concise, and timely information and supportive resources in the short term, and more targeted and detailed information and care in the longer term to maintain and improve treatment experiences for men undergoing EBRT.

Resilience in the Orthopaedic Patient.

➤: Resilience is a dynamic psychological construct that refers to the ability to adapt and improve when facing adversity or other stressors. ➤: Recent investigations in various orthopaedic subspecialties have demonstrated that resilience may contribute to favorable mental health and physical function after a surgical procedure. ➤: More research, using well-designed prospective studies, is necessary to better define the role that resilience and other factors play in the health and outcomes of patients with orthopaedic conditions. ➤: Orthopaedic surgeons can consider incorporating resilience assessments into their practices to aid in identifying patients who will do well with a surgical procedure and those who may benefit from specialized therapy to optimize their health and function.

Comparison of Droplet Size, Coverage, and Drift Potential from UAV Application Methods and Ground Application Methods on Row Crops.

Worldwide, the use of uncrewed aerial vehicles (UAVs) for pesticide application has grown tremendously in the past decade. Their adoption has been slower for Midwestern row crops. This study compared droplet size, coverage, and drift potential of sprays from UAV application methods to those from ground (implement) sprayer methods on corn in the Midwest. Droplet sizes measured during UAV spray trials [geometric mean diameters of 179 and 112 µm for UAV (boom) and UAV (no boom), respectively] were substantially smaller than those deposited during implement spray trials [mean diameters of 303 and 423 µm for implement (regular) and implement (pulse)]. Droplet coverage was high and localized in the middle swath of the field for the UAV with boom (10 to 30 droplets cm-2) and with no boom (60 droplets cm-2). Droplet coverage was broader, covering the entire field width for the implement methods (10 to 40 droplets cm-2). Vertical coverage of droplets was more uniform for UAV methods than implement methods. Although the UAVs produced smaller droplets than the implement methods, we still observed greater potential for downwind pesticide drift during the implement spray trials. Because localized application may be beneficial for pest control and drift reduction, the findings indicate a strong potential for "spot" or "band" spray coverage using UAV methods. This is likely due to the smaller size, reduced spray volumes, and increased agility of UAVs as compared to more conventional methods.

Long-term cost-effectiveness of screening for fracture risk in a UK primary care setting: the SCOOP study.

Community-based screening and treatment of women aged 70-85 years at high fracture risk reduced fractures; moreover, the screening programme was cost-saving. The results support a case for a screening programme of fracture risk in older women in the UK. INTRODUCTION: The SCOOP (screening for prevention of fractures in older women) randomized controlled trial investigated whether community-based screening could reduce fractures in women aged 70-85 years. The objective of this study was to estimate the long-term cost-effectiveness of screening for fracture risk in a UK primary care setting compared with usual management, based on the SCOOP study. METHODS: A health economic Markov model was used to predict the life-time consequences in terms of costs and quality of life of the screening programme compared with the control arm. The model was populated with costs related to drugs, administration and screening intervention derived from the SCOOP study. Fracture risk reduction in the screening arm compared with the usual management arm was derived from SCOOP. Modelled fracture risk corresponded to the risk observed in SCOOP. RESULTS: Screening of 1000 patients saved 9 hip fractures and 20 non-hip fractures over the remaining lifetime (mean 14 years) compared with usual management. In total, the screening arm saved costs (£286) and gained 0.015 QALYs/patient in comparison with usual management arm. CONCLUSIONS: This analysis suggests that a screening programme of fracture risk in older women in the UK would gain quality of life and life years, and reduce fracture costs to more than offset the cost of running the programme.

Screening for high hip fracture risk does not impact on falls risk: a post hoc analysis from the SCOOP study.

A reduction in hip fracture incidence following population screening might reflect the effectiveness of anti-osteoporosis therapy, behaviour change to reduce falls, or both. This post hoc analysis demonstrates that identifying high hip fracture risk by FRAX was not associated with any alteration in falls risk. INTRODUCTION: To investigate whether effectiveness of an osteoporosis screening programme to reduce hip fractures was mediated by modification of falls risk in the screening arm. METHODS: The SCOOP study recruited 12,483 women aged 70-85 years, individually randomised to a control (n = 6250) or screening (n = 6233) arm; in the latter, osteoporosis treatment was recommended to women at high risk of hip fracture, while the control arm received usual care. Falls were captured by self-reported questionnaire. We determined the influence of baseline risk factors on future falls, and then examined for differences in falls risk between the randomisation groups, particularly in those at high fracture risk. RESULTS: Women sustaining one or more falls were slightly older at baseline than those remaining falls free during follow-up (mean difference 0.70 years, 95%CI 0.55-0.85, p < 0.001). A higher FRAX 10-year probability of hip fracture was associated with increased likelihood of falling, with fall risk increasing by 1-2% for every 1% increase in hip fracture probability. However, falls risk factors were well balanced between the study arms and, importantly, there was no evidence of a difference in falls occurrence. In particular, there was no evidence of interaction (p = 0.18) between baseline FRAX hip fracture probabilities and falls risk in the two arms, consistent with no impact of screening on falls in women informed to be at high risk of hip fracture. CONCLUSION: Effectiveness of screening for high FRAX hip fracture probability to reduce hip fracture risk was not mediated by a reduction in falls.

Systematic screening using FRAX® leads to increased use of, and adherence to, anti-osteoporosis medications: an analysis of the UK SCOOP trial.

In the large community-based SCOOP trial, systematic fracture risk screening using FRAX® led to greater use of AOM and greater adherence, in women at high fracture risk, compared with usual care. INTRODUCTION: In the SCreening of Older wOmen for Prevention of fracture (SCOOP) trial, we investigated the effect of the screening intervention on subsequent long-term self-reported adherence to anti-osteoporosis medications (AOM). METHODS: SCOOP was a primary care-based UK multicentre trial of screening for fracture risk. A total of 12,483 women (70-85 years) were randomised to either usual NHS care, or assessment using the FRAX® tool ± dual-energy X-ray absorptiometry (DXA), with medication recommended for those found to be at high risk of hip fracture. Self-reported AOM use was obtained by postal questionnaires at 6, 12, 24, 36, 48 and 60 months. Analysis was limited to those who initiated AOM during follow-up. Logistic regression was used to explore baseline determinants of adherence (good ≥ 80%; poor < 80%). RESULTS: The mean (SD) age of participants was 75.6 (4.2) years, with 6233 randomised to screening and 6250 to the control group. Of those participants identified at high fracture risk in the screening group, 38.2% of those on treatment at 6 months were still treated at 60 months, whereas the corresponding figure for the control group was 21.6%. Older age was associated with poorer adherence (OR per year increase in age 0.96 [95% CI 0.93, 0.99], p = 0.01), whereas history of parental hip fracture was associated with greater rate adherence (OR 1.67 [95% CI 1.23, 2.26], p < 0.01). CONCLUSIONS: Systematic fracture risk screening using FRAX® leads to greater use of AOM and greater adherence, in women at high fracture risk, compared with usual care.

The prevalence of dentine hypersensitivity among adult patients attending a university dental clinic

Objective: To assess the prevalence of dentine hypersensitivity (DH) in an adult population and explore association with sociodemographic variables, dietary habits and oral health behaviours. Design and Methodology: Cross-sectional survey of consecutive dental patients (18 years and over) attending the UWI School of Dentistry polyclinic. Following informed consent, dental examinations were undertaken by two calibrated dentists. Presence of DH was assessed clinically by sensitivity to an air syringe on individual teeth. Patients were also administered a questionnaire which included age, gender, occupation, medical and dental history, brushing and dietary history. Data were processed using statistical software (SPSS version 24). Association between variables were analyzed using the Chi-Square test. Results: 300 patients participated. Age range 18 ­ 81years, mean 44.7 years (SD 15.69). 69% were female and the main ethnic groups were African (45.7%),Indian (30%) and mixed (23%). 48.3% were in employment. Over half of the participants (54.9%) reported a history of sensitive teeth and 52% reported sensitivity to the air syringe on one or more teeth. A history of sensitive teeth was significantly associated with gender (female), frequent consumption of citrus fruits and citrus juice, history of teeth grinding or clenching and twice daily tooth brushing (Chi-square test p <0.05). Conclusions: Prevalence of dentine hypersensitivity was high among this sample of dental patients and associated with gender, dietary practices, tooth grinding and brushing frequency. Management of this condition should include dietary advice, modification of oral habits and advice on tooth brushing techniques.