Narcotic prescribing practices in shoulder surgery before and after the institution of narcotic e-prescribing.

Background: Given the current opioid epidemic, it is crucial to highly regulate the prescription of narcotic medications for pain management. The use of electronic prescriptions (e-scripts) through the hospital's electronic medical record platform allows physicians to fill opioid prescriptions in smaller doses, potentially limiting the total quantity of analgesics patients have access to and decreasing the potential for substance misuse. The purpose of this study is to determine how the implementation of e-scripts changed the quantity of opioids prescribed following shoulder surgeries. Methods: For this single-center retrospective study, data were extracted for all patients aged 18 years or more who received a shoulder procedure between January 2015 and December 2020. Total milligrams of morphine equivalents (MMEs) of opioids prescribed within the 90 days following surgery were compared between 3 cohorts: preimplementation of the 2017 New Jersey Opioid laws (Pre-NJ opioid laws), post-NJ Opioid Laws but pre-escripting, and postimplementation of e-scripting in 2019 (postescripting). Any patient prescribed preoperative opioids, prescribed opioids by nonorthopedic physicians, under the care of a pain management physician, or had a simultaneous nonshoulder procedure was excluded from this study. Results: There were 1857 subjects included in this study; 796 pre-NJ opioid laws, 520 post-NJ opioid laws, pre-escripting, and 541 postescripting. Following implementation of e-scripting on July 1, 2019, there was a significant decrease in total MMEs prescribed (P < .001) from a median of 90 MME (interquartile range 65, 65-130) preimplementation to a median 45 MME (interquartile range 45, 45-90) MME postimplementation Additionally, there was a statistically significant decrease in opioids prescribed for all procedures (P < .001) and for 3 (P < .001) of the 4 orthopedic surgeons included in this study. Conclusion: Our study demonstrated a significant reduction in total MMEs prescribed overall, for all shoulder surgeries, and for the majority of our institution's providers in the postoperative period following the e-scripting implementation in July 2019. E-scripting is a valuable tool in conjunction with education and awareness on the national, institutional, provider, and patient levels to combat the opioid epidemic.

A Virtual Curriculum to Prepare Medical Students to Achieve Accreditation Council for Graduate Medical Education Level-1 Milestones in Orthopaedic Surgery.

As a part of the American healthcare system's response to the Coronavirus Disease 2019 (COVID-19) global pandemic, the Association of American Medical Colleges recommended that medical schools temporarily remove students from clinical settings and transition to an entirely online learning environment. This posed an unprecedented challenge to students in the clinical years of their medical education. To address this unexpected shift, we modified an in-person workshop to teach orthopaedic trauma basics to 5-week virtual course for third year medical students from several schools in New Jersey and Pennsylvania. We focused on moving students toward the Level-1 milestones for basic fracture care with a combination of weekly lectures and virtual interactive small group sessions, all conducted via WebEx and proctored by an orthopaedic attending or resident. The course was well received by students. Participation in the course was completely voluntary and did not count for credit at any institution. The course was valuable to students because the students who registered chose to fully complete the 5-week course and no student missed more than one small group session. On a postcourse survey, 100% of students said they would be highly likely to recommend the course to a future student, and the average rating for educational value of the course was 4.98 of 5. Given the current limitations in clinical education because of the COVID-19 pandemic, our course provides a reasonable alternative to clinical experience and prepares students with the knowledge and many of the skills that are required to succeed as orthopaedic interns. Furthermore, the success of our course this year suggests that similar programing may be a useful adjunct to clinical experiences even when it is safe to return to more traditional medical school scheduling.

Epidemiological insights from a large-scale investigation of intestinal helminths in Medieval Europe.

Helminth infections are among the World Health Organization's top neglected diseases with significant impact in many Less Economically Developed Countries. Despite no longer being endemic in Europe, the widespread presence of helminth eggs in archaeological deposits indicates that helminths represented a considerable burden in past European populations. Prevalence of infection is a key epidemiological feature that would influence the elimination of endemic intestinal helminths, for example, low prevalence rates may have made it easier to eliminate these infections in Europe without the use of modern anthelminthic drugs. To determine historical prevalence rates we analysed 589 grave samples from 7 European sites dated between 680 and 1700 CE, identifying two soil transmitted nematodes (Ascaris spp. and Trichuris trichiura) at all locations, and two food derived cestodes (Diphyllobothrium latum and Taenia spp.) at 4 sites. The rates of nematode infection in the medieval populations (1.5 to 25.6% for T. trichiura; 9.3-42.9% for Ascaris spp.) were comparable to those reported within modern endemically infected populations. There was some evidence of higher levels of nematode infection in younger individuals but not at all sites. The genetic diversity of T. trichiura ITS-1 in single graves was variable but much lower than with communal medieval latrine deposits. The prevalence of food derived cestodes was much lower (1.0-9.9%) than the prevalence of nematodes. Interestingly, sites that contained Taenia spp. eggs also contained D. latum which may reflect local culinary practices. These data demonstrate the importance of helminth infections in Medieval Europe and provide a baseline for studies on the epidemiology of infection in historical and modern contexts. Since the prevalence of medieval STH infections mirror those in modern endemic countries the factors affecting STH decline in Europe may also inform modern intervention campaigns.

Matching into an Orthopedic Residency: Which Application Components Correlate with Final Rank List Order?

OBJECTIVE: To determine if any of the unique elements of the applications of medical students who were granted interviews to an orthopedic residency program correlate to the program's final rank order list of candidate residents. DESIGN: Eight domains of the standard residency application were considered as independent variables for 36 applicants. Personal, identifying information was removed from the application material within each domain, thus blinding the application domains for 5 core faculty members from the program to review and rank independently. These 8 domain rank lists were then compared to the program's final rank list order to determine the correlation of each domain with the final rank list order. SETTING: Academic medical center. PARTICIPANTS: Applicants to a university-based orthopedic surgery residency program who were granted interviews in the 2016 academic year. RESULTS: Two domains of the application correlated with the final rank list order: interview and personal statement. None of the other domains had a significant correlation with the final rank list order. Interobserver variability among the faculty members was high for the rankings of the different domains. CONCLUSIONS: Interview and personal statement were the only domains within the application that had correlation with the final rank list for an orthopedic residency program. A better understanding of how these 2 components affect the rank list may provide opportunity for process improvements.

Molecular archaeoparasitology identifies cultural changes in the Medieval Hanseatic trading centre of Lübeck.

Throughout history, humans have been afflicted by parasitic worms, and eggs are readily detected in archaeological deposits. This study integrated parasitological and ancient DNA methods with a large sample set dating between Neolithic and Early Modern periods to explore the utility of molecular archaeoparasitology as a new approach to study the past. Molecular analyses provided unequivocal species-level parasite identification and revealed location-specific epidemiological signatures. Faecal-oral transmitted nematodes (Ascaris lumbricoides and Trichuris trichiura) were ubiquitous across time and space. By contrast, high numbers of food-associated cestodes (Diphyllobothrium latum and Taenia saginata) were restricted to medieval Lübeck. The presence of these cestodes and changes in their prevalence at approximately 1300 CE indicate substantial alterations in diet or parasite availability. Trichuris trichiura ITS-1 sequences grouped into two clades; one ubiquitous and one restricted to medieval Lübeck and Bristol. The high sequence diversity of T.tITS-1 detected in Lübeck is consistent with its importance as a Hanseatic trading centre. Collectively, these results introduce molecular archaeoparasitology as an artefact-independent source of historical evidence.

Compact and versatile laser system for polarization-sensitive stimulated Raman spectroscopy.

We demonstrate a compact and versatile laser system for stimulated Raman spectroscopy (SRS). The system is based on a tunable continuous wave (CW) probe laser combined with a home-built semi-monolithic nanosecond pulsed pump Nd:YVO4 laser at 1064 nm. The CW operation of the probe laser offers narrow linewidth, low noise and the advantage that temporal synchronization with the pump is not required. The laser system enables polarization-sensitive stimulated Raman spectroscopy (PS-SRS) with fast high resolution measurement of the depolarization ratio by simultaneous detection of Raman scattered light in orthogonal polarizations, thus providing information about the symmetry of the Raman-active vibrational modes. Measurements of the depolarization ratios of the carbon-hydrogen (CH) stretching modes in two different polymer samples in the spectral range of 2825-3025 cm-1 were performed. Raman spectra are obtained at a sweep rate of 20 nm/s (84 cm-1/s) with a resolution of 0.65 cm-1. A normalization method is introduced for the direct comparison of the simultaneously acquired orthogonal polarized Raman spectra.

In Vivo Quantification of Peroxisome Tethering to Chloroplasts in Tobacco Epidermal Cells Using Optical Tweezers.

Peroxisomes are highly motile organelles that display a range of motions within a short time frame. In static snapshots, they can be juxtaposed to chloroplasts, which has led to the hypothesis that they are physically interacting. Here, using optical tweezers, we tested the dynamic physical interaction in vivo. Using near-infrared optical tweezers combined with TIRF microscopy, we were able to trap peroxisomes and approximate the forces involved in chloroplast association in vivo in tobacco (Nicotiana tabacum) and observed weaker tethering to additional unknown structures within the cell. We show that chloroplasts and peroxisomes are physically tethered through peroxules, a poorly described structure in plant cells. We suggest that peroxules have a novel role in maintaining peroxisome-organelle interactions in the dynamic environment. This could be important for fatty acid mobilization and photorespiration through the interaction with oil bodies and chloroplasts, highlighting a fundamentally important role for organelle interactions for essential biochemistry and physiological processes.

Directly interrogating single quantum dot labelled UvrA2 molecules on DNA tightropes using an optically trapped nanoprobe.

In this study we describe a new methodology to physically probe individual complexes formed between proteins and DNA. By combining nanoscale, high speed physical force measurement with sensitive fluorescence imaging we investigate the complex formed between the prokaryotic DNA repair protein UvrA2 and DNA. This approach uses a triangular, optically-trapped "nanoprobe" with a nanometer scale tip protruding from one vertex. By scanning this tip along a single DNA strand suspended between surface-bound micron-scale beads, quantum-dot tagged UvrA2 molecules bound to these '"DNA tightropes" can be mechanically interrogated. Encounters with UvrA2 led to deflections of the whole nanoprobe structure, which were converted to resistive force. A force histogram from all 144 detected interactions generated a bimodal distribution centered on 2.6 and 8.1 pN, possibly reflecting the asymmetry of UvrA2's binding to DNA. These observations successfully demonstrate the use of a highly controllable purpose-designed and built synthetic nanoprobe combined with fluorescence imaging to study protein-DNA interactions at the single molecule level.

Critical elements to building an effective wound care center.

There are a growing number of wound care centers being established globally. The emergence of these centers reflects the increasing incidence and prevalence of chronic wounds as well as the cost to the health care systems these patients represent. A systematic approach to the development and implementation of a comprehensive wound care program is necessary to provide quality wound care as well as to establish a financially viable enterprise. A wound care center can take shape in various forms from small free-standing clinics to large hospital-based programs. Regardless of the physical location, the most important factor for the success of the wound care center is a strong commitment by the members of the multidisciplinary team. The capacity to effectively manage certain wounds can be limited by the absence of key specialties within the team. The physical space and financial support from the sponsoring institution are also important components. This article reviews the critical elements to building and sustaining a successful multidisciplinary wound care center.

Volcanic ash layers illuminate the resilience of Neanderthals and early modern humans to natural hazards.

Marked changes in human dispersal and development during the Middle to Upper Paleolithic transition have been attributed to massive volcanic eruption and/or severe climatic deterioration. We test this concept using records of volcanic ash layers of the Campanian Ignimbrite eruption dated to ca. 40,000 y ago (40 ka B.P.). The distribution of the Campanian Ignimbrite has been enhanced by the discovery of cryptotephra deposits (volcanic ash layers that are not visible to the naked eye) in archaeological cave sequences. They enable us to synchronize archaeological and paleoclimatic records through the period of transition from Neanderthal to the earliest anatomically modern human populations in Europe. Our results confirm that the combined effects of a major volcanic eruption and severe climatic cooling failed to have lasting impacts on Neanderthals or early modern humans in Europe. We infer that modern humans proved a greater competitive threat to indigenous populations than natural disasters.

The effect of point mutation on the equilibrium structural fluctuations of ferric Myoglobin.

The ultrafast equilibrium fluctuations of the Fe(III)-NO complex of a single point mutation of Myoglobin (H64Q) have been studied using Fourier Transform 2D-IR spectroscopy. Comparison with data from wild type Myoglobin (wt-Mb) shows the presence of two conformational substates of the mutant haem pocket where only one exists in the wild type form. One of the substates of the mutant exhibits an almost identical NO stretching frequency and spectral diffusion dynamics to wt-Mb while the other is distinctly different in both respects. The remarkably contrasting dynamics are largely attributable to interactions between the NO ligand and a nearby distal side chain which provides a basis for understanding the roles of these side chains in other ferric haem proteins.

ULTRA: A Unique Instrument for Time-Resolved Spectroscopy.

We report the development of a high-sensitivity time-resolved infrared and Raman spectrometer with exceptional experimental flexibility based on a 10-kHz synchronized dual-arm femtosecond and picosecond laser system. Ultrafast high-average-power titanium sapphire lasers and optical parametric amplifiers provide wavelength tuning from the ultraviolet (UV) to the mid-infrared region. Customized silicon, indium gallium arsenide, and mercury cadmium telluride linear array detectors are provided to monitor the probe laser intensity in the UV to mid-infrared wavelength range capable of measuring changes in sample absorbance of ΔOD ~ 10(-5) in 1 second. The system performance is demonstrated for the time-resolved infrared, two-dimensional (2D) infrared, and femtosecond stimulated Raman spectroscopy techniques with organometallic intermediates, organic excited states, and the dynamics of the tertiary structure of DNA.

Accuracy of injection into the basal joint of the thumb.

To investigate the accuracy of intra-articular injection of the basal joint and to determine the rate of soft-tissue extravasation of injected material in successful intra-articular injection, we injected the basal joint of 30 hands with radiopaque dye (with fluoroscopy guiding needle placement in 8 cases) and then used fluoroscopy to check injection accuracy. Results were recorded depending on the location of the injected dye on fluoroscopic examination. Rates of intra-articular accuracy and soft-tissue extravasation for successful intra-articular injections were 100% and 25% for the fluoroscopy-guided group and 81.8% and 25% for the "blind" group. This study's accuracy rate for intra-articular injection of the basal joint is comparable to the rates reported for injection of larger joints. There is a relatively high soft-tissue extravasation rate for successful intra-articular injection.

Immunohistochemical evidence of nerve growth factor in Dupuytren's diseased palmar fascia.

PURPOSE: Histologically, the pathognomic feature of Dupuytren's contracture (DC) is the myofibroblast. Its occurrence in this disease has been associated with local production of transforming growth factor (TGF)-B. However, nerve growth factor (NGF) is a recognized growth factor involved in wound healing and has been shown to induce the myofibroblast phenotype in cultured fibroblasts. We hypothesized that NGF would be abundant in this disease entity. METHODS: Immunohistochemistry was used to examine for the presence of NGF in 25 surgical specimens from patients with DC and in surgical specimens from 5 other, unrelated procedures. Patient demographics showed that nearly all patients were men, with a mean age of 61 years (range 36-77). Serial sections were probed with antibodies, stained, and then digitally photomicrographed. Disease staging was also performed. Image analysis was then used to measure the percentage of area stained. In addition, representative sections were probed for TrkA, the high-affinity receptor for NGF, and alpha-smooth muscle actin, a cytoskeletal marker of the myofibroblast phenotype. These alternate steps were used to infer functional dependence and the association of NGF with myofibroblast populations. RESULTS: Histologically, all patients had either stage II or III disease. Biopsy results showed an abundance of NGF--over double that of controls. The highest levels of NGF occurred in hypercellular stage II disease. In addition, we confirmed that NGF is linked to the expression of both TrkA receptors and alpha-smooth muscle actin. CONCLUSIONS: Tissue levels of NGF are elevated in Dupuytren's disease. This tissue is competent to respond to NGF and manifests an abundance of myofibroblasts in areas of NGF expression. Nerve growth factor is most apparent in the proliferative (hyperplastic) stage of the disease. These data infer that NGF is linked to the pathologic process.