Towards Novel Nutritional Strategies in Gestational Diabetes: Eating Behaviour and Obesity in Women with Gestational Diabetes Compared with Non-Pregnant Adults.

BACKGROUND: Gestational diabetes is associated with increased risk of obesity, type 2 diabetes and cardiovascular disease. Effective nutritional strategies are needed to reduce BMI and improve long-term maternal cardiometabolic health, but the relative contribution of maternal eating behaviour, a potential barrier to dietary change, has not been explored. We compared eating behaviour in women with gestational diabetes with that of men and non-pregnant women with comparable risk factors, and tested associations between eating behaviour traits and BMI in women with gestational diabetes. We hypothesized that eating behaviour would be unfavourable in gestational diabetes and would be associated with BMI. METHODS: Participants (n = 417) including 53 men, 164 non-pregnant women and 200 women with gestational diabetes (singleton pregnancy; 29 weeks' gestation) were recruited into three prospective studies assessing weight loss interventions, with similar entry criteria. The three-factor eating questionnaire (TFEQ-R18) assessed uncontrolled eating, emotional eating and cognitive restraint at study enrolment. Associations between BMI at study enrolment and TFEQ-R18 (% maximum score) were assessed using linear regression. RESULTS: Women with gestational diabetes had significantly lower uncontrolled eating scores vs. men (53% vs. 65%; p < 0.001) and non-pregnant women (53% vs. 66%; p < 0.001), lower emotional eating scores vs. non-pregnant women (60% vs. 71%; p < 0.001) and higher cognitive restraint (p < 0.001 vs. men and non-pregnant women). In women with gestational diabetes, emotional eating scores were positively associated with BMI at study enrolment (beta coefficient 7.8 (95% CI 3.9 to 11.7), p < 0.001). CONCLUSIONS: Women with gestational diabetes have favourable eating behaviour compared with other population groups. Because BMI at study enrolment was associated with emotional eating, nutritional strategies which reduce emotional eating may provide new opportunities to improve long-term maternal health after gestational diabetes.

Hip Manipulation Under Anesthesia for Post-Hip Arthroscopy Pericapsular Scarring: Indications and Techniques.

Hip arthroscopy has become an increasingly common procedure with expanding indications over the last several decades. With the increase in number of procedures performed a complication profile has emerged, although there is yet to be a formal classification system for complications. The most cited complications include lateral femoral cutaneous nerve neuropraxia, other sensory deficits, chondral or labral iatrogenic damage, superficial infection and deep vein thrombosis. One complication that has not yet been well documented in the literature is pericapsular scarring/adhesions resulting in decreased hip range of motion and function. If this complication is noted to persist after adequate impingement resection and a rigorous post-operative physical therapy regimen, the senior author has addressed this with a hip manipulation under anesthesia. Therefore, this techniques paper aims to describe pericapsular scarring as a post hip-arthroscopy condition which may cause pain and demonstrate our technique to address this diagnosis through hip manipulation under anesthesia.

Pregnancy glucagon-like peptide 1 predicts insulin but not glucose concentrations.

AIMS: Incretin hormones glucagon-like peptide 1 (GLP-1) and gastric inhibitory peptide (GIP) cause increased insulin secretion in non-pregnant adults, but their role in pregnancy, where there are additional metabolically-active hormones from the placenta, is less clear. The aim of the present study was to assess if fasting and post-load incretin concentrations were predictive of pregnancy insulin and glucose concentrations. METHODS: Pregnant women (n = 394) with one or more risk factors for gestational diabetes were recruited at 28 weeks for a 75 g oral glucose tolerance test (OGTT). Glucose, insulin, GLP-1 and GIP were measured in the fasting state and 120 min after glucose ingestion. RESULTS: Fasting plasma GLP-1 concentrations were associated with plasma insulin (standardised ß' 0.393 (0.289-0.498), p = 1.3 × 10-12; n = 306), but not with glucose concentrations (p = 0.3). The association with insulin was still evident when adjusting for BMI (ß' 0.271 (0.180-0.362), p = 1.1 × 10-8; n = 297). Likewise, at 120 min the OGTT GLP-1 concentrations were associated with plasma insulin concentrations (ß' 0.216 (0.100-0.331), p = 2.7 × 10-4; n = 306) even after adjusting for BMI (ß' 0.178 (0.061-0.294), p = 2.9 × 10-3; n = 296), but not with glucose (p = 0.9). GIP concentrations were not associated with insulin or glucose concentrations at either time point (all p > 0.2). In pregnancy plasma GLP-1, but not GIP, concentrations appear to be predictive of circulating insulin concentrations, independently of associations with BMIs. CONCLUSIONS: These results suggest that the relationship between insulin and incretins is preserved in pregnancy, but that other factors, such as placental hormones or counter-regulatory hormones, may be more important determinants of glycaemia and gestational diabetes aetiology.

Survey of blood flow restriction therapy for rehabilitation in Sports Medicine patients.

Background: Blood flow restriction (BFR) therapy has demonstrated benefits across a spectrum of musculoskeletal injuries, including improved strength, endurance, function, and reduction in pain perception. There is, however, no standardized application of BFR therapy among orthopaedic surgeons within the United States (US). Hypothesis: The indication and protocol for BFR therapy vary significantly across providers in the US. Methods: An online survey of 21 multiple-choice questions was sent to 3,281 surgeons listed on a large orthopaedic registry. A cross-sectional study was performed on all surgeons who successfully completed the questionnaire. Surgeons were queried on current or planned use of BFR, indications, contraindications, and peri-operative and non-operative management of sports-related injuries. Results: Overall, 250 physicians completed the survey, with 149 (59.8%) reporting current BFR use and 75.2% initiating use in the last 1-5 years. Most protocols (78.8%) utilize the modality 2-3 times per week while 15.9% use it only once weekly. Anterior cruciate ligament reconstruction (ACLR) rehabilitation was the most reported indication for initiating BFR therapy (95.7%) along with medial patellofemoral ligament reconstruction (70.2%), multiligamentous knee reconstruction (68.8%), meniscus repair (62.4%), collateral ligament reconstruction (50.4%), Achilles tendon repairs (30.5%), and meniscectomy (27%). Only 36.5% reported using BFR after upper extremity procedures, such as distal biceps repair (19.7%), ulnar collateral ligament elbow reconstruction (17%), rotator cuff (16.8%), and shoulder labrum repair (15.3%). For non-operative injuries, 65.8% of surgeons utilized BFR. Of those not currently using BFR therapy, 33.3% intended to implement its use in the future. Conclusion: BFR therapy has increased in popularity with most physicians implementing its use in the last 5 years. BFR was commonly utilized after ACLR. Clinical relevance: BFR allows light-load resistance to simulate high-intensity resistance training. This study describes US orthopaedic surgeons' common practice patterns and patient populations that utilize BFR therapy.

Machine Learning Model Identifies Preoperative Opioid Use, Male Sex, and Elevated Body Mass Index as Predictive Factors for Prolonged Opioid Consumption Following Arthroscopic Meniscal Surgery.

PURPOSE: To develop a predictive machine learning model to identify prognostic factors for continued opioid prescriptions after arthroscopic meniscus surgery. METHODS: Patients undergoing arthroscopic meniscal surgery, such as meniscus debridement, repair, or revision at a single institution from 2013 to 2017 were retrospectively followed up to 1 year postoperatively. Procedural details were recorded, including concomitant procedures, primary versus revision, and whether a partial debridement or a repair was performed. Intraoperative arthritis severity was measured using the Outerbridge Classification. The number of opioid prescriptions in each month was recorded. Primary analysis used was the multivariate Cox-Regression model. We then created a naïve Bayesian model, a machine learning classifier that uses Bayes' theorem with an assumption of independence between variables. RESULTS: A total of 581 patients were reviewed. Postoperative opioid refills occurred in 98 patients (16.9%). Multivariate logistic modeling was used; independent risk factors for opioid refills included male sex, larger body mass index, and chronic preoperative opioid use, while meniscus resection demonstrated decreased likelihood of refills. Concomitant procedures, revision procedures, and presence of arthritis graded by the Outerbridge classification were not significant predictors of postoperative opioid refills. The naïve Bayesian model for extended postoperative opioid use demonstrated good fit with our cohort with an area under the curve of 0.79, sensitivity of 94.5%, positive predictive value (PPV) of 83%, and a detection rate of 78.2%. The two most important features in the model were preoperative opioid use and male sex. CONCLUSION: After arthroscopic meniscus surgery, preoperative opioid consumption and male sex were the most significant predictors for sustained opioid use beyond 1 month postoperatively. Intraoperative arthritis was not an independent risk factor for continued refills. A machine learning algorithm performed with high accuracy, although with a high false positive rate, to function as a screening tool to identify patients filling additional narcotic prescriptions after surgery. LEVEL OF EVIDENCE: III, retrospective comparative study.

Treatment of Coxa Profunda With Open Surgical Hip Dislocation, Rim Resection, Cam Resection, and Labral Reconstruction.

Coxa profunda presents a unique challenge in surgical treatment approach given global acetabular overcoverage. Arthroscopic treatment can be fraught with difficulty obtaining hip distraction for safe arthroscopic instrumentation, and limited arthroscopic access may prevent sufficient osseous resection of the excess acetabular rim. Although hip arthroscopy use has increased markedly over the past decades for all types of hip pathology, coxa profunda may represent one unique indication for surgical hip dislocation. This technique describes open surgical hip dislocation, rim resection, femoral osteoplasty, and labral reconstruction using anterior tibialis allograft for coxa profunda with combined-type femoroacetabular impingement syndrome and labral ossification.

Patients With Generalized Joint Hypermobility Have Thinner Superior Hip Capsules and Greater Hip Internal Rotation on Physical Examination.

Purpose: To compare preoperative hip range of motion (ROM), hip capsular thickness on magnetic resonance imaging (MRI), and bony morphology on radiographs and computed tomography (CT) between patients with and without joint hypermobility as measured by the Beighton Test score (BTS), with subanalysis based on sex and age. Methods: Consecutive patients who underwent hip arthroscopy for a diagnosis of femoroacetabular impingement syndrome with or without dysplasia were retrospectively reviewed. Patient BTS, hip ROM, demographics, surgical data, morphologic measures on radiographs and CT, and MRI findings including hip capsule thickness at various locations were compiled. Multiple statistical tests were performed, including multivariable linear or logistic regression models, while controlling for BTS, age, and sex. Results: In total, 99 patients were included with a mean age of 29 ± 9.9 years; 62 (62.6%), were female. Forty patients (40.4%) had a BTS ≥4. Female patients (P < .001) and younger patients (26.7 vs 30.9 years, P = .030) were more likely to have a BTS ≥4. Male patients had significantly thicker superior capsules (3.4 mm vs. 2.8 mm, P = .034). BTS was not associated with capsular thickness when controlling for sex. On CT, femoral version (18.9° vs 11.4°, P < .001), and McKibben index (37.8° vs. 28.2°, P < .001) were significantly greater in those with a BTS ≥4. Patients with a BTS ≥4 had more hip internal rotation at 90° of flexion (15.0° vs 10.0°, P < .001), when prone (30.0° vs 20.0°, P = .004), and in extension (10.0° vs. 5.0°, P < .001). Conclusions: All female patients, regardless of Beighton score, and all patients with a BTS ≥4 indicated for primary hip arthroscopy for femoroacetabular impingement syndrome with or without dysplasia were more likely to have thinner superior hip capsules on MRI and greater hip internal rotation on exam. Bony morphologic differences exist between sexes and between patients with and without hypermobility, likely contributing to differences in ROM. Level of Evidence: III, retrospective cohort study.

Do intra-articular knee injuries detected by preoperative MRI affect the clinical management of extensor mechanism ruptures?

OBJECTIVES: We sought to determine the prevalence of intra-articular findings at the time of extensor mechanism injury that required subsequent surgical intervention. DESIGN: Retrospective cohort study. SETTING: Level 1 academic trauma center. PATIENTS/PARTICIPANTS: Sixty-seven knees in 66 nonconsecutive patients (mean age 53.6 years, 95.6% male) with extensor mechanism injury and preoperative magnetic resonance imaging (MRI) before undergoing open primary surgical repair. MAIN OUTCOME MEASUREMENTS: Patellar or quadriceps tendon rupture, high or low injury energy level, and age above or below 45 years were used to stratify patients. The primary outcome was additional surgery for intra-articular injury. Demographics, comorbidities, mechanism and location of injury, and internal derangements based on MRI findings were also collected. RESULTS: Fifty-one knees (76.1%) had quadriceps tendon injury, 13 knees (19.4%) had patellar tendon injury, and 3 knees (4.6%) had both. Thirty-four knees (50.7%) had intra-articular pathology and 3 (4.5%) required additional surgery, including 1 knee (7.7%) with patellar tendon injury and 2 knees (3.9%) with quadriceps tendon injury. Patellar tendon injuries were more commonly associated with cruciate ligament injury (P < .01) and occurred in younger patients (P < .001) than quadriceps tendon injury. CONCLUSIONS: 50.7% of cases with extensor mechanism injury had intra-articular pathology but only 4.5% required additional surgery. The results of our study suggest that preoperative MRI is unlikely to be of significant clinical utility in most extensor mechanism injuries but should be considered in cases of patellar tendon rupture in younger patients where the incidence of concomitant cruciate ligament injury is higher. LEVEL OF EVIDENCE: Diagnostic Level III.

Combined Hip Arthroscopy and Periacetabular Osteotomy (PAO): Technical Focus on Arthroscopically Elevating the Iliocapsularis and Performing the Open PAO.

In this Technical Note, we discuss the combined hip arthroscopy and periacetabular osteotomy (PAO) for the treatment of symptomatic hip dysplasia, with a focus on the technique we use for the PAO. We identify modifications that can be made during the arthroscopic portion of the procedure to assist in the PAO dissection, including arthroscopic capsular closure and arthroscopic elevation of the iliocapsularis muscle off the capsule, which allows for expedited open exposure during the PAO.

Excision of Heterotopic Ossification around the Hip: Arthroscopic and Open Techniques.

Heterotopic ossification (HO) can occur as a complication of various pathologies affecting the hip including trauma, tendon avulsions, chronic injury, spinal cord injury, and soft-tissue disruption caused by surgery. When HO is present alongside intra-articular hip pathology such as femoroacetabular impingement syndrome (FAIS) or labral pathology, consideration should be made to combine the surgical excision of the HO with the FAIS decompression or labral repair if the location and size of the HO is appropriate for arthroscopic excision. Often times, the HO is located in such a position that any central compartment work can be completed before turning to the HO excision. If an open approach is required, the modified Gibson approach can be used for lateral hip access, whereas the Smith-Petersen approach provides anterior hip access. In this Technical Note we discuss arthroscopic techniques for excision of HO in the setting of concomitant FAIS, with discussion of when HO excision occurs in relation to cam decompression and labral repair, and mention tips on how to approach HO excision through an open approach.

A narrative review of the last decade's literature on the diagnostic accuracy of septic arthritis of the native joint.

While septic arthritis can be a straightforward diagnosis, there are many cases when the diagnosis is difficult to make. The aim of this study was to review the last decade's literature on the diagnosis of septic arthritis of the native joint in adults and summarize that data in an easy to follow algorithm to clarify how the last decade's data may be applied to the diagnosis of septic arthritis. A search of PubMed and CINAHL databases was performed to identify studies that compared results diagnostic tests for septic arthritis. We cross referenced this search with searches of additional databases (including Cochrane Library and Scopus) to confirm similar search results. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool was used by two independent reviewers to determine study quality and risk of bias. After applying inclusion and exclusion criteria to the initial search, 15 papers total were included for analysis. All 15 papers were of high quality methodology as determined by the QUADAS tool. There were 26 different diagnostics tests used across the 15 papers included for review. Three of those diagnostic tests had specificity and sensitivity greater than 80%. Eight tests had a positive likelihood ratio of ≥10. Three tests had a negative likelihood ratio < 0.1, indicating that they may help to rule out septic arthritis. A flowchart was created to summarize the findings of our review, so that physicians may reference this visual in making the appropriate diagnosis when the commonly held standards of cell count, gram stain, and culture aren't enough to make the diagnosis.

Neuraxial Anesthesia Is Associated With Decreased Pain Scores and Post-Anesthesia Care Unit Opioid Requirement Compared With General Anesthesia in Hip Arthroscopy.

PURPOSE: We sought to identify the immediate postoperative differences in opioid use, pain scores, and post-anesthesia care unit (PACU) length of stay (LOS) after hip arthroscopy related to the type of anesthesia used for the surgical procedure. METHODS: Patients undergoing hip arthroscopy for femoroacetabular impingement syndrome with labral tears by a single surgeon at an academic center between October 2017 and July 2019 were reviewed retrospectively. The primary outcome was PACU opioid administration, measured by morphine equivalents. Secondary parameters included total LOS, postincision LOS, PACU LOS, and PACU arrival/discharge pain scores. Analyses conducted were t tests, Wilcoxon rank sum tests, or χ2 tests. RESULTS: A total of 129 patients met inclusion criteria for this study; 54 male and 75 female, with an average age of 28 (±10.1) years. In total, 52 (40.3%) had general anesthesia and 77 (59.7%) had neuraxial anesthesia, including spinal, epidural, and combined spinal-epidural anesthesia, which were intermixed throughout the study period. Intraoperative and PACU opioid administration demonstrated a significant difference in medians. Neuraxial methods required a lower morphine equivalents in both the operating room (30.0 vs 53.9, P = .001) and PACU (18.2 vs 31.2, P = 0.002). Neuraxial anesthesia had lower median PACU arrival and discharge pain scores (0.0 vs. 5.0, P = .001, 3.0 vs. 4.0, P = .013). There was no statistically significant difference in postincision LOS or traction time. General anesthesia was associated with a longer PACU phase 1 time (1.0 vs 1.3 hours, P = .005). No major adverse events such as death, disability, or prolonged hospitalization occurred in either group. CONCLUSIONS: Neuraxial anesthesia use in routine hip arthroscopy was associated with lower immediate postoperative pain scores, lower intraoperative and immediate postoperative opioid requirements, and may be associated with shorter anesthesia recovery time without any major adverse events when compared with general anesthesia. LEVEL OF EVIDENCE: III, Retrospective Comparative Study.

Recommendations for optimization of fortified and blended food aid products from the United States.

Fortified blended foods (FBFs) were introduced into the Food for Peace program (also known as US Public Law 480) in the 1960s. Minimal changes have since been made to their formulations. A Food Aid Quality Enhancement Project to assess the nutritional adequacy of FBFs for vulnerable populations was conducted, and the findings indicate that FBFs do not meet the nutritional needs of infants and young children between the ages of 6 and 24 months. Improvements are also needed for FBFs intended for school-aged children and adults. Two separate products would better meet the varying nutritional needs of diverse groups of beneficiaries. Proposed here is a two-step strategy for better addressing the needs of today's food aid beneficiaries: 1) improving FBFs for general distribution to households, schools, and emergency settings, with potential efficiencies gained in manufacturing and formulation to reduce costs; 2) developing new products for infants and young children, which would deliver the nutrient density required for growth and development.