Rural Suicide: Demographics, Causes, and Treatment Implications.

Suicide rates in rural areas are higher than urban areas and growing, with current treatment developments only exacerbating this discrepancy. Within individual factors, both age and gender relate to and intersect with personal values related to self-reliance and attitudes toward mental health difficulties and treatment to increase suicide risk. The lethality ubiquitous in rural environments and occupations is a leading factor in rural suicide rates, with other factors such as race alternately noted to be a key factor but with more mixed findings. The cultural values of rural communities as typically negative toward mental health disclosure and treatment contribute to the disengagement of rural communities from treatment that may otherwise prevent suicides, exacerbating the physical lack of treatment access many rural communities experience. Working within the primary care system alongside increased telehealth utilization are suggested to reduce rural suicide rates.

A positive tangent sign predicts the repairability of rotator cuff tears.

HYPOTHESIS: We hypothesize that patients with a positive tangent sign will have rotator cuff tears that are not able to be repaired primarily. METHODS: We performed a retrospective review of the charts of patients who had undergone surgery for repair of a rotator cuff tear. The operative note was reviewed to determine whether the cuff tear was primarily repaired. The magnetic resonance imaging study of each patient was reviewed to assess for a positive or negative tangent sign. The reviewer was blinded to the result of each measurement. RESULTS: Eighty-one patients met the inclusion criteria. Of the 79 included in our analyses, 17 had a positive tangent sign and 62 had a negative tangent sign. There was only 1 patient with a negative tangent sign who had an irreparable rotator cuff tear. There were 3 patients with a positive tangent sign who had a repairable rotator cuff. With a pretest prevalence of irreparable tears of 18.9%, a positive finding suggested a post-test probability of 82.3% with a positive tangent sign and a post-test probability of only 1.6% when the tangent sign was negative. CONCLUSION: Our results showed decision-making value in both a negative tangent sign and a positive tangent sign. The tangent sign is an easily performed and reproducible tool with good intraobserver and interobserver reliability that is a powerful predictor of whether a rotator cuff tear will be repairable.

Inpatient enoxaparin and outpatient aspirin chemoprophylaxis regimen after primary hip and knee arthroplasty: a preliminary study.

Our institution has used a thromboprophylaxis regimen consisting of inpatient enoxaparin and outpatient aspirin for patients at standard risk for venous thrombosis after hip and knee arthroplasty. We reviewed 500 cases using this protocol. Inpatient treatment with enoxaparin averaged 2.75 days, followed by a 28-day course of aspirin. The overall thrombosis rate was 0.6% (1 deep venous thrombosis and 2 pulmonary emboli). Bleeding requiring transfusion of 3 or more units of packed red blood cells occurred in 1.8% of the cases. Fifteen infections were noted, 14 superficial and 1 deep. This compared favorably with a control group of 500 patients using a 14-day course of enoxaparin followed by 14 days of aspirin. We believe that a brief course of inpatient enoxaparin and outpatient aspirin is a safe and effective form of thromboprophylaxis.

Anterior cruciate ligament femoral tunnel drilling through anteromedial portal: axial plane drill angle affects tunnel length.

PURPOSE: The purpose of this study was to correlate femoral tunnel length with axial drilling angle through the anteromedial portal. METHODS: Ten anatomically correct Sawbones knee models (Pacific Research Laboratories, Vashon, WA) were used for this study. With the knee flexed to 120°, tunnels were drilled through a simulated anterior medial portal with a custom outrigger guide. The guide provided consistently reproducible drilling angles of 20°, 40°, and 60° in the axial plane. Femoral tunnel lengths were recorded for each knee at each drilling angle. A 1-way analysis of variance (α = .05) was conducted to compare tunnel length in the 3 groups. Multiple comparisons were conducted by use of a Tukey post hoc test. RESULTS: The mean femoral tunnel lengths at 20°, 40°, and 60° were 37.0 mm, 36.9 mm, and 32.3 mm, respectively. The tunnels drilled at 20° and 40° were significantly longer than the 60° group (P < .001). CONCLUSIONS: Our findings suggest that drilling femoral tunnels through an anteromedial portal at an axial angle of 20° or 40° produces longer femoral tunnels than with an axial drilling angle of 60°. CLINICAL RELEVANCE: On the basis of this study, we recommend a 40° angle when approaching the lateral wall during femoral tunnel drilling through the anteromedial portal to optimize tunnel length while avoiding the acute angle and oblique entry of a 20° angle.

Mini-screw fixation for the treatment of proximal interphalangeal joint dorsal fracture-dislocations.

PURPOSE: Surgical intervention may be necessary to treat unstable dorsal fracture-dislocations of the proximal interphalangeal (PIP) joint of the hand. One method of stabilization is open reduction and internal fixation (ORIF). The purpose of this study was to assess the outcomes of ORIF for unstable dorsal fracture-dislocations of the PIP joint using mini-screws via a volar approach. METHODS: A retrospective chart review with clinical follow-up evaluation was performed on 9 patients who had ORIF for unstable dorsal fracture-dislocations of the PIP joint. The fracture fragment(s) from the middle phalangeal base were reduced and secured using mini-screws. RESULTS: A clinical evaluation was performed at an average of 42 months after surgery. The average arc of motion for the involved PIP joint was 70 degrees (range, 55 degrees -90 degrees ). The average PIP joint motion in the 2 patients with 1 fracture fragment was 85 degrees , and the average PIP joint motion for the remaining 7 patients was 65 degrees . One joint was subluxated with an intra-articular screw. Nine patients had an average flexion contracture of 14 degrees . Seven patients had no pain, and 2 had pain only with heavy activity. CONCLUSIONS: Open reduction and internal fixation of unstable dorsal PIP joint fracture-dislocations using mini-screws can be considered if the fracture fragment(s) can accommodate the screws. The procedure attempts to restore the concave contour of the middle phalangeal base and permits early protected range of motion. The procedure should be approached cautiously, especially in the presence of comminution. Proximal interphalangeal joint range of motion is usually compromised; 8 of our 9 joints had a residual flexion contracture. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.