Effect of Postoperative Ketorolac Administration on the Union Rate Following First Metatarsophalangeal Joint Arthrodesis.

BACKGROUND: To decrease postoperative opioid consumption, nonsteroidal anti-inflammatory drugs (NSAIDs), including ketorolac, are considered a proper substitute with few side effects. Our null hypothesis is that a standard-dose, short-term ketorolac exposure does not increase the nonunion rate of a first metatarsophalangeal joint (MTPJ) arthrodesis. METHODS: In a retrospective cohort study, we included 181 primary first MTPJ arthrodeses from 2016 to 2020 in a single surgeon practice. The surgical technique was identical using a dorsal locking plate after preparing the joint with the cup-and-cone technique. A 30 mg intravenous dose of ketorolac was administered perioperatively, followed by a post-operative oral course of 10 mg oral ketorolac every 6 hours for 5 consecutive days. Patients were placed in a heel weight-bearing CAM boot for a minimum of 6 weeks. Union was determined radiographically at 3 months postoperative. Radiographic nonunion was also categorized clinically as symptomatic versus asymptomatic. RESULTS: At 3 months postoperative, a nonunion occurred in 15 (8.3%) patients. Of the 15 radiographic nonunions, 7 (45%) were clinically asymptomatic, while the other 8 (55%) were symptomatic. Six (75%) of the 8 symptomatic nonunions ultimately underwent revision surgery. The nonunion rate in our study compared to that described in the literature (5.4%) was similar and showed no significant difference (P = .067). CONCLUSION: The use of a short course of oral ketorolac (40 mg/day or less for a maximum of 5 days) does not seem to affect the union rate after first MTPJ arthrodesis and can be used safely and effectively in the management of post-operative pain to decrease opioid consumption following this procedure. LEVELS OF EVIDENCE: Level 4.

Postoperative Considerations in the Management of Hallux Valgus.

Postoperative management of hallux valgus varies widely. Setting preoperative expectations is an important aspect of attaining a successful outcome, but this is not routinely reviewed in the literature. This chapter offers suggestions on successfully navigating this area of patient care. Current concepts focus on pain control, immobilization, and return to activities. This chapter also reviews the current literature in these areas and sets out the authors' preferred management in the postoperative setting.

Trans- Cis Proline Switches in a Pentameric Ligand-Gated Ion Channel: How They Are Affected by and How They Affect the Biomolecular Environment.

Pentameric ligand-gated ion channels (pLGICs) are important neuroreceptors, embedded in neuronal membranes, that mediate fast synaptic transmission. The molecular details of their working mechanisms have still to be fully unravelled due to their complexity and limited structural information available. Here we focus on a potential molecular switch in a prototypical pLGIC, the serotonin-activated 5-HT3 receptor, consisting of the trans- cis isomerization of a proline at the interface between the extracellular and transmembrane domain. Mutagenesis electrophysiology experiments previously showed that if such isomerization could not take place, the channel would not open, but the hypothetical role of this mechanism as key to channel gating is still debated. We investigate this switch within the receptor with molecular dynamics and enhanced sampling simulations. We analyze how the isomerization free energy landscape is affected by the receptor environment in comparison to simplified models. Moreover, we reveal how the isomerization, in turn, affects the structural and electrostatic properties of the receptor at the extracellular-transmembrane domain interface, e.g., by tuning the ion selectivity filter.

Current Concepts in the Evaluation and Management of Type II Superior Labral Lesions of the Shoulder.

BACKGROUND: Superior labrum tears extending from anterior to posterior (SLAP lesion) are a cause of significant shoulder pain and disability. Management for these lesions is not standardized. There are no clear guidelines for surgical versus non-surgical treatment, and if surgery is pursued there are controversies regarding SLAP repair versus biceps tenotomy/tenodesis. OBJECTIVE: This paper aims to briefly review the anatomy, classification, mechanisms of injury, and diagnosis of SLAP lesions. Additionally, we will describe our treatment protocol for Type II SLAP lesions based on three groups of patients: throwing athletes, non-throwing athletes, and all other Type II SLAP lesions. CONCLUSION: The management of SLAP lesions can be divided into 4 broad categories: (1) nonoperative management that includes scapular exercise, restoration of balanced musculature, and that would be expected to provide symptom relief in 2/3 of all patients; (2) patients with a clear traumatic episode and symptoms of instability that should undergo SLAP repair without (age < 40) or with (age > 40) biceps tenotomy or tenodesis; (3) patients with etiology of overuse without instability symptoms should be managed by biceps tenotomy or tenodesis; and (4) throwing athletes that should be in their own category and preferentially managed with rigorous physical therapy centered on hip, core, and scapular exercise in addition to restoration of shoulder motion and rotator cuff balance. Peel-back SLAP repair, Posterior Inferior Glenohumeral Ligament (PIGHL) release, and treatment of the partial infraspinatus tear with debridement, PRP, or (rarely) repair should be reserved for those who fail this rehabilitation program.

Aldosterone Antagonists or Renin-Guided Therapy for Treatment-Resistant Hypertension: A Comparative Effectiveness Pilot Study in Primary Care.

BACKGROUND: Uncontrolled treatment-resistant hypertension (TRH), i.e., blood pressure (BP, mm Hg) ≥140/≥90mm Hg in and out of office on ≥3 different BP medications at optimal doses, is common and has a poor prognosis. Aldosterone antagonist (AA) and renin-guided therapy (RGT) are effective strategies for improving BP control in TRH but have not been compared. METHODS: A comparative effectiveness TRH pilot study of AA vs. RGT was conducted in 4 primary care clinics with 2 each randomized to AA or RGT. The primary outcome was change in clinic BP defined by means of 5 automated office BP values. Eighty-nine patients with apparent TRH were screened and 44 met criteria for true TRH. RESULTS: Baseline characteristics of 20 patients in the AA (70% Black, 45% female, mean age: 57.4 years) and 24 patients in RGT (79% Black, 50% female, 57.8 years) arms were similar with baseline BP 162±5/90±3 vs. 153±3/84±3, respectively, P = 0.11/0.20. BP declined to 144±5/86±4 in AA vs. 132±4/75±3 in RGT, P = 0.07/0.01; BP was controlled to JNC7 (Seventh Joint National Committee Report) goal in 25% vs. 62.5%, respectively, P < 0.01. Although BP changes from baseline, the primary outcome, were not different (-17.6±5.1/-4.0±3.0 AA vs. -20.4±3.8/-9.7±2.0 RGT, P = 0.65/0.10.), more BP medications were added with AA than RGT (+0.9±0.1 vs. +0.4±0.1 per patient, P < 0.01). CONCLUSIONS: In this TRH pilot study, AA and RGT lowered BP similarly, although fewer additional medications were required with RGT. A larger comparative effectiveness study could establish the utility of these treatment strategies for lowering BP of uncontrolled TRH patients in primary care.

At-risk characteristics for hospital admissions and ED visits.

PURPOSE: The purpose of this study was to explore the factors associated with hospital utilization among infants and young children with complex chronic conditions (CCC). DESIGN AND METHODS: A descriptive, retrospective study was conducted with 216 medical records of children with CCC. RESULTS: Greater complexity, younger age, living with siblings, use of public insurance or self-pay, use of more than one type of insurance, and presence of conditions affecting certain body systems were associated with increased hospital and emergency department (ED) utilization. PRACTICE IMPLICATIONS: Nurses must have a heightened awareness of these at-risk characteristics to prevent avoidable hospital admissions and ED visits.

Factors influencing hospital admissions and emergency department visits among children with complex chronic conditions: a qualitative study of parents' and providers' perspectives.

Children with complex chronic conditions (CCC) have greater health care needs and use rates than children in general. Elevated health care use includes more frequent hospital admissions, longer hospital stays, and greater health care expenses. Prior studies have examined population characteristics associated with increased hospital admissions, emergency department (ED) use, and general healthcare use, yet few studies have investigated these events from the parents' or health care providers' point of view. The purpose of this study was to explore parents/caregivers' and health care providers' perceptions of the factors placing infants and young children with CCC at risk for or protecting them against hospital admissions and ED visits. Parents or primary caregivers participated in interviews, and health care providers in pediatric acute care, pediatric primary care, and emergency care participated in focus groups. Interview and focus group data were analyzed using directed content analysis and an ecological risk and protective factors model. The analysis revealed that parents/caregivers and health care providers described risk factors and protective factors on multiple ecological levels surrounding the child with CCC. This article presents these findings, which add to current knowledge of factors influencing hospital admissions and ED visits and may be used to inform interventions addressing high health care utilization in this population. This article concludes with the implications of the findings for future research and nursing practice.

Hyaluronan Does Not Affect Bupivacaine's Inhibitory Action on Voltage-Gated Potassium Channel Activities in Bovine Articular Chondrocytes.

Objectives. The objective of this paper is to determine if hyaluronan affects bupivacaine's anesthetic function. Methods. Whole cell patch clamp recordings were performed on bovine articular chondrocytes cultured in 60 mm dishes. The chondrocytes were treated with phosphate-buffered saline (control group), 7.5 mg/mL hyaluronan (Orthovisc), 0.25% bupivacaine, or a mixture of 7.5 mg/mL hyaluronan and 0.25% bupivacaine. Outward currents were elicited by step depolarization from -90 mV to 150 mV with 5 mV increments and holding for 200 ms. Results. The amplitude of outward currents elicited at 150 mV was 607.1 ± 135.4 pA (mean ± standard error) in the chondrocytes treated with phosphate buffered saline, 550.0 ± 194.9 pA in the chondrocytes treated with hyaluronan, 18.4 ± 8.3 pA in the chondrocytes treated with bupivacaine, and 12.8 ± 2.6 pA in the chondrocytes treated with a mixture of hyaluronan and bupivacaine. Conclusion. Hyaluronan does not affect bupivacaine's inhibitory action on the potassium channel activities in bovine articular chondrocytes. This finding suggests that intra-articular injection of a mixture of hyaluronan and bupivacaine may not affect the anesthetic effects of bupivacaine.

Hyaluronan protects bovine articular chondrocytes against cell death induced by bupivacaine at supraphysiologic temperatures.

BACKGROUND: Bupivacaine and supraphysiologic temperature can independently reduce cell viability of articular chondrocytes. In combination, these 2 deleterious factors could further impair cell viability. HYPOTHESIS: Hyaluronan may protect chondrocytes from death induced by bupivacaine at supraphysiologic temperatures. STUDY DESIGN: Controlled laboratory study. METHODS: Bovine articular chondrocytes were treated with hyaluronan at physiologic (37°C) and supraphysiologic temperatures (45°C and 50°C) for 1 hour and then exposed to bupivacaine for 1 hour at room temperature. Cell viability was assessed at 3 time points: immediately after treatment, 6 hours later, and 24 hours later using flow cytometry and fluorescence microscopy. The effects of hyaluronan on the levels of sulfated glycosaminoglycan in the chondrocytes were determined using Alcian blue staining. RESULTS: (1) Bupivacaine alone did not induce noticeable chondrocyte death at 37°C; (2) bupivacaine and temperature synergistically increased chondrocyte death, that is, when the chondrocytes were conditioned to 45°C and 50°C, 0.25% and 0.5% bupivacaine increased the cell death rate by 131% to 383% in comparison with the phosphate-buffered saline control group; and (3) addition of hyaluronan reduced chondrocyte death rates to approximately 14% and 25% at 45°C and 50°C, respectively. Hyaluronan's protective effects were still observed at 6 and 24 hours after bupivacaine treatment at 45°C. However, at 50°C, hyaluronan delayed but did not prevent the cell death caused by bupivacaine. One-hour treatment with hyaluronan significantly increased sulfated glycosaminoglycan levels in the chondrocytes. CONCLUSION: Bupivacaine and supraphysiologic temperature synergistically increase chondrocyte death, and hyaluronan may protect articular chondrocytes from death caused by bupivacaine. CLINICAL RELEVANCE: This study provides a rationale to perform preclinical and clinical studies to evaluate whether intra-articular injection of a mixture of bupivacaine and hyaluronan after arthroscopic surgery may protect against bupivacaine's chondrotoxicity.

SC AHEC family practice residency program graduates: where are they, who do they serve, and what services do they provide?

The findings of this study of family practice program graduates are consistent with the mission of SC AHEC "to educate and retain primary health care providers." The graduates of these programs are providing a variety of medical services to a diverse patient population in South Carolina and surrounding states.