Ketorolac Injections for Musculoskeletal Conditions: A Narrative Review.

Musculoskeletal conditions of the upper and lower extremities are commonly treated with corticosteroid injections. Ketorolac, a parenteral nonsteroidal anti-inflammatory drug, represents an alternative injectant for common shoulder, hip, and knee conditions. A review of the current literature was conducted on the efficacy of ketorolac injection in musculoskeletal diseases. Several studies support the use and efficacy of ketorolac injection in subacromial bursitis, adhesive capsulitis, and hip and knee osteoarthritis. Given the systemic effects of glucocorticoid injections, ketorolac may be a safe and effective alternative in patients with musculoskeletal disease. However, more evidence is required to better understand the effects ketorolac has on the human body during inflammatory processes.

Sports and Weight Control in Children.

Pediatric obesity is a global concern with distressing comorbid conditions, including mood disturbance, cardiovascular changes, endocrine imbalance, liver disease, sleep apnea, and orthopedic conditions. The primary treatment of this condition includes physical activity. Participating in organized sports has been shown to reduce weight and the complications of pediatric obesity more effectively than individual exercise.

Ultrasound Measurement of Femoral Articular Cartilage Thickness Before and After Marathon Running.

OBJECTIVE: The purpose of this study was to use ultrasonography to measure femoral articular cartilage thickness changes during marathon running, which could support MRI studies showing that deformation of knee cartilage during long-distance running is no greater than that for other weight-bearing activities. MATERIALS AND METHODS: Participants included 38 marathon runners with no knee pain or history of knee injury, aged 18-39. Ultrasound images of the femoral articular cartilage were taken two hours before and immediately after the race. Femoral articular cartilage thickness was measured at both the medial and lateral femoral condyles. RESULTS: The maximum change in femoral articular cartilage thickness, measured at the left outer lateral femoral condyle, was 6.94% (P=.006). All other femoral articular cartilage thickness changes were not significant. CONCLUSION: A change in femoral articular cartilage thickness of 6.94% supports our hypothesis that long-distance running does not induce deformational changes greater than that of regular daily activities. This study using ultrasonography supports MRI evidence that knee cartilage tolerates marathon running well.

Ankle Telemedicine Planning Considerations.

A virtual medical visit, also known as telemedicine or telehealth, is a valuable alternative method of providing health care to patients who do not have easy access to a hospital, or during times when limited social interaction is crucial such as our current COVID-19 pandemic. A virtual approach to evaluating musculoskeletal system ailments is particularly challenging, for diagnosis of these conditions generally rely greatly on physical examination, which may be challenging. However, a properly planned and executed telemedicine visit will yield successful results in most cases. Our aim is to produce a document with instructions and suggestions, including physical examination maneuvers, to help physicians carry out a proper virtual medical visit with patients complaining of ankle musculoskeletal problems. Virtual visits should not be thought of as a replacement for traditional face-to-face medical consultations, but rather a complementary method to provide health care when deemed appropriate. By following this guide, and tailoring it to the specific case at hand, medical providers should be able to effectively carry out a successful telemedicine consultation for musculoskeletal ailments relating to the ankle.Levels of Evidence: Level V.

A Schatzker Type III Tibial Plateau Fracture in a Soccer Player: A Case Report.

The tibial plateau is an important load-bearing surface in the knee, and when fractured, there is subsequent loss of motion and stability. These fractures typically result from axial loading and twisting. Our case outlines a tibial plateau fracture in a 15-year-old soccer player. The physical examination was positive for a decreased range of motion, pain with valgus stress, and positive ballottement. Radiography of the knee revealed joint effusion but no definite fracture. MRI revealed a Schatzker Type III fracture and a partial medial collateral ligament (MCL) tear. Our patient was referred for open repair and internal fixation. The Schatzker classification system is divided by type and location of fracture. Types I through III are located laterally, Type IV is medial, Type V identifies bicondylar fractures, and Type VI identifies tibial diaphysis separation from the metaphysis. These fractures are managed both nonoperatively and operatively. Nonoperative management is recommended for minimally displaced fractures that will heal without notable deformity. Operative management is indicated for displaced and unstable fractures, which include all fracture Types IV through VI, and certain Type I through III fractures that have valgus alignment or large articular surface involvement. Recovery time is lengthy and largely dependent on the fracture type. The first six weeks usually involve non-weightbearing, the second six weeks include weightbearing as tolerated, with knee range of motion exercises and muscle strengthening. Although open repair and internal fixation usually provide good results, some athletes cannot return to their previous levels of activity.

Peri-Operative Method of Applying Chlorhexidine and Iodine as Skin Preparation Solutions: Does It Matter? A Literature Review.

Background: Surgical site infection (SSI) is an adverse event that can lead to increased pain, increased cost, risk of death, and decreased patient satisfaction. Studies have investigated the best solutions to prevent SSI. Chlorhexidine has been suggested as the most efficacious antiseptic. However, scant data exist on application of antiseptic solutions and effectiveness of concentric versus back-and-forth strokes. Because a specific method may result in better outcomes, we aimed to review the literature to compare these two techniques. Methods: PubMed-indexed articles were reviewed using specific keywords, including "back-and-forth," "concentric circle," "chlorhexidine," "iodine," "surgical site infection," "antiseptic," and "skin preparation." Because data showing the correlation between SSI and application method of skin preparation solutions were scant, studies that described skin preparation method but analyzed other types of infection, bacteremia, or colonization were also included in this review. Results: No consensus was found regarding the application method. Two articles showed the superiority of chlorhexidine applied using the back-and-forth technique, whereas one demonstrated the superiority of iodine applied in concentric circles. Conclusions: The method of applying antiseptic solution may be just as important as the choice of solution. More studies are needed to assess method of antiseptic application.

Emergency Airway Management During Awake Craniotomy: Comparison of 5 Techniques in a Cadaveric Model.

BACKGROUND: During awake craniotomy, securing the patient's airway might be necessary electively or emergently. The objective of this study was to compare the feasibility of airway management using a laryngeal mask airway (LMA) and 4 alternative airway management techniques in an awake craniotomy simulation. METHODS: After completing a questionnaire, 9 anesthesia providers attempted airway management in a cadaver positioned to simulate awake craniotomy conditions. Following the simulation, participants rated and ranked the devices in their order of preference. RESULTS: Only 3 approaches resulted in the successful securement of an airway device for 100% of participants: LMA (median; interquartile range time to secure the airway 6 s, 5 to 10 s), fiberoptic bronchoscopy through an LMA (41 s; 23 to 51 s), and video laryngoscopy (49 s; 43 to 127 s). In contrast, the oral and nasal fiberoptic approaches demonstrated only 44.4% (154.5 s; 134.25 to 182 s) and 55.6% (75 s; 50 to 117 s) success rates, respectively. The LMA was the fastest and most reliable primary method to secure the airway (P=0.001). After the simulation, 100% of participants reported that an LMA would be their first choice for emergency airway management, followed by fiberoptic intubation through the LMA (7 of 9 participants) if the LMA failed to properly seat. CONCLUSIONS: We demonstrated that an LMA was the fastest and most reliable primary method to secure an airway in a laterally positioned cadaver with 3-pin skull fixation. Fiberoptic and video laryngoscope airway equipment should be readily available during awake craniotomy procedures, and an attempt to visualize the vocal cords through the LMA should be attempted before removing it for alternative techniques.

Correlation of Pre-Race Anxiety Using the Generalized Anxiety Disorder 2-Item Scale.

An estimated 40 million adults in the United States have been diagnosed with an anxiety disorder, making it the most common psychiatric disorder in the country. Although the data are conflicting and limited, engaging in or increasing exercise has been proposed for the management of anxiety and other mental health disorders. The purpose of this study was to determine if there is a correlation between pre-race anxiety and running experience, sex, body mass index, age, and mental health history using the validated Generalized Anxiety Disorder 2-Item screening tool for anxiety. This study was a prospective trial of 403 adult runners who were scheduled to participate in a 5 K, 10 K, half marathon, or full marathon race. Each participant completed a survey consisting of epidemiologic variables and the Generalized Anxiety Disorder 2-Item screening tool. Results revealed that the runners with more experience and increased mileage demonstrated a decrease in reported worrying on a daily to near-daily basis; whether this finding correlates with a decreased risk of developing an anxiety disorder has yet to be determined. Based on our findings, exercise as a prescription for the treatment and possibly prevention of anxiety should be considered.

Cervical Spine Evaluation by Telephone and Video Visit.

As telecommunication technologies advance, efforts are being made to mitigate direct patient contact in the COVID-19 pandemic due to the risk of contagion. The ability to host telephone and video visits within patient portals within health care institutions will only become increasingly valuable. Neck pain, a common complaint seen in primary care clinics, is well-suited to telemedicine evaluation, as related etiologies are often comparatively straightforward. A good assessment of the cervical spine by telephone or video is possible with the right knowledge and practice. The purpose of this article is to propose questions and maneuvers that can be used to evaluate the cervical spine via telephone or video, as well as likely diagnoses that can be reached through these. Phone and video evaluation of the cervical spine can result in valuable data regarding symmetry, range of motion, functional movement patterns, modified strength testing, and provocative testing. The skill set necessary to do telephone and video visits should be included in the curriculum of physician learners.

Do patients' characteristics influence their healthcare concerns?-A hospital care survey.

BACKGROUND: Hospital performance is often monitored by surveys that assess patient experiences with hospital care. Certain patient characteristics may shape how some aspects of hospital care are viewed and reported on surveys. OBJECTIVE: The aim of the study was to examine factors considered important to patients and determine whether there were differences in answers based on age, gender, or educational level. METHODS: Cross-sectional study based on a hospital survey developed via literature review and specialist recommendations. This study included randomly selected patients 18 years or older who were recently admitted to the hospital or admitted more than 50 days before the survey was being applied. Survey domains included age, gender, educational level, factors considered important for the health care in a hospital setting and sources of information about hospital quality used by each subject. Answers description and statistical analysis using Fisher exact test were performed. RESULTS: The survey was applied to 262 patients who were admitted under different services. The most important concern reported was the risk of getting a hospital-acquired infection (67.18%), followed by understanding explanation from the doctors' plans (64.12%) and doctors' ability to listen carefully (58.78%). Women are more concerned about their risk of falling (p = 0.03). Patients older than 65 years find important that the doctors explain everything in a way they can easily understand (p = 0.02), while lower educated patients consider most if the doctor treats them with courtesy and respect (p = 0.0027). CONCLUSION: Patient characteristics have an effect on how hospital care is perceived. Regardless of the characteristics of the population, the risk of getting an infection was the main concern overall, so it is important that hospitals promote actions to prevent it and share them with patients.

Women's Health Information Survey: Common Health Concerns and Trusted Sources of Health Information Among Different Populations of Female Patients.

Background: Women are more likely to search for information on behalf of both themselves and others, thus making them a valuable target for health information research. The purpose of this project was to identify and compare the most important medical concerns and sources of health information trusted by women in relationship to demographic differences in two different clinical settings within the same geographic area (Mayo Clinic Department of Family Medicine and Beaches Community Health care-a Sulzbacher Center Clinic). Methods: A novel survey tool was developed to obtain information regarding the age, race, and socioeconomic demographics of patients as well as the patients' personal significant medical concerns and trusted sources of health information. Results: Despite the huge development of health care information delivery through online resources, in our study, the majority of patients from both clinics still used and viewed their primary care provider as the most trusted source of health information. The health concerns most reported by both populations included cardiac health, breast and other cancers, and obesity; meanwhile, mental health was significantly more reported by patients from the free clinic. Conclusions: Education level may be an important factor of the awareness and ultimate treatment and prevention of these prevalent diseases. Furthermore, our study results may help improve patient satisfaction, knowledge, and health outcomes.

Scaphoid Cortical Desmoid in a Snowboarder With Persistent Wrist Pain.

A 28-year-old man presented to our clinic with persistent left wrist pain. Three months earlier, he had fallen on an outstretched hand while snowboarding. Initial radiographs showed no fractures or dislocations; however, magnetic resonance imaging revealed evidence of a dorsal projection from the scaphoid waist. There was no evidence of a scaphoid wrist fracture, scapholunate ligament disruption, or injury. The final diagnosis was avulsive cortical irregularity or cortical desmoid, which pertains to new bone formation at sites of muscle insertion. The literature has identified cases found in the deltoid, latissimus dorsi, adductor magnus muscles, and gastrocnemius insertion; however, it has never been reported in the scaphoid region. The proposed mechanism, in this case, is the repetitive pull on the radioscaphoid ligament. Avulsive cortical irregularities are benign conditions that mimic malignant conditions radiologically and microscopically. It is therefore important not to mistake this lesion for more worrisome lesions such as osteosarcoma or fibrosarcoma to avoid unnecessary procedures. In the incidental setting, no further imaging is necessary. If the patient presents with pain, atypical radiographical findings, or a suspicion of malignancy, a magnetic resonance image can provide valuable information and confirmation of diagnosis.

Caffeine Intake and Mental Health in College Students.

Background The effect of caffeine on the human body, both short-term and long-term, has been studied in great depth, particularly its association with psychiatric disorders. This study aims to investigate whether there is a correlation between caffeine intake and anxiety and depression among college students. Methodology A survey was administered to college students at Florida State University. Data regarding participant characteristics and caffeine intake were collected. Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9 scores were used to assess symptoms of anxiety and depression, respectively. Results A total of 114 participants were included in the survey, consisting mainly of women (94 [82.5%]) and junior-level students (37 [32.5%]). The main source of caffeine was coffee (64.0%), and the main reasons for caffeine intake were pleasure (43.9%) and to study outside of class (29.8%); however, no association was found between sex or grade point average and number of cups of caffeine consumed. Upper levels of education (super senior or fifth-year students), depressive symptoms (poor appetite, overeating, sleep disorders, depressed mood), and anxiety were statistically associated with greater caffeine intake (P < 0.05). Conclusions As caffeine is commonly consumed and our study showed that its intake was associated with depressive symptoms and higher levels of anxiety in college students, further studies are needed to determine a possible causality, so that measures may be taken to educate these students about alternative methods for increasing energy and alertness.

Intraoperative management of thrombectomy for acute ischemic stroke: Do we need general anesthesia?

Since 2015, endovascular thrombectomy has been established as the standard of care for re-establishing cerebral blood flow in patients with acute ischemic stroke. Several retrospective observational studies and prospective clinical trials have investigated two anesthetic techniques for endovascular stroke therapy: general anesthesia (GA) and conscious sedation (CS). The recent randomized studies suggest that GA is associated with higher rates of successful recanalization and better functional independence at 3 months compared with the CS technique. However, CS techniques are highly variable, and there is currently a lack of consensus on which anesthetic approach is best in all patients. Numerous patient and procedural factors should ultimately guide the decision of whether GA or CS should be used for a particular patient.

Absence seizures and their relationship to depression and anxiety: Evidence for bidirectionality.

Absence seizures (AS), presenting as short losses of consciousness with staring spells, are a common manifestation of childhood epilepsy that is associated with behavioral, emotional, and social impairments. It has also been suggested that patients with AS are more likely to suffer from mood disorders such as depression and anxiety. This systematic review and meta-analysis synthesizes human and animal models that investigated mood disorders and AS. Of the 1019 scientific publications identified, 35 articles met the inclusion criteria for this review. We found that patients with AS had greater odds of developing depression and anxiety when compared to controls (odds ratio = 4.93, 95% confidence interval = 2.91-8.35, p < .01). The included studies further suggest a strong correlation between AS and depression and anxiety in the form of a bidirectional relationship. The current literature emphasizes that these conditions likely share underlying mechanisms, such as genetic predisposition, neurophysiology, and anatomical pathways. Further research will clarify this relationship and ensure more effective treatment for AS and mood disorders.

Induction of General Anesthesia and Mask Ventilation With a Full-Face Continuous Positive Airway Pressure Mask in a Patient With a Nose Deformity.

Mask ventilation (MV) is an essential component of airway management and can be lifesaving in situations where the placement of a secure airway device proves challenging. Effective MV requires a seal to be created between the mask and the face to maintain patency of the external airway structures and can be difficult in the setting of facial abnormalities or facial trauma. Here we describe a case in which a continuous positive airway pressure (CPAP) mask was used for anesthesia induction and MV in an 85-year-old man who underwent a plastic surgery reconstruction of the left nasal dorsum and ala following a Mohs surgery, which had prevented the use of conventional face mask. An effective seal was achieved, and anesthesia was successfully induced with the mask. We reviewed the literature and discussed alternative approaches for face mask use in the setting of facial abnormalities where the use of a conventional mask is unfeasible.

Bullous Disseminated Herpes Zoster: An Atypical Presentation.

Herpes zoster is an infection resulting from the reactivation of dormant varicella zoster virus (VZV) in a posterior dorsal root ganglion. It affects 50% of immunocompromised patients and, when the viral infection persists, it can lead to a process known as disseminated varicella zoster virus (dVZV). Here we discuss a case of a bullous presentation of VZV with a rapid evolution of disseminated herpes zoster in an immunocompromised patient. Maintaining a broad differential diagnosis is necessary for early diagnosis and treatment of atypical presentations of herpes zoster, which is imperative to avoid increasing morbidity and mortality.

Disseminated herpes zoster with cauda equina symptoms.

Herpes zoster is a common infection resulting from the reactivation of dormant varicella zoster virus in a posterior dorsal root ganglion. The typical dermatomal involvement includes the thoracic region, followed by the face and the cervical and lumbosacral regions, with 1% having disseminated disease. We present a rare case of an immunocompetent 85-year-old man presenting with herpes zoster at the L3-S2 dermatomes, that evolved to disseminated varicella zoster virus (dVZV), with radiologically and laboratory-confirmed lumbosacral plexopathy manifesting with cauda equina syndrome. Here we also discuss the diagnosis and complications of dVZV as well as treatment strategy. By maintaining a high degree of clinical suspicion and initiating early treatment, high-quality patient care and good outcomes are able to be achieved in cases like this.