Grit and postoperative opioid use after total joint arthroplasty.

INTRODUCTION: Perioperative multimodal protocols following total joint replacements have significantly decreased the amount of perioperative and postoperative opioids. Further identification of those requiring more or less opioids through individualisation, may further aid in reducing the amount prescribed. Therefore, the purpose of the study was to evaluate whether a patient's grit, the measurable psychological strength of character to persevere during hardship, measured by postoperative opioid consumption. METHODS: Consecutive patients who had undergone either primary or revision total knee arthroplasty (TKA) or total hip arthroplasty (THA) from February 2019 to August 2020 at our institution logged their opioid use for the first 2 weeks postoperatively, detailing the type, dosage, and number of narcotics they consumed. Those who completed their logs and a grit questionnaire had their average morphine equivalent dose (MED) and grit score calculated. Analysis was then performed to evaluate if any association existed between these 2 variables. RESULTS: There was no correlation between grit score and postoperative opioid consumption in the first 2 weeks following discharge after total joint arthroplasty. A total of 144 patients were eligible to participate and a total of 86 patients met inclusion criteria, 48 patients in the TKA group and 38 in the THA group. Of all patients, 63% were male. The average MED was 95.5 for THAs and 192 for TKAs. The average grit score was 4.23 for THAs and 4.19 for TKAs. CONCLUSIONS: There is not an apparent association between grit score and postoperative opioid consumption in the first 2 weeks after total joint arthroplasty. General psychological resiliency may not be an important predictor of postoperative opioid use with modern postoperative protocols.

Pyogenic flexor tenosynovitis due to Kingella kingae in an infant.

Pyogenic flexor tenosynovitis is relatively common but is seldom reported in young children. Kingella kingae is increasingly recognised as a causative agent. We report on an infant who presented with a palmar deep space infection and pyogenic flexor tenosynovitis caused by K. kingae K. kingae is a fastidious, often culture-negative, organism which has been increasingly recognised as a cause of paediatric orthopaedic infections, including flexor tenosynovitis. Clinical suspicion should be heightened, and antibiotic coverage broadened in the setting of a positive physical examination and negative blood cultures.

A radiologic determination of the different screw cutting patterns in cut and uncut orthopedic cortical screws using a novel imaging technique.

OBJECTIVE: We hypothesize that cut screws will deform in a manner that increases the core and outer diameters of the screw hole compared to uncut controls, and effects will be more pronounced in titanium screws. MATERIALS AND METHODS: We used biomechanical polyurethane foam blocks to simulate cortical bone. We organized four groups of stainless steel and titanium cut and uncut screws. Blocks were fitted with a jig to ensure perpendicular screw insertion. We imaged the blocks using digital mammography and measured them using PACS software. Power analysis determined a power of 0.95 and an alpha error of 0.05. RESULTS: Highly statistically significant differences in core diameter were found after cutting stainless steel and titanium screws. Cutting stainless steel screws increased core diameter by 0.30 mm (95% CI, 0.16 to 0.45; p < .001). Titanium screws' core diameter increased by 0.45 mm (95% CI, 0.30 to 0.61; p < .001). No significant differences were found in the outer diameters of stainless steel and titanium screws after cutting. CONCLUSION: Titanium and stainless steel screw tracts demonstrated screw core diameter and screw thread pattern deformation after cutting. Titanium screws demonstrated more significant effects.

Synovial chondromatosis of the flexor hallucis longus tendon sheath.

This case report discusses a rare case of secondary tenosynovial chondromatosis of the flexor hallucis longus (FHL). Synovial chrondomatosis is a rare, benign proliferative cartilaginous lesion arising from the synovial tissue or bursal lining of or near joints. When it is extra-articular, it is considered tenosynovial chondromatosis. The diagnosis is often delayed given the rarity of presentation and non-specific symptoms. The case was highly unusual in that hindfoot pain was caused by several centimetre-sized osteochondral bodies within the FHL tendon sheath. Anterior cheilectomy was performed. The patient returned to full activity following surgery without recurrence of the disease. The condition can be successfully treated operatively.

Impact of a Multidisciplinary Long-Term Opioid Therapy Safety Program at a Military Tertiary Academic Medical Center.

OBJECTIVE: In light of the ongoing opioid crisis, Naval Medical Center Portsmouth (NMCP) created the Long-Term Opioid Therapy Safety (LOTS) program to reduce risks and improve long-term opioid therapy outcomes. Our primary outcome was change in compliance with the recommended safety metrics. DESIGN: This is a retrospective cohort study performed at NMCP, a large military academic medical center providing comprehensive medical care to DoD beneficiaries. The NMCP LOTS program provides both patient and provider narcotic education as well as medical record auditing. The NMCP LOTS program promotes adherence to published CDC, the DVA, and DoD guidelines. METHODS: Anonymized data were compiled each fiscal quarter and were analyzed retrospectively. Adult patients prescribed opioids for at least 90 days without a gap of 30 days between prescriptions were included in this study. The investigators recorded and reported provider compliance with LOTS metrics over the same period. RESULTS: Compliance with the recommended safety metrics improved. We noted a decrease in the number of long-term opioid patients, concurrent benzodiazepine prescriptions, and patients prescribed greater than 90 morphine equivalents per day during the observation period. The number of naloxone prescriptions for LOTS patients also increased, reflecting improved guideline adherence. CONCLUSION: Systematic education and feedback to providers are effective in creating a system and culture of opioid reduction, safe opioid prescribing, and system accountability. This article presents a comprehensive approach to modifying prescribing patterns of long-term opioids in a large healthcare system.

Arterial Thoracic Outlet Syndrome in a Runner.

Thoracic outlet syndrome (TOS) most commonly manifests in overhead athletes (e.g., baseball pitchers, swimmers, weight lifters) due to nerve compression caused by skeletal abnormalities. We present the case of a 43-year-old recreational runner with unilateral upper extremity pain while running. Vascular imaging identified an aberrant subclavian artery origin with positional compression in the absence of cervical bone anomalies confirming arterial TOS. A first rib resection and anterior scalenectomy led to symptom resolution. This case emphasizes the importance of a broad differential and complete workup in non-overhead athletes presenting with symptoms consistent with neurogenic TOS, as vascular interventions may be necessary to prevent future complications.

Aromatase Inhibitor Symptom Management Practices: A Retrospective Study.

PURPOSE: Aromatase inhibitor (AI)-associated symptoms contribute to early therapy discontinuation. Although guidelines exist for management of these symptoms, little is known about the degree to which physicians address symptoms and adhere to the guidelines for treatment. PATIENTS AND METHODS: In this retrospective chart review, women with hormone receptor-positive breast cancer who were prescribed an AI between October 15, 2012, and September 14, 2017, were randomly selected from the institution's cancer registry. Patient medical records were reviewed to identify the prevalence of symptom documentation and management. Documented symptoms were categorized into musculoskeletal, vasomotor, and urogenital. Symptom treatment guidelines were compiled from the National Comprehensive Cancer Network (NCCN) and the American Cancer Society/American Society of Clinical Oncology (ACS/ASCO). Treatments were categorized as either meeting or not meeting the guidelines. Among patients with symptoms recorded, chi-square tests and time-to-event models were used to examine factors associated with treatment and factors associated with guideline-based treatment. RESULTS: Among 179 women prescribed an AI, 82% had at least one symptom and 46% had multiple symptoms. Of the 147 women with any documented symptom, 97 (66%) received some form of symptom-palliating treatment. Seventy-seven patients (52%) received guideline-based treatments or guideline-based treatments in combination with non-guideline-based treatments. There were no differences in receipt of treatment overall (ie, guideline based or non-guideline based) for either vasomotor or musculoskeletal symptoms by age, race, or stage. CONCLUSION: Although 82% of patients had symptoms documented in their medical records, just over half of those patients received guideline-based treatment.

A Strategy for Changing Adherence to National Guidelines for Decreasing Laboratory Testing for Early Breast Cancer Patients.

INTRODUCTION: Past studies indicate delays in adoption of consensus-based guideline updates. In June 2016, the National Comprehensive Cancer Network changed its guidelines from routine testing to omission of ordering complete blood cell count (CBC) and liver function tests (LFT) in patients with early breast cancer. In response, we developed an implementation strategy to discontinue our historical practice of routine ordering of these tests in asymptomatic patients. METHODS: The ordering of CBC and LFT for clinical stage I-IIIA breast cancer patients was audited in 2016. In June 2016, we utilized the levers of the National Quality Strategy implementation methodology to enact a system-wide change to omit routine ordering. To measure the plan's effectiveness, guideline compliance for ordering was tracked continually. RESULTS: Of 92 patients with early stage cancer in 2016, the overall rate of compliance with guidelines for ordering a CBC and LFT was 82% (88/107) and 87% (93/107), respectively. Segregated by the pre- and post-guideline change time period, the compliance rates for ordering a CBC and LFT were 78% and 87% (P = 0.076). CONCLUSION: In contrast to historical reports of delays in adoption of new evidence-based guideline changes, we were able to quickly change provider practice during the transition from routine ordering to omission of ordering screening blood tests in newly diagnosed patients with early breast cancer.

Homogenizing an urban habitat mosaic: arthropod diversity declines in New York City parks after Super Storm Sandy.

The frequency and intensity of hurricanes are increasing globally, and anthropogenic modifications in cities have created systems that may be particularly vulnerable to their negative effects. Organisms living in cities are exposed to variable levels of chronic environmental stress. However, whether chronic stress ameliorates or exacerbates the negative effects of hurricanes remains an open question. Here, we consider two hypotheses about the simultaneous consequences of acute disturbances from hurricanes and chronic stress from urbanization for the structure of urban arthropod communities. The tipping point hypothesis posits that organisms living in high stress habitats are less resilient than those in low stress habitats because they are living near the limits of their environmental tolerances; while the disturbance tolerance hypothesis posits that high stress habitats host organisms pre-adapted for coping with disturbance, making them more resilient to the effects of storms. We used a before-after-control-impact design in the street medians and city parks of Manhattan (New York City, New York, USA) to compare arthropod communities before and after Super Storm Sandy in sites that were flooded and unflooded during the storm. Our evidence supported the disturbance tolerance hypothesis. Significant compositional differences between street medians and city parks before the storm disappeared after the storm; similarly, unflooded city parks had significantly different arthropod composition while flooded sites were indistinguishable. These differences were driven by reduced occurrences and abundances of arthropods in city parks. Finally, those arthropod groups that were most tolerant to urban stress were also the most tolerant to flooding. Our results suggest that the species that survive in high stress environments are likely to be the ones that thrive in response to acute disturbance. As storms become increasingly common and extreme, this juxtaposition in responses to storm-associated disturbance may lead to diversity loss in cities, potentially leading entire urban landscapes to mirror the reduced diversity of street medians.

Responses of arthropod populations to warming depend on latitude: evidence from urban heat islands.

Biological effects of climate change are expected to vary geographically, with a strong signature of latitude. For ectothermic animals, there is systematic latitudinal variation in the relationship between climate and thermal performance curves, which describe the relationship between temperature and an organism's fitness. Here, we ask whether these documented latitudinal patterns can be generalized to predict arthropod responses to warming across mid- and high temperate latitudes, for taxa whose thermal physiology has not been measured. To address this question, we used a novel natural experiment consisting of a series of urban warming gradients at different latitudes. Specifically, we sampled arthropods from a single common street tree species across temperature gradients in four US cities, located from 35.8 to 42.4° latitude. We captured 6746 arthropods in 34 families from 111 sites that varied in summer average temperature by 1.7-3.4 °C within each city. Arthropod responses to warming within each city were characterized as Poisson regression coefficients describing change in abundance per °C for each family. Family responses in the two midlatitude cities were heterogeneous, including significantly negative and positive effects, while those in high-latitude cities varied no more than expected by chance within each city. We expected high-latitude taxa to increase in abundance with warming, and they did so in one of the two high-latitude cities; in the other, Queens (New York City), most taxa declined with warming, perhaps due to habitat loss that was correlated with warming in this city. With the exception of Queens, patterns of family responses to warming were consistent with predictions based on known latitudinal patterns in arthropod physiology relative to regional climate. Heterogeneous responses in midlatitudes may be ecologically disruptive if interacting taxa respond oppositely to warming.

Habitat and species identity, not diversity, predict the extent of refuse consumption by urban arthropods.

Urban green spaces provide ecosystem services to city residents, but their management is hindered by a poor understanding of their ecology. We examined a novel ecosystem service relevant to urban public health and esthetics: the consumption of littered food waste by arthropods. Theory and data from natural systems suggest that the magnitude and resilience of this service should increase with biological diversity. We measured food removal by presenting known quantities of cookies, potato chips, and hot dogs in street medians (24 sites) and parks (21 sites) in New York City, USA. At the same sites, we assessed ground-arthropod diversity and abiotic conditions, including history of flooding during Hurricane Sandy 7 months prior to the study. Arthropod diversity was greater in parks (on average 11 hexapod families and 4.7 ant species per site), than in medians (nine hexapod families and 2.7 ant species per site). However, counter to our diversity-based prediction, arthropods in medians removed 2-3 times more food per day than did those in parks. We detected no effect of flooding (at 19 sites) on this service. Instead, greater food removal was associated with the presence of the introduced pavement ant (Tetramorium sp. E) and with hotter, drier conditions that may have increased arthropod metabolism. When vertebrates also had access to food, more was removed, indicating that arthropods and vertebrates compete for littered food. We estimate that arthropods alone could remove 4-6.5 kg of food per year in a single street median, reducing its availability to less desirable fauna such as rats. Our results suggest that species identity and habitat may be more relevant than diversity for predicting urban ecosystem services. Even small green spaces such as street medians provide ecosystem services that may complement those of larger habitat patches across the urban landscape.