Nonsteroidal Anti-Inflammatory Drug Injections versus Steroid Injections in the Management of Upper and Lower Extremity Orthopedic Conditions: A Systematic Review with Meta-Analysis.

BACKGROUND: Although corticosteroid injections are an effective treatment for musculoskeletal pathologies, they may not be suitable for all patients. The purpose of this systematic review was to compare clinical outcomes between patients who received NSAID and corticosteroid injections for various orthopedic conditions. METHODS: Medline, Embase, Web of Science, and Cochrane Central Register of Controlled Trials were searched, and meta-analyses were performed using a random-effects model for outcomes presented in three or more studies. Other studies were qualitatively analyzed. RESULTS: A total of 28 articles with 2113 patients were included. A meta-analysis of five studies in patients with shoulder impingement syndrome demonstrated that there was no significant difference in the pain visual analogue scale (VAS) between subacromial NSAID injections and corticosteroid injections at 1 month [weighted mean difference (WMD) -0.244; 95% CI, -1.232 to 0.745; I2, 94.5%]. For patients with knee osteoarthritis, a meta-analysis of three studies demonstrated that there was no significant difference between intraarticular NSAID injections and corticosteroid injections in pain VAS at 1 month (WMD 0.754; 95% CI, -0.413 to 1.921; I2, 90.2%) and 3 months (WMD-0.089; 95% CI, -0.345 to 0.166; I2, 0%). A review of the studies assessing pain outcomes for hip osteoarthritis, adhesive capsulitis, and plantar fasciitis showed no significant differences between the NSAID and corticosteroid groups. CONCLUSION: NSAID injections may be safe and effective alternatives to steroid injections, especially in shoulder impingement syndrome and knee osteoarthritis.

Rib Fractures in Professional Baseball Pitchers: Mechanics, Epidemiology, and Management.

Pitching is a complex kinetic chain activity requiring the transfer of energy from the lower body, through the core and trunk, and finally through the arm to generate explosive acceleration of the baseball. As a result, large forces are generated in the trunk musculature and rib attachments from the late cocking phase of pitching through deceleration. The repetitive cumulative load and high pitch velocities put professional pitchers at risk of rib stress fracture. Given the potential for a prolonged recovery course and high rate of recurrence, early recognition of rib bone stress injury is critical to optimize care. Identifying torso strength imbalances, suboptimal pitching biomechanics (such as late or inadequate pelvic rotation), as well as metabolic deficiencies that may adversely affect bone health are essential to expedite safe return to play and prevent future injury. In this review, we discuss risk factors, mechanism of injury, typical clinical presentation, diagnostic imaging findings, and propose treatment and prevention strategies for rib stress fractures in overhand pitchers.

Clinical evaluation and management of calcific tendinopathy: an evidence-based review.

Calcific tendinopathy (CT) is an important musculoskeletal condition most commonly seen in the shoulder girdle, accounting for 10-42% of all shoulder pain. Despite the high prevalence within the shoulder region, CT has been demonstrated in many tendons throughout the axial and appendicular skeleton. Unlike degenerative tendinopathies, CT appears to be a self-limiting condition that affects otherwise-healthy tendon with deposition of calcium hydroxyapatite crystals between healthy tenocytes. In patients with functionally limiting symptoms or pain, the clinical course may be accelerated through a multitude of treatments including physical therapy and pain management, extracorporeal shock wave therapy, ultrasound-guided percutaneous lavage (UGPL), and operative debridement. Currently, the most efficacious and frequently utilized treatment for shoulder CT is UGPL due to its ability to effectively reduce calcium burden and pain while limiting soft-tissue damage. However, more evidence regarding the treatment and course of CT is needed before determining the most appropriate treatment at all potential sites of CT.

False Elevation of Volume Determined by Bladder Scanner Secondary to Bowel Obstruction.

Bladder scanners allow for quick determination of bladder volumes (BV) with minimal training. BV measured by a machine is generally accurate; however, circumstances exist in which falsely elevated BVs are reported. This case details a patient with a significant small bowel obstruction (SBO) due to superior mesenteric artery syndrome causing a falsely elevated BV. We believe this is the first case report of a SBO causing an elevated BV by bladder scanner. Emergency physicians should be aware of the pitfalls of using bladder scanners, and use their point-of-care ultrasound skills when possible to expand their differential.

Transient transcriptional silencing alters the cell cycle to promote germline stem cell differentiation in Drosophila.

Transcriptional silencing is a conserved process used by embryonic germ cells to repress somatic fate and maintain totipotency and immortality. In Drosophila, this transcriptional silencing is mediated by polar granule component (pgc). Here, we show that in the adult ovary, pgc is required for timely germline stem cell (GSC) differentiation. Pgc is expressed transiently in the immediate GSC daughter (pre-cystoblast), where it mediates a pulse of transcriptional silencing. This transcriptional silencing mediated by pgc indirectly promotes the accumulation of Cyclin B (CycB) and cell cycle progression into late-G2 phase, when the differentiation factor bag of marbles (bam) is expressed. Pgc mediated accumulation of CycB is also required for heterochromatin deposition, which protects the germ line genome against selfish DNA elements. Our results suggest that transient transcriptional silencing in the pre-cystoblast "re-programs" it away from self-renewal and toward the gamete differentiation program.

Transposon Dysregulation Modulates dWnt4 Signaling to Control Germline Stem Cell Differentiation in Drosophila.

Germline stem cell (GSC) self-renewal and differentiation are required for the sustained production of gametes. GSC differentiation in Drosophila oogenesis requires expression of the histone methyltransferase dSETDB1 by the somatic niche, however its function in this process is unknown. Here, we show that dSETDB1 is required for the expression of a Wnt ligand, Drosophila Wingless type mouse mammary virus integration site number 4 (dWnt4) in the somatic niche. dWnt4 signaling acts on the somatic niche cells to facilitate their encapsulation of the GSC daughter, which serves as a differentiation cue. dSETDB1 is known to repress transposable elements (TEs) to maintain genome integrity. Unexpectedly, we found that independent upregulation of TEs also downregulated dWnt4, leading to GSC differentiation defects. This suggests that dWnt4 expression is sensitive to the presence of TEs. Together our results reveal a chromatin-transposon-Wnt signaling axis that regulates stem cell fate.