Patient-Reported Outcomes After Multiple-Revision ACL Reconstruction: Good but Not Great.

PURPOSE: To evaluate the patient-reported and objective functional outcomes of patients undergoing multiple-revision anterior cruciate ligament (ACL) reconstruction surgery. The secondary purpose was to determine failure rates and factors associated with failure, with a focus on posterior tibial slope. METHODS: All patients who underwent a repeat revision ACL reconstruction with a single surgeon over a 13-year period were identified. Chart data were obtained, including radiographic findings, operative details and findings, and postoperative examination findings. Failure was defined as subjective instability with evidence of graft incompetence on physical examination and MRI. Patients completed the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC-SKF) and Tegner Activity Level Scale. Patients who had outcomes scores completed a minimum of 2 years postoperatively were included. RESULTS: Fourteen patients were available for follow-up; 12 underwent secondary revision procedures, and 2 underwent tertiary revisions. Three patients (21%) had subsequent failure of the revision graft with mean time to failure of 27 months. Posterior tibial slope was significantly higher in the failures than in the nonfailures (13.3˚; 95% CI 10.1-16.6 versus 10.1˚; 95% CI 6.7-11.4; P = 0.049). Eleven patients completed outcomes measures at a mean of 42 months postoperatively (range 24-79 months). The mean Tegner activity score was 6.3 at follow-up, compared with 8.3 prior to the original ACL injury. The mean IKDC-SKF score was 70 at follow-up. CONCLUSION: Multiple revision ACL reconstruction surgery appears to have reasonable functional outcomes but is associated with a relatively high failure rate. Activity level following repeat revision surgery is diminished compared to the preinjury state, but most patients are able to return to recreational sports. LEVEL OF EVIDENCE: Therapeutic Study, Level IV.

Surgical Release of the Adductor Longus With or Without Sports Hernia Repair Is a Useful Treatment for Recalcitrant Groin Strains in the Elite Athlete.

BACKGROUND: Chronic strain and/or tendinopathy of the adductor longus tendon can be a cause of long-standing groin pain in the elite athlete, resulting in significant time lost from competition. Accurate diagnosis and treatment can expedite return to play. PURPOSE/HYPOTHESIS: To evaluate return to sport and performance in National Collegiate Athletic Association (NCAA) Division I football players and National Football League (NFL) players following adductor longus release with or without sports hernia repair. We hypothesized that adductor release will be an effective method of treatment for recalcitrant groin/adductor pain in these athletes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A cohort study was performed of all NFL players and NCAA Division I college athletes who had undergone an adductor longus tendon release with or without sports hernia repair by 1 of 2 fellowship-trained orthopaedic surgeons between May 1999 and January 2013. All patients reported groin pain below the inguinal ligament and localized to their adductor longus. Symptoms lasted longer than 10 weeks and limited their ability to effectively perform during sport, as assessed by their coach and self-assessment. Questionnaires were given to all 26 patients to assess long-term surgical outcomes. A subgroup analysis was performed for NFL players, in which "performance scores" were calculated according to individual player statistics while playing. Scores obtained before the diagnosis of chronic adductor longus tendinopathy or strain were compared with those after surgery. Patients with prior abdominal or pelvic surgery, radiographic evidence of degenerative joint disease of the hip, labral tears or femoral acetabular impingement, prostatic or urinary tract disease, or nerve entrapment of the ilioinguinal, genitofemoral, or lateral femoral cutaneous nerves were excluded from the study. RESULTS: A total of 32 athletes underwent an adductor longus tenotomy during the study period. Of these patients, 28 were college- or professional-level athletes who underwent an adductor longus tenotomy, with a mean ± SD follow-up time of 6.2 ± 4.2 years (range, 12-178 months). Of the 32 patients, 20 had a concomitant sports hernia repair in addition to an adductor longus tenotomy. Thirty-one patients (97%) were able to return to their previous sport, and 30 (94%) were able to return at their previous level of play. Thirty patients (94%) reported that they were satisfied with their decision to have surgery. No player complained of weakness or a decrease in running speed or power. Mean return to play was 12 weeks from date of surgery. In the subgroup analysis of 16 NFL players, there were no statistically significant differences for the pre- versus postoperative comparisons of the athlete performance scores (P = .74) and the percentage of the games started versus played (P = .46). After separation of players who had a concomitant hernia repair from players who did not, there was no statistically significant difference in performance scores or percentages of games started. CONCLUSION: In this study of elite athletes, adductor longus tenotomy with or without a concomitant sports hernia repair provided overall acceptable and excellent results. Athletes were able to return to their previous level of athletic competition and performance with consistent relief of groin pain. Return to play in an NFL game averaged 12 weeks following surgery.

Is Campus Rape Primarily a Serial or One-Time Problem? Evidence From a Multicampus Study.

We examined the prevalence and repeat offenses of college men, including fraternity men and student athletes, taking advantage of someone sexually while under the influence of alcohol. Preexisting data from the Core Alcohol and Other Drug Survey included a sample of 12,624 college men at 49 community and 4-year colleges. Results provide further evidence that the problem of campus rape is largely one of serial perpetration. More than 87% of alcohol-involved sexual assault was committed by serial perpetrators. Fraternity men and student athletes were significantly more likely to commit alcohol-involved sexual assault than other men on campus.

Arthroscopic Circumferential Labral Repair for Patients With Multidirectional Instability: A Comparative Outcome Study.

BACKGROUND: Circumferential tears of the glenohumeral labrum are an uncommon injury, comprising 2.4% of all labral lesions. Currently, the clinical outcomes of arthroscopic circumferential labral repair for patients with instability and combined anterior, posterior, and superior labral tears are not well-known. HYPOTHESIS: Patients treated with arthroscopic circumferential shoulder labral repairs will have inferior clinical outcomes and higher failure rates compared with patients who have isolated arthroscopic anterior labral repairs. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective cohort study was performed to identify patients aged 18 years and older who underwent circumferential arthroscopic stabilization for recurrent instability as compared with an age-matched control group of arthroscopic primary anterior labral repairs. Age at surgery, American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form score, Simple Shoulder Test (SST) score, 12-Item Short Form Health Survey (SF-12) score (mental and physical), and overall patient satisfaction with surgery were assessed for each group. RESULTS: A total of 35 consecutive patients (36 shoulders) who underwent an arthroscopic 360° circumferential labral repair were compared with a matched group of 31 patients who underwent an isolated arthroscopic anterior labral repair. The mean follow-up period was 34.3 and 56.8 months, respectively. No significant difference was found between the 2 groups for overall satisfaction with the surgery or recurrent instability. At the time of the follow-up survey, 22% of the patients experienced pain and 25% of the patients experienced instability in the circumferential repair group, whereas 15% of the patients experienced some level of pain and 30% of patients experienced a subjective sense of subtle instability in the isolated repair group. The ASES scores were 87.3 in the combined labral repair group and 93.3 in the isolated anterior group (P = .35), SST scores were 10.7 and 11.3 (P = .70), SF-12 mental scores were 54.6 and 56.8 (P = .80), SF-12 physical scores were 53.2 and 54.2 (P = .98), and age at time of the surgery was 26.7 and 24.6 years (P = .33), respectively. There was no difference between the 2 groups in pre- and postoperative range of motion (P > .05). CONCLUSION: There was no difference in shoulder stability and function in patients after 360° combined labral repairs versus anterior labral repair alone. With proper patient selection, patients can expect similar outcomes despite the more extensive surgical procedure and complex postoperative rehabilitation protocol for circumferential repairs.

Recruitment of Community College Students Into a Web-Assisted Tobacco Intervention Study.

BACKGROUND: United States college students, particularly those attending community colleges, have higher smoking rates than the national average. Recruitment of such smokers into research studies has not been studied in depth, despite a moderate amount information on study recruitment success with smokers from traditional four-year colleges. Recruitment channels and success are evolving as technology evolves, so it is important to understand how to best target, implement, and evaluate recruitment strategies. OBJECTIVE: The aim of this paper is to both qualitatively and quantitatively explore recruitment channels (eg, mass email, in-person referral, posted materials) and their success with enrollment into a Web-Assisted Tobacco Intervention study in this priority population of underserved and understudied smokers. METHODS: Qualitative research methods included key informant interviews (n=18) and four focus groups (n=37). Quantitative research methods included observed online responsiveness to any channel (n=10,914), responses from those completing online screening and study consent (n=2696), and responses to a baseline questionnaire from the fully enrolled study participants (n=1452). RESULTS: Qualitative results prior to recruitment provided insights regarding the selection of a variety of recruitment channels proposed to be successful, and provided context for the unique attributes of the study sample. Quantitative analysis of self-reported channels used to engage with students, and to enroll participants into the study, revealed the relative utilization of channels at several recruitment points. The use of mass emails to the student body was reported by the final sample as the most influential channel, accounting for 60.54% (879/1452) of the total enrolled sample. CONCLUSIONS: Relative channel efficiency was analyzed across a wide variety of channels. One primary channel (mass emails) and a small number of secondary channels (including college websites and learning management systems) accounted for most of the recruitment success. TRIAL REGISTRATION: ClinicalTrials.gov NCT01692730; https://clinicaltrials.gov/ct2/show/NCT01692730 (Archived by WebCite at http://www.webcitation.org/6qEcFQN9Q).

Tobacco Control at Community Colleges: Context and Opportunities.

INTRODUCTION: Tobacco use among United States college-aged students remains higher than that of the national average. While a majority of public health literature has explained smoking programs and policies at traditional four-year colleges and universities, little research exists on programs and policies at two-year community colleges. It is important to understand such efforts at these institutions as they have vastly different infrastructures and enroll a more diverse and at-risk student body compared to traditional four-year colleges. METHODS: The role of community colleges in health efforts aimed at smoking was examined at four community colleges. Qualitative research methods included 18 interviews and four focus groups (N=55), document review, and direct environmental observation. RESULTS: Community colleges offered a limited number of smoking cessation and secondhand smoke prevention initiatives. All colleges provided cessation literature, though additional programming varied by college. Indoor and outdoor smoking policies existed on all campuses though enforcement was problematic. Little evidence was found that current program and policy approaches are based upon best practices or are being employed successfully. CONCLUSIONS: Future tobacco control initiatives at community colleges need to require little infrastructure and minimal staffing, and be low cost. Cessation tools for students must be convenient, understandable, and accessible from multiple locations. Feasible approaches for future initiatives could include testing low cost technology such as Web Assisted Tobacco Interventions (WATI) and outside partnerships with community organizations and health agencies. Policy enforcement could be improved with tobacco policy education at orientation for students, faculty and staff.

Patient Outcomes and Predictors of Success After Revision Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Patient outcomes and predictors of success after revision anterior cruciate ligament (ACL) reconstruction are currently limited in the literature. Existing studies either have a small study size or are difficult to interpret because of the multiple surgeons involved in the care of the study sample. PURPOSE: To determine patient outcomes and predictors of success or failure after a single-stage revision ACL reconstruction by a single fellowship-trained senior surgeon at a single institution. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 78 patients who underwent revision ACL reconstruction by a single surgeon from 2010 to 2014 were contacted and available for follow-up. The mean time from revision procedure to follow-up was 52 months. Those patients who were able to participate in the study sent in a completed Tegner activity level scale, International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, and IKDC Current Health Assessment Form. The patients' medical records were also thoroughly reviewed. RESULTS: Five patients had subsequent failure after revision surgery. The median Tegner score was 6 at follow-up, and the mean subjective IKDC score was 72.5. There was no statistically significant difference in outcome scores when comparing revision graft type, body mass index, sex, need for bone grafting, and time from failure to revision. Patients with failures after primary ACL reconstruction secondary to a traumatic event were found to have statistically significantly higher IKDC scores (mean, 76.6) after revision when compared with nontraumatic failures (mean, 67.1), even when controlling for confounders (P < .017). CONCLUSION: Revision ACL reconstruction is effective in improving patient activity levels and satisfaction. However, the subjective IKDC results are quite variable and likely based on multiple factors. Patients with traumatic injuries contributing to graft failure after primary ACL reconstruction had a statistically significantly, although not clinically significant, higher IKDC score after revision surgery compared with nontraumatic failures. These data may be useful when counseling a patient on whether to pursue revision ACL reconstruction surgery.

Strontium isotopes test long-term zonal isolation of injected and Marcellus formation water after hydraulic fracturing.

One concern regarding unconventional hydrocarbon production from organic-rich shale is that hydraulic fracture stimulation could create pathways that allow injected fluids and deep brines from the target formation or adjacent units to migrate upward into shallow drinking water aquifers. This study presents Sr isotope and geochemical data from a well-constrained site in Greene County, Pennsylvania, in which samples were collected before and after hydraulic fracturing of the Middle Devonian Marcellus Shale. Results spanning a 15-month period indicated no significant migration of Marcellus-derived fluids into Upper Devonian/Lower Mississippian units located 900-1200 m above the lateral Marcellus boreholes or into groundwater sampled at a spring near the site. Monitoring the Sr isotope ratio of water from legacy oil and gas wells or drinking water wells can provide a sensitive early warning of upward brine migration for many years after well stimulation.

Surgical technique for treatment of recalcitrant adductor longus tendinopathy.

Chronic groin pain in the athlete can be a difficult problem to manage. Adductor dysfunction is the most common cause of groin pain in athletes, with the adductor longus being the tendon most commonly involved. The most reproducible finding for adductor longus tendinopathy is tenderness along the tendon with passive abduction and resisted hip adduction in extension. Magnetic resonance imaging and injection of a corticosteroid and anesthetic into the proximal muscle-tendon junction are both helpful in confirming the diagnosis. Nonoperative treatment may consist of protected weight bearing, ice application, ultrasonography, electrical stimulation, and gentle stretching with progressive strengthening. However, nonoperative management is not always successful. In these instances, surgical treatment can be quite effective. We present the indications, surgical technique, and rehabilitation protocol of adductor tenotomy for chronic tendinopathy. This can prove a useful tool for the treatment of recalcitrant groin pain attributable to the adductor longus.

Long-acting beta-agonists with and without inhaled corticosteroids and catastrophic asthma events.

BACKGROUND: It is unclear whether long-acting beta-agonists with concomitant inhaled corticosteroids increase asthma-related intubations and deaths. We pooled data on long-acting beta-agonists with variable and concomitant inhaled corticosteroids to evaluate the risk for catastrophic asthma events. METHODS: We conducted searches of electronic databases, the US Food and Drug Administration website, clinical-trials registries, and selected references through December 2008. We analyzed randomized controlled trials in patients with asthma, which lasted at least 3 months, evaluated long-acting beta-agonists compared with placebo or long-acting beta-agonists with inhaled corticosteroids compared with corticosteroids alone, and included at least 1 catastrophic event, defined as asthma-related intubation or death. RESULTS: In pooled trial data that included 36,588 participants, long-acting beta-agonists increased catastrophic events 2-fold (Peto odds ratio [OR] 2.10; 95% confidence interval [CI], 1.37-3.22). Statistically significant increases were seen for long-acting beta-agonists with variable corticosteroids compared with placebo (OR 1.83; 95% CI, 1.14-2.95) and for concomitant treatment with corticosteroids compared with corticosteroids alone (OR 3.65; 95% CI, 1.39-9.55). Similar increases in risk were seen for variable and concomitant corticosteroid use, salmeterol and formoterol, and children and adults. When the analysis was restricted to trials with controlled corticosteroid use, given as part of the study intervention, concomitant treatment still increased catastrophic events compared with corticosteroids alone (OR 8.19; 95% CI, 1.10-61.18). CONCLUSION: Long-acting beta-agonists increase the risk for asthma-related intubations and deaths, even when used in a controlled fashion with concomitant inhaled corticosteroids.

Variability in the quality of overdose advice in Summary of Product Characteristics (SPC) documents: gut decontamination recommendations for CNS drugs.

AIMS: Deliberate self-poisoning is a major cause of morbidity and mortality. The Summary of Product Characteristics (SPC) document is a legal requirement for all drugs, and Section 4.9 addresses the features of toxicity and clinical advice on management of overdose. The quality and appropriateness of this advice have received comparatively little attention. METHODS: Section 4.9 of the SPC was examined for all drugs in the central nervous system (CNS) category of the British National Formulary. Advice concerning gut decontamination was examined with respect to specific interventions: induced vomiting, oral activated charcoal, gastric lavage, and other interventions. Data were compared with standard reference sources for clinical management advice in poisoning. These were graded 'A' if no important differences existed, 'B' if differences were noted but not thought clinically important, and 'C' if differences were thought to be clinically significant. RESULTS: SPC documents were examined for 258 medications from 67 manufacturers. The overall agreement was 'A' in 23 (8.9%), 'B' in 28 (10.9%) and 'C' in 207 (80.2%). Discrepancies were due to inappropriate recommendation of induced emesis in 21.7% (95% confidence interval 17.1, 27.1), gastric lavage in 38.4% (32.7, 44.4), other gut decontamination in 5.8% (3.6, 9.4) and failure to recommend oral activated charcoal in 57.4% (51.1, 63.4). CONCLUSIONS: Gut decontamination advice in SPC documents with respect to CNS drugs was inadequate. Possible reasons for the observed discrepancies and ways of improving the consistency of advice are proposed.

When the party for some becomes a problem for others: the effect of perceived secondhand consequences of drinking behavior on drinking norms.

The authors examined the influence of fraternity men's expectancies regarding secondhand consequences of excessive drinking behavior on normative standards regarding alcohol use and consumption levels. Participants were 381 men from 26 chapters of 2 national fraternities. One organization participated in a brief intervention involving discussion of secondhand consequences of excessive drinking. Immediate influence of the intervention on perceived secondhand consequences of alcohol use was assessed using a posttest-only, randomized groups design. Results supported a hypothesized measurement model with 1 overall secondhand consequence expectancy construct and 4 subfactors: (a) Noise Disruptive of Sleep and Study, (b) Violence, (c) Sexual Assault, and (d) Property Damage. Cross-sectional analysis at the chapter and individual levels demonstrated that secondhand expectancies had an indirect effect on alcohol consumption, mediated by personal consumption standards for limiting alcohol consumption. The intervention had an effect on secondhand expectancies. Findings suggest that interventions with intact groups can increase secondhand expectancies regarding excessive drinking and may lead to a reduction in excessive alcohol consumption.

Electronic density of states of helically-wrapped carbon nanotubes.

Motivated by evidences of helical wrapping of polymeric molecules around nanotubes, we perform a systematic study of how the electronic density of states of nanotubes is affected by the introduction of a coiling polarizing potential. The coiling perturbation, characterized by the wrapping angle, the polarizing width and the polarization strength, introduces an additional geometrical chirality that may not necessarily coincide with the intrinsic chiral angle of the nanotube. Features of the electronic density of states are shown to depend on this perturbation with different degrees of sensitivity. When correlated with the binding energy between the nanotube and the wrapping molecule, we find that noticeable changes in the density of states occur only for minimally bound structures.

Impact of perceived second-hand consequences related to alcohol use on college students' drinking behavior intent: a test of feasibility.

This article presents the results of an experiment designed to determine the impact of a group discussion about second-hand consequences of alcohol use on college students' intentions to consume alcohol. Participants were students enrolled in two large Community Health courses at a large Midwestern university (n = 184). After randomization of class sections into an intervention or a control group, intervention group students participated in a class discussion on the negative consequences college students experience as a result of other students' drinking behavior, prior to answering survey questions regarding their drinking behavior intent. Compared to controls who completed the questionnaire only, intervention group participants reported intent to limit themselves to fewer drinks per drinking occasion (p = .003) and fewer drinks per week (p = .004). The effects of the brief educational intervention were analyzed using structural equation modeling, to test the feasibility of a hypothesized intervention mechanism.