Does the use of ultrasound affect contamination of musculoskeletal injections sites?

BACKGROUND: Therapeutic musculoskeletal injections require a clean or sterile skin preparation to minimize the risk of infections. Ultrasound guidance for this procedure requires the use of transmission gel in proximity to the injection site, and its effect on maintaining sterility is unknown. QUESTIONS/PURPOSES: We asked: (1) Does sterile ultrasound transmission gel increase skin contamination during therapeutic orthopaedic injections? (2) Does nonsterile gel application result in increased contamination? (3) Does a manufacturer-approved ultrasound probe disinfecting agent in the form of 17.2% isopropanol and 0.28% diisobutylphenoxyethoxyethyl dimethyl benzyl ammonium chloride wipes adequately decontaminate the ultrasound transducer? (4) Does 70% isopropyl alcohol effectively decontaminate skin for administration of musculoskeletal injections? METHODS: Twenty-six healthy volunteers in an outpatient orthopaedic clinical setting were recruited. The subjects' skin was prepared to simulate a therapeutic intraarticular shoulder injection under ultrasound guidance. Four skin swabs for culture from each subject were taken: one sample before preparation with isopropyl alcohol, one sample after skin preparation, one after simulated injection procedure with sterile ultrasound transmission gel using the transducer, and one after mock procedure with nonsterile ultrasound transmission gel. In addition, samples were taken from the nonsterile ultrasound transmission gel and the transducer for culture analysis. Aerobic and anaerobic cultures were incubated during a 5-day period for bacterial species identification. RESULTS: Sterile ultrasound gel use results in an increase in skin contamination (odds ratio [OR], 9; 95% CI, 1.4-57.1; p=0.005). Compared with sterile gel use, application of nonsterile gel did not increase contamination proportion (OR, 1.1; 95% CI, 0.8-1.7; p=0.56). All cultures from nonsterile gel were negative. None of the samples cultured directly from the ultrasound probe were positive for bacteria (0%). Skin preparation with 70% alcohol decreased the proportion of contamination when compared with unprepared skin (OR, 21.0; 95% CI, 3.1-142.2; p=0.001). CONCLUSIONS: Use of ultrasound probes and transmission gel results in greater contamination in simulated intraarticular injections of the shoulder. As such, sterile preparation of the entire injection field, including the adjacent skin where the gel and probe are applied, may be prudent. Future studies are needed to determine if such a preparation decreases contamination and thereby infection rates related to musculoskeletal injections. LEVEL OF EVIDENCE: Level II, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

The routine use of atypical cultures in presumed aseptic revisions is unnecessary.

BACKGROUND: In presumed aseptic hip and knee revisions, it is common practice to send intraoperative cultures to screen for occult infection. Currently no guidelines exist for the routine use of acid-fast bacillus (AFB) and fungal cultures in this setting. QUESTIONS/PURPOSES: We established (1) the rate of positive fungal and AFB cultures in aseptic hip and knee revision arthroplasties, (2) factors associated with positive fungal and AFB cultures, (3) the likelihood that positive cultures represent true-positive results, and (4) the hospital charges of sending fungal and AFB cultures routinely. METHODS: We retrospectively evaluated all 1717 presumed aseptic hip and knee revisions performed from January 2006 to November 2011: 1139 patients had at least one intraoperative fungal culture and 1133 patients had at least one intraoperative AFB culture, with 923 and 920, respectively, achieving 1-year followup. The Musculoskeletal Infection Society criteria were used to classify subsequent infections. We attempted to identify risk factors for positive cultures. RESULTS: We observed six (0.5%) patients with positive AFB cultures and 19 (1.7%) with positive fungal cultures. Patients undergoing reimplantation procedures were more likely to have a positive fungal culture. The true-positive rate was 0% and 0.1% for AFB and fungal cultures, respectively. The total hospital charges for these cultures over the time frame of our study were USD 1,315,533. CONCLUSIONS: Given the extremely low rate of true-positive AFB and fungal cultures in presumed aseptic revision joint arthroplasty and the charges associated with maintaining these cultures, we believe their routine use is unwarranted. LEVEL OF EVIDENCE: Level III, prognostic study. See the Instructions for Authors for a complete description of evidence.

Association between the History of Traumatic Brain Injury and Rates of Dental Treatment, Endodontic Therapy, and Caries Risk: A Records-Based Study.

INTRODUCTION: Traumatic Brain Injury (TBI) is a prevalent health issue in the US and even more prevalent amongst members of the armed forces. The purpose of this project was to evaluate the association between history of TBI and rates of dental treatment performed, endodontic therapy, and high caries risk. METHODS: This was a retrospective medical and dental records study. The first 100 of a chosen dental hygienist's patients in 2016 who were seen for dental prophylaxis appointments were chosen as subjects. Armed Forces Health Longitudinal Technology Application (AHLTA) and Corporate Dental System (CDS) records were used to gather information on these subjects including rank, age, gender, duty status, tobacco use, history of TBI, total number of dental procedures, total Dental Weighted Value (DWV), number of endodontic procedures, endodontic DWV, high caries risk categorization, total days dental fitness class 1, and total days dental fitness class 3. From these subjects, a "TBI group" and a "Non-TBI group" were formed. T-Test analyses were performed to compare these groups to each other in categories of total number of dental procedures, total DWV, total days dental fitness class 1, and total days class 3. Relative risks ratio analysis was used to compare these groups in terms of high caries risk categorization. RESULTS: Eight out of 100 subjects had a history of TBI. All TBI events were mild. Six subjects had 1 event, 1 had 2 events, and 1 had 4 events. The TBI group had a statistically higher mean number of dental procedures (P=0.00000025) and mean total DWV (P=0.0000062) compared to the non-TBI group. No subjects from the TBI group had an endodontic procedure. The TBI group had lower mean days in dental fitness class 1 and more mean days in dental fitness class 3, but the results were not statistically significant. The TBI group had lower high caries risk categorization rates than the non-TBI group, but the results were not statistically significant. CONCLUSIONS: Patients with a history of TBI had a significantly higher number of dental procedures performed and DWV generated compared to patients without a history of TBI.

Sagittal Balance in Adult Idiopathic Scoliosis.

STUDY DESIGN: A narrative review article study. OBJECTIVE: The objective of this study was to highlight guiding principles and challenges faced with addressing sagittal alignment in patients with adult idiopathic scoliosis (AIS) and to discuss effective surgical strategies based upon our clinical experience. SUMMARY OF BACKGROUND DATA: Previous research and guidelines for the treatment of AIS have focused on the correction of spinal deformity in the coronal and axial planes. Failure to address sagittal deformity has been associated with numerous adverse clinical outcomes. METHODS: This is a review of the current body of literature and a description of the rod derotation surgical technique for correction in the sagittal plane. RESULTS: Several studies have offered general goals for postoperative radiographic measures in the sagittal plane for patients with AIS. However, these guidelines are evolving as diagnostic and therapeutic modalities continue to improve. The rod derotation surgical technique through differential metal rods is one method to potentially address sagittal balance in AIS. CONCLUSIONS: Alignment in the sagittal plane is a unique challenge facing surgeons for patients with AIS. Further research with an assessment of functional outcomes and longer follow-up is needed to more precisely guide treatment principles. LEVEL OF EVIDENCE: Level IV.

High-Grade Spondylolisthesis in Adults: Current Concepts in Evaluation and Management.

BACKGROUND: Information regarding the treatment of high-grade spondylolisthesis (HGS) in adults has been previously described; however, previous descriptions of the evaluation and surgical management of HGS do not represent more recent and now established approaches. The purpose of the current review is to discuss current concepts in the evaluation and management of patients with HGS. METHODS: Literature review. RESULTS: HGS is diagnosed in up to 11.3% of adults with spondylolisthesis and typically presents as nonspecific lower back pain. Regarding evaluation, a thorough history and physical examination should be performed, which may help predict the presence of HGS. Diagnostic imaging, and specifically the use of spino-pelvic parameters, are now commonly implicated in guiding treatment course and prognosis. When surgical intervention is indicated, surgical approaches include in situ fusion variations, reduction and partial reduction with fusion, and vertebrectomy. Although the majority of studies suggest improvements with these approaches, the literature is limited by a low level of evidence with regards to the superiority of one technique when compared with others. CONCLUSIONS: HGS is a unique cause of low back pain in adults that carries considerable morbidity, but rarely presents with neurologic symptoms. Although the definitions, classifications, and methods of diagnosis of this spinal deformity have been established and accepted, the ideal surgical management of this deformity remains highly debated. Fusion in situ techniques are often technically easier to perform and provide lower risk of neurologic complications, whereas reduction and fusion techniques offer greater restoration of global spino-pelvic balance. Preoperative spino-pelvic parameters may have utility in assisting in procedural selection; however, future, higher-quality and longer-term studies are warranted to determine the optimal surgical intervention among the widely available techniques currently used, and to better define the indications for these interventions.

Efficient kinetic macrocyclization.

In this article, the highly efficient formation of a series of recently discovered aromatic oligoamide macrocycles consisting of six meta-linked residues is first discussed. The macrocycles, with their backbones rigidified by three-center hydrogen bonds, were found to form in high yields that deviate dramatically from the theoretically allowed value obtained from kinetic simulation of a typical kinetically controlled macrocyclization reaction. The folding of the uncyclized six-residue oligomeric precursors, which belong to a class of backbone-rigidified oligoamides that have been demonstrated by us to adopt well-defined crescent conformations, plays a critical role in the observed high efficiency. Out of two possible mechanisms, one is consistent with experimental results obtained from the coupling of crescent oligoamides of different lengths, which suggests a remote steric effect that discourages the formation of oligomers having lengths longer than the backbone of the six-residue precursors. The suggested mechanism is supported by the efficient formation of very large aromatic oligoamide macrocycles consisting of alternating meta- and para-linked residues. These large macrocycles, having H-bond-rigidified backbones and large internal lumens, are formed in high (>80%) yields on the basis of one-step, multicomponent macrocyclization reactions. The condensation of monomeric meta-diamines and a para-diacid chloride leads to the efficient formation of macrocycles with 14, 16, and 18 residues, corresponding to 70-, 80-, and 90-membered rings that contain internal cavities of 2.2, 2.5, and 2.9 nm across. In addition, the condensation between trimeric or pentameric diamines and a monomeric diacid chloride had resulted in the selective formation of single macrocyclic products with 16 or 18 residues. The efficient formation of the macrocycles, along with the absence of other noncyclic oligomeric and polymeric byproducts, is in sharp contrast to the poor yields associated with most kinetically controlled macrocyclization reactions. This system represents a rare example of highly efficient kinetic macrocyclization reactions involving large numbers of reacting units, which provides very large, shape-persistent macrocycles.

One-pot formation of large macrocycles with modifiable peripheries and internal cavities.

The shape of things to come: Aromatic oligohydrazide macrocycles with planar backbones enforced by three-center hydrogen bonds are formed in high yield from monomeric diacid chlorides and dihydrazides. Macrocycles consisting of six meta-linked pyridine and benzene residues have an internal cavity of about 10 A diameter, while those with alternating meta- and para-linked benzene residues are larger and contain multiple convergent sites (see picture).

Lumbar spinal fusion in the outpatient setting: an update on management, surgical approaches and planning.

Outpatient lumbar spinal fusion surgery has the potential for improved patient satisfaction, speed of recovery, and economic advantages when compared to inpatient surgery. Despite the rise in the number of these procedures performed annually, the literature on this topic remains scarce. As such, there is a need for a comprehensive review of current concepts in indications and management. The current review will present the most recent literature regarding pre-operative, intra-operative, and post-operative considerations when performing outpatient lumbar spinal fusion surgery.

Comparison of Stand-alone Lateral Lumbar Interbody Fusion Versus Open Laminectomy and Posterolateral Instrumented Fusion in the Treatment of Adjacent Segment Disease Following Previous Lumbar Fusion Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to compare clinical and radiographic outcomes of patients who underwent stand-alone lateral lumbar interbody fusion (LLIF) to those who underwent posterolateral fusion (PLF) for symptomatic adjacent segment disease (ASD). SUMMARY OF BACKGROUND DATA: Recent studies have suggested that LLIF can successfully treat ASD; however, there are no studies to date that compare LLIF with the traditional open PLF in this cohort. METHODS: A total of 47 consecutive patients who underwent LLIF or PLF for symptomatic ASD between January 2007 and August 2016 after failure of conservative management were reviewed for this study. Patient-reported outcomes (PROs) were collected on all patients at preoperative, postoperative, and most recent post-operative visit using the Oswestry Disability Index, Visual Analog Scale (VAS)-Back, and VAS-Leg surveys. Preoperative, immediate postoperative, and most recent postoperative radiographs were assessed for pelvic incidence, fusion, intervertebral disc height, segmental and overall lumbar lordosis (LL). Symptomatic ASD was diagnosed if back pain, neurogenic claudication, or lower extremity radiculopathy presented following a previous lumbar fusion. Preoperative plain radiographs were evaluated for evidence of adjacent segment degeneration. RESULTS: A total of 47 patients (23 LLIF, 24 PLF) met inclusion criteria. Operative times (P < 0.001) and intraoperative blood loss (P < 0.001) were significantly higher in the PLF group. Patients who underwent PLF were discharged approximately 3 days after the LLIF patients (P < 0.001). PROs in the PLF and LLIF cohorts showed significant and equivalent improvement, with equivalent radiographic fusion rates. LLIF significantly improve segmental lordosis (P < 0.001), total LL (P = 0.003), and disc height (P < 0.001) from preoperative to immediate postoperative and final follow-up (P = 0.004, P = 0.019, P ≤ 0.001, respectively). CONCLUSION: Although LLIF may provide less perioperative morbidity and shorter length of hospitalization, both techniques are safe and effective approaches to restore radiographic alignment and provide successful clinical outcomes in patients with adjacent segment degeneration following previous lumbar fusion surgery. LEVEL OF EVIDENCE: 3.

Sequence-specific, dynamic covalent crosslinking in aqueous media.

This article describes an associating system that integrates the specificity of multiple hydrogen bonding and the strength of dynamic covalent interactions. Linear oligoamides that sequence-specifically pair into H-bonded duplexes in nonpolar solvents were modified with S-trityl groups, allowing the reversible formation of disulfide bonds. The disulfide-crosslinking reactions of oligoamides capable of pairing via two, four, and six intermolecular H-bonds, along with several control strands, were examined using ESI, MALDI-TOF, reverse phase HPLC, and two-dimensional NMR. Results from these studies demonstrate that this system possesses both the high fidelity of multiply H-bonded assemblies and the high stability of covalent interaction, leading to the sequence-specific crosslinking of complementary oligoamides in not only nonpolar (methylene chloride) solutions but also highly competitive (aqueous) media. Experiments were designed to systematically probe the mechanism behind the specific formation of the sequence-matched products, which revealed a thermodymically controlled process. Multiple pairs in the same solution were crosslinked in a sequence-specific fashion. In addition, a length-dependent selectivity was also observed. Thus, oligoamides with different lengths or sequences did not crosslink into mismatched products. As few as two H-bonds is sufficient to bias the specific formation of the crosslinked product in aqueous media, suggesting that associating units with tunable sizes, high stability, and high specificity can be conveniently designed. The combination of H-bonding and dynamic covalent interactions represents a new, generalizable strategy for developing highly specific molecular associating units that are stable in a wide variety of media. These associating units will greatly facilitate the construction of various structures with many applications.

Improving foldamer synthesis through protecting group induced unfolding of aromatic oligoamides.

The hydrogen bond rigidified backbones of aromatic oligoamides are temporarily interrupted by replacing the amide hydrogens with the acid-labile 2,4-dimethoxybenzyl (DMB) group, which allows the efficient preparation of long folding oligomers that, upon removal of the DMB groups, fold into multiturn helices. [structure: see text]

Neuromonitoring changes in pediatric spinal deformity surgery: a single-institution experience.

OBJECT: Intraoperative monitoring of the spinal cord has become the standard of care during surgery for pediatric spinal deformity correction. The use of both somatosensory and motor evoked potentials has dramatically increased the sensitivity and specificity of detecting intraoperative neurophysiological changes to the spinal cord, which assists in the intraoperative decision-making process. The authors report on a large, single-center experience with neuromonitoring changes and outline the surgical management of patients who experience significant neuromonitoring changes during spinal deformity correction surgery. METHODS: The authors conducted a retrospective review of all cases involving pediatric patients who underwent spinal deformity correction surgery at Shriners Hospital for Children, Philadelphia, between January 2007 and March 2010. Five hundred nineteen consecutive cases were reviewed in which neuromonitoring was used, with 47 cases being identified as having significant changes in somatosensory evoked potentials, motor evoked potentials, or both. These cases were reviewed for patient demographic data and surgical characteristics. RESULTS: The incidence of significant neuromonitoring changes was 9.1% (47 of 519 cases), including 6 cases of abnormal Stagnara wake-up tests, of which 4 had corroborated postoperative neurological deficits (8.5% of 47 cases, 0.8% of 519). In response to neuromonitoring changes, wake-up tests were performed in 37 (79%) of 47 cases, hardware was adjusted in 15 (32%), anesthesiology interventions were reported in 5 (11%), hardware was removed in 5 (11%), the patient was successfully repositioned in 3 (6%), and the procedure was aborted in 13 (28%). In 1 of the 4 patients with new postoperative deficits, the deficit had fully resolved by the last follow-up; the other 3 patients had persistent neurological impairment as of the most recent follow-up examination. The authors observed a sensitivity of 100% for intraoperative neuromonitoring. CONCLUSIONS: Due to the profound risks associated with spinal deformity surgery, intraoperative neurophysiological monitoring is an integral tool to warn of impending spinal cord injury. Intraoperative neuromonitoring appears to provide a safe and useful warning mechanism to minimize spinal cord injury that may arise during scoliosis correction surgery in pediatric patients.

Ingested RNA interference for managing the populations of the Colorado potato beetle, Leptinotarsa decemlineata.

BACKGROUND: RNA interference (RNAi) is a breakthrough technology for conducting functional genomics studies and also as a potential tool for crop protection against insect pests. The major challenge for efficient pest control using RNAi in the field is the development of efficient and reliable methods for production and delivery of double-stranded RNA (dsRNA). In this paper, the potential of feeding dsRNA expressed in bacteria or synthesized in vitro to manage populations of Colorado potato beetle, Leptinotarsa decemlineata (Say) (CPB), was investigated. RESULTS: Feeding RNAi successfully triggered the silencing of all five target genes tested and caused significant mortality and reduced body weight gain in the treated beetles. This study provides the first example of an effective RNAi response in insects after feeding dsRNA produced in bacteria. CONCLUSION: These results suggest that the efficient induction of RNAi using bacteria to deliver dsRNA is a possible method for management of CPB. This could be also a promising bioassay approach for genome-wide screens to identify effective target genes for use as novel RNAi-based insecticides.

Sequence-specific association in aqueous media by integrating hydrogen bonding and dynamic covalent interactions.

Oligoamide strands that associate in a sequence-specific fashion into hydrogen-bonded duplexes in nonpolar solvents were converted into disulfide cross-linked duplexes in aqueous media. Thus, by incorporating trityl-protected thiol groups, which allows the reversible formation of disulfide bonds, into the oligoamide strands, only duplexes consisting of complementary hydrogen-bonding sequences were formed in aqueous solution as well as in methanol. The sequence-specific cross-linking of oligoamide strands was confirmed by MALDI-TOF, reverse-phase HPLC, and by isolating a cross-linked duplex. This study demonstrates that the sequence-specificity characteristic of multiply hydrogen-bonded systems can be extended into competitive media through the interplay of H-bonding and reversible covalent interactions, based on which a new class of molecular associating and ligating units that are compatible with both polar and nonpolar environments can be conveniently obtained.

Synthesis of crescent aromatic oligoamides.

[structures: see text] This article describes the synthetic procedures for the preparation of crescent (and helical) aromatic oligoamides developed in recent years in our laboratory. The large-scale preparation of a variety of monomers derived from various tetrasubstituted benzenes is presented. Three different strategies for constructing various oligomers consisting of meta- and meta/para-linked benzene residues are discussed. Factors affecting coupling efficiency and yields are analyzed. The developed synthetic methods have provided the basis for the preparation of longer oligomers and for the development of solid-phase synthesis.