Umbilical Cord Blood Use for Admission Blood Tests of VLBW Preterm Neonates: A Randomized Control Trial.

OBJECTIVE: Umbilical cord blood (UCB) for admission laboratories is an approach to decrease anemia risk in very low birth weight (VLBW) neonates. We hypothesized that UCB use results in higher hemoglobin concentration [HgB] around 24 hours of life. STUDY DESIGN: A randomized control trial among VLBW infants whose admission laboratories were drawn from UCB (n = 39) or the infant (n = 41) in three U.S. military NICUs (clinicaltrials.gov#NCT02103296). RESULTS: No demographic differences were observed between groups. UCB infants had higher [HgB] at 12 to 24 hours of life (15.5 vs. 14.0 g/dL, p = 0.02). The median time to first transfusion was 17 days longer in the experimental group (p = 0.04), and at discharge, their number of donor exposures was lower (1.1 vs. 1.8, p = 0.04). CONCLUSION: In the first 24 hours of life that is a period of higher risk for hemodynamic instability, UCB utilization for admission bloodwork in VLBW infants results in higher [HgB]. KEY POINTS: · Umbilical cord blood laboratory work in preterm infants is feasible.. · Cord blood use for admission laboratories results in increased hemoglobin in the first 24 hours of life.. · Cord blood use for admission laboratories delays time to first transfusion in preterm infants..

Primary augmentation of percutaneous repair with flexor hallucis longus tendon for Achilles tendon ruptures reduces tendon elongation and may improve functional outcome.

PURPOSE: Achilles tendon ruptures (ATR) result in loss of strength and function of the gastrosoleus-Achilles tendon complex, probably because of gradual tendon elongation and calf muscle atrophy, even after surgical repair. Flexor hallucis longus (FHL) augmentation not only reinforces the repair and provides new blood supply to the tendon, but also protects the repair, internally splinting the repaired Achilles tendon, maintaining optimal tension. We prospectively compared the clinical outcomes of patients with acute ATR, managed with either percutaneous repair only or percutaneous repair and FHL augmentation. METHODS: Patients with acute ATR undergoing operative management were divided into two groups. Thirty patients underwent percutaneous repair under local anesthesia, and 32 patients underwent percutaneous repair augmented by FHL tendon, harvested through a 3 cm longitudinal posteromedial incision, and transferred to the calcaneus, under epidural anesthesia. All patients were treated by a single surgeon between 2015 and 2019 and were followed prospectively for 24 months. RESULTS: The percutaneous only group was younger than the augmented one (35.4 ± 8.0 vs 40.4 ± 6.6 years, p = 0.01). In the augmented group, 25 patients stayed overnight and only 5 were day cases, whereas in the percutaneous only group 4 patients stayed overnight and 28 of them were day cases (p < 0.001). The duration of the procedure was significantly longer in the augmented group (38.9 ± 5.2 vs 13.2 ± 2.2 min, p < 0.001). At 24 months after repair, the Achilles tendon resting angle (ATRA) was better in the augmented group (-0.5 ± 1.7 vs -4.0 ± 2.7, p < 0.001), as was Achilles tendon rupture score (ATRS) (91.7 ± 2.2 vs 89.9 ± 2.4, p = 0.004). Calf circumference of the injured and the non-injured leg did not differ between the groups, as did the time interval to single toe raise and the time interval to walking in tiptoes. Although plantarflexion strength of the operated leg was significantly weaker than the non-operated leg in both groups, the difference in isometric strength of the operated leg between the groups was not significant at 24 months (435 ± 37.9 vs 436 ± 39.7 N, n.s.). CONCLUSION: Percutaneous repair and FHL tendon augmentation may have a place in the management of acute Achilles tendon ruptures, reducing tendon elongation and improving functional outcome. LEVEL OF EVIDENCE: Level II.

Current Topics in Medical Colic.

The list of medical causes of acute or chronic colic in horses is extensive. The purpose of this article is to review 4 medical causes of equine colic with a focus on newer trends in treatment. The 4 topics selected include gastric impaction, gastric glandular disease, colon displacement, and inflammatory bowel disease.

Disease characteristics and mortality among Asian women with breast cancer.

BACKGROUND: Asian women with breast cancer are often studied in aggregate, belying significant intragroup diversity. The authors sought to examine differences in breast cancer characteristics and outcomes among Asian women. METHODS: Asian, non-Hispanic Black, Hispanic, and non-Hispanic White women aged 18 years and older who were diagnosed with breast cancer from 1990 to 2016 were identified in the Surveillance, Epidemiology, and End Results 18 database. Asian patients were subclassified as Chinese, Japanese, Korean, Filipino, Vietnamese, South Asian (Asian Indian or Pakistani), Southeast Asian (SEA, i.e., Cambodian, Laotian, Hmong, or Thai), or other Asian. Unadjusted overall survival (OS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method. Cox proportional hazards models were used to estimate adjusted OS and CSS. RESULTS: In total, 910,415 women were included (Asian, n = 63,405; Black, n = 92,226; Hispanic, n = 84,451; White, n = 670,333). Asian women had higher rates of human epidermal growth factor receptor 2 (HER2)-positive disease compared with White women (18.7% vs 13.8%) and had the highest 10-year unadjusted OS and CSS among all racial/ethnic groups (all P < .001). SEA women had the highest rates of stage IV disease at presentation, whereas Japanese women had the lowest rates (5.9% vs 2.7%; P < .001). Japanese women had the highest 10-year unadjusted CSS (89.4%; 95% confidence interval, 88.7%-90.1%) of any distinct Asian group, whereas SEA women had the worst unadjusted CSS (78%; 95% confidence interval, 74.1%-81.3%; P < .001). After adjustment, SEA women had the worst OS of any Asian group and were the only Asian group without improved OS compared with White women (reference category; P = .08). CONCLUSIONS: Breast cancer characteristics and outcomes vary significantly among Asian women. Future research should consider disaggregation by country or region of origin to identify subgroups that are at risk for worse outcomes than aggregated data may suggest. LAY SUMMARY: Asian women with breast cancer are frequently studied as a single entity. However, Asian ethnic groups differ greatly by country of origin, genetic ancestry, disease frequency, socioeconomic status, patterns of immigration, as well as dietary and cultural practices. Women of different Asian ethnicities vary significantly with regard to cancer characteristics, such as mortality and tumor subtype. Future research should disaggregate these populations to better understand, treat, and counsel Asian patients with breast cancer.

Race and sex differences in HDL peroxide content among American adults with and without type 2 diabetes.

BACKGROUND: High-density lipoprotein (HDL) plays a critical role in protection against atherosclerosic and cardiovascular disease (ASCVD). In addition to contributing to clearing excess vascular cholesterol, HDL particles exhibit antioxidative functions, helping to attenuate adverse effects of oxidized low-density lipoproteins. However, these beneficial properties can be undermined by oxidative stress, inflammation, and unhealthy lifestyles and diet, as well as influenced by race and sex. Thus, when assessing cardiovascular risk, it is important to consider multifactorial aspects of HDL, including antioxidant activity rather than just total amount and type of HDL-cholesterol (HDL-C) particles. Because prior research showed HDL peroxide content (HDLperox) can be inversely associated with normal anti-oxidant HDL activity, elevated HDLperox may serve as a bioindicator of HDL dysfunction. METHODS: In this study, data from a large national cohort of Americans was utilized to determine the impact of sex, race, and diabetes status on HDLperox in middle-aged and older adults. A previously developed cell-free fluorometric method was utilized to quantify HDLperox in serum depleted of apo-B containing lipoproteins. RESULTS: In keeping with predictions, white men and diabetics exhibited HDLperox in the atypical upper range, suggestive of less functional HDL. White men had higher HDLperox levels than African American males (13.46 ± 6.10 vs. 10.88 ± 5.81, p < .001). There was also a significant main effect of type 2 diabetes (F(1,1901) = 14.9, p < .0001). Overall, African Americans evinced lower HDLperox levels, despite more obesity (10.3 ± 4.7 vs.11.81 ± 5.66 for Whites) suggesting that other aspects of lipid metabolism and psychosocial factors account for the higher prevalence of ASCVD in African Americans. CONCLUSION: This research helps to provide a more comprehensive understanding of HDL function in a racially and metabolically diverse adult population. HDLperox content was significantly different in adults with type 2 diabetes, and distinctive in nondiabetic White males, and suggests other processes account for the higher prevalence of ASCVD among African Americans.

Characterizing participants in the North Carolina Breast and Cervical Cancer Control Program: A retrospective review of 90,000 women.

BACKGROUND: The North Carolina Breast and Cervical Cancer Control Program (NC BCCCP) provides breast cancer screening services to underserved women to mitigate disparities in access to care. The authors sought to characterize this understudied population. METHODS: Women 21 years old or older who underwent their first breast cancer screen through NC BCCCP from 2008 to 2018 were included. Demographic factors associated with the timeline of care and odds of a breast cancer diagnosis were identified with negative binomial and logistic regression, respectively. RESULTS: Of the 88,893 women identified, 45.5% were non-Hispanic (NH) White, 30.9% were NH Black, 19.6% were Hispanic, 1.7% were American Indian, and 1.1% were Asian. Breast cancer was diagnosed in 2.5% of the women (n = 2255). Hispanic women were the least likely to be diagnosed with breast cancer (odds ratio vs NH White women, 0.40; 95% confidence interval [CI], 0.34-0.47). Among patients with breast pathology, the median time to diagnosis was 19 days (interquartile range [IQR], 10-33 days), and the time to treatment was 33 days (IQR, 19-54 days). After adjustments, a longer time to diagnosis was significantly associated with age (incidence rate ratio [IRR], 1.01; 95% CI, 1.01-1.02) and being NH Black (vs NH White; IRR, 1.17; 95% CI, 1.06-1.29). A longer time to treatment was significantly associated with age (IRR, 1.01; 95% CI, 1.01-1.01), being NH Black (vs NH White; IRR, 1.20; 95% CI, 1.10-1.31), and being Hispanic (vs NH White; IRR, 1.22; 95% CI, 1.05-1.41). CONCLUSIONS: NC BCCCP participants with breast cancer received treatment within approximately 1 month of presentation, and this finding aligns with quality care benchmarks. Nevertheless, racial/ethnic disparities in timeliness of care persist, and this suggests opportunities for improvement. LAY SUMMARY: This review of approximately 90,000 participants in a breast cancer screening program for uninsured and underinsured women highlights the importance of safety net programs in providing timely care to underserved patients. The authors found that the North Carolina Breast and Cervical Cancer Control Program met timeliness benchmarks from the Centers for Disease Control and Prevention across all racial/ethnic groups. However, non-Hispanic Black women experienced relative delays in the time to diagnosis, and both non-Hispanic Black women and Hispanic women experienced relative delays in the time to treatment. These findings demonstrate how racial/ethnic disparities in the timeliness of care can persist even within a program intended to reduce barriers to access.

Modified Zadek osteotomy without excision of the intratendinous calcific deposit is effective for the surgical treatment of calcific insertional Achilles tendinopathy.

INTRODUCTION: Nonoperative management of calcific insertional Achilles tendinopathy (CIAT) may fail in 10-30% of patients, and various operative procedures have been described to manage those. METHODS: A modified Zadek (dorsal closing wedge) calcaneal osteotomy, without removing the calcific deposits and without detaching the insertion of the Achilles tendon, was performed between November 2016 and December 2017 in 25 consecutive patients (mean age 53.5 years), who were followed for at least 2 years. RESULTS: The osteotomies had united at an average of 5 weeks. Two superficial wound infections (8%) were documented. Patients had returned to their normal activities at an average time of 23 ± 7.7 weeks. Three out of four patients, who practised recreational sport activity, returned to their pre-injury level. VAS and VISA-A scores had significantly improved at 3 months postoperatively (p < .001) and continued to improve for 24 months. CONCLUSION: The modified Zadek osteotomy, without excision of the intra-tendinous calcification, was safe, and significantly improved clinical outcome in patients with CIAT at 2 years after surgery. Level of evidence IV.

Cultural and life style practices associated with low inflammatory physiology in Japanese adults.

Japan is an exceptionally healthy East Asian country with extended longevity. In addition, the typical levels of several proinflammatory proteins, including both C-reactive protein (CRP) and interleukin-6 (IL-6), are often reported to be low when compared to American and European populations. This analysis determined if blood levels of CRP and IL-6 were associated with 4 cultural practices reflective of Japanese behavior and customs -- drinking tea, eating seafood, consuming vegetables, and partaking in relaxing baths regularly - among 382 adults living in Tokyo. Regression models controlled for demographic factors, adiposity (BMI), physical exercise, smoking, alcohol use, and chronic illness (e.g., diabetes). Consuming a Japanese diet was associated with significantly lower CRP and IL-6 levels. More frequent bathing was associated with lower IL-6, but not specifically predictive of low CRP. This study has confirmed prior evidence for low inflammatory activity in Japanese adults and its association with several behavioral practices common in Japan.

Surgical management of chronic Achilles tendon ruptures using less invasive techniques.

BACKGROUND: Surgical management of chronic Tendo Achillis (TA) ruptures usually requires tendon grafting procedures. Several techniques have been described. We examined the outcome of three different less invasive (incisions length less than 3 cm) tendon transfer techniques in the management of patients with a chronic rupture of the TA. METHODS: Of 62 patients (39 males and 23 females; mean age 44.8 years; range 29.3-62 years) with chronic TA ruptures managed operatively, 21 patients had a ≥6cm gap and underwent free ipsilateral semitendinosus (ST) graft (21 patients), whereas patients with smaller gaps had either ipsilateral peroneus brevis (PB) (20 patients) or ipsilateral flexor hallucis longus (FHL) transfer (21 patients). Outcome measures included maximum calf circumference, isometric plantar flexion strength, and the Achilles tendon total rupture score (ATRS), preoperatively and at the last follow up. We also recorded the time to return to activities of daily living (ADL) and sports, and the number of single-leg heel lifts on the affected leg at the last follow up, at an average of 35.4 months. RESULTS: Patient characteristics between groups were similar. All outcome measures significantly improved after surgery (p<0.001), without differences between the three groups. Return to ADL was possible at an average of 4.5 months. Patients undergoing PB transfer had a slower return to sports compared to the other groups, at 6.9±0.5months versus 6.1±0.8 for the FHL and 5.8±0.6 for the ST groups (t-test p=0.005 and p<0.001, respectively). However, 13/14 patients (90%) in the PB group returned to high impact sports, compared to 9/12 (75%) in the FHL and 6/11 (55%) in the ST groups (Fisher's test, p=0.31 and p=0.056, respectively). CONCLUSION: All three techniques produced significant functional improvement, and return to sports was possible in most patients. This study does not demonstrate a clear advantage of one technique over the others.

Minimally Invasive Achilles Tendon Stripping for the Management of Tendinopathy of the Main Body of the Achilles Tendon.

Achilles tendinopathy is a common cause of disability. New nerves fibers grow from the paratenon into the Achilles tendon, and they could play a central role in the development of pain. We report the results of minimally invasive Achilles tendon stripping for Achilles tendinopathy in 47 active patients. The Victorian Institute of Sports Assessment-Achilles questionnaire score improved from 53.8 preoperatively to 85.3 postoperatively (p < .001). After a mean follow-up period of 40.5 months, 41 patients had resumed sporting activities at an average of 3.5 months postoperatively. A sural nerve injury was recorded in 5 patients (10.6%), and all 5 complications occurred during the first 12 cases. As a result, the technique was slightly modified, and no sural nerve neuropathy was observed subsequently. One superficial infection (2.1%) was recorded. Minimally invasive Achilles tendon stripping seems to be an effective, technically simple, and inexpensive treatment of Achilles tendinopathy. Further randomized controlled trials involving more patients are needed to confirm these outcomes.

Expression of anger and ill health in two cultures: an examination of inflammation and cardiovascular risk.

Expression of anger is associated with biological health risk (BHR) in Western cultures. However, recent evidence documenting culturally divergent functions of the expression of anger suggests that its link with BHR may be moderated by culture. To test this prediction, we examined large probability samples of both Japanese and Americans using multiple measures of BHR, including pro-inflammatory markers (interleukin-6 and C-reactive protein) and indices of cardiovascular malfunction (systolic blood pressure and ratio of total to HDL cholesterol). We found that the link between greater expression of anger and increased BHR was robust for Americans. As predicted, however, this association was diametrically reversed for Japanese, among whom greater expression of anger predicted reduced BHR. These patterns were unique to the expressive facet of anger and remained after we controlled for age, gender, health status, health behaviors, social status, and reported experience of negative emotions. Implications for sociocultural modulation of bio-physiological responses are discussed.

Administration of trimethoprim-sulphadimidine does not improve healing of glandular gastric ulceration in horses receiving omeprazole: a randomised, blinded, clinical study.

BACKGROUND: Interest in Equine Gastric Ulcer Syndrome (EGUS) has recently increased in part due to a growing awareness of the differences between squamous and glandular disease. The pathophysiology and epidemiology of squamous and glandular disease are different and recently it has been shown that the response of glandular gastric ulceration to monotherapy with omeprazole is poor. Given these differences it has been recommended that specific treatment guidelines be formulated for equine glandular disease and that adjunctive therapies be investigated. Along these lines it has been suggested that the addition of antimicrobials may enhance healing. The objective of this study was to investigate whether the addition of trimethoprim-sulphadimidine to omeprazole therapy would result in superior healing of naturally occurring equine glandular ulceration compared with omeprazole monotherapy. RESULTS: Combination therapy of omeprazole plus trimethoprim-sulphadimidine could not be demonstrated to be superior to omeprazole monotherapy. Healing of the glandular mucosa was observed in 7/15 (47%; 95% CI 24 to 71%) and 3/13 (23%; 95% CI 7% to 50%) of horses in the TMPS and OMEP groups, respectively (OR = 1.8; 95% CI 0.32 to 10.0; p = 0.67). Improvement of the glandular mucosa was observed in 12/15 (80%; 95% CI 56 to 94%) and 9/13 (69%; 95% CI 42 to 89%) of horses in the TMPS and OMEP groups, respectively (OR = 2.9; 95% CI 0.6 to 15.0; p = 0.25). CONCLUSIONS: The results of the present study do not support the addition of trimethoprim-sulphadimidine to therapeutic protocols for equine glandular ulceration. Several limitations were present in the study and the use of antimicrobials as an adjunctive treatment warrants further investigation. However, given the potential deleterious consequences associated with the indiscriminate use of antimicrobials, the inclusion of antimicrobials in treatment regimes for EGUS is not justified until their efficacy is further validated.

Early signs of osteoarthritis in professional ballet dancers: a preliminary study.

OBJECTIVE: To investigate a cohort of professional ballet dancers for evidence of early signs of osteoarthritis (OA). DESIGN: One radiologist and 1 orthopedic surgeon specialized in musculoskeletal disorders analyzed magnetic resonance imaging scans independently. SETTING: University Teaching Hospital. PARTICIPANTS: Fifteen professional ballet dancers (4 males and 11 females; age range, 19-36 years) experiencing chronic pain in the hip, knee, spine, ankle, or foot joints. MAIN OUTCOME MEASURES: Presence of osteophytes, subchondral sclerosis, joint space narrowing, cysts, and bone marrow changes; the Kellgren and Lawrence scale was used to quantify the knee OA. RESULTS: In the knee, there was thinning and irregularity of the articular cartilage over the medial femoral condyle and bone marrow changes within the lateral femoral condyle. In the hip, there was a loss of joint space and a frayed labrum with deep recess. The first metatarsophalangeal joint showed evidence of osteophytic development. CONCLUSIONS: Early signs of OA, in different joints, were present in a small but highly selected cohort of professional ballet dancers. In future, prospective studies among a number of ballet companies should control for medical and natural history alongside the visual analysis of images and plain radiographs to confirm these preliminary results.

Negative emotions predict elevated interleukin-6 in the United States but not in Japan.

Previous studies conducted in Western cultures have shown that negative emotions predict higher levels of pro-inflammatory biomarkers, specifically interleukin-6 (IL-6). This link between negative emotions and IL-6 may be specific to Western cultures where negative emotions are perceived to be problematic and thus may not extend to Eastern cultures where negative emotions are seen as acceptable and normal. Using samples of 1044 American and 382 Japanese middle-aged and older adults, we investigated whether the relationship between negative emotions and IL-6 varies by cultural context. Negative emotions predicted higher IL-6 among American adults, whereas no association was evident among Japanese adults. Furthermore, the interaction between culture and negative emotions remained even after controlling for demographic variables, psychological factors (positive emotions, neuroticism, extraversion), health behaviors (smoking status, alcohol consumption), and health status (chronic conditions, BMI). These findings highlight the role of cultural context in shaping how negative emotions affect inflammatory physiology and underscore the importance of cultural ideas and practices relevant to negative emotions for understanding of the interplay between psychology, physiology, and health.

Reliability and identification of aortic valve prolapse in the horse.

BACKGROUND: The objectives were to determine and assess the reliability of criteria for identification of aortic valve prolapse (AVP) using echocardiography in the horse. RESULTS: Opinion of equine cardiologists indicated that a long-axis view of the aortic valve (AoV) was most commonly used for identification of AVP (46%; n=13). There was consensus that AVP could be mimicked by ultrasound probe malignment. This was confirmed in 7 healthy horses, where the appearance of AVP could be induced by malalignment. In a study of a further 8 healthy horses (5 with AVP) examined daily for 5 days, by two echocardiographers standardized imaging guidelines gave good to excellent agreement for the assessment of AVP (kappa>0.80) and good agreement between days and observers (kappa >0.6). The technique allowed for assessment of the degree of prolapse and measurement of the prolapse distance that provided excellent agreement between echocardiographers, days and observers (kappa/ICC>0.8). Assessments made using real-time zoomed images provided similar measurements to the standard views (ICC=0.9), with agreement for the identification of AVP (kappa>0.8). Short axis views of the AoV were used for identification of AVP by fewer respondents (23%), however provided less agreement for the identification of AVP (kappa>0.6) and only adequate agreement with observations made in long axis (kappa>0.5), with AVP being identified more often in short axis (92%) compared to long axis (76%). Orthogonal views were used by 31% of respondents to identify the presence of AVP, and 85% to identify cusp. Its identification on both views on 4 days was used to categorise horses as having AVP, providing a positive predictive value of 79% and negative predictive value of 18%. Only the non-coronary cusp (NCC) of the AoV was observed to prolapse in these studies. Prolapse of the NCC was confirmed during the optimisation study using four-dimensional echocardiography, which concurred with the findings of two-dimensional echocardiography. CONCLUSIONS: This study has demonstrated reliable diagnostic criteria for the identification and assessment of AVP that can be used for longitudinal research studies to better define the prevalence and natural history of this condition.

A Multimodal, Resident-led Newborn Emergencies Night Curriculum.

INTRODUCTION: Following graduate medical education duty hour reform, many programs have migrated to a night float model to achieve duty hour compliance. This has led to increased focus on optimizing nighttime education. A 2018 internal program evaluation of the newborn night rotation revealed that most pediatric residents received no feedback and perceived little didactic education during their four-week, night float rotation. One hundred percent of resident respondents were interested in increased feedback, didactics, and procedural opportunities. Our objective was to develop a newborn night curriculum to ensure timely formative feedback, enhance trainee didactic experience, and guide formal education. MATERIALS AND METHODS: A multimodal curriculum was designed to include senior resident-led, case-based scenarios, a pre- and post-test, a pre- and post-confidence assessment, a focused procedure "passport," weekly feedback sessions, and simulation cases. The San Antonio Uniformed Services Health Education Consortium implemented the curriculum starting from July 2019. RESULTS: Thirty-one trainees completed the curriculum in over 15 months. There was a 100% pre- and post-test completion rate. Test scores rose from an average of 69% to 94% (25% increase, P < .0001) for interns and an average of 84% to 97% (13% increase, P < .0001) for third-year residents (PGY-3s). When averaged across domains assessed, intern confidence rose by 1.2 points and PGY-3 confidence rose by 0.7 points on a 5-point Likert scale. One hundred percent of trainees utilized the on-the-spot feedback form to initiate at least one in-person feedback session. CONCLUSIONS: As resident schedules evolve, there is an increased need for focused didactics during the night shift. The results and feedback from this resident-led and multimodal curriculum suggest that it is a valuable tool to improve knowledge and confidence for future pediatricians.

Reliability of quantitative echocardiography in adult sheep and goats.

BACKGROUND: Echocardiography is a non-invasive method for assessment of the ovine and caprine heart. Complete reference ranges for cardiac dimensions and time indices for both species are not currently available and reliability of these measurements has not been evaluated. The objectives for this study are to report reliability, normal cardiac dimensions and time indices in a large group of adult sheep and goats.Fifty-one adult sheep and forty adult goats were recruited. Full echocardiographic examinations were performed in the standing unsedated animal. All animals underwent echocardiography four times in a 72-hour period. Echocardiography was performed three times by one author and once by another. Images were stored and measured offline. Technique and measurement repeatability and reproducibility and any differences due to animal or day were evaluated. Reference ranges (mean ± 2 standard deviations) were calculated for both species. RESULTS: Majority of the images obtained were of good to excellent quality. Image acquisition was straightforward with 5.4% of animals demonstrating a small scanning window. Reliability was excellent for majority of dimensions and time indices. There was less variation in repeatability when compared with reproducibility and differences were greater for technique than for measurements. Dimensions that were less reliable included those for right ventricular diameter and left ventricular free wall. There were many differences in cardiac dimensions between sheep and goats. CONCLUSIONS: This study has demonstrated that specific reference ranges are required for these two species. Repeatability and reproducibility were excellent for the majority of cardiac dimensions and time indices suggesting that this technique is reliable and valuable for examination of clinical cases over time and for longitudinal research studies.

Slowed-Down Rehabilitation Following Percutaneous Repair of Achilles Tendon Rupture.

BACKGROUND: Following percutaneous repair of acute Achilles tendon (AT) ruptures, early postoperative weightbearing is advocated; however, it is debatable how aggressive rehabilitation should be. We compared the clinical and functional outcomes in 2 groups of patients who followed either our "traditional" or a "slowed down" rehabilitation after percutaneous surgical repair. METHODS: Sixty patients were prospectively recruited to a slowed down (29 patients) or a traditional (31 patients) rehabilitation program. Both groups were allowed immediate weightbearing postoperatively; a removable brace with 5 heel wedges was applied at 2 weeks. In the slowed-down group, 1 wedge was removed after 4 weeks. Gradual removal of the boot took place after 4 wedges were kept for 4 weeks. In the traditional group, 1 wedge was removed every 2 weeks, with removal of the boot after 2 wedges had been kept for 2 weeks. The AT Resting Angle (ATRA) evaluated tendon elongation. Patient reported functional outcomes were assessed using the AT Rupture Score (ATRS). Calf circumference difference and the isometric plantarflexion strength of the gastro-soleus complex were evaluated. RESULTS: At the 12-month follow-up, both ATRA and ATRS were more favorable in the slowed-down group. The isometric strength and the calf circumference were more similar to the contralateral leg in the slowed-down group than in the traditional one. CONCLUSION: Following percutaneous repair of acute Achilles tendon patients undergoing slowed down rehabilitation performed better than the traditional one. These conclusions must be considered within the limitations of the present study. LEVEL OF EVIDENCE: Level II, prospective comparative study.

The Cincinnati incision is safe and effective for revision surgery for insertional tendinopathy of the Achilles tendon.

The present study reports the outcomes of revision surgery using a Cincinnati incision with tendon debridement and calcaneoplasty for insertional Achilles tendinopathy (IAT) in a cohort of patients at 24-month follow-up. Patients undergoing revision surgery following failed previous surgery for IAT were prospectively recruited. Patients were assessed pre-operatively and at 3, 6,12 and 24 months. The Victorian Institute of Sport Assessment Scale for Achilles Tendinopathy (VISA-A), the EQ5D questionnaire and the visual analogue scale (VAS) were used for evaluation. Data from 33 patients with a mean age of 43.9 years old are reported. 27% (9 of 33 patients) were female. The left side was involved in 58% (19/33) of patients. No clinically relevant complications were reported in any of the patients. Most of subscales of EQ5D improved at last follow-up: Usual Activities (P = 0.01), Mobility (P = 0.03), Pain/Discomfort (P = 0.001), Thermometer (P = 0.04). No statistically significant change for the subscales Self-Care (P = 0.08) and Anxiety-Depression (P = 0.1) was evidenced. The VISA-A score improved significantly at last follow-up (P < 0.0001), as did the VAS score (P < 0.0001). These results indicated that a Cincinnati incision followed by tendon debridement and calcaneoplasty for revision surgery for IAT is feasible and reliable, achieving clinically relevant improvement in the VISA-A, EQ5D and VAS at 24 months follow-up.

Superior Labial Frenulum Attachment Site and Correlation with Breastfeeding Outcomes.

OBJECTIVES: Current literature suggests that infant oral anatomy may impact breastfeeding outcomes. Our research seeks to evaluate superior labial frenulum (SLF) attachment site grade utilizing a modified existing system and investigate the correlation with breastfeeding outcomes. METHODS: Two hundred and eight dyads were recruited from the nursery at Brooke Army Medical Center. The neonate's SLF and lingual frenulum were evaluated and photo-documented. Photos were assessed by blinded reviewers utilizing a modified Stanford SLF grade. Breastfeeding mothers completed surveys on attitudes and associated pain with feedings 24 h postdelivery, at 2 weeks and at 2 months. Categorical data were analyzed using chi-squared tests or Fisher's exact tests. Means and standard deviations were analyzed using analysis of variance or Wilcoxon's test. RESULTS: At 2 weeks and 2 months, 86.8% and 72.8% were breastfeeding, respectively. At 2 months, SLF grade 1 newborn dyads had a significantly lower breastfeeding rate (50.0%) compared to SLF grade 2 (75.3%) and SLF grade 3 (85.7%) subjects (p = 0.0384). At 2 weeks and 2 months, there was no difference between SLF groups with regard to maternal breastfeeding attitudes or pain scores. There was no significant difference in terms of weight, referrals, or lingual-labial frenulectomy between SLF groups. CONCLUSIONS: Our study shows no correlation between SLF attachment grade and breastfeeding outcomes to include length of breastfeeding, maternally reported confidence, maternal pain, or infant weight. Our findings do not support labial frenulectomy based on SLF grade alone and highlight the need for a more robust functional grading system. LEVEL OF EVIDENCE: 2 Oxford Center for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653 Laryngoscope, 132:2498-2504, 2022.