Failure at the femoral stem extension-condylar interface in a rotating hinge knee without radiographic evidence of loosening.

Modular stem extensions have become ubiquitous in revision total knee arthroplasty systems. Although stem extensions are valuable in addressing bone deficiencies and improving implant fixation, the stem extension-condylar interface may be a point of implant failure. We report a case of failure at the femoral stem extension-condylar interface in a Zimmer NexGen Rotating Hinge Knee (Zimmer, Warsaw, IN). Currently, several published case reports describe failure at the femoral stem extension-condylar interface but only 1 case describes loosening at a taper junction without evidence of set screw failure or taper fracture. Furthermore, no published cases describe this type of failure in the Zimmer NexGen Rotating Hinge Knee (Zimmer).

COVID-19: Global radiation oncology's targeted response for pandemic preparedness.

As the global COVID-19 pandemic escalates there is a need within radiation oncology to work to support our patients in the best way possible. Measures are required to reduce infection spread between patients and within the workforce. Departments need contingency planning to create capacity and continue essential treatments despite a reduced workforce. The #radonc community held an urgent online journal club on Twitter in March 2020 to discuss these issues and create some consensus on crucial next steps. There were 121 global contributors. This document summarises these discussions around themes of infection prevention, rationalisation of workload and working practice in the presence of infection.

Radiation Fractionation Schedules Published During the COVID-19 Pandemic: A Systematic Review of the Quality of Evidence and Recommendations for Future Development.

PURPOSE: Numerous publications during the COVID-19 pandemic recommended the use of hypofractionated radiation therapy. This project assessed aggregate changes in the quality of the evidence supporting these schedules to establish a comprehensive evidence base for future reference and highlight aspects for future study. METHODS AND MATERIALS: Based on a systematic review of published recommendations related to dose fractionation during the COVID-19 pandemic, 20 expert panelists assigned to 14 disease groups named and graded the highest quality of evidence schedule(s) used routinely for each condition and also graded all COVID-era recommended schedules. The American Society for Radiation Oncology quality of evidence criteria were used to rank the schedules. Process-related statistics and changes in distributions of quality ratings of the highest-rated versus recommended COVID-19 era schedules were described by disease groups and for specific clinical scenarios. RESULTS: From January to May 2020 there were 54 relevant publications, including 233 recommended COVID-19-adapted dose fractionations. For site-specific curative and site-specific palliative schedules, there was a significant shift from established higher-quality evidence to lower-quality evidence and expert opinions for the recommended schedules (P = .022 and P < .001, respectively). For curative-intent schedules, the distribution of quality scores was essentially reversed (highest levels of evidence "pre-COVID" vs "in-COVID": high quality, 51.4% vs 4.8%; expert opinion, 5.6% vs 49.3%), although there was variation in the magnitude of shifts between disease sites and among specific indications. CONCLUSIONS: A large number of publications recommended hypofractionated radiation therapy schedules across numerous major disease sites during the COVID-19 pandemic, which were supported by a lower quality of evidence than the highest-quality routinely used dose fractionation schedules. This work provides an evidence-based assessment of these potentially practice-changing recommendations and informs individualized decision-making and counseling of patients. These data could also be used to support radiation therapy practices in the event of second waves or surges of the pandemic in new regions of the world.

Conscientious refusal in reproductive medicine: an educational intervention.

OBJECTIVE: This study evaluates an educational intervention focusing on the ethical reasoning and communication skills necessary in counseling patients about morally objectionable medical interventions. STUDY DESIGN: All students on the core clerkship in obstetrics and gynecology at the University of Miami Miller School of Medicine participated in a structured workshop. Students completed anonymous surveys before and after the workshop. Associations between the participants' change in comfort level in providing nondirective counseling and measured demographic variables were analyzed. RESULTS: Of 140 students, 37% (n = 52) positively changed their comfort level with nondirective options counseling; 10% (n = 14) negatively changed. Change in understanding of the physician's role was reported by 60% (n = 84). The exercise was rated as educationally valuable by 95% (n = 128), with 84% (n = 115) attesting that the workshop would help them "approach things differently." CONCLUSION: Evaluation of multiple parameters demonstrated that this workshop heightened student awareness of the ethical and communications skills challenges posed by this clinical situation.

Self pregnancy testing in an urban family planning clinic: promising results for a new approach to contraceptive follow-up.

BACKGROUND: Immediate initiation of depo-medroxyprogesterone acetate (DMPA) increases continuation and decreases pregnancies compared to conventional (next menstrual period) initiation. A drawback is the need to return in 4 weeks for a repeat pregnancy test to identify any pregnancy that was too early to diagnose on the day of injection. If women can perform home pregnancy tests (HPTs) to detect human chorionic gonadotropin (hCG) in urine, the need for this follow-up visit may be eliminated. This study assesses whether women can perform their own HPT. STUDY DESIGN: This is a single-visit observational trial of an HPT kit. Subjects recruited from a waiting room in an urban family planning clinic received an HPT kit with standard instructions to use immediately. Subjects and a research assistant each interpreted the test. Their results were then compared to a standard cassette type test for detection of hCG performed by clinic staff. kappa was calculated to assess the level of agreement. RESULTS: Three hundred ten subjects enrolled. They were young (mean age, 25.2 years), mostly Hispanic (91%) women. A change in the font and explicitness of the instructions decreased the incidence of invalid tests from 12.7% to 4.8%. The subject and research assistant's interpretation of the test had a high level of agreement, kappa=0.95 [95% confidence interval (CI), 0.92-0.99]. There was also a high level of agreement between the subjects' results and the standard test, kappa=0.88 (95% CI, 0.82-0.95). CONCLUSIONS: Women presenting for pregnancy testing at an urban clinic are able to perform HPTs with a high level of accuracy. The appearance of the instructions influenced the incidence of false-negative and invalid tests. Home pregnancy tests may be useful in follow-up protocols when immediate initiation of DMPA is employed.

Sexual Preferences and Partnerships of Transgender Persons Mid- or Post-Transition.

The process of gender transition has varying effects on various aspects of sexuality. The purpose of this study was to investigate the effects of transitioning on transgender persons' sexual preferences and partnerships. Data were collected through an anonymous online survey. Questions focused on timing of gender transition in relation to change in sexual preference. Transgender individuals have a variety of sexual partners, predominantly cisgender, and may change sexual preference when they transition. Transitioning can be associated with having no primary sexual partner, despite past sexual partnerships. Length of time between identifying as transgender and starting the transition might be associated with changing sexual partner preference, particularly in transgender women. The emerging trends of sexual partnerships and changing sexual preferences related to the transition in this study warrant further investigation. These data provide more understanding of the relationship between transitioning and sexual preferences and partnerships.

Contraception for the transplant patient.

Patients who have had an organ transplant have a need for highly effective contraception. Intrauterine devices, depo-medroxyprogesterone acetate, and implantable etonorgestrel have the highest efficacy combined with the least chance of interaction with antirejection medication regimens. Combined hormonal contraceptives and progestin-only pills are also acceptable methods for patients who do not have other contraindications to their use. Barrier method use should be advocated for any patient who is entering a new sexual relationship and as an adjunct to other methods. Consultation with a gynecologist experienced with the provision of contraceptives to medically complicated patients is advised for all women of reproductive age who have received an organ transplant.

CASTLE Thyroid Tumor: A Case Report and Literature Review.

Carcinoma showing thymus-like differentiation is a rare tumor of the thyroid gland, which is structurally similar to thymic tissue. Overall, it has a favorable prognosis. Radiotherapy has been shown to be an effective local treatment, but there have been reports of distant recurrence. It has been suggested that adding chemotherapy may decrease the risk of recurrence. Here, we present a case report of a patient with a large tumor and extrathyroidal extension. The patient was treated with surgery, radiotherapy, and cisplatin with acceptable toxicity. The patient is free of locally recurrent or distant disease at 3 years.

The Labor Games.

OBJECTIVE: To develop and evaluate a simulation laboratory designed to stimulate learning and increase medical students' preparedness for an obstetrics and gynecology clinical clerkship. METHODS: Ninety-seven medical students participated in the games during their obstetrics and gynecology clerkship in 1 year. Using the resident-as-teacher model, students rotated through seven stations, each with a simulated obstetric task. Points were awarded at each station, and the student with the highest score won. Self-perceived proficiency level and general preparedness for the clerkship were evaluated through paired pregame and postgame assessments. RESULTS: Postassessment results showed statistically significant (P<.001) increases in self-perceived competence performing all tested skills including reading fetal heart tracings, knot-tying, measuring cervical dilation, amniotomy, estimating fetal weight, and estimating blood loss. Approximately 97% enjoyed The Labor Games, 97.9% reported increased knowledge, and 96.9% learned valuable skills. Students also reported feeling more prepared for the obstetrics and gynecology rotation (2.6 compared with 3.3, P<.001). DISCUSSION: The Labor Games improved medical students' self-confidence and self-perceived skill level on obstetric tasks. Students also felt more prepared for the obstetrics and gynecology clerkship. This study creates a low-cost and reproducible simulation laboratory that is identified as effective by medical students in teaching skills, knowledge, and preparedness for an obstetrics and gynecology clerkship.

Locally advanced breast implant-associated anaplastic large-cell lymphoma: a case report of successful treatment with radiation and chemotherapy.

The development of breast implant-associated anaplastic large-cell lymphoma (ALCL) is a rare phenomenon. A typical presentation is an effusion associated with a breast implant. Less commonly, disease can be more advanced locoregionally or distantly. The optimal treatment schema is a topic of debate: localized ALCL can potentially be cured with implant removal alone, while other cases in the literature, including those that are more advanced, have been treated with varying combinations of surgery, chemotherapy, and external beam radiotherapy. This is a case report of breast implant ALCL with pathologically proven lymph node involvement, the fifth such patient reported. Our patient experienced a favorable outcome with radiation therapy and chemotherapy.

The effect of obesity and low-dose oral contraceptives on carbohydrate and lipid metabolism.

BACKGROUND: Combination oral contraceptives (OCs) have little effect on carbohydrate and lipid metabolism in normal-weight women. Based on lack of change in intermediate markers, as well as results of epidemiologic studies, low-dose OCs do not increase the risk of diabetes or cardiovascular disease. Obesity is a risk factor for impaired glucose tolerance, diabetes and coronary artery disease, and most previous OC studies excluded these women; thus, we have limited information about carbohydrate and lipid metabolism in obese OC users. STUDY DESIGN: This study compared changes in carbohydrate and lipid parameters in 71 normal-weight and 38 obese women initiating the OC. Women were randomized to two pills: 30 mcg ethinyl estradiol (EE)/150 mcg levonorgestrel (LNG) or 20 mcg EE/100 mcg LNG. Participants underwent baseline and cycle-3 measurements of fasting serum glucose; insulin; triglycerides and total, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol. RESULTS: Normal-weight and obese participants experienced similar changes in mean glucose, insulin and log homeostatic model assessment, as well as similar changes in total cholesterol, HDL and triglycerides; however, change in mean LDL (-4.9±20.6 mg/dL vs. +3.8±17.3 mg/dL) was different between the obese and normal-weight groups, respectively. Among the obese participants, change in glucose was marginally greater with the higher dose pill (p=.06); otherwise, changes between the body mass index groups were not modified by pill dose. CONCLUSIONS: Obesity had little effect on any OC-induced changes in carbohydrate or lipid metabolism except for a borderline adverse interaction between obesity and OC dose with respect to fasting glucose and a positive interaction between obesity and OC use with respect to LDL cholesterol.