The microbiota of traumatic, open fracture wounds is associated with mechanism of injury.

Open fractures are characterized by disruption of the skin and soft tissue, which allows for microbial contamination and colonization. Preventing infection-related complications of open fractures and other acute wounds remains an evolving challenge due to an incomplete understanding of how microbial colonization and contamination influence healing and outcomes. Culture-independent molecular methods are now widely used to study human-associated microbial communities without introducing culture biases. Using such approaches, the objectives of this study were to (1) define the long-term temporal microbial community dynamics of open fracture wounds and (2) examine microbial community dynamics with respect to clinical and demographic factors. Fifty-two subjects with traumatic open fracture wounds (32 blunt and 20 penetrating injuries) were enrolled prospectively and sampled longitudinally from presentation to the emergency department (ED) and at each subsequent inpatient or outpatient encounter. Specimens were collected from both the wound center and adjacent skin. Culture-independent sequencing of the 16S ribosomal RNA gene was employed to identify and characterize microbiota. Upon presentation to the ED and time points immediately following, sample collection site (wound or adjacent skin) was the most defining feature discriminating microbial profiles. Microbial composition of adjacent skin and wound center converged over time. Mechanism of injury most strongly defined the microbiota after initial convergence. Further analysis controlling for race, gender, and age revealed that mechanism of injury remained a significant discriminating feature throughout the continuum of care. We conclude that the microbial communities associated with open fracture wounds are dynamic in nature until eventual convergence with the adjacent skin community during healing, with mechanism of injury as an important feature affecting both diversity and composition of the microbiota. A more complete understanding of the factors influencing microbial contamination and/or colonization in open fractures is a critical foundation for identifying markers indicative of outcome and deciphering their respective contributions to healing and/or complication.

Diagnosing Infection in Patients Undergoing Conversion of Prior Internal Fixation to Total Hip Arthroplasty.

BACKGROUND: Criteria for diagnosis of infected internal fixation implants at the time of conversion to total hip arthroplasty (THA) are not clear. The purpose of this study is to identify risk factors for infection in patients undergoing conversion to THA. METHODS: We retrospectively reviewed patients at a single institution who underwent conversion to THA from 2009 to 2014. Patients were diagnosed with infection preoperatively using Musculoskeletal Infection Society criteria or postoperatively if they were found to have positive cultures intraoperatively at the time of conversion surgery. Medical comorbidities and preoperative inflammatory markers were compared between infected and noninfected groups. Univariate and multivariate logistic regression analysis were performed to identify independent risk factors for infection. Receiver operating characteristic curves were generated to determine test performance of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). A post hoc power analysis was performed. RESULTS: Thirty-three patients were included in the study. Six patients (18%) were diagnosed with infection. We found no association between comorbidities and infection in this cohort. The mean ESR and CRP were higher in infected (ESR = 41.6 mm/h, CRP = 2.0 mg/dL) vs noninfected (ESR = 19.3 mm/h, CRP = 1.3 mg/dL) groups (both P < .01). ESR >30 mm/h (odds ratio 28.8, 95% confidence interval 2.6-315.4, P = .001) and CRP >1.0 mg/dL (odds ratio 11.5, 95% confidence interval 1.6-85.2, P = .01) were strongly associated with infection. Receiver operating characteristic curves for ESR (area under the curve [AUC] = 0.89) and CRP (AUC = 0.89) demonstrated good fit. CONCLUSION: We report a high incidence of infection in patients who underwent conversion to THA. Preoperative ESR and CRP are effective screening tools though occult infections may still be missed. Patients with borderline or elevated inflammatory markers should raise strong suspicion for infection.

Arthroscopic lysis of adhesions improves knee range of motion after fixation of intra-articular fractures about the knee.

BACKGROUND: Post-traumatic stiffness after open reduction and internal fixation of fractures about the knee can have dramatic effects on function. Traditionally, open quadricepsplasty has been the treatment of choice, but is associated with significant morbidity. PURPOSE: The purpose of this study is to examine the immediate and sustainable range of motion (ROM) changes after surgical arthroscopic lysis of knee adhesions (SALKA) for post-traumatic knee stiffness after open reduction internal fixation (ORIF). METHODS: We retrospectively reviewed a consecutive series of patients at a single institution who underwent SALKA for knee stiffness after intra-articular fractures about the knee treated with ORIF from 2009 to 2015. Pre-operative and immediate post-operative total ROM was assessed while patients were sedated during the SALKA procedure. Total ROM was assessed in the office pre-operatively and compared to the latest post-operative follow-up visit. Immediate post-operative ROM was also compared to the latest post-operative follow-up visit. Two-tailed paired Student's t test was calculated for analysis. RESULTS: Of the 14 patients included in the study, 10 (71 %) had tibial plateau ORIF, 3 (21 %) had patella ORIF, and 1 (8 %) had intra-articular distal femur ORIF. The mean time between ORIF and SALKA was 244 days. The mean follow-up time after SALKA was 135 days. Under sedation during SALKA, the mean total ROM increased from 72° to 127° immediately post-operatively (p < 0.01). The mean pre-operative in-office total ROM was 73° and increased to 104° at the latest follow-up visit (p < 0.01). The mean immediate post-operative ROM was 127° and decreased to 104° at the latest follow-up visit (p = 0.01). CONCLUSION: Lysis of adhesions utilizing SALKA after ORIF about the knee improves knee ROM immediately post-operatively and in the short-term follow-up. However, there is a decrease in the gains in the range of motion over time. Patients should be counseled as such. Lysis of adhesions utilizing arthroscopic techniques may provide a favorable alternative to open quadricepsplasty.

Simulated anesthesia consent discussions demonstrate high level of comprehension and education requirements for patients: A pilot study.

Objective: Patient comprehension of informed consent and demonstration of procedural understanding is often lacking in anesthesiology. The purpose of this study was to determine if patient communication in anesthesiology is being conducted effectively, and in a manner that ensures adequate communication between anesthesia professionals and their patients regarding procedures with associated risks and benefits. Methods: Anesthesia professionals were recorded in a simulated setting explaining anesthesia procedures of increasing complexity with one control scenario. Score means were calculated, and statistical comparisons made between discussion of anesthesia procedures and the control scenario. Results: Calculation of means for 6 readability tests demonstrated the grade level required to understand the medical practitioners' verbal communication was high and increased with complexity of the anesthesia procedure described. The control scenario required a statistically significant lower level of comprehension for the recipient of the information. Conclusion: In simulated settings, anesthesia professionals regularly communicate procedural details in a manner that is difficult for the general public to understand. Subjects could communicate in simple terms when discussing a control. Innovation: This pilot study demonstrated effective methodology, using artificial intelligence technology for transcription, to assess patient comprehension of verbal communication.

Alternative Pre-mRNA Splicing of the Mu Opioid Receptor Gene, OPRM1: Insight into Complex Mu Opioid Actions.

Most opioid analgesics used clinically, including morphine and fentanyl, as well as the recreational drug heroin, act primarily through the mu opioid receptor, a class A Rhodopsin-like G protein-coupled receptor (GPCR). The single-copy mu opioid receptor gene, OPRM1, undergoes extensive alternative splicing, creating multiple splice variants or isoforms via a variety of alternative splicing events. These OPRM1 splice variants can be categorized into three major types based on the receptor structure: (1) full-length 7 transmembrane (TM) C-terminal variants; (2) truncated 6TM variants; and (3) single TM variants. Increasing evidence suggests that these OPRM1 splice variants are pharmacologically important in mediating the distinct actions of various mu opioids. More importantly, the OPRM1 variants can be targeted for development of novel opioid analgesics that are potent against multiple types of pain, but devoid of many side-effects associated with traditional opiates. In this review, we provide an overview of OPRM1 alternative splicing and its functional relevance in opioid pharmacology.

Age-Related Variations in Volar Cortical Angle of the Distal Radius.

Background: The ideal volar locking plate for the treatment of distal radius fracture should anatomically fit the volar surface of the distal radius. The purpose of this study was to measure the volar cortical angle (VCA) of uninjured adult distal radii to determine how well the VCA matches that of modern volar locking plates and whether variations in the VCA are related to demographic factors. Methods: A retrospective radiographic analysis of 273 uninjured adult distal radii was performed. Patients were stratified into age quintiles: less than 27 years, 27 to 43 years, 44 to 51 years, 52 to 64 years, and 65 years or older. The VCA was measured on lateral wrist radiographs, and patient demographics, including age and sex, were collected. Multivariable linear regression analyses were performed to determine the relationship between VCA and demographic factors. Results: The VCA ranged from 23.2° to 42.6°, with a mean of 32.2° (SD = 3.79). Mean VCA was 32.8 (SD = 4.17) in the youngest cohort (<27 years) and 30.4 (SD = 3.63) in the oldest cohort (>65 years). Mean VCA decreased with age, approximately 0.04° per year after adjusting for sex. Men had a 1.6° greater VCA than women after adjusting for age. Conclusion: Mean VCA was greater than the VCA of modern volar locking plates. The VCA decreased with age in both men and women, and men had a greater VCA than women. Such differences must be taken into account to avoid malreduction, tendon irritation, or intra-articular screw placement using current volar plate designs.

Combined RT-qPCR of mRNA and microRNA Targets within One Fluidigm Integrated Fluidic Circuit.

The ability to profile expression levels of a large number of mRNAs and microRNAs (miRNAs) within the same sample, using a single assay method, would facilitate investigations of miRNA effects on mRNA abundance and streamline biomarker screening across multiple RNA classes. A protocol is described for reverse transcription of long RNA and miRNA targets, followed by preassay amplification of the pooled cDNAs and quantitative PCR (qPCR) detection for a mixed panel of candidate RNA biomarkers. The method provides flexibility for designing custom target panels, is robust over a range of input RNA amounts, and demonstrated a high assay success rate.