Genicular nerve radiofrequency ablation: An option for knee osteoarthritis pain.

ABSTRACT: Genicular nerve radiofrequency ablation is an option to treat osteoarthritic knee pain unresponsive to conservative and minimally invasive measures. This article reviews genicular nerve radiofrequency ablation, neuroanatomy of the knee, patient selection, results, and risks and complications of the procedure.

"I have no choice": Influences on Contraceptive Use and Abortion among Women in the Democratic Republic of the Congo.

In 2015, the Democratic Republic of the Congo (DRC) recorded an estimated maternal mortality ratio of 693/100,000 live births. Strict abortion laws, high fertility rates, low contraceptive prevalence, and lack of emergency obstetric care all contribute to the high maternal mortality ratio. This study explored influences on contraceptive use and abortion in the DRC. Qualitative in-depth interviews were conducted with 32 women and 10 healthcare providers in four provinces. Participants were recruited at health centers and households in the study communities. Thematic analysis was used and identified that Congolese women's contraceptive decision-making was shaped by a range of external influences rather than their own independent decisions. Non- autonomous decisions and strict abortion laws influenced the methods used to abort a pregnancy, exposing risks of infection, complication, and fatality. These findings highlight that Congolese women's decisions about their fertility and family planning are constrained by policy and socio-cultural influences.

Asthma and risk of breakthrough varicella infection in children.

BACKGROUND: We recently reported a more rapid waning of vaccine-induced humoral immunity (measles vaccine) in children with asthma. It is unknown if asthma affects susceptibility to vaccine-preventable diseases. OBJECTIVE: To determine whether asthma is associated with an increased risk of vaccine-preventable disease, e.g., breakthrough varicella infection. METHODS: This was a retrospective population-based case-control study that examined cases of breakthrough varicella among children between 2005 and 2011. Children with a diagnosis of breakthrough varicella infection in Olmsted County, Minnesota (infection of >42 days after vaccination) between 2005 and 2011 and two age- and sex-matched controls were enrolled for each case. Asthma status was determined by using predetermined criteria. Conditional logistic regression models were used to calculate matched odds ratios (OR) and their corresponding 95% confidence intervals (CI). RESULTS: Of the 165 cases and their 330 matched controls, 48% were boys and the mean (standard deviation) age at the index date was 6.6 ± 3.5 years for both cases and controls. Of the 330 controls, 80 (24%) had two doses of the varicella vaccine compared with only 23 (14%) of the 165 cases (OR 0.29 [95% CI, 0.14-0.61]; p = 0.001). Children with a history of asthma ever had a higher risk of developing breakthrough varicella compared with those without a history of asthma (adjusted OR 1.63 [95% CI, 1.04-2.55]; p = 0.032) when adjusting for elapsed time since the first varicella vaccination and the number of varicella vaccine doses. CONCLUSIONS: A history of asthma might be an unrecognized risk factor for breakthrough varicella infection. Children with asthma should follow the two-dose varicella vaccine policy.

Preoperative Postvoid Residual Is Not Predictive of Postoperative Urinary Retention in Primary Total Joint Arthroplasty Patients.

Background: Postoperative urinary retention is a common complication after total hip and knee arthroplasty. Postvoid residual (PVR) scanning is a noninvasive method commonly used to evaluate this complication. Preoperatively increased PVR (PrePVR) has been suggested as a risk factor for postoperative catheterization. The aim of this study was to prospectively assess the importance of PrePVR and its relationship with urinary catheter placement, urology consult, and length of stay postoperatively. Methods: Data was prospectively and consecutively collected at a single institution. All patients were bladder scanned preoperatively to collect PrePVR and subsequently scanned on postoperative days zero and one to collect Postoperative PVR. Chart review was performed to determine the number of straight catheterizations, Foley placement, urology consult and length of stay as well as patient demographics. Results: Ninety-four consecutive patients were included in this study. There was a significantly increased postoperative PVR as compared to PrePVR (48.0 mL vs 21.0 mL; P < .0001). A PrePVR >50 mL was not associated with a significant difference in PVR between before and after surgery (P = .13); length of stay (P = .08); need for straight catheterization (P = .11); postoperative Foley placement (P = 1.0); or urology consult (P = 1.0). The only significant risk factor identified for postoperative Foley catheter placement was age (77.7 vs 64.2; P = .02). Conclusions: PrePVR >50 mL was not an accurate predictor of postoperative urinary retention after total joint arthroplasty. PVR significantly increased in all patients. Male sex and increasing age were associated with large increases in PVR postoperatively and an increased risk of catheterization.

Consensus statement: An evidence-based review of exercise, rehabilitation, rest, and return to activity protocols for the treatment of concussion and mild traumatic brain injury.

BACKGROUND: Early diagnosis and appropriate management of concussion/mild traumatic brain injury (mTBI) is critical for preventing poor outcomes and minimizing health care burden. Current clinical guidelines for concussion management focus mostly on diagnosis and return to cognitive and physical activity but provide limited guidance on the use of specific therapeutic interventions. OBJECTIVE: To systematically review the available evidence on therapeutic interventions for concussion/mTBI and develop an evidence-based consensus statement on the use of these interventions in clinical practice. LITERATURE SURVEY: A systematic literature search was performed first in 2018 and 2019, and again in 2022, to identify relevant original research on these interventions. A total of 6303 articles were retrieved through the systematic literature search and screened for inclusion. Eighty articles met inclusion criteria and were included in this review and consensus process. METHODOLOGY: A multispecialty panel was convened to explore management of concussion/mTBI. Interventions evaluated included rest, exercise, rehabilitation, and return to activity (RTA) protocols. Studies were assessed for relevance and methodologic quality and were voted upon to develop an evidence-based consensus statement on the therapeutic appropriateness of these interventions for concussion/mTBI. A meta-analysis was not performed. SYNTHESIS: There was sufficient evidence to recommend exercise as an appropriate therapy for adolescents with acute concussion/mTBI. In other age groups and for other therapeutic modalities, although some studies demonstrated benefits for some of the interventions, mixed results and study limitations prevented the panel from drawing firm conclusions on the efficacy of those interventions. The panel found evidence of detrimental effects from strict rest and high-intensity physical activity. CONCLUSIONS: The panel recommended exercise as an appropriate therapy for acute concussion in adolescents. The evidence on other therapeutic interventions for concussion/mTBI remains limited to small randomized controlled trials and observational studies of moderate to low quality. The panel found no strong evidence to support or recommend against the other evaluated interventions but found most interventions to be safe when used judiciously and in consideration of individual patient needs. High-quality randomized studies with sufficient power are needed to evaluate the effects of rest, rehabilitation, and RTA protocols for the management of concussion/mTBI.

Challenges and opportunities for overcoming dog use in agrochemical evaluation and registration.

Progress in developing new tools, assays, and approaches to assess human hazard and health risk provides an opportunity to re-evaluate the necessity of dog studies for the safety evaluation of agrochemicals. A workshop was held where partic­ipants discussed the strengths and limitations of past use of dogs for pesticide evaluations and registrations. Opportunities were identified to support alternative approaches to answer human safety questions without performing the required 90-day dog study. Development of a decision tree for determining when the dog study might not be necessary to inform pesticide safety and risk assessment was proposed. Such a process will require global regulatory authority participation to lead to its acceptance. The identification of unique effects in dogs that are not identified in rodents will need further evaluation and determination of their relevance to humans. The establishment of in vitro and in silico approaches that can provide critical data on relative species sensitivity and human relevance will be an important tool to advance the decision process. Promising novel tools including in vitro comparative metabolism studies, in silico models, and high-throughput assays able to identify metabolites and mechanisms of action leading to development of adverse outcome pathways will need further development. To replace or eliminate the 90-day dog study, a collaborative, multidisciplinary, international effort that transcends organi­zations and regulatory agencies will be needed in order to develop guidance on when the study would not be necessary for human safety and risk assessment.

Pseudoaneurysm following Two-Stage Hip Revision with Fasciotomy.

In the setting of total hip arthroplasty (THA), pseudoaneurysms are extremely rare and can be difficult to diagnose, as clinical symptoms can mimic symptoms of other more common complications, such as periprosthetic joint infection, hematoma, and nerve damage. We present a case of a 69-year-old male with a history of slipped capital femoral epiphysis 56 years prior and subsequent right THA. The right hip primary arthroplasty was subsequently complicated by multiple dislocations and recurrent prosthetic joint infections. The most recent infection was treated with debridement, antibiotics, and implant retention (DAIR) in 2017. The patient later presented in 2019 with right thigh pain. Upon further analysis, he was diagnosed with Streptococcus bovis positive periprosthetic joint infection. The patient underwent a two-stage revision of the hip using an antibiotic spacer. Two weeks following the second stage, he presented with a sudden onset of uncontrolled atrial fibrillation with rapid ventricular response and a low hemoglobin. The computed tomography scan revealed a large hematoma involving both the anterior and posterior thigh compartments with lab markers that were questionable for infection. An operation to remove the hematoma revealed no purulence, and a large pulsatile pseudoaneurysm on the posterolateral aspect at the mid femur was found. A sharp bone fragment was noted next to the pseudoaneurysm. The pseudoaneurysm was repaired by a vascular surgeon, and the bone fragment was removed. Following this procedure, the patient developed a subsequent periprosthetic joint infection requiring a double DAIR procedure six weeks following the pseudoaneurysm repair and is now on chronic antibiotic suppression. Orthopedic surgeons should be aware of the potential for pseudoaneurysm in the setting of total joint arthroplasty when treating a postsurgical hematoma of sudden onset.

Observing pedestrian-vehicle traffic conflicts in school zones to evaluate the effectiveness of road safety interventions and reduce injuries in Ghana, Vietnam, and Mexico, 2019-2021.

BACKGROUND: Daily more than 3,000 children are injured or killed on the road, often along the school route. Road traffic crashes and resulting injuries are preventable. More can be done to reduce injuries and save lives. Traffic Conflict Techniques (TCTs) are simple methods of collecting observational data to evaluate the effectiveness of road safety interventions through counting and analyzing traffic conflicts. A TCT Toolkit was developed and piloted to analyze pedestrian-vehicle traffic conflicts in school zones in low- and middle-income countries. METHODS: Three non-governmental organizations in Ghana, Vietnam, and Mexico applied three TCTs from the TCT Toolkit to collect traffic conflict data before (pre-intervention) and after (post-intervention) road safety intervention implementation. As the number of traffic conflicts was often less than 100, confidence intervals (CIs) based on gamma distributions were calculated for the traffic conflict rate. Using the calculated traffic conflict rate, the difference between pre- and post-intervention rates was assessed by determining overlap of the CIs. When CIs did not overlap, the difference was said to be statistically significant at the 0.05 level. RESULTS: For each method, results indicated a decrease in traffic conflicts between pre- and post-intervention data collection periods. Pre- and post-intervention traffic conflict rates with non-overlapping CIs demonstrated the results were statistically significant, providing evidence that the road safety interventions were effective. CONCLUSIONS: TCTs are relatively low-cost and simple techniques that provide an opportunity to base road safety improvement decisions on real-world data. TCTs are effective in objectively evaluating road safety interventions and can help decision-makers evaluate strategies for improving road safety, preventing injuries and saving lives.

Ovarian vein thrombosis: a potential clinical consequence of ruptured ectopic pregnancy.

A healthy 32-year-old G3P3 woman with an unknown last menstrual period presented to the emergency department with intense abdominal pain and pain in the right chest that radiated down the right arm. Further workup showed that she had a ruptured ectopic pregnancy with significant haemoperitoneum. After successful laparoscopic evacuation of the ectopic pregnancy and haemoperitoneum, the patient subsequently developed a right ovarian vein thrombosis 4 weeks after the procedure. She was treated with anticoagulation, and further haematological studies did not show any significant findings. Postpartum ovarian vein thrombosis is extremely rare and can be life- threatening if not accurately diagnosed and treated with anticoagulation or surgical management in a timely manner.

Exploring the amphibian exposome in an agricultural landscape using telemetry and passive sampling.

This is the first field study of its kind to combine radio telemetry, passive samplers, and pesticide accumulation in tissues to characterize the amphibian exposome as it relates to pesticides. Understanding how habitat drives exposure in individuals (i.e., their exposome), and how that relates to individual health is critical to managing species in an agricultural landscape where pesticide exposure is likely. We followed 72 northern leopard frogs (Lithobates pipiens) in two agricultural wetlands for insight into where and when individuals are at high risk of pesticide exposure. Novel passive sampling devices (PSDs) were deployed at sites where telemetered frogs were located, then moved to subsequent locations as frogs were radio-tracked. Pesticide concentration in PSDs varied by habitat and was greatest in agricultural fields where frogs were rarely found. Pesticide concentrations in frogs were greatest in spring when frogs were occupying wetlands compared to late summer when frogs occupied terrestrial habitats. Our results indicate that habitat and time of year influence exposure and accumulation of pesticides in amphibians. Our study illustrates the feasibility of quantifying the amphibian exposome to interpret the role of habitat use in pesticide accumulation in frogs to better manage amphibians in agricultural landscapes.

Pregnant adolescents living with HIV: what we know, what we need to know, where we need to go.

INTRODUCTION: HIV-infected pregnant and breastfeeding adolescents are a particularly vulnerable group that require special attention and enhanced support to achieve optimal maternal and infant outcomes. The objective of this paper is to review published evidence about antenatal care (ANC) service delivery and outcomes for HIV-infected pregnant adolescents in low-income country settings, identify gaps in knowledge and programme services and highlight the way forward to improve clinical outcomes of this vulnerable group. DISCUSSION: Emerging data from programmes in sub-Saharan Africa highlight that HIV-infected pregnant adolescents have poorer prevention of mother-to-child HIV transmission (PMTCT) service outcomes, including lower PMTCT service uptake, compared to HIV-infected pregnant adults. In addition, the limited evidence available suggests that there may be higher rates of mother-to-child HIV transmission among infants of HIV-infected pregnant adolescents. CONCLUSIONS: While the reasons for the inferior outcomes among adolescents in ANC need to be further explored and addressed, there is sufficient evidence that immediate operational changes are needed to address the unique needs of this population. Such changes could include integration of adolescent-friendly services into PMTCT settings or targeting HIV-infected pregnant adolescents with enhanced retention and follow-up activities.

A multicenter study to determine motivating factors for residents pursuing obstetrics and gynecology.

OBJECTIVE: This study was undertaken to determine why residents choose obstetrics and gynecology. STUDY DESIGN: Applicants to obstetrics and gynecology residency programs were surveyed; a 5-point scale (5 = most important) was used to rate various aspects of the specialty. Univariate statistics were performed. Bivariate analysis comparing results that were based on gender and timing of decisions was completed with Student t test, chi2, and Kruskal-Wallis tests. RESULTS: A total of 153 applicants (42% response rate) from 10 programs participated; 85.3% of respondents were female. Surgical opportunities, variety of clinical experience, and fast-paced/high-acuity experiences attract applicants to obstetrics and gynecology. When considering programs, resident camaraderie, gynecologic experience, and commitment to education were most important. Over 70% of residents decided to pursue obstetrics and gynecology during or after their third-year clerkship. CONCLUSION: Surgical opportunities and clinical variety appeal to applicants. The majority choose obstetrics and gynecology during or after their core clerkship. In addition, program dynamics are important when choosing a residency.

A multi-institutional survey of newer surgery faculty on the impacts of education debt and debt repayment strategies.

BACKGROUND: The cost associated with becoming a physician is significant, and studies have shown that surgeons, in particular, accrue higher debts than matched controls from other specialties, and the public. These findings, along with the current era of economic turmoil, prompted our investigation into the effects of educational debt on the career, family and lifestyle choices of recently graduated surgeons. Our goal was to query young surgical faculty about the education debt carried, the burden it presents as they embark on a career, and the financial management strategies employed to pay down their debt. STUDY DESIGN: This study is a one-time, cross-sectional survey of regular and adjunct faculty from the University of Minnesota and the Mayo Clinic-Rochester. Participation was voluntary and responses were collected anonymously via SurveyMonkey. Respondents were sorted into two groups: those with and without education debt at the time of residency graduation. We compared these groups on a number of variables. RESULTS: Of the 111 respondents (111/152, 73% response rate), 69 (62.2%) carried debt at the time of graduation from residency. The median educational debt at graduation was $100,000, and surgeons with educational debt carried a significantly higher burden of consumer and total debt than those without educational debt at graduation (p < 0.001). This continued after graduation with 74% (51/69) of residents with debt at graduation falling below the benchmark 36% debt-to-income ratio, and 45% (17/32) of those without debt at graduation in this same high risk financial situation. CONCLUSIONS: Educational debt places a large financial responsibility on the shoulders of most newer faculty. The debt-to-income ratio demonstrated through our results was considerable for both study groups, and unwise according to financial literature. This is of utmost importance to leaders in academe, as salaries are generally lower than private practice colleagues. This can begin in residency with explicit and practical information on surgeon reimbursement, income ranges, and revenue sources (faculty, clinical), debt repayment strategies, and overall training on financial matters early in their residency.

The significant impact of a competency-based preparatory course for senior medical students entering surgical residency.

PURPOSE: Previous data suggest that formal, structured preparation might improve knowledge and skills of senior medical students (SMSs) as they transition to surgical residency. However, subsequent impact on clinical performance has not been demonstrated. METHOD: The authors developed a comprehensive course for SMSs entering surgical residencies and studied the impact of the course on the subsequent performance of 2010 graduates (n = 22) compared with matched peers (16 nonparticipant controls at authors' home institution and 24 nonparticipant peer controls at outside institutions; total n = 62). Through pre- and postcourse surveys, knowledge tests, and technical examinations, they measured confidence and skill acquisition in 32 specific, job-related tasks. They followed participants and matched peers into internship and collected performance evaluations from supervising senior residents to determine whether course graduates would display performance advantages in these same tasks. The authors used t tests for all comparisons, α = 0.05. RESULTS: Participants demonstrated marked improvement in task-specific confidence in all 32 tasks from course beginning to end, with improved scores on written and technical skill examinations. Further, course participants outperformed peers in all 32 tasks in July, with their performance advantage predictably dissipating into the third month of residency. There was a marked correlation between confidence and competence in all tasks. CONCLUSIONS: Competency-based preparation for surgical internship resulted in objective gains in task-specific confidence and test performance at course conclusion, translating to improved performance and better patient care upon residency matriculation. These data emphasize the significant impact of formally preparing SMSs before graduation.

Increasing the lung donor pool: recruitment of the gift of life.

Lungs suitable for organ donation are a scarce resource. Recent efforts with alternative ventilatory strategies have yielded promise to the potential expansion of lungs suitable for transplantation.

How to practice evidence-based medicine.

Evidence-based medicine is defined as the conscientious, explicit, and judicious use of current best evidence, combined with individual clinical expertise and patient preferences and values, in making decisions about the care of individual patients. In an effort to emphasize the importance of evidence-based medicine in plastic surgery, the American Society of Plastic Surgeons and Plastic and Reconstructive Surgery have launched an initiative to improve the understanding of evidence-based medicine concepts and provide tools for implementing evidence-based medicine in practice. Through a series of special articles aimed at educating plastic surgeons, the authors' hope is that readers will be compelled to learn more about evidence-based medicine and incorporate its principles into their own practices. As the first of the series, this article provides a brief overview of the evolution, current application, and practice of evidence-based medicine.

Personality profiling of the modern surgical trainee: insights into generation X.

PURPOSE: Surgical education is undergoing a revolution in its approach to training. Duty-hour limitations, the need for strong teamwork, and increased cross-coverage have all impacted the culture of a surgical residency. This, combined with the profound shift in our culture at large has led to the suggestion that our specialty is attracting a different or more "modern" trainee (Generation X) with personality attributes that differ considerably from previous surgical residents. Historically, personality profiling of surgeons (Myers-Briggs Type Indicator (MBTI)) has favored the ESTJ personality type [extroversion (E), sensing (S), thinking (T), and judging (J)]. We hypothesized that the changing surgical training paradigms are attracting a different personality profile. To test this, we administered the MBTI examination to a large cohort of surgical trainees in one academic surgical training program. METHODS: In 2009, with Institutional Review Board (IRB) approval, we administered online MBTI Step I form M tests to all 41 categorical surgery residents from our Accreditation Council for Graduate Medical Education (ACGME)-accredited general surgery program. The test results were distributed by a certified MBTI consultant and compared with previously published data of staff surgeons. The data were analyzed using a χ(2) analysis to determine differences between groups (α = 0.05). RESULTS: Of the 41 categorical surgery residents, 39 (95%) residents completed the MBTI assessment, (54% male). The most frequent preferential personality type of the resident surgeon was ISTJ [introversion (I)], 30.8%, n = 12. When the results were compared with previously published personality profiles of practicing surgeons, there was a significant difference (p = 0.009) between E and I, contrasting the 2 groups (Table 1). However, the preferences of sensing, thinking, and judging (STJ) over all others was not significantly different (p = 0.203). CONCLUSION: Most current surgical trainees demonstrate the I personality type. This finding contrasts with established literature, which showed a preference for the E personality type among surgeons trained under the apprenticeship model of residency. As surgical training continues to evolve, it is imperative that we consider the personality traits of the modern trainee and how they might impact the development and implementation of our educational objectives and affect relationships among staff and resident trainees.