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Matthew D Smith,1,2 Danielle E Brazier,1 Emily J Henderson1,2 1Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; 2Older People’s Unit, Royal United Hospital NHS Foundation Trust, Bath, UKCorrespondence: Matthew D Smith Email matthew.smith@Bristol.ac.ukAbstract: Gait dysfunction is a key defining feature of Parkinson’s disease (PD), and is associated with symptoms of freezing and an increased risk of falls. In this narrative review, we cover the putative mechanisms of gait dysfunction in PD, the assessment of gait abnormalities, and the management of symptoms caused by the inherent difficulty in walking. Our understanding of the causes of gait problems in PD has progressed in recent times, moving from neurocognitive theory to correlates of affected neuronal pathways. In particular, this can be shown to correspond with abnormalities in responses to dual-task paradigms and dysfunction in cholinergic signaling. Great progress has been made in the sophistication and precision of gait assessment; however, it has firmly remained in the research domain. There is significant momentum behind wearable technologies that can be used by patients in their own environment, acting as digital biomarkers that can not only reflect progression but also independently discriminate PD from non-PD individuals. The treatment of gait dysfunction has historically relied on physical therapies and training combined with a view to mitigating the impact of such consequences as falls. Pharmacological therapies that are the mainstay of treatment in PD have tended to address symptoms like bradykinesia; however, optimization of dopaminergic therapies likely has a positive effect on quality of gait. Other targets have been assessed with the goal of improving gait, of which medications that improve cholinergic signaling appear most promising. Neuromodulation techniques are increasingly used in the form of deep-brain stimulation; however, standard targets, such as the globus pallidus interna, have a modest effect on gait. Considerable benefit has been seen through targeting the pedunculopontine nucleus, and a dual-target approach may be warranted. Stimulation of the spinal cord and brain through direct or magnetic approaches has been assessed, but requires further evidence.Keywords: falls, freezing of gait, gait assessment, neurodegeneration, neuropathology

Charles Birbara,1 Eugene J Dabezies JR,2 Aimee M Burr,3 Robert J Fountaine,3 Michael D Smith,3 Mark T Brown,3 Christine R West,3 Rosalin H Arends,3 Kenneth M Verburg3 1Department of Medicine, University of Massachusetts School of Medicine, Worcester, MA, 2Pensacola Research Consultants, Pensacola, FL, 3Clinical Development and Operations Business Unit, Pfizer Inc., Groton, CT, USA Background/objective: The objective of this study was to investigate the safety and efficacy of subcutaneous (SC) and intravenous (IV) tanezumab administration in osteoarthritis (OA) patients.Materials and methods: Study 1027 (NCT01089725), a placebo-controlled trial, evaluated the efficacy of SC tanezumab (ie, 2.5, 5, and 10 mg) and the therapeutic equivalence of 10 mg tanezumab given subcutaneously versus intravenously every 8 weeks in the symptomatic treatment of OA. Coprimary endpoints were: change from baseline in Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) Pain and Physical Function indices, and Patient’s Global Assessment (PGA) of OA. Study 1043 (NCT00994890) was a long-term, noncontrolled safety study of tanezumab (ie, 2.5, 5, and 10 mg) subcutaneously administered every 8 weeks. Both studies were discontinued prematurely due to a US Food and Drug Administration partial clinical hold. Results: Due to the clinical hold, Study 1027 was underpowered, and no statistical analyses were performed. Mean (standard error [SE]) change from baseline to week 8 in WOMAC Pain in tanezumab groups ranged from −3.59 (0.26) to −3.89 (0.32), versus −2.74 (0.25) with placebo. Mean (SE) change from baseline to week 8 in WOMAC Physical Function ranged from −3.13 (0.25) to −3.51 (0.28) with tanezumab and was −2.26 (0.24) with placebo. PGA mean (SE) change from baseline to week 8 ranged from −0.90 (0.11) to −1.08 (0.12) with tanezumab and was −0.78 (0.10) with placebo. Similar effectiveness was associated with tanezumab in Study 1043. Few patients in either study (1.4%–5.2%) discontinued due to adverse events. Five patients required total joint replacements in Study 1027 (placebo, n=2 [2.8%]; tanezumab 2.5 mg, n=3 [4.1%]) and 34 patients in Study 1043 (tanezumab 2.5 mg, n=11 [4.8%]; tanezumab 5 mg, n=8 [3.6%]; tanezumab 10 mg, n=15 [6.6%]). Conclusion: Preliminary results show similar efficacy and safety for both SC and IV administration of tanezumab based on the direct comparisons reported here and indirect comparisons with published results, confirming pharmacokinetic/pharmacodynamic modeling predictions. Keywords: tanezumab, subcutaneous, osteoarthritis, efficacy, safety

Lynn R Webster,1 Michael D Smith,1 Cemal Unal,2 Andrew Finn3 1PRA Health Sciences, Salt Lake City, UT, USA; 2Biometrical Solutions LLC, Raleigh, NC, USA; 3BioDelivery Sciences International, Inc., Raleigh, NC, USA Abstract: In developmental research, plasma buprenorphine concentrations comparable to a 2 mg buprenorphine–naloxone (BN) sublingual tablet have been achieved with a 0.75 mg dose of BN buccal film, a small, bioerodible polymer film for application to mucosal membranes. This was a randomized, double-blind, placebo-controlled, single-dose, four-period crossover study in opioid-dependent subjects with chronic pain receiving >100 mg oral morphine equivalents daily who experienced withdrawal following a naloxone challenge dose. The objective of the study was to determine if intravenous (IV) naloxone doses of 0.1 and 0.2 mg would produce a withdrawal response when coadministered with a 0.75 mg IV dose of buprenorphine. Fifteen subjects receiving 90–1,260 mg oral morphine equivalents per day enrolled and completed the study. Precipitated withdrawal occurred in 13% (2/15) of placebo-treated subjects and 47% (7/15) of buprenorphine-treated subjects. When combined with the 0.75 mg dose of buprenorphine, a 0.1 mg dose of naloxone increased the incidence of precipitated withdrawal to 60%, and a 0.2 mg dose of naloxone increased the incidence to 73%. By 15 minutes postdose, the mean change in Clinical Opioid Withdrawal Scale (COWS) score from predose was 3.0 for placebo, 6.9 for buprenorphine, 9.8 for BN 0.1 mg, and 12.4 for BN 0.2 mg. The mean COWS score with each active treatment was significantly greater than placebo (P

Pulmonary artery pseudoaneurysms are rare. We present a case of a 78-year old female who developed a pulmonary artery pseudoaneurysms causing hemoptysis after undergoing endovascular placement of a left atrial appendage occlusion device. The pulmonary arery pseudoaneurysm was treated with coil embolization.

Purpose: Determine if there is a difference in adverse events (AE) between right or left hepatic percutaneous biliary drain placement (PTBD) in patients with biliary strictures. Materials & methods: This retrospective study included patients with benign or malignant biliary stricture treated with PTBD at a single institution from 7/28/2004–3/30/2021. 357 patients met inclusion criteria, 77 (21.6 %) had PTBD on the left and 280 (78.4 %) on the right. AEs associated with the initial drain placement or during subsequent intervention were collected and categorized. AEs that were grouped as periprocedural included: surgery, infection, hemorrhage, and drain failure. AEs in the postprocedural group included: chills, catheter displacement, cholangitis, biliary stones, drain malfunction, fever resolving without treatment, and pericatheter leakage. Surgery was considered a major AE and the remaining AEs were categorized as minor. Statistical analyses were performed using Logistic Regression Analysis and p-values less than 0.05 were considered statistically significant. Results: Overall, there was no statistically significant difference in AEs between right and left drains in the periprocedural and postprocedural period (p = 0.832, OR = 0.95 and p = 0.808, OR = 0.93 respectively). When analyzing minor AEs individually, only cholangitis occurred at a higher rate on the right side (p = 0.033, OR = 0.43). There was no statistical difference in the rate of major AEs in the periprocedural period between left and right drains (p = 0.311, OR = 1.37). Conclusion: Current literature is equivocal when comparing right versus left percutaneous biliary drains. This analysis describes no statistically significant difference in AEs between right and left hepatobiliary drains aside from slightly higher incidence of cholangitis for right sided drains.

Background: Previous reports identified an association between obese adolescents (OAs) and lower extremity (LE) fractures after blunt trauma. However, the type of LE fracture remains unclear. We hypothesized that OAs presenting after motor vehicle collision (MVC) have a higher risk of severe LE fracture and will require a longer length of stay (LOS) and more support services upon discharge, compared to non-OAs. Methods: The 2017–2019 Trauma Quality Improvement Program database was queried for adolescents (12–17-years-old) presenting after MVC. The primary outcome was LE fracture. A severe fracture was defined by abbreviated injury scale ≥3. OAs were defined by a body mass index (BMI) ≥30. Results: From 22,610 MVCs, 3325 (14.7 %) included OAs. The rate of any LE fracture was higher for OAs (21.6 % vs. 18.8 %, p

Background: Shoulder arthroplasty has become an increasingly common procedure used to treat degenerative, inflammatory, and traumatic conditions of the glenohumeral joint. With a significant increase in primary anatomic and reverse total shoulder arthroplasty, revision procedures have likewise increased. Updates in shoulder arthroplasty have allowed for the convertibility of implants, which allows for the retention of both glenoid and humeral components during revision surgery. This review aims to highlight the epidemiology, indications, and outcomes of convertible-platform total shoulder arthroplasty procedures. Methods: A review of the current literature surrounding convertible-platform shoulder arthroplasty was completed to highlight the advantages and disadvantages of commercially available instrumentation and implant systems as well as their outcomes. Discussion: Leading causes of shoulder arthroplasty revision surgery include glenoid failure, implant instability, and rotator cuff dysfunction. Variations in implant design between inlay and onlay humeral components and metal-backed glenoid components are important considerations at the time of revision surgery. Advantages of convertible-platform systems include increased efficiency and decreased complications during revision procedures as well as shorter recovery, lower cost, and better functional outcomes. Limitations of convertible systems include poorly positioned components during the index procedure, excessive soft-tissue tensioning, and problems associated with metal-backed glenoid implants. Changes in arm length have also been documented. These findings indicate the benefit of additional research and design to improve the effectiveness and utility of convertible-platform shoulder arthroplasty systems.

Background: Capitellar osteochondritis dissecans (OCD) lesions are common in athletes. Osteochondral autograft transfer (OAT) is one possible treatment option, though outcomes including return to sport (RTS) data are limited to small series. The purpose of this study was to systematically review RTS following OAT for capitellar OCD lesions. Our secondary objectives were to evaluate patient-reported outcomes (PROs), range of motion (ROM), and complications after OAT. Methods: PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature were searched for peer-reviewed articles on “osteochondral autograft transfer” and related terms for capitellar OCD lesions. Articles were included if they reported an RTS rate and had a follow-up time point of at least 12 months. Data on RTS rates, PRO measures, complications, and ROM were extracted. Articles were assessed for methodological quality using the Methodological Index for Non-randomized Studies criteria. Results: Six hundred sixty-six articles were retrieved, and 24 articles (470 patients) met the inclusion criteria. In total, 454/470 patients (97%) returned to sports following OAT for OCD. The RTS rate ranged from 79% to 100%. Return to previous level of performance ranged from 10% to 100%. Timmerman-Andrews postoperative scores (range = 169-193) were most often reported, with 87% of patients showing scores within the excellent range. Disabilities of the Arm, Shoulder, and Hand and Japanese Orthopedic Association scores were also excellent postoperatively for all studies reporting, with higher scores among centralized lesions vs. lateral. Conclusions: Following OAT for capitellar OCD lesions, RTS rates are high; however, athletes should be counseled on the potential of a return to lower performance or the need to change positions. Lateral lesion location may negatively impact outcomes. PRO scores are typically excellent and postoperative ROM consistently improves. This information helps counsel patients regarding expectations and outcomes of OAT for OCD of the capitellum.

Background: The optimal training program to transform a new resident into a competent and capable surgeon is constantly evolving. Competency-based evaluation represents a change in mindset from quantitative or chronologic metrics for graduate readiness. As surgery becomes more specialized, more dependent on technology, and more public, we must continue to improve our ability to pass on technical skills. Approaching surgery in a component-based fashion enables even the most complex operation to be broken down into smaller sets of steps that range the entire spectrum of complexity. Treating an operation through the lens of its components, emphasizing stepwise forward progression in a trainee's experience, may provide a way to train competent surgeons more efficiently. Current case-logging products do not provide adequate granularity to apply this methodology. Methods: Application design relied on the involvement of local surgeons from all specialties and subspecialties related to general surgical training. Individual interviews with multiple experts in each field were used to generate a list of most commonly performed operations. Once a consensus was reached, the same surgeons were queried on what they felt were the core steps that make up each operation. This information was utilized to create a novel mobile application which enables the user to record cases by date, attending surgeon, specific operation, and which portions of the operation they were able/allowed to perform. Conclusion: Component-based case logging through the Logix application may be a useful adjunct as we continue to implement competency-based surgical training. Future investigation will assess user experience and compare subjective and objective metrics of training progression between the Logix application and currently utilized products. The information provided by the application stands to benefit not just trainees, but educators, training programs, and regulatory bodies. Key message: Component-based case logging via a novel mobile application stands to increase the efficiency of surgical training and more effectively assess trainee competency.

Background: Embracing patient viewpoints can enhance the translation of novel therapeutics to clinical settings. This study evaluated the acceptability of using extracellular vesicles (EVs) as a biological therapy for preventing postoperative atrial fibrillation (AF), through engagement with patients, providing insights into their attitudes and information needs. Methods: Patients participated in prerecorded presentations, virtual focus groups, and surveys to assess their perspectives on EV therapy and determine the factors influencing their acceptance of the intervention. Results: Participants with postoperative AF experienced prolonged intensive care unit and hospital stays, compared to those of patients with normal heart rhythm. Prior to the presentation, a number of participants were unfamiliar with postoperative AF and biological therapies. However, postpresentation and post–focus group activities resulted in enhanced understanding of the research, with high levels of comprehension reported by all participants. The level of acceptance of EV therapy tended to increase, with a majority expressing willingness to participate in clinical trials and accept the therapy. The focus groups identified and addressed common questions regarding the potential risks and side effects of EVs, their source, dosing, utility for patients with preexisting AF, and the risk of human immunodeficiency virus (HIV) contraction or allergic reactions. Conclusions: The study highlights the importance of providing education, involving the patient's circle of care, and addressing patient concerns, to promote acceptance of therapies such as EV therapy for postoperative AF. Clinical Trial Registration: NCT05032495. Résumé: Contexte: Adopter le point de vue des patients permet de faciliter l’introduction de nouveaux traitements en milieu clinique. Cette étude visait à évaluer l’acceptabilité des vésicules extracellulaires comme traitement biologique dans la prévention de la fibrillation auriculaire postopératoire en favorisant un rapprochement avec les patients, en comprenant leurs attitudes et leurs besoins d’information. Méthodologie: Les patients ont assisté à des présentations préenregistrées, ont participé à des groupes de discussion virtuels et ont rempli des questionnaires. L’objectif était d’évaluer leur point de vue sur les vésicules extracellulaires et de déterminer les facteurs influençant l’acceptation de l’intervention. Résultats: Les participants atteints de fibrillation auriculaire postopératoire sont restés plus longtemps à l’unité des soins intensifs et à l’hôpital par comparaison aux patients ayant un rythme cardiaque normal. Avant la présentation, un certain nombre de participants ne connaissaient pas la fibrillation auriculaire postopératoire et les traitements biologiques. Cependant, après la présentation et le groupe de discussion, les participants ont pu mieux comprendre la recherche, et tous ont indiqué un niveau de compréhension élevé. Le degré d’acceptation des vésicules extracellulaires avait tendance à augmenter. En effet, la majorité des patients se disait prête à participer à des essais cliniques et à accepter le traitement. Les groupes de discussion ont relevé et abordé des questions communes concernant les risques et effets secondaires des vésicules extracellulaires, leur source, leur dose, leur utilité pour les patients présentant une fibrillation auriculaire préexistante et le risque d’infection par le virus de l’immunodéficience humaine (VIH) ou de réactions allergiques. Conclusions: L’étude souligne l’importance de l’éducation, de la participation du réseau de soins du patient et de la prise en compte des préoccupations du patient pour favoriser l’acceptation de traitements comme les vésicules extracellulaires pour la fibrillation auriculaire postopératoire. Enregistrement de l’essai clinique: NCT05032495.

Objective: The study objective was to determine if intraoperative peritoneal catheter placement is associated with improved outcomes in neonates undergoing high-risk cardiac surgery with cardiopulmonary bypass. Methods: This propensity score–matched retrospective study used data from 22 academic pediatric cardiac intensive care units. Consecutive neonates undergoing Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery category 3 to 5 cardiac surgery with cardiopulmonary bypass at centers participating in the NEonatal and Pediatric Heart Renal Outcomes Network collaborative were studied to determine the association of the use of an intraoperative placed peritoneal catheter for dialysis or passive drainage with clinical outcomes, including the duration of mechanical ventilation. Results: Among 1490 eligible neonates in the NEonatal and Pediatric Heart Renal Outcomes Network dataset, a propensity-matched analysis was used to compare 395 patients with peritoneal catheter placement with 628 patients without peritoneal catheter placement. Time to extubation and most clinical outcomes were similar. Postoperative length of stay was 5 days longer in the peritoneal catheter placement cohort (17 vs 22 days, P = .001). There was a 50% higher incidence of moderate to severe acute kidney injury in the no-peritoneal catheter cohort (12% vs 18%, P = .02). Subgroup analyses between specific treatments and in highest risk patients yielded similar associations. Conclusions: This study does not demonstrate improved outcomes among neonates with placement of a peritoneal catheter during cardiac surgery. Outcomes were similar apart from longer hospital stay in the peritoneal catheter cohort. The no-peritoneal catheter cohort had a 50% higher incidence of moderate to severe acute kidney injury (12% vs 18%). This analysis does not support indiscriminate peritoneal catheter use, although it may support the utility for postoperative fluid removal among neonates at risk for acute kidney injury. A multicenter controlled trial may better elucidate peritoneal catheter effects.

Objective: Aortoesophageal fistula is a rare, life-threatening condition. There is no consensus regarding the surgical management of the esophagus in this condition. Methods: We retrospectively evaluated 13 patients diagnosed with aortoesophageal fistulas at a single institution from 2003 to 2021. Descriptive statistics were used to analyze patient characteristics, operative characteristics, and patient outcomes. Kaplan–Meier survival analysis was performed. Results: Patients’ mean age was 63.5 years, and 6 (46.2%) were female. The most common presenting symptoms were hemoptysis/hematemesis (69.2%), chest/back pain (46.2%), and fever (38.5%). Twelve patients (92.3%) had a history of aortic procedures. The median time between the index operation and repair of the secondary aortoesophageal fistula in the 12 patients was 5 months. The index operation was a thoracic endovascular aortic repair in 10 of 12 patients (83.3%). Eleven patients (84.6%) underwent primary esophageal repair with flap coverage (omentum or muscle). One of these patients needed an esophagectomy within 1 year. The primary surgical management of the aorta was graft excision and replacement, aside from 1 patient who underwent primary repair. The 30-day survival was 69.2%, and 1-year and 5-year survivals were 31.7%. There were no recurrent infections at the esophageal fistula site. Conclusions: Aortoesophageal fistula remains a rare condition, but its case numbers have increased with thoracic endovascular aortic repair. It continues to be a difficult condition to manage and has a high fatality rate. Esophageal-preserving surgery may be a safe and less-invasive option for patients with a small defect.

Background: Mohs micrographic surgery (MMS) is used for the treatment of high-risk cutaneous squamous cell carcinoma (cSCC). MMS examines the surgical margins in real time and does not commonly examine the central component of the tumor. Objective: To determine if debulk specimens provide additional details relevant to tumor staging not gained from routine MMS. Methods: A retrospective chart review of debulk specimens taken during MMS for cSCC was performed. Dermatopathology reports were analyzed and tumors were staged using Brigham and Women’s Hospital and American Joint Committee on Cancer’s 8th edition staging systems. Results: Permanent section evaluation of debulk specimens did not result in clinically meaningful information for staging that could not be gained from MMS layers or initial biopsy analysis. Limitations: A single institution, and a small sample size of 39 tumors. Conclusions: Evaluation of debulk specimens during MMS may not always be an effective use of time or health care resources.

Stent migration is a rare but significant complication following endovascular procedures. Techniques for managing dislodged stents have included surgical, endovascular, and conservative approaches. This case details a patient who had a covered stent placed within the left renal vein which later migrated to the pulmonary artery causing damage to the tricuspid valve. The migrated stent was successfully removed using a percutaneous endovascular approach utilizing fluoroscopy and transesophageal echocardiogram guidance.

A generation ago thrombolytic therapy led to a paradigm shift in myocardial infarction (MI), from Q-wave/non-Q-wave to ST-segment elevation MI (STEMI) vs non-STEMI. Using STE on the electrocardiogram (ECG) as a surrogate marker for acute coronary occlusion (ACO) allowed for rapid diagnosis and treatment. But the vast research catalyzed by the STEMI paradigm has revealed increasing anomalies: 25% of “non-STEMI” have ACO with delayed reperfusion and higher mortality. Studying these limitations has given rise to the occlusion MI (OMI) paradigm, based on the presence or absence of ACO in the patient rather than STE on ECG. The OMI paradigm shift harnesses advanced ECG interpretation aided by artificial intelligence, complementary bedside echocardiography and advanced imaging, and clinical signs of refractory ischemia, and offers the next opportunity to transform emergency cardiology and improve patient care. This State-of-the-Art Review examines the paradigm shifts from Q wave to STEMI to OMI.

Hypothesis and/or Background: The incidence of elbow medial ulnar collateral ligament (MUCL) injuries has been increasing, leading to advances in surgical treatments. However, it is not clear that there is consensus among surgeons regarding diagnostic imaging, the indications for acute surgery and postoperative rehabilitation. The purpose of this study is evaluate surgeon variability in the presurgical, surgical, and postsurgical treatment of MUCL injuries regarding the imaging modalities used for diagnosis, indications for acute surgical treatment, and postoperative treatment recommendations for rehabilitation and return to play (RTP). Our hypothesis is that indications for acute surgical treatment will be highly variable based on MUCL tear patterns and that agreement on the time to RTP will be consistent for throwing athletes and inconsistent for nonthrowing athletes. Methods: A survey developed by 6 orthopedic surgeons with expertise in throwing athlete elbow injuries was distributed to 31 orthopedic surgeons who routinely treat MUCL injuries. The survey evaluated diagnostic and treatment topics related to MUCL injuries, and responses reaching 75% agreement were considered as high-level agreement. Results: Twenty-four surgeons responded to the survey, resulting in a 77% response rate. There is 75% or better agreement among surveyed surgeons regarding acute surgical treatment for distal full thickness tears, ulnar nerve transposition in symptomatic patients or with ulnar nerve subluxation, postoperative splinting for 1-2 weeks with initiation of rehabilitation within 2 weeks, the use of bracing after surgery and the initiation of a throwing program at 3 months after MUCL repair with internal brace by surgeons performing 20 or more MUCL surgeries per year. There were a considerable number of survey topics without high-level agreement, particularly regarding the indications for acute surgical treatment, the time to return to throwing and time RTP in both throwing and nonthrowing athletes. Discussion and/or Conclusion: The study reveals that there is agreement for the indication of acute surgical treatment of distal MUCL tears, duration of bracing after surgery, and the time to initiate physical therapy after surgery. There is not clear agreement on indications for surgical treatment for every MUCL tear pattern, RTP time for throwing, hitting and participation in nonthrowing sports.

Objective: To determine the appropriateness of ophthalmology recommendations from an online chat-based artificial intelligence model to ophthalmology questions. Patients and Methods: Cross-sectional qualitative study from April 1, 2023, to April 30, 2023. A total of 192 questions were generated spanning all ophthalmic subspecialties. Each question was posed to a large language model (LLM) 3 times. The responses were graded by appropriate subspecialists as appropriate, inappropriate, or unreliable in 2 grading contexts. The first grading context was if the information was presented on a patient information site. The second was an LLM-generated draft response to patient queries sent by the electronic medical record (EMR). Appropriate was defined as accurate and specific enough to serve as a surrogate for physician-approved information. Main outcome measure was percentage of appropriate responses per subspecialty. Results: For patient information site-related questions, the LLM provided an overall average of 79% appropriate responses. Variable rates of average appropriateness were observed across ophthalmic subspecialties for patient information site information ranging from 56% to 100%: cataract or refractive (92%), cornea (56%), glaucoma (72%), neuro-ophthalmology (67%), oculoplastic or orbital surgery (80%), ocular oncology (100%), pediatrics (89%), vitreoretinal diseases (86%), and uveitis (65%). For draft responses to patient questions via EMR, the LLM provided an overall average of 74% appropriate responses and varied by subspecialty: cataract or refractive (85%), cornea (54%), glaucoma (77%), neuro-ophthalmology (63%), oculoplastic or orbital surgery (62%), ocular oncology (90%), pediatrics (94%), vitreoretinal diseases (88%), and uveitis (55%). Stratifying grades across health information categories (disease and condition, risk and prevention, surgery-related, and treatment and management) showed notable but insignificant variations, with disease and condition often rated highest (72% and 69%) for appropriateness and surgery-related (55% and 51%) lowest, in both contexts. Conclusion: This LLM reported mostly appropriate responses across multiple ophthalmology subspecialties in the context of both patient information sites and EMR-related responses to patient questions. Current LLM offerings require optimization and improvement before widespread clinical use.

Abstract. Objectives:. To develop and validate a prediction model for a deep surgical site infection (SSI) after fixation of a tibial plateau or pilon fracture. Design:. Pooled data from 2 randomized trials (VANCO and OXYGEN). Setting:. Fifty-two US trauma centers. Patients:. In total, 1847 adult patients with operatively treated tibial plateau or pilon fractures who met criteria for a high risk of infection. Intervention:. We considered 13 baseline patient characteristics and developed and externally validated prediction models using 3 approaches (logistic regression, stepwise elimination, and machine learning). Main Outcomes and Measures:. The primary prediction model outcome was a deep SSI requiring operative debridement within 182 days of definitive fixation. Our primary prognostic performance metric for evaluating the models was area under the receiver operating characteristic curve (AUC) with clinical utility set at 0.7. Results:. Deep SSI occurred in 75 VANCO patients (8%) and in 56 OXYGEN patients (6%). The machine learning model for VANCO (AUC = 0.65) and stepwise elimination model for OXYGEN (AUC = 0.62) had the highest internal validation AUCs. However, none of the external validation AUCs exceeded 0.64 (range, 0.58 to 0.64). Conclusions:. The predictive models did not reach the prespecified clinical utility threshold. Our models' inability to distinguish high-risk from low-risk patients is likely due to strict eligibility criteria and, therefore, homogeneous patient populations.

Background: Extremity surgeons frequently operate on the preoperative stretcher rather than the operating room (OR) table. This study sought to identify differences between stretcher-based (SB) and OR table–based (TB) procedures with regard to time efficiency and OR team member preferences. Methods: We conducted a prospective randomized controlled trial comparing the efficiency of SB vs OR TB foot and ankle procedures. Fifty-two patients undergoing a hardware removal, isolated gastrocnemius recession, soft tissue procedure, or foreign body removal at our day surgery unit were included. Start time and exit time were recorded. “Start time” was the number of minutes between the patient entering the OR and first incision. “Exit time” was the number of minutes between the procedure ending and the patient exiting the OR. Surveys were disseminated to OR staff who participated in the included cases. Results: The total measured time in the OR was an average 6 minutes shorter in the Stretcher group compared to the OR Table group (10 minutes vs 16 minutes, P

Background: As lung transplant candidates are older with increased comorbidities, we sought to examine the prevalence and outcomes of lung transplant recipients after prior cardiac surgery. Methods: Lung transplants were identified from the United Network for Organ Sharing/Organ Procurement and Transplantation Network Database. Patients were stratified based on prior cardiac surgery (no surgery [NS], prior coronary artery bypass grafting [CABG], prior valve [Valve]). Unadjusted comparisons were performed among all groups, and propensity matching was utilized for adjusted comparisons. Survival was examined with Kaplan-Meier methods. Results: A total of 28,710 patients were identified, 467 (1.6%) had prior CABG and 84 (0.3%) had prior valvular surgery. Before matching, the NS group was significantly younger, less commonly male, and had lower lung allocation scores. There were significantly fewer bilateral lung transplants in the CABG and Valve groups. Length of stay was shortest in the CABG group, but there were no significant differences in postoperative stroke, dialysis, or in-hospital mortality. There was an increased incidence of cardiac/cerebrovascular cause of death in CABG recipients (18.3%) and malignancy death in Valve recipients (23.3%). Following matching, CABG 5-year survival was lower than NS (p

OBJECTIVE:. ICU delirium commonly complicates critical illness associated with factors such as cardiopulmonary bypass (CPB) time and the requirement of mechanical ventilation (MV). Recent reports associate hyperoxia with poorer outcomes in critically ill children. This study sought to determine whether hyperoxia on CPB in pediatric patients was associated with a higher prevalence of postoperative delirium. DESIGN:. Secondary analysis of data obtained from a prospective cohort study. SETTING:. Twenty-two-bed pediatric cardiac ICU in a tertiary children’s hospital. PATIENTS:. All patients (18 yr old or older) admitted post-CPB, with documented delirium assessment scores using the Preschool/Pediatric Confusion Assessment Method for the ICU and who were enrolled in the Precision Medicine in Pediatric Cardiology Cohort from February 2021 to November 2021. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. Of 148 patients, who underwent cardiac surgery, 35 had delirium within the first 72 hours (24%). There was no association between hyperoxia on CPB and postoperative delirium for all definitions of hyperoxia, including hyperoxic area under the curve above 5 predetermined Pao2 levels: 150 mm Hg (odds ratio [95% CI]: 1.176 [0.605–2.286], p = 0.633); 175 mm Hg (OR 1.177 [95% CI, 0.668–2.075], p = 0.572); 200 mm Hg (OR 1.235 [95% CI, 0.752–2.026], p = 0.405); 250 mm Hg (OR 1.204 [95% CI, 0.859–1.688], p = 0.281), 300 mm Hg (OR 1.178 [95% CI, 0.918–1.511], p = 0.199). In an additional exploratory analysis, comparing patients with delirium within 72 hours versus those without, only the z score for weight differed (mean [sd]: 0.09 [1.41] vs. –0.48 [1.82], p < 0.05). When comparing patients who developed delirium at any point during their ICU stay (n = 45, 30%), MV days, severity of illness (Pediatric Index of Mortality 3 Score) score, CPB time, and z score for weight were associated with delirium (p < 0.05). CONCLUSIONS:. Postoperative delirium (72 hr from CPB) occurred in 24% of pediatric patients. Hyperoxia, defined in multiple ways, was not associated with delirium. On exploratory analysis, nutritional status (z score for weight) may be a significant factor in delirium risk. Further delineation of risk factors for postoperative delirium versus ICU delirium warrants additional study.

OBJECTIVES:. Our study aimed to assess the time to positivity (TTP) of clinically significant blood cultures in critically ill children admitted to the PICU. DESIGN:. Retrospective review of positive blood cultures in patients admitted or transferred to the PICU. SETTING:. Large tertiary-care medical center with over 90 PICU beds. PATIENTS:. Patients 0–20 years old with bacteremia admitted or transferred to the PICU. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. The primary endpoint was the TTP, defined as time from blood culture draw to initial Gram stain result. Secondary endpoints included percentage of cultures reported by elapsed time, as well as the impact of pathogen and host immune status on TTP. Host immune status was classified as previously healthy, standard risk, or immunocompromised. Linear regression for TTP was performed to account for age, blood volume, and Gram stain. Among 164 episodes of clinically significant bacteremia, the median TTP was 13.3 hours (interquartile range, 10.7–16.8 hr). Enterobacterales, Staphylococcus aureus, Streptococcus agalactiae, and Streptococcus pneumoniae were most commonly identified. By 12, 24, 36, and 48 hours, 37%, 89%, 95%, and 97% of positive cultures had resulted positive, respectively. Median TTP stratified by host immune status was 13.2 hours for previously healthy patients, 14.0 hours for those considered standard risk, and 10.6 hours for immunocompromised patients (p = 0.001). Median TTP was found to be independent of blood volume. No difference was seen in TTP for Gram-negative vs. Gram-positive organisms (12.2 vs. 13.9 hr; p = 0.2). CONCLUSIONS:. Among critically ill children, 95% of clinically significant blood cultures had an initial positive result within 36 hours, regardless of host immune status. Need for antimicrobial therapy should be frequently reassessed and implementation of a shorter duration of empiric antibiotics should be considered in patients with low suspicion for infection.

Objective:. This study evaluated the association between preoperative education and adherence to downstream components of enhanced recovery programs (ERPs) and surgical outcomes among patients undergoing elective colorectal surgery. Background:. ERPs improve outcomes for surgical patients. While preoperative education is an essential component of ERPs, its relationship with other components is unclear. Methods:. This was a retrospective cohort study of all ERP patients undergoing elective colorectal surgery from 2019 to 2022. Our institutional ERP database was linked with American College of Surgeons National Surgical Quality Improvement Program data and stratified by adherence to preoperative education. Primary outcomes included adherence to individual ERP components and secondary outcomes included high-level ERP adherence (>70% of components), length of stay (LOS), readmissions, and 30-day complications. Results:. A total of 997 patients were included. The mean (SD) age was 56.5 (15.8) years, 686 (57.3%) were female, and 717 (71.9%) were white. On adjusted analysis, patients who received preoperative education (n = 877, 88%) had higher adherence rates for the following ERP components: no prolonged fasting (estimate = +19.6%; P < 0.001), preoperative blocks (+8.0%; P = 0.02), preoperative multimodal analgesia (+18.0%; P < 0.001), early regular diet (+15.9%; P < 0.001), and postoperative multimodal analgesia (+6.4%; P < 0.001). High-level ERP adherence was 13.4% higher (P < 0.01) and LOS was 2.0 days shorter (P < 0.001) for those who received preoperative education. Classification and regression tree analysis identified preoperative education as the first-level predictor for adherence to early regular diet, the second-level predictor for LOS, and the third-level predictor for ERP high-level adherence. Conclusion:. Preoperative education is associated with adherence to ERP components and improved surgical outcomes.

Dermatomyositis (DM) presents with inflammatory myopathy and distinct skin manifestations, often linked to specific autoantibodies. Anti-transcriptional intermediary factor-1 gamma (TIF-1γ) antibodies (Abs) are typically linked to DM in older patients and malignancy in 15% to 40% of cases. We highlight a case of a 24-year-old female who presented with weakness of proximal muscles, periorbital edema, heliotrope rash, erosions on oral mucosa, and painful scaly rash on the lower extremities. Transcriptional intermediary factor-1 gamma Abs were positive, confirming inflammatory myopathy. Treatment with steroid pulse therapy and immunoglobulin led to improvement. Evaluation for malignancy yielded unremarkable results. This case underscores the importance of recognizing and managing DM with TIF-1γ Ab positive, even in atypical demographics, and highlights the need for comprehensive malignancy evaluation.

Anaphylaxis is an acute, potentially fatal, systemic hypersensitivity reaction that warrants prompt diagnosis and management. It continues to be challenging to anticipate who may be at risk of a severe, life-threatening allergic reaction. Anaphylaxis can be caused by a range of allergens, such as certain foods, medications, latex, insect stings, etc. Cofactors that augment the severity of clinical symptoms and increase the risk of poor outcomes include exercise, stress, infectious diseases, underlying mast cell disease, active allergic disease such as asthma, advanced age, intake of certain medications, history of previous anaphylaxis, and delayed or missed administration of adrenaline. According to the European Anaphylaxis Registry, food is the major elicitor of anaphylaxis, especially eggs, cow milk, and nuts, in children and adolescents. Reaction to insect venom has also been noted in young adulthood. Early recognition of signs and symptoms and prompt treatment are crucial in anaphylaxis management to avoid serious and even fatal outcomes. It is crucial for both individuals and clinicians to identify the cause of anaphylaxis. Biomarkers of anaphylaxis, such as histamine, tryptase, platelet activation factor (PAF), chymase, carboxypeptidase A3, dipeptidyl peptidase I (DPPI), basogranulin, CCL-2, hsa-miR-451a, may be useful in diagnosis and management. The purpose of this review article is to present a comprehensive overview of current evidence and expert opinions regarding the risk factors that predispose individuals to anaphylaxis. Additionally, it provides insights into potential biomarkers and genetic markers for accurate diagnosis and management. This review underscores the significance of expert guidance in enhancing patient outcomes and enabling self-management of anaphylactic episodes.

Background: Several common pregnancy conditions significantly increase a woman’s risk of future cardiovascular diseases (CVD). Patient education and interventions aimed at awareness and self-management of cardiovascular risk factors may help modify future cardiovascular risk. The aim of this systematic review was to examine education interventions for cardiovascular risk after pregnancy, clinical measures/scales, and knowledge outcomes in published qualitative and quantitative studies. Methods: Five databases were searched (from inception to June 2023). Studies including interventions and validated and nonvalidated measures of awareness/knowledge of future cardiovascular risk among women after complications of pregnancy were considered. Quality was rated using the Mixed Methods Appraisal Tool. Results were analyzed using the Synthesis Without Meta-analysis reporting guideline. Characteristics of interventions were reported using the Template for Intervention Description and Replication. Fifteen studies were included; 3 were randomized controlled trials. Results: In total, 1623 women had a recent or past diagnosis of hypertensive disorders of pregnancy, gestational diabetes mellitus, and/or premature birth. Of the 7 studies that used online surveys or questionnaires, 2 reported assessing psychometric properties of tools. Four studies used diverse educational interventions (pamphlets, information sheets, in-person group sessions, and an online platform with health coaching). Overall, women had a low level of knowledge about their future CVD risk. Interventions were effective in increasing this knowledge. Conclusions: In conclusion, women have a low level of knowledge of risk of CVD after pregnancy complications. To increase this level of knowledge and self-management, this population has a strong need for psychometrically validated tailored education interventions. Résumé: Contexte: Plusieurs problèmes médicaux liés à la grossesse augmentent significativement le risque d’une maladie cardiovasculaire (MCV) ultérieure chez les femmes. L’éducation des patients et les interventions axées sur la sensibilisation aux facteurs de risques cardiovasculaire et sur l’autoprise en charge pourraient aider à limiter le risque de MCV. La présente analyse des études qualitatives et quantitatives publiées visait à examiner les interventions éducatives au sujet des risques cardiovasculaires après la grossesse, les mesures et échelles cliniques qui y sont associées, et les résultats de ces interventions sur le plan des connaissances. Méthodologie: Des recherches ont été réalisées dans cinq bases de données (de leur date de création jusqu’à juin 2023). Les études considérées incluaient des interventions et des mesures validées ou non de la sensibilisation des femmes au sujet des risques de MCV après des complications liées à la grossesse ou de leurs connaissances à ce sujet. La qualité des études a été évaluée avec l’Outil d’évaluation de la qualité méthodologique des études incluses dans une revue mixte, et les résultats ont été évalués à l’aide de la méthodologie Synthesis Without Meta-analysis. Les caractéristiques des interventions ont été relevées selon le modèle Template for Intervention Description and Replication. Quinze études ont été retenues, dont 3 essais contrôlés randomisés. Résultats: Au total, 1623 femmes avaient reçu récemment ou auparavant un diagnostic de trouble hypertensif lié à la grossesse, de diabète gestationnel et/ou de travail prématuré. Parmi les 7 études ayant eu recours à des questionnaires ou des sondages en ligne, 2 mentionnaient l’évaluation des propriétés psychométriques des outils. Dans 4 études, plusieurs interventions éducatives ont été utilisées (dépliants, feuillets informatifs, séances de groupe en personne et plateforme en ligne offrant un accompagnement en matière de santé). De manière générale, le niveau de connaissance des femmes au sujet de leur risque de MCV était faible, mais les interventions se sont révélées efficaces pour améliorer ces connaissances. Conclusions: En conclusion, les femmes ne connaissent pas bien les risques de MCV associés aux complications survenues au cours de la grossesse. Pour améliorer le niveau des connaissances et l’autoprise en charge, des interventions conçues pour cette population et validées sur le plan psychométrique sont indispensables.

Background: Corticosteroid injections (CSIs) can be an effective nonsurgical treatment for patients with rotator cuff tears. Recent large database studies have raised concern that CSI may result in a higher reoperation rate, increased infection risk, and worse outcome after arthroscopic rotator cuff repair (ARCR). The purpose of this study was to evaluate the reoperation rate, incidence of postoperative infection, and two-year outcomes of patients undergoing ARCR with and without the use of preoperative CSI. Methods: An institutional database generated from fellowship-trained orthopedic sports surgeons was retrospectively queried for patients who underwent ARCR with a minimum of two-year follow-up. Inclusion criteria consisted of 1) primary full-thickness rotator cuff tear and 2) preoperative and minimum two-year patient-reported outcome measures (PROMs). Of the 219 patients identified, 134 patients had preoperative subacromial CSI administered within one year of ARCR. Reoperation rate, number of injections, Visual Analog Scale, American Shoulder and Elbow Surgeons Score, Single Assessment Numeric Evaluation, and Veterans Rand 12-Item Health Survey Physical Component Score/Mental Component Score were compared between groups at six months, one year, and two years. Chi-square and t-tests were used to compare baseline differences, postoperative infections, and reoperations. A repeated measures Analyses of Covariance was used to measure differences between PROMs at each time point. Simple Analyses of Covariance were used for the two-year sub-analyses for patients receiving CSI within 90 days of surgery and if multiple preoperative CSI had been given (α ≤ 0.05). Results: There were no significant demographic differences between groups (P > .05). Preoperative use of subacromial CSI within one year prior to ARCR did not increase reoperation rate (P = .85) or impact PROMs at any timepoint. There were two reoperations during the study period in the CSI group (2 lysis of adhesions). No infections occurred in either cohort. No differences were found if injections were performed within 90 days of surgery or if more than one CSI was administered within the year prior to surgery (P > .05). Conclusion: Our results show that preoperative CSI prior to primary ARCR did not increase risk of reoperation, infection, or influence PROMs with a minimum follow-up of 2 years.

Purpose: Arthroplasty of the basal, or carpometacarpal, joint of the thumb has been shown to decrease pain, improve strength, improve range of motion, and allow return to work. This study sought to assess whether basal joint arthroplasty also allows for a return to sports and recreational activities. Methods: A survey assessing participation in sports and recreational activities, timing of return to play after surgery, enjoyment, and the presence of pain and limitations was mailed to patients who had undergone an arthroplasty of the basal joint of the thumb over a 3-year period. Results: Of the 333 patients who underwent thumb carpometacarpal arthroplasty, met the criteria, and responded, 73% were able to successfully return to sports and recreational activities, with decreased pain and at the same or increased level of play, frequency of participation, and level of enjoyment for their sport or recreational activity. Patients were more likely to successfully return to sports and recreational activities if they had undergone surgery on their nondominant hand, did not stop their sport or recreational activity before surgery, were able to return within 9 months of surgery, and reported no postoperative limitations. Successful return to sports and recreational activities was not related to age, sex, surgeon, level of play, or the type of sport or recreational activity. Conclusions: Most patients who replied to our survey reported successful return to sports and recreational activities after arthroplasty of the basal joint of the thumb. Type of study/level of evidence: Prognostic IV.

We present a boy with X-linked adrenoleukodystrophy (X-ALD) who was found to have lumbar nerve root enhancement on a screening MRI of the spine. The MRI was performed for lower extremity predominant symptoms. Several weeks after this MRI, he developed leg pain and was averse to walking long distances. He was diagnosed with Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) with electromyography, nerve conduction studies, and serial imaging. His case is consistent with CIDP in association with X-ALD based on improvement with intravenous immunoglobulin (IVIG) with continued contrast enhancement and lower extremity symptoms 8 weeks after his initial scans. Contrast enhancement of nerve roots has not been previously described in X-ALD. Nerve root enhancement has been seen in other leukodystrophies such as globoid cell leukodystrophy and metachromatic leukodystrophy. This case also demonstrates comorbid X-ALD with CIDP and highlights possible mechanisms from the literature for this association. We also review the broad differential of cauda equina nerve root enhancement.

Objective: Pneumonia, both in the community and the hospital setting, represents a significant cause of morbidity and mortality in the cardiothoracic patient population. Diagnosis of pneumonia can be masked by other disease processes and is often diagnosed after the patient is already experiencing the disease. A noninvasive, sensitive test for pneumonia could decrease hospitalizations and length of stay for patients. We have developed a porcine model of pneumonia and evaluated the exhaled breath of infected pigs for biomarkers of infection. Methods: Anesthetized 60-kg adult pigs were intubated, and a bronchoscope was used to instill a solution containing 12 × 108 cfu of methicillin-sensitive Staphylococcus aureus or a control solution without bacteria (Sham) into the distal airways. The pigs were then reintubated on postoperative days 3, 6, and 9, with bronchoscopic bronchial lavages taken at each time point. At each time point, a 500-mL breath was captured from each pig. The breath was evacuated over a silicon microchip, with the volatile carbonyl compounds from the breath captured via oximation reaction, and the results of this capture were analyzed by ultra-high performance liquid chromatography mass spectrometry. Results: A total of 64% of the pigs inoculated with methicillin-sensitive S. aureus demonstrated consolidation on chest radiography and increasing counts of methicillin-sensitive S. aureus in the bronchial lavages over the span of the experiment, consistent with development of pneumonia. Analysis of the exhaled breath demonstrated 1 carbonyl compound (2-pentenal) that increased 10-fold over the span of the experiment, from an average of 0.0294 nmol/L before infection to an average of 0.3836 nmol/L on postoperative day 9. The amount of 2-pentenal present was greater in the breath of infected pigs than in the noninfected pigs or the sham inoculated pigs at postoperative days 6 and 9. Using an elevated concentration of 2-pentenal as a marker of infection yielded a sensitivity of 88% and specificity of 92% at postoperative day 6, and a sensitivity and specificity of 100% at postoperative day 9. Conclusions: We were able to successfully develop a clinical pneumonia in adult 60-kg pigs. The concentration of 2-pentenal correlated with the presence of pneumonia, demonstrating the potential for this compound to function as a biomarker for methicillin-sensitive S. aureus infection in pigs.

BACKGROUND: In October 2015, the Massachusetts Medicaid program temporarily stopped reimbursement for procedures in which the International Classification of Diseases, Tenth Edition, code for serum aneuploidy screening used by certain communities was stipulated. This change led to a substantial number of patients who went without aneuploidy screening for approximately 3 years. OBJECTIVE: This study aimed to determine the change in use and cost-effectiveness of prenatal aneuploidy serum screening in a low-risk Hispanic Medicaid population in Massachusetts. STUDY DESIGN: We conducted a retrospective chart review of Spanish-speaking pregnant patients younger than 35 years of age who underwent aneuploidy serum screening at a Massachusetts community health center. The study compared the aneuploidy serum screening rates for the periods before and after May 2016 when the Massachusetts Medicaid program, MassHealth, temporarily discontinued reimbursement for the screening. Based on these rates, we developed a Markov cohort simulation model to assess the economic value of reimbursed aneuploidy screening vs nonreimbursed or limited screening. Clinical outcomes included trisomy 21, live births, and therapeutic abortions for a trisomy 21 diagnosis. Economic outcomes included discounted quality-adjusted life years and lifetime medical costs, net health benefit, and incremental cost-effectiveness ratios. RESULTS: Before the MassHealth policy change, 69% (55/80) of pregnant individuals selected quad or sequential screens in comparison with only 9% (10/112) who selected screens after the policy change. Traditional aneuploidy serum screening in a low-risk (aged

Background: Donation after circulatory death with thoracoabdominal normothermic regional perfusion (DCD-NRP) for cardiac transplant has promising results, though data for lung transplant is lacking. This study evaluates lung transplant outcomes using DCD-NRP allografts. Methods: All patients who underwent lung transplantation (LT) from June 1, 2020, to July 5, 2023, at a single institution were evaluated. Recipients received organs from DCD-NRP or brain dead (control) donors (donation after brain death (DBD)). All DCD-NRP were adult, primary bilateral LT (BLT) without preoperative extracorporeal membrane oxygenation (ECMO). Inclusion criteria for controls were age >18 years, BLT, no preoperative ECMO, and primary transplantation. Comparison was separated by LT or heart-lung transplant (HLT). The primary outcome was primary graft dysfunction (PGD) grade 3 at 72 hours. Results: There were 8 LT and 3 HLT in the DCD-NRP cohort, and 138 BLT and 7 HL DBD controls. PGD grade 3 at 72 hours was 0% in the entire DCD-NRP cohort (vs control: 9.4% LT and 0% HLT). There were no statistically significant differences in donor and recipient characteristics, though DCD-NRP HLT had significantly shorter ischemic time (85 vs 200 minutes, p

Background: The association of social vulnerability (SV) and cardiac transplant survival remains poorly defined, particularly related to long-term outcomes. The purpose of this study was to define the impact of SV on survival among heart transplant recipients with at least 1 year of survival post-transplant. Methods: Heart transplant recipients were identified using the United Network for Organ Sharing database between June 1, 2006, and December 31, 2020. The Center for Disease Control’s Social Vulnerability Index (SVI) database was used to stratify patients based on SVI into 3 groups: low:

Abstract. Proximal femur fractures in the aging population present a variety of challenges. Physiologically, patients incurring this fracture are typically frail, with significant medical comorbidities, yet require early surgical treatment to restore mobility to prevent deterioration. Socioeconomically, the occurrence of a fragility fracture may be the beginning of the loss of independence, and the burdens of rehabilitation and support are borne by the individual patient and health care systems.

Purpose: Chemoradiation therapy (CRT) is the standard treatment for squamous cell carcinoma of the anus (SCCA). This study aimed to investigate the relationship between vaginal dosimetry and long-term patient-reported dyspareunia after treatment. We further aimed to use the anterior vaginal wall (AVW) as an organ at risk to define an actionable dosimetric clinical goal to decrease the risk of patient-reported dyspareunia. Methods and Materials: Women with SCCA treated with intensity modulated radiation therapy–based CRT were surveyed at least 2 years after successfully completing therapy. A Female Sexual Function Index (FSFI) pain subscore ≤4 was used to define dyspareunia. Dosimetric parameters were calculated for both the full vaginal canal and AVW. Multivariable linear regression models were created to identify predictors of FSFI pain subscore using backward selection to identify final variables include in the models. An actionable dosimetric predictor for dyspareunia was established using the Youden index method for cutoff optimization. Results: Of 184 women who were contacted, 90 (49%) returned completed surveys. Of those who completed surveys, 51 (56.7%) reported being sexually active, and 47 had dosimetric data available for review. Of sexually active respondents, 32 (68%) had an FSFI pain subscore ≤4. Multiple regression models were generated using the full vaginal canal and AVW as organs at risk, and both models showed similar predictive relationships with volumetric dose parameters emerging as the best dosimetric predictors for dysparenuia. Age over 65 years was also associated with higher FSFI pain subscores (eg, less pain with intercourse) in both models. AVW V35 Gy < 60% was identified as the optimal cutoff to reduce the risk of patient-reported dyspareunia. Conclusions: Increased dose to the vaginal canal is significantly associated with worse patient-reported dyspareunia following CRT for SCCA. Minimizing dose to the AVW to V35 Gy < 60% may reduce the risk of this quality of life-limiting toxicity. Further prospective evaluation is needed to validate these findings.

Introduction/Purpose: Infection of an ankle fracture is a devastating complication that can lead to chronic pain, limited motion or amputation. Traditional treatment strategies after infection involve aggressive surgical debridement, implant removal and prolonged antibiotic therapy. Non-anatomic cement spacers for the tibiotalar joint have previously been described with mixed results. Articulating spacers have shown improved outcomes and may be used as definitive treatment. Currently, there are no prefabricated TAR spacers on the market. The use of 3D printing to create custom implants is emerging, however, there is a paucity of literature regarding their use. We present a case of post-infectious ankle arthritis in 14 year old patient treated with a 3D printed total ankle replacement with built in antibiotic spacer (TAR-AS). Methods: A CT scan was performed in accordance with computer aided design (CAD) parameters. Bilateral lower extremities were scanned to allow the unaffected side to be mirrored and be the basis for implant design. Slice spacing less than 1.25mm with pixel size of 0.5mm. The studies were in DICOM files and within a timeframe where no significant change in patient anatomy had occurred. The implants were fabricated by selective laser melting (SLM) of cobalt chrome alloy (CoCrMo) by Restor3d (Durham, NC). Our design incorporated a stacked gyroid component to facilitate antibiotic cement impregnation. In terms of surgical technique, the custom TAR-AS followed a similar approach to a patient specific TAR procedure. Prior to implantation, the gyroid component of the TAR-AS was filled with Simplex bone cement with tobramycin (Stryker). Results: At six months postoperatively, our patient reported no limitation in activities. AOFAS scores improved from 46/100 preoperatively to 83/100 at six months postoperatively. Radiographic parameters showed no signs of implant failure, loosening or change in alignment. Intraoperative cultures remained negative. Conclusion: We present a case demonstrating the utilization of 3D generated prostheses for treatment of post-infection ankle arthritis. The TAR-AS represents a significant advancement in the management of ankle infections. This innovative approach combines the benefits of joint replacement and continued antibiotic elution. With further research and continued technological advancements, the TAR-AS has the potential to become the gold standard for the treatment of infected TAR. Despite the promising results, challenges remain in the implementation of TAR-AS. Long term follow up studies are needed to evaluate the durability and longevity of the implant. Total ankle with built in antibiotic spacer Superior view of tibial tray with antibiotic cement packed in gyroid

Introduction/Purpose: This study sought to establish normative values for baseline physical and mental health by foot and ankle diagnosis using validated Patient-Reported Outcomes Measurement Information System (PROMIS) scores and to compare the correlation between these two outcomes across common foot and ankle diagnoses. Additionally, it investigated the effect of specific foot and ankle diagnoses on self-reported mental health at first presentation. Methods: We retrospectively reviewed baseline PROMIS Physical Function Short Form 10a (PF10a) and PROMIS Global-Mental (PGM) scores of 14,374 patients who had one of the 10 most common foot and ankle diagnoses seen at our institution between 2016 and 2021. Pearson correlation coefficients were calculated to assess the relationship between PF10a and PGM by diagnosis. A multivariable regression model was also used to determine the effect of each diagnosis on PGM score. Results: On unadjusted analysis, patients diagnosed with an ankle fracture had the lowest mean physical function, while patients with hallux valgus had the highest (PF10a=33.9 vs 46.7). Patients with foot/ankle osteoarthritis had the worst mean self-reported mental health, while patients with hallux rigidus had the best (PGM=49.9 vs 53.4). PF10a and PGM scores were significantly positively correlated for all diagnoses; the correlation was strongest in patients diagnosed with foot/ankle osteoarthritis or hammertoes (r=0.511) and weakest in patients with ankle fractures (r=0.239) or ankle sprains (r=0.287). Chronic conditions, including hammertoes (β=-4.9, 95%CI [-5.6, -4.2], p< 0.001), foot/ankle osteoarthritis (β=-4.8, 95%CI [-5.5, -4.1], p< 0.001), and hallux valgus (β=-4.6, 95%CI [-5.3, -3.9], p< 0.001) were associated with the largest negative effects on patients’ self-reported mental health. Conclusion: Self-reported physical function and mental health varied across common foot and ankle diagnoses and were more tightly correlated in chronic than acute conditions. The effect of diagnosis on mental health scores appears to be worse for more chronic diagnoses, including those that are generally associated with relatively unimpaired physical function. Comparison of mean unadjusted PROMIS Physical Function 10a and PROMIS Global-Mental scores by diagnosis.

Objective:. To compare the rates of revision surgery for symptomatic neuromas in patients undergoing primary transtibial amputations with and without targeted muscle reinnervation (TMR). Design:. Retrospective cohort study. Setting:. Level I trauma hospital and tertiary military medical center. Patients/Participants:. Adult patients undergoing transtibial amputations with and without TMR. Intervention:. Transtibial amputation with targeted muscle reinnervation. Main Outcome Measurements:. Reoperation for symptomatic neuroma. Results:. During the study period, there were 112 primary transtibial amputations performed, 29 with TMR and 83 without TMR. Over the same period, there were 51 revision transtibial amputations performed, including 23 (21%) in the patients undergoing primary transtibial amputation at the study institution. The most common indications for revision surgery were wound breakdown/dehiscence (42%, n = 25), followed by symptomatic neuroma 18% (n = 9/51) and infection/osteomyelitis (17%, n = 10) as the most common indications. However, of the patients undergoing primary amputation at the study's institution, there was no difference in reoperation rates for neuroma when comparing the TMR group (3.6%, n = 1/28) and no TMR group (4.0%, n = 3/75) (P = 0.97). Conclusions:. Symptomatic neuroma is one of the most common reasons for revision amputation; however, this study was unable to demonstrate a difference in revision surgery rates for neuroma for patients undergoing primary transtibial amputation with or without targeted muscle reinnervation. Level of Evidence:. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Climate change poses a substantial threat to human health, and operating rooms (ORs) have an outsized environmental impact. The Program for Research in Sustainable Medicine (PRiSM) designed a protocol for minor foot and ankle surgery intended to reduce waste, streamline instrument trays, and minimize laundry. We conducted a randomized controlled trial to compare the carbon footprint of procedures performed using the PRiSM protocol vs a traditional protocol. Methods: Forty adult patients undergoing foreign body removal, hammertoe correction, toe amputation, hardware removal, mass excision, or gastrocnemius recession were randomized to the PRiSM or our “Traditional” protocol. The PRiSM protocol used a smaller instrument tray, fewer drapes and towels, and minimal positioning blankets. No changes were made to surgical site preparation or operative techniques. Environmental impact was estimated using the carbon footprint, measured in kilograms of carbon dioxide equivalents (CO 2 e). Emissions associated with OR waste, instrument processing, and laundry were calculated. Results: On average, PRiSM cases had a smaller carbon footprint than Traditional cases (17.3 kg CO2e [SD = 3.2] vs 20.6 kg CO 2 e [SD = 2.0], P

Hypertrophic cardiomyopathy is the most common inherited cardiomyopathy, with a prevalence of 1:200 to 1:500. Cardiac amyloidosis, another cardiomyopathy caused by myocardial deposition of abnormally folded TTR protein, can be acquired or hereditary. The presence of pathogenic TTR gene variants in patients with phenotypic HCM is an underrecognized and clinically important entity.

Background: Examining characteristics of patients with atrial fibrillation (AF) has the potential to help in identifying groups of patients who might benefit from different management approaches. Methods: Secondary analysis of online survey data was combined with clinic referral data abstraction from 196 patients with AF attending an AF specialty clinic. Cluster analyses were performed to identify distinct, homogeneous clusters of AF patients defined by 11 relevant variables: CHA2DS2-VASc score, age, AF symptoms, overall health, mental health, AF knowledge, perceived stress, household and recreation activity, overall AF quality of life, and AF symptom treatment satisfaction. Follow-up analyses examined differences between the cluster groups in additional clinical variables. Results: Evidence emerged for both 2- and 4-cluster solutions. The 2-cluster solution involved a contrast between patients who were doing well on all variables (n = 129; 66%) vs those doing less well (n = 67; 34%). The 4-cluster solution provided a closer-up view of the data, showing that the group doing less well was split into 3 meaningfully different subgroups of patients who were managing in different ways. The final 4 clusters produced were as follows: (i) doing well; (ii) stressed and discontented; (iii) struggling and dissatisfied; and (iv) satisfied and complacent. Conclusions: Patients with AF can be accurately classified into distinct, natural groupings that vary in clinically important ways. Among the patients who were not managing well with AF, we found 3 distinct subgroups of patients who may benefit from tailored approaches to AF management and support. The tailoring of treatment approaches to specific personal and/or behavioural patterns, alongside clinical patterns, holds potential to improve patient outcomes (eg, treatment satisfaction). Résumé: Contexte: L’examen des caractéristiques des patients atteints de fibrillation auriculaire (FA) pourrait permettre de mieux cerner les groupes qui pourraient bénéficier de différentes approches de prise en charge. Méthodologie: Nous avons combiné une analyse secondaire de données issues d’un sondage en ligne et les données issues de l’orientation clinique de 196 patients atteints de FA d’une clinique spécialisée en FA. Des analyses par grappes ont été réalisées pour cerner des groupes homogènes et distincts de patients atteints de FA, définis grâce à 11 variables pertinentes : score CHA2DS2-VASc, âge, symptômes de FA, état de santé général, état de santé mentale, niveau de connaissances sur la FA, niveau de stress perçu, activités récréatives et domestiques, qualité de vie générale avec la FA, et satisfaction concernant le traitement des symptômes de FA. Des ana-lyses ultérieures ont permis de se pencher sur les différences entre les groupes pour d’autres variables cliniques. Résultats: Deux solutions de regroupement des patients sont apparues possibles à l’analyse : en 2 groupes ou en 4 groupes. Le regroupement en 2 groupes mettait en relief le contraste entre les patients qui avaient des résultats favorables pour tous les paramètres (n = 129; 66 %) et ceux qui avaient des résultats moins favorables (n = 67; 34 %). Le regroupement en 4 groupes permettait d’observer les données plus en détail, et démontrait que le groupe avec des résultats moins favorables se subdivisait en 3 sous-groupes avec des distinctions pertinentes, qui vivaient leur maladie de façon différente. Les 4 groupes finaux étaient les suivants : (i) patients avec une expérience positive; (ii) patients vivant du stress et du mécontentement; (iii) patients vivant des difficultés et une insatisfaction; et (iv) patients vivant une satisfaction complaisante. Conclusions: Les patients atteints de FA peuvent être classés avec exactitude dans des groupes naturels distincts dont les différences sont d’intérêt clinique. Parmi les patients chez qui la prise en charge de la FA n’est pas optimale, il existe 3 sous-groupes différents qui pourraient tirer profit d’une approche de soutien et de prise en charge adaptée à leur profil. La personnalisation des approches thérapeutiques selon le type de comportements et de traits de personnalité, en plus du tableau clinique, pourrait permettre d’améliorer les résultats des patients (p. ex. la satisfaction par rapport au traitement).