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Purpose The purpose of this study was to investigate outcomes following arthroscopic elbow contracture release to describe the use of arthroscopy for improvement in extension/flexion and pronation/supination arcs of motion at a single institution for degenerative and posttraumatic etiologies. Methods Consecutive arthroscopic elbow arthrolysis performed between 2003 and 2015 were retrospectively reviewed. Basic patient demographics, indications for surgery, preoperative and postoperative elbow range of motion, postoperative patient outcome score, and all complications were recorded and analyzed. Results Fifty-two patients were included with an average follow-up of 5.1 years (range 1.4 to 9.4). Severe contractures made up 50% of cases, followed by 23% moderate, and 27% mild. Average extension/flexion for the post-traumatic group (n = 30) increased by 63° ± 31 and by 29° ± 24 for the degenerative group (n = 22). Average gain in pronosupination was 38° ± 62 in the post-traumatic group and 13°±23 in the degenerative group. Postoperative DASH scores were 17.5 ± 18.4 for post-traumatic cases and 12.8 ± 19.3 for degenerative cases. Conclusion Arthroscopic elbow contracture release is an effective intervention for degenerative and post-traumatic elbow contracture for both flexion/extension and pronosupination contracture. Furthermore, a two-stage release should be considered when both flexion and pronosupinaton contractures are present. Level of Evidence IV, case series, treatment study

OBJECTIVE To determine the number and species of animals cared for by the PetSafe program at the Purdue University College of Veterinary Medicine (a community service offered to meet the short-term housing needs of pets, especially pets owned by victims of intimate partner violence) from 2004 through 2019 and collect information on duration of stay, outcome, health problems, and expenses. ANIMALS 229 animals cared for by the PetSafe program. PROCEDURES Medical records were reviewed for information on species, breed, age, duration of stay, outcome of stay, client referral source, whether the animal had been cared for previously, health problems, medical interventions, and expenses incurred. RESULTS There were 124 dogs, 95 cats, 6 ferrets, and 4 sugar gliders; 187 of the animals were returned to their owners, 37 were rehomed, and 5 were euthanized because of medical conditions. The most common health problems were dental disease and dermatological complaints (eg, flea infestation and resulting fleabite dermatitis). None of the animals had physical evidence of abuse. Mean duration of stay was 22 days (range, 1 to 93 days), and mean ± SD cost per animal was $368 ± $341. CLINICAL RELEVANCE Over the 16-year period of the study, the number and species of animals cared for by the PetSafe program at Purdue and the health problems encountered in those animals were relatively stable, and the program was able to meet the relatively predictable financial costs incurred through existing sources of funding.

Background The COVID-19 pandemic resulted in public health and policy measures to reduce in-person contact and the transmission of the virus. These measures impacted daily life and mental well-being (MWB). The aims of this study were to explore the MWB impacts of COVID-19 on children and assess the associations among perceived changes in physical activity (PA) and sedentary behaviors (SB), with perceived MWB changes, using a mixed-methods approach. Methods A convergent parallel mixed-methods design consisting of an online survey with a convenience sample and interviews was conducted from May through July 2020 with parents/caregivers of kindergarten through 5th graders in the St. Louis region. Survey domains assessed included child MWB, PA, and SB. Interviews were recorded, transcribed, and qualitatively analyzed using a code book developed to elicit themes. Survey data was analyzed with chi-squared tests and logistic regressions. The dependent variable was perceived change in child MWB due to the impact of COVID-19. Independent variables included perceived changes in PA, SB, and child concerns about COVID-19. Results Sample size consisted of 144 surveys and 16 interviews. Most parents reported a perceived decrease in child MWB (74%), a decrease in child PA (61%), and an increase in child SB (91%). Discontentment with stay-at-home orders and concern about COVID-19 were associated with a perceived decrease in MWB. Children whose PA decreased were 53% less likely to have the same or better MWB (OR 0.47) and children whose outside PA decreased were 72% less likely to have the same or better MWB (OR 0.28). Common qualitative themes included difficulty in adjusting to COVID-19 restrictions due to school closures and lack of socializing, child concerns about family getting sick, and PA benefits for improving MWB. Conclusions Based on parent perceptions, MWB decreased with COVID-19. Maintained or increased child PA improved the chances MWB would remain the same or improve. Parent interviews provide context to these findings by showing how COVID-19 impacted MWB and the associations between PA and MWB. Understanding protective factors for child MWB during COVID-19 is important to offset negative long-term health outcomes from this ongoing pandemic.

Objective To adapt the Boston Assessment of TBI-Lifetime (BAT-L) interview specifically for female survivors of intimate partner violence (IPV), validate the adapted BAT-L/IPV, and report the prevalence of head injury. Setting The BAT-L is the first validated instrument to diagnose traumatic brain injuries (TBIs) throughout the life span for post-9/11 veterans. The BAT-L/IPV was adapted to target diagnostic issues belonging exclusively to IPV while maintaining its life span approach. Participants Community-dwelling convenience sample of 51 female survivors of IPV with subthreshold (n = 10) or full diagnostic criteria (n = 41) of posttraumatic stress disorder. Design Standard TBI criteria were evaluated using a semistructured clinical interview. Main measures The BAT-L/IPV is compared with the Ohio State University TBI Identification Method (OSU-TBI-ID) scoring approach as the criterion standard. Results Correspondence between the BAT-L/IPV and the OSU-TBI-ID score was excellent (Cohen κ = 0.86; Kendall τ-b = 0.89). Sensitivity = 89.3% (95% CI, 81.2-97.4); specificity = 98.3% (95% CI, 95.0-100); positive predictive value = 98.0% (95% CI, 94.2-100); and negative predictive value = 90.6% (95% CI, 83.5-97.7). On the BAT-L/IPV, more than one-third (35.3%) of IPV survivors reported TBI secondary to an IPV-related assault, 76.5% reported IPV subconcussive head injury, 31.4% reported attempted strangulation, and 37.3% reported non-IPV TBI. Conclusions The BAT-L/IPV performed well in diagnosing TBI in female IPV survivors as compared with the criterion standard. The prevalence of TBI was frequent; subconcussive head injury was pervasive. Greater awareness for head injury risk and increased diagnostic specificity of TBI in IPV survivors is needed.

Die periprothetische Fraktur des Acetabulums stellt in den meisten Fallen eine komplexe Verletzung und grose Herausforderung an ein Behandlungsteam dar. Die insgesamt immer noch seltene Entitat ist in den vergangenen Jahren aufgrund demografischer Veranderungen in Zunahme begriffen. Mehrere Behandlungsalgorithmen wurden in den vergangenen Jahren publiziert und bieten zunehmend die Moglichkeit der standardisierten Therapiekonzeptentwicklung. Eine hohe Bedeutung fur die Qualitat der Versorgung haben die Klassifikation der Frakturen und eine dezidierte praoperative Planung. Die Haufigkeit von intraoperativ aufgetretenen Frakturen wurde in der Literatur initial mit 0,4 % angegeben. In den vergangenen Jahren wurden jedoch mehrere Studien publiziert, die mittels CT-Untersuchungen eine deutlich hohere Rate an intraoperativ entstandenen, (oft) sog. okkulten Frakturen aufdeckten. Die Ursachen sind multifaktoriell und hangen signifikant damit zusammen, ob es sich um eine zementfreie Press-fit-Verankerung der Pfannenkomponente oder um eine zementierte Form handelt. In ca. 75 % der Falle liegt der Fraktur ein Niedrigenergietrauma zugrunde. In diesen Fallen sollten systemische Prozesse wie osteoporotische Veranderungen der Knochensubstanz oder das mogliche Vorliegen von Low-grade-Infekten bedacht werden. Wir mochten in dieser Arbeit einen Uberblick uber Diagnostik, Planung, Herausforderungen und osteosynthetische Versorgungsmoglichkeiten bei periprothetischen Acetabulumfrakturen geben.

Summary Background With increasingly precise radiotherapy and advanced medical imaging, the concept of radiotherapy target volume planning might be redefined with the aim of improving outcomes. We aimed to investigate whether target volume reduction is feasible and effective compared with conventional planning in the context of radical chemoradiotherapy for patients with locally advanced non-small-cell lung cancer. Methods We did a multicentre, open-label, randomised, controlled trial (PET-Plan; ARO-2009-09) in 24 centres in Austria, Germany, and Switzerland. Previously untreated patients (aged older than 18 years) with inoperable locally advanced non-small-cell lung cancer suitable for chemoradiotherapy and an Eastern Cooperative Oncology Group performance status of less than 3 were included. Undergoing 18F-fluorodeoxyglucose (18F-FDG) PET and CT for treatment planning, patients were randomly assigned (1:1) using a random number generator and block sizes between four and six to target volume delineation informed by 18F-FDG PET and CT plus elective nodal irradiation (conventional target group) or target volumes informed by PET alone (18F-FDG PET-based target group). Randomisation was stratified by centre and Union for International Cancer Control stage. In both groups, dose-escalated radiotherapy (60–74 Gy, 2 Gy per fraction) was planned to the respective target volumes and applied with concurrent platinum-based chemotherapy. The primary endpoint was time to locoregional progression from randomisation with the objective to test non-inferiority of 18F-FDG PET-based planning with a prespecified hazard ratio (HR) margin of 1·25. The per-protocol set was included in the primary analysis. The safety set included all patients receiving any study-specific treatment. Patients and study staff were not masked to treatment assignment. This study is registered with ClinicalTrials.gov , NCT00697333 . Findings From May 13, 2009, to Dec 5, 2016, 205 of 311 recruited patients were randomly assigned to the conventional target group (n=99) or the 18F-FDG PET-based target group (n=106; the intention-to-treat set), and 172 patients were treated per protocol (84 patients in the conventional target group and 88 in the 18F-FDG PET-based target group). At a median follow-up of 29 months (IQR 9–54), the risk of locoregional progression in the 18F-FDG PET-based target group was non-inferior to, and in fact lower than, that in the conventional target group in the per-protocol set (14% [95% CI 5–21] vs 29% [17–38] at 1 year; HR 0·57 [95% CI 0·30–1·06]). The risk of locoregional progression in the 18F-FDG PET-based target group was also non-inferior to that in the conventional target group in the intention-to-treat set (17% [95% CI 9–24] vs 30% [20–39] at 1 year; HR 0·64 [95% CI 0·37–1·10]). The most common acute grade 3 or worse toxicity was oesophagitis or dysphagia (16 [16%] of 99 patients in the conventional target group vs 17 [16%] of 105 patients in the 18F-FDG PET-based target group); the most common late toxicities were lung-related (12 [12%] vs 11 [10%]). 20 deaths potentially related to study treatment were reported (seven vs 13). Interpretation 18F-FDG PET-based planning could potentially improve local control and does not seem to increase toxicity in patients with chemoradiotherapy-treated locally advanced non-small-cell lung cancer. Imaging-based target volume reduction in this setting is, therefore, feasible, and could potentially be considered standard of care. The procedures established might also support imaging-based target volume reduction concepts for other tumours. Funding German Cancer Aid (Deutsche Krebshilfe).

Background: Traditionally, treatment with the excimer laser requires determining the minimal erythema dose on healthy skin or using plaque-based induration; however, these protocols often lead to underdosing of psoriatic plaques and reduced treatment efficacy. Objective: To prospectively evaluate the effect of the excimer laser on plaque psoriasis using an optimal therapeutic dose (OTD) protocol. Methods: Subjects with stable plaque psoriasis were tested with the Multi-Microdose (MMD) tip on the XTRAC excimer laser to determine a minimum blistering dose (MBD). Treatment was then initiated at 20% less than the MBD. A single psoriatic lesion was treated once weekly for up to 11 sessions. The change from baseline of the target lesion's modified psoriasis area severity index (mPASI), quality of life and safety were evaluated. Results: Thirteen subjects with a mean age of 48.9±14.9 years and Fitzpatrick skin types I-IV participated in the study. Target plaque mPASI significantly decreased at all time points relative to baseline with significant improvement by the second treatment. Patients reached mPASI-75 within 5±2 sessions. By the end of the study 92% of patients achieved mPASI-75. On average, patients maintained an mPASI score ≥50% for 60 days. Treatment was well tolerated with no erosions or hyperpigmentation. Erythema was the most common adverse event. Conclusion: The OTDTM protocol with the MMD® tip allows determining the optimal dose locally on the psoriatic plaque itself. Consequently, ineffectual dosing levels and treatments are minimized. The OTD protocol reduces treatment frequency from 2-3 times per week to once weekly. J Drugs Dermatol. 2020;19(4):349-354. doi:10.36849/JDD.2020.4891.

Introduction Post-traumatic stress disorder (PTSD) is associated with an increased risk of cardiovascular and metabolic diseases and physical inactivity. Cardiorespiratory fitness (CRF), which is modifiable by physical activity, is a strong independent predictor of cardiometabolic health. However, the relationship between CRF and cardiometabolic health in veterans with PTSD is unknown. Thus, this study aimed to explore the cross-sectional relationships among CRF, indices of cardiometabolic health (ie, HbA1c, blood lipids, blood pressure, waist-hip ratio, and body mass index), and PTSD severity in veterans with PTSD. Materials and Methods This study was approved by the local Institutional Review Board. All participants were informed of the study risks and provided consent prior to participation. Participants (n = 13) completed a cardiopulmonary exercise test, a fasting blood draw, and the Clinician Administered PTSD Scale. Correlations between CRF and cardiometabolic health were examined with Spearman’s rank correlations, and differences in PTSD symptom severity were explored as a function of CRF (ie, low-to-moderate vs. high CRF), using multiple linear regression. Results Peak oxygen uptake ($\dot{\mathrm{V}}$O2peak) was correlated with high-density lipoproteins rho = 0.60, P = 0.04 and diastolic blood pressure rho = −0.56, P = 0.05. Ventilatory threshold was correlated with HbA1c rho = −0.61, P = 0.03 and diastolic blood pressure rho = −0.56, P = 0.05. Higher CRF was associated with lower total PTSD severity standardized β = −0.84, P = 0.01, adjusted R2 = 0.47, total Cluster C symptoms (avoidance/numbing) β = −0.71, P = 0.02, adjusted R2 = 0.49, and total Cluster D symptoms (hyperarousal) β = −0.89, P = 0.01, adjusted R2 = 0.41, while adjusting for age and smoking status. Conclusions These preliminary findings suggest that CRF and by proxy physical activity may be important factors in understanding the increased risk of cardiovascular and metabolic disease associated with PTSD.

The excimer laser has emerged as an efficacious treatment modality for many dermatologic diseases. The excimer laser is an alternative to standard narrowband ultraviolet B (NBUVB) phototherapy treatment in patients with limited disease. In comparison to standard NBUVB, the excimer laser requires fewer treatment sessions, has reduced treatment duration, requires a lower cumulative UVB dose, and limits UVB exposure to lesional skin. This review addresses the mechanism, safety, application, and efficacy of the excimer laser for the treatment of these conditions.

Background: Incisional hernias can be associated with pain or discomfort. Surgical repair especially mesh reinforcement, may likewise induce pain. The primary objective was to assess the incidence of pain after hernia repair in patients with and without pre-operative pain or discomfort. The secondary objectives were to determine the preferred mesh type, mesh location and surgical technique in minimizing postoperative pain or discomfort. Materials and methods: A registry-based prospective cohort study was performed, including patients undergoing incisional hernia repair between September 2011 and May 2019. Patients with a minimum follow-up of 3–6 months were included. The incidence of hernia related pain and discomfort was recorded perioperatively. Results: A total of 1312 patients were included. Pre-operatively, 1091 (83%) patients reported pain or discomfort. After hernia repair, 961 (73%) patients did not report pain or discomfort (mean follow-up = 11.1 months). Of the pre-operative asymptomatic patients (n = 221), 44 (20%, moderate or severe pain: n = 14, 32%) reported pain or discomfort after mean follow-up of 10.5 months. Of those patients initially reporting pain or discomfort (n = 1091), 307 (28%, moderate or severe pain: n = 80, 26%) still reported pain or discomfort after a mean follow-up of 11.3 months postoperatively. Conclusion: In symptomatic incisional hernia patients, hernia related complaints may be resolved in the majority of cases undergoing surgical repair. In asymptomatic incisional hernia patients, pain or discomfort may be induced in a considerable number of patients due to surgical repair and one should be aware if this postoperative complication.

Single-visit “screen-and-treat” strategies using visual inspection with acetic acid (VIA) and cryotherapy (liquid nitrous oxide ablation) in low-resource settings are commonly used to detect and treat precancerous lesions for cervical cancer prevention. This study compared VIA sensitivity and specificity in rural indigenous Guatemalan communities, to that of oncogenic human papillomavirus (HPV) testing for detection of precancerous changes, using cytology as the reference standard. Between 3–8 September 2017, trained nurses examined 222 women aged 23–58 years with VIA. Specimens for liquid-based cytology and HPV testing were obtained prior to VIA with a cytobrush and transported in PreservCyt to a US clinical laboratory. VIA and HPV test sensitivities were assessed as proportions of women with abnormal cytology that had abnormal VIA or HPV results, respectively, and specificities, as proportions with normal cytology with normal VIA or negative HPV tests. Of 222 women, 18 (8.1%) had abnormal cytology (1 carcinoma in a participant who received VIA-based cryotherapy in 2015, 4 high- and 5 low-grade squamous intraepithelial lesions, and 8 atypical squamous cells of undetermined significance (ASCUS)). Excluding ASCUS, sensitivities of VIA and HPV were 20.0% and 100%, respectively. VIA-based screening may not be acceptable for detecting precancerous lesions, and field cryotherapy for preventing malignancy. The World Health Organization recommended in 2021 “…using HPV DNA detection as the primary screening test rather than VIA or cytology”.

Background Many orthopedic practices routinely code hip fracture hemiarthroplasty as Current Procedural Terminology (CPT) 27125 even though 27236 is the correct CPT code. Our objective is to determine the financial impact this simple mistake has on surgeon reimbursement. Methods Our data comprised cases assigned International Classification of Diseases, Tenth Revision code S72.001A through S72.035A and CPT code 27125 or 27236 within the American College of Surgeons National Surgical Quality Improvement Program 2016-2017 database. Relative value units (RVUs) per CPT code and the Centers for Medicare and Medicaid Services reported that RVU conversion factor of $36.0896 per 1 RVU was used to calculate reimbursement per case. The dollar difference and percent difference per case was then calculated between cases assigned CPT code 27125 and those assigned 27236. Results Our total sample consisted of 12,287 National Surgical Quality Improvement Program cases. Of those, 4185 (34%) were cases of a hip fracture treated with hemiarthroplasty that were incorrectly coded as CPT code 27125. That error in coding results in a decrease in reimbursement of $35.01 per case, a 5.51% difference. Conclusion Since the current healthcare reimbursement model relies solely on CPT codes to determine RVUs, it is imperative that orthopedic surgeons understand the financial impact of incorrect coding. Although correct coding of hemiarthroplasty procedures for hip fractures is an easy task to fix in the future, we hope that through this study a greater emphasis is placed on coding in orthopedic surgery.

Background:We describe a thick fascial band arising from the medial aspect of the lateral plantar aponeurosis diving deep into the forefoot crossing over a branch of the lateral plantar nerve. Because a review of current literature resulted in limited and outdated sources, we sought to first determine the frequency of this fascial band and the location where it crosses the lateral plantar nerve and, second, discuss the clinical applications these anatomical findings could have.Methods:50 pairs of cadaveric feet (n = 100) were dissected to investigate for presence of the fascial band and its interaction with the lateral plantar nerve. Images were taken of each foot with the fascial band. ImageJ was used to take 2 measurements assessing the relationship of the tuberosity of the base of the fifth metatarsal to where the nerve crossed deep to the fascial band.Results:Overall, 38% of the feet possessed the fascial band. It was found unilaterally in 10 pairs and bilaterally in 14 pairs. On average, the point at which the lateral plantar nerve passed deep to the fascial band was 2.0 cm medial and 1.7 cm anterior to the tuberosity of the base of the fifth metatarsal.Conclusion:When present, the deep band of the lateral plantar aponeurosis (PA) was consistently found to be crossing the lateral plantar nerve. The discovery of the location where this most commonly occurs has not been previously reported and adds an interesting dimension that elevates an anatomical study to one that has clinical potential.Clinical Relevance:The established target zone gives a precise location for where the relationship between the deep band of the lateral PA and the lateral plantar nerve exists when evaluating the foot. The target zone provides a potential springboard for future investigations concerning said relationship clinically.

Acrodermatitis continua of Hallopeau (ACH) is a rare, sterile pustular eruption of one or more digits. The condition presents with tender pustules and underlying erythema on the tip of a digit, more frequently arising on a finger than a toe. As far as classification, ACH is considered a localized form of pustular psoriasis. The eruption typically occurs after local trauma or infection, but such a history is not always present and various other etiologies have been described including infectious, neural, inflammatory, and genetic causes. The natural progression of ACH is chronic and progressive, often resulting in irreversible complications such as onychodystrophy that can result in anonychia, as well as osteitis that can result in osteolysis of the distal phalanges. Because of the rarity of ACH, there have been no randomized controlled studies to evaluate therapies, resulting in an absence of standardized treatment guidelines. In clinical practice, a wide variety of treatments have been attempted, with outcomes ranging from recalcitrance to complete resolution. In recent years, the introduction of biologics has provided a new class of therapy that has revolutionized the treatment of ACH. Specifically, rapid and sustained responses have been reported with the use of anti-tumor necrosis factor agents like infliximab, adalimumab, and etanercept; IL-17 inhibitors like secukinumab; IL-12/23 inhibitors like ustekinumab; and IL-1 inhibitors like anakinra. Nevertheless, there remains a considerable need for more research into treatment for the benefit of individual patients with ACH as well as for the clinical knowledge gained by such efforts. The purpose of this review is to provide a comprehensive overview of the key features of ACH as well as a discussion of clinical management strategies for this unique and debilitating condition.

Tofacitinib is an oral Janus kinase inhibitor approved for the treatment of psoriatic arthritis (PsA). It provides an alternative option for patients who have had an inadequate response and tolerance to other disease modifying antirheumatic drugs (DMARDs). It has demonstrated comparable efficacy to biologics, is effective in the management of treatment resistant disease, and is reported to improve enthesitis, dactylitis, and radiographic progression. Tofacitinib is also associated with an increased risk of serious infections, malignancy, and laboratory abnormalities. There is currently a large armamentarium of therapies for psoriatic arthritis, and choosing among treatments can be challenging. Due to this wide selection, a thorough assessment of psoriatic disease phenotype, patient preference, disease presentation, and comorbidities is critical. This review addresses key considerations in patient selection for the treatment of PsA with tofacitinib.

There is no therapy currently available for fully repairing articular cartilage lesions. Our laboratory has recently developed a visible light-activatable methacrylated gelatin (mGL) hydrogel, with the potential for cartilage regeneration. In this study, we further optimized mGL scaffolds by supplementing methacrylated hyaluronic acid (mHA), which has been shown to stimulate chondrogenesis via activation of critical cellular signalling pathways. We hypothesized that the introduction of an optimal ratio of mHA would enhance the biological properties of mGL scaffolds and augment chondrogenesis of human bone marrow-derived mesenchymal stem cells (hBMSCs). To test this hypothesis, hybrid scaffolds consisting of mGL and mHA at different weight ratios were fabricated with hBMSCs encapsulated at 20 × 106 cells/ml and maintained in a chondrogenesis-promoting medium. The chondrogenenic differentiation of hBMSCs, within different scaffolds, was estimated after 8 weeks of culture. Our results showed that mGL/mHA at a 9:1 (%, w/v) ratio resulted in the lowest hBMSC hypertrophy and highest glycosaminoglycan production, with a slightly increased volume of the entire construct. The applicability of this optimally designed mGL/mHA hybrid scaffold for cartilage repair was then examined in vivo. A full-thickness cylindrical osteochondral defect was surgically created in the rabbit femoral condyle, and a three-dimensional cell-biomaterial construct was fabricated by in situ photocrosslinking to fully fill the lesion site. The results showed that implantation of the mGL/mHA (9:1) construct resulted in both cartilage and subchondral bone regeneration after 12 weeks, supporting its use as a promising scaffold for repair and resurfacing of articular cartilage defects, in the clinical setting.

Background: As the role of the clinical exercise physiologist expands, early mobility is an area of potential focus. A rural Midwestern intensive care unit began a mobility program alongside its open-heart surgery program. The mobility specialist, who was trained as a clinical exercise physiologist, was tasked to ambulate the open-heart surgery patients. The purpose of this pilot study was to determine the effectiveness of a mobility specialist on ambulation frequency and distance on post open-heart surgery patients. Methods: Data were collected retrospectively for 1 month on ambulation frequency and distance to determine the mobility specialist's impact on the variables. Results: Data was collected on 18 patients (15 male, 3 female) over the month. Overall, when the mobility specialist was present, patients ambulated further (M = 421 feet versus 189 feet, P = 0.039) and more often (M = 3.32 versus 1.43 ambulations per day, P < 0.001). Conclusion: In this study, having a mobility specialist with a background in exercise physiology led to more frequent and distant ambulation. Therefore, a mobility specialist should be considered an integral member of a multidisciplinary clinical team in rural intensive care units.

Generalized pustular psoriasis (GPP) is a rare and potentially life-threatening variant of psoriasis that is characterized by recurrent, acute onset, widely distributed pustular eruptions on inflamed, erythematous skin. It is important to recognize acute GPP as a subtype of psoriasis associated with high morbidity and mortality so therapy can be initiated without delay. Since GPP was first described in 1910 by Leopold von Zumbusch, it has been inconsistently defined, stratified, and diagnosed in the literature. Multiple definitions and diagnostic criteria have been proposed over the years. Recently, formal consensus guidelines on GPP have been published by international groups. This article reviews the current evidence and understanding in the diagnosis and screening of GPP.

Introduction Sleep is essential for overall health and well-being, yet more than one-third of adults report inadequate sleep. The prevalence is higher among people with psoriasis, with up to 85.4% of the psoriatic population reporting sleep disruption. Poor sleep among psoriasis patients is particularly concerning because psoriasis is independently associated with many of the same comorbidities as sleep dysfunction, including cardiovascular disease, obesity, and depression. Given the high prevalence and serious consequences of disordered sleep in psoriasis, it is vital to understand the nature of sleep disturbance in this population. This study was designed to help meet this need by using survey data from Citizen Pscientist, an online patient portal developed by the National Psoriasis Foundation. Methods Our analysis included 3118 participants who identified as having a diagnosis by a physician of psoriasis alone or psoriasis with psoriatic arthritis. Demographic information, psoriasis severity and duration, sleep apnea status, smoking and alcohol consumption, itch timing, and sleep characteristics were included. Two separate multivariate logistic regression models in STATA were used to determine whether the presence of psoriatic arthritis, age, gender, body mass index, comorbid sleep apnea, psoriasis severity, timing of worst itch, smoking status, or high-risk alcohol consumption were associated with sleep difficulty or low sleep quantity, defined by the American Academy of Sleep Medicine as less than 7 h of sleep per night on average. Results Results from the multivariate logistic regressions found that sleep difficulty was associated with psoriatic arthritis (OR 2.15, 95% CI [1.79–2.58]), female gender (2.03 [1.67–2.46]), obese body mass index (BMI ≥ 30) (1.25 [1.00–1.56]), sleep apnea (1.41 [1.07–1.86]), psoriasis severity of moderate (1.59 [1.30–1.94]) or severe (2.40 [1.87–3.08]), and smoking (1.60 [1.26–2.02]). Low sleep quantity was associated with obese BMI (1.62 [1.29–2.03]), sleep apnea (1.30 [1.01–1.68]), psoriasis severity of moderate (1.41 [1.16–1.72]) or severe (1.40 [1.11–1.76]), and smoking (1.62 [1.31–2.00]). Sleep difficulty and low sleep quantity were not associated with age, alcohol consumption, or timing of worst itch. Conclusion These results are potentially meaningful in several aspects. We identify an important distinction between sleep difficulty and sleep quantity in psoriatic disease, whereby having psoriatic arthritis and being female are each associated with sleep difficulty despite no association with low sleep quantity. Furthermore, there is conflicting evidence from prior studies as to whether psoriasis severity is associated with sleep difficulty, but this well-powered, large study revealed a strong, graded relationship between psoriasis severity and both sleep difficulty and low sleep quantity. Overall, our results show that both sleep difficulty and low sleep quantity were associated with multiple factors in this analysis of a large psoriatic cohort. These findings suggest that dermatologists may gather clinically useful information by screening psoriatic patients for trouble sleeping and low sleep quantity to identify potential comorbidities and to more effectively guide disease management.

Background Intramedullary fixation of a comminuted subcapital metacarpal fracture using a headless compression screw was first described in 2010. The purpose of this study was to identify and evaluate all studies reporting clinical outcomes of intramedullary screw fixation of metacarpal fractures. Methods A comprehensive search of the literature was performed under Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines to identify all relevant studies. Outcome measures included mean follow-up, evidence of radiographic union, functional outcomes, and quality-of-life measures. Results Nine articles for a total of 169 metacarpal fractures were identified. Average patient age was 32 years; 86.5 percent of the patients were men; and the majority of fractures occurred in the small finger (74 percent). Most fractures occurred in the neck (n = 66), followed by shaft (n = 31) and head (n = 10). The average follow-up was 11 months, with an average metacarpophalangeal joint flexion of 86 degrees (n = 83) and digit total active motion of 251 degrees (n = 72). Radiographic union was achieved in 100% of reported cases (n = 132) at or before the latest follow-up. Grip strength in four studies showed an average of 96 percent compared to the contralateral hand. No serious complications were reported. Nine minor complications were reported, including four cases of hardware removal in asymptomatic patients. Conclusion The review of the literature suggests intramedullary fixation of metacarpal neck and shaft fractures using headless compression screws has thus far proven to be a safe and successful surgical treatment option resulting in excellent clinical outcomes.

Dupilumab is a fully human monoclonal IgG4 antibody directed against the alpha subunit of the IL-4 receptor and prevents the signaling of IL-4 and IL-13, two type 2 cytokines known to be important drivers of atopic diseases. In March of 2017, the United States Food and Drug Administration (FDA) approved dupilumab for the treatment of moderate-to-severe atopic dermatitis in adults that is uncontrolled with topical medications, becoming the first biologic agent approved to treat this chronic skin condition. In October of 2018, Dupilumab received approval by the FDA as an add-on maintenance therapy in patients with moderate-to-severe asthma aged 12years or older with an eosinophilic phenotype or with oral corticosteroid-dependent asthma. This review summarizes the characteristics of dupilumab and the clinical research that has been published to date, including treatment efficacy and adverse events.

The mental health status of veteran cancer survivors is understudied. Given that studies show that physical activity (PA) may alleviate mental distress in cancer patients, the purpose of this study was to examine the relationship between PA and mental distress in veteran lung and colorectal cancer survivors. Data for the present study were retrieved from the 2016 Behavioral Risk Factor Surveillance System. The relationship between PA and the number of mentally distressful days in the last 30 days was examined among veteran lung cancer survivors and veteran colorectal cancer survivors with survey-weighted multiple linear regression. After adjusting for relevant covariates, results showed that colorectal cancer survivors had significantly more mentally distressful days compared to lung cancer survivors, B = 0.75 (95% confidence interval [CI] = 0.64, 0.86). Furthermore, PA was significantly related to fewer days of mental distress in both lung and colorectal cancer survivors, B = −0.33 (95% CI = −0.4...

Mittelfusknochen- und Zehenfrakturen sind die haufigsten Verletzungen des Fusskeletts. Undislozierte Frakturen konnen mit gutem Erfolg konservativ behandelt werden. Langfristige Entlastungen und eine das Sprunggelenk einbeziehende Ruhigstellung sind nicht erforderlich. Basisnahe Metatarsalefrakturen sind fast immer mit Lisfranc-Luxationen assoziiert; die Therapie muss die Instabilitat der tarsometatarsalen Gelenkreihe mitberucksichtigen. Eine differenzierte Betrachtung erfordern die Basisfrakturen des 5. Mittelfusknochens. Die korrekte Klassifizierung ist notwendig, um eine adaquate Therapie einleiten zu konnen. Generell werden intraartikulare Stufenbildungen, Abkippungen >10° und Verkurzungen zwischen 3 mm und 5 mm unter besonderer Berucksichtigung der Position der Metatarsalekopfchen als Operationsindikation empfohlen. Eine operative Therapie von Zehenfrakturen ist nur selten notwendig.

Brodalumab is one of the most efficacious biologic agents available for psoriasis. It also has a unique mechanism; it is the only agent that blocks the entire interleukin 17 receptors instead of blocking individual cytokines. However, the main drawback is that brodalumab has an FDA mandated black box warning regarding suicide. This is an up-to-date article reviews the scientific validity of this issue with brodalumab and suicide. Areas covered: A worldwide literature search was conducted on the above issue regarding suicide risk and brodalumab. All relevant articles on this topic searchable in public domain were utilized. Expert opinion: The FDA black box warning is based on three completed suicides that happened in one research location out of 390 research sites worldwide. All three completed suicides have alternative explanations unrelated to brodalumab. The overall data from phase III clinical trials shows that psoriasis patients recorded significant improvement in depression after treatment with brodalumab. The overall impression is that the suicide issue is far from being scientifically validated and this is why the FDA itself stated in the package insert that "the cause and effect relationship these suicides and brodalumab has not been established."

Organophosphorus (OP) nerve agents and pesticides present significant threats to civilian and military populations. OP compounds include the nefarious G and V chemical nerve agents, but more commonly, civilians are exposed to less toxic OP pesticides, resulting in the same negative toxicological effects and thousands of deaths on an annual basis. After decades of research, no new therapeutics have been realized since the mid-1900s. Upon phosphylation of the catalytic serine residue, a process known as inhibition, there is an accumulation of acetylcholine (ACh) in the brain synapses and neuromuscular junctions, leading to a cholinergic crisis and eventually death. Oxime nucleophiles can reactivate select OP-inhibited acetylcholinesterase (AChE). Yet, the fields of reactivation of AChE and butyrylcholinesterase encounter additional challenges as broad-spectrum reactivation of either enzyme is difficult. Additional problems include the ability to cross the blood brain barrier (BBB) and to provide therapy in the central nervous system. Yet another complication arises in a competitive reaction, known as aging, whereby OP-inhibited AChE is converted to an inactive form, which until very recently, had been impossible to reverse to an active, functional form. Evaluations of uncharged oximes and other neutral nucleophiles have been made. Non-oxime reactivators, such as aromatic general bases and Mannich bases, have been developed. The issue of aging, which generates an anionic phosphylated serine residue, has been historically recalcitrant to recovery by any therapeutic approach—that is, until earlier this year. Mannich bases not only serve as reactivators of OP-inhibited AChE, but this class of compounds can also recover activity from the aged form of AChE, a process referred to as resurrection. This review covers the modern efforts to address all of these issues and notes the complexities of therapeutic development along these different lines of research.

Background: Since 2006, efforts have been made to increase the identification of traumatic brain injuries (TBIs) in post-9/11 military personnel. The BAT-L is the first validated instrument to diagnose TBIs throughout the lifespan in post-9/11 Veterans. The objective is to investigate the correspondence of the Boston Assessment of TBI-Lifetime (BAT-L) diagnostic prevalence and injury severity of traumatic brain injury with in-theater medical records from Department of Defense (DoD). Methods: A convenience sample of 153 Veterans deployed in 2011 enrolled in the TRACTS longitudinal cohort study was examined. Retrospective review of DoD online medical records to determine diagnostic prevalence and injury severity for all head injury cases during deployment were compared with diagnostic prevalence and injury severity from the BAT-L clinical interview using Chi-square analyses.Results: There was moderate correspondence for TBI diagnosis between the BAT-L and DoD records (κ = 0.42). Sensitivity was 72.7% and specificity was 82.8%. Comparison of injury severity also had moderate correspondence (κ = 0.41). Missing TBI diagnostic data from DoD records was frequent; 43% percent of TBIs reported on the BAT-L did not have any documentation of mTBI assessment or diagnosis in DoD records while 83% did not have in-theater documentation.Conclusions: Diagnosis of TBI via the BAT-L retrospective interview was both sensitive and specific when compared to DoD medical records. However, diagnostic correspondence was only moderate. This lack of diagnostic agreement was related to multiple factors including lack of documentation of injury, differences in assessment tools and goals, and other combat-related motivational factors associated with failure to report injuries while deployed. Several policies were implemented to address underreporting and under-documentation of TBI, yet challenges remain. Findings suggest changes at both individual-level (e.g. service members) and system-level (e.g. DoD/military branches) are needed to adequately diagnose and document all TBI during deployment.

Post-9/11 U.S. veterans are clinically complex with multiple co-occurring health conditions that lead to increased morbidity and mortality, risk for suicide, and decreased quality of life, but underutilization and resistance to treatment remain significant problems. Increased isolation and decreased community and social support due to coronavirus disease (COVID-19) have exacerbated mental health risk. This study evaluated the safety and feasibility of home-based telemental health group workshops to improve reintegration and social connection in post-9/11 U.S. military personnel. Seventy-four (61 males/13 females) post-9/11 U.S. military veterans were randomized to receive 12 sessions of STEP-Home cognitive-behavioral group workshop or present-centered group therapy. Treatment was delivered either in person (traditional medical center setting, treatment as usual [TAU]), or via home-based synchronous videoconferencing (VC). The change to VC occurred due to social distancing guidelines during COVID-19. Mean age was 41.0 years (SD = 11.5, range 24-65). Forty-five (36 males/9 females) participated in VC and 29 (25 males/4 females) in TAU. Demographics were similar across treatment milieu. There were no differences in therapist treatment adherence for TAU versus VC. Therapist satisfaction was higher for TAU groups (q value.05). Veterans showed higher enrollment, attendance, group cohesion, and veteran-to-veteran support for VC compared to TAU (q values.05). Safety procedures were successfully implemented via VC. Results demonstrate the safety, feasibility, and high satisfaction of group telemental health in U.S. veterans. Higher enrollment and treatment adherence for telemental health delivery resulted in a greater likelihood of receiving an effective treatment dose than TAU. Strong group cohesion and veteran-to-veteran support were achievable via telehealth. Telemental health offers convenient, efficient, and cost-effective care options for veterans and may be particularly helpful for patients with high psychiatric burden.

Background Psoriasis is an inflammatory, IL-17–driven skin disease in which autoantigen-induced CD8+ T cells have been identified as pathogenic drivers. Objective Our study focused on comprehensively characterizing the phenotypic variation of CD8+ T cells in psoriatic lesions. Methods We used single-cell RNA sequencing to compare CD8+ T-cell transcriptomic heterogeneity between psoriatic and healthy skin. Results We identified 11 transcriptionally diverse CD8+ T-cell subsets in psoriatic and healthy skin. Among several inflammatory subsets enriched in psoriatic skin, we observed 2 Tc17 cell subsets that were metabolically divergent, were developmentally related, and expressed CXCL13, which we found to be a biomarker of psoriasis severity and which achieved comparable or greater accuracy than IL17A in a support vector machine classifier of psoriasis and healthy transcriptomes. Despite high coinhibitory receptor expression in the Tc17 cell clusters, a comparison of these cells with melanoma-infiltrating CD8+ T cells revealed upregulated cytokine, cytolytic, and metabolic transcriptional activity in the psoriatic cells that differed from an exhaustion program. Conclusion Using high-resolution single-cell profiling in tissue, we have uncovered the diverse landscape of CD8+ T cells in psoriatic and healthy skin, including 2 nonexhausted Tc17 cell subsets associated with disease severity.

Physical activity (PA) pre-COVID-19 was lower in rural areas compared to non-rural areas. The purpose of this study was to determine COVID-19’s impact on PA in rural and non-rural residents. A cross-sectional study consisting of a convenience sample of 278 participants (50% rural, 50% non-rural) from 25 states completed an online survey describing their PA behaviors and perceptions during COVID-19. The global physical activity questionnaire was used to determine PA in various domains and summed to determine if the participant met the PA guidelines. Rural participants had a significantly higher body mass index, lower income, and a lower educational attainment. Conversely, non-rural participants reported more barriers to PA. There was no difference in the perception of COVID-19’s impact on PA, specifically, however, rural participants were significantly less likely to meet cardiorespiratory PA recommendations compared to non-rural participants. Conclusions: This study demonstrates the continued disparity in PA between rural and non-rural residents, despite the supposition of COVID-19 being less impactful in rural areas due to sparse populations. Efforts should be pursued to close the PA gap between rural and non-rural residents.

Embryonal tumor with multilayered rosettes (ETMR) is a malignant brain tumor that typically occurs in children under the age of three. Most patients die within two years of diagnosis, and more effective, targeted therapies are urgently needed. To better characterize the oncogenic mechanisms of key driver alterations and identify novel therapeutic targets, we studied the cellular heterogeneity of ETMR using single-cell RNA sequencing. Analyses conducted on >3,000 high-quality cells collected from ten primary and relapse specimens revealed a common cellular hierarchy across all tumors: A highly proliferative neural stem cell-like population (SOX2+) gives rise to intermediate progenitors (ASCL1+) and more differentiated neuron-like cells (STMN2/4+). These malignant populations closely match histological patterns of ETMR (i.e. rosettes, neuropil), as observed by immunofluorescence microscopy. Comparison to single-cell datasets from human embryos indicates resemblance to cell populations of the developing brain, but also reveals key ETMR-specific differences, including expression of the chromosome 19 miRNA cluster (C19MC, the presumed genetic driver of most ETMRs), which is restricted to the stem cell-like population. We next investigated if targeting C19MC is a viable strategy to disrupt the cellular hierarchy of ETMR. Silencing with antisense oligonucleotides shows pronounced reduction of cell line growth for a specific subset of the 46 members of C19MC. These miRNAs share seed sequences with evolutionary conserved miRNAs that have been shown to regulate pluripotency and self-renewal of embryonic stem cells. We hypothesize that select C19MC members play similar roles in ETMR and represent bona fide targets for therapeutic targeting using antisense technology.

Background: Among Medicare value-based payment programs for acute myocardial infarction (AMI), the Hospital Readmissions Reduction Program uses International Classification of Diseases, Tenth Revision ( ICD-10 ) codes to identify the program denominator, while the Bundled Payments for Care Improvement Advanced program uses diagnosis-related groups (DRGs). The extent to which these programs target similar patients, whether they target the intended population (type 1 myocardial infarction), and whether outcomes are comparable between cohorts is not known. Methods: In a retrospective study of 2176 patients hospitalized in an integrated health system, a cohort of patients assigned a principal ICD-10 diagnosis of AMI and a cohort of patients assigned an AMI DRG were compared according to patient-level agreement and outcomes such as mortality and readmission. Results: One thousand nine hundred thirty-five patients were included in the ICD-10 cohort compared with 662 patients in the DRG cohort. Only 421 patients were included in both AMI cohorts (19.3% agreement). DRG cohort patients were older (70 versus 65 years, P P P P P P P =0.006) than the ICD-10 cohort. Two observations help explain these differences: 61% of ICD-10 cohort patients were assigned procedural DRGs for revascularization instead of an AMI DRG, and type 1 myocardial infarction patients made up a smaller proportion of the DRG cohort (34%) than the ICD-10 cohort (78%). Conclusions: The method used to identify denominators for value-based payment programs has important implications for the patient characteristics and outcomes of the populations. As national and local quality initiatives mature, an emphasis on ICD-10 codes to define AMI cohorts would better represent type 1 myocardial infarction patients.

Background: Injuries of the distal syndesmosis in ankle fractures are traditionally treated with a temporary adjusting screw fixation. Conventional fluoroscopic and X-ray examinations cannot reliably diagnose malpositions of the fixed tibiofibular syndesmosis. Postoperative computer tomography allows a reliable control of the transfixed region.The aim of the retrospective single-study was to clarify whether an intraoperative 3D image intensifier examination can detect malpositions of the syndesmosis already intraoperatively and whether the examination has an influence on the postoperative revision rate.Methods: In 200 patients with tibiofibular syndesmosis injuries, an intraoperative 3D scan was performed after reduction of the distal tibiofibular syndesmosis and placement of the adjusting screw. Postoperative computer tomography of both ankle joints was performed in all patients. Results: 15% of all intraoperative 3D scans (30 patients) showed a finding requiring correction in the area of the ankle joint. In 7% of the cases, a malposition of the fibula in the tibial incisura requiring correction was found. Further corrections were necessary due to the extent and position of the osteosynthesis material (7%) and for the removal of joint bodies (1%). Postoperative computer tomographies of the ankle joints showed no deformities requiring revision. Conclusion: An intraoperative 3D scan allows a reliable assessment of the injured ankle region and reduces the postoperative revision rate. This makes a postoperative routine CT examination of the ankle joint dispensable.

[This corrects the article DOI: 10.1371/journal.pone.0243302.].

Bacteria deploy rearrangement hotspot (Rhs) proteins as toxic effectors against both prokaryotic and eukaryotic target cells. Rhs proteins are characterized by YD-peptide repeats, which fold into a large β-cage structure that encapsulates the C-terminal toxin domain. Here, we show that Rhs effectors are essential for type VI secretion system (T6SS) activity in Enterobacter cloacae (ECL). ECL rhs(−) mutants do not kill Escherichia coli target bacteria and are defective for T6SS-dependent export of hemolysin-coregulated protein (Hcp). The RhsA and RhsB effectors of ECL both contain Pro−Ala−Ala−Arg (PAAR) repeat domains, which bind the β-spike of trimeric valine−glycine repeat protein G (VgrG) and are important for T6SS activity in other bacteria. Truncated RhsA that retains the PAAR domain is capable of forming higher-order, thermostable complexes with VgrG, yet these assemblies fail to restore secretion activity to ∆rhsA ∆rhsB mutants. Full T6SS-1 activity requires Rhs that contains N-terminal transmembrane helices, the PAAR domain, and an intact β-cage. Although ∆rhsA ∆rhsB mutants do not kill target bacteria, time-lapse microscopy reveals that they assemble and fire T6SS contractile sheaths at ∼6% of the frequency of rhs(+) cells. Therefore, Rhs proteins are not strictly required for T6SS assembly, although they greatly increase secretion efficiency. We propose that PAAR and the β-cage provide distinct structures that promote secretion. PAAR is clearly sufficient to stabilize trimeric VgrG, but efficient assembly of T6SS-1 also depends on an intact β-cage. Together, these domains enforce a quality control checkpoint to ensure that VgrG is loaded with toxic cargo before assembling the secretion apparatus.

Purpose To investigate, if patients with complex proximal tibial fracture have realistic expectations on open reduction and internal fixation. Methods 114 patients (mean 49 years, SD ± 13) with closed AO-type B and C proximal tibial fracture were grouped (group B, respectively C). Prior to surgery expectations concerning knee function, pain, return to work/sports, and the risk for osteoarthritis was assessed with the Hospital for Special Surgery-Knee Surgery Expectations Survey (HFSS-KSE) and a non-validated ten-item survey. Results 92% of patients expected at least an almost natural knee postoperatively. All items regarding restoring knee function were ranked to be at least important in both groups. 65% in group B and 47% in group C expected at most occasional pain. 83% in group B and 67% in group C expected full return to work without any limitations. Patients with low physical work intensity expected significantly shorter incapacity to work in both groups (7.8, respectively 8.9 weeks). 71% in group B and 60% in group C expected to return to sports with at most small limitations. 33% in group B and 22% in group C assumed risk for osteoarthritis will be prevented by surgery. Conclusion Expectations on surgery for complex proximal tibial fracture are high regardless of fracture type. The prognosis of many health and lifestyle domains was overestimated. The risk for osteoarthritis was underestimated. This study should sensitize surgeons to discuss realistic expectations. This may help to improve patient comprehension what leads to sensible expectations, resulting in improved patients´ satisfaction. Level of evidence IV. Trial registration number 14104, Date of registration: 06/2015.