Search

Background: Despite advances in surgery and pharmacotherapy, there remains significant residual ischemic risk after coronary artery bypass grafting surgery. Methods: In REDUCE-IT (Reduction of Cardiovascular Events With Icosapent Ethyl–Intervention Trial), a multicenter, placebo-controlled, double-blind trial, statin-treated patients with controlled low-density lipoprotein cholesterol and mild to moderate hypertriglyceridemia were randomized to 4 g daily of icosapent ethyl or placebo. They experienced a 25% reduction in risk of a primary efficacy end point (composite of cardiovascular death, myocardial infarction, stroke, coronary revascularization, or hospitalization for unstable angina) and a 26% reduction in risk of a key secondary efficacy end point (composite of cardiovascular death, myocardial infarction, or stroke) when compared with placebo. The current analysis reports on the subgroup of patients from the trial with a history of coronary artery bypass grafting. Results: Of the 8179 patients randomized in REDUCE-IT, a total of 1837 (22.5%) had a history of coronary artery bypass grafting, with 897 patients randomized to icosapent ethyl and 940 to placebo. Baseline characteristics were similar between treatment groups. Randomization to icosapent ethyl was associated with a significant reduction in the primary end point (hazard ratio [HR], 0.76 [95% CI, 0.63–0.92]; P =0.004), in the key secondary end point (HR, 0.69 [95% CI, 0.56–0.87]; P =0.001), and in total (first plus subsequent or recurrent) ischemic events (rate ratio, 0.64 [95% CI, 0.50–0.81]; P =0.0002) compared with placebo. This yielded an absolute risk reduction of 6.2% (95% CI, 2.3%–10.2%) in first events, with a number needed to treat of 16 (95% CI, 10–44) during a median follow-up time of 4.8 years. Safety findings were similar to the overall study: beyond an increased rate of atrial fibrillation/flutter requiring hospitalization for at least 24 hours (5.0% vs 3.1%; P =0.03) and a nonsignificant increase in bleeding, occurrences of adverse events were comparable between groups. Conclusions: In REDUCE-IT patients with a history of coronary artery bypass grafting, treatment with icosapent ethyl was associated with significant reductions in first and recurrent ischemic events. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01492361.

Objective To evaluate the efficacy of prophylactic mesh placement during end colostomy formation at reducing rates of parastomal hernia using the most recently available data. Background Systematic reviews and meta-analyses of randomized controlled trials (RCTs) have uniformly concluded that the use of prophylactic surgical mesh when fashioning an end colostomy reduces the risk of parastomal hernia. However, recent RCTs have failed to corroborate these findings. This study was designed to provide an updated systematic review and meta-analysis evaluating the efficacy of prophylactic mesh placement during end colostomy formation. Methods A search of Medline, EMBASE, and CENTRAL was performed. Articles were included if they were RCTs that compared the use of prophylactic mesh to no prophylactic mesh during construction of an end colostomy following colorectal resection for benign or malignant disease. The primary outcome was parastomal hernia rate. A pairwise meta-analysis was performed using inverse variance random effects. Results From 1,089 citations, 12 RCTs with 581 patients having prophylactic mesh placement and 671 patients not having prophylactic mesh placement met inclusion criteria. Incidence of parastomal hernia was significantly reduced in patients receiving prophylactic mesh (OR 0.60, 95% CI 0.46 to 0.80, p = 0.0003, I2 = 74%). Results were no longer significantly different when only studies conducted in the last 5 years were analyzed (p = 0.10). There was no significant difference in postoperative morbidity, postoperative mortality, colostomy-specific morbidity, or length of stay between groups. Conclusions There remains a significant reduction in the risk of parastomal hernia with the use of prophylactic mesh at the time of end colostomy formation, despite recent evidence suggesting no difference. Further contemporary trials with the application of modern surgical technology are required.

Background Postoperative ipsilateral anterior cruciate ligament (ACL) tears after tibial eminence fracture fixation has been previously noted in the literature. This study aims to describe the prevalence of and risk factors for postoperative ACL tears in a cohort of patients operatively treated for tibial eminence fracture. Methods A retrospective review of children undergoing treatment of a tibial eminence fracture at 10 tertiary care children's hospitals was performed. The primary outcome of interest was subsequent ACL rupture. Incidence of ACL tear was recorded for the entire cohort. Patients who sustained a postoperative ACL tear were compared with those without ACL tear and analyzed for demographics and risk factors. A subgroup analysis was performed on patients with a minimum of 2-year follow-up data or those who had met the primary outcome (ACL tear) before 2 years. Results A total of 385 pediatric patients were reviewed. 2.6% of the cohort experienced a subsequent ACL tear. The median follow-up time was 6.5 months (SD=6.4 mo). Subsequent ACL tears occurred at a median of 10.2 months (SD=19.5 mo) postoperatively. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL tear (P=0.01). Patients with a subsequent ACL tear were older on average (13.5 vs. 12.2 y old), however, this difference was not statistically significant (P=0.08). Subgroup analysis of 46 patients who had a 2-year follow-up or sustained an ACL tear before 2 years showed a 21.7% incidence of a subsequent ACL tear. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL rupture (P=0.006) in this subgroup. Postoperative ACL tears occurred in patients who were older at the time that they sustained their original tibial eminence fracture (13.4 vs. 11.3 y old, P=0.035). Conclusions Ipsilateral ACL tears following operatively treated pediatric tibial eminence fractures in a large multicenter cohort occurred at a rate of 2.6%. However, in those with at least 2 years of follow-up, the incidence was 21.7%. Subsequent ACL tear was more likely in those with completely displaced (type III or IV) tibial eminence fractures and older patients. Level of evidence Level III-retrospective cohort study.

Background: There is a high rate of concomitant injuries reported in pediatric patients with tibial spine fractures, ranging from 40% to 68.8%. Many tibial spine fractures are treated without initial magnetic resonance imaging (MRI). Purpose: To understand rates of concomitant injury and if the reported rates of these injuries differed among patients with and without pretreatment MRI. Study Design: Cross-sectional study; level of evidence, 3. Methods: We performed an institutional review board–approved multicenter retrospective cohort study of patients treated for tibial spine fractures between January 1, 2000, and January 31, 2019, at 10 institutions. Patients younger than 25 years of age with tibial spine fractures were included. Data were collected on patient characteristics, injury, orthopaedic history, pretreatment physical examination and imaging, and operative findings. We excluded patients with multiple trauma and individuals with additional lower extremity fractures. Patients were categorized into 2 groups: those with and those without pretreatment MRI. The incidence of reported concomitant injuries was then compared between groups. Results: There were 395 patients with a tibial spine fracture who met inclusion criteria, 139 (35%) of whom were reported to have a clinically significant concomitant injury. Characteristics and fracture patterns were similar between groups. Of patients with pretreatment MRI, 79 of 176 (45%) had an identified concomitant injury, whereas only 60 of 219 patients (27%) without pretreatment MRI had a reported concomitant injury ( P < .001). There was a higher rate of lateral meniscal tears ( P < .001) in patients with pretreatment MRI than in those without. However, there was a higher rate of soft tissue entrapment at the fracture bed ( P = .030) in patients without pretreatment MRI. Overall, 121 patients (87%) with a concomitant injury required at least 1 treatment. Conclusion: Patients with pretreatment MRI had a statistically significantly higher rate of concomitant injury identified. Pretreatment MRI should be considered in the evaluation of tibial spine fractures to improve the identification of concomitant injuries, especially in patients who may otherwise be treated nonoperatively or with closed reduction. Further studies are necessary to refine the indications for MRI in patients with tibial spine fractures, determine the characteristics of patients at highest risk of having a concomitant injury, define the sensitivity and specificity of MRI in tibial spine fractures, and investigate patient outcomes based on pretreatment MRI status.

Background:Tibial spine fractures (TSFs) are relatively rare pediatric injuries. Postoperative arthrofibrosis remains the most common complication, with few studies having examined factors associated with its development.Purpose:To identify risk factors for arthrofibrosis and required MUA or lysis of adhesions in the largest known cohort of patients with TSFs.Study Design:Case-control study; Level of evidence, 3.Methods:This was a multicenter study of 249 patients ≤18 years old who had a TSF between January 2000 and February 2019. Patients were separated into cohorts based on whether they developed arthrofibrosis, defined as a 10° deficit in extension and/or 25° deficit in flexion at postoperative 3 months or a return to the operating room for manipulation under anesthesia (MUA) and/or lysis of adhesions.Results:A total of 58 (23.3%) patients developed postoperative arthrofibrosis, with 19 (7.6%) requiring a return to the operating room for MUA. Patients with arthrofibrosis were younger (mean ± SD, 11.3 ± 2.7 vs 12.3 ± 2.8 years; P = .029). They were more likely to have a nonsport, trauma-related injury (65.4% vs 32.1%; P < .001) and a concomitant ACL injury (10.3% vs 1.1%; P = .003). Those with arthrofibrosis had longer operative times (135.0 vs 114.8 minutes; P = .006) and were more likely to have been immobilized in a cast postoperatively (30.4% vs 16.6%; P = .043). In multivariate regression, concomitant anterior cruciate ligament (ACL) injury (odds ratio [OR], 20.0; P = .001), traumatic injury (OR, 3.8; P < .001), age Conclusion:Surgeons should be cognizant of arthrofibrosis risk in younger patients with concomitant ACL tears and traumatic injuries not resulting from athletics. Furthermore, postoperative immobilization in a cast should be avoided given the high risk of arthrofibrosis. Concomitant ACL injury is associated with a higher return to the operating room for MUA.

Aortoesophageal fistula (AEF) is a rare complication of esophageal interventions. We present a 49-year-old woman who underwent Roux-en-Y gastric bypass with a recurrent gastrojejunal anastomotic leak requiring covered esophageal stent placement. She presented 1 month later with abdominal pain, leukocytosis, and hematemesis. A computed tomography scan demonstrated migration of the esophageal stent with aortic erosion concerning for AEF. She underwent emergent endovascular exclusion of an AEF to the descending thoracic aorta with subsequent esophageal resection and diversion and aortic endograft explant, resection, and homograft repair on postoperative day 6 allowing for staged removal of prosthetic material and maintenance of inline flow.

Small unmanned aerial systems (popularly known as sUAS or drones) have been widely used in low-altitude sensing of vegetation coverage. However, the assessments of vegetation status largely rely on...

Background Closed reduction and percutaneous pinning in a crossed or lateral configuration is the standard treatment for supracondylar humerus (SCH) fractures. We compared mid-term patient-reported outcomes (PROs), radiographic outcomes, and complication rates between patients treated with crossed versus lateral pinning. Methods We reviewed 508 pediatric patients treated surgically for Gartland type-III SCH fractures from 2008 to 2017. We included patients aged 5 to 17 years at the time of telephone interviews, who had available radiographs. We excluded those unable to be reached by telephone; those who declined to be surveyed; and those lost to follow-up. Our sample comprised 142 participants (28%) (mean±SD age at surgery, 5.2±2.0 y), 93 (65%) of whom were treated with lateral pinning and 49 (35%) with crossed pinning. Participants' parents completed the Quick Disabilities of the Arm, Shoulder, and Hand and the Patient-Reported Outcomes Measurement Information System Parent Proxy at a mean 4.4 years (range: 2 to 10 y) postoperatively. Postoperative radiographs were reviewed to assess reduction. Bivariate analysis was performed to determine whether outcomes differed by pinning technique (α=0.05). Results The proportions of participants achieving complete reduction were not significantly different between pin configuration groups (P=0.71). At follow-up, the 2 groups did not differ significantly in any PRO scores (all, P>0.05). Conclusion We found no differences between crossed and lateral pinning of Gartland type-III SCH fractures in terms of radiographic reduction, PROs, or complication rates at mid-term follow-up. Level of evidence Level III.

Objective Opioid prescriptions after surgery are effective for pain management but have been a significant contributor to the current opioid epidemic. Our objective is to review pragmatic approaches to develop and implement evidence-based guidelines based on a learning health system model. Summary background data During the last 2 years there has been a preponderance of data demonstrating that opioids are overprescribed after surgery. This contributes to a number of adverse outcomes, including diversion of leftover pills in the community and rising rates of opioid use disorder. Methods We conducted a MEDLINE/PubMed review of published examples and reviewed our institutional experience in developing and implementing evidence-based postoperative prescribing recommendations. Results Thirty studies have described collecting data regarding opioid prescribing and patient-reported use in a cohort of 13,591 patients. Three studies describe successful implementation of opioid prescribing recommendations based on patient-reported opioid use. These settings utilized learning health system principles to establish a cycle of quality improvement based on data generated from routine practice. Key components of this pathway were collecting patient-reported outcomes, identifying key stakeholders, and continual assessment. These pathways were rapidly adopted and resulted in a 37% to 63% reduction in prescribing without increasing requests for refills or patient-reported pain scores. Conclusion A pathway for creating evidence-based opioid-prescribing recommendations can be utilized in diverse practice environments and can lead to significantly decreased opioid prescribing without adversely affecting patient outcomes.

Background/purpose: With the evolution of assisted fertility and prenatal diagnostic technology, the prevalence of multi-fetal pregnancy increased, followed by the demand for prenatal intervention if genomic aberration was detected. How to distinguish the affected foetus from the normal co-twin before selective fetal reduction is therefore challenging. Objectives: We retrospectively reviewed the cases of dichorionic twins at our centre during 2004–2018, where selective fetal reduction was requested because one foetus carried a pathogenic genomic aberration. Five cases were enrolled, including three foetuses with trisomy 21, one foetus with microduplication and one foetus with microdeletion disorders. Method: We labelled the affected foetus by prenatal ultrasound and rapid molecular tools. For the twins without discriminating sonographic features (e.g., the same gender and no distinct placentae), interphase fluorescence in situ hybridization, rapid microarray and short tandem repeat markers were applied to identify the affected foetus. Results: Selective fetal reduction was allocated accurately for all individuals. Two cases delivered at term, while two delivered preterm, and one developed fetal loss of the co-twin. Conclusion: We proposed a working scheme of integrating imaging and molecular techniques to correctly identify the affected co-twin before selective fetal reduction to ensure the accuracy of the identification. Keywords: Rapid molecular techniques, Selective fetal reduction in twins, Genomic aberration

Peripheral nerve blocks (PNBs) have recently been associated with a higher incidence of complications than previously thought. We compared: (1) incidence of PNB-related residual neurological symptoms and (2) patient selection, operative practices, and anesthesia practices for pediatric knee surgery patients before and after changes in PNB administration at our institution.We compared data from pediatric patients who underwent knee surgery with PNBs from 2014 to 2016 (cohort 1; 100 patients) or 2017 to 2019 (cohort 2; 104 patients). Cohort 2 was treated after PNB administration was limited to a dedicated anesthesia block team at our institution. We used t tests and χ2 tests, with an α level of 0.05.The incidence of PNB-related neurological complications was lower in cohort 2 (0.96%;) than cohort 1 (6%) (P=0.045). The 1 complication in cohort 2 was numbness proximal to the knee. Cohort 1 had 5 cases of numbness proximal to the knee and 1 case of neuropathic pain upon palpation of the PNB site. The proportion of female patients was greater in cohort 2 (57%) than cohort 1 (36%) (P=0.01); age and body mass index did not differ between cohorts. In cohort 2, the mean operating time was longer, and tourniquets were used more frequently (both, P0.01). A greater proportion of PNBs were performed by fellows in cohort 2 (67%) versus cohort 1 (55%) (P=0.01). A smaller proportion of PNBs were performed by residents in cohort 2 (6.9%) versus cohort 1 (16%) (P=0.01). The most common anatomic site for PNBs was the femoral nerve (51%) in cohort 1 and the saphenous nerve (51%) in cohort 2 (P0.01).The incidence of PNB-related complications after pediatric knee surgery decreased significantly after institutional changes in the regulation of PNB use. This decrease may be explained by shifts toward more experienced providers administering PNBs and preference for more distal anatomic sites, suggesting ways other institutions may lower their PNB complication rates.Level III-retrospective prognostic study.

CASE We describe a case of dysplasia epiphysealis hemimelica (DEH) of the anterior tibiotalar joint that presented as toe walking in a 6-year-old boy. Radiographs and magnetic resonance images showed substantial exostosis at the anterior ankle that blocked dorsiflexion. He underwent surgical excision and casting for equinus, restoring ankle range of motion and gait. CONCLUSION Although DEH is benign, it can cause major deficits and permanent damage to a joint when neglected. Recognition of subtle presentations of DEH, such as toe walking, is crucial. Early treatment can restore joint motion and prevent deformity and arthritis.

Background: Although the athleticism required of cheerleaders has increased, the risks of cheerleading have been less studied as compared with other sports. Purpose: To update our understanding of the epidemiology of cheerleading-related injuries. Study Design: Descriptive epidemiology study. Methods: We analyzed the National Electronic Injury Surveillance System (NEISS) for cheerleading-related injuries presenting to nationally representative emergency departments (EDs) in the United States from January 2010 through December 2019. Extracted data included patient age and sex, injury characteristics (diagnosis, body region injured, time of year, and location where injury occurred), and hospital disposition. Using patient narratives, we recorded the cheerleading skills, settings, and mechanisms that led to injury. NEISS sample weights were used to derive national estimates (NEs) from actual case numbers. Results: From 2010 to 2019, a total of 9868 athletes (NE = 350,000; 95% CI, 250,000-450,000) aged 5-25 years presented to US EDs for cheerleading injuries. The annual number of injuries decreased by 15%, from 982 (NE = 35,000; 95% CI, 27,000-44,000) to 897 (NE = 30,000; 95% CI, 18,000-42,000) ( P = .048), corresponding to a 27% decline in the injury rate per 100,000 cheerleaders ( P < .01). The annual number of injuries caused by performing stunts decreased by 24%, from 240 (NE = 8700; 95% CI, 6700-11,000) to 216 (NE = 6600; 95% CI, 4000-9200) ( P = .01), with a 36% decline in the corresponding injury rate per 100,000 cheerleaders ( P < .01). Despite these decreases, annual incidence of concussions/closed head injuries increased by 44%, from 128 (NE = 3800; 95% CI, 2900-4700) to 171 (NE = 5500; 95% CI, 3400-7700) ( P = .02), and patients requiring hospital admission increased by 118%, from 18 (NE = 330; 95% CI, 250-410) to 24 (NE = 720; 95% CI, 440-1000) ( P < .01). The hospital admission rate increased by 9.0% ( P = .02). Conclusion: The number of cheerleading-related injuries presenting to US EDs decreased from 2010 to 2019. However, the incidence of concussions/closed head injuries and hospital admissions increased, suggesting that further measures are needed to improve safety for cheerleaders.

This study examined the molecular characterization of a prenatal case with true fetal mosaicism of small supernumerary marker chromosome 16 (sSMC(16)). A 41-year-old female underwent amniocentesis at 19 weeks of gestation due to advanced maternal age. Chromosomal analysis for cultured amniocytes revealed a karyotype of 47,XY,+mar[4]/46,XY[16]. Spectral karyotyping and metaphase fluorescence in situ hybridization (FISH) demonstrated that the sSMC was derived from chromosome 16 (47,XY,+mar.ish der(16)(D16Z1+)[13/20]). Confined placental mosaicism was initially suspected because the prenatal ultrasound revealed a normal structure and the pregnancy was uneventful. However, interphase FISH of cord blood performed at 28 weeks of gestation showed 20% mosaicism of trisomy chromosome 16 (nuc ish(D16Z2×3)[40/200]). Chromosome microarray analysis further demonstrated 55% mosaicism of an 8.02 Mb segmental duplication at the subcentromeric region of 16p12.1p11.1 (arr[GRCh37] 16p12.1p11.1(27021975_35045499)×3[0.55]). The results demonstrated a true fetal mosaicism of sSMC(16) involving chromosome16p12.1p11.1 that is associated with chromosome 16p11.2 duplication syndrome (OMIM #614671). After non-directive genetic counseling, the couple opted for late termination of pregnancy. This case illustrated the use of multiple molecular cytogenetic tools to elucidate the origin and structure of sSMC, which is crucial for prenatal counseling, decision making, and clinical management.

Case Iliotibial band (ITB) autograft is used for anterior cruciate ligament (ACL) reconstruction in prepubescent patients. No reports have described ITB salvage techniques for failed reconstruction. We describe a 13-year-old boy who sustained a multiligamentous knee injury, experienced a failed primary reconstruction, and required a revision ITB ACL, lateral collateral ligament, and posterior lateral corner reconstruction with reuse of his ITB autograft. At the 2-year follow-up, he returned to playing competitive sports. Conclusion This case shows that salvage of an ITB ACL autograft can be an option in early reconstruction failure.

Background: While operative treatment of displaced pediatric tibial eminence fractures has generally been shown to be safe, post-operative complications including arthrofibrosis, infection, fixation failure, and postoperative ipsilateral ACL injuries remain prevalent. The purpose of this study was to describe the prevalence of and risk factors for post-operative ACL tears in a cohort of patients surgically treated for tibial eminence fracture. Methods: We performed a retrospective review of children undergoing treatment of a tibial eminence fracture at 10 tertiary children’s hospitals.. The primary outcome was subsequent ACL rupture. Patients with 2 year follow up data and those that had met the primary outcome within the 2 year period, were analyzed for demographics, risk factors and survival analyses Results: 385 pediatric patients were reviewed. Overall, 46 patients had either 2 year follow up data or met the primary outcome measure of an ACL tear prior to the 2 year mark. Mean age was 11.2 years old (SD 2.8), and the median follow time was 36.4 months (SD 17.7 months) There was a 21.7% incidence of subsequent ACL tear in the cohort analyzed. Subsequent ACL tears occurred at a median of 10.2 months (SD 19.5 months) postoperatively. There was a statistically significant association with higher Myers & McKeever grade tibial spine fractures (Type III and IV) and subsequent ACL rupture ( p=0.006). Subsequent ACL tears occurred in patients who were older when they had their original tibial eminence fracture, 13.4 years old versus 11.3 years old ( p=0.035). There was no statistically significant relationship between ipsilateral ACL tear and body mass index, operative time, fixation method used, postoperative weight bearing status, type of postoperative immobilization, contact versus non-contact injury mechanism, type of post-operative physical therapy protocol based on chi-squared or t-test ( p>0.05). Conclusion: Subsequent ipsilateral ACL tears following operatively treated pediatric tibial eminence fractures in a large multicenter cohort occurred at a rate of 21.7%. They were associated with completely displaced (Type III or IV) tibial eminence fractures, and older patients. Clinicians should therefore continue to follow patients for at least 2 years after treatment of pediatric tibial eminence fractures in order to track this potential complication. [Table: see text]

Introduction: Bacillus anthracis is bacterial cause of the highly fatal, zoonotic disease anthrax. Tasmanian pepper (Tasmannia lanceolata) has been previously documented for its antiseptic properties against other pathogenic bacteria. This study sought to investigate the effectiveness of T. lanceolata as an inhibitory agent against B. anthracis. Methods: Tasmannia lanceolata berry and leaf extracts were prepared with either water or methanol as the extraction solvent. Growth inhibition was assessed against B. anthracis strain PMO through disc diffusion as assaying. The relative MIC values of each extract was quantified to evaluate efficacy as a sterilant. The degree of toxicity of each extract was achieved using the widely used Artemia franciscana nauplii bioassay. Results: T. lanceolata leaf extracts inhibited the growth of B. anthracis in the disc diffusion assay, with MIC values of 2333 and 1873 μg/mL respectively. In contrast, the T. lanceolata berry extracts were completely devoid of growth inhibitory activity. All T. lanceolata extracts (both berry and leaf) were non-toxic (LC50 values substantially >1000 μg/mL) as determined via the Artemia franciscana bioassay. Conclusion: T. lanceolata berry and leaf extracts are not only non-toxicity, but also had moderate growth inhibitory bioactivity against B. anthracis, highlighting their potential in the treatment of anthrax.

Introduction: Yersinia enterocolitica is a major source of food poisoning via the consumption of contaminated meat products, causing acute gastroenteric yersiniosis. Tasmannia lanceolata has been widely documented for its antiseptic properties, repressing the growth of an extensive range of bacteria. Despite this, Tasmannia lanceolata has yet to be been tested for its inhibitory capacity against Y. enterocolitica. Methods: T. lanceolata leaf and berry extracts were prepared by maceration and growth inhibitory activity against a clinical strain of Y. enterocolitica was examined by disc diffusion assays. The MIC values of the extracts were determined to quantify and compare their relative efficacies. Toxicity was determined using an Artemia franciscana nauplii bioassay. Results: T. lanceolata leaf and berry extracts displayed potent growth inhibitory activity in the disc diffusion assay against Y. enterocolitica. The ethyl acetate and chloroform leaf extracts (MICs of 30 and 53 μg/mL respectively) and the hexane berry extract (MIC = 34 μg/mL) were particularly potent growth inhibitors. The methanol and water extracts of both the berry and leaf, as well as the leaf ethyl acetate extract, also had strong growth inhibitory activity against Y. enterocolitica, albeit with a higher MIC values (250-300μg/mL). All other extracts had lower efficacy, although their MIC values also indicated good inhibitory activity (with the exception of the chloroform berry extract). When assessed for toxicity, all T. lanceolata extracts were non-toxic (LC50 values >1000 μg/mL) in the Artemia franciscana bioassay. Conclusion: The non-toxicity of the T. lanceolata berry and leaf extracts, combined with the potent inhibitory bioactivity observed against Y. enterocolitica, demonstrates their potential as therapeutic agents in the prevention and treatment of yersiniosis.

Background Opioids are overprescribed after surgical procedures, leading to dependence and diversion into the community. This can be mitigated by evidence-based prescribing practices. We investigated the feasibility of an opioid-sparing pain management strategy after surgical procedures. Study Design Patients undergoing 6 procedures were offered the opportunity to participate in an opioid-sparing pain management pathway. Patients were advised to use acetaminophen and ibuprofen, and were provided with a small “rescue” opioid prescription for breakthrough pain. They were then surveyed postoperatively about opioid use and patient-reported outcomes measures. Overall cohort characteristics and differences between opioid users and non-users were analyzed. Results A total of 190 patients were analyzed. Median prescription size was 5 (interquartile range [IQR] 4 to 6) pills and opioid use was 0 (IQR 0 to 4) pills. Fifty-two percent of patients used no opioids after procedures. Median number of leftover pills was 2 (IQR 0 to 5). Median pain score was 1 (IQR 1 to 2) and satisfaction score was 10 (IQR 8 to 10). Almost all (91%) patients agreed that their pain was manageable. Patients who used opioids were younger (52 ± 14 vs 59 ± 13 years; p = 0.001), reported higher pain scores (2 [IQR 1 to 2] vs 1 [1 to 2]; p = 0.014), received larger rescue prescriptions (6 ± 3 vs 4 ± 4 pills; p = 0.003), and were less likely to agree that their pain was manageable (82% vs 98%; p = 0.001). There were no other significant differences between opioid users and non-users. Conclusions Patients reported minimal or no opioid use after implementation of an opioid-sparing pathway, and still reported high satisfaction and pain control. These results demonstrate the effectiveness and acceptability of major reduction and even elimination of opioids after discharge from minor surgical procedures.

BACKGROUND The spatial order of physeal maturation around the distal tibia has been shown to place adolescent patients at risk for certain transitional injuries, such as Tillaux or triplane fractures. Less is known about physeal maturation around the knee. The purpose of this study was to establish the spatial order of physeal maturation in the normal human knee using magnetic resonance imaging (MRI). METHODS We retrospectively collected all knee MRI scans from patients presenting to our institution from January 2004 to January 2014. Patients who were suspected on the basis of clinical or radiographic findings of having abnormal knee physeal development or injury were excluded. We then applied a previously described MRI staging system of knee physeal maturation to the MRI scans of the remaining patients at 8 defined knee locations. Associations between the stage of maturation and mean chronological age were then evaluated across the 8 knee locations. Interrater and intrarater reliabilities were assessed. RESULTS A total of 165 knee MRI scans (from 98 boys, 67 girls) met the inclusion criteria. Significant differences were found between each stage of physeal maturation and the mean chronological ages at all 8 knee locations for both boys and girls (each, P

It is possible to generate real-time and location-by-location data of many types of human dynamic events based on social media information for the awareness of events in public health. Analyzing these events is useful in understanding spatiotemporal trends and patterns of how diseases spread and also provides indications for users’ sentiment about the concerned disease. This article examines the spatial and temporal patterns of social media posts based on the content, attributes, and follower activities of posts on social media. We describe the spatial features of the topic discussed in the posts and the spatial relationship among comments on the posts. We present models for describing the diffusion process of these posts and for exploring their spatiotemporal patterns. Our results suggest that (1) the long-term trends of the topics in users’ views seem to be stable, (2) results from analyzing follower activities of posts are critical in describing the spatial patterns of the posts, and (3) the diffusion process of an event in social media is still similar to that of a traditional information diffusion model. Our findings are useful for understanding social media and social events. The processes we describe in this article suggest a standard form of analysis that can be adopted for extracting spatiotemporal patterns of information diffusion and for data mining in social media posts.

Childhood obesity is a growing epidemic in the United States, and is associated with an increased risk of lower-extremity physeal fractures, and fractures requiring operative intervention. However, no study has assessed the risk upper extremity physeal fractures among overweight children. Our purpose was to compare the following upper-extremity fracture characteristics in overweight and obese children with those of normal-weight/underweight children (herein, “normal weight”): mechanism of injury, anatomical location, fracture pattern, physeal involvement, and treatment types. We hypothesized that overweight and obese children would be higher risk for physeal and complete fractures with low-energy mechanisms and would therefore more frequently require operative intervention compared with normal-weight children. We performed a cross-sectional review of our database of 608 patients aged 2 to 16 years, and included patients who sustained isolated upper-extremity fractures at our level-1 pediatric tertiary care center from January 2014 to August 2017. Excluded were patients who sustained pathologic fractures and those without basic demographic or radiologic information. Using body mass index percentile for age and sex, we categorized patients as obese (≥95th percentile), overweight (85th to

Background: Injured anterior cruciate ligament (ACL) tissue retains proprioceptive nerve fibers, vascularity, and biomechanical properties. For these reasons, remnant ACL tissue is often preserved during the treatment of ACL injuries. Purpose: To assess through a cadaveric model whether reorienting and retensioning the residual ACL via an osteotomy improves knee stability after partial ACL tear, with substantial remnant tissue and intact femoral and tibial attachments. Study Design: Controlled laboratory study. Methods: In 8 adult cadaveric knees, we measured anterior tibial translation and rotational laxity at 30° and 90° of flexion with the ACL in its native state and in 3 conditions: partial tear, retensioned, and ACL-deficient. The partial-tear state consisted of a sectioned anteromedial ACL bundle. Results: In the native state, the translation was 10 ± 2.7 mm (mean ± SD) at 30° of flexion and 8.4 ± 3.6 mm at 90° of flexion. Anterior translation of the knees in the partial-tear state (14 ± 2.7 mm at 30° and 12 ± 2.7 mm at 90°) was significantly greater than baseline ( P < .001 for both). Translation in the ACL-retensioned state (9.2 ± 1.7 mm at 30° and 7.2 ± 2.1 mm at 90°) was significantly less than in the ACL-deficient state ( P < .001 for both), and translation was not significantly different from that of the intact state. For ACL-deficient knees, translation (20 ± 4.3 mm at 30° and 16 ± 4.4 mm at 90°) was significantly greater than all other states ( P < .001 for all). Although rotational testing demonstrated the least laxity at 30° and 90° of flexion in the retensioned and intact states and the most laxity in the ACL-deficient state, rotation was not significantly different among any of the experimental states. Conclusion: In a cadaveric model of an incomplete ACL tear, a reorienting and retensioning core osteotomy at the tibial insertion of the remnant ACL improved anteroposterior translation of the knee without compromising its rotational laxity. Clinical Relevance: The findings of this study support the concept of ACL tissue reorienting and retensioning in the treatment of ACL laxity as an area for future investigation.

Knee flexion contractures can arise from posterior capsule arthrofibrosis secondary to trauma, surgery, or chronic degenerative disease. This leads to limited knee extension and increased mechanical stress on the contralateral joint. Depending on the severity of the contracture, a treatment option may include surgical release of the posterior capsule. Arthroscopic posterior capsular release has been reported previously to have excellent resolution of extension deficits with minimal risk of postoperative complications. These techniques typically use an array of instruments, including shavers, biters, or scissors to perform arthrolysis of the posteromedial and posterolateral capsules. Our primary objective is to present a modified arthroscopic surgical technique for percutaneous treatment of knee flexion contracture using a spinal needle to perform a posterior capsule release., Technique Video Video 1 Posterolateral and posteromedial capsular release of the knee. After placing the patient in a supine position on the operating table, the knee is flexed to 90° and the arthroscope is inserted into the anteromedial compartment for visualization of the posterolateral compartment via the Gillquist interval. A needle is then inserted through the skin and into the joint laterally. As shown, the beveled edge of the needle is used to section the posterolateral capsule layer by layer until the entire capsule is released. After completion of the posterolateral release, the arthroscope is inserted into the anterolateral portal between the posterior cruciate ligament and the anterolateral border of medial femoral condyle to allow for visualization of the posteromedial compartment. A needle is then inserted through the skin and into the joint medially. Once again, the beveled edge of the needle is used to section the capsule layer by layer until the entire capsule is released. After completion of the posterior capsular release, knee range of motion can be performed to assess improvements in knee extension.

The basolateral amygdala (BLA) is critical for reward behaviors via a projection to the nucleus accumbens (NAc). Specifically, BLA-NAc projections are involved in reinforcement learning, reward-seeking, sustained instrumental responding, and risk behaviors. However, it remains unclear whether chronic stress interacts with BLA-NAc projection neurons to result in maladaptive behaviors. Here we take a chemogenetic, projection-specific approach to clarify how NAc-projecting BLA neurons affect avoidance, reward, and feeding behaviors in male mice. Then, we examine whether chemogenetic activation of NAc-projecting BLA neurons attenuates the maladaptive effects of chronic corticosterone (CORT) administration on these behaviors. CORT mimics the behavioral and neural effects of chronic stress exposure. We found a nuanced role of BLA-NAc neurons in mediating reward behaviors. Surprisingly, activation of BLA-NAc projections rescues CORT-induced deficits in the novelty suppressed feeding, a behavior typically associated with avoidance. Activation of BLA-NAc neurons also increases instrumental reward-seeking without affecting free-feeding in chronic CORT mice. Taken together, these data suggest that NAc-projecting BLA neurons are involved in chronic CORT-induced maladaptive reward and motivation behaviors.

Transmission of dengue virus is a complex process with interactions between virus, mosquitoes and humans, influenced by multiple factors simultaneously. Studies have examined the impact of climate or socio-ecological factors on dengue, or only analyzed the individual effects of each single factor on dengue transmission. However, little research has addressed the interactive effects by multiple factors on dengue incidence. This study uses the geographical detector method to investigate the interactive effect of climate and socio-ecological factors on dengue incidence from two perspectives: over a long-time series and during outbreak periods; and surmised on the possibility of dengue outbreaks in the future. Results suggest that the temperature plays a dominant role in the long-time series of dengue transmission, while socio-ecological factors have great explanatory power for dengue outbreaks. The interactive effect of any two factors is greater than the impact of single factor on dengue transmission, and the interactions of pairs of climate and socio-ecological factors have more significant impact on dengue. Increasing temperature and surge in travel could cause dengue outbreaks in the future. Based on these results, three recommendations are offered regarding the prevention of dengue outbreaks: mitigating the urban heat island effect, adjusting the time and frequency of vector control intervention, and providing targeted health education to travelers at the border points. This study hopes to provide meaningful clues and a scientific basis for policymakers regarding effective interventions against dengue transmission, even during outbreaks., Author summary Dengue is among the rapidly spreading vector-borne diseases and is widespread in tropical and subtropical areas. In China, dengue is a serious public health problem, especially in the southeastern regions with rapid urbanization, such as Guangzhou City. Since 1998, more than 40,000 dengue cases have been reported in Guangzhou. Dengue transmission is affected by multiple factors, including climate and different socio-ecological factors. This study indicates that temperature has a significant effect on the long-time series of dengue transmission, while socio-ecological factors play an important role in dengue outbreaks. The interactive effect of temperature and socio-ecological factors contributes to dengue outbreak in Guangzhou. Increasing temperature and surge in travel could cause a dengue outbreak in the future. We have made suggestions about policies and measures regarding its prevention in Guangzhou.

Fundamentally, river plume dynamics are controlled by the buoyancy due to river effluent and mixing induced by local forcing such as winds and tides. Rarely the influence of far-field internal waves on the river plume dynamics is documented. Our 5-day fix-point measurements and underway acoustic profiling identified hydrodynamic processes on the dispersal pathway of the Pearl River plume. The river plume dispersal was driven by the SW monsoon winds that induced the intrusion of cold water near the bottom. The river effluent occupied the surface water, creating strong stratification and showing on-offshore variability due to tidal fluctuations. However, intermittent disruptions weakened stratification due to wind mixing and perturbations by nonlinear internal waves (NIWs) from the northern South China Sea (NSCS). During events of NIW encounter, significant drawdowns of the river plume up to 20 m occurred. The EOF deciphers and ranks the contributions of abovementioned processes: (1) the stratification/mixing coupled by wind-driven plume water and NIWs disruptions (81.7%); (2) the variation caused by tidal modulation (6.9%); and (3) the cold water intrusion induced by summer monsoon winds (5.1%). Our findings further improve the understanding of the Pearl River plume dynamics influenced by the NIWs from the NSCS.

We examined the association of sociodemographic factors on mental health risk within the city of Akron (Ohio). A Spatial Bayesian Hierarchical model was used in this study. We found that the risk of poor mental health was positively associated with the proportion of people lacking sufficient sleep (RR = 0.42, 95% CI:0.22-0.62), the percentage of people below poverty (RR = 0.12, 95% CI: 0.09, 0.16), and the percentage of married couples (RR = 0.02, 95% CI: -0.05, 0.08). On the contrary, the percentage of female population (RR = -0.06, 95% CI: -0.13, 0.01), the percentage of the black population (RR = -0.05, 95% CI: -0.08, -0.02), and the college-educated population (RR = -0.03, 95% CI: -0.09, 0.04) was negatively associated with the risk of poor mental health. We also found that the sociodemographic variables have spatially varying effects across different neighborhoods. Future studies will examine the joint spatial effect of poor mental health risk and suicide ideation in the study area.

Continuous intracranial pressure (ICP) monitoring is a cornerstone of neurocritical care after severe brain injuries such as traumatic brain injury and acts as a biomarker of secondary brain injury. With the rapid development of artificial intelligent (AI) approaches to data analysis, the acquisition, storage, real-time analysis, and interpretation of physiological signal data can bring insights to the field of neurocritical care bioinformatics. We review the existing literature on the quantification and analysis of the ICP waveform and present an integrated framework to incorporate signal processing tools, advanced statistical methods, and machine learning techniques in order to comprehensively understand the ICP signal and its clinical importance. Our goals were to identify the strengths and pitfalls of existing methods for data cleaning, information extraction, and application. In particular, we describe the use of ICP signal analytics to detect intracranial hypertension and to predict both short-term intracranial hypertension and long-term clinical outcome. We provide a well-organized roadmap for future researchers based on existing literature and a computational approach to clinically-relevant biomedical signal data.

Supracondylar humerus (SCH) fractures are reported to be approximately twice as common among boys as among girls. Little is known about sex-associated differences in fracture patterns and complications. We compared the incidence of pediatric SCH fractures, injury mechanism (high-energy or low-energy), fracture subtypes, associated neurologic injuries, and treatment types by patient sex. We reviewed 1231 pediatric SCH fractures treated at 1 center from 2008 to 2017, analyzing sex distributions overall and by year and fracture subtype. We noted patient demographic characteristics, injury mechanisms, neurologic injuries, and treatments (nonoperative or operative). Binomial 2-tailed, chi-squared, and Student's t tests were used for analysis. Multiple logistic regression was performed to assess associations between sex, age, and injury mechanism. Alpha = 0.05. We found no significant difference in the distribution of girls (52%) vs boys (48%) in our sample compared with a binomial distribution (P = .11). Annual percentages of fractures occurring in girls ranged from 46% to 63%, and sex distribution did not change significantly over time. The mean (± standard deviation) age at injury was significantly younger for girls (5.5 ± 2.5 years) than for boys (6.1 ± 2.5 years) (P

Effort-related choice tasks are used to study aspects of motivation in both rodents and humans (Der-Avakian and Pizzagalli Biol Psychiatry 83(11):932–939, 2018). Various dopaminergic manipulations and antidepressant treatments can shift responding to these tasks (Randall et al. Int J Neuropsychopharmacol 18(2), 2014; Yohn et al. Psychopharmacology 232(7):1313–1323, 2015). However, while chronic stress can precipitate mood disorders in humans, there is relatively little known about whether chronic stress elicits maladaptive behaviors in rodent effort-related choice tasks. Chronic corticosterone (CORT) elicits an increase in negative maladaptive behaviors in male mice (David et al. Neuron 62(4):479–493, 2009; Gourley et al. Biol Psychiatry 64(10):884–890, 2008; Olausson et al. Psychopharmacology 225(3):569–577, 2013). We hypothesized that chronic CORT administration to male mice would reduce motivation for a higher effort, higher reward option, and shift responding to a less effortful, but a lesser reward. Adult male C57BL/6J mice were administered either vehicle (n = 10) or CORT (n = 10) (~ 9.5 mg/kg/day) in their drinking water for 4 weeks, and then throughout all behavioral experiments (15 weeks total), and were tested in a Y-Maze barrier task and a fixed ratio concurrent (FR/chow) choice task. Chronic CORT reduced Y-maze HR arm choice when more effort was required to obtain the 4 food pellets (15-cm barrier in the high-reward (HR) arm, p

Closed reduction with percutaneous pin fixation is commonly used to treat pediatric supracondylar humerus fractures. Various pin configurations of varying biomechanical strength have been described. However, to our knowledge, no biomechanical study has focused on pin alignment in the sagittal plane. Our goal was to compare the stability of fixation using 3 different pin constructs: 3 lateral pins diverging in the coronal plane but parallel in the sagittal plane (3LDP), 3 lateral pins diverging in the coronal and sagittal planes (3LDD), and 2 crossed pins (1 medial and 1 lateral). Transverse fractures were made through the olecranon fossa of 48 synthetic humeri, which were then reduced and pinned in the 3LDP, 3LDD, and crossed-pin configurations (16 specimens per group) using 1.6-mm Kirschner wires. The sagittal plane pin spread was significantly greater in the 3LDD group than in the 3LDP group, whereas we found no difference in the coronal plane. Sagittal extension testing was performed from 0° to 20° at 1°/s for 10 cycles using a mechanical torque stand. The torque required to extend the distal fragment 20° from neutral was compared between groups using one-way analysis of variance with multiple comparison post-hoc analysis. P values ≤.05 were considered significant. The 3LDD configuration was more stable than the 3LDP and crossed-pin configurations. The mean torque required to displace the pinned fractures was 5.7 Nm in the 3LDD group versus 4.1 Nm in the 3LDP group and 3.7 Nm in the crossed-pin group (both, P

Introduction/Background: Lateral discoid meniscus (LDM) is the most common congenital anomaly of the knee. Due to the significant heterogeneity in pathomorphology, LDM treatment remains challenging. Treatment approaches and surgical techniques vary widely among surgeons and different types of LDM. Current classification systems inadequately describe the spectrum of pathology or dictate treatment. Hypothesis/Purpose: The Pediatric Research in Sports Medicine (PRISM) meniscal study group developed and tested the reliability of a novel classification system designed to comprehensively capture the intricacies of LDM pathomorphology and guide treatment decisions. Methods: The PRISM LDM Classification System was developed through an initial review of existing classification systems followed by group consensus method by pediatric meniscal surgeons from 20 tertiary academic centers. Four factors were evaluated: (1) meniscal width (surface area), (2) meniscal height (thickness, +/- horizontal delamination), (3) peripheral stability (and instability pattern), and (4) tearing (and tear location)(Table 1). A stepwise arthroscopic exam utilizing two standard anterior viewing portals was established for optimizing diagnosis of LDM features. From a set of 101 arthroscopic videos submitted for review, 41 were selected for quality by 3 of the authors (non-’readers’). Five ‘readers’ then performed assessments using the classification system. Interobserver reliability of the primary and secondary rating factors was assessed using the Fleiss kappa coefficient (K, 95% CI), designed for multiple readers with nominal variables (Reliability Classification: Fair 0.21-0.40 fair, Moderate 0.41-0.60, Substantial 0.61-0.80, and Excellent 0.80-1.00). Results: The majority of the primary and secondary rating factors demonstrated ‘substantial’ reliability, such as meniscal width (complete vs. incomplete, K 0.609; 0.512-0.706) and posterior horn stability (stable vs. unstable, K 0.693; 0.594-0.792), or ‘moderate’ reliability, such as meniscal height (normal vs. abnormal, K 0.444; 0.347-0.541), overall stability, (stable vs. unstable, K 0.569; 0.472-0.666), and tear presence (tear vs. no tear, K 0.541; 0.444-0.638). Several features demonstrated only ‘fair’ agreement, including anterior horn stability (stable vs. unstable, K 0.358; 0.258-0.457), meniscal body stability (stable vs. unstable, K 0.314; 0.214-0.413), and tear type (no tear, radial, vertical, complex, K 0.386; 0.325-0.446). Conclusion/Discussion: A novel classification system that more comprehensively and descriptively characterizes the spectrum of LDM pathology demonstrated moderate or substantial agreement in most diagnostic categories analyzed. Specific features demonstrating fair agreement may warrant investigation of alternative steps in the arthroscopic exam or descriptors to improve agreement. A comprehensive classification system is critical to advance LDM research from single-center, level 4 studies to prospective multicenter efforts that will enhance improve communication, research, and evidence-based treatment of LDM pathology.

Foot and ankle problems in the young athlete differ from those in adults. These differences relate primarily to skeletal maturity, as the presence of open growth plates and secondary ossification centers and the more cartilaginous nature of pediatric bone impact the injury patterns and treatment approaches for children. Coalitions tend to present during childhood, as bones begin to ossify, and may require resection. Pes planus is normal in infancy but may cause problems in adolescence, especially if rigid. Hallux valgus is primarily managed conservatively, and surgery, if needed, is often delayed until skeletal maturity. Accessory naviculars are common in up to 20% of the population but may be excised if persistently painful. Osteochondroses such as Sever’s disease, Iselin’s disease, Kohler’s disease, and Freiberg’s disease can present in adolescent athletes; these typically resolve with conservative management. Osteochondritis dissecans (OCDs) usually occurs in the talus and requires drilling or grafting when advanced. Distal tibial fractures in an open physis pose a risk of leg length discrepancy and must be carefully evaluated; triplane and Tillaux fractures are unique fracture types found in adolescents nearing skeletal maturity. Most adolescent athletes will recover well from foot fractures and ankle sprains without surgery, but some variants require more aggressive intervention.

We present a rare male fetus with karyotype of mosaic 45,X that comprises two types of aberrant Y chromosomes arising de novo (Yq12 deletion and isodicentric Yq11.22). Both types of the aberrant Y chromosomes lack the AZFc region which are expected to result in oligospermia but unaffected male external genitalia. Genetic analyses by karyotyping, chromosome microarray (CMA), and multiplex ligation-dependent probe amplification (MLPA) for the fetus revealed conflicting results. Additional molecular cytogenetics tools including fluorescence in situ hybridization (FISH) and multicolor banding (mBAND) were performed, which help resolving the discrepancy and delineated the composition of the aberrant Y chromosomes. This report highlighted the importance of incorporating multiple genetic technologies for accurate characterization of complex chromosomal rearrangements, which aid in the prenatal diagnosis and genetic counseling. Keywords: AZF, CMA, FISH, idic(Y), Karyotyping, mBAND

Background: Cesarean deliveries represent a large percentage of deliveries worldwide. Patients undergoing repeat cesarean deliveries are known to have increased risks for surgical complications. However, little is known regarding potential differences in pain. We sought to compare postoperative opioid consumption and pain scores in opioid na&iuml, ve patients undergoing primary versus repeat non-emergent cesarean delivery. Methods: This was a retrospective cohort study. Patient inclusion criteria included: having a non-emergent cesarean delivery, receiving a spinal procedure for surgical anesthesia without general anesthesia, and following the same postoperative pain management protocols. Exclusion criteria included: history of opioid tolerance, illicit drug use, or prior, non-obstetric, major abdominal surgery. The primary outcome marker was total morphine equivalents consumed 0&ndash, 72 h post-procedure compared between the primary versus repeat cesarean delivery groups. Secondary outcome markers were opioid consumption and pain scores in 24-h period increments for the first 72 h postoperatively. Results: 1617 patients were screened. 217 primary and 377 repeat cesarean deliveries met criteria for comparison. Reduced opioid consumption was demonstrated for the total opioid consumption 0&ndash, 72 h for the repeat cesarean delivery group (median = 35) compared to the primary cesarean delivery group (median = 58), p = 0.0005. When divided into 24-h periods, differences were demonstrated for the 24&ndash, 48 and 48&ndash, 72 h periods but not the 0&ndash, 24 h period. Pain scores did not differ statistically. Conclusion: Opioid na&iuml, ve obstetric patients who undergo non-emergent repeat cesarean delivery demonstrate lower opioid consumption in the postoperative period. Providers should be aware of this potential difference in order to better educate patients and provide adequate pain management. Highlights: The study reviewed differences in opioid consumption between primary and repeat cesarean deliveries. All patients received the same protocol for spinal dosage and pain management. Repeat cesarean deliveries were associated with lower opioid consumption.

Saliva and Urine samples were collected for the study on how nitrate and nitrite concentration in human body may be related to the corresponding health risk in a high cancer incidence area. The study area includes three known cancer villages in Huai River basin, China. The results of analyzing collected sample show that there are higher levels of nitrate and nitrite concentration in human saliva and urine sample collected in the study area as compared to those collected in other areas. In addition, levels of nitrate and nitrite concentration in saliva and urine sample change significantly with the ages of sampled population. NO3-concentrations in saliva and urine sample are the most outstanding among the middle-aged and elderly populations. It means that the middle-aged and elderly populations have relatively high vivo nitrate reductive transformation rates and they also have higher N-nitroso compounds synthesis risks in the studied cancer villages.

Lateral humeral condyle fractures in children are treated with several approaches, yet it is unclear which has the best treatment outcomes. We hypothesized that functional outcomes would be equivalent between treatment types, reduction approaches, and fixation types. Our purpose was to assess patient-reported outcomes and complications by treatment type (operative versus nonoperative), reduction approach (open versus percutaneous), and fixation type (cannulated screws versus Kirschner wires). We retrospectively reviewed data from acute lateral humeral condyle fractures treated at our level-1 pediatric trauma center from 2008 to 2017. Patients were included if they were 8 years or older and had completed clinical follow-up. Fractures were categorized by fracture severity as mild (5-mm displacement or >2-mm displacement with concomitant elbow dislocation or other elbow fracture). We extracted data on patient age, sex, treatment type, reduction approach, fixation type, patient-reported outcomes (shortened Disabilities of the Arm, Shoulder, and Hand and Patient Reported Outcome Measurement Information System upper extremity), treatment complications, and follow-up duration. Patients in the operative versus nonoperative group and across fracture severity subgroups did not differ significantly by age, sex, or follow-up duration. Bivariate analysis was performed to determine whether outcomes differed by intervention. Alpha = 0.05. No differences were observed in patient-reported outcomes between operative versus nonoperative groups for the mild and severe fracture subgroups. No differences were observed between approach (open versus percutaneous) or instrumentation (cannulated screw versus Kirschner wire fixation) for any outcome measure within the operative group. Patients whose fractures were stabilized with screws versus wires had significantly higher rates of return to the operating room (94% versus 8.3%, P

Background: The association between body mass index (BMI) and severity of osteochondritis dissecans (OCD) of the knee at presentation is poorly understood. Hypothesis: We hypothesized that adolescents in higher BMI percentiles for age and sex would have OCD lesions that were more severe at their initial presentation and located more posteriorly on the condyle as compared with adolescents in lower BMI percentiles. Study Design: Cohort study; Level of evidence, 3. Methods: This study included patients aged 10 to 18 years who were treated for knee OCD at a tertiary care hospital from 2006 to 2017. Patients with noncondylar OCD or missing BMI data within 3 months of presentation were excluded. Patients were stratified per the Centers for Disease Control and Prevention guidelines as underweight, normal weight, overweight, or obese, and the groups were compared according to age, side of lesion, 4 markers of lesion severity (cystic changes, loose fragments, subchondral fluid, and subchondral edema), and surgical treatment. Lesion angle was measured in reference to a line parallel to the femoral axis drawn through the center of a best-fit circle covering the distal condyle. Data were analyzed using chi-square tests, relative risk, Student t tests, analysis of variance, and linear regression of cumulative running percentages. Bonferroni correction was performed when applicable. Results: A total of 77 patients met our inclusion criteria (mean age, 14.2 years; range, 10.1-18.8): 2 were underweight, 50 had normal BMI, 13 were overweight, and 12 were obese. We found correlations between BMI percentile and surgical treatment ( R 2 = .732), subchondral fluid ( R 2 = .716), subchondral edema ( R 2 = .63), loose fragments ( R 2 = .835), and the presence of at least 1 marker of lesion severity ( R 2 = .857) ( P < .0001 for all). No correlation was observed for cystic changes ( R 2 = .026). There were significant associations between BMI ≥80th percentile and subchondral edema (risk ratio, 2.5; 95% CI, 1.3-4.8), medial condylar lesions (risk ratio, 1.3; 95% CI, 1.01-1.7), and lesions more anterior on the condyle ( P < .05). Conclusion: Higher BMI in adolescents was strongly correlated with multiple markers of severity of knee OCD at initial presentation as well as with more anterior lesions.

Introduction: Clostridium perfringens is the etiological agent of clostridial myonecrosis and enteritis necroticans. Infections result in exotoxin production, tissue necrosis and unless promptly treated, often result in death. Methods: Tasmannia lanceolata extracts were investigated for C. perfringens growth inhibitory activity by disc diffusion analysis and MIC determination. Toxicity was evaluated by Artemia nauplii bioassay and the most potent extracts were phytochemically evaluated by GC-MS headspace analysis. Results: All T. lanceolata berry and leaf extracts displayed potent C. perfringens growth inhibition. The berry extracts were more potent growth inhibitors than the corresponding leaf extracts, although the leaf extracts were also potent growth inhibitors. The berry aqueous, methanolic and ethyl acetate extracts were particularly potent growth inhibitors, with MIC values of 654, 65 and 329 µg/mL respectively. T. lanceolata leaf also displayed good efficacy, with an MIC of 839, 1255 and 625 µg/mL for the aqueous, methanolic and ethyl acetate extracts respectively. All extracts were nontoxic in the Artemia franciscana bioassay, with LC50 values substantially > 1000 µg/mL. Non-biased GC-MS analysis of the aqueous, methanolic and ethyl acetate berry extracts revealed the presence of high relative levels of a diversity of terpenoids. Conclusions: The lack of toxicity of the T. lanceolata extracts and their potent growth inhibitory bioactivity against C. perfringens indicates their potential as medicinal agents in the treatment and prevention of clostridial myonecrosis and enteritis necroticans. GC-MS metabolomic profiling studies indicate that these extracts contained a diversity of terpenoids, with monoterpenoids being particularly abundant.

Background Body mass index (BMI) above the normal range has been associated with poorer treatment outcomes in patients with osteochondritis dissecans (OCD) of the knee. Patients with BMIs over 25kg/m2 show an increased risk of postoperative arthritis, and BMI has also been shown to be independently predictive of osteochondral allograft transplantations failure in knee OCD. However, these data have largely focused on post-treatment outcomes relating BMI and OCD. Considering the increase in childhood obesity in the U.S., there is a dearth of research regarding how BMI affects OCD at presentation. This is an especially important question given the effect that various load-bearing forces have on the articular surface. Humeral capitellum lesions in young athletes, for example, have been shown to be more anterior in baseball players than gymnasts, owing to different vectors of force distribution. In this paper, we asked whether any differences in knee OCD lesions, in terms of either severity or location, were associated with changes in patient BMI. We hypothesized that patients with higher BMI percentiles would have femoral condylar OCD lesions that were more severe at initial presentation and were located more posteriorly on the condyle. Methods A retrospective review was performed for patients 10- to 18-years old treated for OCD of the knee at a tertiary-care hospital from 2006-2017. Exclusion criteria consisted of location of OCD other than the femoral condyle and lack of BMI data within three months of presentation. BMI percentile was analyzed as a continuous variable and used to stratify patients into groups per CDC guidelines: underweight, normal, overweight, and obese. Markers of severity included lesion size, cystic changes, subchondral fluid, subchondral edema, and the need for surgical treatment and fixation. Age and laterality were also assessed. Angle of lesion incidence was determined by applying a best fit circle to the distal condyles and measuring the average angle in reference to a line parallel to the femoral axis drawn through the center of the circle. Analysis was performed using t-test and linear regression analysis. Results Of 339 patients initially identified with knee OCD, 263 (78%) patients were excluded: 145 (43%) for age >19 years, 31 (9%) for age 80th percentile vs 22.52±16.99° for Discussion and Conclusions In this sample, increasing BMI percentile was strongly correlated with the severity of lesion at initial presentation and with the need for surgery. Cystic changes were the only markers of lesion noted to decrease as BMI percentile increased. Given that cystic changes are a sign of a chronic OCD lesion, overweight and obese patients may present earlier in the disease course. Contrary to our original hypothesis, increasing BMI percentile is actually associated with femoral condylar lesions that are more anterior, rather than more posterior. This finding may be due to a preference for repetitive loading of the knee in the standing position. To our knowledge, this is the first study to show a relationship between BMI and severity or location of femoral condylar OCD at presentation. These results have important implications for the prevention and early detection of OCD in pediatric patients, and they show a role for future biomechanical and population-based studies of body mass on OCD of the femoral condyles. [Figure: see text]

Background Magnetic resonance imaging (MRI) is often indicated in the diagnosis of pediatric knee trauma, but using traditional MRIs in children can be time-consuming, require anaesthesia, and sometimes cause discomfort. Recently, 3D turbo spin echo (TSE) MRIs with isotropic datasets have been found to reduce acquisition times substantially, but they have been little-studied in pediatric patients. The purpose of our study was to determine the arthroscopy-based diagnostic performance of 10-minute isotropic 3D TSE MRI for the detection of internal derangement in children with acute knee trauma. Methods Institutional review board approval was obtained for prospective data collection, and informed consent and assent were obtained from all parents and children, respectively. The final study group consisted of 60 children (38 boys, 22 girls; 11 (2-16) years-of-age) with acute knee trauma who underwent 10-minute isotropic 3D prototype CAIPIRINHA SPACE MRI at 3 T and subsequent arthroscopic knee surgery. Two fellowship-trained musculoskeletal radiologists retrospectively evaluated the MRI studies independently and resolved discrepancies through consensus. Outcome variables included image quality, motion artifacts, meniscal abnormalities, cruciate ligament tears, and cartilage lesions. Statistical analysis included the diagnostic performance of MRI with arthroscopy as the reference standard and inter-reader agreements using kappa statistics. Results All studies were suitable for diagnostic interpretation with good-to-very-good image quality and little-to-no motion degradation in the majority of cases. The sensitivities/specificities/accuracies of MRI were 0.93/0.93/0.93 for 15/60 (25%) medial meniscal tears, 0.95/0.90/0.92 for 21/60 (35%) lateral meniscal tears, 0.83/1.0/0.92 for 10/60 (17%) discoid menisci, 1.0/0.95/0.98 for 16/60 (27%) anterior cruciate ligament tears, 1.0/0.95/0.98 for 2/60 (3%) posterior cruciate ligament tears, 1.0/1.0/1.0 for 5/60 (8%) osteochondritis dissecans lesions, and 0.71/0.97/0.84 for 48 (13%) defects in 360 cartilage segments. The inter-reader agreements were overall good-to-very-good (kappa, 0.730 -1.00). Conclusion 10-minute isotropic 3D TSE MRI of the knee is feasible in children with acute knee trauma and yields high diagnostic accuracies for the diagnosis of internal knee derangement. Accuracies for the detection of meniscal tears, discoid menisci, anterior and posterior cruciate ligament tears, osteochondritis dissecans lesions, and cartilage defects ranged from 84-100%. Using previously published protocols for pediatric 2D MRI knee exams with total acquisition times of 25 minutes as a benchmark for traditional MRI, a 10-minute protocol could increase the efficiency by a factor of two or more, and thus substantially improve the availability of MRI and timely care for children with acute knee trauma. [Table: see text]

Background: Tibial spine fractures most commonly occur in children aged 8 to 14 years and are occasionally seen in adults. Although the annual incidence is 3 per 100,000 children, they account for 2-5% of pediatric knee injuries with effusions and are associated with substantial complications including ACL deficiency and arthrofibrosis. The rise in competitive youth sports has brought increased public attention to this injury. Meyers and McKeever Type II fractures are displaced anteriorly with an intact posterior hinge. This specific subtype of pediatric tibial spine fractures has controversy in the literature whether they should be treated non-operatively or operatively. The purpose of this study was to identify assess for variability amongst pediatric orthopaedic surgeons when treating pediatric type II tibial spine fractures. Methods: A discrete choice experiment was conducted to determine the patient and injury attributes that influence the management of type II pediatric tibial spine fractures by pediatric orthopaedic surgeons. A convenience sample of 14 pediatric orthopaedic surgeons reviewed 40 case vignettes (Figure 1) that included radiographs displaying fractures with varying degrees of displacement (range: 2.5 – 6.0 mm) and a brief description on the patient’s sex, age (8-17), mechanism of injury (fall, collision, hypertension, twist), and predominant sport (swimming, football, basketball, nonathlete). Surgeons were asked whether they would treat the fracture operatively or non-operatively. Physes were blinded. A mixed effects model was used to determine the patient attributes most likely to influence the surgeon’s decision for operative treatment of a tibial spine fracture. In addition, the association between surgeon propensity for operative treatment based on surgeon training, years in practice, and risk-taking behavior based on the Jackson Personality Inventory subscale was assessed. A receiver operating characteristic curve was used to determine probability of surgical treatment based on the degree of fracture displacement. Results: Surgeon demographics are summarized in Table 1. Overall, the 14 respondents selected operative treatment in 75% of the presented cases. The degree of fracture displacement was the only patient attribute that was significantly associated with treatment choice (pConclusions / Significance: There is substantial variation among pediatric orthopaedic surgeons when treating type II tibial spine fractures. The decision to operate is significantly based on the degree of fracture displacement. However, there is no standardization regarding how to treat type II tibial spine fractures and therefore better treatment algorithms are needed to optimize patient outcomes. Learning about the current treatment preferences among surgeons given different patient factors can highlight current variation in practice patterns and direct efforts toward promoting the most optimal treatment strategies. [Table: see text]

Introduction: Natesto®, testosterone nasal gel (TNG), is a testosterone therapy (TTh) indicated for adult male hypogonadism.1 This study allowed titration decisions to be based on physicians’ assessment of patient symptoms. Methods: Hypogonadal males on active topical testosterone therapy (TThE) or naive to any form of testosterone therapy (TThN) were treated with 22 mg TNG daily (11 mg twice daily) for 90 days. Titration was determined by the physician at Day 90 wherein the dose was increased to 33 mg daily if symptoms were not properly managed. Total testosterone (TT) levels were collected at Day 90 and 120 and the quantitative Androgen Deficiency in the Aging Male (qADAM) symptom questionnaire was administered on Days 0, 30, 60, 90, and 120. Results: At study endpoint, 77.0% of all patients were in the normal TT range. Mean qADAM scores increased from 30.8 at baseline to 35.5 (6.6) at Day 90. Physician assessments resulted in 37% patients being up-titrated for an additional 30 days, however, qADAM scores did not change significantly at the higher dose. Conclusions: The majority of patients achieved the normal range of testosterone with TNG when physicians based their titration decision on an assessment of symptoms. Sexual function and energy-related symptoms were predictive of improvements resulting from treatment. These symptoms were the most relevant indicators for physicians in making decisions relating to titration.