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Cardiorenal syndrome (CRS) is a complex interdependent relationship between the heart and kidneys, prevalent in hospitalized patients with acute decompensated heart failure (ADHF). The main aim of this study is to evaluation of cardiac and renal function, treatment factors, and outcomes in view of mortality and persistent renal dysfunction in acute decompensated heart failure (cardio renal syndrome type 1) patients. We studied 100 patients hospitalised with ADHF and acute kidney injury (AKI). Patients were evaluated clinically, biochemically, ultrasonographically, and echocardiographically to assess demographics, etiologic and risk factors, cardiac and renal function, and outcomes in view of mortality and persistent renal dysfunction. The study monitored the patients until discharge and follow up with three months to one year. Record information about functional improvement, worsening symptoms, and mortality. The majority of the patients were males (72%), with dyspnea being the most common symptom (92%) followed by decreased urinary output (82%). The mean age of the patients was 62.60 years. Low level of Mean arterial pressure (MAP) 18.97 (95% CI 4.59 to 78.37, P 0.0001), estimated glomerular filtration rate (eGFR) 0.92(95% CI 0.87 to 0.99; P 0.02), maximum creatinine 3.08 (95% CI 1.67 to 5.67, P 0.0001), maximum level of urea 1.02(95% CI, P 0.001), lower Left ventricular ejection fraction (LVEF) 1.05 (95% CI 0.15 to 0.84, P 0.04) were independently predictors of in-hospital mortality. CRS-1 is associated with increased risk of mortality (25%), residual renal dysfunction (16%) at one year follow up. Persistent renal dysfunction, renal replacement therapy possibly improves for the treating persistent renal dysfunction, and recurrent HHF (more than 2 admissions) post hospitalisation index within twelve months were predictors of mortality (25%) at one-year.

Background Context: Both Transforaminal (TF) and Interlaminar (IL) endoscopic approaches are established techniques of decompression for lumbar compressive radiculopathy. In the absence of adequate literature, there is always some dilemma in selecting the approach for endoscopic decompression leading to long learning curves and high chances of inadequate decompression, iatrogenic instability, dural tear, or dysesthesia. Hence authors propose a new surgical nomenclature and algorithm for selection of endoscopic approach. Methods: This retrospective study included 396 of 626 consecutive patients who met the inclusion criteria, who underwent either TF (n=302) or IL (n=202) full endoscopic spine surgery. MRI findings of every patient were classified as per FAPDIS (Facet angle, Anterior pathology, Posterior pathology, Dorsal, Inferior, and Superior migration) algorithm. Inter-observer variations were calculated. The targeted nomenclature was used to define the selection of endoscopic TF or IL approach for symptomatic nerve root decompression. All patients were followed up for preop and postop 6 months VAS and Oswestry Disability Index score for validation of FAPDIS algorithm. Results: Median age: 46.8 years; Sides and levels operated 330 single-level ipsilateral, 54 multiple-level ipsilateral, 6 single-level bilateral, and 6 multiple-level bilateral. Interobserver agreement in the selection of TF approach was 0.873 and IL approach was 0.882. Interobserver variability was also calculated for each FAPDIS factor, selection of P3 and P4 pathology was the main reason for disagreement. All other FAPDIS factors show good to excellent correlation. The overall VAS score decreased from a preoperative value of 9 to 1 at 6 months follow-up (p-value < 0.001), and the overall Oswestry Disability Index score improved from 89 to 12 (p-value

Category: Trauma; Hindfoot Introduction/Purpose: Malunion is a disabling complication of talar neck fractures and is prevalent in approximately 17% of cases. The impact of talar neck malunions (TNM) on foot biomechanics and functional outcomes is not well established. The available evidence is primarily derived from cadaveric studies which have demonstrated that TNMs result in reduced motion and significant alterations in contact characteristics of the subtalar joint. Owing to the paucity of literature on this subject, we conducted this study to evaluate the kinematic and pedobarographic changes and functional outcomes associated with TNMs. Methods: In this study, adult patients with talar neck malunions (TNM) without ankle arthrosis were prospectively enrolled over a 5-year period. The Rammelt and Zwipp classification was utilized to categorize the deformities. Demographic data and ankle and subtalar range of motion were assessed. Weight-bearing anteroposterior (AP), lateral, and long axial radiographs, as well as CT scans of both feet, were obtained. Dynamic pedobarography was performed to evaluate gait kinematics and plantar pressure distribution. Functional outcomes were evaluated using the Manchester Oxford Foot Questionnaire (MOxFQ), Visual Analog Score, and the EQ5D questionnaire. The t-test was utilized to compare the range of motion, pedobarographic and kinematic parameters between the normal and pathologic foot. Furthermore, correlation coefficients were calculated to determine the strength of the association between changes in talar neck geometry, plantar pressures, kinematics, and functional outcomes. Results: A total of 10 patients, 6 males, and 4 females, with a mean age of 32.4 years were enrolled. On the TNM side, significant increases were observed in step length and step time, while significant decreases were noted in the single limb support time and single limb support center of pressure line. Moreover, midfoot forces were significantly increased, whereas the forefoot and hindfoot forces were significantly decreased on the TNM side. A strong positive correlation was found between midfoot force and the talar torsion angle, and a moderate negative correlation was observed between hindfoot and midfoot forces and the inclination angle. A strong positive correlation was also noted between high midfoot pressures and VAS Scores, MOxFQ scores, and the EQ5D walking and usual activities domains. Conclusion: This study demonstrates that TNMs are associated with decreased single limb support time, increased step length and time, increased midfoot pressures, and decreased forefoot and hindfoot pressures. Additionally, an increase in talar neck torsion after TNM is linked with higher midfoot pressures, which can lead to higher levels of pain and poorer function. Our findings provide valuable insights into the altered foot biomechanics after TNMs, which can assist surgeons in offering optimal management strategies for these patients.

Category: Ankle; Trauma Introduction/Purpose: Syndesmosis injury can be of a varying magnitude; little information exists about the influence of degree of initial syndesmotic injury/instability on functional outcomes in ankle fractures, nor is there any correlation of this with follow up radiological parameters. Aims and Objectives: To identify and define morphological patterns of syndesmotic injury in ankle fractures according to a zone based evaluation, and correlate initial degree of instability with mid-term functional and radiological outcomes using validated scores Design: Retrospective cohort study, to review a prospective question. Methods: 40 complex ankle fractures out of 120 ankle fractures in our ankle registry met the inclusion criteria ie significant documented syndesmosis involvement needing stabilization, with all initial clinical and radiological records available. The patients were followed up between January 2020 to July 2021. Injury characteristics, fracture morphology of posterior malleolus, medial malleolus and fibula were noted and classified by validated classification systems based on x-rays and CT scan. The syndesmosis was analyzed on axial CT scan; it was divided into 3 zones, A,B,C from anterior to posterior, and degree of displacement and morphology was noted. Immediate post-operative radiographs were evaluated for fracture and syndesmosis reduction. The patients were evaluated at final follow up with both ankle specific scores (Olerud Molander score, Ankle-Hindfoot scale, Manchester-Oxford Foot questionnaire) and quality of life score (SF-12). Ankle Osteoarthritis grade was used to evaluate radiological outcomes. Results: Mean follow-up was 19 months. 22(55%) patients had syndesmotic widening on plain radiographs; however in pre- operative CT scan evaluation 40(100%) patients had syndesmotic injury based on the Zone evaluation of the syndesmosis. 22 patients had Zone A injury (widening, AITFL, Chaput, Wagstaff). 22 patients had widening of Zone B. Zone C was involved in 30 patients (PM fracture,PITFL involvement). At final follow up; the mean OMAS was 83.38±16.35, mean Ankle-Hindfoot scale= 88±9.98, mean Mox-FQ score=27.15±13.35 & mean SF-12 were (MCS=56.59±8.24, PCS=51.18±8.48). There was no significant difference in outcome scores based on fracture types, Posterior malleolus morphology, or based on zones of syndesmosis injury. Syndesmosis malreduction contributed to significantly poorer outcomes (SF-12, OMAS, MoxFQ) Conclusion: Despite a zonal classification of syndesmotic injury on CT and more clarity of injury patterns, we could not corelate the site and extent of syndesmotic injury with final functional and radiological outcomes. The one factor that has significant influence is initial accurate reduction of both the malleolar fractures and syndesmosis injury. In this the CT based axial classification may play a role.

Category: Ankle; Trauma Introduction/Purpose: Approximately 10-15% of posterior malleolar fractures (PMFs) are "small shell," extra-articular fragments. Current classification systems present difficulties to perform a uniform typification of PMFs and contain no consensus on whether they should be fixed. Anatomical studies have identified two distinct components of the posterior inferior tibiofibular ligament (PITFL); the superficial band is thought to be more important than its deep counterpart in imparting syndesmotic stability. However, the involvement of one or both bands of the PITFL by small shell PMFs has not been evaluated so far. Hence, we conducted this study to perform 3D mapping of small shell PMFs and to determine whether surgeons should fix these routinely. Methods: Ankle fracture patients with a ‘small shell’ PMF (Haraguchi 3/Mason 1/Bartoníček 1 or 2) were included. Demographics, radiological features, treatment, and outcomes were recorded. 3D models of the fractured tibiae were generated from CT scans and superimposed on a statistical shape model of the right tibia, which served as a template. Fracture lines along with footprints of superficial and deep PITFL were marked on the template. 3D fracture heat maps were generated. Size of the fracture fragments and involvement of the superficial and deep PITFL footprints were quantified using a custom MATLAB script (Figure 1). Sparing of the footprint was defined as an overlap of < 1% between the fracture line and the footprint areas. Odds ratios (OR) with 95% confidence intervals (CI) were determined to determine which variables correlated with sparing of the PITFL footprint; P-values of < 0.05 were considered significant. Results: Thirty-nine patients were included. The superficial PITFL footprint was spared in 15 (38%), deep PITFL in 10 (26%), and both in 4 cases (10%). Males and Weber C fractures had a higher likelihood of sparing the superficial and deep PITFL footprints, respectively (P = 0.04). Supination external rotation (SER) patterns were less likely to demonstrate syndesmotic widening if either PITFL footprint was spared. Direct fixation of the PMF was done in 1 case; syndesmotic fixation in 25 cases and in 14 cases, no syndesmotic fixation was done. Of these, 11 were SER injuries where stability was achieved after fixation of medial and lateral malleoli. In 1 SER and pronation external rotation (PER) injury case, the syndesmosis was stable after fixation of a large Chaput fragment. Conclusion: This study demonstrated that 48% of small shell PMFs spare either the superficial or deep footprint of the PITFL; in 10% both PITFL footprints were spared. Hence, 58 % of small-shell PMFs may not benefit from direct fixation. Additionally, SER injuries with small shell PMFs that spare either PITFL footprint may not demonstrate radiographic instability and may not need direct or indirect fixation after addressing other components of the ankle fracture. However, given the fact that syndesmotic stability is not dictated by the PITFL alone, it remains prudent to stress the syndesmosis per-operatively to determine if syndesmotic fixation is needed.

Background:. Skin lightening (SL) is a practice involving the use of chemicals to lighten the skin that is more common among skin of color (SOC) individuals, particularly women, and can lead to adverse health consequences. Objective:. In this study, we examine SL habits, including both general lightening and lightening for the treatment of a skin condition, among SOC individuals in the United States and the role of colorism in motivating these behaviors. Methods:. A cross-sectional survey was administered to SOC individuals through ResearchMatch, an online national health registry. Demographics, rates of SL, SL habits, and perceived colorism among SL users and nonusers were collected and analyzed with χ2, Fisher’s exact, Analysis of variance (ANOVA), Spearman correlation, and t tests. Results:. A total of 455 participants completed the survey. Ninety-seven participants (21.3%) reported using SL agents: 73.2% (71/97) used SL agents for the treatment of a skin condition and 26.8% (26/97) used the products for general SL. Only 22.6% (22/97) of SL users consulted a medical provider before using the products. Forty-four participants (45.4%) were unaware of their SL product ingredients, and 35.1% (34/97) reported using hydroquinone-based products. Composite colorism scores were significantly higher in SL users than nonusers (20.03 vs 18.20; P < .001). Limitations:. This study used self-reported racial/ethnic groups to characterize those with SOC rather than assessing actual skin tones of participants, which could have led to variability. Conclusion:. SL among SOC individuals is prevalent in the U.S. and poses a health risk, as many SL users are unaware of product ingredients, do not consult a medical provider before use, and have access to potentially unsafe formulations. Dermatologists should address skin tone and pigmentary concerns with their SOC patients.

Objectives: The Prospective Randomized On-X Mechanical Prosthesis Versus St Jude Medical Mechanical Prosthesis Evaluation (PROSE) trial purpose was to investigate whether a current-generation mechanical prosthesis (On-X; On-X Life Technologies/Artivion Inc) reduced the incidence of thromboembolic-related complications compared with a previous-generation mechanical prosthesis (St Jude Medical Mechanical Prosthesis; Abbott/St Jude Medical). This second report documents the valve-related complications by individual prostheses and by Western and Developing populations. Methods: The PROSE trial study was conducted in 28 worldwide centers and incorporated 855 subjects randomized between 2003 and 2016. The study enrollment was discontinued on August 31, 2016. The study protocol, and analyses of 10 demographic variables and 24 risk factors were published in detail in 2021. Results: The total patient population (N = 855) included patients receiving an On-X valve (n = 462) and a St Jude Medical valve (n = 393). The overall freedom evaluation showed no differences at 5 years between the prostheses for thromboembolism or for valve thrombosis. There were also no differences in mortality. There were several differences between Developing and Western populations. The freedom relations at 5 years for mortality favored Western over Developing populations. Valve thrombosis was differentiated by position and site: aortic

The role of the posterior cruciate ligament (PCL) in total knee arthroplasty (TKA) surgery continues to be a source of debate among the adult reconstruction community. In native knee flexion, the PCL is comprised of an anterolateral and posteromedial bundle that work together to limit posterior tibial translation and allow adequate femoral rollback for deep flexion. In the arthritic knee, the PCL can often become dysfunctional and attenuated, which led to the development of posterior stabilized (PS) TKA bearing options. PS TKAs implement a cam-post construct to functionally replace a resected PCL. While PS designs may facilitate balancing knees with significant deformity, they are associated with complications such as postfracture, increased wear, and patellar clunk/crepitus. In recent years, newer designs have been popularized with greater degrees of congruency and incorporation of medial and lateral pivoting to better recreate native knee kinematics. The American Joint Registry has confirmed the recent predilection for ultra-congruent and cruciate-retaining TKA inserts over PS TKAs during the last decade. Studies have failed to identify an overall clinical superiority between the cruciate substituting and sacrificing designs. The literature has also failed to identify clinical consequences from PCL resection with modern, more conforming TKA designs. In this article, we review modern PCL sacrificing designs and discuss the impact of each on the kinematics after TKA. We also will delineate the role of the PCL in modern TKA in the hopes to better understand the recent surge in sacrificing but not substituting knee implants.

Adverse local tissue reaction is an uncommon but frequently described complication after total hip arthroplasty (THA). It is most often associated with metal-on-metal hips and less frequently with metal-on-polyethylene implants as part of a mechanically assisted crevice corrosion process. In this report, we describe a rare case of an atypical adverse local tissue reaction in a patient with a ceramic-on-ceramic THA. Abrasive backside liner wear from a prominent screw head, failure of the liner locking mechanism, and liner fragmentation secondary to component-component impingement created an atypical mass and fluid collection leading to THA failure. This case demonstrates the importance of appropriate cup-liner positioning, thorough workup of pain after THA, and the ability of ceramic debris to cause an associated, atypical adverse local tissue reaction.

Summary:. Traumatic dog bites of the face and head are common among the pediatric population, although injuries resulting in total or subtotal scalp avulsions are rare and life-threatening. Standard treatment in these cases includes attempts at replantation or free tissue transfer; however, these procedures may not always be possible. An alternative treatment option involves the use of dermal substitutes, such as Integra (Integra LifeScience Corporation), with subsequent skin grafting. More recently, an alternative skin substitute called NovoSorb Biodegradable Temporizing Matrix (BTM) (PolyNovo North America LLC) has displayed favorable reconstructive outcomes in recent burn literature. NovoSorb BTM is a novel, fully synthetic bilayer scaffold made of biodegradable polyurethane matrix covered with a sealing membrane. In this report, the authors describe a 3-year-old boy who presented emergently with a severe dog bite avulsion to the subpericranial level of approximately 80% of his scalp, which was not replantable. The surgical plan involved a staged reconstruction using Integra and later skin grafting. Purulent infection ensued and required removal of Integra less than 2 weeks from application. Upon clearing of the infection, the wound was successfully closed with BTM and subsequent skin grafting. With proper wound management and over 6 months of follow-up, the patient experienced excellent healing of the graft with stable calvarial coverage and an acceptable aesthetic outcome. He will undergo tissue expansion of the remaining hair-bearing scalp in the future.

Approximately 17 years after a primary metal-on-metal total hip arthroplasty, a 59-year-old female developed pain, swelling, and weakness in her right hip accompanied by laboratory findings and imaging suggestive of an adverse local tissue reaction. Acetabular revision was performed to upsize the femoral head and improve hip stability. Upon impaction of the new, non-option ceramic femoral head onto the unsleeved retained stem, the head split into two pieces without fragmentation. The surgery was completed using a cobalt-chromium head, which was impacted without issue onto the stem’s taper. Although BIOLOX delta femoral heads do not require titanium sleeves, we believe that careful consideration should be given to their use in revision total hip arthroplasty with ceramic heads, regardless of the extent of trunnion damage noted intraoperatively.

Background: Heart failure with preserved ejection fraction represents a major unmet clinical need with limited treatment options. Recent device therapies under investigation have focused on decompression of the left atrium through an implantable interatrial shunt. Although these devices have shown favorable safety and efficacy signals, an implant is required to maintain shunt patency, which may increase the patient risk profile and complicate subsequent interventions requiring transseptal access. Methods: The Alleviant System is a no-implant approach to creating an interatrial shunt using radiofrequency energy to securely capture, excise, and extract a precise disk of tissue from the interatrial septum. Acute preclinical studies in healthy swine (n = 5) demonstrated the feasibility of the Alleviant System to repeatably create a 7 mm interatrial orifice with minimal collateral thermal effect and minimal platelet and fibrin deposition observed histologically. Results: Chronic animal studies (n = 9) were carried out to 30- and 60-day time points and exhibited sustained shunt patency with histology demonstrating completely healed margins, endothelialization, and no trauma to adjacent atrial tissue. Preliminary clinical safety and feasibility were validated in a first-in-human study in patients with heart failure with preserved ejection fraction (n = 15). All patients demonstrated shunt patency by transesophageal echocardiographic imaging at 1, 3, and 6 months, as well as cardiac computed tomography imaging at 6-month follow-up timepoints. Conclusions: Combined, these data support the safety and feasibility of a novel no-implant approach to creating an interatrial shunt using the Alleviant System. Continued follow-up and subsequent clinical studies are currently ongoing.

Clonidine is used as an antihypertensive medication due to its effect on decreasing peripheral vascular resistance and therefore lowering blood pressure. Alpha antagonism in the medulla and the posterior hypothalamus causing a reduction in sympathetic activation allows for clonidine to be used as an effective off-label treatment for attention-deficit/hyperactivity disorder (ADHD). This is a case of a 28-year-old female with hypertension, ADHD, and depression who developed acute heart failure with significant troponemia after ingesting 30 pills of clonidine. We illustrate the possible rare diagnosis of systolic heart failure and coronary vasospasm secondary to clonidine overdose.

Erythrodermic psoriasis is a rare subtype of psoriasis vulgaris that presents with diffuse erythema and desquamation over greater than 75% of the body’s surface area. We present a case of a 57-year-old male who was admitted with a diffuse, erythematous scaly rash covering his entire body, with associated subjective fevers. Skin biopsy revealed erythrodermic psoriasis, and blood cultures were positive for methicillin-sensitive Staphylococcus aureus . Echocardiogram revealed a mitral valve vegetation. Clinical improvement was achieved with intravenous antibiotic administration and topical corticosteroids without the use of immunomodulators.

الملخص: أهداف البحث: على الرغم من توافر مجموعة واسعة من المضادات الحيوية، لا يتم الشفاء من العدوى العضلية الهيكلية بنجاح. إن إزالة الأوشظة، والأنسجة النخرية المصابة والغرسات ضرورية. وقد أجريت هذه الدراسة لتقييم فعالية خرز البولي ميثيل ميثكريلات، ولتحديد المتغيرات التي تؤثر على علاج وتكرار الالتهابات العضلية الهيكلية. طرق البحث: ضمت هذه الدراسة ٨٢ مريضا يعانون من التهاب العظم والنقي المزمن، الذين عولجوا على مدى ست سنوات في مستشفى الرعاية الثالثة. تابعنا ٧١ مريضا لمدة عام. وتم تقييم البيانات السريرية الدوائية لمكافحة العدوى وشفاء العظام في زيارة المتابعة الأخيرة. تم تقييم العلاقة بين حساسية المضادات الحيوية والمقاومة وتكرار العدوى لتركيبات جينتامايسين+ سيفروكسيم، وجينتامايسين+ فانكومايسين. النتائج: كان لدى ٥٣ (٦٥.٤٪) من المرضى طريق خارجي للعدوى، بينما قَدِم ٥٦(٦٨.٥١٪) من المرضى مع إفرازات جيبية وقت المراجعة. تم التحقق عند ٤٢ (٥٩٪) من المرضى من التشخيص مع مزرعة بكتيريا إيجابية. بالإضافة إلى ذلك، استخدمنا خرزات المضادات الحيوية من الجينتامايسين +السيفوروكسيم في ٧٤ (٩٠٪) من المرضى، في حين أن في ٨ (١٠٪) من المرضى استخدمنا الجنتامايسين + الفانكومايسين على أساس المزرعة ونتائج الحساسية. وتم العثور على عودة العدوى عند خمس حالات من الجنتامايسين +السيفوروكسيم واثنين من حالات الجنتامايسين + الفانكومايسين. الاستنتاجات: المضادات الحيوية التي تحتوي على خرز البولي ميثيل ميثكريلات فاعلة في علاج التهاب العظم والنقي المزمن وفي منع تكرار العدوى. ومن الضروري تحديد العوامل المختلفة المسؤولة عن تكرار الإصابة. وهذا قد يساعد الأطباء في التنبؤ بتكهن المرض وتقليل خطر النتائج السلبية. Abstract: Objective: Despite the availability of an extensive array of antibiotics, musculoskeletal infections are not cured successfully. It is necessary to remove sequestra, infected necrotic tissue, and implants. This study was undertaken to assess the efficacy of poly methyl methacrylate (PMMA) beads and identify the variables that influence eradication and recurrence in the treatment of musculoskeletal infections. Methods: This study was conducted on 82 patients with chronic osteomyelitis who were treated over a period of 6 years at our tertiary care hospital. We followed up with 71 patients for one year. Clinicoradiological data for the control of infection and bone healing were assessed at the final follow up visit. The correlation between antibiotic sensitivity/resistance and infection was evaluated for Gentamicin + Cefuroxime and Gentamicin + Vancomycin combinations. Chi-squared testing, using SPSS version 16.0, was used for statistical analysis, and a p-value < 0.05 was considered significant. Results: Fifty-three patients (65.4%) had an exogenous route of infection. Fifty-six patients (68.51%) presented with a discharging sinus on first presentation. In 42 patients (59%), the diagnosis was verified with a positive bacterial culture. In addition, we used antibiotic beads of Gentamicin + Cefuroxime in 74 patients (90%), while in 8 patients (10%), we used Gentamicin + Vancomycin, based on culture and sensitivity results. Recurrence was found in five cases of Gentamicin + Cefuroxime and two cases of Gentamicin + Vancomycin (p = 0.065). Conclusion: Antibiotics containing PMMA beads are effective in the treatment of chronic osteomyelitis and in preventing the recurrence of infection. It is imperative to identify various factors responsible for the recurrence of infection. This may help clinicians predict the prognosis of the disease and minimise the risk of adverse outcomes.

Summary:. When the external nasal valve (ENV) is excessively narrow or lacks support, nasal obstruction can develop causing decreased airflow. Although cartilage grafts may support a collapsed nasal ala, addressing severe nasal stenosis requires further intervention. Techniques to move flared ala inward are well-known; however, repositioning a medially displaced alar base is less commonly described. Our surgical team developed an inferiorly based alar groove flap to achieve lateral movement of a malpositioned alar base, with goals of widening the ENV and improving nasal symmetry and cosmesis. A retrospective chart review was performed on a series of five patients over a two-year period. Charts were reviewed for demographic data, medical and surgical history, functional airway complaints, and subjective aesthetic concerns. All patients presented with unilateral ENV collapse, alar base malposition, and nostril asymmetry. Our operative method consisted of repositioning the affected alar base laterally and inferiorly to alleviate nostril stenosis and using an alar rim graft to support the ENV. Postoperatively, all patients demonstrated immediate alleviation of subjective nasal obstruction and improvement in size of ENV aperture, nostril symmetry, and overall cosmesis. Four patients showed lasting postoperative results. One patient experienced restenosis by 4 months and required revision. Our inferiorly based alar groove flap provides a reproducible solution for repositioning a medially displaced alar base. This technique reliably corrects ENV stenosis, relieves airway obstruction, and improves nasal symmetry and cosmesis.

Category: Ankle; Ankle Arthritis; Trauma Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis is a routinely utilized salvage procedure that treats patients with severe talar and subtalar joint disease. Unfortunately, nonunion is a relatively common complication postoperatively which can increase risks and costs for patients. The goal of this study is to review the literature to identify risk factors for nonunion post TTC arthrodesis and stratify them based on strength of evidence. A meta-analysis will be performed on risk factors when appropriate to establish values based on pre-existing studies. Methods: Five databases (CINAHL, Cochrane Library, EMBASE, MEDLINE, and Web of Science) were searched from inception to May 17th, 2020. Two independent reviewers screened abstracts and full-text articles for those that included risk factors predictive of nonunion for TTC arthrodesis. Any disagreements were discussed between the two reviewers and a third reviewer served as the ultimate decision maker if a consensus could not be reached. Relevant data regarding participants’ characteristics, study design, follow-up time, statistical tests and identified risk factors were extracted from the included studies. The two reviewers independently appraised the methodological quality of the studies using the Quality In Prognosis Studies tool. Those risk factors described in multiple studies were included in the meta-analysis. Random effects meta-analyses were summarized as forest plots of individual study and pooled random effect results. Results were reported as odds ratios (OR) with 95% confidence intervals (CI). Results: Database search identified 428 articles, of which 113 were screened for full text. Eight studies involving 607 patients were included and 33 potential risk factors for nonunion were identified. Risk factors were stratified into demographic, preoperative, intraoperative and postoperative. Results of the meta-analysis established two significant risk factors for nonunion following TTC arthrodesis. Strong evidence supports that prior neurological deficits, such as Charcot neuroarthropathy and diabetes neuropathy, are associated with nonunion following surgery (OR: 2.86, 95% CI: 1.56 - 5.23). There was moderate evidence to suggest that preoperative infection was predictive for nonunion (OR: 3.99, 95% CI: 1.26 - 12.68). Although our meta- analysis did not find smoking (OR: 1.75, 95% CI: 0.90 - 3.38) or diabetes (OR: 2.28, 95% CI: 0.98 - 5.34) to be significant risk factors, multiple high quality studies support these as comorbidities that increase the likelihood of nonunion. Conclusion: TTC arthrodesis can be an effective salvage procedure but is associated with high nonunion rates. The results of our meta-analysis suggest that prior neurological deficits, such as Charcot neuroarthropathy or diabetes neuropathy, have strong evidence for failure to achieve union. Although our meta-analysis did not find other statistically significant risk factors, the findings of individual studies in our review suggest that diabetes mellitus and smoking are both factors which can lead to failure of fusion. Surgeons should be cognizant of these risks when performing TTC arthrodesis and carefully monitor patients with the aforementioned comorbidities to achieve successful results.

Objectives:. Practices regarding anticoagulation use in coronavirus disease 2019 focus primarily on its efficacy in the critically ill without a clear understanding of when to begin anticoagulation. We sought to understand the association of preinfection daily oral anticoagulation use and the short-term mortality of patients hospitalized with coronavirus disease 2019. Design:. Retrospective chart review. Setting:. Large health system with high coronavirus disease 2019 prevalence. Patients:. Patients 60 years or older admitted to the hospital with positive coronavirus disease 2019 polymerase chain reaction test. Interventions:. We compared both those on warfarin and those on a direct oral anticoagulant prior to admission and throughout disease course with those who were never exposed to an oral anticoagulant. Results:. Our primary outcome was inhospital mortality at 21 days from the first coronavirus disease 2019 test ordered. Patients in the direct oral anticoagulant group (n = 104) were found to have significantly lower 21-day all-cause in hospital mortality than patients in the control group (n = 894) both prior to adjustment (14.4% vs 23.8%; odds ratio, 0.57 [0.29–0.92]; p = 0.03) and after controlling for age, gender, and comorbidities (odds ratio, 0.44 [0.20–0.90]; p = 0.033). Patients on warfarin (n = 28) were found to have an elevated unadjusted mortality rate of 32% versus 23.8% in the control group (odds ratio, 1.51 [0.64–3.31]; p = 0.31). After adjustment, a reduction in mortality was observed but not found to be statistically significant (odds ratio, 0.29 [0.02–1.62]; p = 0.24). There was no statistical difference noted in the number of bleeding events in each group. Conclusions:. In this retrospective cohort study evaluating oral anticoagulant use among patients with coronavirus disease 2019, we found that patients who are on daily oral anticoagulation at the time of infection and throughout their disease course had significantly lower risk of all-cause mortality at 21 days. Validation of these findings should be performed on population-based levels. While research regarding anticoagulation algorithms is ongoing, we believe these results support future randomized control trials to understand the efficacy and risk of the use of early oral anticoagulation.

Background:. The safety of concurrently performing mastopexy and breast augmentation is controversial, due to the risk of breast tissue and nipple neurovascular compromise and overall potential high complications rates. This article describes a concurrent procedure of augmentation with implants and a “Tailor-Tack” mastopexy that consistently achieves an aesthetically pleasing breast with acceptable complication rates. Methods:. This is a retrospective chart review of all consecutive breast augmentations performed concurrently with mastopexy using the “Tailor-Tack” technique by the 2 senior authors (M.M. and O.T.) over an 8-year period. Independent variables were patient demographics, surgical approach, implant type, shape, size, duration of follow-up, and complications. Complications were categorized as “early” (ie, first 30 days) or “late” (ie, after 30 days). Potential early complications include hematoma, skin necrosis, infection, and nipple loss. Potential late complications include recurrent breast ptosis, poor shape of the nipple areolar complex, hypertrophic scarring, implant rupture, capsular contracture, decreased nipple sensation, implant extrusion, reoperation, and scar revisions. The key principle of the technique is to place the breast implant in the dual plane first, and then perform the tailor tacking of the skin for the mastopexy second. Results:. Fifty-six consecutive patients underwent augmentation and mastopexy over 8 years with this technique. The average age of the studied patients was 41.2 years. The average follow-up time period was 2.1 years (±8.9 months). Fifty-four patients (96.4%) had implants placed through the periareolar approach, 2 patients (3.6%) had implants placed via the inframammary approach. All implants were placed in a dual plane. Fifty-two patients (92.9%) received silicone implants and 4 patients (7.1%) received saline implants. Patient preference determined implant choice. All but 5 patients had textured implants. Average implant size was 277 cm3 (range 120–800 cm3). Ten patients had complications (17.9%). Complications included hypertrophic scarring in 5 (8.9%) patients; poor nipple-areola complex shape in 4 patients (7.1%); implant ruptures in 3 patients (5.4%); capsular contracture in 3 patients (5.4%); and recurrent ptosis in 2 patients (3.6%). There were no reported early complications such as nipple loss, breast skin necrosis, decreased nipple sensation, implant infections, or extrusions. However, 6 patients (10.7%) required return trips to the operating room for revisions, and 1 patient (1.8%) had a nipple areolar complex scar revised in the office, yielding a 12.5% surgical revision rate for the late complications. Conclusions:. It is safe to concurrently perform mastopexy and breast augmentation. In our 8-year review, there were no early catastrophic complications such as skin loss, nipple loss, implant extrusion, or infection. The complications that occurred were the same complications known to occur with the independent performance of mastopexy alone or breast augmentation alone, and they occurred at rates comparable to or less than the national averages for those procedures when they are performed independently. The paramount principle for the success of this technique is to first adjust breast volume and then perform an intraoperatively determined skin resection to fit the new breast volume.

Background: Chronic conditions are expensive to treat because of the ongoing prescription cost burden. Generic drug discount programs (GDDPs) that offer generics at discounted price may prove beneficial to reduce pharmacy costs for the same.Objective: The objective of this study was to assess the extent to which GDDPs provide drug coverage for five common chronic conditions.Methods: A content analyses of preexisting information was conducted. Extent of coverage based on top 200 generic drugs prescribed during 2008 for the treatment of chronic conditions such as hypertension, mental disorders, arthritis, pulmonary/respiratory conditions, and diabetes were identified. Commonly prescribed medications for these diseases were identified using published peer reviewed clinical guidelines. List of drugs covered under a GDDP for stores, Wal-Mart, Walgreens, CVS, Kroger, HEB, Target, and Randalls were obtained and compared to assess drug coverage by retail dollar sales and sales volume. Descriptive statistics and frequency/percentage of coverage were reported using SAS 9.2.Results: GDDPs covered the highest number of drugs for hypertension (21-27 across different GDDPs) and the least (3-5 across different GDDPs) for pulmonary/respiratory conditions. Arthritis (5-11), mental disorders (6-11) and diabetes (5-7) had similar coverage. When compared to the top 200 drugs by retail dollars spent during 2008, hypertension (68%-87%) and diabetes (63%-88%) had the highest coverage followed by respiratory conditions (30%-50%), arthritis (22%-48%), and mental disorders (21%-38%). Similar result was obtained when GDDP coverage was compared with the top 200 generic drugs by sales volume, where diabetes (63-88%) and hypertension (57%-74%) had the highest coverage and mental disorders remained the lowest (23%-37%).Conclusion/Implications: Drug coverage in GDDPs varied by pharmacies across the five common chronic conditions evaluated which may limit accessibility of these programs for uninformed consumers. Drug coverage was higher for diabetes and hypertension compared to mental disorders, arthritis, and pulmonary/respiratory conditions. Innovative strategies such as a national GDDP formulary list or internet-based technological tools to help consumers identify comparative drug coverage may be useful to improve access to these medications.

Oral cancer patients suffer severe mechanical and function related pain. Some patients report increased sensitivity to spicy, pungent and acidic foods. Pain is attributed to neuronal sensitization by the release of chemical mediators from the cancer and cancer microenvironment. Pain mediators activate and sensitize multiple transient receptor potential (TRP) ion channels including TRP ankyrin 1 (TRPA1). TRPA1 is co-expressed and localized with other TRP channels to a subpopulation of primary sensory neurons of the trigeminal ganglia detecting noxious thermal, mechanical and chemical stimuli. This study was designed to evaluate chemosensory changes due to sensitization of the TRPA1 ion channel in preclinical models. A two bottle choice drinking assay was used to evaluate aversion to the TRPA1 agonist, allyl isothiocyanate (AITC), which is responsible for the pungent taste of mustard, horseradish and wasabi. Fifty, naive wild type female mice (C57BL/6) were single housed. Liquid intake over 5 day periods was measured from two drinking bottles one with AITC dissolved in dimethyl sulfoxide (DMSO), and the other vehicle (0.25% DMSO). Five AITC concentrations (0.06 mM, 0.1 mM, 0.25 mM, 0.5 mM and 1mM) were tested (n = 10 mice per group). Positions of the bottles were exchanged daily to avoid habituation. Naive female mice demonstrated statistically significant aversion to AITC concentrations 0.25 mM (p= 0.0001), 0.5 mM (p ≤ 0.0001) and 1mM (p ≤ 0.0001), two way ANOVA, Tukey's multiple comparisons test. Mice offered lower AITC concentrations did not show significant aversion. Naive mice demonstrated significant aversion to AITC concentrations ≥ 0.25 mM. Additional testing is being performed in tongue cancer bearing mice. Aversion to a non-aversive concentration of AITC (≤ 0.1 mM) is expected to identify the change in chemosensitivity and difference between sensitive vs. non sensitive cancers. [ABSTRACT FROM AUTHOR]