Search

Andrea Nicole Weber,1 Joshua Trebach,2 Marielle A Brenner,2 Mary Margaret Thomas,3 Nicholas L Bormann4 1Department of Psychiatry, University of Iowa, Iowa City, IA, USA; 2Department of Emergency Medicine, University of Iowa, Iowa City, IA, USA; 3Hardin Library for the Health Sciences, University of Iowa, Iowa City, IA, USA; 4Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USACorrespondence: Andrea Nicole Weber, Department of Psychiatry, University of Iowa, 500 Newton Road, 1-308 MEB, Iowa City, IA, 52242, USA, Tel +1-319-335-6980, Fax +1-319-384-7467, Email andrea-n-weber@uiowa.eduAbstract: Illicitly manufactured fentanyl (IMF) is a significant contributor to the increasing rates of overdose-related deaths. Its high potency and lipophilicity can complicate opioid withdrawal syndromes (OWS) and the subsequent management of opioid use disorder (OUD). This scoping review aimed to collate the current OWS management of study populations seeking treatment for OWS and/or OUD directly from an unregulated opioid supply, such as IMF. Therefore, the focus was on therapeutic interventions published between January 2010 and November 2023, overlapping with the period of increasing IMF exposure. A health science librarian conducted a systematic search on November 13, 2023. A total of 426 studies were screened, and 173 studies were reviewed at the full-text level. Forty-nine studies met the inclusion criteria. Buprenorphine and naltrexone were included in most studies with the goal of transitioning to a long-acting injectable version. Various augmenting agents were tested (buspirone, memantine, suvorexant, gabapentin, and pregabalin); however, the liberal use of adjunctive medication and shortened timelines to initiation had the most consistently positive results. Outside of FDA-approved medications for OUD, lofexidine, gabapentin, and suvorexant have limited evidence for augmenting opioid agonist initiation. Trials often have low retention rates, particularly when opioid agonist washout is required. Neurostimulation strategies were promising; however, they were developed and studied early. Precipitated withdrawal is a concern; however, the rates were low and adequately mitigated or managed with low- or high-dose buprenorphine induction. Maintenance treatment continues to be superior to detoxification without continued management. Shorter induction protocols allow patients to initiate evidence-based treatment more quickly, reducing the use of illicit or non-prescribed substances.Keywords: synthetic opioids, treatment, diagnosis, prevention, addiction medicine

Ashley A Thompson,1 Ioanna K Bolia,1 Amir Fathi,1 Andrew Dobitsch,1 Christian A Cruz,1 Rajvarun Grewal,2 Alexander E Weber,1 Frank A Petrigliano,1 George F Hatch III1 1USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, 90033, USA; 2California Health Sciences University, Clovis, CA, 93612, USACorrespondence: Ioanna K Bolia, USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, 1520 San Pablo St #2000, Los Angeles, CA, 90033, USA, Email ioanna.bolia-kavouklis@med.usc.eduAbstract: Despite early reports of high failure rates in knee ligament repair techniques resulting in favor of reconstruction, newer advances in surgical technology have shifted the attention back to repair with the addition of various tissue augmentation techniques. Ligament repair preserves proprioceptors in the native ligament and avoids autograft tendon harvest, minimizing the complications associated with donor site ruptures in reconstruction techniques. Tissue augmentation has been successfully used in knee ligamentous and tendon repair procedures, as well as in some upper extremity procedures. This study provides a clinical update on the surgical techniques, biomechanics, and outcomes with the application of various tissue augmentation techniques in the ligaments surrounding the knee joint.Keywords: knee, tissue augmentation, ligament repair, suture augmentation, ligament reconstruction, internal brace

Nicholas L Bormann,1 Andrea N Weber,2,3 Benjamin Miskle,2,4 Stephan Arndt,2,5 Alison C Lynch2,6 1Psychiatry and Psychology, Mayo Clinic Health System, Albert Lea, MN, USA; 2Psychiatry, University of Iowa, Iowa City, Iowa, USA; 3Internal Medicine, University of Iowa, Iowa City, Iowa, USA; 4Pharmacy, University of Iowa, Iowa City, Iowa, USA; 5Biostatistics, University of Iowa, Iowa City, Iowa, USA; 6Family Medicine, University of Iowa, Iowa City, Iowa, USACorrespondence: Nicholas L Bormann, Psychiatry and psychology, Mayo Clinic Health System, 408 W Fountain St, Albert Lea, MN, 56007, USA, Tel +1 507 377 6411, Fax +1 507 377 6443, Email bormann.nicholas@mayo.eduPurpose: Cravings for drugs and alcohol have been significantly associated with worse treatment outcomes. We investigated if improvements in recovery capital (RC) (eg, a measure of social capital/network, financial resources, education, and cultural factors) over time were associated with decreased reported cravings.Patients and Methods: The original cohort consisted of 133 participants (63 females) with opioid use disorder seeking outpatient treatment, who completed the Assessment of Recovery Capital (ARC) (range 0 to 50) and the Brief Addiction Monitor (BAM) thrice over the 6-month study. Intervention was medication and case management. Analysis included one-way mixed models testing change over time for ARC total scores and single question craving rating (5-point Likert scale). Cross-lagged panel estimates used structural equation models with variables z-scored, allowing for path coefficient evaluation as standard deviations (sd).Results: Total ARC significantly increased over the study (χ 2 = 33.77, df = 2, p < 0.0001), with baseline of 36.6 (n = 114, sd = 11.1) and 6-month of 41.2 (n = 107, sd = 9.5). Craving also changed significantly (χ 2 = 8.51, df = 2, p < 0.015), with baseline of 1.1 (n = 101, sd = 1.2) and 6-month of 0.9 (n = 107, sd = 1.1). The cross-lag from baseline RC to 3-month craving was significant (β = − 0.28, SE = 0.11, z = − 2.53, p < 0.011). The converse was not true; baseline craving did not affect later RC. Results were similarly significant when comparing 3-month to 6-month. The majority of sample was on buprenorphine.Conclusion: As RC improves, the reported cravings at both 3- and 6-month study time points are significantly reduced. When evaluated inversely, there was not a significant association with baseline cravings and follow-up RC. Significant path coefficients provide an estimation of a directional effect from increased RC towards craving reduction.Keywords: substance-related disorders, epidemiologic measurements, cohort studies, opiate substitution treatment, drug users

Congenital dental agenesis, particularly in younger adults, can have a profound impact on aesthetics and overall quality of life. The scientific literature offers various management strategies for this condition, with orthodontic movement and implant-supported rehabilitation being central to treatment. However, achieving predictable and successful outcomes necessitates a comprehensive multidisciplinary approach. Such an approach integrates diverse professional perspectives to ensure accurate diagnosis, prognosis, and treatment planning, ultimately aiming to restore dental function and address aesthetic concerns effectively. In this case report, we present the successful rehabilitation of a young patient with congenital agenesis of the mandibular central incisors. The treatment strategy combined oral surgery (extraction of deciduous teeth and autogenous bone graft), orthodontic movement (opening spaces to allow implant installation), periodontics (connective tissue graft), implantology, and prosthetic planning. We detail the specific surgical approaches employed and discuss how their integration contributed to the overall success of the case. This multidisciplinary treatment approach not only restored dental function but also met the patient’s aesthetic expectations and enhanced the patient’s quality of life, highlighting the importance of a coordinated approach in managing complex dental conditions.

Various indices of climate variability and extremes are extensively employed to characterize potential effects of climate change. Particularly, the semiarid region of Brazil is influenced by adverse effects of these changes, especially in terms of precipitation. In this context, the main objective of the present study was to characterize the regional trends of extreme precipitation indices in the semiarid region of Brazil (SAB), using daily precipitation data from the IMERG V06 product, spanning the period from 1 January 2001 to 31 December 2020. Twelve extreme precipitation indices were considered, which were estimated annually, and their spatial and temporal trends were subsequently analyzed using the nonparametric Mann–Kendall test and Sen’s slope. The analysis revealed that the peripheral areas of the SAB, especially in the northwest and extreme south regions, exhibited higher intensity and frequency of extreme precipitation events compared to the central portion of the area. However, a negative trend in event intensity was noted in the north, while positive trends were identified in the south. The frequency of extreme events showed a predominance of negative trends across most of the region, with an increase in consecutive dry days particularly throughout the western SAB. The average total precipitation index was above 1000 mm in the north of the SAB, whereas in the central region, the precipitation averages were predominantly below 600 mm, with rainfall intensity values ranging between 6 and 10 mm/day. Over the span of 20 years, the region underwent an average of 40 consecutive dry days in certain localities. A negative trend was observed in most of the indices, indicating a reduction in precipitation intensity in future decades, with variations in some indices. The dry years observed towards the end of the analyzed period likely contributed to the observed negative trends in the majority of extreme precipitation indices. Such trends directly impact the intensity and frequency of extreme weather events in the SAB. The study is important for highlighting and considering the impacts of changes in precipitation extremes in the semiarid region of Brazil. Based on the obtained results, we advocate the implementation of public policies to address future challenges, such as incorporating adaptations in water resource management, sustainable agricultural practices, and planning for urban and rural areas.

With the aim of investigating the relationship between the funding of public basic education and the educational results achieved, this study analyzed a pre-selected set of foreign academic works and identified elements that can be used to encourage debate about the Brazilian model of educational financing. The study used the scoping review technique expanded by elements of the systematic literature of review to analyze the selected foreign studies. The study demonstrated that the availability of financial resources capable of providing an adequate set of inputs, accompanied by an efficient, responsible management process and subject to social control methods, is a crucial requirement for improving educational results and reducing the negative effects generated by low socioeconomic status (SES). It was also observed that although socioeconomic status is an important predictor of educational results, it can be mediated by actions carried out inside and outside school. Additionally, this study demonstrates that educational results need to be measured using indicators other than those obtained through standardized tests, such as: access; school performance; frequency; school dropout; student involvement; completion; progress between stages; improvement in social indicators/social mobility; compliance with the rights provided for in legislation, among others.

The ability to interact or engage with the instructor, other students, and the content i.e., to experience online student engagement, is one main difference between traditional and digital media employed in teaching and learning processes. As literature on this topic in the Turkish context has proliferated, to date, virtually no systematic reviews of this research have been carried out in order to identify potential gaps in the literature. To address this issue, this study investigated previously conducted research in chronological order on student engagement at the post-secondary level in the Turkish context using a PRISMA-based systematic review screening process. The results show that online engagement research and practices have clearly increased and diversified over time. Specifically, online engagement research in the Turkish context has tended to focus on computer science students studying in online-only, LMS-supported environments where their behavioral engagement has been investigated quantitatively. Considering these findings, this systematic review suggests that future studies in the Turkish context should examine other fields besides computer science education, focus more on collaborative tools and the social dimension of engagement, use more qualitative methods, and investigate blended environments as well as online-only.

Abstract The saturated hydraulic conductivity, k sat , is a crucial variable to describe the hydromechanical behavior of soils. The value of k sat of lateritic soils that are typically found in tropical regions is highly affected by the soil’s structure, void ratio, and fine particle aggregation. As a result, the determination of k sat in the field or in the laboratory is complex and involves greater variability, depending on the type of test and on the spatial location of sampling. This paper presents a study of k sat values of lateritic soils, analyzing them using Statistic, Multilayer Perceptron Artificial Neural Networks (ANN) and Decision Trees (CHAID). This study aims to support decision-making regarding the type of test and depth chosen for sampling in laterite soils and understanding the factors influencing the permeability of such soils. An extensive literature review on the k sat values of lateritic soils was performed, providing data for the establishment of a database comprise of 722 registries. According to agronomic and geotechnical soil classifications, the Brazilian lateritic soils presents a “moderate” hydraulic conductivity. A significant variation of permeability values along the depth was identified, particularly for depths between 0.1 and 0.2 m. Regarding the importance of testing variables, the ANN indicated a high dependency on the type of test. The decision tree divided field test and laboratory test automatically, inferring the relevance of the type of test to the determination of k sat .

Andrea Weber,1 Benjamin Miskle,1 Alison Lynch,1 Stephan Arndt,1,2 Laura Acion3 1Department of Psychiatry, University of Iowa Health Care, Iowa City, IA, USA; 2Department of Biostatistics, University of Iowa, Iowa City, IA, USA; 3Universidad de Buenos Aires – CONICET, Instituto de Cálculo, Ciudad Autónoma de Buenos Aires, ArgentinaCorrespondence: Andrea Weber, Department of Psychiatry, University of Iowa Health Care, 500 Newton Road, Iowa City, IA, 52242, USA, Tel +1 319 384 8014, Fax +1 319 384 7467, Email andrea-n-weber@uiowa.eduPurpose: Substance use disorders (SUDs) are widespread and cause significant morbidity and mortality, yet most people in the United States with a SUD do not receive treatment. Recommendations call for widespread use of pharmacotherapy, including medications for opioid use disorder (MOUD). However, many facilities do not offer a full array of medication treatments. This study aims to characterize programs that do and do not offer pharmacotherapy as part of addiction treatment services. We hypothesized that the availability of pharmacotherapy would predict the existence of other recommended components of treatment.Patients and Methods: We analyzed characteristics regarding treatment facilities (n = 15,782) recorded by the 2019 National Survey of Substance Abuse Treatment Services (N-SSATS) to determine how many SUD treatment facilities offer any pharmacotherapy. We compared facilities that offer any pharmacotherapy to facilities that offer none.Results: We found that 65% of SUD treatment facilities that responded to the N-SSATS survey provided at least one pharmacotherapy, while 35% of SUD treatment facilities did not. The facilities that provided at least one pharmacotherapy offered, on average, 6 additional treatment options (Cohen’s d = 0.87; 95% CI: 0.84– 0.91). Psychiatric medications were the most commonly available pharmacotherapy, followed by buprenorphine/naloxone and naltrexone.Conclusion: These results support that pharmacotherapy availability, such as MOUD, at SUD treatment facilities is associated with an increased number of recommended treatment components. Since MOUD has been shown elsewhere to reduce mortality for people with OUD, it should be universally available at SUD treatment facilities. Further efforts are needed to make pharmacotherapy more widely available.Keywords: substance use treatment, buprenorphine, naltrexone, pharmacotherapy

Emily S Mills,1 Jacob A Becerra,1 Katie Yensen,1 Ioanna K Bolia,1 Edward C Shontz,1 Kareem J Kebaish,1 Andrew Dobitsch,1 Laith K Hasan,1 Aryan Haratian,1 Charlton D Ong,2 Jordan Gross,2 Frank A Petrigliano,1 Alexander E Weber1 1Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; 2Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USACorrespondence: Ioanna K Bolia, USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, 1520 San Pablo st #2000, Los Angeles, CA, 90033, USA, Tel +1 9703432813, Fax +8181 658 5920, Email ioanna.bolia-kavouklis@med.usc.eduAbstract: Hip osteoarthritis (OA) can be idiopathic or develop secondary to structural joint abnormalities of the hip joint (alteration of normal anatomy) and/or due to a systemic condition with joint involvement. Early osteoarthritic changes to the hip can be completely asymptomatic or may cause the development hip symptomatology without evidence of OA on radiographs. Delaying the progression of hip OA is critical due to the significant impact of this condition on the patient’s quality of life. Pre-OA of the hip is a newly established term that is often described as the development of signs and symptoms of degenerative hip disease but no radiographic evidence of OA. Advanced imaging methods can help to diagnose pre-OA of the hip in patients with hip pain and normal radiographs or aid in the surveillance of asymptomatic patients with an underlying hip diagnosis that is known to increase the risk of early OA of the hip. These methods include the delayed gadolinium-enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC), quantitative magnetic resonance imaging (qMRI- T1rho, T2, and T2&ast; relaxation time mapping), 7-Tesla MRI, computed tomography (CT), and optical coherence tomography (OCT). dGEMRIC proved to be a reliable and accurate modality though it is limited by the significant time necessary for contrast washout between scans. This disadvantage is potentially overcome by T2 weighted MRIs, which do not require contrast. 7-Tesla MRI is a promising development for enhanced imaging resolution compared to 1.5 and 3T MRIs. This technique does require additional optimization and development prior to widespread clinical use. The purpose of this review was to summarize the results of translational and clinical studies investigating the utilization of the above-mentioned imaging modalities to diagnose hip pre-OA, with special focus on recent research evaluating their implementation into clinical practice.Keywords: hip, pre-osteoarthritis, dGEMRIC, 7T MRI, qMRI, OCT, delayed gadolinium-enhanced magnetic resonance imaging of cartilage, optical coherence tomography, quantitative magnetic resonance imaging

Abstract This article evaluates four statistical methods of multiple imputation to fill in the missing data of daily precipitation in Northeast Brazil (NEB). We used a daily database collected by 94 rain gauges distributed in NEB from January 1, 1986 to December 31, 2015. The methods were: random sampling from the observed values; predictive mean matching, Bayesian linear regression; and bootstrap expectation maximization algorithm (BootEm). To compare these methods, missing data from the original series were initially excluded. The next step was to create three scenarios for each method, in which 10\%, 20\% and 30\% of the data were removed at random. The BootEM method presented the best statistical results. With the average bias between the complete series and the imputed series values ranging between -0.91 and 1.30 mm/day. The values of the Pearson correlation ranging between 0.96, 0.91 and 0.86 respectively for 10\%, 20\% and 30\% missing data. We conclude that this is an adequate method for the reconstruction of historical precipitation data in NEB.

Thunderstorms can generate intense electrical activity, hail, and result in substantial economic and human losses. The development of very short-term forecasting tools (nowcasting) is essential to provide information to alert systems in order to mobilize most efficiently the population. However, the development of nowcasting tools depends on a better understanding of the physics and microphysics of clouds and lightning formation and evolution. In this context, the objectives of this study are: (a) to describe the environmental conditions that led to a genesis of a thunderstorm that produce hail on 7 January 2012, in the Metropolitan Area of São Paulo (MASP) during the CHUVA-Vale campaign, and (b) to evaluate the thunderstorm microphysical properties and vertical structure of electrical charge. Data from different sources were used: field campaign data, such as S-band radar, and 2- and 3-dimensional lightning networks, satellite data from the Geostationary Operational Environmental Satellite-13 (GOES-13), the Meteosat Second Generation (MSG), and reanalysis of the European Centre for Medium-Range Weather Forecasts Reanalysis v5 (ERA5). The thunderstorm developed in a region of low-pressure due to the presence of a near-surface inverted trough and moisture convergence, which favored convection. Convective Available Potential Energy (CAPE) of 1053.6 J kg−1 at the start of the thunderstorm indicated that strong convective energy was present. Microphysical variables such as Vertically Integrated Liquid water content (VIL) and Vertically Integrated Ice (VII) showed peaks of 140 and 130 kg m−2, respectively, before the hail reached the surface, followed by a decrease, indicating content removal from within the clouds to the ground surface. The thunderstorm charge structure evolved from a dipolar structure (with a negative center between 4 and 6 km and a positive center between 8 and 10 km) to a tripolar structure (negative center between 6 and 7.5 km) in the most intense phase. The first lightning peak (100 flashes in 5 min−1) before the hail showed that there had been a lightning jump. The maximum lightning occurred around 18:17 UTC, with approximately 350 flashes 5 min−1 with values higher than 4000 sources 500 m−1 in 5 min−1. Likewise, the vertical cross-sections indicated that the lightning occurred ahead of the thunderstorm’s displacement (maximum reflectivity), which could be useful in predicting these events.

Ioanna K Bolia, Kevin Mertz, Ethan Faye, Justin Sheppard, Sagar Telang, Jacob Bogdanov, Laith K Hasan, Aryan Haratian, Denis Evseenko, Alexander E Weber, Frank A Petrigliano USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USACorrespondence: Ioanna K Bolia, 1520 San Pablo Street Suite 2000, Los Angeles, CA, 90033, USA, Tel +1 9703432813, Fax +1 818-658-5925, Email frank.petrigliano@med.usc.eduAbstract: Knee fibrosis is characterized by the presence of excessive connective tissue due to dysregulated fibroblast activation following local or systemic tissue damage. Knee fibrosis constitutes a major clinical problem in orthopaedics due to the severe limitation in the knee range of motion that leads to compromised function and patient disability. Knee osteoarthritis is an extremely common orthopedic condition that is associated with patient disability and major costs to the health-care systems worldwide. Although knee fibrosis and osteoarthritis (OA) have traditionally been perceived as two separate pathologic entities, recent research has shown common ground between the pathophysiologic processes that lead to the development of these two conditions. The purpose of this review was to identify the pathophysiologic pathways as well as key molecules that are implicated in the development of both knee OA and knee fibrosis in order to understand the relationship between the two diagnoses and potentially identify novel therapeutic targets.Keywords: fibrosis, molecules, knee, osteoarthritis

This study presents a method for estimating the mean and variance of total CO2 emission from multiple sources used by a company. The procedure is also readily applicable to estimate these parameters for other greenhouse gases (GHG) inventories and to determine a reliable confidence interval for the total emissions of GHG of a company. Our method represents an improvement over the existing methods that assume independence between emissions from different sources. The foundation of the proposed method is an iterative decomposition process applied to analyze the emissions correlations among activities, raw materials and other inputs used in a company’s operations. From these correlations and the individual estimates of means and variances of emission factors, we show how to generate a confidence interval for the total GHG emission of a company. The application of the method is illustrated for a hypothetical manufacturing plant of bicycles and car toys, whose total CO2 emission is estimated within a precise confidence interval.

Abstract The Cerrado encompasses a complex network of hydrographic basins, which is responsible for the formation and maintenance of the riparian and gallery forests. Alterations in the vegetation resulting from the paleoclimatic changes that occurred during the Pleistocene influenced the current distribution of these humid forests. To understand of the evolutionary dynamics of this landscape on the population structure of the associated organisms, we studied the population genetics of the Antilophia galeata (Pipridae), a bird endemic to the gallery forests of the Cerrado. For this, we evaluated the variability of the mitochondrial control region of 71 A. galeata specimens from 18 localities distributed throughout the Cerrado. The results indicated the existence of significant substructure among the populations located in the peripheral areas of the Cerrado, in comparison with the populations found in the central portion, reflecting historical changes in the environment. We also found high levels of diversity in all the populations, while the analysis of the demographic history revealed a scenario of stability. Overall, then, these findings indicate that the historical modifications of the gallery forest distribution may have been most accentuated in the peripheral zones, with a greater stability and connectivity persisting in the central portion of the biome.

Aryan Haratian, Katie Yensen, Jennifer A Bell, Laith K Hasan, Tara Shelby, Brandon Yoshida, Ioanna K Bolia, Alexander E Weber, Frank A Petrigliano USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USACorrespondence: Frank A PetriglianoUSC Epstein Family Center for Sports Medicine at Keck Medicine of USC, 1520 San Pablo Street, Suite 2000, Los Angeles, CA, 90033, USATel +1 323 442-5822Email fpetrigliano@gmail.comAbstract: Shoulder instability is a relatively common injury especially in the young athletic population and its surgical management continues to remain a controversial topic in sports medicine orthopedics. Anterior instability is the most common type encountered and is estimated to have an incidence rate of 0.08 per 1000 person–years in the general population; however, this figure is likely higher in the young athletic population. While in recent practice, arthroscopic surgery has become the new gold standard for management, reported failure rates as high as 26% and high recurrence rates in specific subpopulations such as young men in high collision sports have led to the consideration of alternative open procedures such as open Bankart repair, Latarjet, capsular shift, and glenoid bone grafting. These procedures may be preferred in specific patient subgroups such as young athletes involved in contact sports and those with Hill–Sachs defects and multidirectional instability, with postoperative recurrence rates of instability as low as 10%. The purpose of this review is to provide an overview of different open surgical techniques in the management of shoulder instability and summarize patient outcomes including recurrence rates for shoulder instability, return to sport, range of motion (ROM), muscle strength, and complications either individually by procedure or in comparison with other techniques, with special focus on their impact in the athletic population.Keywords: open shoulder stabilization, athletes, anterior instability, open Bankart repair, open Latarjet, open capsular shift

Introduction: The aim of this study was to evaluate the bleaching effect after aging simulation in teeth submitted to bonding and debonding of orthodontic brackets. Materials and methods: For this study, 90 human premolars were selected, and randomly divided into 6 groups: control, bleaching, and other 4 groups submitted to bleaching after bonding and debonding brackets using different methods. Color measurement of sample through the CIE L*a*b* system was performed in three moments: T1 – after brackets debonding, T2 – after staining cycling, and T3 – after bleaching. For evaluation of results among the components L*, a* and b*, the two criteria analysis of variance and the multiple comparison Tukey test (p

Laith K Hasan, Aryan Haratian, Michael Kim, Ioanna K Bolia, Alexander E Weber, Frank A Petrigliano USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USACorrespondence: Frank A PetriglianoClinical Orthopaedic Surgery, Chief, USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, 1520 San Pablo st#2000, Los Angeles, CA, 90033, USATel +1 310 403-0441Email fpetrigliano@gmail.comAbstract: One emerging technology with the potential to improve and further transform the field of orthopaedic surgery is virtual reality (VR). VR has been explored and used in many different specialties with clinical applications, such as psychiatric therapy, pain management, rehabilitation, and traumatic brain injury. Recent studies have suggested that the use of VR during the training of orthopaedic surgery residents produces similar or improved surgical performance by residents. This is an area where VR can provide a tremendous benefit to the field of orthopaedic surgery, as it offers a safe and accessible complement to orthopaedic surgical training outside of the operating room (OR) and without involving patients directly. This review will elucidate the current state of virtual reality use in the training of orthopaedic surgeons and highlight key benefits and challenges in its application as a training resource.Keywords: virtual reality, orthopaedic, surgery, medical education, training

Andrea Weber,1 Benjamin Miskle,1 Alison Lynch,1 Stephan Arndt,2 Laura Acion3 1Department of Psychiatry, University of Iowa Health Care, Iowa City, IA, USA; 2Department of Biostatistics, University of Iowa, Iowa City, IA, USA; 3Universidad de Buenos Aires – CONICET, Instituto de Cálculo, Ciudad Autónoma de Buenos Aires, ArgentinaCorrespondence: Andrea WeberDepartment of Psychiatry, University of Iowa Health Care, 500 Newton Road, Iowa City, IA, 52242, USATel +1 319-384-8014Fax +1 319-384-7467Email andrea-n-weber@uiowa.eduAbstract: This review examines the impact of stigma on pregnant people who use substances. Stigma towards people who use drugs is pervasive and negatively impacts the care of substance-using people by characterizing addiction as a weakness and fostering beliefs that undermine the personal resources needed to access treatment and recover from addiction, including self-efficacy, help seeking and belief that they deserve care. Stigma acts on multiple levels by blaming people for having a problem and then making it difficult for them to get help, but in spite of this, most pregnant people who use substances reduce or stop using when they learn they are pregnant. Language, beliefs about gender roles, and attitudes regarding fitness for parenting are social factors that can express and perpetuate stigma while facilitating punitive rather than therapeutic approaches. Because of stigmatizing attitudes that a person who uses substances is unfit to parent, pregnant people who use substances are at heightened risk of being screened for substance use, referred to child welfare services, and having their parental rights taken away; these outcomes are even more likely for people of color. Various treatment options can successfully support recovery in substance-using pregnant populations, but treatment is underutilized in all populations including pregnant people, and more knowledge is needed on how to sustain engagement in treatment and recovery activities. To combat stigma when working with substance-using pregnant people throughout the peripartum period, caregivers should utilize a trauma-informed approach that incorporates harm reduction and motivational interviewing with a focus on building trust, enhancing self-efficacy, and strengthening the personal skills and resources needed to optimize health of the parent-baby dyad.Keywords: stigma, pregnancy, substance use, opioid use, harm reduction

Andre Anvari, Amir Fathi, Ioanna K Bolia, Eric Piatt, Laith K Hasan, Aryan Haratian, Alexander E Weber, Frank A Petrigliano USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USACorrespondence: Frank A PetriglianoUSC Epstein Family Center for Sports Medicine at Keck Medicine of USC, San Pablo st#2000, Los Angeles, CA, 90033, USATel +1 310 403-0441Email fpetrigliano@gmail.comAbstract: Ulnar collateral ligament (UCL) reconstruction has been successfully utilized to treat symptomatic UCL insufficiency in overhead athletes. Despite the overall success of the procedure, attempts have been made to improve upon the original technique with the goal of hastening return to sport. Most recently, there has been interest in repairing or reconstructing the native ligament with internal brace (IB) augmentation. Biomechanical cadaveric studies assessing UCL repair with IB augmentation have attempted to evaluate the efficacy of this treatment; however, the literature is seemingly divided on its benefit. Preliminary clinical studies suggest internal bracing may allow a faster return to sport than conventional techniques. The purpose of this review was to provide an analysis of the current evidence on IB augmentation in UCL repair of the elbow as it pertains to biomechanical advantages/disadvantages, reported surgical techniques, and clinical outcomes in comparison with traditional UCL reconstruction techniques.Keywords: return to sport, elbow, internal brace, UCL

Aryan Haratian, Tara Shelby, Laith K Hasan, Ioanna K Bolia, Alexander E Weber, Frank A Petrigliano USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USACorrespondence: Frank A PetriglianoUSC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USATel +1 323 442-5822Email Frank.Petrigliano@med.usc.eduAbstract: Tranexamic acid (TXA) is a lysine analog that exhibits an anti-fibrinolytic effect by directly preventing the activation of plasminogen as well as inhibiting activated plasmin from degrading fibrin clots, thereby promoting hemostasis and reducing the duration and quantity of blood loss. The aims of this study were to summarize the indications, routes of administration, safety, and clinical outcomes of TXA use throughout the different subspecialities in orthopedic surgery. Given that orthopedic procedures such as TKA, THA, fracture fixation, and various spine surgeries involve significant intraoperative blood loss, TXA is indicated in providing effective perioperative hemostasis. Additionally, use of TXA in orthopedic trauma has been indicated as a measure to reduce blood loss especially in a group with potential for hemodynamic compromise. TXA has been implicated in reducing the risk of blood transfusions in orthopedic trauma, joint surgery, and spine surgery, although this effect is not seen as prominently in sports medicine procedures. There remains disagreement in literature as to whether TXA via any route of administration can improve other clinically significant outcomes such as hospital length of stay and total operative time. Procedures that rely extensively on clarity on visualization of the surgical field such as knee and shoulder arthroscopies can greatly benefit from the use of TXA, thereby leading to less intraoperative bleeding, with better visual clarity of the surgical field. While most studies agree thrombosis due to TXA is unlikely, new research in cells and animal models are evaluating whether TXA can negatively impact other aspects of musculoskeletal physiology, however with conflicting results thus far. As of now, TXA remains a safe and effective means of promoting hemostasis and reducing intraoperative blood loss in orthopedic surgery.Keywords: tranexamic acid, TXA, orthopaedic surgery, operative blood loss, transfusion rate, outcomes

Ioanna K Bolia, Aryan Haratian, Jennifer A Bell, Laith K Hasan, Nima Saboori, Ryan Palmer, Frank A Petrigliano, Alexander E Weber USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USACorrespondence: Alexander E WeberUSC Epstein Family Center for Sports Medicine at Keck Medicine of USC, 1520 San Pablo Street, Suite 2000, Los Angeles, CA, 90033, USAEmail weber.ae@gmail.comAbstract: Anterior cruciate ligament reconstructions (ACLR) are a relatively common procedure in orthopedic sports medicine with an estimated 130,000 arthroscopic operations performed annually. Most procedures are carried out on an outpatient basis, and though success rates of ACLR are as high as 95%, pain remains the most common postoperative complication delaying patient discharge, and thereby increasing the costs associated with patient care. Despite the success and relative frequency of ACLR surgery, optimal and widely accepted strategies and regimens for controlling perioperative pain are not well established. In recent years, the paradigm of pain control has shifted from exclusively utilizing opiates and opioid medications in the acute postoperative period to employing other agents and techniques including nerve blocks, intra-articular and periarticular injections of local anesthetic agents, NSAIDs, and less commonly, ketamine, tranexamic acid (TXA), sedatives, gabapentin, and corticosteroids. More often, these agents are now used in combination and in synergy with one another as part of a multimodal approach to pain management in ACLR, with the goal of reducing postoperative pain, opioid consumption, and the incidence of delayed hospital discharge. The purpose of this review is to consolidate current literature on various agents involved in the management of postoperative pain following ACLR, including the role of classically used opiate and opioid medications, as well as to describe other drugs currently utilized in practice either individually or in conjunction with other agents as part of a multimodal regimen in pain management in ACLR.Keywords: anterior cruciate ligament reconstruction, ACL, postoperative pain, patient outcomes, multimodal pain management

Aryan Haratian, Ioanna K Bolia, Laith K Hasan, Amir Fathi, Samantha Solaru, Andrew Homere, Frank A Petrigliano, Alexander E Weber USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USACorrespondence: Alexander E WeberUSC Epstein Family Center for Sports Medicine at Keck Medicine of USC, 1520 San Pablo Street, Suite 2000, Los Angeles, CA, 90033, USAEmail weber.ae@gmail.comPurpose: The purpose of this study was to systematically review the outcomes of arthroscopic management of meniscal cysts and to compare the results across the reported surgical techniques.Methods: Following the PRISMA methodology, 3 databases (PubMed, Scopus and Web of Science) were searched from inception to June 2021 for randomized controlled trials (RCTs) and observational studies reporting outcomes on patients with meniscal cysts who underwent arthroscopic surgery. The Mixed Methods Appraisal Tool (MMAT) was used to evaluate the study quality.Results: Eighteen studies examining 753 patients (761 meniscal cysts; 92.5% in the lateral meniscus) were included. Overall, 486/736 (66.0%) patients underwent purely arthroscopic decompression, 174/736 (23.6%) received arthroscopic excision, 58/736 (7.9%) received arthroscopy assisted percutaneous drainage, and 18/736 (2.4%) received a combined procedure. The recurrence rate for meniscal cysts was 7.1% across all arthroscopic procedures; 8.3%, 3.4%, and 0% for arthroscopic decompression, arthroscopic excision, and arthroscopy assisted percutaneous drainage, respectively. A total of 79.3% of patients returned to the same level of sport and 85.7% had resolution or minimal knee symptoms after arthroscopic surgery for meniscal cysts. Patient perception of surgical outcomes after any type of arthroscopic surgery for meniscal cysts was reported by 5 studies, with 189/203 (93.1%) reporting satisfaction with their surgical procedure.Conclusion: Based on current evidence, arthroscopic management of meniscal cysts yields satisfactory patient outcomes, low cyst recurrence rates and high return to sport rates regardless of the surgical technique. Rates of cyst recurrence were relatively higher with arthroscopic decompression versus excision and percutaneous drainage; however, prospective studies using modern surgical techniques are necessary to better evaluate the surgical outcomes and to compare those with nonoperative modalities, given that a significant proportion of the included articles in this review were relatively outdated.Level of Evidence: Systematic review of level II and IV studies.Keywords: systematic review, meniscal cyst, arthroscopic surgery, outcomes

Laith K Hasan, Brittney Deadwiler, Aryan Haratian, Ioanna K Bolia, Alexander E Weber, Frank A Petrigliano USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USACorrespondence: Frank A PetriglianoUSC Epstein Family Center for Sports Medicine at Keck Medicine of USC, 1520 San Pablo st#2000, Los Angeles, CA, 90033, USATel +1 310 403-0441Email fpetrigliano@gmail.comAbstract: The global pandemic caused by SARS-CoV-2, or COVID-19, continues to impact all facets of daily life. Clinical manifestations of COVID-19 commonly include musculoskeletal symptoms such as myalgias, arthralgias, and neuropathies/myopathies. The inflammatory response and its impact on the respiratory system have been the focus of most studies. However, the literature is more limited regarding the inflammatory response and its implications for other organ systems, specifically the musculoskeletal system. Previous studies have described how systemic inflammation may play a role in bone and joint pathology. Furthermore, it is important to understand the effects current therapeutics used in the treatment of COVID-19 may have on the musculoskeletal system. In this study, we will review the current understanding of the effect COVID-19 has on the musculoskeletal system, provide an overview of musculoskeletal symptoms of patients infected with the virus, and address key issues for clinicians to address during the care of COVID-19 patients.Keywords: COVID-19, musculoskeletal system, SARS-CoV-2