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Background: There is considerable controversy regarding whether a double-bundle reconstruction of the posterior cruciate ligament is superior to single-bundle techniques. The purpose of this study was to compare posterior tibial translation and external rotation following double and single-bundle tibial inlay reconstruction of the posterior cruciate ligament in both a posterolateral corner-deficient and a repaired cadaver model. Methods: Posterior drawer testing, dial testing, and stress radiography were performed on nine cadaver knees. The intact knees served as controls. The posterior cruciate ligament and the posterolateral corner structures were resected, and each knee then underwent a double-bundle reconstruction of the posterior cruciate ligament. Following testing, both with and without the posterolateral corner repaired, the posteromedial bundle was released and the knee was retested with a single-bundle reconstruction. Results: With dial testing, external rotation measured a mean (and standard error) of 7.6° ± 0.4° at 30° of knee flexion and 9.0° ± 0.8° at 90° after the double-bundle reconstruction with posterolateral corner repair, and it measured 11.2° ± 1.4° at both 30° and 90° after the single-bundle reconstruction with posterolateral corner repair. When dial testing was performed after the double-bundle reconstruction without posterolateral corner repair, external rotation measured a mean of 15.8° ± 1.9° at 30° and 16.9° ± 2.0° at 90°; after the single-bundle reconstruction without posterolateral corner repair, it measured 20.1° ± 1.8° at 30° and 20.3° ± 1.7° at 90°. Without posterolateral corner repair, the double-bundle reconstruction permitted significantly less external rotation than did the single-bundle reconstruction at 30° (p = 0.03). Stress radiography showed the mean posterior displacement after the double-bundle reconstruction with posterolateral corner repair to be 3.3 ± 1.4 mm. This value was not significantly different from the mean posterior displacement of 4.8 ± 1.0 mm after the single-bundle reconstruction with posterolateral corner repair, and both values were similar to that for the intact control (2.9 ± 0.5 mm) (p = 0.254). However, the single-bundle reconstruction without posterolateral corner repair was associated with significantly increased posterior displacement when compared with the intact controls (p = 0.039) and with the double-bundle reconstruction without posterolateral corner repair (p = 0.026). Conclusions: Double-bundle reconstruction of the posterior cruciate ligament offers measurable benefits in terms of rotational stability and posterior translation in the setting of an untreated posterolateral corner injury. With the posterolateral corner intact, at time zero, the double-bundle reconstruction used in this study provided more rotational constraint to the knee at 30° and it did not further reduce posterior translation. Clinical Relevance: Compared with single-bundle reconstruction, double-bundle reconstruction provided increased rotational and posterior control, which was most pronounced in the setting of an untreated posterolateral corner injury. This increased stability may be beneficial in the common clinical setting, in which these reconstructions tend to stretch over time. On the other hand, the persistence of the rotational overconstraint at 30° of knee flexion seen with the double-bundle reconstruction in this study may be a risk factor for osteoarthritis.

Background Recently we retrospectively collected clinical data to predict hamstring graft diameter. Prospective data collection will improve and further define prediction of hamstring graft size. Hypothesis Clinical anthropometric data can be used to predict hamstring graft size. Study Design Cohort study (prevalence); Level of evidence, 1. Methods Fifty consecutive patients with anterior cruciate ligament deficiency scheduled for reconstruction using hamstring autograft were prospectively evaluated. Preoperatively we recorded height, weight, body mass index, age, gender, leg length, thigh length, shank length, bilateral thigh circumference, and Tegner score. Intraoperative measurements of both the gracilis and semitendinosus tendons were made, including absolute length before fashioning the graft and final diameter of the quadrupled graft using sizing tubes calibrated to 0.5 mm. Bivariate correlation coefficients (Pearson r) were calculated to identify relationships among clinical data and intraoperatively measured hamstring graft length and diameter. Results Strongest correlations for graft lengths were height and leg length measurements. Shorter persons with shorter leg, thigh, and shank lengths tended to have shorter gracilis and semitendinosus grafts. Likewise, the strongest correlations for graft diameter were weight and thigh circumference. Self-reported activity level and age did not correlate. Gender comparison revealed that women who were shorter, lighter, and had smaller body mass indices were more likely to have smaller graft diameters and shorter graft lengths. Conclusion Patients weighing less than 50 kg, less than 140 cm in height, with less than 37 cm thigh circumference, and with body mass index less than 18 should be considered at high risk for having a quadrupled hamstring graft diameter less than 7 mm. When separated by gender, small graft diameters are most likely in older, short, female subjects with small thigh circumferences or young, skinny, male subjects with small thigh circumferences and low body mass index. Common clinical measurements can be used for preoperative identification of patients at risk for insufficient graft tissue and would be useful for patient counseling and alternative graft source planning.

Objective The authors detail the public health need for depression prevention research and the decisions made in designing an experiment testing problem solving therapy as "indicated" preventive intervention for high-risk older adults with subsyndromal depression. Special attention is given to the recruitment of African Americans because of well-documented inequalities in mental health services and depression treatment outcomes between races. Methods A total of 306 subjects (half white, half African American) with scores of 16 or higher on the Center for Epidemiological Studies of Depression Scale, but with no history of major depressive disorder in the past 12 months, are being recruited and randomly assigned to either problem solving therapy-primary care or to a dietary education control condition. Time to, and rate of, incident episodes of major depressive disorder are to be modeled using survival analysis. Level of depressive symptoms will be analyzed via a mixed models approach. Results Twenty-two subjects have been recruited into the study, and to date eight have completed the randomly assigned intervention and postintervention assessment. Four of 22 have exited after developing major depressive episodes. None have complained about study procedures or demands. Implementation in a variety of community settings is going well. Conclusion The data collected to date support the feasibility of translating from epidemiology to RCT design and implementation of empirical depression prevention research in later life.

Purpose: The ideal surgical management of isolated and combined posterior cruciate ligament (PCL) injuries is controversial. One active debate concerns the advantages of an open tibial inlay technique versus an arthroscopic transtibial tunnel technique. Therefore, the goal of this study is to biomechanically compare arthroscopic and open double-bundle PCL tibial inlay procedure with and without posterolateral corner (PLC) deficiency. Methods: Ten matched pairs of cadaveric knees were randomly assigned to undergo PCL sectioning and reconstruction using either the open inlay or arthroscopic inlay approach. Clinical testing consisted of posterior drawer, TELOS stress testing, and dial testing at both 30° and 90°. The knee conditions tested were intact, after PCL sectioning, after PLC release, and following PCL reconstruction, with and without the PLC repair. Both 1-way repeated measures and 2-way mixed design analyses of variance were used to determine differences between the knee conditions, with significance set at P Results: After PCL and PLC reconstruction, 10 of 10 open specimens and 9 of 10 arthroscopic specimens were a grade 0 posterior drawer. The remaining arthroscopic specimen was grade I. The average radiographic posterior displacement for arthroscopic and open reconstructions (PCL+/PLC+) was 3.9 and 2.7 mm, respectively, with no significant difference. However, if the PLC was deficient (PCL+/PLC-), the translation for arthroscopic and open specimens increased to 8.5 and 6.5 mm, respectively, and was statistically different from the intact state but not from each other. At 30° of knee flexion, both the open and arthroscopic specimen averaged 8.4° of external rotation. At 90° of knee flexion, the external rotation measurements increased to 9.6° and 9.3° in the arthroscopic and open groups, respectively. Additionally, there was no significant difference in external rotation between intact and reconstructed knees with either group. Conclusions: The arthroscopic method of double-bundle inlay PCL reconstruction provides comparable stability to the open inlay using clinically relevant measurement tools both in the PLC intact or deficient state. Clinical Relevance: This novel arthroscopic double-bundle PCL inlay reconstruction provides comparable stability to the open approach with a potential for lower operative morbidity.

When older adults with major depressive disorder (MDD) are treated with an antidepressant at adequate dosage, 50% to 70% either fail to adequately respond or respond but then relapse within the first 6 to 12 weeks of treatment.1–3 While up to 67% of older depressed patients will eventually respond to vigorous antidepressant pharmacotherapy,4,5 there is little published evidence regarding the success of treating older adults with depression who have failed to respond to pharmacotherapy with a selective serotonin reuptake inhibitor (SSRI).5 Our group previously demonstrated an equivalent rate of response to an “augmentation strategy” (adding bupropion sustained release, nortriptyline, or lithium to paroxetine) or a “switch strategy” (venlafaxine extended release [XR]) in a cohort of paroxetine nonresponders.4 In that report, we observed that venlafaxine XR was generally better tolerated than the augmentation strategies.4 This observation led us to hypothesize that, in older depressed adults who do not respond to an SSRI, switching to a dual reuptake inhibitor may be an effective and well-tolerated pharmacotherapy strategy. Duloxetine has been shown to be safe and effective in the treatment of MDD among adults aged 55 years or older.6 Specifically, in this analysis that pooled older subjects from 2 randomized controlled trials in which subjects received duloxetine 60 mg/day for up to 9 weeks,6 the estimated probability of remission for duloxetine-treated subjects was 44.1%, and the discontinuation rate due to adverse events was 21.0%. In an open-label study of subjects aged 65 years or older treated with duloxetine at doses of 80 to 120 mg/day,7 the rate of remission was 69.8% at week 28 with a discontinuation rate due to adverse events of 26.7% by week 52. In that open-label study, the adverse events leading to discontinuation in greater than 1.0% of enrolled patients were somnolence (4.0%), dizziness (3.0%), diarrhea (2.0%), hypertension (2.0%), and vomiting (2.0%). At these doses of 80 to 120 mg/day, Wohlreich et al.7 also did not report any significant changes in cardiac intervals detected by electrocardiogram. These studies provide preliminary evidence that duloxetine is effective and tolerated in older adults. While reflecting both efficacy and effectiveness, these studies may not reflect real-world stepped-care practice in which serotonin-norepinephrine reuptake inhibitors (SNRIs) are prescribed after nonresponse to an SSRI.8 In order to improve the evidence base of treatment options for older adults who do not respond to optimized treatment with an SSRI, it is useful to describe the response rates for these nonresponders after being switched to an SNRI. In this report, we present open-label data examining how older subjects fare when they are treated with duloxetine as a second-line agent after failing SSRI monotherapy with escitalopram. Our goal is to describe the antidepressant response achieved during treatment in an uncontrolled study and the reported side effects among older adults treated with open-label duloxetine delivered under protocolized conditions after failure of protocolized treatment with escitalopram. On the basis of our experience with venlafaxine XR rescue pharmacotherapy,4 we predicted that approximately half of escitalopram nonresponders would respond to duloxetine.

Purpose The purpose of this study was to compare a new arthroscopic technique for capsular plication with the standard open inferior capsular shift for reducing volume in a multidirectional instability model. Methods Seven fresh-frozen cadaveric shoulders (mean age, 55 years) were dissected down to the capsule. A viscous liquid was injected into each shoulder joint and the volume measured. An arthroscopic multi-pleated anterior, posterior, and inferior capsular plication was performed through a single anterior and posterior portal by use of bioabsorbable suture anchors. The shoulder joint volume was again measured, and the sutures were then cut to restore the volume back to the original size. A humerus-based capsular release from 4 o'clock to 6 o'clock to the 8-o'clock position (right shoulder) was performed, the capsule shifted, and the volume recorded. A repeated-measures analysis of variance test was used with significance set at P = .05. Results The mean baseline shoulder volume was 20 ± 9 mL (range, 10 to 35 mL). The arthroscopic plication resulted in a mean decrease of 58% ± 12%. The open inferior capsular shift resulted in a mean difference of 45% ± 11%. There was a significant decrease in volume between the arthroscopic and open capsular shifts ( P = .006, β = .92). Conclusions This study proved our hypothesis that with this new arthroscopic technique for capsular plication, arthroscopic volume reduction can be achieved at least as well as with the standard open technique. Clinical Relevance As the clinical results in the literature improve with improvements in arthroscopic techniques for treating shoulder instability, this arthroscopic method of repair could become invaluable in overcoming the challenge of capsular volume reduction when addressing multidirectional shoulder instability arthroscopically.

The anterior cruciate ligament (ACL) serves an important stabilizing and biomechanical function for the knee. Reconstruction of the ACL remains one of the most commonly performed procedures in the field of sports medicine. Reconstruction of the ACL with bone-patella tendon-bone (BPTB) autograft secured with interference screw fixation has been the historical reference standard and remains the benchmark against which other methods are gauged. This article reviews the reconstruction of the ACL with BPTB autograft including the surgical technique, rationale for BTPB use, and outcomes.

Background The implementation of treated municipal water systems in the 20th century led to a dramatic decrease in waterborne disease in the United States. However, communities with deficient water systems still experience waterborne outbreaks. In August 2004, we investigated an outbreak of gastroenteritis on South Bass Island, Ohio, an island of 900 residents that is visited by >500,000 persons each year. Methods To identify the source of illness, we conducted a case-control study and an environmental investigation. A case was defined as diarrhea in a person who traveled to the island during the period from May 1 through 30 September 2004 and became ill within 2 weeks after the visit. Healthy travel companions served as matched control subjects. We also performed an environmental assessment and extensive testing of island water sources. Results Among the 1450 persons reporting illness, Campylobacter jejuni, norovirus, Giardia intestinalis, and Salmonella enterica serotype Typhimurium were identified in 16, 9, 3, and 1 persons, respectively. We interviewed 100 case patients and 117 matched control subjects. Case patients were more likely to drink water on the island than control subjects (68% vs. 35%; matched odds ratio, 4.3; 95% confidence interval, 2.2-9.3). Sampling of ground water wells indicated contamination with multiple fecal microbes, including Escherichia coli, C. jejuni, Salmonella species, and Giardia species. Irregularities in sewage disposal practices that could have contaminated the underground aquifer were noted. Conclusions The combined epidemiological and environmental investigation indicated that sewage-contaminated ground water was the likely source of this large outbreak. Long-term changes to the island's water supply and sewage management infrastructure are needed.

Background The California Environmental Protection Agency (Cal/EPA) recently completed a health effects assessment of exposure to environmental tobacco smoke (ETS) which resulted in California listing ETS as a Toxic Air Contaminant in January 2006. As part of the assessment, studies on the association between exposure to ETS and breast cancer were reviewed. Methods Twenty-six published reports (including 3 meta-analyses) evaluating the association between ETS exposure and breast cancer were reviewed. A weight-of-evidence approach was applied to evaluate the data and draw conclusions about the association between breast cancer and ETS exposure. Results The published data indicate an association between ETS and breast cancer in younger primarily premenopausal women. Thirteen of 14 studies (10 case–control and four cohort) that allowed analysis by menopausal status reported elevated risk estimates for breast cancer in premenopausal women, seven of which were statistically significant. Our meta-analyses indicated elevated summary relative risks ranging from OR 1.68 (95% C.I. 1.31, 2.15) for all 14 studies to 2.20 (95% C.I. 1.69, 2.87) for those with the best exposure assessment. Conclusions Cal/EPA concluded that regular ETS exposure is causally related to breast cancer diagnosed in younger, primarily premenopausal women and that the association is not likely explained by bias or confounding.

Persistent organic pollutants (POPs) are anthropogenic chemicals that are poorly biodegradable and have the potential for adverse human health effects. Although national regulations and an international treaty have resulted in the gradual decline of many POPs in human blood and breast milk, the levels of other POPs continue to rise. Children and developing fetuses are sensitive to health effects from these substances. This article reviews the health risks posed by the POPs that have been largely banned or regulated and the potential for health effects from a variety of other chemicals in widespread use today.

The authors review the psychological and emotional aspects of late-life depression complicated by cognitive impairment and propose a treatment model for modifying interpersonal psychotherapy (IPT) to better serve this group of patients and their family caregivers. The key component of this modification, named “IPT-CI” (for C ognitive I mpairment) is a combined patient/caregiver approach that provides psychoeducation for both parties, opportunity for problem solving for both parties individually, and a forum for role dispute resolution through joint meetings. Caregivers thus have regular input into the therapeutic process and are encouraged to extend the therapeutic work between meetings to help the patient to maintain progress despite memory loss and/or impairments in insight, judgment, or executive function. A detailed case vignette provides an illustration of the use of this modified form of IPT

Background The utility of Interpersonal Psychotherapy (IPT) has been documented as a maintenance treatment for late life depression as mono-therapy or in combination with antidepressant medication. Late life depression, however, is frequently co-morbid with declining memory or other cognitive abilities such that the usefulness of one-to-one psychotherapies is called into question for this subgroup. Additionally, concerned caregivers often accompany these patients to request help and their role in the presenting symptoms and in their potential resolution must also be addressed by any successful psychotherapy in this population. Objectives To explore ways in which IPT could be modified to better serve the particular presentation and needs of depressed elders with cognitive decline along with their caregivers. Methods Various modifications of traditional IPT techniques were experimented with and refined in our collaborative late life research center using regular group supervision and feedback from patients and their caregivers. Results A key component of these modifications involves the integration of the caregiver into the treatment process in flexible ways that recognize their own role transition that is taking place simultaneously with that of the patient's role transition from a greater to a lesser functional state. Other techniques for resolving role conflicts, particularly those directly involving care issues for the patient, are also delineated. These modifications are collectively referred to as IPT-CI for cognitive impairment. A brief case vignette is presented. Conclusion The modifications outlined in this communication reflect an evolving work-in-progress and serve as a framework for the future development of a manual of guidelines to assist healthcare personnel to optimally treat this population and their caregivers. Copyright © 2006 John Wiley & Sons, Ltd.

Children are especially vulnerable to environmental pollution, a major cause of disease, death, and disability in countries at every level of development. This article reviews threats to children, including air and water pollution, toxic industrial chemicals, pesticides, heavy metals, and hazardous wastes. Global climate change is expected to exacerbate many of these issues. Examples of innovative nongovernmental organizations and governmental programs that address the impacts of environmental hazards on children are included. International travel, adoption, migration, and movement of goods and pollutants worldwide make these conditions concerns for all pediatricians.

Background: The use of tobacco is a well-established cause of preventable morbidity and mortality. There have been few studies examining the effect of tobacco use on outcomes and complications after arthroscopic knee procedures such as anterior cruciate ligament (ACL) reconstruction. Purpose: To investigate the relationship between tobacco use and rates of postoperative infection, venous thromboembolism (VTE), arthrofibrosis, and subsequent ACL reconstruction after primary ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: A national insurance database was queried for patients who underwent arthroscopic-assisted ACL reconstruction using Current Procedural Terminology code 29888. Patients underage for tobacco use in all regions of the United States (age Results: A total of 13,358 patients who underwent ACL reconstruction met inclusion and exclusion criteria, including 1659 patients with documented tobacco use and 11,699 matched controls. The incidence of infection was significantly higher in patients who use tobacco (2.0%) versus matched controls (0.9%; odds ratio [OR], 2.3; P < .0001). The rate of VTE was also significantly higher in patients who use tobacco (1.0%) compared with matched controls (0.5%; OR, 1.9; P = .035). The rate of subsequent ACL reconstruction was significantly higher in the tobacco use cohort (12.6%) compared with matched controls (7.8%; OR, 1.7; P < .0001). There was no significant difference in the rate of postoperative stiffness after ACL reconstruction between patients who use tobacco (2.0%) and matched controls (2.3%; OR, 0.9; P = .656). Conclusion: ACL reconstruction in patients who use tobacco is associated with significantly increased rates of infection, VTE, and subsequent ACL reconstruction compared with controls. There was no association between tobacco use and postoperative arthrofibrosis after primary ACL reconstruction.

Chapter 4 outlines late-life depression. It explores the causes of depression (including medical conditions, medication, and alcohol), treatments for depression, and other diagnoses (bipolar disorder, co-occuring anxiety, and personality disorders), depression and cognitive impairment, and collaborative care.

This chapter presents an introduction to interpersonal therapy for cognitive impairment (IPT-ci). It discusses the purpose of this manual, research using IPT in older individuals, and the use of IPT with depressed elders in a research setting.

This chapter summarizes the adaptations that make up interpersonal psychotherapy for cognitive impaired older adults (IPT-ci). This includes the engagement of caregivers, the delivery of IPT-ci in common care settings, and who should implement IPT-ci.

Chapter 11 outlines flexible individual and joint sessions for interpersonal therapy for cognitive impairment (IPT-ci). In contrast to traditional IPT, which was designed as an individual treatmentwith an allowance to meet a significant other at some point for clarificationof their respective social role(s), the core of IPT-ci is its comprehensive inputfrom the patient and all involved parties whose role may be evolving intocaregiver status from the first meeting.

Chapter 3 reviews of gerontology and geriatric medicine. It presents background information on gerontology (physiologic changes of aging, the aging process), polypharmacy, the effects of medication in the elderly, sleep problems, and other issues related to older age. The importance of social support for the elderly is also discussed.

Chapter 12 discusses steady states maintenance and long-term planning in interpersonal therapy for cognitive impairment (IPT-ci). It discusses planning for future contingencies, last wills and testaments, and advanced directives.

This chapter presents future directions for the development of interpersonal therapy for cognitive impairment (IPT-ci). This includes the potential use of IPT-ci as a training paradigm for a geriatric mental health specialist, and further directions for research.

Chapter 7 outlines specific techniques for using interpersonal psychotherapy (IPT) for cognitively impaired (ci) patients. This chapter discusses the conceptualization of IPT-ci, the steps involved in IPT-ci, strategies for caregivers, as well as the evaluation process, psychoeducation, and the IPT contract.

Chapter 9 explores specific interpersonal psychotherapy (IPT) foci in IPT for cognitive impairment (IPT-ci). The four foci or problem areas of IPT are role transition, unresolved grieving, role dispute, and interpersonal deficit/sensitivity. These are each outlined using illustrative case examples.

Chapter 10 explores the role transition of the caregiver in interpersonal psychotherapy (IPT). This includes outlines of transitions to caregivers for adult child caregivers, spouse caregivers, siblings, and friends, which are illustrated using case vignettes.

Chapter 8 discusses the involvement of the family or caregivers into the interpersonal psychotherapy (IPT) treatment process. Using illustrative case studies, it outlines the roles of the adult child caregiver (including the issues that adult caregivers may face, shared caregiving duties, inadequate care), spouses are caregivers, adult child/intact spouse collaboration, and nonfamily caregivers.

Background:Arthrofibrosis after knee arthroscopy is a challenging complication. Previous studies reporting incidences of manipulation under anesthesia (MUA) or lysis of adhesions (LOA) after knee arthroscopy are limited by confounders such as small sample size and regional sampling bias.Purpose:To investigate the incidence of MUA or LOA after common arthroscopic knee procedures.Study Design:Descriptive epidemiology study.Methods:A national insurance database was retrospectively queried for arthroscopic knee procedures from 2007 to 2011. The incidence of postoperative MUA and LOA within 3 and 6 months postoperatively was determined for each of 13 common arthroscopic knee surgeries, including ligamentous reconstructive procedures, cartilage restoration procedures, and meniscal procedures.Results:A total of 330,714 unique patients who underwent knee arthroscopy were included in the study. The overall incidence of MUA was 0.06% to 6.00% by 3 months and 0.11% to 8.00% by 6 months postoperatively. The incidence of LOA was somewhat less, ranging from 0.04% to 4.00% by 3 months and 0.06% to 6.00% by 6 months postoperatively. Isolated arthroscopic partial meniscectomy had the lowest incidence of postoperative MUA and LOA, while multiligament reconstructions and meniscal transplants had the highest incidences.Conclusion:The overall incidence of MUA and LOA after arthroscopic knee procedures is low but rises significantly as the number of concomitant procedures or complexity of the procedures increases. This information may be useful in counseling patients on the likelihood of MUA or LOA based on the type of arthroscopic knee procedure that is planned.

Current advances in posterior cruciate ligament reconstruction have led to excellent clinical and functional outcomes. It is helpful to review anatomy, cadaver sectioning studies, biomechanical studies, clinical outcome data, and novel surgical techniques for posterior cruciate ligament reconstruction, including all-inside reconstructions. Surgeons also should be aware of current controversies regarding transtibial versus inlay, autograft versus allograft, and single-bundle versus double-bundle reconstructions.

From the Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI; Department of Pediatrics, UCSF Benioff Children’s Hospital Oakland, Oakland, CA; Western States Pediatric Environmental Health Specialty Unit, University of California, San Francisco, CA; Children’s Environmental Health and Disease Prevention Research Center at Dartmouth; Department of Biological Sciences, Dartmouth College, Hanover, NH; Arsenic Health Effects Research Program, University of California, Berkeley, CA; and Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, NH A rsenic is a naturally occurring element and anthropogenic contaminant present in 2 general forms: inorganic and organic. Inorganic arsenic is considered highly toxic to humans. The International Agency for Research on Cancer, Agency for Toxic Substances and Disease Registry, and the US Environmental Protection Agency (EPA) all classify inorganic arsenic as a human carcinogen. The health effects of organic forms are not fully understood; however, some of the organic forms also may have toxic and potentially carcinogenic properties. Children can be exposed to arsenic in multiple ways. An important source of chronic exposure to inorganic arsenic worldwide is contaminated drinking water. However, because municipal water systems in the US are regulated to meet federal standards, the primary exposure to arsenic for most people in the US is food. One food known to be particularly high in arsenic is rice, a staple for much of the world’s population. Rice grown throughout the world contains arsenic, particularly US-grown rice. Though the amount and forms of arsenic found in different rice cultivars vary, the average levels of inorganic arsenic detected in rice are high enough to raise questions about potential health impacts, including for children. Dietary exposure to arsenic is of particular concern for children for several reasons. First, exposure to arsenic and other chemicals during critical windows of vulnerability in early childhood may result in greater health risks. Second, children typically have greater exposure to contaminants per unit body weight than adults in part because of their greater consumption rates and high caloric needs. Finally, children may also be more exposed to contaminants unique to certain foods because of their selective eating patterns and limited dietary choices. For example, rice is used in many first foods and is a key component of numerous processed foods marketed specifically to children. Thus, it is important for clinicians to become familiar with childhood arsenic exposure, potential health effects, and strategies to reduce exposure. Given the concern about children’s consumption of arsenic in rice, the US Food and Drug Administration (FDA) has published brief statements on this topic to

Increased contact stresses after meniscectomy have led to an increased focus on meniscal preservation strategies to prevent articular cartilage degeneration. Platelet-rich plasma (PRP) has received attention as a promising strategy to help induce healing and has been shown to do so both in vitro and in vivo. Although PRP has been used in clinical practice for some time, to date, few clinical studies support its use in meniscal repair.We sought to (1) evaluate whether PRP augmentation at the time of index meniscal repair decreases the likelihood that subsequent meniscectomy will be performed; (2) determine if PRP augmentation in arthroscopic meniscus repair influenced functional outcome measures; and (3) examine whether PRP augmentation altered clinical and patient-reported outcomes.Between 2008 and 2011, three surgeons performed 35 isolated arthroscopic meniscus repairs. Of those, 15 (43%) were augmented with PRP, and 20 (57%) were performed without PRP augmentation. During the study period, PRP was used for patients with meniscus tears in the setting of no ACL reconstruction. Complete followup at a minimum of 2 years (mean, 4 years; range, 2-6 years) was available on 11 (73%) of the PRP-augmented knees and 15 (75%) of the nonaugmented knees. Clinical outcome measures including the International Knee Documentation Committee (IKDC) score, Tegner Lysholm Knee Scoring Scale, and return to work and sports/activities survey tools were completed in person, over the phone, or through the mail. Range of motion data were collected from electronic patient charts in chart review. With the numbers available, a post hoc power calculation demonstrated that we would have expected to be able to discern a difference using IKDC if we treated 153 patients with PRP and 219 without PRP assuming an alpha rate of 5% and power exceeding 80%. Using the Lysholm score as an outcome measure, post hoc power estimate was 0.523 and effect size was -1.1 (-2.1 to -0.05) requiring 12 patients treated with PRP and 17 without to find statistically significant differences at p = 0.05 and power = 80%.There was no difference in the proportion of patients who underwent reoperation in the PRP group (27% [four of 15]) compared with the non-PRP group (25% [five of 20]; p = 0.89). Functional outcome measures were not different between the two groups based on the measures used (mean IKDC score, 69; SD, 26 with PRP and 76; SD, 17 without PRP; p = 0.288; mean, Tegner Lysholm Knee Scoring Scale, 66, SD, 32 with PRP and 89; SD, 10 without PRP; p = 0.065). With the numbers available there was no difference in the proportion of patients who returned to work in the PRP group (100% [six of six]) compared with the non-PRP group (100% [nine of nine]) or in the patients who returned to their regular sports/activities in the PRP group (71% [five of seven]) compared with the non-PRP group (78% [seven of nine]; p = 0.75).Patients who sustain meniscus injuries should be counseled at the time of injury about the outcomes after meniscus repair. With our limited study group, outcomes after meniscus repair with and without PRP appear similar in terms of reoperation rate. However, given the lack of power and nature of the study, modest size differences in outcome may not have been detected. Future larger prospective studies are needed to definitively determine whether PRP should be used with meniscal repair. Additionally, studies are needed to determine if PRP and other biologics may benefit complex tear types.Level III, therapeutic study.

As the baby-boomer generation continues to age, the number of Alzheimer’s disease cases is expected to double in the next decade. The functional disability and need for clinical management associated with this trend will outstrip our current workforce. Making the correct diagnosis and prescribing cognitive enhancing drugs is relatively easy compared to the time and effort required to educate and support caregivers and help them cope with the complications of neurocognitive disorders such as depression, psychosis, agitation, and growing dependency for basic function [1]. Ninety five percent of these patients will be managed in home settings that will require time and effort from family members who are traditionally women that manage their own family with children as well as their aging parents, many of whom also work themselves to make ends meet financially. Social service agencies will therefore figure large in this equation to provide day care and in-home help. The traditional roles that social workers offer with aging adults (such as evaluating environment and functioning, assessing psychosocial support needs and how to fill them, exploring in-home assistance or alternate housing or placement options, as well as providing direct psychotherapy) are now needed more than ever [2]. Social workers are typically found playing these roles in hospitals, on inpatient psychiatry units, in multi-disciplinary geriatric care clinics, nursing homes and community-based social agencies that cater to the needs of elders.

Knee arthroscopy is a very common procedure performed by all orthopedic surgeons, including those who are not sports medicine fellowship trained. Many types of intra-articular knee pathology can be characterized and addressed, and thus, knowing how to effectively and safely perform knee arthroscopy is an important skill for every orthopedic surgeon to have. Anatomic landmarks provide the surgeon with references for portal creation, and knowledge of the location of neurovascular structures relative to these portals is imperative. The standard anteromedial and anterolateral portals provide access to most areas of the knee and allow for simple meniscal and cartilage procedures. However, certain hard-to-reach areas of the knee and more advanced arthroscopic techniques may require secondary portals. Thus, as indications for knee arthroscopy continue to expand, portal placement and arthroscopic technique continue to be refined. The basics and the technique needed to perform a thorough and safe knee arthroscopy are outlined in the following chapter.

ACL injuries are a common reason for knee surgery in young healthy patients. The clinical diagnosis of ACL tear is straightforward, though coexistent pathology is frequently present and must be recognized for surgical and rehabilitation planning. A careful history, physical examination including provocative maneuvers, and imaging as dictated from the exam are key in establishing an appropriate diagnosis. MRI is useful in identifying ACL injuries and their concomitant knee pathologies though certain cases may be challenging. This chapter outlines cases of ACL injury and reconstruction and discusses surgical intervention, which can be pursued in the carefully chosen active patient through an individualized approach. Techniques for improving ACL reconstruction are under constant analysis and development.

Although most medial collateral ligament (MCL) injuries do not require repair or reconstruction, there are some that do. These include some multiple ligament injuries, entrapment of the ligament in the joint, and some distal injuries. If the ligament is robust, it can be repaired primarily; however, if the ligament is significantly damaged, or in a chronic injury, a reconstruction can be carried out with a free soft tissue graft or with a semitendinosus graft that is left attached distally (modified Bosworth technique). This chapter details all of these options.

Psychological distress in long-term care (LTC) settings is highly prevalent and crosses many conventional psychiatric diagnostic boundaries. Mental health professionals who consult in LTC facilities have experienced firsthand the impact of a variety of nonpharmacological therapeutic approaches on individual residents, yet these are rarely investigated in a systematic fashion, and even less commonly reported in the literature. The present report summarizes the state-of-evidence of "talk therapies" for depression and psychological well-being in LTC facilities by reviewing controlled trials of psychotherapy for LTC residents published in English-language peer-reviewed journals. We excluded studies of nonpharmacological approaches designed primarily to curb behavioral disturbances of dementia, and those psychosocial interventions using an approach other than "talk therapy" in individual or group format since they have been reviewed in detail elsewhere. A majority of the 18 studies that met our inclusion criteria reported significant short- and, in some cases, longer-term benefits on instruments measuring depression, hopelessness, self-esteem, perceived control, and a host of other psychological variables. However, these findings must be interpreted within the severe methodological limitations of many studies, including small sample sizes, variable study entry criteria, short duration of trials, heterogeneous outcome assessment methods, and lack of detail on intervention methods. Nevertheless, the positive efficacy of these approaches, when understood within the framework of potential serious complications of pharmacotherapy for frail elders with multiple comorbidities, polypharmacy, and a narrow therapeutic index, suggests a strong need for methodologically rigorous trials of psychotherapy in the LTC setting, especially in combination with pharmacotherapy.

Objective The objective of this study was to describe the correlates of prior antidepressant exposure and its association with response to protocolized treatment in older patients with major depression. Methods Based on their prior antidepressant treatment exposure, 193 elderly patients with a major depressive episode were divided into three groups: those with no prior treatment for their current episode (not treated [TN]), those with antidepressant trials of inadequate dose or duration ("treatment-inadequate" [TI]), and those with at least one adequate trial but persisting depression ("treatment-resistant" [TR]). All patients then received protocolized treatment with interpersonal psychotherapy (IPT) and paroxetine plus pharmacologic augmentation if needed. The demographic, clinical, and outcome information were compared among these three groups. Results Approximately one-third of the patients referred to the study had been adequately treated (TR), one-third had been inadequately treated (TI), and one-third were not treated for the current episode (TN). Treatment completion rates and reasons for dropping out did not differ statistically among TR, TI, and TN patients. TR patients took longer to respond (13.0 weeks) than either TI or TN patients (7.6 and 8.0 weeks, respectively). TR and TI patients had lower response rates (67% and 71%) than TN patients (86%). Conclusions Prior treatment exposure is an important correlate of course and outcome in late-life depression. Most TR and TI patients eventually respond, but TR patients may require more intensive and longer courses of treatment than TI and TN patients.

Objective The goal of this study was to test the efficacy of paroxetine for primary insomnia in older adults. Methods Adults over age 55 with primary insomnia were randomly assigned to six weeks of double-blind treatment with paroxetine (N = 14) or placebo (N = 13). Outcome measures included persistence or resolution of insomnia; weekly diary measures of sleep quality, daytime alertness, and mood; and pre-/postpolysomnographic measures of sleep latency, wake time after sleep onset, and sleep efficiency. Results Although weekly diary-based measures showed improved subjective sleep quality, daytime alertness, and mood with paroxetine, the authors observed no effect on sleep efficiency or categorical response rates. Conclusion Paroxetine appears to be ineffective for treating primary insomnia in old age.

Preservation of the menisci is increasingly emphasized in orthopedic care of the knee. Techniques are rapidly emerging that allow easier accomplishment of this goal. In particular, the development of all-inside arthroscopic meniscal repair devices has facilitated more ready repair. A number of laboratory and clinical studies have examined these devices and comparisons with more traditional techniques have been made. Numerous reports of potential complications from these new technologies have also been described in the literature. This review covers the current options for treatment of meniscal repair, laboratory and clinical data, and also potential complications.

Background: To determine the optimal duration of an antidepressant trial in elderly patients, the authors examined the probability of eventually responding to treatment based on early improvement. Methods: Four hundred seventy-two elderly patients with major depression (nonpsychotic, nonbipolar) were treated under protocolized conditions for up to 12 weeks and assessed weekly with the Hamilton Rating Scale for Depression. The probability of full response after 12 weeks of treatment was calculated in patients who had not fully responded after periods of treatment that lasted for 4 to 10 weeks. Results: Most of the patients who had shown a partial improvement after 4 weeks of treatment became full responders after 4 or more additional weeks of treatment. By contrast, only a few of those who were nonresponders became full responders even after up to 8 additional weeks of treatment. Conclusions: After 4 weeks of treatment, it is possible to reliably identify a subgroup of elderly patients with depression who are more likely to benefit from a change in their treatment than from a few additional weeks of treatment with the same agent.

Elderly patients with major depression, including those having a first episode, are at high risk for recurrence of depression, disability, and death.We tested the efficacy of maintenance paroxetine and monthly interpersonal psychotherapy in patients 70 years of age or older who had depression (55 percent of whom were having a first episode) in a 2-by-2, randomized, double-blind, placebo-controlled trial. Among patients with a response to treatment with paroxetine and psychotherapy, 116 were randomly assigned to one of four maintenance-treatment programs (either paroxetine or placebo combined with either monthly psychotherapy or clinical-management sessions) for two years or until the recurrence of major depression. Clinical-management sessions, conducted by the same nurses, social workers, and psychologists who provided psychotherapy, involved discussion of symptoms.Major depression recurred within two years in 35 percent of the patients receiving paroxetine and psychotherapy, 37 percent of those receiving paroxetine and clinical-management sessions, 68 percent of those receiving placebo and psychotherapy, and 58 percent of those receiving placebo and clinical-management sessions (P=0.02). After adjustment for the effect of psychotherapy, the relative risk of recurrence among those receiving placebo was 2.4 times (95 percent confidence interval, 1.4 to 4.2) that among those receiving paroxetine. The number of patients needed to be treated with paroxetine to prevent one recurrence was 4 (95 percent confidence interval, 2.3 to 10.9). Patients with fewer and less severe coexisting medical conditions (such as hypertension or cardiac disease) received greater benefit from paroxetine (P=0.03 for the interaction between treatment with paroxetine and baseline severity of medical illness).Patients 70 years of age or older with major depression who had a response to initial treatment with paroxetine and psychotherapy were less likely to have recurrent depression if they received two years of maintenance therapy with paroxetine. Monthly maintenance psychotherapy did not prevent recurrent depression. (ClinicalTrials.gov number, NCT00178100.).

Background: Anxiety disorders are common in later life, but little is known about the long-term benefits and risks of pharmacotherapy. Method: 30 patients aged 60 years and older, with a DSM-IV anxiety disorder, entered a 32-week trial of citalopram. Data gathered at baseline and follow-up included anxiety symptoms using Hamilton Rating Scale for Anxiety (HAM-A) scores, quality of life using the Medical Outcomes Study 36-item Short Form (SF-36), and sleep using the Pittsburgh Sleep Quality Index (PSQI). Data analysis consisted of mixed-effect repeated measures models of HAM-A scores and pre-post comparison of SF-36 and PSQI scores. Results: 30 persons entered treatment; most (27/30) had a primary DSM-IV diagnosis of generalized anxiety disorder (2 had panic disorder; 1 had posttraumatic stress disorder). Three subjects discontinued study medication due to side effects, 5 were terminated because of nonresponse, and 5 dropped out of the study for other reasons; thus, 17 subjects (57%) completed 32 weeks of treatment. Subjects' HAM-A scores improved significantly, with continuing improvements up until about 20 weeks of treatment. On the basis of a criterion of reduction in HAM-A to < 10 during the trial, 60% (18/30) of subjects were responders. Those who completed the 32-week trial had significant improvements in sleep and quality of life-including social functioning, vitality, mental health, and role difficulties due to emotional problems. Conclusions: In this 32-week study of citalopram for elderly persons with anxiety disorders, 60% responded. Those who received a full course of treatment experience significant improvements in quality of life and sleep quality.

To compare the knee ligamentous injury patterns and associated multisystem trauma in patients who have sustained simultaneous bilateral knee multiligamentous injuries (MLI) to patients with unilateral MLIs. Patients with simultaneous bilateral and unilateral knee MLIs after motor vehicle accidents were identified from 2007 to 2014 at a single institution. Chart and radiographic reviews were performed to identify patient demographics, extremity fractures and associated head, thoracic, abdominal and spine injuries. The MLIs were characterized by ligamentous injury pattern and associated neurovascular deficits. Injury Severity Score (ISS) and New ISS (NISS) were calculated. Seven bilateral MLIs and 32 unilateral MLIs were identified. Between the cohorts, there were no significant differences in ligamentous injury pattern or associated neurovascular injuries. For the bilateral MLI cohorts, 71.4 % of patients sustained chest trauma, 57.1 % abdominal trauma, 57.1 % at least a single-level spine injury and 28.6 % head trauma. The ISS was 33.4 ± 23.4 with patients spending an average of 12.4 days in the intensive care unit. Other than the number of days in the ICU, these values were all significantly higher than those of the unilateral knee MLI cohort. Additionally, there was a significantly higher post-operative complication rate in the bilateral MLI cohort (71.4 vs. 6.3 %, P

Background: Findings from national surveys suggest that everyone in the United States is exposed to perchlorate. At high doses, perchlorate, thiocyanate, and nitrate inhibit iodide uptake into the thyroid and decrease thyroid hormone production. Small changes in thyroid hormones during pregnancy, including changes within normal reference ranges, have been linked to cognitive function declines in the offspring. Objectives: We evaluated the potential effects of low environmental exposures to perchlorate on thyroid function. Methods: Serum thyroid hormones and anti-thyroid antibodies and urinary perchlorate, thiocyanate, nitrate, and iodide concentrations were measured in 1,880 pregnant women from San Diego County, California, during 2000–2003, a period when much of the area’s water supply was contaminated from an industrial plant with perchlorate at levels near the 2007 California regulatory standard of 6 μg/L. Linear regression was used to evaluate associations between urinary perchlorate and serum thyroid hormone concentrations in models adjusted for urinary creatinine and thiocyanate, maternal age and education, ethnicity, and gestational age at serum collection. Results: The median urinary perchlorate concentration was 6.5 μg/L, about two times higher than in the general U.S. population. Adjusted associations were identified between increasing log10 perchlorate and decreasing total thyroxine (T4) [regression coefficient (β) = –0.70; 95% CI: –1.06, –0.34], decreasing free thyroxine (fT4) (β = –0.053; 95% CI: –0.092, –0.013), and increasing log10 thyroid-stimulating hormone (β = 0.071; 95% CI: 0.008, 0.133). Conclusions: These results suggest that environmental perchlorate exposures may affect thyroid hormone production during pregnancy. This could have implications for public health given widespread perchlorate exposure and the importance of thyroid hormone in fetal neurodevelopment. Citation: Steinmaus C, Pearl M, Kharrazi M, Blount BC, Miller MD, Pearce EN, Valentin-Blasini L, DeLorenze G, Hoofnagle AN, Liaw J. 2016. Thyroid hormones and moderate exposure to perchlorate during pregnancy in women in Southern California. Environ Health Perspect 124:861–867; http://dx.doi.org/10.1289/ehp.1409614

Objectives: Biceps tenodesis can be performed open or arthroscopically and can be positioned in a suprapectoral or subpectoral position. Suprapectoral tenodesis can be carried out arthroscopically, whereas the subpectoral tenodesis is performed as an open procedure. The goal of this study is to compare the incidence of postoperative stiffness between arthroscopic suprapectoral and open subpectoral biceps tenodesis and evaluate risk factors for its occurrence. Methods: Study Design: The charts of all patients who underwent arthroscopic or open biceps tenodesis who were a minimum of two years post-procedure were reviewed. Patients with preoperative frozen shoulder, prior shoulder surgery, or massive rotator cuff tears which required longer post-operative immobilization were excluded. Post-operative stiffness was defined as persistent range of motion deficit (oof forward flexion and abduction; o of internal or external rotation) and pain resulting in a diagnosis of post-operative frozen shoulder and requiring either an injection, lysis of adhesions/manipulation, or both. Analysis: Means were calculated for continuous variables and compared using Students t test. Frequencies for categorical variables were compared using chi square tests. Results: We identified 249 consecutive biceps tenodeses from 2008-11 (106 arthroscopic, 143 open) that met inclusion and exclusion criteria. A significantly increased incidence of post-operative stiffness was found in the arthroscopic tenodesis cohort as compared to the open cohort (17.9% vs. 5.6%, p=0.002). The groups were otherwise well matched. ( Table I). Further analysis was performed comparing patients with and without post-operative stiffness within the arthroscopic cohort. ( Table II) Female gender (63.2% vs 33.3%, p = 0.016) and smoking (36.8% vs 16.1%, p = 0.040) were independent risk factors for post-operative stiffness after arthroscopic tenodesis. Location of the tenodesis from the top of the humeral head as measured on x-ray was 32.4 mm (stiff cohort) versus 50.3 mm (non-stiff cohort) (p < 0.0001). BMI, workmans compensation status and concomitant procedures did not significantly increase the risk of post-operative stiffness. Auto-immune diagnoses such as diabetes mellitus and thyroid disease were also not significant predictors for post-operative stiffness. Of the 19 arthroscopic tenodesis patients who developed post-operative stiffness, 18 had normal range of motion and were pain free by final follow up. In 16 patients, symptoms resolved with one or more injections; two patients did require reoperation, undergoing arthroscopic lysis of adhesions and manipulation. Conclusion: Our results demonstrate a notable incidence of post-operative stiffness after arthroscopic suprapectoral tenodesis. This occurs more commonly in females and smokers. A more proximal location of the tenodesis is noted in patients who develop post-operative stiffness. The relationship between this issue and the arthroscopic suprapectoral tenodesis technique may be multifactorial, with potential etiologies including increased soft-tissue manipulation, fluid extravasation, bursal resection in the sub-deltoid space, increased risk of bleeding in the region of the bicipital sheath, or possibly an effect related to over-tensioning of the biceps with a presentation mimicking post-operative capsulitis, that improves over time and with symptom-based management.

Summary: Much controversy exists regarding the potential advantages and disadvantages of various graft choices for anterior cruciate ligament reconstruction. Advocates of hamstring autografts often cite the limited apparent morbidity associated with semitendinosus or semitendinosus and gracilis harvest, including evidence that hamstring tendons may regenerate after harvest. In this article, we attempt to summarize the functional, radiographic, and histologic studies to date that examine hamstring regeneration. Ultimately, it appears that tendon-like tissue regenerates in the vast majority of patients, but the anatomic location and biomechanical quality of the neotendon may be inferior. Regardless, functional deficits after hamstring harvest appear to be minimal in most individuals. Key Words: Anterior cruciate ligament—Hamstring— Regeneration—Tendon.

SUMMARY Objective To explore clinical and treatment-response variability in late-onset vs early-onset non-bipolar, non-psychoticmajor depression.Methods We grouped patients from a late-life depression treatment study according to illness-course characteristics: thosewith early-onset, recurrent depression (n¼59), late-onset, recurrent depression (n¼27), and late-onset, single-episodedepression (n¼95). Early-onset was defined as having a first lifetime episode of major depression at age 59 or earlier;late-onset was defined as having a first episode of major depression at age 60 or later. We characterized the three groupsof patients with respect to baseline demographic, neuropsychological, and clinical characteristics, use of augmentation phar-macotherapy to achieve response, and treatment outcomes.Results Rates of response, remission, relapse, and termination were similar in all three groups; however, patients with late-onset, recurrent major depression took longer to respond to treatment than those with late-onset, single-episode depression(12 weeks vs 8 weeks) and had more cognitive and functional impairment. Additionally, patients with recurrent depression(whether early or late) were more likely to require pharmacotherapy augmentation to achieve response than patients with asingle lifetime episode.Conclusion Late-onset, recurrent depression takes longer to respond to treatment than late-onset single-episode depres-sion and is more strongly associated with cognitive and functional impairment. Further study of biological, neuropsycho-logic, and psychosocial correlates of late-onset, recurrent depression is needed. Copyright # 2005 John Wiley & Sons, Ltd.key words—major depression; late-onset; treatment outcome