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A lesser tuberosity osteotomy (LTO) is commonly performed during total shoulder arthroplasty to access the glenohumeral joint. Healing of the LTO is critical to optimizing the outcome of the procedure and is enhanced by a repair that provides stability and compression across the osteotomy site. The purpose of this article is to describe a technique that uses a tensionable suture construct to repair the LTO during anatomic total shoulder arthroplasty using a stemless humeral component. The technique involves passing a row of high-tensile sutures through bone tunnels lateral to the osteotomy site (transosseous sutures) and another row of sutures through the humeral implant (implant sutures). One limb of each bone tunnel suture is then tied to its corresponding limb of implant suture and the remaining free strands of the tied sutures are manually tensioned and tied to each other. This technique is an efficient and reproducible method for creating compression and stability across the osteotomy site that facilitates bony healing.

Objectives: Current National Comprehensive Cancer Network guidelines recommend definitive chemoradiation rather than surgery for patients with locally advanced clinical stage T3 and N2 (stage IIIB) lung cancer involving the chest wall. The data supporting this recommendation are controversial. We studied whether surgery confers a survival advantage over definitive chemoradiation in the National Cancer Database. Methods: We identified all patients with clinical stage T3 and N2 lung cancer in the National Cancer Database from 2004 to 2017 who underwent a lobectomy with en bloc chest wall resection and compared them with patients with clinical stage T3 and N2 lung cancer who had definitive chemoradiation. We used propensity score matching to minimize confounding by indication while excluding patients with tumors in the upper lobes to exclude Pancoast tumors. We used 1:1 propensity score matching and Kaplan–Meir survival analyses to estimate associations. Results: Of 4467 patients meeting all inclusion/exclusion criteria, 210 (4.49%) had an en bloc chest wall resection. Patients undergoing surgical resection were younger (mean age = 60.3 ± 10.3 years vs 67.5 ± 10.4 years; P

ABSTRACT: Background: Pediatric spinal deformity surgery affects ultimate spinal height in the growing child. This effect on ultimate spinal height has also been shown to affect pulmonary development and ultimately pulmonary function. There has been an increasing trend toward growth-friendly spinal surgery in early onset scoliosis to minimize the negative consequences of early spinal fusion surgery. Such growth-friendly techniques include VEPTR, MCGR, and Shilla. Which technique allows for the most growth after initial implantation is still not clear. Methods: An extensive literature review on the topic of pediatric spinal growth was undertaken. Topics reviewed include: normal growth, growth after intervention by various methods, and the effect on pulmonary function. We have summarized the literature for the techniques identified and compared these with normal population data.. Results: The data for various surgical techniques were reviewed. These included VEPTR, standard growing rods, and MCGR. The measurement techniques for determining ultimate spinal growth varied based upon the technique for measurement and the timing of initial and final measurements. The results of attained spinal growth were not directly correlated to pulmonary function values. Conclusions: There is still no standardized ideal time or technique for assessing the best results in this area. We suggest that some of what is called growth from growth-friendly techniques is lengthening from the initial deformity correction. This nomenclature needs to be clarified. In addition, how and when to determine ultimate spinal growth from each surgical technique and by which radiographic technique needs to be standardized.

This report describes the physics case, the resulting detector requirements, and the evolving detector concepts for the experimental program at the Electron-Ion Collider (EIC). The EIC will be a powerful new high-luminosity facility in the United States with the capability to collide high-energy electron beams with high-energy proton and ion beams, providing access to those regions in the nucleon and nuclei where their structure is dominated by gluons. Moreover, polarized beams in the EIC will give unprecedented access to the spatial and spin structure of the proton, neutron, and light ions. The studies leading to this document were commissioned and organized by the EIC User Group with the objective of advancing the state and detail of the physics program and developing detector concepts that meet the emerging requirements in preparation for the realization of the EIC. The effort aims to provide the basis for further development of concepts for experimental equipment best suited for the science needs, including the importance of two complementary detectors and interaction regions. This report consists of three volumes. Volume I is an executive summary of our findings and developed concepts. In Volume II we describe studies of a wide range of physics measurements and the emerging requirements on detector acceptance and performance. Volume III discusses general-purpose detector concepts and the underlying technologies to meet the physics requirements. These considerations will form the basis for a world-class experimental program that aims to increase our understanding of the fundamental structure of all visible matter.

Background:. Nipple areolar complex (NAC) reconstruction often signifies completion of the breast reconstruction process for some patients and has been shown to improve both psychosocial and sexual well-being. Several techniques have been described; however, there currently exists little evidence in the literature describing outcomes or patient satisfaction. Methods:. A retrospective analysis of NAC reconstructions over the last decade was queried for patient demographics, operative technique, and postoperative outcomes. A standardized, validated survey was also utilized to evaluate overall satisfaction, with a focus on aesthetic outcome, shape, color, and projection. Results:. Eighty-three patients were identified, with 49 (59.0%) completing the survey. The modalities used for reconstruction include the C-V flap (45.7%), the modified skate flap technique (42.2%), and free nipple grafting (FNG, 12.0%). No significant differences in age, BMI, or comorbidities were found among the three types. The most utilized donor site for skate flap reconstruction was the suprapubic area (37.1%). There were also no significant differences in complication rate (C-V 10.5%, FNG 10%, skate 5.7%, P = 0.630) or revision surgery (C-V 2.6%, FNG 0%, skate 5.7%, P = 0.732). The most common complication was nipple necrosis. Adjusting for time to follow-up using multivariate analysis, there was a significant difference in overall patient satisfaction when compared across all three techniques, with the modified skate flap having the highest mean overall satisfaction scores. Conclusions:. NAC reconstruction can be completed safely and effectively with a variety of techniques. The modified skate flap technique was associated with high levels of patient satisfaction and a low complication rate.

Objective: Novel tissue leaflets (RESILIA tissue) may improve durability of bioprosthetic heart valves. The COMMENCE trial is an ongoing prospective study to evaluate valve replacement using RESILIA tissue. This report describes mid-term outcomes in the mitral cohort of COMMENCE. Methods: Adult patients requiring mitral valve replacement were enrolled in a prospective, single-arm trial at 17 sites in the United States and Canada. An independent clinical events committee adjudicated safety events using definitions from established guidelines, and hemodynamic performance was evaluated by an independent echocardiographic core laboratory. Results: Eighty-two patients (median age 70 years) successfully underwent mitral valve replacement with the study valve. Five-year event-free probabilities for all-cause mortality, structural valve deterioration, and reoperation were 79.9%, 98.7%, and 97.1%, respectively. Hemodynamic valve function measurements were stable through the 5-year follow-up period; valvular leaks were infrequently observed and primarily clinically insignificant/mild. Conclusions: Mitral valve replacement patients implanted with a RESILIA tissue bioprosthesis had a good safety profile and clinically stable hemodynamic performance.

The spin structure function of the neutron is traditionally determined by measuring the spin asymmetry of inclusive electron deep inelastic scattering (DIS) off polarized 3He nuclei. In such experiments, nuclear corrections are significant and must be treated carefully in the interpretation of experimental data. Here we study the feasibility of suppressing model dependencies by tagging both spectator protons in the process of DIS off neutrons in 3He at the forthcoming Electron-Ion Collider (EIC). This allows for a reconstruction of the momentum of the struck neutron to ensure it was nearly at rest in the initial state, thereby reducing sensitivity to nuclear corrections and suppressing contributions from electron DIS off protons in 3He. Using realistic accelerator and detector configurations, we demonstrate that the EIC can probe the neutron spin structure from xB of 0.003 to 0.651. We find that the double spectator tagging method results in reduced uncertainties by a factor of 2 on the extracted neutron spin asymmetries over all kinematics and by a factor of 10 in the low-xB region, thereby providing valuable insight into the spin and flavor structure of nucleons.

By listening to the “voice” of patients, Northwell Health, New York's largest healthcare organization, took an evidence-based approach to empowering physicians and advanced care providers. The Relationship Centered Communication course utilizes experiential learning to strengthen patient-centered communication and empathy skills to elicit provider–patient relationships grounded in partnership. This case study highlights (1) The pragmatic cultural journey requiring visionary leadership, strong collaborations, and an evolving educational strategy. (2) Over the course of 6 years, 3300+ providers were educated in this evidence-based communication course. (3) As a result, Northwell's Hospital Consumer Assessment of Healthcare Providers and Systems “Communication with Doctors” domain has increased by 22 percentile rank points, when compared nationally to peers, in addition to other notable patient experience metric improvements within ambulatory medical practice.

Category: Ankle; Trauma Introduction/Purpose: Tibiotalocalcaneal (TTC) nailing in the setting of acute ankle trauma has become increasingly popular over the last decade, with expanding indications. Potential advantages of TTC nailing include: less soft tissue dissection, decreased wound burden, and earlier weightbearing. No consensus exists as to whether formal joint preparation is necessary, and at one or both joints. While some argue that joint preparation is not necessary due to inherent joint destruction from the injury and reaming during TTC nailing, others advocate for preparation to facilitate fusion and ensure no further motion occurs at the joint which could lead to nonunion and/or hardware failure. The purpose of this study was to quantify the proportion of ankle and subtalar joint articular surface destruction associated with reaming for TTC nail fixation. Methods: Twelve cadaver feet from 6 specimens were procured. The specimens were reduced and pinned into neutral ankle dorsiflexion and neutral hindfoot alignment. Prior to reaming, each specimen was secured in a simulated supine position. Per standard TTC nailing technique, a 3.0 millimeter (mm) guide wire was inserted under fluoroscopy, retrograde from the calcaneus, through the talus, and into the tibia, followed by a 12mm opening reamer. The specimens were then dissected, exposing the tibial plafond (TP), talar dome (TD), posterior facet of the talus (PFT), and posterior facet of the calcaneus (PFC). Clinical images of each joint were obtained at an angle of 90 degrees and 12 centimeters (cm) from the joint surface. The images were processed using the ImageJ software platform. The total joint surface area, area of articular destruction, and the remaining joint surface area were calculated. The percentage of joint destruction associated with reaming was then calculated. Results: The mean surface area values and percentages of articular surface destruction are summarized in Table 1. The mean surface area (cm 2 ) after reaming was 11.82, 13.70, 9.23, and 7.79 for the TP, TD, PFT, PFC, respectively. The percentage of articular cartilage destruction was 9.32%, 10.33%, 8.89%, and 10.28% for the TP, TD, PFT, PFC, respectively. No joint destruction was observed in the middle facets of the subtalar joint. Conclusion: This study demonstrates that reaming for TTC nail placement involves only a small portion (roughly 8-10%) of each of the articular surfaces of the ankle and subtalar joints. Violation of the middle facet of the subtalar joint did not occur. These results suggest that a significant portion of hindfoot articular surface remains after reaming for TTC nail. Formal joint preparation may be beneficial to aid with fusion after TTC nail placement, particularly when used in younger, more active individuals who sustain hindfoot and ankle trauma.

Background. Therapeutic donors (TDs) are individuals who undergo organ removal for medical treatment with no replacement organ, and the organ is then transplanted into another person. Transplant centers in the United States have started using TDs for kidney transplantation (KT). TD-KT recipient outcomes may be inferior to those of non-TD-living-donor (non-TD-LD)-KT or deceased-donor (DD)-KT because of the conditions that led to nephrectomy; however, these outcomes have not been sufficiently evaluated. Methods. This was a retrospective cohort study using Organ Procurement and Transplantation Network data. Via optimal matching methods, we created 1:4 fivesomes with highly similar characteristics for TD-KT and non-TD-LD-KT recipients and then separately for TD-KT and DD-KT recipients. We compared a 6-mo estimated glomerular filtration rate (eGFR) between groups (primary endpoint) and a composite of death, graft loss, or eGFR 0.05). However, the 6-mo composite outcome occurred more frequently with TD-KT than with non-TD-LD-KT and DD-KT (18%, 2% [P < 0.001], and 8% [P = 0.053], respectively). Conclusions. Early graft function was no different between well-matched groups, but TD-KT demonstrated a higher risk of otherwise poor 6-mo outcomes compared with non-TD-LD-KT and DD-KT. Our results support selective utilization of TD kidneys; however, additional studies are needed with more detailed TD kidney information to understand how to best utilize these kidneys.

IMPORTANCE:. Acute liver failure (ALF) carries significant morbidity and mortality, for both pediatric and adult patients. Albumin dialysis via the molecular adsorbent recirculating system (MARS) is a form of extracorporeal liver support (ELS) that can reduce hepatic encephalopathy (HE), a main driver of mortality in ALF. However, data on MARS and its benefit on mortality have been inconsistent. OBJECTIVES:. We sought to report our experiences and patient outcomes from the first 2 years of operation of a new ELS program, within an established pediatric liver transplantation center. DESIGN, SETTING, AND PARTICIPANTS:. Retrospective review of outcomes in pediatric and adult patients treated with MARS therapy for ALF, from 2021 to 2022. MAIN OUTCOMES AND MEASURES:. Outcomes included reduction in HE and biochemical markers of ALF after MARS therapy, survival, and transplant-free survival. Comparisons were made via Wilcoxon signed-rank test. RESULTS:. Five pediatric and two adult patients underwent MARS for ALF. Ages ranged from 2 to 29 years. Overall, 21 MARS runs were performed (median 3 runs per patient, 12.4 hr per run [interquartile range, IQR 10.1–17]). Overall survival was 85.7%, and transplant-free survival was 71.4%. There was a statistically significant reduction in HE score with MARS therapy (median 3 [IQR 3–4] to 1 [IQR 0–1], p = 0.03), and in ALF biomarkers including ammonia (256 µL/dL [195–265] to 75 µL/dL [58–101], p = 0.02), aspartate aminotransferase (6,362 U/L [920–8,305] to 212 U/L [72–431], p = 0.02), alanine aminotransferase (8,362 U/L [3,866–9,189] to 953 U/L [437–1,351], p = 0.02), and international normalized ratio (4.5 [3.3–6.7] to 1.3 [1.2–1.4], p = 0.02). CONCLUSIONS AND RELEVANCE:. MARS therapy for ALF was well tolerated by both pediatric and adult patients, and resulted in significant improvement in clinical and biochemical parameters. We demonstrated encouraging overall and transplant-free survival, suggesting that early initiation of MARS with relatively long and frequent cycle times may be of significant benefit to ALF patients, and is worthy of additional study in larger cohorts.

We report on two venous arterialization (VA) techniques for treatment of CLTI in patients traditionally considered as having no treatment options for standard arterial endovascular or surgical bypass procedures. Screening and the preprocedural workup findings are outlined as deciding factors in determining a patient’s fitness for the two techniques, with a focus on careful preprocedure arterial duplex ultrasound and assessment for vein suitability. Cardiac and infection screening are also factors in determining patient suitability for VA. In addition, radiographic assessment for the presence of medial artery calcification, which is used as a marker of technical difficulty and is a predictor of poor outcomes, is required. Ultimately, anatomic factors are used to determine the decision between hybrid superficial VA and or endovascular deep VA. Those with an occluded anterior tibial artery and suitable great saphenous vein are prioritized to hybrid superficial VA, and those with an occluded posterior tibial artery to endovascular deep VA. Both procedures are described in detail in this report of vascular and surgical techniques.

Background:. A patient’s preoperative satisfaction with their breasts and baseline psychosocial, sexual, and physical well-being are important considerations when planning breast reconstruction. We sought to elucidate variances in preoperative responses among patients undergoing postmastectomy breast reconstruction. Methods:. Preoperative BREAST-Q responses and demographic data, including race, generation, median household incomeinstitutional review board and body mass index (BMI) were collected from breast cancer patients scheduled for mastectomy. Associations between demographic group and survey response were analyzed by chi-square or independent t-tests. Results:. In total, 646 of 826 patients identified had complete data and were included in the final analysis. Patients in BMI group 1 (16–24.9) were more likely to report feeling “very satisfied” with how they looked unclothed compared with patients in other BMI groups (P = 0.031). Conversely, patients in groups 3 and 4 (35+), reported lower satisfaction (P = 0.037) and felt less attractive without clothes (P = 0.034). Asian women were less likely to feel attractive (P = 0.007), and Black patients were less likely to feel of equal worth to other women (P < 0.001). Finally, patients were less likely to report confidence in social settings if they were Black (P < 0.001), Asian (P < 0.001), from the millennial generation (P = 0.017), or living in zip codes with median household income less than $55,000 (P = 0.042). Conclusions:. Breast cancer patients’ feelings toward their natural breasts vary widely between demographic groups. Understanding baseline psychosocial factors in this population is key to informing preoperative discussions and interpreting postoperative satisfaction.

Background:. Prior studies contrasting oncoplastic reduction (OCR) to traditional lumpectomy have validated oncoplastic reduction surgery with similar survival and oncological outcomes. The purpose of this study was to evaluate if there was a significant difference in the time to initiation of radiation therapy after OCR in comparison with the standard breast-conserving therapy (lumpectomy). Methods:. The patients included were from a database of breast cancer patients who all underwent postoperative adjuvant radiation after either OCR or lumpectomy at a single institution between 2003 and 2020. Patients who experienced delays in radiation for nonsurgical reasons were excluded. Comparisons were made between the groups in the time to radiation and complication rates. Results:. A total of 487 patients underwent breast-conserving therapy, with 220 having undergone OCR and 267 lumpectomy patients. There was no significant difference in days to radiation between patient cohorts (60.5 OCR, 56.2 lumpectomy, P = 0.059). There was a significant difference in the number of complications between OCR and lumpectomy patients (20.4% OCR, 2.2% lumpectomy, P < 0.001). However, of patients who had complications, there was no significant difference in the number of days to radiation (74.3 OCR, 69.3 lumpectomy, P = 0.732). Conclusions:. Compared with lumpectomy, OCR was not associated with an increased time to radiation but was associated with higher complications. Statistical analysis did not reveal surgical technique or complications to be independent, significant predictors of increased time to radiation. Surgeons should be aware that although complications may remain higher in OCR, this does not necessarily translate to delays in radiation.

Objectives: Stereotactic body radiation therapy (SBRT) is an established primary treatment modality in patients with lung cancer who have multiple comorbidities and/or advanced-stage disease. However, its role in otherwise healthy patients with stage I lung cancer is unclear. In this context, we compared the effectiveness of SBRT versus surgery on overall survival using a national database. Methods: We identified all patient with clinical stage I non–small cell lung cancer from the National Cancer Database from 2004 to 2016. We defined otherwise healthy patients as those with a Charlson-Deyo comorbidity index of 0 and whose treatment plan included options for either SBRT or surgery. We further excluded patients who received SBRT due to a contraindication to surgery. We first used propensity score matching and Cox proportional hazard models to identify associations. Next, we fit 2-stage residual inclusion models using an instrumental variables approach to estimate the effects of SBRT versus surgery on long-term survival. We used the hospital SBRT utilization rate as the instrument. Results: Of 25,963 patients meeting all inclusion/exclusion criteria, 5465 (21%) were treated with SBRT. On both Cox proportional hazards modeling and propensity-score matched Kaplan-Meier analysis, surgical resection was associated with improved survival relative to SBRT. In the instrumental-variable–adjusted model, SBRT remained associated with decreased survival (hazard ratio, 2.64; P

Background: Coronary artery bypass grafting 30-day unplanned readmission is a focus for the CMS Hospital Readmissions Reduction Program. Awareness of the critical elements of the care delivery environment, including hospital infrastructure and patient clinical profiles that predispose toward readmission, is essential to proactively decrease readmissions. Methods: The Healthcare Cost and Utilization Project-State Inpatient Database, American Hospital Association Annual Health Survey Database, and Healthcare Information Management Systems Society data sets were merged to create a single data set of patient- and hospital-level data from 8 states. Isolated coronary artery bypass grafting procedures were queried for all-cause 30-day readmission, and backwards stepwise logistic regression was performed. Readmission rate was then used to categorize hospitals into quartiles, and analysis focused on the hospitals with the lowest (Q1) and highest (Q4) readmission rates. Univariate analysis was performed comparing Q1 and Q4 hospitals. Results: A total of 150,215 patients underwent isolated coronary artery bypass grafting with 23,244 (15.5%) readmitted patients among 903 hospitals. Model area under the curve was 0.709 (95% confidence interval, 0.702–0.716), with the top 3 readmission determinants related to discharge disposition. Compared to Q1, Q4 patients more often were female, were >70 years of age, and had Medicare as a primary payor (P < .001). Low readmission rate hospitals were characterized by higher costs; not-for-profit status; having Joint Commission accreditation; and higher total admissions, operative volume, hospital/ICU beds, full-time physicians, nurses, and ancillary personnel (P < .001). Conclusion: Readmission after coronary artery bypass grafting is strongly influenced by discharge disposition. However, hospital factors such as scale, personnel, and ownership structure are significant contributors to readmission. Focus beyond patient factors to include the entire continuum of care is required to enhance outcomes, of which readmission is one surrogate measure.

Background. The success of orthotopic liver transplantation as a life-saving treatment has led to new indications and a greater competition for organ grafts. Pediatric patients with acute liver-related crises can benefit from orthotopic liver transplantation, but organ availability in the limited time can be a major obstacle. Crossing ABO blood group barriers could increase the organs available to such patients Methods. From November 2010 to June 2015, 176 children aged 0.2−to18 y were transplanted in the King Faisal Specialist Hospital and Research Center. Out of those, 19 children were transplanted across blood group barriers (ABO incompatible). The underlying diseases were biliary atresia (n = 6); progressive familial intrahepatic cholestasis type 2 (n = 4); Crigler-Najjar syndrome (n = 3); hepatoblastoma (n = 2); and urea cycle disorder, Caroli disease, cryptogenic cirrhosis, and neonatal sclerosing cholangitis (n = 1 each). Immunosuppression consisted of basiliximab, mycophenolate, tacrolimus, and steroids. Pretransplant prophylactic plasmapheresis, high-dose immunoglobulins, and rituximab were not administered. Results. The grafts were from living donors (n = 17) and deceased donors (n = 2). Living donor morbidity was nil. The recipient median age was 21 mo (5−70 mo). After a median follow-up of 44 mo, 2 recipients (10%) died because of sepsis, 1 because of uncontrolled acute myeloid leukemia. The overall rejection rate was 7%, and no grafts were lost because of antibody-mediated rejection (AMR). HLA matching was 3.8 of 6 (A, B, DR), and there were 2 patients presented with acute cellular rejection, 1 patient with AMR, and 1 patient with biliary strictures. Conclusions. ABO incompatible liver transplantation is a feasible and life-saving option even with antibody and B-cell depletion-free protocol without increasing the risks for AMR. We speculate that this excellent result is most likely because of presence of relatively low titer ABO isoagglutinins and the high HLA match compatibility caused by habit of longstanding interfamilial marriages as typical of Saudi Arabia.

Background: Achieving microscopically negative (R0) surgical margins in gallbladder cancer often requires a partial hepatectomy with associated risk of morbidity and potential to delay adjuvant therapy. Prior studies on the importance of margin status in resectable gall bladder cancer include small numbers of patients with positive (R1) resection margins and are underpowered. Methods: We queried the National Cancer Database to identify patients undergoing resection of gallbladder adenocarcinoma between 2004 and 2015. Patients presenting with metastatic disease, those who received neoadjuvant therapy, and those with fewer than 3 lymph nodes assessed were excluded. 1:1 propensity score matching was used to develop cohorts undergoing either R0 or R1 resection, matched for demographic, pathologic, and facility characteristics. Kaplan–Meier analysis was used to assess the association between margin status and overall survival. Results: A total of 1,439 patients met inclusion criteria; 1,285 underwent R0 and 154 underwent R1 resection. On Kaplan–Meier analysis of propensity-matched cohorts, patients undergoing R0 resection had a median overall survival that was 18 months longer than those undergoing R1 resection (34.6 ± 2.0 months vs 16.3 ± 1.7 months, P

Background:. There is increasing evidence that lidocaine is toxic to adipocytes and their precursors, which can contribute to the variability in fat graft resorption. Erector spinae plane (ESP) block is a new technique to provide analgesia of the trunk and would avoid lidocaine at the fat graft donor site. The aim of this study was to compare the efficacy of ESP block versus tumescent local anesthesia (TLA). Methods:. A retrospective review was performed for all patients who underwent autologous fat grafting from the abdomen at the University of New Mexico Hospital between February 2016 and March 2019. These patients received either ESP block or TLA during abdominal fat harvest. The primary endpoints were intraoperative, postoperative, and total morphine equivalents. Results:. There was no difference in the mean intraoperative, postoperative, and total morphine equivalents administered between the ESP and TLA groups. Conclusions:. ESP block is equivalent to TLA for analgesia when using an abdominal donor site for fat harvest. ESP block should be considered in fat-grafting cases to avoid the potential toxicity of lidocaine to the viability of adipocytes and preadipocytes.

Background: Diabetes mellitus and peripheral neuropathy are established risk factors for complications in operatively treated ankle fractures. Generally, the presence of peripheral neuropathy and diabetic nephropathy have been used as independent variables in studies of diabetic ankle fracture cohorts but are typically treated as binary risk factors. Our purpose was to quantify the effects of risk factors on complication rate specific to diabetic patients undergoing ankle fracture fixation. Methods: We identified 617 rotational ankle fractures treated operatively at a single academic medical center from 2010 to 2019, of which 160 were identified as diabetic. Of these, 91 ankle fractures in 90 diabetic patients met criteria for retrospective review of clinical and radiographic data. Criteria included perioperative laboratory studies, including glycated hemoglobin (HbA 1c ) and estimated glomerular filtration rate (eGFR), as well as follow-up radiographs in the electronic record. We defined complications in this surgical cohort as deep surgical site infection, unplanned return to the operating room, and failure of fixation. Logistic regression was performed and odds ratios (ORs) calculated. Results: The overall complication rate was 28.6% (26/91) in this cohort. Median follow-up was 29 weeks (range: 5-520 weeks). Mean perioperative HbA 1c in patients who experienced postoperative complications was 7.6% (range: 5.1%-14.2%) compared with 7.8% (range: 5.6%-13.5%) who did not ( P = .69). Diabetic patients with chronic kidney disease (eGFR

Objective: To perform a pilot study to assess the efficacy of intraneural facilitation, a novel manual technique, in the treatment of carpal tunnel syndrome (CTS). Design: Patients with clinical and electrodiagnostic evidence of CTS were randomized into intraneural facilitation or sham groups. Setting: Electrodiagnostic laboratory in a university medical center. Participants: Patients referred to our electrodiagnostic laboratory were screened based on nerve conduction studies that were diagnostic for distal median neuropathy at the wrist or CTS. A total of 14 participants were enrolled; 4 participants withdrew prior to randomization, with the remaining 10 participants (N=10) divided equally between treatment and control groups. There was a 9:1 female-to-male sex ratio and average duration of symptoms was 28.5 months. Interventions: Treatment was performed twice weekly for 3 weeks. Main Outcome Measures: Primary outcomes were the Boston Carpel Tunnel Questionnaire (BCTQ) and Boston Functional Status Scale at enrollment and at 1 week and 3 months after completion of intervention. A secondary outcome was ultrasonography (US) of the median nerve performed at baseline and 1 week after intervention. Results: Ten participants completed the trial, 5 each in the treatment and 5 each in the sham groups. The total percentage change in BCTQ and Boston Functional Status Scale scores decreased at baseline, 1 week, and 3 months after intervention. However, there was no difference between control and intraneural facilitation group. Within-group differences showed nonstatistically significant differences for all the groups except for the BCTQ questionnaires after 3 months of intraneural facilitation therapy was completed (P=.043) compared with baseline. Between-group differences showed large effects for the BCTQ questionnaires (d=1.933) and wrist to forearm ratio (WFR) 1 week after completion of intervention. Conclusions: This pilot study suggests that intraneural facilitation might improve symptoms and possibly function but did not improve median nerve cross-sectional area or WFR in CTS at follow-up evaluation 3 months after completion of intervention.

Background: A smartphone-enabled device has been developed that provides a single-lead electrocardiogram using a portable monitor. The increase in direct-to-consumer medical devices may lead to health disparities affecting members of socially disadvantaged populations. Objective: Here we provide a single center’s experience in the use of this device in a pediatric cardiology clinic using a loan-based program. We also compare it to retrospective data from patients who received a traditional nonlooping event monitor. Methods: Forty AliveCor Kardia monitor devices were purchased with grant support from the South Carolina TeleHealth Alliance. The devices were provided between June 2018 and August 2019 to patients presenting to the pediatric cardiology clinic who would have otherwise received a nonlooping event monitor. A retrospective chart review was performed for all patients who were given a MicroER nonlooping event monitor between May and December of 2017. Results: Over a 15-month period, 65 patients were given the smartphone device. A total of 692 tracings were recorded by patients with 9 abnormal recordings. Of the devices expected to be returned, 35 devices have been returned to clinic (54%). Over an 8-month period, 61 patients received the traditional event monitors, accounting for a total of 142 transmissions with 3 abnormal transmissions. Conclusion: Our results reveal adequate use of the device with reliable tracings and show more frequent utilization of the smartphone-enabled device. Utilization of these devices in a loan-based program may improve access to care with improved methods to ensure return of the devices.

We present a case report of an 84-year-old male who presented with a profunda femoris artery (PFA) pseudoaneurysm 8 years after the index revision total hip arthroplasty procedure. Failure of revision hardware and subsequent migration of implants led to damage of the PFA and pseudoaneurysm formation. The patient was hemodynamically unstable on presentation and required emergent endovascular intervention. Once medically stabilized, the patient underwent extensive debridement of the aneurysm and hematoma bed and broken hardware was removed to prevent further complications. At 6-month follow-up, the patient was able to mobilize independently and had returned to all prior levels of activities of daily living. We discuss the vascular anatomy of the hip, the paucity of literature on PFA pseudoaneurysm, as well as the likely etiology of total hip arthroplasty failures.

Background: The potential benefit of surgical resection of intrahepatic cholangiocarcinoma in patients with locoregionally advanced disease has not been definitively determined. Methods: The National Cancer Database was queried to identify patients with clinical evidence of node-positive intrahepatic cholangiocarcinoma. Resected patients were stratified by margin status and lymph node ratio (nodes positive to nodes harvested). Risk of death was determined using Cox regression models and Kaplan-Meier survival functions. Results: A total of 1,425 patients with T(any)N1M0 intrahepatic cholangiocarcinoma were identified. Two hundred twelve (14.9%) underwent surgical resection. On multivariable Cox regression, R0 resection afforded a survival benefit regardless of lymph node ratio (lymph node ratio > 0.5: hazard ratio 0.466, 95% confidence interval 0.304–0.715; lymph node ratio ≤ 0.5: hazard ratio 0.444, 95% confidence interval 0.322–0.611), whereas a survival benefit was only seen in R1 patients with lymph node ratio ≤ 0.5 (hazard ratio 0.470, 95% confidence interval 0.316–0.701). On Kaplan-Meier, median survival was 11.6 months with chemotherapy, 15.7 months with R0 resection in lymph node ratio > 0.5, and 22.2 months with R0 resection in lymph node ratio ≤ 0.5 (P < .001). Discussion: Margin negative resection is associated with a risk-adjusted survival benefit for patients with clinically N1 intrahepatic cholangiocarcinoma regardless of the degree of regional lymph node involvement.

Providing hemodynamic support for patients with hypertrophic cardiomyopathy and cardiogenic shock can be challenging because inotropic medications worsen intraventricular obstruction, and the effect of appropriate mechanical support remains undefined. We report a patient with hypertrophic cardiomyopathy in shock because of takotsubo cardiomyopathy requiring venoarterial extracorporeal membrane oxygenation and septal reduction for full recovery. (Level of Difficulty: Advanced.)

The paper contains a new proof that a complete, non-compact hyperbolic 3–manifold with finite volume contains an immersed, closed, quasi-Fuchsian surface.

Background:. Mohs micrographic surgery (MMS) has become the predominant modality of excision for non-melanoma skin cancers (NMSC). Patients are referred for MMS under the assumption that it is the most effective procedure for definitive removal of the cancer while also allowing for maximal tissue preservation to achieve optimal cosmesis. The objective of this study was to investigate outcomes of serial excision (SE) as an alternative excision modality for NMSC. Methods:. Patients undergoing SE for basal cell carcinoma or squamous cell carcinoma by the senior author from 2009 to 2020 were retrospectively reviewed. Patient demographics, lesion characteristics, and excision characteristics were recorded. The primary outcome was the number of excisions required to achieve negative margins. Results:. In total, 129 patients with 205 NMSC lesions were retrospectively reviewed. An estimated 69 lesions (33.7%) were located in high risk areas, as defined by the National Comprehensive Cancer Network. Negative margins were achieved in 191 (93.2%) lesions. In 88.3% of lesions (n = 181/205), negative margins were achieved in 2 or less excisions. 12 lesions (5.9%) were referred for MMS. Conclusions:. Our results demonstrate that SE is an effective modality for definitive removal of NMSC. Recent research reveals that SE is much less expensive than MMS, and therefore places a smaller financial burden on the patient and the healthcare system as a whole. Relative to MMS, SE offers similar if not increased benefits for lower cost. Our findings highlight the need to critically reassess the select indications for MMS.

Xanthogranulomatous endometritis (XGE) is an extremely rare chronic inflammatory condition, which may be associated with endometrial hyperplasia, endometrial carcinoma, or cervical stenosis. Imaging features can be easily misdiagnosed as an aggressive malignancy. We present a case of XGE, which is the first case of XGE with serial multimodality imaging examinations, in addition to clinical, surgical and pathologic correlations. As such, this unique case illustrates the evolution of this rare disease. Keywords: Xanthogranulomatous endometritis, Xanthogranulomatous inflammation, Endometrial carcinoma

Background: The global COVID-19 pandemic caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has highlighted the need for rapid, accurate, and accessible diagnostics to enable timely treatment and outbreak control. However, current diagnostic tests based on RT-qPCR are insufficient to meet the global testing demand because of their high cost and complexity and supply chain shortages. Reverse transcription loop-mediated isothermal amplification (RT-LAMP) is a promising alternative to RT-qPCR because of its sensitivity, speed, and robustness to sample inhibitors. Here, we describe the development and optimisation of a sample-to-answer workflow, including a simple lysis and inactivation protocol that provides results in

Summary. The authors present a case of a 11-year-old girl with fibrous dysplasia involving the nasal cavity and sphenoid sinus that potentially required a tracheostomy for anesthesia. The tumor was to be approached through both supraorbital and Le Fort I osteotomies. The tumor prevented nasal intubation, and the necessity of maxillomandibular fixation to reduce the osteotomized maxilla with traditional fixation prevented oral intubation. Given the age of the patient and the desire to avoid a tracheostomy scar, a decision was made to utilize custom fixation plates. Virtual surgical planning was utilized to design custom cutting guides with splints for maxillomandibular fixation. These custom maxillary orthognathic plates ensured accurate reduction of the osteotomized maxillary segment and allowed for placement of an oral endotracheal tube. Despite the oral endotracheal tube preventing maxillomandibular fixation, use of custom plates established proper occlusion as determined immediately after extubation and at postoperative visits.

Background: In a context where specialist physicians are lacking and usually inaccessible, trained nurses can provide affordable cervical cancer screening and management services to women. Considering the rapid development of emerging cervical cancer prevention, diagnostic, and treatment procedures, nurses need to update their skills and knowledge regularly in the most appropriate way possible. Furthermore, the management of difficult cases in these settings is challenging, since many patients referred for specialty care cannot afford those services and must continue their care with local health providers. In this study, we applied and reviewed the telementoring scheme ECHO (Extension for Community Health Outcomes) designed to provide support for the Women's Health Program of the Cameroon Baptist Convention Health Services, a programme run by trained nurses that provides lower-cost cervical cancer screening and treatment to women in Cameroon. Methods: Since June 2018, the Women's Health Program of the Cameroon Baptist Convention Health Services has benefited from the expertise of specialist consultants in the USA, Canada, Europe, and Africa through monthly telementoring meetings using the ECHO model to review clinical cases and provide tailored didactic lectures. During each ECHO teleconference, clinicians from Cameroon and other African countries present two clinical cases to experts who provide recommendations for management, and experts give a didactic lecture on a topic relevant to providers, including cervical cancer prevention. In December, 2018, we administered a survey to Women's Health Program providers who had attended at least one ECHO session to collect data on baseline characteristics, previous training, and programme satisfaction. Findings: Between June, 2018, and August, 2019, 28 clinical cases were reviewed and 15 lectures presented. The number of participants in these ECHO sessions has increased from 5–10 to about 40–45. 16 nurses (median age 32 years [range 25–55 years]) completed the satisfaction survey; 15 were women (94%). Most participants had previously been trained to perform cervical cancer counselling (15 [94%]), to screen for cervical cancer with visual methods or to collect specimens for HPV testing (15 [94%]), to perform cervical biopsies (12 [75%]), and to treat with cryotherapy or thermal coagulation (13 [82%]). All respondents enjoyed the opportunity of learning with peers, 10 (63%) reported that ECHO sessions increased their ability to access specialty care, 14 (88%) reported that these sessions have improved the coordination of care, and 12 (75·0%) that these sessions have improved the quality of patients care. Most clinicians had adopted best-practice care following these sessions (12 [75%]), or developed additional clinical skills (10 [63%]). Interpretation: Within the Cameroon Baptist Convention Health Services Women's Health Program, results from Project ECHO have shown improved clinical skills and knowledge for providers, and enhanced quality of care for patients. This simple and inexpensive tool has the potential to foster quality improvement of cervical cancer prevention programmes in resource-limited countries. After the success of the programme in Cameroon, ten other African countries have joined the ECHO sessions. Funding: None

Introduction: Opioid-related adverse drug events (ORADEs) are an increasingly recognized complication associated with the common prescription of opioids after orthopedic surgery. In this study, we attempted to understand how potential ORADEs following hip replacement surgery in older patients affected hospital length of stay, hospital revenue, and their association with specific risk factors and clinically relevant diseases occurring during hospitalization. Methods: We conducted a retrospective study using the Centers for Medicare and Medicaid Services Administrative Database to analyze Medicare discharges after hip replacement surgery to identify potential ORADEs. The impact of potential ORADEs on mean hospital length of stay (LOS) and hospital revenue was analyzed. Results: The potential ORADE rate in patients who underwent hip replacement surgery was 8.6%. The mean LOS for discharges with a potential ORADE was 1.41 days longer than that for discharges without an ORADE. The mean hospital revenue per day with a potential ORADE was US$1708 less than without an ORADE. Potential ORADEs were also found to be strongly associated with poor patient outcomes such as pneumonia, septicemia, and shock. Discussion: Potential ORADEs in hip replacement surgery in older patients are associated with longer hospitalizations, decreased hospital revenue per day, certain patient risk factors, and clinically relevant diseases occurring during hospitalizations. Our finding of an association between potential ORADEs and decreased hospital revenue per day may be attributed to the management of these adverse events, as a patient may need to undergo additional testing, may need additional treatment regimens, and may need a higher level of care. Conclusion: By reducing the use of opioids and employing a multimodal analgesic approach, we may improve patient care, decrease hospital lengths of stay, and increase hospital revenue

We describe a patient who underwent a renal cell carcinoma resection with inferior vena cava thrombectomy complicated by tumor embolization. This resulted in massive pulmonary embolism requiring venous-arterial extracorporeal membrane oxygenation. The patient was ineligible for systemic or catheter-directed thrombolysis because of the recent surgical resection and postoperative hemorrhage. Hence, the patient underwent percutaneous suction thrombectomy with successful removal of the tumor thrombus and significant clinical improvement. This report represents a unique case of suction thrombectomy for the removal of tumor embolus from the pulmonary circulation and highlights the ability of suction thrombectomy in the management of massive pulmonary embolism. Keywords: Pulmonary embolism, Continuous aspiration embolectomy, Renal cell carcinoma

Recently PHOBOS has focused on the study of fluctuations and correlations in particle production in heavy-ion collisions at the highest energies delivered by the Relativistic Heavy Ion Collider (RHIC). In this report, we present results on event-by-event elliptic flow fluctuations in Au + Au collisions at √sNN =200 GeV. A data-driven method was used to estimate the dominant contribution from non-flow correlations. Over the broad range of collision centralities, the observed large elliptic flow fluctuations are in agreement with the fluctuations in the initial source eccentricity.

Jugular vein aneurysms are rare vascular abnormalities that are most commonly encountered in the pediatric population. We report two separate cases in infants, both of whom presented with enlarging neck masses and were found to have jugular vein aneurysms. Diagnosis was established with duplex ultrasonography, computed tomography angiography, digitally subtracted catheter venography, and magnetic resonance imaging in one case and magnetic resonance imaging with magnetic resonance angiography/magnetic resonance venography, gray scale ultrasonography, and digital subtraction catheter venography in the other case. Both aneurysms were treated by surgical resection.

Particle production and correlation functions from Au+Au reactions have beenmeasured as a function of both beam energy (2-10.7AGeV) and impact parameter.These results are used to probe the dynamics of heavy-ion reactions, confronthadronic models over a wide range of conditions and to search for the onset ofnew phenomena.