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Introduction: Physicians vary widely in how they treat some health conditions, despite strong evidence favoring certain treatments over others. We examined physicians’ perspectives on factors that support or hinder evidence-based decisions and the implications for delivery systems, payers, and policymakers. Methods: We used Choosing Wisely ® recommendations to create four clinical vignettes for common types of decisions. We conducted semi-structured interviews with 36 specialists to identify factors that support or hinder evidence-based decisions. We examined these factors using a conceptual framework that includes six levels: patients, physicians, practice sites, organizations, networks and hospital affiliations, and the local market. In this model, population characteristics and payer and regulatory factors interact to influence decisions. Results: Patient openness to behavior modification and expectations, facilitated and hindered physicians in making evidence-based recommendations. Physicians’ communication skills were the most commonly mentioned facilitator. Practice site, organization, and hospital system barriers included measures of emergency department throughput, the order in which test options are listed in electronic health records (EHR), lack of relevant decision support in EHRs, and payment incentives that maximize billing and encourage procedures rather than medical management or counseling patients on behavior change. Factors from different levels interacted to undermine evidence-based care. Most physicians received billing feedback, but quality metrics on evidence-based service use were nonexistent for the four decisions in this study. Conclusions and Implications: Additional research and quality improvement may help to modify delivery systems to overcome barriers at multiple levels. Enhancing provider communication skills, improving decision support in EHRs, modifying workflows, and refining the design and interpretation of some quality metrics would help, particularly if combined with concurrent payment reform to realign financial incentives across stakeholders.

Objective: The objective of this work is to assess the prevalence of the sliver sign, defined as an intraarticular linear or curvilinear ossific density, in association with knee effusion in patients with acute knee trauma, as a predictor of recent lateral patellar dislocation (LPD).Materials and Methods: A retrospective radiology database search for the term 'patellar dislocation' on MRI knee exams performed at our institution over a 7-year period identified 216 studies. Of these, 142 exams met true positive gold standard diagnostic criteria for LPD. Imaging findings of both the retrospectively identified radiographs and subsequent MRI were recorded. Accuracy of radiographic interpretation was also analyzed.Results: After review by an experienced musculoskeletal radiologist, 27 patients (19%) with LPD had knee radiographs demonstrating intraarticular osseous fragments. The majority of these patients had fragments (22/27, 81%) that were linear or curvilinear in configuration. A smaller subset of patients had fragments (5/27, 19%) that were rounded or oblong, felt to most likely represent sequelae of chronic dislocation. The fragments were identified on the patellar view only in eight of 27 patients (30%). These fragments were often initially misinterpreted, with the diagnosis explicitly stated in the report in 2/27 cases (7%). More often, the fractures were described vaguely (13/27, 48%), interpreted incorrectly (6/27, 22%), or missed (6/27, 22%). All 27 patients had moderate or large knee joint effusions.Conclusions: In the setting of acute knee trauma, knee radiographs demonstrating a joint effusion and an intraarticular sliver-like osseous fragment correlate with recent lateral patellar dislocation. The routine trauma knee radiographic series does not include a patellar view but probably should, especially in young patients. [ABSTRACT FROM AUTHOR]

Background: Burnout is common amongst surgical trainees and its consequences can be detrimental to both mental health and patient care. As such, wellness and professional development have moved to the forefront of discussion in surgical education. The purpose of this study is to describe the current landscape of wellness and professional development education, as well as barriers to initiation of dedicated curricula., Methods: Electronic surveys were distributed to 115 publicly available program director (PD) or coordinator emails for integrated and independent plastic surgery programs., Results: The survey response rate was 40%. Burnout was a problem within 28.6% of respondent's programs. An additional 50% reported "they had dealt with burnout, but it was not a problem." Thus, 78.6% of respondents reported burnout issues amongst their trainees. While all respondents believed that prioritizing resident wellness was 1 of their many roles, 78.6% felt that this role should be shared. Forty percent of programs did not have wellness programming with 84.2% indicating that the addition of a dedicated curriculum would benefit their trainees. Common barriers to implementation included: lack of interest, impingement upon free time, lack of resources, onerous initiation, and concern regarding a shift from academic focus. Eighty three percent of respondents would be interested in adopting curricula from another program., Conclusions: Burnout remains a major issue, affecting over 75% of plastic surgery programs; however, the current landscape of wellness and professional development curricula is highly variable. Adopting curricula from other programs may address commonly cited barriers., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Despite advancements in cystic fibrosis (CF) therapeutics, the persistence of chronic infections necessitates continued use of nebulized therapies. Though the Cystic Fibrosis Foundation recommends well-defined cleaning and disinfection of nebulizers to mitigate pathogen exposure risks, discrepancies between Cystic Fibrosis Foundation guidelines, manufacturers' instructions, and variability in center recommendations contribute to confusion and non-standardized practices., Methods: A digital survey was distributed to directors, associate directors, and care coordinators of CF centers across the United States to investigate the methods, frequency, and educational practices surrounding nebulizer care they provide patients. Responses were analyzed using descriptive techniques and chi-square analyses., Results: Of 855 distributed surveys, 129 respondents provided insights into nebulizer care recommendations. Discrepancies in disinfection frequency were notable, with 18% of respondents recommending disinfecting nebulizers less than daily. Approximately 20% of respondents were unsure if their recommendations aligned with Cystic Fibrosis Foundation guidelines while 73% reported that their recommendations strictly adhered to the published guidelines. Of this 73%, all recommended at least daily cleaning, with 69% specifying cleaning before reuse; and 88% recommended disinfection at least daily, with 36% specifying disinfection before reuse. Only 10% recommended both cleaning and disinfection after every use. Disinfection less than daily was recommended by 11% of the respondents who felt they were strictly following the guidelines. We also highlight respondents who cited barriers to strict adhesion to the published guidelines., Conclusions: The highlighted variations in CF centers' recommendations for nebulizer care with deviations from Cystic Fibrosis Foundation guidelines underscore the necessity for developing clear and practical guidelines that consider both efficacy and the realities of patient adherence. Collaboration among CF care centers, patients, guideline committees, and other stakeholders is essential to develop recommendations that effectively address the challenges faced by the CF community, ensuring the safe and effective nebulizer use., (Copyright © 2024 by Daedalus Enterprises.)

Autologous breast reconstruction with a deep inferior epigastric artery perforator (DIEP) flap is an excellent option for many patients proceeding with mastectomy for surgical management of their breast cancer. As microsurgical techniques and results improve and ensure consistent flap survival, optimizing aesthetic outcomes may become a primary focus. This article outlines 20 tips that can improve aesthetic results in DIEP flap breast reconstruction, based on our senior author's 8-year career in microsurgical breast reconstruction, with an emphasis on enhanced cosmesis. We highlight tips on preoperative planning, intraoperative, and revision stages of the reconstruction and provide a schematic for integrating the tips into a reader's microsurgical breast reconstruction practice., Competing Interests: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Objective: To identify preoperative MRI findings in patients with arthroscopically confirmed hypermobile lateral meniscus utilizing a standard MRI knee protocol, with comparison to normal control and lateral meniscal tear groups., Subjects and Methods: All patients with arthroscopically confirmed hypermobile lateral meniscus diagnosed at our institution were retrospectively identified. The following structures were evaluated on preoperative knee MRIs: superior and inferior popliteomeniscal fascicles, lateral meniscus and meniscocapsular junction, popliteal hiatus, and soft tissue edema around the popliteal hiatus. The same MRI features were evaluated in the normal control and lateral meniscal tear groups., Results: Study, normal control, and lateral meniscal tear patients (18 each) were included. In the study group, 94.4% had superior popliteomeniscal fascicle abnormality, 89.0% had inferior popliteomeniscal fascicle abnormality, and 72.2% had lateral meniscal abnormality. Incidence of these abnormalities was significantly higher than in the normal control group. Meniscal abnormalities in the study group all involved the posterior horn meniscocapsular junction, 12/13 of which had vertical signal abnormality at the junction and 1/13 with anterior subluxation of the entire posterior horn. Popliteus hiatus measurements were largest in the lateral meniscal tear group., Conclusion: In patients with hypermobile lateral meniscus, the combination of popliteomeniscal fascicle abnormality and vertical signal abnormality at the meniscocapsular junction was seen in the majority of patients. Popliteomeniscal fascicle signal abnormality without identifiable lateral meniscal injury was the next most common imaging appearance. Radiologists may provide valuable information by suggesting the diagnosis of hypermobile lateral meniscus in such cases., (© 2023. The Author(s), under exclusive licence to International Skeletal Society (ISS).)

Breast reconstruction is an integral part of breast cancer treatment and offers significant psychosocial benefits for patients undergoing mastectomy as a part of their treatment plan. Autologous breast reconstruction (ABR) utilizes a patient's own tissue to reconstruct the mastectomy defect, obviating the need for the implantation of a foreign object. As the field of plastic surgery progresses, ABR has become an excellent option for the recreation of a native breast mount. With that said, there are patient populations who present unique challenges when optimizing an aesthetic ABR result. We aim to discuss these challenging groups, including patients with both high and low body mass index (BMI), patients with a history of massive weight loss, patients who require post-mastectomy radiation therapy (PMRT), and patients electing for unilateral procedures where the surgeon attempts to match the reconstructed breast with the native breast. In our discussion, we review the literature recommendations for management as well as our experiences with our own patient cases. Ultimately, we believe this procedure can be performed in a wide variety of patient types and can be offered to those who may not be considered the "ideal" candidate.

This review illustrates the imaging features of rhabdomyolysis across multiple modalities and in a variety of clinical scenarios. Rhabdomyolysis is the rapid breakdown of striated muscle following severe or prolonged insult resulting in the release of myocyte constituents into circulation. In turn, patients develop characteristically elevated serum creatine kinase, positive urine myoglobin, and other serum and urine laboratory derangements. While there is a spectrum of clinical symptoms, the classic presentation has been described as muscular pain, weakness, and dark urine. This triad, however, is only seen in about 10% of patients. Thus, when there is a high clinical suspicion, imaging can be valuable in evaluating the extent of muscular involvement, subsequent complications such as myonecrosis and muscular atrophy, and other etiologies or concurrent injuries causing musculoskeletal swelling and pain, especially in the setting of trauma. Sequela of rhabdomyolysis can be limb or life-threatening including compartment syndrome, renal failure, and disseminated intravascular coagulation. MRI, CT, ultrasound, and 18-FDG PET/CT are useful modalities in the evaluation of rhabdomyolysis., (© 2023. The Author(s), under exclusive licence to International Skeletal Society (ISS).)

Neutrophil extracellular traps (NETs), a key component of early defense against microbial infection, are also associated with tissue injury. NET composition has been reported to vary with some disease states, but the composition and variability of NETs across many healthy subjects provide a critical comparison that has not been well investigated. We evaluated NETs from twelve healthy subjects of varying ages isolated from multiple blood draws over a three-and-one-half-year period to delineate the variability in extracellular DNA, protein, enzymatic activities, and susceptibility to protease inhibitors. We calculated correlations for NET constituents and loss of human bronchial epithelial barrier integrity, measured by transepithelial electrical resistance, after NET exposure. We found that although there was some variability within the same subject over time, the mean NET total DNA, dsDNA, protein, LDH, neutrophil elastase (NE), and proteinase 3 (PR3) in isolated NETs were consistent across subjects. NET serine protease activity varied considerably within the same donor from day to day. The mean NET cathepsin G and MPO were significantly different across donors. IL-8 > IL-1RA > G-CSF were the most abundant cytokines in NETs. There was no significant difference in the mean concentration or variability of IL-8, IL-1RA, G-CSF, IL-1α, IL-1β, or TNF-α in different subjects' NETs. NET DNA concentration was correlated with increased NET neutrophil elastase activity and higher NET IL-1RA concentrations. The mean reduction in protease activity by protease inhibitors was significantly different across donors. NET DNA concentration correlated best with reductions in the barrier integrity of human bronchial epithelia. Defining NET concentration by DNA content correlates with other NET components and reductions in NET-driven epithelial barrier dysfunction, suggesting DNA is a reasonable surrogate measurement for these complex structures in healthy subjects.

Pediatric pulmonology fellowship training programs are required by the Accreditation Council for Graduate Medical Education to report Pediatric Subspecialty Milestones biannually to track fellow progress. However, several issues, such as lack of subspecialty-specific context and ambiguous language, have raised concerns about their validity and applicability to use for fellow assessment and curriculum development. In this Perspective, we briefly share the process of the Pediatric Pulmonology Milestones 2.0 Work Group in creating new specialty-specific Milestones and tailoring information on the Harmonized Milestones to pediatric pulmonologists, with the goal of improving the Milestones' utility for stakeholders, including pulmonology fellows, faculty, program directors, and accrediting bodies. In addition, we created a supplemental guide to better link the Milestones to pulmonary-specific scenarios to create a shared mental model between stakeholders and remove a potential detriment to validity. Through the process, a number of guiding principles were clarified, including: 1 ) every Milestone should be able to be assessed independently, without overlap with other Milestones; 2 ) there should be clear developmental progression from one Milestone to the next; 3 ) Milestones should be based on the unique skills expected of pediatric pulmonologists; and 4 ) health equity should be a core component to highlight as a top priority to all stakeholders. In this Perspective, we describe these principles that guided formulation of the Pediatric Pulmonary Milestones to help familiarize the pediatric pulmonary community with the new Milestones. In addition, we share lessons learned and challenges in our process to inform other specialties that may soon participate in this process., (Copyright © 2024 by the American Thoracic Society.)

Introduction: The Cystic Fibrosis Foundation (CF Foundation) recommends the provision of genetic counseling (GC) to help educate families and decrease anxiety around the cystic fibrosis (CF) newborn screening process. Unfortunately, access to genetic counselors is limited, especially for CF trained genetic counselors. We hypothesized that the GC process for families could be improved by utilizing telemedicine to leverage the availability of two dedicated, CF trained genetic counselors to provide access to GC for several CF centers. In addition, we hoped to demonstrate that use of trained CF genetic counselors, delivering GC via telemedicine at the time of sweat testing, would provide families with understanding of CF genetics as well as result in high satisfaction with the newborn screening process., Methods: GC was provided by CF trained genetic counselors via telemedicine at the time of sweat testing. Following the counseling session, families were administered an anonymous written survey to evaluate their impression of the services provided. A subset of 50 families was recruited for an assessment of gained knowledge regarding CF genetics using the Ciske knowledge inventory. Using χ 2  analysis, Ciske knowledge inventory data from our telemedicine GC families was compared to counseled and uncounseled Ciske historical controls. Lastly, in-depth interviews about the newborn screening process for CF were performed with 10 families and interviews were coded for emerging themes., Results: During the 4 years of the study, 250 patients received GC. Overall comfort with the counseling rated 4.77 out of 5 using a Likert scale. After counseling by telemedicine, parents demonstrated improved understanding of the genetic implications of an abnormal CF newborn screen for their family, with 100% of families understanding that their child was a carrier for CF as compared to 97.2% of counseled (p = .023) and 78.5% of uncounseled (p = .0007) from Ciske historical controls. The study group also showed improvement in understanding of both parents possibly being carriers, with an 87.7% correct response rate compared to a 37.0% correct response rate in the counseled group (p < .0001) and a 35.4% correct response rate in the non-counseled group (p < .0001) from Ciske historical controls. Subgroup analysis at one site showed a significant increase in the number of infants with completed sweat tests from previous years (49% in 2013 vs. 80% in 2017 during the study, p < .0001)., Conclusions: GC by telemedicine was well received by families and demonstrated improved family knowledge acquisition and understanding of CF as it related to risks for their child as well as identification of risks for other family members. Furthermore, in addition to an increase is those receiving GC, a subgroup analysis demonstrated a significant increase in the number of infants receiving sweat tests. This study demonstrates that GC via telemedicine for CF is feasible and demonstrates improvement in parent understanding of CF genetics. Furthermore, this method can be implemented effectively across a wide geographical area with a limited number of CF trained genetic counselors to improve access to care for patients and families., (© 2023 Wiley Periodicals LLC.)

Aims: The benefit of MRI in the preoperative assessment of scaphoid proximal fragment vascularity remains controversial. The purpose of this study is to compare preoperative MRI findings to intraoperative bleeding of the proximal scaphoid., Methods: A retrospective review of 102 patients who underwent surgery for scaphoid nonunion between January 2000 and December 2020 at a single institution were identified. Inclusion criteria were: isolated scaphoid nonunion; preoperative MRI assessing the proximal fragment vascularity; and operative details of the vascularity of the proximal fragment with the tourniquet deflated. MRI results and intraoperative findings were dichotomized as either 'yes' or 'no' for the presence of vascularity. A four-fold contingency table was used to analyze the utility of preoperative MRI with 95% confidence intervals. Relative risk was calculated for subgroups to analyze the association between variables and MRI accuracy., Results: Preoperative MRI identified 55 proximal scaphoid fragments with ischaemia and 47 with vascularized proximal fragments. After the proximal fragment was prepared, the tourniquet was deflated and assessed for bleeding; 63 proximal fragments had no bleeding and 39 demonstrated bleeding. MRI was not reliable or accurate in the assessment of proximal fragment vascularity when compared with intraoperative assessment of bleeding. No patient or MRI factors were identified to have a statistical impact on MRI accuracy., Conclusion: Current preoperative MRI protocols and diagnostic criteria do not provide a high degree of correlation with observed intraoperative assessment of proximal fragment bleeding. While preoperative MRI may assist in surgical planning, intraoperative assessment remains the best means for assessing proximal fragment vascularity in scaphoid nonunion. Future efforts should focus on the development of objective measures of osseous blood flow that may be performed intraoperatively., Competing Interests: A. Y. Shin reports royalties or licenses from TriMed Orthopedics/Mayo Medical Ventures and consulting fees from Integra Life Sciences, all of which are unrelated to this study. A. Y. Shin is also Editor of Techniques in Hand and Upper Extremity., (© 2023 The British Editorial Society of Bone & Joint Surgery.)

The Wellness-Inspired Resident Education (WIRE) curriculum is a resident-driven educational program consisting of six formal panels or lectures that are fully incorporated into the yearly resident didactic schedule, in addition to informal events and a resident wellness retreat. The curriculum promotes personal and professional wellness, enhances resident and department camaraderie, and provides opportunities to network with leaders in the field of plastic surgery. This paper provides the context which inspired the development of this curriculum, as well as key steps for successful implementation of wellness educational programming at any institution., Competing Interests: DECLARATION OF COMPETING INTEREST The authors have no relevant competing interests to disclose., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: This article reviews new approaches, facilitators, barriers, and opportunities to increasing adoption of standardized asthma management programs in the outpatient care setting., Recent Findings: Primary care clinicians providing asthma care in the outpatient setting are challenged by the complexity of guidelines and want standardization of tools that are easy to use and that can be integrated within their practice's workflow. Programs that integrate clinical decision support tools within a practice's electronic health record and provide support from specialists may enhance uptake of asthma management programs in the outpatient setting and reduce asthma morbidity. Lack of an implementation science framework, consideration for organizational context, and clinician buy-in are recently recognized barriers to adoption of asthma programs and improved asthma outcomes. In addition, many of these interventions are labor intensive, costly, and may not be capable of wide dissemination because of the EHR interoperability problem., Conclusion: Programs that simplify the guidelines, integrate clinical decision support within the EHR, and ground their approach with an implementation science framework may improve the quality of asthma care provided in the outpatient setting., (Copyright © 2023 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Conflicts of interest None disclosed.

Objective : confluent T1 hypointense marrow signal is widely accepted to represent osteomyelitis on MRI. Some authors have suggested that non-confluent bone marrow signal abnormality should be considered early osteomyelitis. The purpose of this study was to address this issue by comparing the rate of osteomyelitis and amputation based on T1 marrow signal characteristics. Materials and methods : a total of 112 patients who underwent MRI of the foot for the evaluation of possible osteomyelitis were included. Patients were assigned to confluent T1 hypointense, reticulated T1 hypointense, and normal bone marrow signal groups. Results : patients with confluent T1 hypointense signal on MRI had significantly higher rates of osteomyelitis and amputation at 2 and 14 months post-MRI than the reticulated T1 hypointense group ( p < 0.001 ). Six patients had normal T1 signal, 16.7 % of whom had osteomyelitis and underwent amputation by 2 months post-MRI. Of 61 patients with reticulated T1 hypointense signal, 19.7 % had a diagnosis of osteomyelitis at 2 months post-MRI and 30.8 % had a diagnosis of osteomyelitis at 14 months post-MRI; moreover, 14.8 % and 31.5 % underwent amputation by 2 and 14 months post-MRI, respectively. Of 45 patients with confluent T1 hypointense signal, 73.3 % of patients had osteomyelitis at 2 months post-MRI and 82.5 % had osteomyelitis at 14 months post-MRI. In this group, 66.7 % underwent amputation by 2 months post-MRI and 77.8 % underwent amputation by 14 months post-MRI. Conclusions : over half of the patients with suspected pedal osteomyelitis who had reticulated or normal T1 bone marrow signal on MRI healed with conservative measures. Therefore, we recommend terminology such as "osteitis", "reactive osteitis", or "nonspecific reactive change" to describe bone marrow edema-like signal and reticulated hazy T1 hypointense signal without associated confluent T1 hypointensity. Moreover, we recommend that the MRI diagnosis of osteomyelitis is reserved for confluent T1 hypointense bone signal in the area of concern., Competing Interests: The contact author has declared that none of the authors has any competing interests., (Copyright: © 2023 Christin A. Tiegs-Heiden et al.)

Competing Interests: Conflicts of interest: the authors declare they have no conflicts of interest.

Neutrophil extracellular traps contribute to lung injury in cystic fibrosis and asthma, but the mechanisms are poorly understood. We sought to understand the impact of human NETs on barrier function in primary human bronchial epithelial and a human airway epithelial cell line. We demonstrate that NETs disrupt airway epithelial barrier function by decreasing transepithelial electrical resistance and increasing paracellular flux, partially by NET-induced airway cell apoptosis. NETs selectively impact the expression of tight junction genes claudins 4, 8 and 11. Bronchial epithelia exposed to NETs demonstrate visible gaps in E-cadherin staining, a decrease in full-length E-cadherin protein and the appearance of cleaved E-cadherin peptides. Pretreatment of NETs with alpha-1 antitrypsin (A1AT) inhibits NET serine protease activity, limits E-cadherin cleavage, decreases bronchial cell apoptosis and preserves epithelial integrity. In conclusion, NETs disrupt human airway epithelial barrier function through bronchial cell death and degradation of E-cadherin, which are limited by exogenous A1AT., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Hudock, Collins, Imbrogno, Kramer, Brewington, Ziady, Zhang, Snowball, Xu, Carey, Horio, O’Grady, Kopras, Meeker, Morgan, Ostmann, Skala, Siefert, Na, Davidson, Gollomp, Mangalmurti, Trapnell and Clancy.)

This review illustrates the multimodality assessment of transfascial muscle and other soft tissue herniations of the extremities. Transfascial herniations of the extremities can develop from congenital or acquired disruptions of the deep fascia, resulting in herniation of the underlying muscle, nerve, or soft tissue tumor into the subcutaneous tissues. While most patients present with a painless subcutaneous nodule that may change in size with muscle activation, some may experience focal or diffuse extremity symptoms such as pain and paresthesias. Although the diagnosis may be clinically suspected, radiologic evaluation is useful for definitive diagnosis and characterization. Ultrasound is the preferred modality for initial workup through a focused and dynamic examination. Magnetic resonance imaging can be utilized for equivocal, complicated, and preoperative cases. Computed tomography is less useful in the evaluation of transfascial herniations in the extremities due to similarities in the attenuation between muscle and fascia, which can decrease the conspicuity of small defects., (© 2022. The Author(s), under exclusive licence to International Skeletal Society (ISS).)

Competing Interests: None.

The interosseous membrane (IOM) of the leg is a component of the tibiofibular syndesmosis that serves an important role in stabilization, as well as transferring forces to the fibula during weight-bearing. We present two separate cases of acute traumatic rupture of the midportion of the interosseous membrane in high school soccer players with blunt trauma to the anterior shin with MRI and ultrasound confirmation., (© 2022. The Author(s), under exclusive licence to International Skeletal Society (ISS).)

Background: Magnetic resonance imaging (MRI) is considered to be the gold standard for imaging of osteochondritis dissecans (OCD)., Purpose/hypothesis: The purpose was to determine the additional value of a preoperative computed tomography (CT) scan in adolescent patients with capitellar OCD of the elbow. Consistent with the fact that OCD is a lesion involving the subchondral bone, the hypothesis was that CT would be superior to MRI for imaging OCD of the capitellum., Study Design: Cohort study (diagnosis); Level of evidence, 3., Methods: All patients being treated surgically for an OCD of the capitellum between 2006 and 2016 at one institution were reviewed for preoperative imaging. A total of 28 patients met the inclusion criteria. Corresponding MRI and CT scans were compared retrospectively. Multiple parameters were recorded, with special emphasis on OCD lesion size, fragmentation, and tilt as well as joint surface integrity, loose bodies, and osteophytes., Results: The OCD lesions were best seen on CT scans, whereas MRI T1-weighted images overestimated and T2-weighted images underestimated the size of defects. A subchondral fracture nonunion was found on CT scans in 18 patients, whereas this was seen on MRI T1-weighted images in only 2 patients ( P < .001) and MRI T2-weighted images in 4 patients ( P < .001). Fragmentation of the OCD fragment was found on CT scans in 17 patients but on MRI scans in only 9 patients ( P = .05). Osteophytes as a sign of secondary degenerative changes were seen on CT scans in 24 patients and were seen on MRI scans in 15 patients ( P = .02). Altogether, only 51 of 89 secondary changes including loose bodies, effects on the radial head and ulnohumeral joint, and osteophytes that were seen on CT scans were also seen on MRI scans ( P = .002)., Conclusion: OCD fragmentation and secondary changes were more often diagnosed on CT. These factors indicate OCD instability or advanced OCD stages, which are indications for surgery. In an adolescent who is considered at risk for OCD (baseball, gymnastics, weightlifting, tennis) and who has lateral elbow joint pain with axial or valgus load bearing, CT is our imaging modality of choice for diagnosing and staging OCD of the capitellum.

Many preclinical studies of infectious diseases have neglected experimental designs that evaluate potential differences related to sex with a concomitant over-reliance on male model systems. Hence, the NIH implemented a monitoring system for sex inclusion in preclinical studies., Methods: Per this mandate, we examined the lung burdens of Pneumocystis murina infection in three mouse strains in both male and female animals at early, mid, and late time points., Results: Females in each strain had higher infection burdens compared to males at the later time points., Conclusion: Females should be included in experimental models studying Pneumocystis spp.

Competing Interests: Conflicts of interest None disclosed.

Objective: To assess MRI abnormalities of the medial patellofemoral ligament (MPFL) in patients with clinically and MRI-proven superficial medial collateral ligament (sMCL) injuries and determine the clinical significance., Materials and Methods: High-field strength knee MRI examinations were selected which demonstrated sMCL injuries. These cases were retrospectively reviewed for the presence, location, and severity of MPFL abnormality. The MPFL was divided into a more superior transverse component arising from a femoral attachment (tMPFL), and a broader more inferior oblique decussation component (odMPFL) arising from the anterior margin of the upper sMCL. Chart review was performed to determine the clinical relevance of any MPFL findings., Results: One hundred patients with MCL injury were identified. These included 37 grade I sprains, 33 partial tears, 20 high-grade partial tears, and 10 full thickness tears. Abnormal edema was present at the femoral attachment of the tMPFL in 83%. The odMPFL was abnormal in 90%, most commonly involving the femoral third. No patients had imaging evidence of concurrent lateral patellar dislocation on the initial MRI study. No patients had documented patellofemoral instability at the time of original injury or upon follow-up. No patients required MPFL reconstruction., Conclusion: The MRI appearance of the MPFL is abnormal in the majority of patients with clinically and MRI-documented sMCL sprains and tears. These cases had no evidence of concurrent lateral patellar dislocation on the initial MRI and did not develop patellar instability symptoms., (© 2021. ISS.)

Patients with chronic respiratory diseases use home nebulizers that are often contaminated with pathogenic microbes to deliver aerosolized medications. The conditions under which these microbes leave the surface as bioaerosols during nebulization are not well characterized. The objectives of this study were to (i) determine whether different pathogens detach and disperse from the nebulizer surface during aerosolization and (ii) measure the effects of relative humidity and drying times on bacterial surface detachment and aerosolization. Bacteria were cultured from bioaerosols after Pari LC Plus albuterol nebulization using two different sources, as follows: (i) previously used nebulizers donated by anonymous patients with cystic fibrosis (CF) and (ii) nebulizers inoculated with bacteria isolated from the lungs of CF patients. Fractionated bioaerosols were collected with a Next-Generation Impactor. For a subset of bacteria, surface adherence during rewetting was measured with fluorescence microscopy. Bacteria dispersed from the surface of used CF patient nebulizers during albuterol nebulization. Eighty percent (16/20) of clinical isolates inoculated on the nebulizer in the laboratory formed bioaerosols. Detachment from the plastic surface into the chamber solution predicted bioaerosol production. Increased relative humidity and decreased drying times after inoculation favored bacterial dispersion on aerosols during nebulized therapy. Pathogenic bacteria contaminating nebulizer surfaces detached from the surface as bioaerosols during nebulized therapies, especially under environmental conditions when contaminated nebulizers were dried or stored at high relative humidity. This finding emphasizes the need for appropriate nebulizer cleaning, disinfection, and complete drying during storage and informs environmental conditions that favor bacterial surface detachment during nebulization. IMPORTANCE Studies from around the world have demonstrated that many patients use contaminated nebulizers to deliver medication into their lungs. While it is known that using contaminated medications in a nebulizer can lead to a lung infection, whether bacteria on the surface of a contaminated nebulizer detach as bioaerosols capable of reaching the lung has not been studied. This work demonstrates that a subset of clinical bacteria enter solution from the surface during nebulization and are aerosolized. Environmental conditions of high relative humidity during storage favor dispersion from the surface. We also provide results of an in vitro assay conducted to monitor bacterial surface detachment during multiple cycles of rewetting that correlate with the results of nebulizer/bacterial surface interactions. These studies demonstrate for the first time that pathogenic bacteria on the nebulizer surface pose a risk of bacterial inhalation to patients who use contaminated nebulizers.

Motorized vessels are a major source of anthropogenic noise and can have adverse effects on species relying on sound for communication and feeding. Monitoring noise levels received by endangered southern resident killer whales (SRKWs) requires knowing the number, distance, and speed of surrounding vessels, including small boats that do not have Automatic Identification Systems (AIS). A method for estimating their speed is required to predict received noise levels and compliance with vessel regulations. We compared theodolite and photogrammetry methods to estimate the number, distance, and speed of vessels in SRKW Salish Sea summertime critical habitat. By treating AIS as "truth", we found photogrammetry-derived ranges and speeds were more variable than theodolite estimates. Error in photogrammetry-derived speeds increased with range. Overall, we found time saved in the field using photogrammetry was more than offset by long analysis time. Theodolite data were relatively easy to collect, and produced accurate and precise results., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Competing Interests: The authors declare no conflicts of interest.