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Introduction: Both knotted all suture anchors and metal anchors are used for arthroscopic Bankart repair. We retrospectively evaluated and compared clinical and functional outcomes after arthroscopic Bankart repair using the knotted all-suture anchors and knotted metal anchors. Materials and methods: In a retrospective cohort analysis, patients who underwent arthroscopic Bankart repair without any concomitant additional lesion repair using either all-suture anchors or metal anchors, between January 2015 and May 2018 were identified. Their pre- and post-operative functional and clinical outcomes were compared using Rowe and WOSI scores. The recurrence rate in the two groups was also compared. Results: A total of 41 patients in all suture anchors group and 47 in the metal anchors group were identified as per inclusion and exclusion criteria. The demographic profile of both groups was comparable. There was no significant difference in clinical and functional outcome between the two suture anchor groups as per Rowe (pre-operative 40.13+6.51 vs 38.09+6.24 and post-operative 2 years 93.28+7.09 vs 92.55+9.2) and WOSI (pre-operative 943.05+216.64 vs 977.55+165.46 and post-operative 2 years 278.21+227.56 vs 270.94+186.25) scores. There was a significant improvement in both the groups between pre-operative and post-operative ROWE and WOSI scores at 6 months and 2 years follow-up as compared to pre-operative scores (p

Phillip Mitchell Johansen,1,&ast; Alan M Nguyen,2,&ast; Ali Ahmed Mohamed,1,&ast; Natasha Mehta,2,&ast; Julie Georgia Pilitsis,1,&ast; Benjamin Westerhaus,2,&ast; Anthony Giuffrida2,&ast; 1Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA; 2Cantor Spine Institute, Fort Laderdale, FL, USA&ast;These authors contributed equally to this workCorrespondence: Phillip Mitchell Johansen, Charles E. Schmidt College of Medicine Florida Atlantic University, 777 Glades Road, BC 71, Room 235, Boca Raton, FL, 33431, USA, Tel +1 (561) 297-4341, Email p.m.johansen27@gmail.comIntroduction: Sacroiliac joint (SIJ) pathology is typically diagnosed and treated with fluoroscopy-guided intraarticular injections. Most practitioners use only an anteroposterior (AP) or oblique view. Although injection into the periarticular space may yield adequate pain relief, intraarticular needle placement is imperative to identify SIJ pathology and plan future management. This study highlights the importance of obtaining an additional lateral view during fluoroscopy to better evaluate SIJ disease.Methods: A retrospective review of 38 patients who underwent fluoroscopy guided SIJ injection was conducted, for which IRB approval was granted by the MetroWest Medical Center Institutional Review Board. Patient demographics (age, sex, BMI) and pre- and post-operative numerical rating scale (NRS) scores were collected, and initial needle location was reviewed. Patients were placed into groups according to initial needle location. Statistical analysis was conducted using a Mann–Whitney U-test with significance defined as p < 0.05.Results: The 21 females and 17 males had a mean age and BMI of 70.5 years and 27.8 kg/m2, respectively. Thirty-one patients had initial intraarticular needle placement confirmed with lateral arthrogram, and 7 patients had initial periarticular needle placement, requiring needle readjustment in lateral confirmatory view. Both groups had similar demographic characteristics. No statistically significant differences were found between the two groups’ mean NRS score improvement (p=0.108).Conclusion: Using only the AP or oblique view during needle placement results in miss rates of nearly 20% while adding a lateral view can lower miss rates to near 0%. While pain relief may be adequate in either case, proper diagnosis and future management relies upon accurate needle placement.Keywords: corticosteroid injections, fluoroscopy, intraarticular, periarticular

Neel Mehta,1,&ast; Neal E Slatkin,2,3,&ast; Robert J Israel,4,&ast; Nancy Stambler,5,&ast; Eric D Shah6,&ast; 1Department of Anesthesiology, Weill Cornell School of Medicine, New York, NY, USA; 2School of Medicine, University of California Riverside, Riverside, CA, USA; 3Medical Affairs, Salix Pharmaceuticals, Bridgewater, NJ, USA; 4Clinical and Medical Affairs, Bausch Health US LLC, Bridgewater, NJ, USA; 5Clinical Research, Progenics Pharmaceuticals, a Subsidiary of Lantheus Holdings Inc, North Billerica, MA, USA; 6Division of Gastroenterology and Hepatology, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA&ast;These authors contributed equally to this workCorrespondence: Eric D Shah, Division of Gastroenterology and Hepatology, University of Michigan | Michigan Medicine, 300 N Ingalls Street, Ann Arbor, MI, 48109, USA, Tel +1 877 285-7788, Email ershah@umich.eduPurpose: We evaluated the impact of baseline patient characteristics on safety and efficacy of methylnaltrexone, a peripherally acting μ-opioid receptor antagonist, in patients with advanced illness with opioid-induced constipation (OIC).Patients and Methods: This analysis pooled data from 2 randomized, double-blind, placebo-controlled studies (study 302: NCT00402038; study 4000: NCT00672477) in patients with advanced illness, including cancer, and OIC. Patients were randomized to receive subcutaneous methylnaltrexone (study 302: 0.15 mg/kg; study 4000: 8 or 12 mg based on weight) or placebo every other day for 2 weeks. The proportions of patients achieving rescue-free laxation within 4 or 24 hours after the first dose of study drug were assessed in patient subgroups stratified by baseline age, Eastern Cooperative Oncology Group (ECOG) performance status, cancer status, laxative type, and opioid requirement. Treatment-emergent adverse events (TEAEs) were evaluated.Results: Overall, 363 patients were included in this analysis (methylnaltrexone, 178; placebo, 185). Mean (SD) age was 66.3 (13.7) years and 48.5% were men overall. A significantly greater proportion of patients receiving methylnaltrexone versus placebo achieved rescue-free laxation within 4 hours (111/178 [62.4%] vs 31/185 [16.8%]; P< 0.0001) and 24 hours (135/178 [75.8%] vs 81/185 [43.8%]; P< 0.0001) of the first dose. These trends were consistent across all subgroups. Most patients experienced ≥ 1 TEAE in the overall population (methylnaltrexone, 82.1%; placebo, 76.2%), which remained consistent when stratified by baseline characteristics. More than half of TEAEs were gastrointestinal in nature. Abdominal pain was more common in patients receiving methylnaltrexone than placebo across baseline characteristic subgroups.Conclusion: Methylnaltrexone treatment was superior to placebo in achieving rescue-free laxation within 4 and 24 hours after the first dose, irrespective of patients’ cancer status, baseline ECOG performance status, or baseline opioid or laxative use. The methylnaltrexone safety profile remained consistent across baseline characteristic subgroups.Keywords: methylnaltrexone, opioid-induced constipation, μ-opioid receptor antagonist

Nicholas Barker,1 Ian A Scott,1 Robert Seaton,2 Naitik Mehta,2 Vikrant R Kalke,2 Lyndell Redpath2 1Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; 2Patient Quality and Safety Improvement Service, Queensland Health, Brisbane, AustraliaCorrespondence: Ian A Scott, Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, 199 Ipswich Road, Brisbane, 4102, Australia, Tel +61-7-31767355, Fax +61-7-31765214, Email ian.scott@health.qld.gov.auPurpose: To assess accuracy of early diagnosis, appropriateness and timeliness of response, and clinical outcomes of older general medical inpatients with hospital-acquired sepsis.Methods: Hospital abstracts of inpatient encounters from seven digital Queensland public hospitals between July 2018 and September 2020 were screened retrospectively for diagnoses of hospital-acquired sepsis. Electronic medical records were retrieved and cases meeting selection criteria and classified as confirmed or probable sepsis using pre-specified criteria were included. Investigations and treatments following the first digitally generated alert of clinical deterioration were compared with a best practice sepsis care bundle. Outcome measures comprised 30-day all-cause mortality after deterioration, and unplanned readmissions at 14 days after discharge.Results: Of the 169 screened care episodes, 59 comprised probable or confirmed cases of sepsis treated by general medicine teams at the time of initial deterioration. Of these, 43 (72.9%) had no mention of sepsis in the differential diagnosis on first medical review, and only 38 (64%) were managed as having sepsis. Each care bundle component of blood cultures, serum lactate, and intravenous fluid resuscitation and antibiotics was only delivered in approximately 30% of cases, and antibiotic administration was delayed more than an hour in 28 of 38 (73.7%) cases.Conclusion: Early recognition of sepsis and timely implementation of care bundles are challenging in older general medical patients. Education programs in sepsis care standards targeting nurses and junior medical staff, closer patient monitoring, and post-discharge follow-up may improve patient outcomes.Keywords: early recognition, clinical deterioration, management, care bundle, mortality, readmissions, older adults, frailty

Neesurg Mehta,1 Rodney D Fong,1,2 Machelle Wilson,3 Kareem Moussa,1 Parisa Emami-Naeini,1,4 Ala Moshiri,1 Glenn Yiu,1 Susanna S Park1 1Department of Ophthalmology and Vision Science, University of California Davis Health, Sacramento, CA, USA; 2University of Nevada, Reno School of Medicine, Reno, NV, USA; 3Department of Public Health Sciences, Division of Biostatistics, University of California, Davis, CA, USA; 4Department of Ophthalmology, Veterans Administration Hospital, Mather, CA, USACorrespondence: Susanna S Park, Department of Ophthalmology & Vision Science, University of California Davis Health, Ernest E. Tschannen Eye Institute, 4860 Y St, Sacramento, CA, 95817, USA, Tel +1 916 734 6074, Fax +1 916 703 5076, Email sscpark@ucdavis.eduPurpose: To evaluate real-world experience using intravitreal brolucizumab (IVBr), alone or in combination with aflibercept, in eyes with neovascular age-related macular degeneration (nAMD) treated previously with other inhibitors of VEGF (anti-VEGF).Methods: This was a retrospective study of all eyes with nAMD treated with IVBr on a treat-and-extend protocol at a single center. Best-corrected visual acuity (BCVA), optical coherence tomography (OCT) at baseline and final visit, and drug-related adverse events were analyzed. Eyes with recurrent macular fluid on IVBr every 8 weeks were treated with a combination therapy alternating between IVBr and aflibercept every month.Results: Among 52 eyes (40 patients) on IVBr, all had been previously treated with other anti-VEGF therapy, with 73% having persistent macular fluid. After a mean follow-up of 46.2± 27.4 weeks on IVBr, the mean treatment interval for intravitreal therapy increased to 8.8± 2.1 weeks on IVBr from a baseline of 6.1± 3.1 weeks (p< 0.001). Macular fluid decreased and BCVA was stable/improved in 61.5% of eyes on IVBr. Ten eyes with increased macular fluid on IVBr monotherapy when extended to every 8 weeks were treated with combination therapy alternating between IVBr and aflibercept every 4 weeks. In these eyes, 80% had improved macular fluid on OCT and 70% stable or improved BCVA after a median follow-up of 53 weeks on combination therapy. Mild intraocular inflammation developed in four eyes, all occurring on IVBr monotherapy, and none had associated vision loss.Conclusion: In the real world, IVBr used to treat eyes with nAMD previously treated with other anti-VEGF therapies appears to be well tolerated and associated with an improvement in macular fluid, stabilization of BCVA, and/or increase in intravitreal treatment interval. Combination therapy alternating between IVBr and aflibercept monthly appears to be well tolerated and can be considered for eyes with macular fluid on IVBr every 8 weeks.Keywords: age-related macular degeneration, aflibercept, anti-VEGF, brolucizumab, intravitreal injection; optical coherence tomography

Nandita Mehta, Sunana Gupta, Atul Sharma, Mohd Reidwan Dar Department of Anesthesiology and Intensive Care, Acharya Shri Chander College of Medical Sciences and Hospital, Jammu, Jammu and Kashmir, India Abstract: Older people undergoing any surgery have a higher incidence of morbidity and mortality, resulting from a decline in physiological reserves, associated comorbidities, polypharmacy, cognitive dysfunction, and frailty. Most of the clinical trials comparing regional versus general anesthesia in elderly have failed to establish superiority of any single technique. However, the ideal approach in elderly is to be least invasive, thus minimizing alterations in homeostasis. The goal of anesthetic management in laparoscopic procedures includes management of pneumoperitoneum, achieving an adequate level of sensory blockade without any respiratory compromise, management of shoulder tip pain, provision of adequate postoperative pain relief, and early ambulation. Regional anesthesia fulfills all the aforementioned criteria and aids in quick recovery and thus has been suggested to be a suitable alternative to general anesthesia for laparoscopic surgeries, particularly in patients who are at high risk while under general anesthesia or for patients unwilling to undergo general anesthesia. In conclusion, we report results of successful management with thoracic combined spinal epidural for laparoscopic cholecystectomy of a geriatric patient with ischemic heart disease with chronic obstructive pulmonary disease and renal insufficiency. Keywords: geriatric anesthesia, bupivacaine, segmental anesthesia, laparoscopic surgery

Joyce S Willens,1 Iwona Bucior,2 Shay Bujanover,2 Neel Mehta3 1Villanova University, Villanova, PA, 2Depomed, Inc., Newark, CA, 3Weill-Cornell Pain Medicine Center, New York, NY, USA Abstract: When used in multimodal analgesia for acute pain, nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce the requirement for opioids during the perioperative period. To provide more insight into pain treatment during the outpatient period, we examined the use of opioid rescue medication (RM) and described the relationship between pain intensity and RM use in patients with acute pain after bunionectomy. Patients received placebo or 25 mg of a liquid-filled capsule version of the NSAID diclofenac potassium (DPLFC; n=188 patients/group) every 6 hours during the 48-hour inpatient period through the end of outpatient dosing on day 4. Opioid RM (hydrocodone/acetaminophen tablets, 5 mg/500 mg) was available as needed, but taken at least 1 hour post-study medication. Fewer patients taking DPLFC versus placebo requested opioid RM during the inpatient period (4.8%–44.7% versus 25.0%–90.4%) and also during the outpatient period (3.7%–16.0% versus 13.1%–46.4%). Moderate or severe pain after surgery (P=0.0307 and P=0.0002, respectively) or at second dose (P=0.0006 and P=0.0002, respectively) was predictive of RM use. Patients taking RM (placebo/DPLFC) reported more adverse events (RM 55.7%/40.6%; no RM 29.4%/26.0%). Most adverse events in the RM group were opioid-related. In summary, this study shows that DPLFC lowers the requirement for opioids, which is associated with a reduction in the occurrence of treatment side effects, while maintaining adequate analgesia for patients with moderate acute pain in both the outpatient and outpatient periods. Patients with more severe pain are more likely to use RM, but they still use fewer opioids when treated with DPLFC. This suggests that multimodal treatment using DPLFC and an opioid may offer an important clinical benefit in the treatment of acute pain, including in the home environment. Keywords: nonsteroidal anti-inflammatory drugs, diclofenac, opioids, opioid sparing, acute pain

Nitish Mehta,1 Roger A Goldberg,2 Chirag P Shah21University of Massachusetts Medical School, Worcester, MA, USA; 2Department of Retina, Ophthalmic Consultants of Boston, Boston, Massachusetts, USAPurpose: Dense, vision-obscuring calcification on the posterior aspect of silicone intraocular lenses (IOLs) is often not amenable to neodymium:yttrium-aluminum-garnet capsulotomy, and, in prior reports, has required IOL exchange. We report the successful removal of dense calcium deposition on the posterior surface of a three-piece silicone lens using pars plana vitrectomy (PPV).Materials and methods: A 23-gauge PPV was performed using the Stellaris® vitrectomy system. A light pipe was used to retroilluminate the IOL, and a dense fibrous tissue setting with a low cut-rate and high aspiration rate was able to clear the visual axis of the dystrophic calcification without damaging the IOL optic.Results: Visual acuity improved from 20/100 to 20/25.Conclusion: Small-gauge PPV may be utilized to remove dense dystrophic calcium deposits on the lens surface in lieu of IOL exchange. Keywords: cataract surgery, technique, Nd:YAG capsulotomy, IOL exchange

The neonatal mortality rate in India is high and stagnant. Special Care Newborn Units (SCNUs) have been set up at different levels of Health Care Delivery System to provide quality newborn-care services in several hospitals to meet this challenge. Many units are located in the districts where the burden of neonatal deaths is high, and access to special newborn care is poor. The study was conducted to assess the functioning of SCNUs in six centers of India. The evaluation was based on an analysis of secondary data from the six units that had been functioning for at least three year. A cross-sectional survey was also conducted to assess the availability of Quality care and Aseptic practices implemented at different levels of SNCUs. Descriptive statistics were used for analyzing the inputs (Quality care and aseptic practices) and outcomes (morbidity and mortality). The rate of mortality among admitted neonates was taken as the key outcome variable to assess the performance of the units. Chi-square test was used for analyzing the trend of case-fatality rate over a period of 3 years considering the first year of operationalization as the base. Correlation coefficients were estimated to understand the possible association of case-fatality rate with factors, such as bed:doctor ratio, bed:nurse ratio, average duration of stay, and bed occupancy rate, and the asepsis score was determined. The rates of admission increased from a median of 16.7 per 100 deliveries in 2012 to 19.5 per 100 deliveries in 2014. The case-fatality rate shows progressive decline in all the units in Last 3 years. Proportional mortality due to sepsis and low birthweight (LBW) declined significantly over two years (LBW

Bulk Se90Pb10−xSnx (x = 0, 2, 4, 6, and 8) glassy alloys have been obtained by quenching technique, where x indicates the atomic mass percentage (at. mass%) of tin. The differential scanning calorimeter (DSC) technique is used under non-isothermal conditions to determine different characteristic temperatures such as the glass transition temperature Tg, on-set and peak crystallization temperatures Tc and Tp, and melting temperature Tm. The thermal stability parameter of current ternary Se90Pb10−xSnx glasses exhibits A nonlinear compositional dependence with a maximum value for x = 8 at. mass% of Sn. The mean values of the crystallization rate (< Kp >) are lowest at x = 2 and 8, suggesting that a long time is required for these two compositions to fully crystallize. As a result, their stability against devitrification is at its highest, whereas the composition containing 6 at. mass% of Sn has the highest rate of crystallization and the lowest stability against devitrification. [ABSTRACT FROM AUTHOR]

Background Traumatic experience can result in life-long changes in the ability to cope with future stressors and emotionally salient events. These experiences, particularly during early development, are a significant risk factor for later life anxiety disorders such as posttraumatic stress disorder (PTSD). However, because traumatic experience typically results in strong episodic memories, it is not known whether such long-term memories are necessary for particular features of PTSD, such as enhanced fear and anxiety. Here, we used a fear conditioning procedure in juvenile rats before maturation of the neural systems supporting declarative memory to assess the necessity of early memory to the later life development of PTSD-related symptoms. Methods Nineteen-day old rats were exposed to unpredictable and inescapable footshocks, and fear memory for the shock context was assessed during adulthood. Thereafter, adult animals were either exposed to single-trial fear conditioning or elevated plus maze or sacrificed for basal diurnal corticosterone and quantification of neuronal glucocorticoid and neuropeptide Y receptors. Results Early trauma exposed rats displayed stereotypic footshock reactivity, yet by adulthood, hippocampus-dependent contextual fear-related memory was absent. However, adult rats showed sensitized fear learning, aberrant basal circadian fluctuations of corticosterone, increased amygdalar glucocorticoid receptors, decreased time spent in the open arm of an elevated plus maze, and an odor aversion associated with early-life footshocks. Conclusions These results suggest that traumatic experience during developmental periods of hippocampal immaturity can promote lifelong changes in symptoms and neuropathology associated with human PTSD, even if there is no explicit memory of the early trauma. © 2014 Society of Biological Psychiatry.