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We examined beliefs and practices regarding firearm assessment and lethal means safety counseling (LMSC) among U.S. Air Force (USAF) mental health providers (MHPs) and behavioral health technicians (BHTs). Data were collected from 204 USAF MHPs (74.0%; n = 151) and BHTs (26.0%; n = 53) via an anonymous, voluntary survey. A modest proportion indicated they strongly/extremely believe that firearm ownership (42.2%) and storage practices (58.3%) are related to suicide risk. A minority indicated they "strongly"/"extremely" believe that LMSC will yield changes in storage practices (30.9%) and decreases in suicide risk (29.9%). Across patient scenarios, most indicated that "most of the time"/"always" they assess for firearm access (74.5%-99.5%) and provide LMSC (57.8%-95.6%). About half (52.5%) reported having distributed cable locks. Most (59.3%) indicated they are somewhat interested/very interested in receiving additional training on LMSC. MHPs, compared with BHTs, were significantly more likely to report believing a link between firearm ownership and storage practices and suicide risk, believing LMSC is effective at reducing suicide risk, providing LMSC to female patients and patients with current suicidal ideation, and having distributed cable locks. Findings suggest that there is not widespread agreement among USAF MHPs and BHTs that personal firearm ownership and nonsecure storage practices are associated with elevated suicide risk, and there were low levels of confidence in the effectiveness of LMSC. Yet, most USAF MHPs and BHTs reported they integrate firearm access assessment and LMSC as part of their routine clinical care, particularly for patients with identified suicide risk. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Introduction: Assessing military medical teams' ability to respond to large-scale mass casualty (MASCAL) events has become a priority in preparing for future conflicts. MASCAL exercises rely on large numbers of simulated patients with limited medical training. Role-players must be appropriately prepared to ensure that medical exercises adequately assess the expected capabilities of military medical units. The Uniformed Services University of the Health Sciences (USUHS) has evaluated future military providers for decades using a large-scale, multiday, immersive simulation called Bushmaster. Despite a robust casualty training system, the fidelity of the portrayals remained limited., Materials and Methods: Through collaboration with national military medical experts, a comprehensive casualty depiction system was developed. This system relied on structured casualty cards linked to time-based illness scripts. Structured casualty cards included an appropriate balance of disease non-battle injuries and trauma, included multipatient presentations based on shared events (i.e., multiple injured personnel due to an aircraft crash), normal and pathologic combat stress, population/unit considerations, requirements for different roles within the medical unit, and expected clinical outcomes. Illness scripts, supplemented by video guides, included time-based courses of illness/injury and prescribed responses to different typical treatments. This system was piloted during an annual MASCAL exercise (Operation Bushmaster) at USUHS. Clinical faculty were queried on the fidelity of this new system while role-players were evaluated on feasibility., Results: Three hundred casualty cards linked to 49 illness scripts were created, peer-reviewed, and piloted at Bushmaster. A total of 170 military members with limited medical training portrayed simulated patients utilizing the new casualty depiction system. Clinical faculty members strongly agreed that the improved casualty depiction system improved the realism of individual patient presentations (96%). Eighty-three percent of role-players strongly agreed that the casualty depiction system was easy to understand., Conclusions: This improved casualty depiction system was a feasible approach to enhance the fidelity of a MASCAL exercise. It has since been shared with military medical units around the globe to assist with their MASCAL exercises, making future multisite evaluations of this casualty depiction system possible., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Background: With three COVID-19 vaccines currently authorized for use in the US, vaccine hesitancy has the potential to sabotage COVID-19 vaccination efforts and be detrimental to overall health outcomes. In order to realize the extent of vaccine hesitancy, an adequate understanding of the role that self-identified barriers and epidemiologic factors may play is timely and important. Objectives: The objectives of this study were to 1) determine if there is a relationship between vaccine hesitancy and epidemiologic factors, and 2) identify perceived patient-reported barriers associated with receiving a COVID-19 vaccine. Methods: A written questionnaire was utilized to collect data from eligible patients over a 15-week period between October 2020 and February 2021. A combination of non-parametric tests and descriptive statistics were used to analyze this data. Results: A majority of patients were either very strongly in support of (28.2%) or very strongly against (29.7%) receiving a COVID-19 vaccine. Notable findings included the comparison of patients with advanced degrees being more likely to get vaccinated (48.1%) to those without advanced degrees (38.8%) ( P = .032). There was also a significant difference between races regarding their interest in receiving a COVID-19 vaccine. Blacks were much more likely to answer very strongly against receiving the vaccine (60.9%) compared to Caucasians (22.1%) and Hispanics (30.4%) ( P <.001). The most reported barrier to receiving a COVID-19 vaccine was concern for side effects. Conclusion: This study provides a glimpse into possible correlations between vaccine hesitancy and epidemiologic factors as well as patient-reported barriers to receiving a COVID-19 vaccine. With widespread vaccination underway, it is imperative that we learn about and address concerns about receiving the COVID-19 vaccine to ensure community protection against this serious life-threatening infectious disease., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Knowing when suicidal ideation (SI) or suicide attempt (SA) is most likely to occur in a deployed environment would aid in focusing prevention efforts. This study aims to determine when evacuation for SA and SI is most likely to occur based on the absolute and relative number of months in a deployed setting., Materials and Methods: This is a case-control study of active-duty military personnel evacuated from the U.S. Central Command area of responsibility for SI or an SA between April 1, 2020, and March 30, 2021. The arrival month and expected departure month were identified for all the included evacuees. The month of evacuation and proportion of completed deployment were compared. Secondary outcomes of mental health diagnosis or need for a waiver was also examined., Results: A total of 138 personnel evacuated for SI or attempted suicide during the 12-month study period were included in the analysis. Evacuations occurring during month 3 of deployment were significantly higher (P < .0001) than those during other months. The 30% and 50% completion point of deployment had statistically higher frequencies of evacuations for SI/SA (<.0001). A secondary analysis revealed that 25.4% of the individuals had a documented preexisting behavioral health condition before deployment (P < .0001)., Conclusion: Specific points along a deployment timeline were significant predictors for being evacuated for SI and SA., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: Safe, efficient, and reliable innovations among donation systems are needed to meet the growing global demand for source plasma. This study assessed the ability of a new donation system to collect appropriate product weights based on the US Food and Drug Administration nomogram for source plasma collections. Procedure duration and safety endpoints were also collected., Study Design and Methods: The Rika Plasma Donation System (Terumo BCT, Inc., Lakewood, CO) was evaluated in a prospective, open-label, multicenter study. Healthy adults meeting FDA and Plasma Protein Therapeutics Association requirements for source plasma donor eligibility were consented and enrolled in the study resulting in 124 evaluable products., Results: The target product collection weights (ie, including plasma and anticoagulant) by participant weight category were: 705 g (110-149 lbs), 845 g (150-174 lbs), and 900 g (≥175 lbs). The mean reported product collection weights by participant weight category were 705.0 ± 0.00, 845.0 ± 0.20, and 899.9 ± 0.31 g, respectively. The mean overall procedure time was 31.5 ± 5.41 minutes. The mean procedure times by participant weight category were 25.6 ± 3.13, 30.5 ± 4.45, and 33.7 ± 4.80 minutes, respectively. Procedure-emergent adverse events (PEAEs) occurred in five participants. All PEAEs were consistent with known risks for apheresis donation, and none were related to the donation system., Conclusions: The new donation system collected the target product collection weight in 100% of evaluable products. The mean procedure collection time was 31.5 minutes. The system is a new efficient platform that consistently collects the appropriate weight of the source plasma., (© 2023 Wiley Periodicals LLC.)

Introduction: Feeding and eating disorders can be difficult to treat and frequently co-occur with other mental health conditions. The last systematic review of eating disorders in a military and veteran population was published in 2015. An updated review is warranted to re-examine the current literature on eating disorders in the active duty and veteran populations., Materials and Methods: A systematic review that described the prevalence, co-occurrence of other disorders and/or events, and health care utilization of U.S. active duty members and veterans was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Databases and Medical Subject Headings (MeSH) terms used are listed in Appendix A. Each category of the literature was extracted and graded using the Oxford Centre for Evidence-Based Medicine Levels of Evidence., Results: Twenty-one studies revealed prevalence estimates with varying rates based on demographic information. Trauma exposure is consistently associated with eating disorder development. Individuals diagnosed with eating disorders had greater health care utilization., Conclusions: Research on eating disorders in the military and veteran populations has expanded in recent years. Limitations of the evidence included in this review stem from the use of self-reported questionnaires, changes to medical record systems, and limited generalizability to the overall population of patients with eating disorders. Further research should investigate the impact of demographic factors and trauma exposure on the development of an eating disorder within the military and veteran populations., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Sulfamethoxazole-trimethoprim (SMZ-TMP), a commonly prescribed antibiotic for backyard hens, is neither Food and Drug Administration approved nor prohibited in laying hens in the United States. The aim of this study was to determine whether plasma concentrations above targeted minimum inhibitory concentration breakpoint values for Enterobacteriaceae could be achieved with oral dosing. Five Rhode Island red hens ( Gallus gallus domesticus ) were administered a single dose of 96 mg/kg SMZ-TMP (80 mg/kg SMZ and 16 mg/kg TMP) IV followed by the same dose orally after a washout period. Following oral dosing, mean SMZ concentrations exceeded the target breakpoint for approximately 12 hours; however, TMP only briefly exceeded the target breakpoint. Bioavailability was 60.5% for SMZ and 82.0% for TMP. Ten naïve birds were allocated into control (n = 4) and treatment (n = 6) groups for a 7-day multi-dose study. Treatment birds received an oral suspension dosed at 16 mg/kg TMP and 80 mg/kg SMZ every 48 hours (on days 1, 3, 5, and 7); TMP tablets were additionally dosed at 25 mg/bird on days 1, 3, 5, and 7, and 50 mg/bird on days 2, 4, and 6. Plasma SMZ-TMP concentrations were measured on a multiple time interval by ultraperformance liquid chromatography-mass spectrometry, and pharmacokinetic analyses were performed using a noncompartmental model. No accumulation for either drug was noted following repeated dosing, and no statistical differences in biochemical values, packed cell volumes, or weight were found between pre- and posttreatment in either the treatment or control groups. Sulfamethoxazole (80 mg/kg q48h PO) and TMP (24.1-28.0 mg/kg q24h PO) maintained therapeutic plasma concentrations at or exceeding the minimum inhibitory concentration breakpoint of Enterobacteriaceae for 72 and 24 hours for TMP and SMZ, respectively, without evidence of adverse effects or drug accumulation. Further studies are needed to refine this dosage regimen and evaluate adverse effects in ill birds.

Objective: Sporadic bacterial cystitis in both dogs and humans is often caused by Escherichia coli. In humans, nitrofurantoin is a first-line antimicrobial for the treatment of bacterial cystitis but in dogs a lack of available data may be part of the reason it is only recommended as a second-line treatment. The objective of this preliminary study was to determine the plasma pharmacokinetics and urine concentrations of nitrofurantoin monohydrate-macrocrystalline in dogs., Animals: 8 healthy female hound dogs., Procedures: From July 26 to July 28, 2021, dogs received a single oral dose of nitrofurantoin monohydrate-macrocrystalline 100 mg with food. Blood and urine were collected at predetermined times. Nitrofurantoin concentrations were assayed by UPLC-MS/MS and plasma data were analyzed using noncompartmental methods., Results: Plasma concentrations were low for all dogs with a mean ± SD maximum concentration (Cmax) of 0.242 ± 0.098 μg/mL (range, 0.14 to 0.42 µg/mL) occurring between 2 and 24 hours. Urine concentrations were manyfold higher than for plasma. Cmax in urine was 134 ± 54 µg/mL (range, 49.1 to 218 µg/mL) occurring between 6 and 36 hours. As seen in other species, nitrofurantoin concentrated in urine with concentrations being 500 times higher than the concentration in plasma., Clinical Relevance: Results suggested that nitrofurantoin monohydrate-macrocrystalline formulation of nitrofurantoin should be effective in treating bacterial cystitis caused by susceptible uropathogens.

Objective: The Uniformed Services University of the Health Sciences 5-week psychiatry clerkship educates about 180 students a year at sites around the USA. In 2017, weekly in-person experiential learning sessions were implemented for local students and resulted in improved performance in several end-of-clerkship Objective Structured Clinical Examination (OSCE) skills as compared to distant learners who did not receive these sessions. The difference in performance (~ 10%) highlighted a need to provide comparable training for distant learners. Providing in-person, repeated simulated experiential training at multiple distant sites was not practical, requiring development of a novel online approach., Methods: Students at all four distant sites over 2 years (n = 180) participated in five weekly synchronous online experiential learning sessions, while local students (n = 180) received five weekly in-person experiential learning sessions. Tele-simulation used the same curriculum, centralized faculty, and standardized patients as the in-person iterations. Overall end-of-clerkship OSCE performance was compared for learners receiving online versus in-person experiential learning for non-inferiority. Specific skills were compared to receiving no experiential learning., Results: Overall OSCE performance was non-inferior for students who received synchronous online as compared to in-person experiential learning. Performance on each skill other than communication improved significantly when comparing students who received online versus no experiential learning (p < 0.05)., Conclusions: The use of weekly online experiential learning to enhance clinical skills is comparable to in-person efforts. Virtual, simulated, synchronous experiential learning provides a feasible and scalable platform for training complex clinical skills to clerkship students, a critical capability given the impact the pandemic has had on clinical training., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Objective: U.S. military service members, veterans, and their families increasingly seek care from providers with limited knowledge of military culture. The 16-item core DSM-5 Cultural Formulation Interview (CFI) was designed to integrate cultural factors into assessment and treatment of mental disorders. Although the CFI was designed for use with all patients, it is unknown whether the CFI adequately assesses military culture. The authors describe a methodology to determine the need for specific CFI versions and how to create a version for use with persons affiliated with the military., Methods: Published articles on cultural competence in the military were systematically reviewed. Cultural domains were abstracted from each article, inductively coded, and hierarchically organized for assessment against the core CFI. A military CFI was created with additional implementation instructions, questions, and probes when the core CFI was inadequate for eliciting relevant cultural domains., Results: Sixty-three articles were included. Coding revealed 22 military culture domains, of which only five would be elicited in the core CFI without additional guidance. Twelve of 16 questions in the core CFI required additional instructions, five benefited from question edits, and 10 needed additional probing questions. On the basis of these results, the authors crafted a military version of the CFI for service members, veterans, and their families., Conclusions: The military CFI for clinicians assesses aspects of military culture that are not comprehensively evaluated through the core CFI. The development process described in this article may inform the creation of other versions when the core CFI does not comprehensively assess cultural needs for specific populations.

Background: Entrustable Professional Activities (EPAs) assessments measure learners' competence with an entrustment or supervisory scale. Designed for workplace-based assessment EPA assessments have also been proposed for undergraduate medical education (UME), where assessments frequently occur outside the workplace and may be less intuitive, raising validity concerns. This study explored how assessors make entrustment determinations in UME, with additional specific comparison based on familiarity with prior performance in the context of longitudinal student-assessor relationships., Methods: A qualitative approach using think-alouds was employed. Assessors assessed two students (familiar and unfamiliar) completing a history and physical examination using a supervisory scale and then thought-aloud after each assessment. We conducted a thematic analysis of assessors' response processes and compared them based on their familiarity with a student., Results: Four themes and fifteen subthemes were identified. The most prevalent theme related to "student performance." The other three themes included "frame of reference," "assessor uncertainty," and "the patient." "Previous student performance" and "affective reactions" were subthemes more likely to inform scoring when faculty were familiar with a student, while unfamiliar faculty were more likely to reference "self" and "lack confidence in their ability to assess.", Conclusions: Student performance appears to be assessors' main consideration for all students, providing some validity evidence for the response process in EPA assessments. Several problematic themes could be addressed with faculty development while others appear to be inherent to entrustment and may be more challenging to mitigate. Differences based on assessor familiarity with student merits further research on how trust develops over time., (© 2022. The Author(s).)

Purpose: The reproducibility and consistency of assessments of entrustable professional activities (EPAs) in undergraduate medical education (UME) have been identified as potential areas of concern. EPAs were designed to facilitate workplace-based assessments by faculty with a shared mental model of a task who could observe a trainee complete the task multiple times. In UME, trainees are frequently assessed outside the workplace by faculty who only observe a task once., Method: In November 2019, the authors conducted a generalizability study (G-study) to examine the impact of student, faculty, case, and faculty familiarity with the student on the reliability of 162 entrustment assessments completed in a preclerkship environment. Three faculty were recruited to evaluate 18 students completing 3 standardized patient (SP) cases. Faculty familiarity with each student was determined. Decision studies were also completed. Secondary analysis of the relationship between student performance and entrustment (scoring inference) compared average SP checklist scores and entrustment scores., Results: G-study analysis revealed that entrustment assessments struggled to achieve moderate reliability. The student accounted for 30.1% of the variance in entrustment scores with minimal influence from faculty and case, while the relationship between student and faculty accounted for 26.1% of the variance. G-study analysis also revealed a difference in generalizability between assessments by unfamiliar (φ = 0.75) and familiar (φ = 0.27) faculty. Subanalyses showed that entrustment assessments by familiar faculty were moderately correlated to average SP checklist scores (r = 0.44, P < .001), while those by unfamiliar faculty were weakly correlated (r = 0.16, P = .13)., Conclusions: While faculty and case had a limited impact on the generalizability of entrustment assessments made outside the workplace in UME, faculty who were familiar with a student's ability had a notable impact on generalizability and potentially on the scoring validity of entrustment assessments, which warrants further study., (Copyright © 2021 by the Association of American Medical Colleges.)

Background: Community pharmacies are poised to see more veterinary prescriptions as a result of increased pet ownership especially during the coronavirus disease 19 pandemic. Concern has been raised about the lack of veterinary pharmacy training that community pharmacists receive, but no studies have evaluated the actual prevalence of errors in veterinary prescriptions including the prevalence of prescription writing errors., Objectives: This study identifies the prevalence of errors in veterinary prescriptions at independent community pharmacies., Methods: An electronic form was used to ensure required information was pulled from the pharmacy software systems in a consistent manner. Information was pulled from the hard copy image and the prescription label corresponding to that fill. Prescribing trends, such as species and errors, were assessed using descriptive statistics for the overall sample. Error comparisons between written and verbal prescriptions and between weight-based and nonweight-based prescriptions were assessed using chi-square and Fisher exact tests., Results: Weight, although not legally required but clinically necessary for evaluation of veterinary prescriptions, was omitted from 97.8% of prescriptions. When evaluating the prevalence of errors between handwritten and verbal prescriptions, it was more likely to see errors in prescriptions handwritten by the veterinarian (105 of 119; 88%) than verbal prescriptions (257 of 389; 66%). Conversely, handwritten prescriptions were less likely to omit the required Drug Enforcement Agency number on controlled substance prescriptions., Conclusion: Based on the number of errors seen in both handwritten and verbal prescriptions, emphasis should be placed on training pharmacists to be competent in clinically evaluating veterinary prescriptions and training veterinarians on handwriting prescriptions to include both legally and clinically required information needed before dispensing., (Copyright © 2022 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

In response to the COVID pandemic, Uniformed Services University (USU) suspended clerkships. As the nation's military medical school, USU had to keep students safe while still preparing them to be military physicians. In this commentary, we, a group of USU students, explore what this experience taught us about military medicine., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Objective: This retrospective study compares differences in clinical performance on the psychiatry clerkship Objective Structured Clinical Examination (OSCE) between students receiving traditional repeated clinical simulation with those receiving repeated clinical simulation using the Kolb Cycle., Methods: Psychiatry clerkship OSCE scores from 321 students who completed their psychiatry clerkship in 2016 and 2017 were compared. Specific performance measures included communication skills as determined by the Essential Elements of Communication, gathering a history, documenting a history and mental status exam, defending a differential diagnosis, and proposing a treatment plan. Results were calculated using repeated two-way analysis of variance between students receiving no simulation and traditional repeated simulation training (TRS) as compared to students receiving no simulation and repeated simulation utilizing the Kolb cycle (KRS)., Results: Students who received KRS performed significantly better in three of the five components of the clerkship OSCE as compared to students who received TRS. Specifically, students who received KRS performed better on gathering a history (+ 14.1%, p < 0.001), documenting a history (+ 13.4%, p < 0.001), and developing a treatment plan (+ 16.7%, p < 0.001). There were no significant differences in communication skills or in developing and defending a differential diagnosis., Conclusions: Psychiatry clerkship students engaged in repeated simulations explicitly integrated with the Kolb cycle demonstrate improved clinical skills as measured by OSCE performance. Integration of the Kolb cycle in designing simulation experiences should be carefully considered and may serve as a model for individualized coaching in programs of assessment.

Purpose: To have subject matter experts evaluate the Core Entrustable Professional Activities for Entering Residency (Core EPAs) with the EQual rubric to determine if revisions were required and, if applicable, how to focus revision efforts., Method: Ten entrustable professional activity (EPA) experts were invited to evaluate the 13 Core EPAs. Experts had a 6-month window (December 2018-May 2019) to complete the evaluation, which contained the complete EQual rubric and 3 additional prompts, one of which-"Do you think this EPA requires revision?"-was limited to a "yes/no" response. Descriptive statistics for overall and domain-specific EQual rubric scores for each of the 13 Core EPAs were calculated. Free-text responses to why and/or how a Core EPA should be revised were summarized for any Core EPA that scored below a cutoff or for which the majority of experts recommended revision., Results: Six experts completed the evaluation. Most Core EPAs' (9/13) overall score was above the cutoff, indicating that they align with the key domains of the EPA construct. The remaining 4 Core EPAs (2, 7, 9, and 13) scored below the overall cutoff, suggesting that they may require revision. A majority of experts felt that Core EPAs 6, 7, 9, and 13 required revision. With regard to domain-specific scores, Core EPAs 2, 3, 7, 9, and 13 were below the discrete units of work cutoff; Core EPAs 7, 9, and 13 were below the entrustable, essential, and important tasks of the profession of medicine cutoff; and Core EPA 9 was below the curricular role cutoff., Conclusions: The Core EPAs represent a promising initial framework of EPAs for undergraduate medical education. Some Core EPAs might benefit from revision. The process of improving the Core EPAs must continue if they are to standardize outcomes for medical school graduates.

Objective: To quantify in-hospital systolic blood pressure variability among patients with intracerebral hemorrhage, determine the association between high systolic blood pressure variability (HSBPV) and 90-day severe disability or death, and examine the association between pre-hospital factors and HSBPV., Methods: Adult, radiologically confirmed, intracerebral hemorrhage patients enrolled in a multi-site cohort were included. Using a semi-automated algorithm, systolic blood pressure values recorded from routine non-invasive systolic blood pressure monitoring in critical and acute care settings were extracted for the duration of hospitalization. Inter and intra-patient systolic blood pressure variability was quantified using generalized estimating equation methods. Modified Poisson and logistic regression models were fit to determine the association between HSBPV and 90-day severe disability or death and between pre-hospital characteristics and HSBPV, respectively., Results: A total of 566 patients managed at four certified stroke centers were included. Over 120,000 systolic blood pressure readings were analyzed, and a standard deviation (SD) of 13.0 was parameterized as a cut-off point to categorize HSBPV. Patients with HSBPV had a greater risk of 90-day severe disability or death (relative risk: 1.20, 95% confidence interval: 1.04-1.39), after controlling for age, pre-morbid functional status, and other disease severity measures. Greater likelihood of in-hospital HSBPV was independently observed in elderly, female patients, and in patients with high admission systolic blood pressure., Conclusion: Quantification of HSBPV is feasible utilizing routinely collected systolic blood pressure readings, and a singular cut-off parameter for systolic blood pressure variability demonstrated association with 90-day severe disability or death. Elderly, female, and patients with high admission systolic blood pressure may be more likely to demonstrate HSBPV during hospitalization.

Background: Standard gamble (SG) directly measures patients' valuation of their health state. We compare in-hospital and day-90 SG utilities (SGU) among intracerebral hemorrhage patients and report a 3-way association between SGU, EuroQoL-5 dimension, and modified Rankin Scale at day 90., Methods and Results: Patients with intracerebral hemorrhage underwent in-hospital and day-90 assessments for the modified Rankin Scale, EuroQoL-5 dimension, and SG. SG provides patients a choice between their current health state and a hypothetical treatment with varying chances of either perfect health or a painless death. Higher SGU (scale, 0-1) indicates lower risk tolerance and thus higher valuation of the current health state. Logistic regression was used to estimate the likelihood of low SGU (≤0.6), and Wilcoxon paired signed-rank test compared in-hospital and day-90 SGU. In-hospital and day-90 SG was obtained from 381 and 280 patients, respectively, including 236 paired observations. Median (interquartile range) in-hospital and day-90 SGUs were 0.85 (0.40-0.98) and 0.98 (0.75-1.00; P <0.001). In-hospital SGUs were lower with advancing age ( P =0.007), higher National Institutes of Health Stroke Scale, and intracerebral hemorrhage scores ( P <0.001). Proxy-based assessments resulted in lower SGUs; median difference (95% CI), -0.2 (-0.33 to -0.07). After adjustment, higher National Institutes of Health Stroke Scale and proxy assessments were independently associated with lower SGU, along with an effect modification of age by race. Day-90 SGU and modified Rankin Scale were significantly correlated; however, SGUs were higher than the EuroQoL-5 dimension utilities at higher modified Rankin Scale levels., Conclusions: Divergence between directly (SGU) and indirectly (EuroQoL-5 dimension) assessed utilities at high levels of functional disability warrant careful prognostication of intracerebral hemorrhage outcomes and should be considered in designing early end-of-life care discussions with families and patients.

Purpose: Entrustable professional activities (EPAs) are a hot topic in undergraduate medical education (UME); however, the usefulness of EPAs as an assessment approach remains unclear. The authors sought to better understand the literature on EPAs in UME through the lens of the 2010 Ottawa Conference Criteria for Good Assessment., Method: The authors conducted a scoping review of the health professions literature (search updated February 2018), mapping publications to the Ottawa Criteria using a collaboratively designed charting tool., Results: Of the 1,089 publications found, 71 (6.5%) met inclusion criteria. All were published after 2013. Forty-five (63.4%) referenced the 13 Core Entrustable Professional Activities for Entering Residency developed by the Association of American Medical Colleges (AAMC). Forty (56.3%) were perspectives, 5 (7.0%) were reviews, and 26 (36.6%) were prospective empirical studies. The publications mapped to the Ottawa Criteria 158 times. Perspectives mapped more positively (83.7%) than empirical studies (76.7%). Reproducibility did not appear to be a strength of EPAs in UME; however, reproducibility, equivalence, educational effect, and catalytic effect all require further study. Inconsistent use of the term "EPA" and conflation of concepts (activity vs assessment vs advancement decision vs curricular framework) limited interpretation of published results. Overgeneralization of the AAMC's work on EPAs has influenced the literature., Conclusions: Much has been published on EPAs in UME in a short time. Now is the time to move beyond opinion, clarify terms, and delineate topics so that well-designed empirical studies can demonstrate if and how EPAs should be implemented in UME.

Objective: This retrospective study compared faculty-selected evaluation scores with those mathematically calculated from behaviorally anchored assessments., Methods: Data from 1036 psychiatry clerkship clinical evaluations (2012-2015) was reviewed. These clinical evaluations required faculty to assess clinical performance using 14 behaviorally anchored questions followed by a faculty-selected overall evaluation. An explicit rubric was included in the overall evaluation to assist the faculty in interpreting their 14 assessment responses. Using the same rubric, mathematically calculated evaluations of the same assessment responses were generated and compared to the faculty-selected evaluations., Results: Comparison of faculty-selected to mathematically calculated evaluations revealed that while the two methods were reliably correlated (Cohen's kappa = 0.314, Pearson's coefficient = 0.658, p < 0.001), there was a notable difference in the results (t = 24.5, p < 0.0001). The average faculty-selected evaluation was 1.58 (SD = 0.61) with a mode of "1" or "outstanding," while the mathematically calculated evaluation had an average of 2.10 (SD = 0.90) with a mode of "3" or "satisfactory." 51.0% of the faculty-selected evaluations matched the mathematically calculated results: 46.1% were higher and 2.9% were lower., Conclusions: Clerkship clinical evaluation forms that require faculty to make an overall evaluation generate results that are significantly higher than what would have been assigned solely using behavioral anchored assessment questions. Focusing faculty attention on assessing specific behaviors rather than overall evaluations may reduce this inflation and improve validity. Clerkships may want to consider removing overall evaluation questions from their clinical evaluation tools.

Background: Intracerebral hemorrhage is a devastating disease with no specific treatment modalities. A significant proportion of patients with intracerebral hemorrhage are transferred to large stroke treatment centers, such as Comprehensive Stroke Centers, because of perceived need for higher level of care. However, evidence of improvement in patient-centered outcomes for these patients treated at larger stroke treatment centers as compared to community hospitals is lacking. METHODS / DESIGN: "Efficient Resource Utilization for Patients with Intracerebral Hemorrhage (EnRICH)" is a prospective, multisite, state-wide, cohort study designed to assess the impact of level of care on long-term patient-centered outcomes for patients with primary / non-traumatic intracerebral hemorrhage. The study is funded by the Texas state legislature via the Lone Star Stroke Research Consortium. It is being implemented via major hub hospitals in large metropolitan cities across the state of Texas. Each hub has an extensive network of "spoke" hospitals, which are connected to the hub via traditional clinical and administrative arrangements, or by telemedicine technologies. This infrastructure provides a unique opportunity to track outcomes for intracerebral hemorrhage patients managed across a health system at various levels of care. Eligible patients are enrolled during hospitalization and are followed for functional, quality of life, cognitive, resource utilization, and dependency outcomes at 30 and 90 days post discharge. As a secondary aim, an economic analysis of the incremental cost-effectiveness of treating intracerebral hemorrhage patients at higher levels of care will be conducted., Discussion: Findings from EnRICH will provide much needed evidence of the effectiveness and efficiency of regionalized care for intracerebral hemorrhage patients. Such evidence is required to inform policy and streamline clinical decision-making.

Purpose: It is essential to have sufficient bone bulk and density at the implant site in order to achieve good bone-to-implant contact and primary stability, which are crucial for osseointegration. A new osteotomy preparation technique was recently introduced that uses a bone preservation method that creates a layer of compacted bone along the surface of the osteotomy. The hypothesis of this study was that this novel technique would increase primary implant stability, bone mineral density, and the percentage of bone at the implant surface compared with drilling technique., Materials and Methods: A total of 72 osteotomies were created in porcine tibial plateau bone samples using three preparation techniques: standard drilling; osseous extraction drilling with a new tapered, multi-fluted bur design; and osseous densification with the same multi-fluted bur rotating in a reversed direction that preserved and created a compacted layer of bone. The surgical process (temperature increase, drilling force, and torque), mechanical stability during the insertion and removal of 4.1-mm and 6.0- mm diameter implants (implant torque and stability quotient), and bone imaging (scanning electron microscopy, microcomputed tomography measurement of bone mineral density, and histomorphology) were compared among the three preparation techniques., Results: Osseous densification significantly increased insertion and removal torques compared to standard drilling or extraction drilling. No significant differences in implant stability quotient readings or temperature increases were demonstrated among the three groups. Although the same bur was used for extraction drilling and osseous densification techniques, the osseous densification osteotomy diameters were smaller than both the extraction drilling and standard drilling osteotomies due to the spring-back effect of bone elastic strain created. Imaging methods documented a layer of increased bone mineral density around the periphery of osseous densification osteotomies. The percentage of bone at the implant surface was increased by approximately three times for implants prepared with osseous densification compared with standard drilling., Conclusion: This study confirmed the hypothesis that the osseous densification technique would increase primary stability, bone mineral density, and the percentage of bone at the implant surface compared with drilling. By preserving bulk bone, it is hypothesized that the healing process will be accelerated due to the bone matrix, cells, and biochemicals that are maintained in situ and autografted along the surface of the osteotomy site. The healing response requires further study in vivo.

Context: Ground reaction force (GRF) and tibiofemoral force magnitudes and directions have been shown to affect anterior cruciate ligament loading during landing. However, the kinematic and kinetic factors modifying these 2 forces during landing are unknown., Objective: To clarify the intersegmental kinematic and kinetic links underlying the alteration of the GRF and tibiofemoral force vectors secondary to changes in the sagittal-plane body position during single-legged landing., Design: Crossover study., Setting: Laboratory., Patients or Other Participants: Twenty recreationally active participants (age = 23.4 ± 3.6 years, height = 171.0 ± 9.4 cm, mass = 73.3 ± 12.7 kg)., Intervention(s): Participants performed single-legged landings using 3 landing styles: self-selected landing (SSL), body leaning forward and landing on the toes (LFL), and body upright with flat-footed landing (URL). Three-dimensional kinetics and kinematics were recorded., Main Outcome Measure(s): Sagittal-plane tibial inclination and knee-flexion angles, GRF magnitude and inclination angles relative to the tibia, and proximal tibial forces at peak tibial axial forces., Results: The URL resulted in less time to peak tibial axial forces, smaller knee-flexion angles, and greater magnitude and a more anteriorly inclined GRF vector relative to the tibia than did the SSL. These changes led to the greatest peak tibial axial and anterior shear forces in the URL among the 3 landing styles. Conversely, the LFL resulted in longer time to peak tibial axial forces, greater knee-flexion angles, and reduced magnitude and a more posteriorly inclined GRF vector relative to the tibia than the SSL. These changes in LFL resulted in the lowest peak tibial axial and largest posterior shear forces among the 3 landing styles., Conclusions: Sagittal-plane intersegmental kinematic and kinetic links strongly affected the magnitude and direction of GRF and tibiofemoral forces during the impact phase of single-legged landing. Therefore, improving sagittal-plane landing mechanics is important in reducing harmful magnitudes and directions of impact forces on the anterior cruciate ligament.

Military cultural competence has recently gained national attention. Experts have posited that limited outcomes in the treatment of posttraumatic stress disorder and depression in the military may be related to limited familiarity with the military. National surveys have indicated low military cultural competence among providers and limited educational efforts on military culture or pertinent military pathology in medical schools and residency training programs. Military families, with their own unique military cultural identity, have been identified as a population with increased risks associated with deployment. In response to these findings, several curricula regarding military culture have been established and widely distributed. Assessments of military cultural competence have also been developed. The clinical impact of enhanced cultural competence in general has thus far been limited. The military, however, with its highly prescribed cultural identity, may be a model culture for further study.

Objective: Cultural competence is widely considered a cornerstone of patient care. Efforts to improve military cultural competency have recently gained national attention. Assessment of cultural competence is a critical component to this effort, but no assessment of military cultural competence currently exists., Methods: An assessment of military cultural competence (AMCC) was created through broad input and consensus. Careful review of previous cultural competency assessment designs and analysis techniques was considered. The AMCC was organized into three sections: skills, attitudes, and knowledge. In addition to gathering data to determine absolute responses from groups with different exposure levels to the military (direct, indirect, and none), paired questions were utilized to assess relative competencies between military culture and culture in general., Results: Piloting of the AMCC revealed significant differences between military exposure groups. Specifically, those with personal military exposure were more likely to be in absolute agreement that the military is a culture, were more likely to screen for military culture, and had increased knowledge of military culture compared to those with no military exposure. Relative differences were more informative. For example, all groups were less likely to agree that their personal culture could be at odds with military culture as compared to other cultures. Such perceptions could hinder asking difficult questions and thus undermine care., Conclusion: The AMCC is a model for the measurement of the skills, attitudes, and knowledge related to military cultural competence. With further validity testing, the AMCC will be helpful in the critical task of measuring outcomes in ongoing efforts to improve military cultural competence. The novel approach of assessing variance appears to reduce bias and may also be helpful in the design of other cultural competency assessments.

Military combat is a common trauma experience associated with posttraumatic stress disorder (PTSD). Trauma-related nightmares are a hallmark symptom of PTSD. They can be resistant to label-pharmacological PTSD treatment, and they are associated with a variety of adverse health outcomes. The purpose of this article is to review and evaluate prazosin therapy for combat-related PTSD nightmares. Consistent with available literature for all-causes PTSD nightmares, prazosin is an effective off-label option for combat-related PTSD nightmares. Future trials may further instruct use in specific combat-exposure profiles.

The use of computational modeling to predict injury mechanisms and severity has recently been investigated, but few models report failure level ligament strains. The hypothesis of the study was that models built off neutral ankle experimental studies would generate the highest ligament strain at failure in the anterior deltoid ligament, comprised of the anterior tibiotalar ligament (ATiTL) and tibionavicular ligament (TiNL). For models built off everted ankle experimental studies the highest strain at failure would be developed in the anterior tibiofibular ligament (ATiFL). An additional objective of the study was to show that in these computational models ligament strain would be lower when modeling a partial versus complete ligament rupture experiment. To simulate a prior cadaver study in which six pairs of cadaver ankles underwent external rotation until gross failure, six specimen-specific models were built based on computed tomography (CT) scans from each specimen. The models were initially positioned with 20 deg dorsiflexion and either everted 20 deg or maintained at neutral to simulate the cadaver experiments. Then each model underwent dynamic external rotation up to the maximum angle at failure in the experiments, at which point the peak strains in the ligaments were calculated. Neutral ankle models predicted the average of highest strain in the ATiTL (29.1 ± 5.3%), correlating with the medial ankle sprains in the neutral cadaver experiments. Everted ankle models predicted the average of highest strain in the ATiFL (31.2 ± 4.3%) correlating with the high ankle sprains documented in everted experiments. Strains predicted for ligaments that suffered gross injuries were significantly higher than the strains in ligaments suffering only a partial tear. The correlation between strain and ligament damage demonstrates the potential for modeling to provide important information for the study of injury mechanisms and for aiding in treatment procedure.

Purpose: To examine the effects of different sagittal plane body positions during single-leg landings on biomechanics and muscle activation parameters associated with risk for anterior cruciate ligament (ACL) injury., Methods: Twenty participants performed single-leg drop landings onto a force plate using the following landing styles: self-selected, leaning forward (LFL) and upright (URL). Lower extremity and trunk 3D biomechanics and lower extremity muscle activities were recorded using motion analysis and surface electromyography, respectively. Differences in landing styles were examined using 2-way Repeated-measures ANOVAs (sex × landing conditions) followed by Bonferroni pairwise comparisons., Results: Participants demonstrated greater peak vertical ground reaction force, greater peak knee extensor moment, lesser plantar flexion, lesser or no hip extensor moments, and lesser medial and lateral gastrocnemius and lateral quadriceps muscle activations during URL than during LFL. These modifications of lower extremity biomechanics across landing conditions were similar between men and women., Conclusions: Leaning forward while landing appears to protect the ACL by increasing the shock absorption capacity and knee flexion angles and decreasing anterior shear force due to the knee joint compression force and quadriceps muscle activation. Conversely, landing upright appears to be ACL harmful by increasing the post-impact force of landing and quadriceps muscle activity while decreasing knee flexion angles, all of which lead to a greater tibial anterior shear force and ACL loading. ACL injury prevention programmes should include exercise regimens to improve sagittal plane body position control during landing motions.

While high ankle sprains are often clinically ascribed to excessive external foot rotation, no experimental study documents isolated anterior tibiofibular ligament (ATiFL) injury under this loading. We hypothesized that external rotation of a highly everted foot would generate ATiFL injury, in contrast to deltoid ligament injury from external rotation of a neutral foot. Twelve (six pairs) male cadaveric lower extremity limbs underwent external foot rotation until gross failure. All limbs were positioned in 20° of dorsiflexion and restrained with elastic athletic tape. Right limbs were in neutral while left limbs were everted 20°. Talus motion relative to the tibia was measured using motion capture. Rotation at failure for everted limbs (46.8 ± 6.1°) was significantly greater than for neutral limbs (37.7 ± 5.4°). Everted limbs showed ATiFL injury only, while neutral limbs mostly demonstrated deltoid ligament failure. This is the first biomechanical study to produce isolated ATiFL injury under external foot rotation. Eversion of the axially loaded foot predisposes the ATiFL to injury, forming a basis for high ankle sprain. The study helps clarify a mechanism of high ankle sprain and may heighten clinical awareness of isolated ATiFL injury in cases of foot eversion prior to external rotation. It may also provide guidance to investigate the effect of prophylactic measures for this injury., (Copyright © 2012 Orthopaedic Research Society.)

Shoe-surface interface characteristics have been implicated in the high incidence of ankle injuries suffered by athletes. Yet, the differences in rotational stiffness among shoes may also influence injury risk. It was hypothesized that shoes with different rotational stiffness will generate different patterns of ankle ligament strain. Four football shoe designs were tested and compared in terms of rotational stiffness. Twelve (six pairs) male cadaveric lower extremity limbs were externally rotated 30 deg using two selected football shoe designs, i.e., a flexible shoe and a rigid shoe. Motion capture was performed to track the movement of the talus with a reflective marker array screwed into the bone. A computational ankle model was utilized to input talus motions for the estimation of ankle ligament strains. At 30 deg of rotation, the rigid shoe generated higher ankle joint torque at 46.2 ± 9.3 Nm than the flexible shoe at 35.4 ± 5.7 Nm. While talus rotation was greater in the rigid shoe (15.9 ± 1.6 deg versus 12.1 ± 1.0 deg), the flexible shoe generated more talus eversion (5.6 ± 1.5 deg versus 1.2± 0.8 deg). While these talus motions resulted in the same level of anterior deltoid ligament strain (approxiamtely 5%) between shoes, there was a significant increase of anterior tibiofibular ligament strain (4.5± 0.4% versus 2.3 ± 0.3%) for the flexible versus more rigid shoe design. The flexible shoe may provide less restraint to the subtalar and transverse tarsal joints, resulting in more eversion but less axial rotation of the talus during foot∕shoe rotation. The increase of strain in the anterior tibiofibular ligament may have been largely due to the increased level of talus eversion documented for the flexible shoe. There may be a direct correlation of ankle joint torque with axial talus rotation, and an inverse relationship between torque and talus eversion. The study may provide some insight into relationships between shoe design and ankle ligament strain patterns. In future studies, these data may be useful in characterizing shoe design parameters and balancing potential ankle injury risks with player performance.

Hydrostatic pressure (HP) is a key component of the in vivo joint environment and has been shown to enhance chondrogenesis of stem cells. The objective of this study was to investigate the interaction between HP and TGF-β3 on both the initiation and maintenance of a chondrogenic phenotype for joint tissue derived stem cells. Pellets generated from porcine chondrocytes (CCs), synovial membrane derived stem cells (SDSCs) and infrapatellar fat pad derived stem cells (FPSCs) were subjected to 10 MPa of cyclic HP (4 h/day) and different concentrations of TGF-β3 (0, 1 and 10 ng/mL) for 14 days. CCs and stem cells were observed to respond differentially to both HP and TGF-β3 stimulation. HP in the absence of TGF-β3 did not induce robust chondrogenic differentiation of stem cells. At low concentrations of TGF-β3 (1 ng/mL), HP acted to enhance chondrogenesis of both SDSCs and FPSCs, as evident by a 3-fold increase in Sox9 expression and a significant increase in glycosaminoglycan accumulation. In contrast, HP had no effect on cartilage-specific matrix synthesis at higher concentrations of TGF-β3 (10 ng/mL). Critically, HP appears to play a key role in the maintenance of a chondrogenic phenotype, as evident by a down-regulation of the hypertrophic markers type X collagen and Indian hedgehog in SDSCs irrespective of the cytokine concentration. In the context of stem cell based therapies for cartilage repair, this study demonstrates the importance of considering how joint specific environmental factors interact to regulate not only the initiation of chondrogenesis, but also the development of a stable hyaline-like repair tissue.

Engineering cartilaginous tissue of a scale necessary to treat defects observed clinically is a well-documented challenge in the field of cartilage tissue engineering. The objective of this study was to determine how the composition and mechanical properties of cartilaginous tissues that are engineered by using bone marrow-derived mesenchymal stem cells (MSCs) depend on the scale of the construct. Porcine bone marrow-derived MSCs were encapsulated in agarose hydrogels, and constructs of different cylindrical geometries (Ø4×1.5 mm; Ø5×3 mm; Ø6×4.5 mm; Ø8×4.5 mm) were fabricated and maintained in a chemically defined serum-free medium supplemented with transforming growth factor-β3 for 42 days. Total sulfated glycosaminoglycan (sGAG) accumulation by day 42 increased from 0.14% w/w to 0.88% w/w as the construct geometry increased from Ø4×1.5 to Ø8×4.5 mm, with collagen accumulation increasing from 0.31% w/w to 1.62% w/w. This led to an increase in the dynamic modulus from 90.81 to 327.51 kPa as the engineered tissue increased in scale from Ø4×1.5 to Ø8×4.5 mm. By decreasing the external oxygen tension from 20% to 5%, it was possible to achieve these higher levels of mechanical functionality in the smaller engineered tissues. Constructs were then sectioned into smaller subregions to quantify the spatial accumulation of extracellular matrix components, and a model of oxygen diffusion and consumption was used to predict spatial gradients in oxygen concentration throughout the construct. sGAG accumulation was always highest in regions where oxygen concentration was predicted to be lowest. In addition, as the size of the engineered construct increased, different regions of the construct preferentially supported either sGAG or collagen accumulation, thus suggesting that gradients in regulatory factors other than oxygen were playing a role in determining levels of collagen synthesis. The identification of such factors and the means to control their spatial concentration within developing tissues represents a central challenge in engineering large cartilaginous grafts.

Various forms of mechanical stimulation have been shown to enhance chondrogenesis of mesenchymal stem cells (MSCs). However, the response of MSCs undergoing chondrogenesis to such signals has been shown to depend on the temporal application of loading. The objective of this study was to determine the effect of dynamic compression on cartilage-matrix-specific gene expression and to relate this response to the local biochemical environment and cell phenotype at the time of loading. At 0, 7, 14, and 21 days extracellular matrix (ECM) deposition within MSC-seeded agarose hydrogels due to transforming growth factor-β3 stimulation was determined biochemically and histologically, and then reverse transcription-polymerase chain reaction was used to examine the effects of dynamic compression on cartilage-matrix-specific gene expression. The results of these experiments show that the local environment in the core of the constructs is more favorable for chondrogenesis in comparison to the annulus, as evident from both ECM synthesis and gene expression. Additionally, we found that the response of the cells to mechanical stimulus varied with both the spatial region within the constructs and the temporal application of loading. Dynamic compression applied at day 21 was found to enhance levels of cartilage matrix gene expression following a peak in expression levels at day 14 in free swelling constructs, suggesting that mechanical signals play a key role in the maintenance of a chondrogenic phenotype. The application of mechanical stimulus to enhance cartilage ECM synthesis may be an important tool in regenerative medicine-based cartilage repair. The results of this study suggest that a chondrogenic phenotype and/or a well-developed pericellular matrix must first be established before dynamic compression can have a positive effect on cartilage-matrix-specific gene expression.

Mechanical signals can play a key role in regulating the chondrogenic differentiation of mesenchymal stem cells (MSCs). The objective of this study was to determine if the long-term application of cyclic hydrostatic pressure could be used to improve the functional properties of cartilaginous tissues engineered using bone marrow derived MSCs. MSCs were isolated from the femora of two porcine donors, expanded separately under identical conditions, and then suspended in cylindrical agarose hydrogels. Constructs from both donors were maintained in a chemically defined media supplemented with TGF-β3 for 42 days. TGF-β3 was removed from a subset of constructs from day 21 to 42. Loaded groups were subjected to 10 MPa of cyclic hydrostatic pressurisation at 1 Hz for one hour/day, five days/week. Loading consisted either of continuous hydrostatic pressure (CHP) initiated at day 0, or delayed hydrostatic pressure (DHP) initiated at day 21. Free swelling (FS) constructs were cultured in parallel as controls. Constructs were assessed at days 0, 21 and 42. MSCs isolated from both donors were morphologically similar, demonstrated comparable colony forming unit-fibroblast (CFU-F) numbers, and accumulated near identical levels of collagen and GAG following 42 days of free swelling culture. Somewhat unexpectedly the two donors displayed a differential response to hydrostatic pressure. For one donor the application of CHP resulted in increased collagen and GAG accumulation by day 42, resulting in an increased dynamic modulus compared to FS controls. In contrast, CHP had no effect on matrix accumulation for the other donor. The application of DHP had no effect on either matrix accumulation or construct mechanical properties for both donors. Variability in the response to hydrostatic pressure was also observed for three further donors. In conclusion, this study demonstrates that the application of long-term hydrostatic pressure can be used to improve the functional properties of cartilaginous tissues engineered using bone marrow derived MSCs by enhancing collagen and GAG accumulation. The response to such loading however is donor dependent, which has implications for the clinical utilisation of such a stimulus when engineering cartilaginous grafts using autologous MSCs., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Knee hyperextension has been described as a mechanism of isolated anterior cruciate ligament (ACL) tears, but clinical and experimental studies have produced contradictory results for the ligament injuries and the injury sequence caused by the hyperextension loading mechanism. The hypothesis of this study was that bicruciate ligament injuries would occur as a result of knee hyperextension by producing high tibio-femoral (TF) compressive forces that would cause anterior translation of the tibia to rupture the ACL, while joint extension would simultaneously induce rupture of the posterior cruciate ligament (PCL). Six human knees were loaded in hyperextension until gross injury, while bending moments and motions were recorded. Pressure sensitive film documented the magnitude and location of TF compressive forces. The peak bending moment at failure was 108 N m±46 N m at a total extension angle of 33.6 deg±11 deg. All joints failed by simultaneous ACL and PCL damages at the time of a sudden drop in the bending moment. High compressive forces were measured in the anterior compartments of the knee and likely produced the anterior tibial subluxation, which contributed to excessive tension in the ACL. The injury to the PCL at the same time may have been due to excessive extension of the joint. These data, and the comparisons with previous experimental studies, may help explain the mechanisms of knee ligament injury during hyperextension. Knowledge of forces and constraints that occur clinically could then help diagnose primary and secondary joint injuries following hyperextension of the human knee.

During fracture healing and microfracture treatment of cartilage defects mesenchymal stem cells (MSCs) infiltrate the wound site, proliferate extensively and differentiate along a cartilaginous or an osteogenic lineage in response to local environmental cues. MSCs may be able to directly sense their mechanical environment or alternatively, the mechanical environment could act indirectly to regulate MSC differentiation by inhibiting angiogenesis and diminishing the supply of oxygen and other regulatory factors. Dynamic compression has been shown to regulate chondrogenesis of MSCs. In addition, previous studies have shown that a low oxygen environment promotes in vitro chondrogenesis of MSCs. The hypothesis of this study is that a low oxygen environment is a more potent promoter of chondrogenic differentiation of MSCs embedded in agarose hydrogels compared to dynamic compression. In MSC-seeded constructs supplemented with TGF-beta3, GAG and collagen accumulation was higher in low oxygen conditions compared to normoxia. For normoxic and low oxygen culture GAG accumulation within the agarose hydrogel was inhomogeneous, with low levels of GAG measured in the annulus of constructs maintained in normoxic conditions. Dynamic compression did not significantly increase GAG or collagen accumulation in normoxia. However under low oxygen conditions, dynamic compression reduced GAG accumulation compared to free-swelling controls, but remained higher than comparable constructs maintained in normoxic conditions. This study demonstrates that continuous exposure to low oxygen tension is a more potent pro-chondrogenic stimulus than 1h/day of dynamic compression for porcine MSCs embedded in agarose hydrogels.

Numerous studies on the mechanisms of ankle injury deal with injuries to the syndesmosis and anterior ligamentous structures but a previous sectioning study also describes the important role of the posterior talofibular ligament (PTaFL) in the ankle's resistance to external rotation of the foot. It was hypothesized that failure level external rotation of the foot would lead to injury of the PTaFL. Ten ankles were tested by externally rotating the foot until gross injury. Two different frequencies of rotation were used in this study, 0.5 Hz and 2 Hz. The mean failure torque of the ankles was 69.5+/-11.7 Nm with a mean failure angle of 40.7+/-7.3 degrees . No effects of rotation frequency or flexion angle were noted. The most commonly injured structure was the PTaFL. Visible damage to the syndesmosis only occurred in combination with fibular fracture in these experiments. The constraint of the subtalar joint in the current study may have affected the mechanics of the foot and led to the resultant strain in the PTaFL. In the real world, talus rotations may be affected by athletic footwear that may influence the location and potential for an ankle injury under external rotation of the foot.

The knee is often a site of injury that can often lead to a chronic disease known as osteoarthritis (OA). The disease may be initiated, in part, by acute injuries to joint cartilage and its cells. In a recent study by this laboratory, using Flemish Giant rabbits, an impact compressive load on the tibial femoral joint was shown to cause significant levels of acute damage to chondrocytes in cartilage of the medial and lateral tibial plateaus. In the current study, using the same model, histological and mechanical data from the plateaus were documented at 6 and 12 months post impact, and compared to the unimpacted control limbs and a limb from unimpacted, control animals. The mechanical properties of cartilage were measured with indentation relaxation tests on the medial and lateral plateaus in regions covered and uncovered by the meniscus. The histological studies on impacted limbs showed surface lesions on both plateaus, thickening of the underlying subchondral bone at 12 months and numerous occult microcracks at the calcified cartilage-subchondral bone interface at 6 and 12 months, without significant changes in cartilage thickness or its mechanical properties versus controls. Yet, there was an increase in both the matrix and fiber moduli and a decrease in the permeability of uncovered, medial plateau cartilage in both limbs of impacted animals between 6 and 12 months post impact that was not documented in control animals., (Copyright (c) 2010 Elsevier Ltd. All rights reserved.)

The current study describes the development of a small animal, closed-joint model of traumatic anterior cruciate ligament (ACL) and meniscal rupture. This model can be used in future studies to investigate the roles of these acute damages on the long-term health of an injured knee joint. Forty-two Flemish Giant rabbits received an insult to the left tibiofemoral joint ex vivo in order to document optimal energy and joint orientation needed to generate ACL and meniscal rupture, without gross fracture of bone. Impact energies ranged from 10 J to 22 J, and joint flexion angle ranged from 60 deg to 90 deg. Three in vivo animals were impacted at 13 J with the knee flexed at 90 deg, as this was determined to be the optimal load and joint orientation for ACL and meniscal ruptures, and sacrificed at 12 weeks. Impact data from the ex vivo group revealed that 13 J of dropped-mass energy, generating approximately 1100 N of load on the knee, would cause ACL and meniscal ruptures, without gross bone fracture. Acute damage to the lateral and medial menisci was documented in numerous ex vivo specimens, with isolated lateral meniscal tears being more frequent than isolated medial tears in other cases. The in vivo animals showed no signs of ill health or other physical complications. At 12 week post-trauma these animals displayed marked degeneration of the traumatized joint including synovitis, cartilage erosion, and the formation of peripheral osteophytes. Histological microcracks at the calcified cartilage-subchondral bone interface were also evident in histological sections of these animals. A closed-joint model of traumatic ACL and meniscal rupture was produced, without gross bone fracture, and a pilot, in vivo study showed progressive joint degeneration without any other noticeable physical impairments of the animals over 12 weeks. This closed-joint, traumatic injury model may be useful in future experimental studies of joint disease and various intervention strategies.

Objective: To investigate the effect of fracture configuration on the mechanical properties of standard interlocking nails (ILNs) and a novel angle-stable ILN (ILNn) in bending., Study Design: In vitro experimental study., Sample Population: Synthetic tibial gap fracture bone models., Methods: Bone models, featuring a 5 or 120 mm central defect, respectively, mimicking a simple diaphyseal and a comminuted fracture involving both metaphyses, were implanted with 6 or 8 mm screwed or bolted standard ILNs (ILN6s, ILN6b, ILN8s, ILN8b, respectively) or an ILNn. Specimens were tested in 4-point bending. Construct angular deformation (AD) and slack were statistically compared (P<.05)., Results: With increasing gap size, standard ILN construct AD increased significantly by approximately 27% in ILN8b and by up to 105% in ILN6s. Similarly, standard ILN construct slack significantly increased by approximately 33% in ILN8b (from approximately 4.2 degrees to approximately 5.6 degrees) and by up to approximately 130% in ILN6s (from approximately 7 degrees to approximately 16 degrees). Conversely, there was no difference in the ILNn construct AD (approximately 4 degrees) regardless of gap size. ILNn AD was the lowest of all groups and occurred without slack., Conclusions: This study demonstrated that the angle-stable ILNn provided construct stability regardless of fracture configuration, whereas the intrinsic slack of standard ILNs could jeopardize construct stability in a fracture configuration involving the metaphyses., Clinical Relevance: Use of standard ILNs may be optimal in diaphyseal fractures where circumferential nail/cortical contact could augment repair stability. Conversely, the angle-stable ILNn may represent a reliable fracture stabilization method for diaphyseal fractures as well as fractures involving the metaphyseal regions.

Background: Valgus bending of the knee is promoted as an anterior cruciate ligament injury mechanism and is associated with a characteristic "footprint" of bone bruising. The hypothesis of this study was that during ligamentous failure caused by valgus bending of the knee, high tibiofemoral contact pressures induce acute osteochondral microdamage., Methods: Four knee pairs were loaded in valgus bending until gross injury with or without a tibiofemoral compression pre-load. The peak valgus moment and resultant motions of the knee joint were recorded. Pressure sensitive film documented the magnitude and location of tibiofemoral contact. Cartilage fissures were documented on the tibial plateau, and microcracks in subchondral bone were documented from micro-computed tomography scans., Findings: Injuries were to the anterior cruciate ligament in three knees and the medial collateral ligament in seven knees. The mean (standard deviation) peak bending moment at failure was 107 (64)Nm. Valgus bending produced regions of contact on the lateral tibial plateau with average maximum pressures of approximately 30 (8)MPa. Cartilage fissures and subchondral bone microcracks were observed in these regions of high contact pressure., Interpretation: Combined valgus bending and tibiofemoral compression produce slightly higher contact pressures, but do not alter the gross injury pattern from isolated valgus bending experiments. Athletes who sustain a severe valgus knee bending moment, may be at risk of acute osteochondral damage especially if the loading mechanism occurs with a significant tibiofemoral compression component.

Background: High rotational traction between football shoes and the playing surface may be a potential mechanism of injury for The abstract goes here and covers two columns. the lower extremity., Hypothesis: Rotational traction at the shoe-surface interface depends on shoe design and surface type., Study Design: Controlled laboratory study., Methods: A mobile testing apparatus with a compliant ankle was used to apply rotations and measure the torque at the shoe-surface interface. The mechanical surrogate was used to compare 5 football cleat patterns (total of 10 shoe models) and 4 football surfaces (FieldTurf, AstroPlay, and 2 natural grass systems) on site at actual surface installations., Results: Both artificial surfaces yielded significantly higher peak torque and rotational stiffness than the natural grass surfaces. The only cleat pattern that produced a peak torque significantly different than all others was the turf-style cleat, and it yielded the lowest torque. The model of shoe had a significant effect on rotational stiffness., Conclusion: The infill artificial surfaces in this study exhibited greater rotational traction characteristics than natural grass. The cleat pattern did not predetermine a shoe's peak torque or rotational stiffness. A potential shoe design factor that may influence rotational stiffness is the material(s) used to construct the shoe's upper., Clinical Relevance: The study provides data on the rotational traction of shoe-surface interfaces currently employed in football. As football shoe and surface designs continue to be updated, new evaluations of their performance must be assessed under simulated loading conditions to ensure that player performance needs are met while minimizing injury risk.

The knee is one of the most frequently injured joints in the human body. Approximately 91% of ACL injuries occur during sporting activities, usually from a non-contact event. The most common kinetic scenarios related with ACL injuries are internal twisting of the tibia relative to the femur or combined torque and compression during a hard landing. The hypothesis of this study was that the magnitudes and types of motion observed after ACL rupture would significantly change from the relative joint displacements present just before ACL injury. Compression or torsion experiments were conducted on 7 pairs of knee joints with repetitive tests at increasing intensity until catastrophic failure. ACL injury was documented in all cases at 5.4+/-2kN of TF compression or 33+/-13Nm of internal tibial torque. The femur displaced posteriorly relative to the tibia in pre-failure and with a higher magnitude in failure tests under both loading conditions. In compression experiments there was internal rotation of the tibia in pre-failure tests, but external rotation of the tibia after the ACL failed. In torsion experiments, failure occurred at 58+/-19 degrees of internal tibial rotation, and valgus rotation of the femur increased significantly after ACL injury. These new data show that the joint motions can vary in magnitude and direction before and after failure of the ACL. Video-based studies consistently document external rotation of the tibia combined with valgus knee bending as the mechanism of ACL injury although these motions could be occurring after ACL rupture.