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Introduction:. Natural radiation exposure in the general population averages 3 milliSieverts (mSv) annually; however, radiation exposure in orthopaedic residents is not well defined. Despite protective measures, evidence of radiation-related diseases in orthopaedic surgeons is increasing. The purpose of this study was to quantify radiation exposure in orthopaedic residents and to determine the variability of exposure among post graduate year (PGY) of residency. Methods:. Monthly radiation exposure was measured prospectively over a 12-month period in orthopaedic surgery residents from a single program. Participants wore dosimeters above (“exposed”) and beneath (“shielded”) protective lead. The primary outcome measure was the absolute value of radiation exposure in mSv. Repeated measures analysis was used to assess exposure with age, sex, year of training, operating room (OR) days, and height. Results:. Mean annual occupational radiation exposure was 3.30 ± 0.64 mSv over an average of 107 ± 38 OR days. Mean exposure per OR day was 0.033 ± 0.008 mSv. PGY-2 and PGY-3 residents had the highest cumulative exposure, and PGY-5 residents had the highest mean exposure per OR day (0.044 ± 0.009 mSv/d). Number of OR days per month and PGY level were significant predictors of radiation exposure (p < 0.05). Sex, age, and height were not significant in predicting radiation of the exposed dosimeter. Conclusions:. Orthopaedic residents' exposure to radiation is nearly twice the general population's exposure. Given that yearly radiation exposure was highest during early residency years, but exposure based on number of OR days was highest in the final year of training, it is essential for resident education regarding radiation safety and safe clinical practices throughout their training.

Introduction: Up to 20% of EGFR-mutated NSCLC cases harbor uncommon EGFR mutations, including atypical exon 19 and compound mutations. Relatively little is known about the efficacy of osimertinib in these cases. Methods: Patients treated with first-line osimertinib for NSCLC with rare EGFR exon 19 (non E746_A750del) or compound mutations were included. Response assessment and time to progression were determined using Response Evaluation Criteria in Solid Tumors version 1.1 criteria. Kaplan-Meier analyses were used to estimate progression-free survival (PFS), time to treatment discontinuation (TTD), and overall survival (OS). Results: Thirty-seven patients with NSCLC harboring an atypical EGFR exon 19 mutation or compound mutation were treated with first-line osimertinib at Johns Hopkins from 2016 to 2021. Overall response rate (ORR) was 76% and median PFS, TTD, and OS were 13 months (95% confidence interval [CI]: 10–15), 22 months (95% CI: 17–32) and 36 months (95% CI, 29–48), respectively. Among atypical exon 19 mutations (n = 25), ORR was 80%, median PFS was 12 months (95% CI: 10–15), median TTD was 19 months (95% CI: 17–38), and median OS was 48 months (95% CI: 25–not reached). Compound mutations (n = 12) had an ORR of 67%, median PFS of 14 months (95% CI: 5–22), median TTD of 26 months (95% CI: 5–36), and median OS of 36 months (95% CI: 20–46). Twelve patients (32%) continued first-line osimertinib after local therapy for oligoprogression. Conclusions: Osimertinib exhibited favorable outcomes for rare EGFR exon 19 and compound mutations. The heterogeneity in outcomes among these groups of tumors with similar mutations underscores the need for continued reporting and further study of outcomes among rare variants to optimize management for each patient.

Background: Debridement, antibiotics, and implant retention (DAIR) is a well-accepted surgical strategy for periprosthetic joint infection (PJI) following total knee arthroplasty (TKA). DAIR in TKA may be incorrectly thought of as a “simple” procedure not requiring formal specialized training in arthroplasty. Currently, there are no studies comparing the risk of treatment failure based on surgeon fellowship training. Methods: A retrospective review was performed of consecutive patients who underwent DAIR for TKA PJI at our institution. Two cohorts were created based on whether DAIR was performed by an arthroplasty fellowship-trained (FT) surgeon or nonarthroplasty fellowship-trained (NoFT) surgeon. Primary outcome was treatment failure following DAIR at a minimum of 1 year postoperatively. Treatment failure was based on the Tier 1 International Consensus Meeting definition of infection control. Secondary outcomes were also recorded including death during the totality of PJI treatment. Results: A total of 112 patients were identified (FT = 68, NoFT = 44). At a mean follow-up of 7.3 years [standard deviation = 3.9], 73 patients (59.8%) failed treatment. Fellowship training in arthroplasty significantly improved treatment success rates (FT, 35/68 [51.5%]; NoFT, 10/44 [22.7%]; odds ratio 2.5 [95% confidence interval 1.1 to 5.9; P = .002]). Survivorship also differed significantly between the cohorts; at timepoints of 1.5 months, 5 months, 30 months, and 180 months, survivorship of the FT cohort was 79.4%, 67.6%, 54.4%, and 50.7%, respectively, compared with a survivorship of 65.9%, 52.3%, 25%, and 22.7% in the NoFT cohort (P = .002). Conclusions: TKA PJI treated with DAIR should not be considered a simple procedure. Improved treatment success may be associated with subspecialty fellowship training in arthroplasty. Level of Evidence: IV.

Background:. Social media use has grown across healthcare delivery and practice, with dramatic changes occurring in response to the coronavirus (COVID-19) pandemic. The purpose of this study was to conduct a comprehensive systematic review to determine the current landscape of social media use by (1) orthopaedic surgery residencies/fellowship training programs and (2) individual orthopaedic surgeons and the change in use over time. Methods:. We searched 3 electronic databases (PubMed, MEDLINE, and Embase) from their inception to April 2022 for all studies that analyzed the use of social media in orthopaedic surgery. Two reviewers independently determined study eligibility, rated study quality, and extracted data. Methodology was in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results:. Twenty-eight studies were included, of which 11 analyzed social media use by orthopaedic surgery residency and fellowship training programs and 17 examined its use by individual orthopaedic surgeons. Among residency and fellowship programs, Instagram was identified as the most common platform used, with 42% to 88% of programs reporting program-specific Instagram accounts, followed by Twitter/X (20%-52%) and Facebook (10%-38%). Social media was most commonly used by programs for recruitment and information dissemination to prospective residency applicants (82% and 73% of included studies, respectively). After the start of the COVID-19 pandemic, there was a 620% and 177% increase in the number of training programs with Instagram and Twitter/X accounts, respectively. Individual use of social media ranged from 1.7% to 76% (Twitter/X), 10% to 73% (Facebook), 0% to 61% (Instagram), 22% to 61% (LinkedIn), and 6.5% to 56% (YouTube). Conclusions:. Instagram, Twitter/X, and Facebook are the premier platforms that patients, residency applicants, and institutions frequent. With the continued growth of social media use anticipated, it will be critical for institutions and individuals to create and abide by guidelines outlining respectful and professional integration of social media into practice. Level of Evidence:. Level IV.

Background: Peripheral artery disease (PAD) impacts more than 200 million people worldwide. The understanding of the genetics of the disease and its clinical implications continue to evolve. This systematic review provides a comprehensive summary of all DNA variants that have been studied in association with the diagnosis and progression of PAD, with a meta-analysis of the ones replicated in the literature. Methods: A systematic review of all studies examining DNA variants associated with the diagnosis and progression of PAD was performed. Candidate gene and genome-wide association studies (GWAS) were included. A meta-analysis of 13 variants derived from earlier smaller candidate gene studies of the diagnosis of PAD was performed. The literature on the progression of PAD was limited, and a meta-analysis was not feasible because of the heterogeneity in the criteria used to characterize it. Results: A total of 231 DNA variants in 112 papers were studied for the association with the diagnosis of PAD. There were significant variations in the definition of PAD and the selection of controls in the various studies. GWAS have established 19 variants associated with the diagnosis of PAD that were replicated in several large patient cohorts. Only variants in intercellular adhesion molecule-1 (rs5498), IL-6 (rs1800795), and hepatic lipase (rs2070895) showed significant association with the diagnosis of PAD. However, these variants were not noted in the published GWAS. Conclusions: Genetic research in the diagnosis of PAD has significant heterogeneity, but recent GWAS have demonstrated variants consistently associated with the disease. More research focusing on the progression of PAD is needed to identify patients at risk of adverse events and develop strategies that would improve their outcomes.

Category: Midfoot/Forefoot; Hindfoot Introduction/Purpose: Previous studies have shown that workers compensation patients (WC) have worse outcomes, and higher complications rates after orthopaedic surgery. Despite orthopaedic surgeons being the third highest prescribers of narcotic pain medication in the United States there have been no studies to specifically evaluate narcotic use among the WC population. The purpose of this study was to investigate narcotic use among WC patients who underwent foot or ankle operative procedures compared with a procedure matched control group. Methods: A retrospective review was conducted for WC and non-WC patients ages 18 to 70 years old who underwent foot (CPT 28001-28899) or ankle (CPT 27600-27899) procedures in an orthopaedic surgery practice from October 2017 through January 2020. Data collection included demographics, social, surgical, perioperative follow-up and complications. Outcomes measures were timing and number of narcotic prescriptions, total morphine milligram equivalents (MME), and procedure type. Data analysis was performed with SPSS version 28. Comparisons were conducted with Mann-Whitney U test, chi square test, or Fisher’s exact test. Power analysis determined sample size with a 0.05 alpha level, 0.80 power, and 0.5 effect size. Results: 142 total patients met inclusion criteria, with 71 WC patients and 71 non-WC patients. There were no differences regarding the type of foot or ankle procedure performed (p=0.598). WC patients had double the number of overall narcotic prescriptions (median 2 vs 1; p < 0.001). WC patients were prescribed in total 1,125 oxycodone MME and 871.8 hydrocodone MME (P < 0.001), versus 750 oxycodone MME and 450 hydrocodone MME among the non-WC group (p < .008). There was no difference in the number of tramadol prescriptions (p = 0.571). WC patients experienced more days between the date of last narcotic prescription and both index surgery date (median 27 vs 1, p = 0.001) and initial clinic visit date (median 105 vs 49, p = 0.002). Conclusion: This data demonstrates that WC patients portend worse outcomes and utilize narcotics at twice the rate and for longer periods of time post-operatively than non-WC patients. Increased narcotic use may potentiate narcotic dependence and likely leads to worse outcomes. Treating physicians must be aware of these trends in order to best manage these patients. Physicians may need to have longer discussions with WC patients regarding narcotic use post operatively as well as about outcomes and goals of surgery. Physicians should set early expectations with WC patients and clear limits on the amount of narcotics they are willing to prescribe postoperatively.

Category: Ankle; Other Introduction/ Purpose: Osteochondral lesions of the talus (OCLT) are common injuries that can be difficult to treat. To date, long-term patient reported outcome measures (PROMs) of patients with particulated juvenile allograft cartilage implantation with or without calcaneal autograft have not been compared. Methods: From 2010-2012, thirteen patients with difficult to treat OCLTs underwent arthroscopic-assisted implantation of particulated juvenile allograft cartilage (DeNovo NT ® ) with or without autogenous calcaneal bone grafting by a single surgeon. Calcaneal bone graft use was determined by lesion size >150 mm 2 and/or deeper than 5 mm. Patients were evaluated using physical examination, patient interviews, and PROMs. Pre-operative and post-operative PROMs were compared with a Mann Whitney test. Results: When comparing patients in regards to calcaneal bone graft implantation, no difference in age, BMI, pre-operative PROMs, or follow-up was noted, however, calcaneal bone graft patients did have a significantly larger lesion size (188.5±50.9 vs. 118.7±29.4mm 2 respectively; p-value=0.027). VAS and FAAM ADL scores during final follow-up improvement did not significantly differ between cohorts. The FAAM Sports score improved significantly more for the DeNovo alone group compared to the bone graft cohort (p-value=0.032). The AOFAS score improvement did not differ between cohorts (p-value=0.944), however, the SF-36 PCS improved significantly more for the DeNovo alone group compared to the bone graft cohort (p-value=0.038). No intraoperative/perioperative complications were observed with calcaneal bone grafting. Conclusion: While patients followed over the course of ~8 years after implantation of particulated juvenile allograft cartilage (DeNovo NT ® ) with/without autogenous calcaneal bone graft had positive post-operative PROMs, patients without calcaneal bone graft had significantly greater improvement in functional outcome scores. Whether these differences are due to graft incorporation or larger lesion size is unclear.

Background: Patients with eosinophilic esophagitis (EoE) have a unique esophageal microbiome with increased presence of Haemophilus influenzae, but its role in the disease is unclear. Objective: Microbiome-derived bacterial LPS activation of Toll-like receptors (TLR) is a potential mechanism for inducing inflammation in other chronic inflammatory diseases, but it has not been studied in EoE. Our aim was therefore to study microbiome-derived bacterial LPS activation of TLRs in EoE. Methods: We studied 10 patients with active EoE, 9 patients with inactive EoE, and 10 control patients. Esophageal biopsy samples from the controls, patients with active EoE (>15 eosinophils/hpf), and patients with inactive EoE were immunostained for the presence of H influenzae LPS, presence of TLR4, and colocalization of LPS and TLR4. Staining intensity was measured by using confocal laser microscopy and scored on a scale from 0 to 3 as the average score assigned by 2 blinded observers. Results: H influenzae LPS was detected by positive staining in 20 of the 29 patients (69.0%), including 9 of the 10 patients with active EoE (90.0%), 8 of the 9 patients with inactive EoE (89.9%), and 3 of the 10 controls (30%); its level was greater in the patients with active EoE than in the controls (P = .063). TLR4 was detected by positive staining in 19 of the 29 patients (65.5%), including 9 of the 10 patients with active EoE (90.0%), 4 of the 9 patients with inactive EoE (44.4%), and 6 of the 10 controls (60.0%); its level was higher in the patients with active EoE than in those with inactive EoE (P = .096). The result of testing for colocalization of LPS and TLR4 was positive in 8 of 10 patients with active EoE (80.0%), 1 of 9 patients with inactive EoE (11.1%), and 1 of 10 control patients (10.0%), with greater colocalization of H influenzae LPS and TLR4 staining density in the samples from patients with active EoE than in the controls or the patients with inactive EoE (P = .009 and P = .018, respectively). Conclusion: Esophageal microbiome–rich H influenzae LPS colocalizes to TLR4 in active EoE. These data lend further support to a role for the esophageal microbiome in modulating the activity of EoE.

Gastropulmonary fistula represents a late complication of sleeve gastrectomy and, if untreated, has high morbidity and mortality. We present a case report of a 29-year-old female who developed a gastropulmonary fistula 3 years after a sleeve gastrectomy. Dual energy CT of the chest and upper abdomen demonstrated a cavitary left lower lobe lesion associated with a focal complex pleural effusion; iodinated oral contrast confirmed the presence of a fistulous connection through the left hemidiaphragm. The patient underwent a thoracotomy, left lower lobectomy, resection of the infected segment of the left hemidiaphragm with primary repair, drainage of a subphrenic abscess and a gastric repair; the patient was discharged 2-weeks postprocedure.

Renal cryoablation (CA) has become an accepted treatment option for patients with small renal tumors and co-morbidities that make them less favorable for surgical intervention. Complications from renal CA have been previously reported and are generally associated with increasing size and central location of the tumor. Ureteral injury from renal CA, although rare, can be difficult to manage and may require complex surgeries in patients who are poor surgical candidates to begin with. We report a case of a renal mass CA complicated by proximal ureteral necrosis and transection, treated with multiple minimally invasive procedures ultimately resulting in successful bridging of the necrotic segment with nephroureteral stent and thus avoiding major surgery.

Axial gout is an atypical presentation of gout caused by monosodium urate deposition in the axial skeleton. Spinal gout presents nonspecifically and can be a difficult diagnosis. The diagnosis of gout is a clinical one, with imaging and labs providing supporting evidence. Current imaging modalities such as magnetic resonance, computed tomography, and X-ray can be nonspecific and lead to invasive procedures for diagnosis. Dual-energy computed tomography allows clear visualization of urate collection and is a valuable tool to make a confident diagnosis of spinal gout. Here, we present a case of a man with longstanding severe gout in which dual-energy computed tomography played a key role in diagnosis.

A 16-year-old boy sustained a complete, closed, intrasubstance rupture of both heads of the biceps brachii after a rope swing accident. The patient was managed with open direct repair of the muscle belly. After the surgery, he underwent an extensive physical therapy regimen and regained full range of motion and strength. To our knowledge, this is the youngest reported case of a subacute intrasubstance rupture of the biceps brachii muscle treated surgically in the literature. There is no consensus in the literature regarding the optimal management of these injuries. Given the satisfactory outcome, we suggest that open direct repair of the muscle belly is a reasonable option for the pediatric population.

Background: Type VIII superior labrum anterior posterior (SLAP) tears are described as SLAP type II tears with posterior extension to the posterior inferior glenohumeral ligament. These tears are a common source of pain, instability, and decreased function in active individuals, particularly overhead or throwing athletes. Indications: Type VIII SLAP tears can cause pain and loss of sports performance, especially in a throwing athlete. This patient is a quarterback and pitcher who had magnetic resonance imaging and arthroscopic evidence of a type VIII SLAP tear with pain and inability to throw at his preinjury level. Technique Description: In the lateral decubitus position, a standard posterior portal is established along with anterior and accessory lateral portals. A type VIII SLAP tear is identified and the arm is taken out of balanced suspension traction and placed in abduction and external rotation which shows displacement of the posterior labrum and peelback of the superior labrum indicating pathologic labral instability. The labrum is then elevated and glenoid prepared to achieve healthy bleeding bone. Tape sutures are then passed around the labrum and placed into a glenoid anchor starting superiorly and continuing the repair posteroinferiorly. Three anchors were placed in the superior labrum using a percutaneous technique, with 2 more placed from the posterior portal to complete the 5-anchor repair. The posterior portal is then closed with a single monofilament suture to prevent a potential stress riser in the capsule. Results: The literature suggests that athletes with type VIII SLAP tears can expect improved functional outcomes and high return to play rates (>90%); however, only 50% to 70% of throwing athletes return to the same level of play. Discussion/Conclusion: Type VIII SLAP tears are an important cause of shoulder pain and dysfunction, particularly in overhead athletes. Arthroscopic repair of type VIII SLAP tears can improve functional outcomes and ability to return to sport; however, throwing athletes experience lower rates of return to previous level. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background: Snapping scapula syndrome (SSS) is a disruption of the normal smooth motion of the scapulothoracic joint leading to clicking or “snapping” which can be painful or painless. There are a variety of etiologies with first-line treatment being conservative. If patients fail extensive nonoperative treatments, then surgery may be considered. Although technically challenging, arthroscopic treatment is recommended due to its decreased morbidity and improved cosmesis. Indications: We present a 21-year-old man with a 2-year history of mechanical popping and crepitus with overhead and scapulothoracic motion of his left arm. After failing an extensive trial of conservative therapy, the patient underwent scapulothoracic arthroscopy with bursectomy and partial resection of the superomedial border of the scapula. Technique Description: The patient is positioned prone with the operative arm behind the back to elevate the medial border off the chest wall. The scapula is outlined. Two arthroscopic portals are used; the superior portal is 3 cm medial to the medial border of the scapula at the level of the scapular spine and the inferior portal is 4 cm inferior to this at the inferomedial angle of the scapula. Viewing is typically done from the inferior portal, and the superior portal is used for resection of the bursa and superomedial border of the scapula. A shaver and ablator are used to perform a bursectomy and expose the superomedial border of the scapula. An arthroscopic bur is used to partially resect the superomedial border of the scapula at approximately 3.5 cm wide and 2 cm deep. Results: Although there are limited studies examining outcomes after scapulothoracic arthroscopy, the current literature suggests that scapulothoracic arthroscopy is effective in improving crepitus, pain, and clinical outcome scores. Discussion/Conclusion: In cases of SSS which have failed exhaustive conservative therapy, arthroscopic bursectomy and partial bony resection can be an effective treatment option with minimal invasiveness, improved cosmesis, and early return to activities. Proper patient positioning and careful portal placement are critical to avoid iatrogenic injury, particularly to neurologic structures. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background: Arthroscopic transosseous-equivalent (TOE) techniques may offer additional advantages, including a more efficient surgery with a self-reinforcing construct with equivalent clinical results to medial knotted TOE repair for rotator cuff tears (RCTs). Indications: An arthroscopic knotless double-row (DR) rotator cuff repair (RCR) using FiberTak RC anchors for medial row fixation with box configuration may be an appropriate construct for operatively indicated small-to-moderate full-thickness RCTs. Technique: Our modified technique uses TOE repair principles to address RCTs too small for traditional 4.75-mm anchors using medial row fixation and too large to apply a single medial to lateral anchor repair. The patient is placed in a beach chair position. In addition to standard anterior and posterior portals, a lower lateral working portal and a higher posterolateral viewing portal are made. Subsequent to supraspinatus footprint visualization/preparation, two 2.6-mm FiberTak RC anchors each loaded with 1 LabralTape and 1 FiberWire are placed medially. The 4 sets of sutures for one anchor are placed through the rotator cuff tendon together in 1 spot and the process is repeated for the second anchor. One FiberWire from each anchor is then tied extracorporeally and then a double pulley technique is used to compress the medial aspect of the repair at the footprint in a box configuration. Finally, 1 limb of LabralTape from each of the medial anchors along with the corresponding FiberWire is secured through 2 lateral-row 4.75-mm anchors anteriorly and posteriorly to restore the lateral footprint and secure the rotator cuff in TOE box configuration. This modified technique can provide anatomical compression of the rotator cuff tendon at the footprint with additional medial compression achieved by the box configuration while taking advantage of knotless fixation. Results: Postoperatively, a sling is worn for 4 weeks, passive range of motion (ROM) is initiated at 2 weeks, active ROM is begun at 6 weeks, and strengthening at 3 months. Patients may return to full unrestricted activities around 5 to 6 months. Discussion/Conclusion: A modified arthroscopic DR RCR with box configuration is an excellent treatment option for patients with small-to-moderate full-thickness RCT who fail conservative treatment. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

The aging population, particularly the thin and frail, has an increased risk of long-term cardiac implantable electronic device complications. This case is that of an elderly, thin-skinned patient who presented with a pacemaker pocket erosion 4 years after elective generator change, potentiated by a small pocket size with a superficial suture fixating the generator in the subcutaneous pocket. The risk for device erosion may have been mitigated during the generator change by increasing the size of the pocket, using a submuscular pocket, and potentially an absorbable antibacterial envelope. Fixation of the generator is considered optional. Résumé: Le risque de complications liées aux dispositifs électroniques cardiaques implantables est plus grand à long terme au sein de la population vieillissante, particulièrement chez les personnes minces et fragiles. Nous présentons ici le cas d’un patient âgé, à la peau fine, qui, quatre ans après le remplacement non urgent du générateur de son stimulateur cardiaque, a présenté une érosion de la loge du boîtier aggravée par la petite taille de celle-ci. Une suture superficielle fixait le générateur dans la loge sous-cutanée. Le risque d’érosion de la loge du boîtier aurait pu être atténué par l’augmentation de la taille de la loge lors du remplacement du générateur, par le recours à une loge sous-musculaire, et peut-être par l’utilisation d’une enveloppe antibactérienne résorbable. La fixation du générateur est jugée facultative.

BACKGROUND: Accurate estimates of gestational age in pregnancy are important for the provision of optimal care. Although current guidelines generally recommend estimating gestational age via first-trimester ultrasound measurement of crown–rump length, error associated with this method can range from 3 to 8 days of gestation. In pregnancies resulting from assisted reproductive technology, estimated due date can be calculated on the basis of the age of the embryo and the date of embryo transfer, arguably providing the most accurate estimates possible. We have developed and extensively validated statistical models to estimate gestational age postnatally using metabolomic markers from blood samples in combination with clinical and demographic data. These models have shown high accuracy compared with first-trimester ultrasound, the recommended method for estimating gestational age in spontaneous pregnancies. We hypothesized that gestational age derived from date and stage of embryo at transfer in newborns conceived using assisted reproduction therapy would provide the most accurate reference standard possible to evaluate and compare the accuracy of both first-trimester ultrasound and metabolomic model–based gestational dating. OBJECTIVE: This study aimed to validate both first-trimester ultrasound dating and postnatal metabolomic gestational age estimation models against gestational age derived from date and stage of embryo at transfer in a cohort of newborns conceived via assisted reproductive technology, both overall and in important subgroups of interest (preterm birth, small for gestational age, and multiple birth). STUDY DESIGN: This was a retrospective cohort study of infants born in Ontario, Canada between 2015 and 2017 and captured in the provincial birth registry. Spontaneous conceptions were randomly partitioned into a model derivation sample (80%) and a test sample (20%) for model validation. A cohort of assisted conceptions resulting from fresh embryo transfers was derived to evaluate the accuracy of both ultrasound and model-based gestational dating. Postnatal gestational age estimation models were developed with multivariable linear regression using elastic-net regularization. Gestational age estimates from dating ultrasound and from postnatal metabolomic models were compared with date of embryo transfer reference gestational age in the independent test cohorts. Accuracy was quantified by calculating mean absolute error and the square root of mean squared error. RESULTS: Our model derivation cohort included 202,300 spontaneous conceptions, and the testing cohorts included 50,735 spontaneous conceptions and 1924 assisted conceptions. In the assisted conception cohort, first-trimester dating ultrasound was accurate to within approximately ±1.5 days compared with date of embryo transfer reference overall (mean absolute error, 0.21 [95% confidence interval, 0.20–0.23]). When compared with gestational age derived from date of embryo transfer, the metabolomic estimation models were accurate to within approximately ±5 days overall (0.79 [0.76–0.81] weeks). When ultrasound was used as the reference in validating the metabolomic model, the mean absolute error was slightly higher overall (0.81 [0.78–0.84] weeks). In general, the accuracy of gestational age estimates derived from ultrasound or metabolomic models was highest in term infants and lower in preterm and small-for-gestational-age newborns. CONCLUSION: Our findings support the accuracy of ultrasound as a gestational age dating tool. They also support the potential utility of metabolic gestational age dating algorithms in settings where ultrasound or other accurate methods of estimating gestational age are not available because of lack of infrastructure or specialized training (eg, low-income countries). However, the accuracy of metabolomic model–based dating was generally lower than that of ultrasound.

Abstract. The American Board of Orthopaedic Surgery (ABOS) is the national organization charged with defining education standards for graduate medical education in orthopaedic surgery. The purpose of this article is to describe initiatives taken by the ABOS to develop assessments of competency of residents to document their progress toward the independent practice of orthopaedic surgery and provide feedback for improved performance during training. These initiatives are called the ABOS Knowledge, Skills, and Behavior Program. Web-based assessment tools have been developed and validated to measure competence. These assessments guide resident progress through residency education and better define the competency level by the end of training. The background and rationale for these initiatives and how they serve as steps toward competency-based education in orthopaedic residency education in the United States will be reviewed with a vision of a hybrid of time and competency-based orthopaedic residency education that will remain 5 years in length, with residents assessed using standardized tools.

Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) is a multiorgan syndrome with rare and heterogenous cardiac manifestations. We present the case of a man with pericardial effusion complicated by cardiac tamponade, new onset atrial fibrillation, and high-degree atrioventricular block leading to a diagnosis of POEMS syndrome. (Level of Difficulty: Advanced.)

Objectives (1) To evaluate safety, tolerability, and technical success of lidocaine iontophoresis and a tympanostomy tube placement system for adults in an office setting and (2) to meet regulatory evidence requirements for new drugs and devices. Study Design Prospective, multicenter, single arm. Setting Patients were recruited in 8 community-based practices in the United States between June and September 2017. Subjects and Methods This study evaluated tympanic membrane anesthesia and tube placement in 30 adults. Anesthesia was achieved via iontophoresis of a lidocaine/epinephrine solution. Tube placement was conducted using an integrated myringotomy and tube delivery system. Tolerability of tube placement was measured using a patient-reported visual analog scale from 0 mm ( no pain ) to 100 mm ( worst possible pain ). Mean pain score was compared to a performance goal of 45 mm, where statistical superiority represents mild pain or less. Technical success and safety through 3 weeks postprocedure were evaluated. Results Twenty-nine (29/30, 96.7%) patients had tube(s) successfully placed in all indicated ears. One patient demonstrated inadequate tympanic membrane anesthesia, and no tube placement was attempted. The mean (SD) pain score of 9.4 (15.7) mm was statistically superior to the performance goal. There were no serious adverse events. Seven nonserious events were related to device, procedure, or drug: inadequate anesthesia (1), vertigo (1), and dizziness (1) at the time of procedure and ear discomfort (1), tube occlusion (2), and medial tube migration (1) postprocedure. Conclusion Lidocaine iontophoresis provides acceptable tympanic membrane anesthesia for safe, tolerable, and successful in-office tube placement using an integrated myringotomy and tube delivery system.

Iatrogenic Cushing syndrome (CS) is a well-known complication of treating patients with systemic steroids. More rarely, it has been described in HIV-positive patients on ritonavir (RTV) while using the inhaled corticosteroid fluticasone, which is metabolized through the cytochrome P450 3A4 (CYP3A4) enzyme system. In the presence of RTV, a known CYP3A4 enzyme inhibitor, the interaction can result in impaired metabolism and systemic accumulation of inhaled fluticasone resulting in iatrogenic CS. Iatrogenic CS has been less often described with inhaled budesonide compared to inhaled fluticasone. Therefore, inhaled budesonide is often used as an alternative therapy for patients on RTV to avoid iatrogenic CS. We report the fifth case report of budesonide-induced iatrogenic CS in an HIV-positive patient on RTV. We highlight the importance of early recognition of the syndrome and distinguishing it from HIV lipodystrophy. Finally, we review the literature for cases of iatrogenic CS involving RTV and commonly used steroids.

Background: In 2015, there were 5·9 million deaths in children aged under 5 years worldwide: mortality is highest in sub-Saharan Africa (81 per 1000 livebirths) and sepsis is an important cause of these deaths. Paediatric sepsis is preventable and treatable, yet remains a serious and life-threatening condition. Prompt recognition and early treatment can improve survival; however, the understanding of how to identify and manage paediatric sepsis in sub-Saharan Africa is poor because of a lack of regional data. These data are crucial for the identification of high-risk patients, development of triage systems, and the reduction of barriers to care. In this study, we aim to identify mortality risk factors for paediatric sepsis patients at a national referral hospital in Tanzania. Methods: We conducted an exploratory analysis of prospective cohort pilot data. We included children aged between 28 days and 14 years in the emergency medicine department at Muhimbili National Hospital in Dar es Salaam with sepsis (defined as ≥2 clinical criteria for systemic inflammatory response syndrome). The primary outcome was in-hospital mortality and secondary outcomes included mortality in the emergency department and length of stay. We used t-tests and Wilcoxon rank-sum, Kruskal Wallis, χ2, and Fisher's exact tests for data analysis. Findings: Of the 2232 children screened between July 1 and September 30, 2017, 433 were eligible, 405 were enrolled, and 402 were followed to discharge or death. Median age was 25·2 months (IQR 11·4–63·5) and prevalence of malaria and HIV was 9·1% (28/307) and 1·7% (n=7), respectively. 247 (61·0%) patients were referred from outside health facilities and 116/244 (47·5%) had received antibiotics before arrival. Mortality was 14·2% (n=57): 89·5% (n=51) died on a hospital ward and 10·5% (n=6) died in the emergency department. Non-survivors were younger than survivors (median age 16 and 27 months, respectively, p=0·002), and more likely to have respiratory insufficiency (54 (94·7%) vs 293 (84·9%), p=0·046) or altered mental status (43 (75·4%) vs 171 (49·6%), p

A case of May-Thurner-like syndrome was found to be a result of a pelvic kidney compressing the left common iliac vein. Cross-sectional imaging demonstrated transverse mobility of the pelvic kidney which has not been described previously. The ectopic kidney’s mobility resulted in intermittent venous compression. In a patient with recurrent lower extremity deep venous thrombosis and a pelvic kidney, the possibility of movement of the kidney resulting in venous compression needs to be considered.

Background: The Global Burden of Disease (GBD) study assesses health losses from diseases, injuries, and risk factors using disability-adjusted life-years, which need a set of disability weights to quantify health levels associated with non-fatal outcomes. The objective of this study was to estimate disability weights for the GBD 2013 study. Methods: We analysed data from new web-based surveys of participants aged 18–65 years, completed in four European countries (Hungary, Italy, the Netherlands, and Sweden) between Sept 23, 2013, and Nov 11, 2013, combined with data previously collected in the GBD 2010 disability weights measurement study. Surveys used paired comparison questions for which respondents considered two hypothetical individuals with different health states and specified which person they deemed healthier than the other. These surveys covered 183 health states pertinent to GBD 2013; of these states, 30 were presented with descriptions revised from previous versions and 18 were new to GBD 2013. We analysed paired comparison data using probit regression analysis and rescaled results to disability weight units between 0 (no loss of health) and 1 (loss equivalent to death). We compared results with previous estimates, and an additional analysis examined sensitivity of paired comparison responses to duration of hypothetical health states. Findings: The total analysis sample consisted of 30 230 respondents from the GBD 2010 surveys and 30 660 from the new European surveys. For health states common to GBD 2010 and GBD 2013, results were highly correlated overall (Pearson's r 0·992 [95% uncertainty interval 0·989–0·994]). For health state descriptions that were revised for this study, resulting disability weights were substantially different for a subset of these weights, including those related to hearing loss (eg, complete hearing loss: GBD 2010 0·033 [0·020–0·052]; GBD 2013 0·215 [0·144–0·307]) and treated spinal cord lesions (below the neck: GBD 2010 0·047 [0·028–0·072]; GBD 2013 0·296 [0·198–0·414]; neck level: GBD 2010 0·369 [0·243–0·513]; GBD 2013 0·589 [0·415–0·748]). Survey responses to paired comparison questions were insensitive to whether the comparisons were framed in terms of temporary or chronic outcomes (Pearson's r 0·981 [0·973–0·987]). Interpretation: This study substantially expands the empirical basis for assessment of non-fatal outcomes in the GBD study. Findings from this study substantiate the notion that disability weights are sensitive to particular details in descriptions of health states, but robust to duration of outcomes. Funding: European Centre for Disease Prevention and Control, Bill and Melinda Gates Foundation.

Background: Between April and June, 2012, a reactive cholera vaccination campaign was done in Haiti with an oral inactivated bivalent whole-cell vaccine. We aimed to assess the effectiveness of the vaccine in a case-control study and to assess the likelihood of bias in that study in a bias-indicator study. Methods: Residents of Bocozel or Grand Saline who were eligible for the vaccination campaign (ie, age ≥12 months, not pregnant, and living in the region at the time of the vaccine campaign) were included. In the primary case-control study, cases had acute watery diarrhoea, sought treatment at one of three participating cholera treatment units, and had a stool sample positive for cholera by culture. For each case, four control individuals who did not seek treatment for acute watery diarrhoea were matched by location of residence, enrolment time (within 2 weeks of the case), and age (1–4 years, 5–15 years, and >15 years). Cases in the bias-indicator study were individuals with acute watery diarrhoea with a negative stool sample for cholera. Controls were selected in the same manner as in the primary case-control study. Trained staff used standard laboratory procedures to do rapid tests and stool cultures from study cases. Participants were interviewed to collect data on sociodemographic characteristics, risk factors for cholera, and self-reported vaccination. Data were analysed by conditional logistic regression, adjusting for matching factors. Findings: From Oct 24, 2012, to March 9, 2014, 114 eligible individuals presented with acute watery diarrhoea and were enrolled, 25 of whom were subsequently excluded. 47 participants were analysed as cases in the vaccine effectiveness case-control study and 42 as cases in the bias-indicator study. 33 (70%) of 47 cholera cases self-reported vaccination versus 167 (89%) of 188 controls (vaccine effectiveness 63%, 95% CI 8–85). 27 (57%) of 47 cases had certified vaccination versus 147 (78%) of 188 controls (vaccine effectiveness 58%, 13–80). Neither self-reported nor verified vaccination was significantly associated with non-cholera diarrhoea (vaccine effectiveness 18%, 95% CI −208 to 78 by self-report and −21%, −238 to 57 by verified vaccination). Interpretation: Bivalent whole-cell oral cholera vaccine effectively protected against cholera in Haiti from 4 months to 24 months after vaccination. Vaccination is an important component of efforts to control cholera epidemics. Funding: National Institutes of Health, Delivering Oral Vaccines Effectively project, and Department of Global Health and Social Medicine at Harvard Medical School.

Background: Several promising new diagnostic methods and algorithms for tuberculosis have been endorsed by WHO. National tuberculosis programmes now face the decision on which methods to implement and where to place them in the diagnostic algorithm. Methods: We used an integrated model to assess the effects of different algorithms of Xpert MTB/RIF and light-emitting diode (LED) fluorescence microscopy in Tanzania. To understand the effects of new diagnostics from the patient, health system, and population perspective, the model incorporated and linked a detailed operational component and a transmission component. The model was designed to represent the operational and epidemiological context of Tanzania and was used to compare the effects and cost-effectiveness of different diagnostic options. Findings: Among the diagnostic options considered, we identified three strategies as cost effective in Tanzania. Full scale-up of Xpert would have the greatest population-level effect with the highest incremental cost: 346 000 disability-adjusted life-years (DALYs) averted with an additional cost of US$36·9 million over 10 years. The incremental cost-effectiveness ratio (ICER) of Xpert scale-up ($169 per DALY averted, 95% credible interval [CrI] 104–265) is below the willingness-to-pay threshold ($599) for Tanzania. Same-day LED fluorescence microscopy is the next most effective strategy with an ICER of $45 (95% CrI 25–74), followed by LED fluorescence microscopy with an ICER of $29 (6–59). Compared with same-day LED fluorescence microscopy and Xpert full rollout, targeted use of Xpert in presumptive tuberculosis cases with HIV infection, either as an initial diagnostic test or as a follow-on test to microscopy, would produce DALY gains at a higher incremental cost and therefore is dominated in the context of Tanzania. Interpretation: For Tanzania, this integrated modelling approach predicts that full rollout of Xpert is a cost-effective option for tuberculosis diagnosis and has the potential to substantially reduce the national tuberculosis burden. It also estimates the substantial level of funding that will need to be mobilised to translate this into clinical practice. This approach could be adapted and replicated in other developing countries to inform rational health policy formulation. Funding: United States Agency for International Development.

Background: The burden of ischaemic and haemorrhagic stroke varies between regions and over time. With differences in prognosis, prevalence of risk factors, and treatment strategies, knowledge of stroke pathological type is important for targeted region-specific health-care planning for stroke and could inform priorities for type-specific prevention strategies. We used data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) to estimate the global and regional burden of first-ever ischaemic and haemorrhagic stroke during 1990–2010. Methods: We searched Medline, Embase, LILACS, Scopus, PubMed, Science Direct, Global Health Database, the WHO library, and regional databases from 1990 to 2012 to identify relevant studies published between 1990 and 2010. We applied the GBD 2010 analytical technique (DisMod-MR) to calculate regional and country-specific estimates for ischaemic and haemorrhagic stroke incidence, mortality, mortality-to-incidence ratio, and disability-adjusted life-years (DALYs) lost, by age group (aged