Search

The transition from internship to residency is a critical period for trainees. This study investigated factors that influence the transition of residents from postgraduate year 1 (PGY-1) to dermatology residency. In June 2019, a program director–specific survey and a resident-oriented survey were administered via Survey Monkey. An email containing survey hyperlinks was sent via the Association of Professors of Dermatology Listserv to program directors, who were asked to forward the email to their current trainees. A total of 44 dermatology residents and 33 program directors responded. More than 58% of program directors identified a preliminary year in internal medicine as most beneficial. Both residents and program directors indicated rheumatology, infectious disease, and allergy and immunology as the most relevant PGY-1 electives. Eighty-two percent of program directors expected

The primary goal of this study was to compare the utilization of plate versus intramedullary nail (IMN) in the treatment of humerus fractures. Secondarily, we sought to examine whether any differences in demographics and clinical course of patients who receive a nail versus plate affect the procedure selection process.The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients surgically treated for a humeral shaft fracture from the years 2007-2015, using current procedural terminology (CPT) code. Patients with overlapping procedures, nonunion, polytrauma, and malignancy were excluded. The Charlson Comorbidity Index (CCI) was calculated to compare preoperative comorbidities. A two-sample Wilcoxon rank-sum (Mann-Whitney U) test was used to compare numerical values, whereas the Fisher exact and Chi-squared analyses were performed to compare categorical variables. A p value 0.05 was considered significant. Preoperative variables with a p value 0.05 and a clinical prevalence 1%, indicating statistical and clinical significance, were included in a logistic regression for multivariate analysis to identify any independent predictors for procedure selection (IMN versus PF) based on preoperative patient characteristics.During the study period plate fixation increased from 7 cases per year to 272 cases per year, while IMN increased from 8 cases per year to 80 cases per year. IMNs were mostly in older patients (63.85 vs 56.19 years, p 0.001), and patients with a higher Charlson Comorbidity Index (CCI) (4.64 vs 2.79, p 0.001). IMN was associated with shorter operation times (104 min vs 128 min, p 0.001) and longer lengths of hospital stay (3.43d vs 2.78d, p 0.001). No significant differences in overall complication rates were seen between patients who received IMN versus PF. However, the postoperative mortality rate was higher in patients who received IMN compared to PF (2.19% vs 0.40%, p 0.01). Based on the regression analysis, patient age was the only independent patient factor demonstrated to predict the utilization of IMN over PF in older patients with humeral shaft fractures p = 0.043).According to this NSQIP-based analysis, the rate of PF and IMN utilization increased in the treatment of humeral shaft fractures over a period of 8 years, but PF was performed at an overall a higher rate than IMN. Intramedullary nailing was preferred over PF in older patients with more comorbidities. The last possibly contributed to the higher 30-day mortality rate observed in patients who received IMN compared to PF.Retrospective comparative study.

Background Cutibacterium (formerly Propionibacterium) acnes persists in the dermis despite standard skin antiseptic agents, prompting some surgeons to use topical antimicrobials such as benzoyl peroxide and clindamycin prior to shoulder arthroplasty surgery. However, the efficacy of these topical agents has not been established. Methods The upper backs of 12 volunteers were randomized into 4 treatment quadrants: topical benzoyl peroxide, topical clindamycin, combination topical benzoyl peroxide and clindamycin, and a negative control. The corresponding topical agents were applied to each site twice daily for 3 days. A 3-mm dermal punch biopsy specimen was obtained from each site and cultured for 14 days to assess for C acnes growth. Positive cultures were assessed for the hemolytic phenotype. The McNemar test was used to compare the proportion of positive cultures in each group. Results C acnes grew in 4 of 12 control sites (33.3%), 1 of 12 benzoyl peroxide sites (8.3%), 2 of 12 clindamycin sites (16.7%), and 2 of 12 combination benzoyl peroxide–clindamycin sites (16.7%). The C acnes hemolytic phenotype was present in 2 of 12 control specimens (16.7%) compared with 0 (0.0%) in the benzoyl peroxide group, 2 of 12 (16.7%) in the clindamycin group, and 2 of 12 (16.7%) in the combination benzoyl peroxide–clindamycin group. There were no statistically significant differences between treatment arms. Conclusion The topical application of benzoyl peroxide and clindamycin did not eradicate C acnes in all subjects. The clinical implications of these findings are yet to be determined.

Context:Malnutrition is well-studied in various aspects of the orthopaedic literature, most commonly in relation to arthroplasty, spine surgery, and trauma. However, the management of nutritional deficiencies is commonly overlooked among orthopaedic sports medicine providers. The purpose of this article is to analyze the available sports medicine literature to review the associations between malnutrition and the management of orthopaedic sports medicine patients from a treatment and performance standpoint.Evidence Acquisition:PubMed was searched for relevant articles published from 1979 to 2019.Study Design:Clinical review.Level of Evidence:Level 4.Results:Few studies exist on the implications of macronutrient deficiencies specific to orthopaedic sports medicine procedures. Interestingly, micronutrient disorders—namely, hypovitaminosis D and iron deficiency—have been well studied and may lead to worse postoperative outcomes, injury rates, and athletic performance. Nutritional supplementation to correct such deficiencies has been shown to mitigate these effects, though further study is required.Conclusion:Nutritional deficiencies are highly prevalent in orthopaedic sports medicine patients, and practitioners should be aware of their potential effects on treatment and performance outcomes. Management of such deficiencies and their effect on surgical patients remain an area of potential future research. Future studies are warranted in order to explore the potential therapeutic role of nutritional supplementation to prevent complications after common orthopaedic sports medicine procedures, improve athletic performance, and reduce injury rates.

Objective Inhibition of hedgehog (HH) signaling prevents cartilage degeneration and promotes repair in animal models of osteoarthritis (OA). This study, undertaken in OA models and in human OA articular cartilage, was designed to explore whether kappa opioid receptor (KOR) modulation via the inhibition of HH signaling may have therapeutic potential for achieving disease-modifying activity in OA. Methods Primary human articular cartilage and synovial tissue samples from patients with knee OA undergoing total joint replacement and from healthy human subjects were obtained from the National Disease Research Interchange. For in vivo animal studies, a partial medial meniscectomy (PMM) model of knee OA in rats was used. A novel automated 3-dimensional indentation tester (Mach-1) was used to quantify the thickness and stiffness properties of the articular cartilage. Results Inhibition of HH signaling through KOR activation was achieved with a selective peptide agonist, JT09, which reduced HH signaling via the cAMP/CREB pathway in OA human articular chondrocytes (P = 0.002 for treated versus untreated OA chondrocytes). Moreover, JT09 markedly decreased matrix degeneration induced by an HH agonist, SAG, in pig articular chondrocytes and cartilage explants (P = 0.026 versus untreated controls). In vivo application of JT09 via intraarticular injection into the rat knee joint after PMM surgery significantly attenuated articular cartilage degeneration (60% improvement in the tibial plateau; P = 0.021 versus vehicle-treated controls). In JT09-treated rats, cartilage content, structure, and functional properties were largely maintained, and osteophyte formation was reduced by 70% (P = 0.005 versus vehicle-treated controls). Conclusion The results of this study define a novel mechanism for the role of KOR in articular cartilage homeostasis and disease, providing a potential unifying mechanistic basis for the overlap in disease processes and features involving opioid and HH signaling. Moreover, this study identifies a potential novel therapeutic strategy in which KOR modulation can improve outcomes in patients with OA.

Herpes simplex virus (HSV) infections are ubiquitous in the population in the more than half of all people seropositive HSV-2. While these in cause oral or genital lesions, anywhere on the body Herpetic whitlow class painful swollen, vesicular lesion of the digits due to HSV infection. In some instances, however, the skin lesion of HSV may appear atypical. In the following report, we describe a unique case of a hemorrhagic, pustular appearing herpetic whitlow infection of the hand. This report serves to remind physicians to consider the diagnosis of HV for a painful skin lesion of the hand, as herpetic whitlow can mimic more serious conditions and early detection can limit the spread of the disease.

Purpose of review Infantile hemangiomas are the most common vascular tumor of infancy. Treatment of infantile hemangiomas was revolutionized when propranolol, a nonselective β-blocker, was reported to be effective therapy. In this review, we highlight the lessons learned using propranolol to treat infantile hemangiomas. We also describe the ongoing effort to understand the mechanism of action of propranolol. Recent findings Although the pathogenesis of infantile hemangiomas is not fully understood, maternal hypoxic stress and embolization of placental tissue are suggested to be critical components in their development. The mechanism of action of propranolol remains unclear, however various molecular mechanisms are detailed in this review. Propranolol treatment remains a well tolerated therapy, with low risk of adverse events or long-term neurocognitive effects. Dosing recommendations and optimal treatment duration vary among studies, and should be altered in patients with certain medical conditions such as Posterior fossa anomalies, Hemangioma, Arterial lesions, Cardiac abnormalities/coarctation of the aorta, Eye anomalies (PHACE) syndrome. Summary Propranolol is a well tolerated and effective treatment for infantile hemangiomas. The efficacy of propranolol for infantile hemangiomas is clear, however questions pertaining to mechanism of action, pretreatment risk stratification, and optimal dosing remain unanswered. The guidelines for managing infantile hemangiomas with propranolol will continue to adapt as research catches up to clinical experience.

Repetitive overhead throwing generates tremendous demands on the shoulder joint of the overhead athlete. Clinicians, therapists, and medical staff are charged with optimizing a throwing athlete's shoulder mobility and stability to maximize performance and prevent injury. Modifiable risk factors such as strength asymmetry, glenohumeral range of motion deficits, and scapulothoracic joint abnormalities contribute to the overhead athlete's predisposition to shoulder injury. Most shoulder injuries in the overhead thrower can be successfully treated nonoperatively to allow in-season return to sport. The optimal rehabilitation program must be based on an accurate evaluation of historical and physical information as well as diagnostic imaging. Return to play decisions should be individualized and should weigh subjective assessments along with objective measurements of range of motion, strength, and function. The purpose of this clinical commentary is to summarize the current literature regarding the nonoperative treatment options for these common injuries, and to present a treatment plan to safely return these athletes to the field of play. Level of evidence 5.

Background Cross-linked polyethylene (XLPE) liners have shown lower wear rates than conventional polyethylene liners in total hip arthroplasty. The primary aim of our study was to report our most recent analysis of wear rates and clinical outcomes of a third-generation XLPE liner. Secondary aims were to investigate the rate of adverse events related to mechanical failure or oxidation of this liner. Methods A series of 266 total hip arthroplasties using a specific XLPE liner were retrospectively reviewed. Radiographs were examined to determine linear and volumetric wear rates and presence of osteolysis. Clinical outcomes, revision rates, mechanical failures, and risk factors for accelerated polyethylene wear were additionally investigated. Results The mean age at the time of surgery was 65.8 years and the mean follow-up was 5.5 years. The mean linear wear rate was 0.003 mm/year and the mean volumetric wear rate was 0.42 mm3/year, and there was no evidence of osteolysis. Harris hip scores increased from 50.9 preoperatively to 96.0 at the latest follow-up. The revision rate was 0.4%, with no liner rim fractures and no liner dissociations/loosenings. Femoral head material, head size, age, body mass index, and time since implantation had no effect on wear rates. Conclusions Wear rates for this third-generation XLPE liner were low at mid-term follow-up, and no adverse sequelae of oxidation or deleterious mechanical properties were observed. This remained true regardless of femoral head size and material or patient age and body mass index. Further analysis will be necessary to ensure continued wear resistance, oxidative stability, and mechanical strength at long-term follow-up.

Background: Many factors contribute to the risk for subsequent anterior cruciate ligament reconstruction (ACLR) within 2 years from the index procedure. Purpose/Hypothesis: The purpose of this study was 2-fold: (1) to evaluate the incidence of subsequent (revision or contralateral) ACLR at 2 years in a large cohort and (2) to explore the association between patient-specific factors and early subsequent ACLR risk by age group. We hypothesize that 2-year subsequent (revision or contralateral) ACLR rates will be low and that risk factors for subsequent (revision or contralateral) ACLR will vary depending on a patient’s age group. Study Design: Case-control study; Level of evidence, 3. Methods: The California Office of Statewide Health Planning and Development Ambulatory Surgery Database was retrospectively reviewed to assess the incidence of 2-year subsequent (revision or contralateral) ACLR and to identify patient-specific risk factors for early subsequent (revision or contralateral) ACLR by age group between 2005 and 2014. Results: Of 94,108 patients included, the rate of subsequent (revision or contralateral) ACLR was highest in patients younger than 21 years (2.4 per 100 person-years; 95% CI, 2.3-2.6) and lowest in those older than 40 years (1.3 per 100 person-years; 95% CI, 1.2-1.4). Younger age, white race (compared with Hispanic in all age groups and Asian in age 40 years), private insurance if age younger than 21 years, public insurance or worker's compensation claims if age older than 30 years were significantly associated with an increased risk of subsequent (revision or contralateral) ACLR at 2 years. Conclusion: Results of the present study provide insight into subsequent (revision or contralateral) ACL reconstruction, which can be used to assess and modify treatment for at-risk patients and highlight the need for data mining to generate clinically applicable research using national and international databases.

Repetitive overhead throwing generates tremendous demands on the shoulder joint of the overhead athlete. Clinicians, therapists, and medical staff are charged with optimizing a throwing athlete's shoulder mobility and stability to maximize performance and prevent injury. Modifiable risk factors such as strength asymmetry, glenohumeral range of motion deficits, and scapulothoracic joint abnormalities contribute to the overhead athlete's predisposition to shoulder injury. Most shoulder injuries in the overhead thrower can be successfully treated nonoperatively to allow in-season return to sport. The optimal rehabilitation program must be based on an accurate evaluation of historical and physical information as well as diagnostic imaging. Return to play decisions should be individualized and should weigh subjective assessments along with objective measurements of range of motion, strength, and function. The purpose of this clinical commentary is to summarize the current literature regarding the nonoperative treatment options for these common injuries, and to present a treatment plan to safely return these athletes to the field of play.5.

Background: There is a need for novel skin antiseptic agents to combat the health-care burdens associated with surgical site infection (SSI) and bacterial resistance. The purpose of this proof-of-principle pilot study was to investigate the potential of the phenolic compound protocatechuic acid (PCA) as a topical antimicrobial for surgical skin antisepsis. Methods: The Kirby-Bauer method of disc diffusion was used to investigate the in vitro antimicrobial activity and comparative effectiveness of PCA and 7 related compounds against SSI pathogens. To explore the in vivo efficacy of topical PCA for providing deep, penetrating skin antisepsis, living Cutibacterium acnes was intradermally injected into the skin of female BALB/c mice. Mice were assigned to treatment with daily applications of topical PCA at 3 doses (78, 39, and 19.5 mM) or no treatment (n = 2 mice per group). After 96 hours, infected skin samples were harvested to compare mean C. acnes counts by treatment. Results: Compared with other polyphenols, PCA demonstrated the broadest spectrum of antimicrobial activity against tested SSI pathogens, including drug-resistant organisms. At 96 hours following infection, the mean C. acnes burden in untreated mice was 6.65 log colony-forming units (CFUs) per gram of skin. Compared with the untreated group, daily topical application of 78 mM of PCA was associated with a significantly lower C. acnes CFU burden in mice skin (mean, 5.51 log CFUs per gram of skin; p = 0.0295). Both lower dosages of topical PCA failed to show an effect. Conclusions: PCA demonstrated laboratory efficacy against pathogens implicated in SSI, including drug-resistant organisms. In vivo, topical PCA demonstrated dose-dependent skin penetration and antimicrobial activity against mouse skin C. acnes loads. Human clinical studies exploring the antimicrobial efficacy of topical PCA for preoperative shoulder skin antisepsis are warranted. Clinical Relevance: Topical PCA may have the potential to improve current shoulder SSI treatment and prevention protocols.

Background Reducing the rising health-care burden associated with shoulder surgical site infection (SSI) is of paramount importance. The purpose of this study was to investigate the antimicrobial efficacy of protocatechuic acid (PCA) as a topical reagent for surgical skin antisepsis surrounding the shoulder joint. Methods This was a 2-phase skin-disinfection trial involving the human shoulder. The shoulders of healthy volunteers were randomized to topical treatment with PCA (a 10% concentration of PCA in Phase I [11 subjects] and a 17% concentration in Phase II [12 subjects]), with a control of isopropyl alcohol (IPA) applied to the contralateral shoulder. Mechanical scraping was performed for skin harvest following reagent application, and samples were sent for aerobic and anaerobic culture. Sterilization rates and bacterial counts were determined for each treatment group, and the proportion of subjects with persistent Cutibacterium acnes colonization following topical application of PCA was determined using DNA sequencing analysis. Results The topical application of 10% PCA was associated with significantly higher aerobic and anaerobic sterilization rates (90.9% and 81.8%, respectively) compared with treatment with IPA (p = 0.0143 and p = 0.0253, respectively). The topical application of 17% PCA was associated with a significantly higher anaerobic sterilization rate (83.3%) and trended toward a significantly higher aerobic sterilization rate (91.7%) compared with treatment with IPA (p = 0.0143 and p = 0.083, respectively). C. acnes was identified in 18.2% and 0% of subjects following treatment with 10% and 17% PCA, respectively. Conclusions The topical application of PCA was associated with a reduction in the bacterial burden of human shoulder skin and demonstrated dose-dependent antimicrobial activity against C. acnes in young, healthy subjects. Clinical studies in a shoulder surgical population are warranted to determine the potential for application in surgical skin antisepsis to reduce shoulder SSI. Level of evidence Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Objectives: NCAA Division I beach volleyball is a recently introduced sport that has been played for 3 seasons to date. Since the introduction of this new level of athletic participation for women’s’ beach volleyball, no study has been performed to compare the injury patterns between court and sand volleyball playing surfaces. The goal of this study is to compare the injury patterns and incidence in women’s collegiate court and beach volleyball in order to aid trainers, coaches and medical staff in effectively preparing and treating these collegiate athletes. Methods: A 3 year, retrospective review of all training room injury reports were analyzed for both beach and court volleyball from the 2015 through 2017 seasons. Non-athletic injuries or illness were excluded from analysis. Standardized injury rates for beach and court surfaces were calculated by normalizing the total number of injuries by the number of athletes and sets played. To compare the injury patterns among court versus beach volleyball players, injuries were categorized into one of six body regions (abdomen, lower extremity, upper extremity, thorax, head, and back). The proportion of injuries to each of these regions by playing surface was then calculated to compare injury patterns by playing surface. Chi-squared test and odds ratios were used to compare injury rates. Results: Between 2015 and 2017, 90 court volleyball injuries were recorded, while 49 beach volleyball injuries were recorded in the same time period. Court volleyball players had nearly quadruple the injury rate when compared to beach volleyball players, 0.039 and 0.010 injuries per athlete-set respectively (OR 4.05, 95%CI 2.85-5.76, pConclusion: The data suggests a significantly higher incidence of injury for court volleyball players when normalized for gameplay exposure. There were, also significant differences in injury patterns with court volleyball players having a higher proportion of lower extremity injuries and beach volleyball having a higher proportion of back injuries. Recognizing these differences can aid in the establishment of preventative strength and conditioning programs as well as post training treatment protocols for these athletes which may increase both the individuals as well as the teams overall competitive success.

Objectives: Currently little information is available in evaluating micronutrient requirements in elite athletes. Despite evidence that groups of NCAA athletes may be deficient in Vitamin D, no study to date has examined Vitamin D levels with respect to their predicative values for injuries to the ‘posterior chain’ musculature. The objective of this study was to evaluate the association between hypovitaminosis D and posterior chain injuries in NCAA Division I track and field athletes. Methods: After IRB approval, we evaluated data for men’s and women’s outdoor track and field teams from 2015-2018 at a large NCAA Division I athletics program. Vitamin D levels were drawn during pre-season annual physicals. The cutoff for hypovitaminosis D was set at 40 nmol/L. Demographic and athletic tenure data were recorded and analyzed, and competitive events were grouped into one of four categories: 1) running events, 2) jumping events, 3) throwing events, and 4) multiple event types. Student T tests, chi-squared tests, and multivariate logistic regression were performed. Results: The analysis consisted of 145 (58% female, 42% male) NCAA Division I track athletes. Eighty-five of the 145 athletes had hypovitaminosis D. A full breakdown of athlete characteristics by vitamin D status can be seen in Figure 1 and Table 1. Of the 145 athletes analyzed, 33 (22.7%) suffered a muscular injury to their posterior chain musculature. Multinomial logistic regression identified hypovitaminosis D as an independent risk factor for posterior chain injury (relative risk ratio: 3.23, p=0.016). Age, BMI, and event type were not predictive of a posterior chain injury. Of note, 4 (4.7%) athletes in the hypovitaminosis D group suffered multiple posterior chain injuries, with 2 (2.4%) athletes suffering 2 separate injuries and 2 (2.4%) athletes suffering 3 separate injuries. None of the athletes in the normal Vitamin D group suffered multiple posterior chain injuries. Conclusion: These results demonstrate that pre-season hypovitaminosis D is an independent risk factor for posterior chain muscular injury in NCAA division I track athletes. These data suggest that early detection of hypovitaminosis D may play a critical role in injury prevention for these athletes. [Table: see text]

Objectives: Most research on the role of vitamin D on skeletal health has been dedicated to the elderly for fracture prevention. However, there is a paucity of research examining the role of vitamin D in elite track and field athletes. The objective of this study was to evaluate the prevalence of stress reactions and fractures in NCAA Division I track and field athletes, and to determine the relationship between fractures and serum vitamin D levels. Methods: After IRB approval, we evaluated data for men’s and women’s outdoor track and field teams from 2015-2018 at a large NCAA Division I athletics program. Vitamin D levels were drawn during pre-season annual physicals. The cutoff for hypovitaminosis D was set at 40 nmol/L. Demographic and athletic tenure data were recorded and analyzed, and competitive events were grouped into one of four categories: 1) running events, 2) jumping events, 3) throwing events, and 4) multiple event types. Student T tests, chi-squared tests, and multivariate logistic regression were performed. Results: Of the 148 athletes analyzed, greater than 50% had hypovitaminois D (Figure 1). There were 29 (19.6%) athletes sustained a stress fracture or stress reaction. There was no difference in mean vitamin D levels in the injured group vs the non-injured group (43.55 ± 11.97 vs. 39.61 ± 12.32, respectively; p=0.122). Additionally, multivariate logistic regression failed to demonstrate an association between stress fracture or reaction incidence and vitamin D status, age, BMI, or event type (p>0.05 for all). Conclusion: These data suggest that NCAA Division I track and field athletes suffer a high rate of stress fractures and reactions, though those with hypovitaminosis D are not at increased risk of these injuries. This is the first study to demonstrate this in a heterogeneous population of elite athletes. Future studies investigating other modifiable risk factors for fracture in this population are warranted to prevent the health and athletic consequences of these fractures.

Here, we report a case of a middle-aged woman presenting with severe, long-standing, hyperkeratotic plaques of the lower extremities unrelieved by over-the-counter medications. Initial history and clinical findings were suggestive of an inherited ichthyosis. Ichthyoses are genetic disorders characterized by dry scaly skin and altered skin-barrier function. A diagnosis of ichthyosis vulgaris was confirmed by histopathology. Etiology, prevalence, and treatment options are discussed.