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Early periprosthetic fractures (PPFx) following primary total hip arthroplasty (THA) create significant morbidity. Established risk factors for early PPFx include age, gender, body mass index, surgical approach, and implant fixation. We investigated the role of femoral fixation on early PPFx (90 days postoperatively) in a high-risk cohort undergoing direct anterior approach (DAA) THA.The final cohort comprised 344 consecutive patients (390 hips) with risk factors for PPFx (age68 years and body mass index25 kg/mWe observed 8 early PPFx (2.1%), all fractures occurring in the noncemented group. Baseline demographics were similar but not equal, with the cemented group being older (78.0 versus 76.3 years; P = .004) with a greater proportion of females (91.9% versus 69.4%; P.001). The rate of early PPFx was significantly higher with noncemented fixation compared to cemented fixation (3.5% versus 0.0%; P = .023). A post hoc power analysis confirmed sufficient power (1-β = 0.81).Although baseline risk factors for early PPFx are not easily modifiable, surgical factors can be modified. Cemented fixation has the potential to markedly reduce the risk of early PPFx in high-risk patients undergoing DAA THA.

Virtual Reality (VR) has been used as a distraction tool in various medical settings to reduce pain and anxiety associated with procedures. This study evaluates the effectiveness of VR as a distraction tool for decreasing fear, anxiety, and pain in pediatric patients undergoing common outpatient orthopaedic procedures.A total of 210 patients were recruited from a single orthopaedic clinic between October 2017 and July 2019. Patients were randomized to the VR group or to the control group (standard of care). Outpatient procedures included cast and/or pin removals. Primary outcome measures were collected preprocedure and postprocedure using validated surveys, and included: fear (Children's Fear Scale), anxiety (Children's Anxiety Meter-State), and pain (Numerical Rating Scale). Patients and caregivers in the VR group completed a satisfaction survey at the end of their appointment. Fear, anxiety, and pain scores between the 2 groups were analyzed using multivariable linear regression models, and the satisfaction survey was analyzed using descriptive statistics.One hundred twenty nine patients were included in the final analysis, with 85 patients in the VR group and 44 patients in the control group. During the procedure, patients in the VR group reported significantly lower average fear scores ( P0.001) and anxiety scores ( P =0.003) as compared with controls. There were no differences between the groups in fear and anxiety scores before and after the procedure, or pain scores before, during, or after the procedure. Overall, patients and caregivers in the VR group reported high satisfaction scores, with 97% of patients and 95% of caregivers recommending this intervention to others.VR technology was found to be an effective distraction tool to improve fear and anxiety during cast removal procedures. Findings build on a body of evidence that supports the use of distraction tools in clinics, specifically pediatric orthopaedics, to improve fear and anxiety. The distraction tools can be easily translated into current practices.Level I.

Insurance companies are increasingly making unilateral determinations of admission status for primary total knee arthroplasty (TKA). These determinations may differ from those based on surgeon-derived criteria for outpatient knee replacement. The goal of this study is to determine if insurance company determinations of outpatient status are as reliable as surgeon-derived criteria in predicting outpatient discharge after TKA.We retrospectively reviewed 709 patients who were preoperatively authorized for outpatient TKA. Patients were stratified into 2 groups: "outpatient per surgeon" (appropriate for outpatient surgery per institutional protocols) or "outpatient per insurance" (appropriate for inpatient surgery per institutional protocols but denied inpatient status by insurance). The primary endpoint of this study was the conversion rate of outpatient to inpatient stay. Univariate logistic regression was performed to compare the odds of conversion to inpatient stay between outpatient per surgeon and outpatient per insurance procedures and other covariates.The cohort included 434 outpatient per insurance (61.2%) and 275 outpatient per surgeon (38.8%) patients. Surgeons accurately predicted outpatients' discharge 92.0% of the time, while insurance companies did so 81.3% of time (P.001). Outpatient per insurance procedures (odds ratio [OR] 2.20, P = .003) and body mass index35 kg/mDetermining inpatient versus outpatient status is a complex decision involving both clinical and social factors. Surgeons accurately predicted outpatient discharge 92% of the time. Moreover, outpatient per insurance procedures were twice as likely to be converted to inpatient status. Therefore, insurance companies should leave deciding admission status up to both the patient and surgeon.

The present work addresses the ultrasonic NDT of rails, more precisely of the rail foot. The practical constraint is that transducers must be located on the rail head, whereas the region of interest is the rail foot. Thus, there is no direct acoustic path between the transducers and the region of interest. As classical delay and sum methods cannot be applied to such cases, the goal of the paper is to numerically assess the potentiality of the topological imaging method to investigate the rail foot. Three specific typical rail foot defects are investigated, namely, longitudinal vertical cracks, corrosion pits and rail injuries. Simulating eight transducers with different polarizations, the images obtained show that the detection and approximate location of the various defects are possible.

Brownian coating thermal noise in detector test masses is limiting the sensitivity of current gravitational-wave detectors on Earth. Therefore, accurate numerical models can inform the ongoing effort to minimize Brownian coating thermal noise in current and future gravitational-wave detectors. Such numerical models typically require significant computational resources and time, and often involve closed-source commercial codes. In contrast, open-source codes give complete visibility and control of the simulated physics, enable direct assessment of the numerical accuracy, and support the reproducibility of results. In this article, we use the open-source SpECTRE numerical relativity code and adopt a novel discontinuous Galerkin numerical method to model Brownian coating thermal noise. We demonstrate that SpECTRE achieves significantly higher accuracy than a previous approach at a fraction of the computational cost. Furthermore, we numerically model Brownian coating thermal noise in multiple sub-wavelength crystalline coating layers for the first time. Our new numerical method has the potential to enable fast exploration of realistic mirror configurations, and hence to guide the search for optimal mirror geometries, beam shapes and coating materials for gravitational-wave detectors., Comment: 15 pages, 5 figures. Results are reproducible with the ancillary input files

Virtual reality (VR) technology has seen increasing use in physical rehabilitation and in the management of acute and chronic pain. Functional movement disorders (FMDs) are a source of disability with no known association to neurologic pathology, and patients are generally offered multidisciplinary treatment approaches to improve functional movement. However, patients who are not compliant with rehabilitation may have persistent FMD and long-term disability. Given VR’s use in physical rehabilitation, it may serve as a useful adjunct for the management of FMD. Utilizing an application called MovementTM to create a playlist of targeted applications for the restoration of motor function and balance, this case study presents the application of VR as a tool to engage patients in physical therapy for the management of FMD. The VR games were selected to encourage movement while customization of levels within the games facilitated achievement of physical therapy goals. Physical rehabilitation aided by VR, when used in collaboration with a multidisciplinary care team, may be used to facilitate recovery from FMD.

Children often require anesthesia for simple diagnostic and therapeutic procedures. The aim of this study was to evaluate the feasibility of using virtual reality (VR) to reduce sedation in children undergoing minor surgical procedures. In this prospective, non-randomized clinical trial, pediatric patients at a free-standing children’s hospital undergoing hormone implant placement, removal, or exchange were recruited to use VR and local anesthesia instead of procedural sedation or general anesthesia (GA). Patients were enrolled between November 2017 and March 2020, and were compared to historic controls who underwent similar procedures without VR between April 2016 and February 2020. Primary outcome measure was successful procedure completion without sedation or GA. Secondary measures included assessments of pain, fear and anxiety, patient compliance, procedural and recovery times. Twenty-eight patients underwent 29 procedures with VR. Hormone implants (72%), removals (7%), or exchanges (21%) were completed without GA, sedation or IV placement. Procedure lengths and pain scores were similar between VR patients and historic controls, but recovery times were significantly shorter in VR patients (18 vs 65 min, p

Augmented reality (AR) has promise as a clinical teaching tool, particularly for remote learning. The Chariot Augmented Reality Medical (CHARM) simulator integrates real-time communication into a portable medical simulator with a holographic patient and monitor. The primary aim was to analyze feedback from medical and physician assistant students regarding acceptability and feasibility of the simulator.Using the CHARM simulator, we created an advanced cardiovascular life support (ACLS) simulation scenario. After IRB approval, preclinical medical and physician assistant students volunteered to participate from August to September 2020. We delivered augmented reality headsets (Magic Leap One) to students before the study. Prior to the simulation, via video conference, we introduced students to effective communication skills during a cardiac arrest. Participants then, individually and remotely from their homes, synchronously completed an instructor-led ACLS AR simulation in groups of three. After the simulation, students participated in a structured focus group using a qualitative interview guide. Our study team coded their responses and interpreted them using team-based thematic analysis.Eighteen medical and physician assistant students participated. We identified four domains that reflected trainee experiences: experiential satisfaction, learning engagement, technology learning curve, and opportunities for improvement. Students reported that the simulator was acceptable and enjoyable for teaching trainees communication skills; however, there were some technical difficulties associated with initial use.This study suggests that multiplayer AR is a promising and feasible approach for remote medical education of communication skills during medical crises.The online version contains supplementary material available at 10.1007/s40670-022-01598-7.

Most consumer-level low-cost unmanned aerial vehicles (UAVs) have limited battery power and long charging time. Thus, they cannot accomplish some practical tasks such as providing service to cover an area for an extended time, also known as persistent covering. Algorithmic approaches are limited mostly due to the computational complexity and intractability of the problem. Approximation algorithms that assume unlimited energy have been considered to segment a large area into smaller cells that require periodic visits under the latency constraints. In this letter, we explore geometric and topological properties that allow us to significantly reduce the size of the optimization problem. Consequently, the proposed method can efficiently determine the minimum number of UAVs needed and schedule their routes to cover an area persistently. We experimentally demonstrate that the proposed algorithm has better performance than the baseline.

Purpose of review Commercial availability of virtual reality headsets and software has exponentially grown over the last decade as it has become more sophisticated, less expensive, and portable. Although primarily used by the general public for entertainment, virtual reality has been adopted by periprocedural clinicians to improve patient experiences and treatments. The purpose of this review is to explore recently reported evidence for virtual reality effectiveness for pediatric periprocedural care and discuss considerations for clinical implementation. Recent findings In the preprocedure setting, practitioners use virtual reality to introduce children to periprocedural environments, distract attention from preprocedural vascular access, and increase cooperation with anesthesia induction. Intraprocedure, virtual reality decreases sedation requirements, and in some instances, eliminates anesthesia for minor procedures. Virtual reality also augments pain reduction therapies in the acute and extended rehabilitation periods, resulting in faster recovery and improved outcomes. Virtual reality seems to be well treated for pediatric use, given close clinical care and carefully curated content. Summary Given the multiple clinical applications of virtual reality to supplement pediatric periprocedural care, practitioners should consider developing clinical programs that reliably provide access to virtual reality. Future research should focus on identification of patient characteristics and types of software that yield optimal patient outcomes.

Background Intimidation constitutes a learning barrier for undergraduates and its reporting rate to authorities remains suboptimal. Methods A randomized controlled trial was conducted to evaluate the effectiveness of three interventions designed to increase reporting by undergraduates during their surgical rotation. As adjuncts to a standardized lecture, participants were assigned to a simulated intimidation scenario, a video of intimidation events, or a control group. Surveys were completed before the interventions, and at the end of the rotation. Results Of the 119 included participants, 17.6% reported that they had been intimidated during their previous rotation as compared to 37.0% after the surgical rotation. There were no statistically significant differences in the reporting of intimidation between the groups. However, 65.5% of all participants declared feeling more at ease to report intimidation, yet the reporting rate remained low. Conclusion Intimidation during clerkship persists as a frequent problem although the best method to increase its reporting remains unclear.

Purpose Pediatric radiation therapy (RT) requires optimal immobilization that often necessitates daily anesthesia. To decrease anesthesia use, we implemented a novel audiovisual-assisted therapeutic ambience in RT (AVATAR) system that projects video onto a radiolucent screen within the child's line of vision to provide attentional diversion. We investigated its reduction on anesthesia use, payer charges, and treatment time, in addition to its impact on radiation delivery. Methods and Materials A 6-year retrospective analysis was performed among children undergoing RT (n = 224) 3 years before and 3 years after the introduction of AVATAR. The frequency of anesthesia use before and after AVATAR implementation, in addition to RT treatment times, were compared. The number of spared anesthesia treatments allowed for a charge to payer analysis. To document the lack of surface dose perturbation by AVATAR, a phantom craniospinal treatment course was delivered both with and without AVATAR. Additionally, an ion chamber course was delivered to document changes to the dose at depth. Results More children were able to avoid anesthesia use entirely in the post-AVATAR cohort compared with the pre-AVATAR cohort (73.2% vs 63.4%; P = .03), and fewer required anesthesia for each treatment (18.8% vs 33%; P = .03). AVATAR introduction reduced anesthesia use for all ages studied. Treatment time per session was reduced by 38% using AVATAR compared with anesthesia. There were 326 fewer anesthesia sessions delivered over 3 years after AVATAR was introduced, with an estimated savings of >$500,000. Optically stimulated luminescent dosimeters revealed a small increase in dose of 0.8% to 9.5% with AVATAR, whereas the use of a thermomolded face mask increased skin dose by as much as 58%. Conclusions AVATAR introduction decreased anesthesia use in children undergoing RT. More children avoided anesthesia entirely, and fewer needed anesthesia for every treatment, resulting in a reduction in treatment time and savings of nearly $550,000 in approximately 3 years, with minimal perturbation of RT dose delivery.

Background The aim of the present study was to evaluate the effectiveness of the Bedside Entertainment and Relaxation Theater (BERT) on fear, anxiety, and pain outcomes in pediatric orthopaedic patients associated with cast removal and/or pin removal in the outpatient clinic setting. Methods A total of 66 pediatric patients between the ages of 2 and 6 undergoing clinic procedures were recruited for this study and randomized into the control group or the intervention (BERT) group. Patients in the control group received standard of care during the cast room procedure; patients in the BERT group were given headphones and watched a movie on a projector during the procedure. Fear, anxiety, and pain were measured before and after the procedure. Procedures included cast removal, pin removal, or a combination of the 2. Results Patients in the BERT group reported less fear and anxiety overall after the procedure than patients in the control group (P=0.009, 0.015). Adjusting for procedure type (ie, pin removal), patients in the BERT group reported a 0.67 point decrease (95% confidence interval: 0.04, 1.30) on the fear scale after the procedure (P=0.039) and a 1.81 point decrease (95% confidence interval: 0.04, 3.59) on the anxiety scale associated with the procedure (P=0.045), compared with the control group. Patients and caregivers reported high satisfaction with BERT. Conclusion This randomized, controlled trial demonstrates an evidence-based distraction tool that can be implemented across medical centers for pediatric patients undergoing office based orthopaedic procedures. BERT can be used to reduce fear and anxiety associated with these procedures, and increased patient and parent satisfaction. Level of evidence Level I.

International audience; The internal geometry of a wind instrument can be estimated from acoustic measurements. For woodwind instruments, this involves characterizing the inner shape (bore) but also the side holes (dimensions and location). In this study, the geometric parameters are recovered by a gradient-based optimization process, which minimizes the deviation between simulated and measured linear acoustic responses of the resonator for several fingerings through an observable function. The acoustic fields are computed by solving a linear system resulting from the 1D spectral finite elements spatial discretization of the wave propagation equations (including thermo-viscous effects, radiation and side holes). The “full waveform inversion” (FWI) technique exploits the fact that the gradient of the cost function can be computed by solving the same linear system as that of the direct problem but with a different source term. The gradient is computed with better accuracy and less additional cost than with finite-difference. The dependence of the cost function on the choice of the observed quantity, the frequency range and the fingerings used, is first analyzed. Then, the FWI is used to reconstruct, from measured impedances, an elementary instrument with 14 design variables. The results, obtained in about 1 minute on a laptop, are in excellent agreement with the direct geometric measurements.

Delayed cerebral ischemia (DCI) affects 30% of patients following aneurysmal subarachnoid hemorrhage (aSAH) and is a major driver of morbidity, mortality, and intensive care unit length of stay for these patients. DCI is strongly associated with cerebral arterial vasospasm, reduced cerebral blood flow and cerebral infarction. The current standard treatment with intravenous or intra-arterial calcium channel antagonist and balloon angioplasty or stent has limited efficacy. A simple treatment such as a cervical sympathetic block (CSB) may be an effective therapy but is not routinely performed to treat vasospasm/DCI. CSB consists of injecting local anesthetic at the level of the cervical sympathetic trunk, which temporarily blocks the innervation of the cerebral arteries to cause arterial vasodilatation. CSB is a local, minimally invasive, low cost and safe technique that can be performed at the bedside and may offer significant advantages as complementary treatment in combination with more conventional neurointerventional surgery interventions. We reviewed the literature that describes CSB for vasospasm/DCI prevention or treatment in humans after aSAH. The studies outlined in this review show promising results for a CSB as a treatment for vasospasm/DCI. Further research is required to standardize the technique, to explore how to integrate a CSB with conventional neurointerventional surgery treatments of vasospasm and DCI, and to study its long-term effect on neurological outcomes.

Pre-weaned porcine islets (PPIs) represent an unlimited source for islet transplantation but are functionally immature. We previously showed that necrostatin-1 (Nec-1) immediately after islet isolation enhanced the in vitro development of PPIs. Here, we examined the impact of Nec-1 on the in vivo function of PPIs after transplantation in diabetic mice. PPIs were isolated from pancreata of 8–15-day-old, pre-weaned pigs and cultured in media alone, or supplemented with Nec-1 (100 µM) on day 0 or on day 3 of culture (n = 5 for each group). On day 7, islet recovery, viability, oxygen consumption rate, insulin content, cellular composition, insulin secretion capacity, and transplant outcomes were evaluated. While islet viability and oxygen consumption rate remained high throughout 7-day tissue culture, Nec-1 supplementation on day 3 significantly improved islet recovery, insulin content, endocrine composition, GLUT2 expression, differentiation potential, proliferation capacity of endocrine cells, and insulin secretion. Adding Nec-1 on day 3 of tissue culture enhanced the islet recovery, proportion of delta cells, beta-cell differentiation and proliferation, and stimulation index. In vivo, this leads to shorter times to normoglycemia, better glycemic control, and higher circulating insulin. Our findings identify the novel time-dependent effects of Nec-1 supplementation on porcine islet quantity and quality prior to transplantation.

Purpose The purpose of this report is to demonstrate the successful application of virtual reality to improve physical therapy in the pediatric cardiovascular intensive care unit. Early mobilization and cognitive stimulation improve morbidity of critically ill children. However, maintaining child engagement with these therapies can be challenging, especially during extended intensive care stays. Summary of key points While virtual reality has been successfully used as an analgesic and anxiolytic in the cardiovascular intensive care unit, this report demonstrates its novel use as a tool to augment physical therapy for a child who had been debilitated after heart transplantation. Virtual reality encouraged the child to engage in physical therapy sessions, participate for greater durations, and directly address barriers to discharge. Conclusions and recommendations for clinical practice While further studies are needed to define best practice, this report demonstrates that virtual reality can be safely used for carefully selected and monitored children in critical care.

Introduction The optimal fixation method for total knee arthroplasty (TKA) is still a debate. Cemented fixation has excellent long-term results and is the gold standard. However, longevity in the younger, heavier, and more active population is suboptimal. Cementless TKA offers the opportunity to gain biological fixation and overcome these shortcomings. Methods This is a retrospective review of all consecutive cementless TKA procedures performed at a single academic institution from 2016 until 2020. Demographics, aseptic revisions, and septic revisions were pulled from the electronic medical record. The number of yearly implanted cementless TKA prosthesis was determined to analyze utilization trends. Results Eight-hundred and two patients were identified with a mean age of 61.57 ± 7.78 years, and a mean of BMI 32.12 ± 5.98 kg/m2. The mean time to revision was 12.31 ± 13.91 months. There were four septic failures and nine aseptic failures during the study period. Of these nine aseptic failures only five were due to mechanical loosening. There was a yearly linear increase in the use of cementless fixation. Conclusion Cementless fixation is here to stay, and its use will continue to increase. Early and mid-term outcomes have been excellent thus far. Changing clinical practice takes time but we have already seen this transition take place in total hip arthroplasty. As technology and design continue to evolve, we believe it is a possibility.