Search

To study the prevalence and quality of application of minimal clinically important difference (MCID), substantial clinical benefit (SCB), patient-acceptable symptomatic state (PASS), and maximum outcome improvement (MOI), reported in the orthopaedic sports medicine knee and shoulder literature in recent years and to bring awareness of proper use of such metrics. A literature review of all shoulder and knee articles published from the American Journal of Sports Medicine (AJSM), Journal of Shoulder and Elbow Surgery (JSES), and Arthroscopy from 2016 to 2020 was performed, specifically investigating whether MCID, SCB, PASS, or MOI were used or reported. Additionally, the way these metrics were reported and interpreted was recorded. Out of 5,039 studies, 889 shoulder and knee studies met the inclusion criteria. Overall, 16.7% reported either MCID, PASS, or SCB. MCID was the most reported across all 3 journals. MCID was reported 12.4% of the time throughout the 5 years. PASS was reported 3.2% and SCB 1.1% of the time over the 5 years. MOI was not reported by any of the journals during this period. There was a statistically significant increase in MCID reporting in 2 of the 3 journals over the 5-year course, Arthroscopy (P =.02) and AJSM (P =.05). There was no statistically significant increase in PASS or SCB reporting rates in all 3 journals. Only 39.1% of studies reported MCID correctly (i.e., defined as the number of individual patients meeting MCID/total patients in the study). This study shows an increasing trend in the use of clinically significant outcome metrics, such as MCID, for interpretation of patient-reported outcomes; however, these individual metrics are often not being used on the individual level and subsequently not reported accurately. We recommend determining whether the specific metric met the threshold per individual patient and then reporting those as a percentage of the sample population to achieve the full potential of these metrics and translate them accurately across various studies. As the usage of clinically significant outcome metrics rises, so does the need for accurate reporting. These findings will encourage future studies to follow a more standardized format. [ABSTRACT FROM AUTHOR]

Job syndrome is a disease of autosomal dominant hyper-IgE syndrome (AD-HIES). Patients harboring STAT3 mutation are particularly prone to airway remodeling and airway infections. Airway epithelial cells play a central role as the first line of defense against pathogenic infection and express high levels of STAT3. This study thus interrogates how AD-HIES STAT3 mutations impact the physiological functions of airway epithelial cells. This study created human airway basal cells expressing 4 common AD-HIES STAT3 mutants (R382W, V463del, V637M, and Y657S). In addition, primary airway epithelial cells were isolated from a patient with Job syndrome who was harboring a STAT3-S560del mutation and from mice harboring a STAT3-V463del mutation. Cell proliferation, differentiation, barrier function, bacterial elimination, and innate immune responses to pathogenic infection were quantitatively analyzed. STAT3 mutations reduce STAT3 protein phosphorylation, nuclear translocation, transcription activity, and protein stability in airway basal cells. As a consequence, STAT3-mutated airway basal cells give rise to airway epithelial cells with abnormal cellular composition and loss of coordinated mucociliary clearance. Notably, AD-HIES STAT3 airway epithelial cells are defective in bacterial killing and fail to initiate vigorous proinflammatory responses and neutrophil transepithelial migration in response to an experimental model of Pseudomonas aeruginosa infection. AD-HIES STAT3 mutations confer numerous abnormalities to airway epithelial cells in cell differentiation and host innate immunity, emphasizing their involvement in the pathogenesis of lung complications in Job syndrome. Therefore, therapies must address the epithelial defects as well as the previously noted immune cell defects to alleviate chronic infections in patients with Job syndrome. [ABSTRACT FROM AUTHOR]

• Patients of marginalized racial groups experience lower odds of being electively admitted compared to White patients. • Black patients have an increased likelihood of poorer outcomes and increased length of stay for UIA compared to White patients. • Rates of in-hospital complications were not significantly different between races. Strong evidence demonstrates that race is associated with health outcomes. Previous neurosurgical research has focused predominantly on subjective data, such as patient satisfaction. Our objective was to assess whether racial disparities are present in primary objective outcomes for treatment of intracranial, unruptured aneurysms in the United States. Data from the 2012–2015 National Inpatient Sample (NIS) database was analyzed. Patients who underwent either open or endovascular treatment of unruptured intracranial aneurysms were included (n = 11663). Patients were stratified by race, and those of unknown race or whose race sample size was too underpowered for analysis were excluded (n = 1202), along with those who experienced head trauma (n = 110) or concurrent AVM (n = 71). Poor outcome was defined as in-hospital mortality, discharge to a nursing facility or hospice, placement of a tracheostomy tube, or placement of a gastrostomy tube. The associations between race and adverse outcomes were determined through multivariate logistic regression, corrected for potentially confounding variables such as age, sex, procedural type, elective procedure, obesity, diabetes, tobacco, severity of illness, and hospital type. 7478 White, 1460 Black, 1086 Hispanic, and 279 Asian patients were included in the final analysis. Complication rates were not significantly different between races, however Black patients experienced the highest proportion of complications (24 %). After adjusting for confounders, the odds of poor outcomes were significantly higher for Black patients (OR = 1.32 95 % CI: 1.07–1.62; p = 0.008) when compared to White patients. Black and Hispanic patients demonstrated a longer length of stay (Black, B: 0.04; 95 % CI: 0.03, 0.06; p < 0.001; Hispanic, B: 0.04; 95 % CI: 0.02, 0.05; p < 0.001) when compared to White patients. Our nationwide analysis using the NIS suggests that Black patients treated for unruptured intracranial aneurysms experience worse outcomes and longer lengths of stay when compared to White patients. Recognizing the differences in objective outcomes and the presence of neurosurgical healthcare disparities is an important first step in providing equitable care to all patients. Future studies that carefully follow the social determinants of health and consider more confounding factors in the association between outcomes and determinants are needed. [ABSTRACT FROM AUTHOR]

Whether the use of fludrocortisone affects outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH). We conducted a retrospective analysis of 78 consecutive patients with a ruptured aSAH at a single academic center in the United States. The primary outcome was the score on the modified Rankin scale (mRS, range, 0 [no symptoms] to 6 [death]) at 90 days. The primary outcome was adjusted for age, hypertension, aSAH grade, and time from aSAH onset to aneurysm treatment. Secondary outcomes were neurologic and cardiopulmonary dysfunction events. Among 78 patients at a single center, the median age was 58 years [IQR, 49 to 64.5]; 64 % were female, and 41 (53 %) received fludrocortisone. The adjusted common odds ratio, aOR, of a proportional odds regression model of fludrocortisone use with mRS was 0.33 (95 % CI, 0.14-0.80; P = 0.02), with values <1.0 favoring fludrocortisone. Organ-specific dysfunction events were not statistically different: delayed cerebral ischemia (22 % vs. 39 %, P = 0.16); cardiac dysfunction (0 % vs. 11 %; P = 0.10); and pulmonary edema (15 % vs. 8 %; P = 0.59). The risk of disability or death at 90 days was lower with the use of fludrocortisone in aSAH patients. [ABSTRACT FROM AUTHOR]

PASTA (partial articular supraspinatus tendon avulsion) lesions are a subset of partial rotator cuff tears that are commonly treated by surgeons. Multiple surgical techniques exist for managing these lesions, including debridement, transtendinous repair, and completion of the tear and repair. Each of these techniques provides its own set of advantages and disadvantages, and currently there is no consensus on which method provides the best clinical outcomes or ease of procedure. Here, we present our repair technique for PASTA lesions, which involves a bursal split that takes the advantages of previous techniques by allowing improved visualization of the footprint and suture passing while avoiding the takedown any of Sharpey's fibers. [Display omitted] [ABSTRACT FROM AUTHOR]

BACKGROUND: Cardiac allograft rejection is the leading cause of early graft failure and is a major focus of postheart transplant patient care. While histological grading of endomyocardial biopsy samples remains the diagnostic standard for acute rejection, this standard has limited diagnostic accuracy. Discordance between biopsy rejection grade and patient clinical trajectory frequently leads to both overtreatment of indolent processes and delayed treatment of aggressive ones, spurring the need to investigate the adequacy of the current histological criteria for assessing clinically important rejection outcomes. METHODS: N=2900 endomyocardial biopsy images were assigned a rejection grade label (high versus low grade) and a clinical trajectory label (evident versus silent rejection). Using an image analysis approach, n=370 quantitative morphology features describing the lymphocytes and stroma were extracted from each slide. Two models were constructed to compare the subset of features associated with rejection grades versus those associated with clinical trajectories. A proof-of-principle machine learning pipeline—the cardiac allograft rejection evaluator—was then developed to test the feasibility of identifying the clinical severity of a rejection event. RESULTS: The histopathologic findings associated with conventional rejection grades differ substantially from those associated with clinically evident allograft injury. Quantitative assessment of a small set of well-defined morphological features can be leveraged to more accurately reflect the severity of rejection compared with that achieved by the International Society of Heart and Lung Transplantation grades. CONCLUSIONS: Conventional endomyocardial samples contain morphological information that enables accurate identification of clinically evident rejection events, and this information is incompletely captured by the current, guideline-endorsed, rejection grading criteria. [ABSTRACT FROM AUTHOR]

The optimal approach to identify SARS-CoV-2 infection among college students returning to campus is unknown. Recommendations vary from no testing to two tests per student. This research determined the strategy that optimizes the number of true positives and negatives detected and reverse transcription polymerase chain reaction (RT-PCR) tests needed. A decision tree analysis evaluated five strategies: (1) classifying students with symptoms as having COVID-19, (2) RT-PCR testing for symptomatic students, (3) RT-PCR testing for all students, (4) RT-PCR testing for all students and retesting symptomatic students with a negative first test, and (5) RT-PCR testing for all students and retesting all students with a negative first test. The number of true positives, true negatives, RT-PCR tests, and RT-PCR tests per true positive (TTP) was calculated. Strategy 5 detected the most true positives but also required the most tests. The percentage of correctly identified infections was 40.6%, 29.0%, 53.7%, 72.5%, and 86.9% for Strategies 1–5, respectively. All RT-PCR strategies detected more true negatives than the symptom-only strategy. Analysis of TTP demonstrated that the repeat RT-PCR strategies weakly dominated the single RT-PCR strategy and that the thresholds for more intensive RT-PCR testing decreased as the prevalence of infection increased. Based on TTP, the single RT-PCR strategy is never preferred. If the cost of RT-PCR testing is of concern, a staged approach involving initial testing of all returning students followed by a repeat testing decision based on the measured prevalence of infection might be considered. [ABSTRACT FROM AUTHOR]

Both hook plate fixation and suture button-anchor fixation have been reported to yield good results in the treatment of acute acromioclavicular joint reconstruction. In addition to a mandatory secondary procedure, hook plate fixation clearly has an increased prevalence of post-traumatic acromioclavicular arthritis in the short term that is likely to progress in the long term. Conversely, suture button-anchor fixation-a minimally invasive technique that creates less soft-tissue disruption, does not require hardware removal, and does not violate the acromioclavicular joint-is more likely to promote primary healing of the coracoclavicular ligaments, reduce the risk of late displacement, and minimize the development of post-traumatic acromioclavicular arthritis. As stated by the noted architect Frank Lloyd Wright, it is not only about form (i.e., alignment), it is about function as well. [ABSTRACT FROM AUTHOR]

Evidence-based medicine (EBM) guidelines were first introduced in 1986 and were defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research. Level of evidence (LOE) stratifies publications from Level I to Level V and provides the foundation for EBM. Three questions should be asked when an LOE is assigned to a scientific article: (1) What is the research question? (2) What is the study type? and (3) What is the hierarchy of evidence? In cases in which LOE is not appropriate or relevant (basic science and laboratory-based investigations), a clinical relevance statement should be used. Unfortunately, study quality is not assessed by the assigned hierarchy level. LOE and EBM have increased the number of investigations published with better levels of evidence. As authors, reviewers, editors, and publishers, we desire a system that is consistent, effective, and reliable. Fortunately, the system has proven to have all of those attributes with good interobserver and intra-observer values. The increase in investigations with higher LOEs allows for more frequent use of EBM. [ABSTRACT FROM AUTHOR]

Background We report on a Phase 1 trial of photodynamic therapy (PDT) for superficial head and neck (H&N) lesions. Due to known oxygen dependencies of PDT, translational measurements of lesion hemoglobin oxygen saturation (S t O 2 ) and blood volume (tHb) were studied for associations with patient outcomes. Methods PDT with aminolevulinc acid (ALA) and escalating light doses was evaluated for high-grade dysplasia, carcinoma-in-situ, and microinvasive carcinomas of the H&N. Among 29 evaluable patients, most (18) had lesions of the tongue or floor of mouth (FOM). Disease was intact in 18 patients and present at surgical margins in 11 patients. In 26 patients, lesion S t O 2 and tHb was measured. Results Local control (LC) at 24 months was 57.5% among all patients. In patients with tongue/FOM lesions LC was 42.7%, and it was 50.1% for those with intact lesions. Lesion tHb was not associated with 3-month complete response (CR), but S t O 2 was higher in patients with CR. In tongue/FOM lesions, baseline S t O 2 [mean(SE)] was 54(4)% in patients (n = 12) with CR versus 23(8)% in patients (n = 6) with local recurrence/persistence (p = 0.01). Similarly, for intact disease, baseline S t O 2 was 54(3)% in patients (n = 10) with CR versus 28(8)% in patients (n = 5) without CR (p = 0.03). In patients with intact disease, higher baseline S t O 2 associated with 24-month local control (p = 0.02). Conclusions Measurement of the physiologic properties of target lesions may allow for identification of patients with the highest probability of benefiting from PDT. This provides opportunity for optimizing light delivery based on lesion characteristics and/or informing ongoing clinical decision-making in patients who would most benefit from PDT. [ABSTRACT FROM AUTHOR]

Background: Considerable effort has gone into improving outcomes from out-of-hospital cardiac arrest (OHCA). Studies suggest that survival is improving; however, prior studies had insufficient data to pursue the relationship between markers of guideline compliance and temporal trends. The objective of the study was to evaluate trends in OHCA survival over an 8-year period that included the implementation of the 2005 and 2010 international cardiopulmonary resuscitation (CPR) guidelines.Methods and Results: This was a population-based cohort study of all consecutive treated OHCA patients of presumed cardiac cause between 2006 and 2013 in the City of Toronto, Canada, and surrounding regions. Temporal changes were measured by χ2 trend test. The association between year of the OHCA and survival was evaluated using logistic regression and joinpoint analysis. A total of 23 619 patients with OHCA met study inclusion criteria. During the study period, survival to hospital discharge doubled (4.8% in 2006 to 9.4% in 2013; P<0.0001), and survival with good neurological outcome increased (6.2% in 2010 to 8.5% in 2013; P=0.005). Improvements occurred in the rates of bystander CPR and automated external defibrillator application, high-quality CPR metrics, and in-hospital targeted temperature management. After adjusting for the Utstein variables, survival to hospital discharge (odds ratio, 1.12; 95% confidence interval, 1.09-1.15) and survival with good neurological outcome (odds ratio, 1.13; 95% confidence interval, 1.05-1.22) increased with each year of study.Conclusions: Survival after OHCA has improved over time. This trend was associated with improved rates of bystander CPR, automated external defibrillator use, high-quality CPR metrics, and in-hospital targeted temperature management. The results suggest that multiple factors, each improving over time, may have contributed to the observed increase in survival. [ABSTRACT FROM AUTHOR]

Unrecognized rotatory instability as evidenced by a high-grade pivot shift is well known to compromise anterior cruciate ligament (ACL) reconstruction results. By measuring which patients have anterior tibial subluxation of the lateral compartment ≥ 6 mm on a preoperative MRI, surgeons may be better able to counsel patients on postoperative expectations, as well as prepare for additional procedures to treat high-grade rotatory instability. Additionally, as there is an increased incidence of lateral meniscus tears in high-grade rotatory ACL lesions, surgeons should be vigilant and prepared to repair lateral meniscus root and ramp lesions. Furthermore, early identification of those patients with anterior tibial subluxation of the lateral compartment ≥6 mm will provide the opportunity for early surgery, as it is known that patients with high-grade rotatory instability are likely to sustain further intra-articular damage and have poorer outcomes if surgery is delayed. However, when there is doubt of high-grade rotatory instability after an ACL injury, examining the patient with a pivot shift maneuver should still be the "gold standard". [ABSTRACT FROM AUTHOR]

It would stand to reason that, in shoulder instability patients with bipolar bone loss, the combination of a bone block procedure and a remplissage procedure would provide better results than each one alone. Why would this be the case? When performing these procedures in the lateral decubitus position for patients with critical bipolar bone loss, the humeral head is anteriorly and inferiorly subluxed. This is most likely due to the incompetent restraints when in traction. A bone block procedure alone doesn't necessarily reduce the glenohumeral center of rotation; rather, it increases the "jump distance," making it more difficult for the humerus to dislocate over the bone block. However, the remplissage procedure not only makes the Hill-Sachs lesion extra-articular and prevents the defect from levering out the humerus, but also seems to pull the humeral head posteriorly centering it in the glenoid. This provides a posterior tether to the humeral head while increasing the jump distance over the bone block even further. In the future, one can anticipate a significant increase in remplissage-augmented bone block procedures in patients with bipolar bone loss. [ABSTRACT FROM AUTHOR]

Whether to repair a shoulder SLAP lesion or perform a biceps tenodesis depends on a multitude of factors: patient age, activity or work level, type of SLAP tear, location of SLAP tear, and quality of labral tissue. Determining which procedure to perform does not have such a simple, one-size-fits-all solution. For patients younger than 40 years, repair of type 2 SLAP tears that do not directly affect the biceps anchor (i.e., those tears from the 12:30 clock-face position to the 2-o'clock position or from the 10-o'clock position to the 11:30 clock-face position) is generally successful. For tears at the biceps anchor in patients younger than 40 years, repair the SLAP tear but perform tenodesis of the biceps. For type 3 SLAP tears, debride the bucket-handle component and spare the biceps because it usually is not involved. For type 4 tears, perform tenodesis. In patients older than 40 years, type 2 and type 4 SLAP tears are predominantly treated with biceps tenodesis with debridement of the SLAP tear, if indicated. SLAP repair is rarely indicated in patients older than 40 years because the tissue is usually degenerative and frayed. [ABSTRACT FROM AUTHOR]

Study Objective: For emergency department (ED) patients with chest pain, discharge decisions often hinge on troponin results. Push-alert notifications deliver results immediately to physician smartphones. Our objective is to determine whether troponin push alerts improve the time to discharge decisions for ED patients with chest pain.Methods: In an academic ED, we assessed the effect of a quality improvement initiative using troponin push alerts to physician smartphones, with a cluster-randomized evaluation. Participating physicians were randomized to receive troponin push alerts (intervention) or not receive them (control). We retrospectively identified patients treated by participating physicians during the study period who were discharged from the ED with chest pain. The primary outcome was the time from final troponin result to discharge decision. Secondary outcomes included length of stay. A linear mixed model was used to adjust for physician clustering.Results: During the study, 1,554 patients were discharged from the ED with chest pain. There were 551 patients in the control group and 554 in the intervention group who met inclusion criteria. The overall median interval from final troponin result to discharge decision was 79.7 minutes (interquartile range [IQR] 33.6 to 167.8 minutes); it was 94.3 minutes (IQR 36.2 to 177.8 minutes) in the control group and 68.5 minutes (IQR 30.5 to 157.2 minutes) in the intervention group. This 25.8-minute difference in medians (95% confidence interval 24.6 to 28.0 minutes) was statistically significant. Total ED length of stay was 345 minutes (IQR 261 to 419 minutes) in the control group and 328 minutes (IQR 250 to 408 minutes) in the intervention group.Conclusion: Physicians who received troponin push alerts discharged their patients with chest pain 26 minutes faster than those without troponin notifications. Total ED length of stay did not significantly improve for these patients. [ABSTRACT FROM AUTHOR]