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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]

• The Impella device does not have the capability of determining native cardiac output. • Admittance electrode technology can assess chamber volume and calculate cardiac output accurately. • A modified Impella device fitted with admittance electrodes is able to provide accurate, instantaneous native cardiac output data in various hemodynamic conditions. • The modified Impella provides simultaneous pressure-volume loop data that can be used for better understanding of real-time cardiac function in clinical situations. The current Impella cardiopulmonary (CP) pump, used for mechanical circulatory support in patients with cardiogenic shock (CS), cannot assess native cardiac output (CO) and left ventricular (LV) volumes. These data are valuable in facilitating device management and weaning. Admittance technology allows for accurate assessment of cardiac chamber volumes. This study tested the ability to engineer admittance electrodes onto an existing Impella CP pump to assess total and native CO as well as LV chamber volumes in an instantaneous manner. Impella CP pumps were fitted with 4 admittance electrodes and were placed in the LVs of adult swine (n = 9) that were subjected to 3 different hemodynamic conditions, including Impella CP speed adjustments, administration of escalating doses of dobutamine and microsphere injections into the left main artery to result in cardiac injury. CO, according to admittance electrodes, was calculated from LV volumes and heart rate. In addition, CO was calculated in each instance via thermodilution, continuous CO measurement, the Fick principle, and aortic velocity-time integral by means of echocardiography. Modified Impella CP pumps were placed in swine LVs successfully. CO, as determined by admittance electrodes, was similar by trend to other methods of CO assessment. It was corrected for pump speed to calculate native CO, and calculated LV chamber volumes trended as expected in each experimental protocol. We report, for the first time, that an Impella CP pump can be fitted with admittance electrodes and used to determine total and native CO in various hemodynamic situations. Transvalvular mechanical circulatory support devices such as the Impella CP do not have the ability to provide real-time information on native cardiac output (CO) and left ventricular (LV) volumes. This information is critical in device management and in weaning in patients with cardiogenic shock. We demonstrate, for the first time, that Impella CP pumps coupled with admittance electrodes are able to determine native CO and LV chamber volumes in multiple hemodynamic situations such as Impella pump speed adjustments, escalating dobutamine administration and cardiac injury from microsphere injection. A modified Impella cardiopulmonary pump with admittance electrodes and data output with real-time cardiac output and chamber volumes. The Impella-cardiopulmonary (CP) pump with admittance electrodes is able to provide real-time left ventricle (LV) chamber volumes, including stroke volume (SV). Using SV and heart rate, native cardiac output (CO) is calculated, with total CO calculated by the addition of pump flow. Pressure-volume data, obtainable by simultaneous LV pressure waveform, can be analyzed on a connected computer. The dashed line indicates future integration into Impella Controller, which could provide pump-weaning capabilities as native CO improves. [Display omitted] [ABSTRACT FROM AUTHOR]

Is "killing the biceps" during rotator cuff repair a capital crime or a lawful act? One of the most passionately debated topics in shoulder surgery is what to do with the biceps during rotator cuff repair: save it, tenotomize it, or perform tenodesis. Results of repair are not very successful, and given that repair of massive rotator cuff tears shows a 40% to 57% failure rate, there is renewed interest in sparing the biceps tendon as a humeral head depressor—or so that it may be used as a local graft for revision rotator cuff repair. The literature regarding tenodesis versus biceps sparing during rotator cuff repair is controversial. There are so many confounding variables affecting rotator cuff repair outcomes (tear size, comorbidities, age, tissue quality, etc.) that we do not believe that anything less than a randomized, prospective study that matches groups is likely to provide a conclusive verdict. [ABSTRACT FROM AUTHOR]

Open heart surgeries for coronary arterial bypass graft and valve replacements are performed on 400,000 Americans each year. Unexplained hypotension during recovery causes morbidity and mortality through cerebral, kidney, and coronary hypoperfusion. An early detection method that distinguishes between hypovolemia and decreased myocardial function before onset of hypotension is desirable. We hypothesized that admittance measured from a modified pericardial drain can detect changes in left ventricular end-systolic, end-diastolic, and stroke volumes. Admittance was measured from 2 modified pericardial drains placed in 7 adult female dogs using an open chest preparation, each with 8 electrodes. The resistive and capacitive components of the measured admittance signal were used to distinguish blood and muscle components. Admittance measurements were taken from 12 electrode configurations in each experiment. Left ventricular preload was reduced by inferior vena cava occlusion. Physiologic response to vena cava occlusion was measured by aortic pressure, aortic flow, left ventricle diameter, left ventricular wall thickness, and electrocardiogram. Admittance successfully detected a drop in left ventricular end-diastolic volume (P <.001), end-systolic volume (P <.001), and stroke volume (P <.001). Measured left ventricular muscle resistance correlated with crystal-derived left ventricular wall thickness (R 2 = 0.96), validating the method's ability to distinguish blood from muscle components. Admittance measured from chest tubes can detect changes in left ventricular end-systolic, end-diastolic, and stroke volumes and may therefore have diagnostic value for unexplained hypotension. [Display omitted] [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]

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]

Objectives: To assess the impact of a community pharmacist-delivered care transition intervention on 30-day hospital readmissions.Setting: A single private 263-bed hospital in the Midwest United States and 12 partnering community pharmacies, 1 serving as primary pharmacy.Practice Innovation: Adult general medicine inpatients were evaluated by nursing staff with the use of a worksheet based on the Better Outcomes by Optimizing Safe Transitions (BOOST) readmission risk toolkit. The highest-risk patients were enrolled in a 3-contact intervention. First, a pharmacist from the primary community pharmacy delivered an in-room work-up. The pharmacist focused on medication education, problem identification, and verifying medication access following discharge. A pharmacist visited the hospital for approximately 4 hours most weekdays, during which the pharmacist saw 3-4 patients. A community pharmacist telephoned these patients 8 and 25 days after discharge.Evaluation: The intervention was provided to 555 patients who had a mean readmission risk worksheet score of 1.90 (SD 1.13) and not provided to 430 patients with lower readmission risk worksheet scores, which averaged 0.68 (SD 0.86; P < 0.001). Thirty-day readmissions to the study hospital were lower for intervention patients (8.1%) versus comparison patients (21.4%; P < 0.001). Thirty-day readmissions to any hospital were calculated for a subsample of 129 intervention patients and 103 comparison patients with Medicare Fee for Service insurance for which claims were available, but the difference (10.9% and 15.5%, respectively) did not reach statistical significance (P = 0.328).Practice Implication: A community pharmacy was successful in partnering with a hospital and other community pharmacies to lead a care transitions intervention associated with reduced 30-day same-hospital readmissions.Conclusion: A community pharmacist-led intervention delivered to higher-risk patients showed a significant decrease in readmission rate to the same hospital compared with lower-risk patients hospitalized in the same unit but not receiving the intervention. This supports the community pharmacists' role in care transitions. [ABSTRACT FROM AUTHOR]

Background: There is increasing evidence that using frequent invasive measures of pressure in patients with heart failure results in improved outcomes compared to traditional measures. Admittance, a measure of volume derived from preexisting defibrillation leads, is proposed as a new technique to monitor cardiac hemodynamics in patients with an implantable defibrillator.Objective: The purpose of this study was to evaluate the accuracy of a new ventricular volume sensor (VVS, CardioVol) compared with 3-dimenssional echocardiography (echo) in patients with an implantable defibrillator.Methods: Twenty-two patients referred for generator replacement had their defibrillation lead attached to VVS to determine the level of agreement to a volume measurement standard (echo). Two opposite hemodynamic challenges were sequentially applied to the heart (overdrive pacing and dobutamine administration) to determine whether real changes in hemodynamics could be reliably and repeatedly assessed with VVS. Equivalence of end-diastolic volume (EDV) and stroke volume (SV) determined by both methods was also assessed.Results: EDV and SV were compared using VVS and echo. VVS tracked expected physiologic trends. EDV was modulated -10% by overdrive pacing (14 mL). SV was modulated -13.7% during overdrive pacing (-6 mL) and increased over baseline +14.6% (+8 mL) with dobutamine. VVS and echo mean EDVs were found statistically equivalent, with margin of equivalence 13.8 mL (P <.05). Likewise, mean SVs were found statistically equivalent with margin of equivalence 15.8 mL (P <.05).Conclusion: VVS provides an accurate method for ventricular volume assessment using chronically implanted defibrillator leads and is statistically equivalent to echo determination of mean EDV and SV. [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]

Massive irreparable rotator cuff tears without glenohumeral arthritis are a common cause of shoulder pain and disability. Many surgical treatment options have been proposed, including debridement, partial repair, tendon transfer, superior capsule reconstruction, balloon spacer placement, bursal acromial reconstruction, and reverse shoulder arthroplasty. Interposition graft bridging reconstruction, as evidenced by the mid-term results of the current study, may also be considered, at least for now. However, let's see if this procedure will truly stand the test of time because all orthopaedic surgeons know that the one thing that ruins good results is long-term follow-up! [ABSTRACT FROM AUTHOR]

The advantages of using ultrasound over magnetic resonance imaging (MRI) in the diagnosis of rotator cuff pathology include patient and technical factors. Patient factors include the lack of claustrophobia or positioning constraints. Technical considerations include dynamic and real-time assessment, absence of contraindications due to implants, decreased cost, and portability. However, the limitations of ultrasound include operator dependency and skill, limited availability of experienced ultrasonographers, decreased sensitivity for other shoulder pathology, and possible less sensitivity for some types of rotator cuff pathology. In my practice, MRI, when indicated, is still the test of choice, as it is readily available, more versatile in diagnosing a wide range of shoulder pathologies, and not dependent on the availability of a skilled ultrasound operator. Should there still be concern for an unrecognized partial subscapularis tendon injury after MRI, ultrasound can then be performed. [ABSTRACT FROM AUTHOR]

Although proficiency training will never completely replace the apprenticeship model, improvement in arthroscopic surgical-simulator technology permits students to spend less time observing and more time doing. The best models and simulators allow measurement and documentation of skill-based progression. Once basic skills have been satisfactorily demonstrated, trainees transitioning to actual operative arthroscopy should be expected to contribute to safer and more efficient patient care while continuing to learn and improve. [ABSTRACT FROM AUTHOR]

Objectives This study hypothesized that bright spots in intravascular optical coherence tomography (IVOCT) images may originate by colocalization of plaque materials of differing indexes of refraction. To quantitatively identify bright spots, we developed an algorithm that accounts for factors including tissue depth, distance from light source, and signal-to-noise ratio. We used this algorithm to perform a bright spot analysis of IVOCT images and compared these results with histological examination of matching tissue sections. Background Bright spots are thought to represent macrophages in IVOCT images, and studies of alternative etiologies have not been reported. Methods Fresh human coronary arteries (n = 14 from 10 hearts) were imaged with IVOCT in a mock catheterization laboratory and then processed for histological analysis. The quantitative bright spot algorithm was applied to all images. Results Results are reported for 1,599 IVOCT images co-registered with histology. Macrophages alone were responsible for only 23% of the bright spot–positive regions, although they were present in 57% of bright spot–positive regions (as determined by histology). Additional etiologies for bright spots included cellular fibrous tissue (8%), interfaces between calcium and fibrous tissue (10%), calcium and lipids (5%), and fibrous cap and lipid pool (3%). Additionally, we showed that large pools of macrophages in CD68 + histology sections corresponded to dark regions in comparative IVOCT images; this is due to the fact that a pool of lipid-rich macrophages will have the same index of refraction as a pool of lipid and thus will not cause bright spots. Conclusions Bright spots in IVOCT images were correlated with a variety of plaque components that cause sharp changes in the index of refraction. Algorithms that incorporate these correlations may be developed to improve the identification of some types of vulnerable plaque and allow standardization of IVOCT image interpretation. [ABSTRACT FROM AUTHOR]

Background Implantable cardioverter-defibrillators monitor intracardiac electrograms (EGMs) to discriminate between ventricular and supraventricular tachycardias. The incidence of inappropriate shocks remains high because of misclassification of the tachycardia in an otherwise hemodynamically stable individual. Coupling EGMs with an assessment of left ventricular (LV) stroke volume (SV) could help in gauging hemodynamics during an arrhythmia and reducing inappropriate shocks. Objective The purpose of this study was to use the admittance method to accurately derive LV SV. Methods Ultrasonic flow probe and LV endocardial crystals were used in canines (n = 12) as the standard for LV SV. Biventricular pacing leads were inserted to obtain admittance measurements. A tetrapolar, complex impedance measurement was made between the Bi-V leads. The real and imaginary components of impedance were used to discard the myocardial component from the blood component to derive instantaneous blood conductance (G b ). Alterations in SV were measured during right ventricular pacing, dopamine infusion, and inferior vena cava occlusion. Results G b tracks steady-state changes in SV more accurately than traditional magnitude (ie, |Y|, without removal of the muscle signal) during right ventricular pacing and dopamine infusion ( P = .004). Instantaneous LV volume also was tracked more accurately by G b than ∣Y∣ in the subset of subjects that underwent inferior vena cava occlusions (n = 5, P = .025). Finite element modeling demonstrates that admittance shifts more sensitivity of the measurement to the LV blood chamber as the mechanism for improvement (see Online Appendix ). Conclusion Monitoring LV SV is possible using the admittance method with biventricular pacing leads. The technique could be piggybacked to complement EGMs to determine if arrhythmias are hemodynamically unstable. [ABSTRACT FROM AUTHOR]

Lee et al. show that metabolic reprogramming induced by an oncogene affects histone acetylation. Under conditions of low glucose, Akt activates the acetyl-CoA-generating enzyme ATP-citrate lyase, leading to alterations in histone acetylation marks in tumors. In vivo, oncogenic Kras or Akt expression stimulates histone acetylation changes preceding tumor development. [ABSTRACT FROM AUTHOR]

Abstract: Though gold nanoparticles have been considered bio-inert, recent studies have questioned their safety. To reduce the potential for toxicity, we developed a nanoclustering of gold and iron oxide as a nanoparticle (nanorose) which biodegrades into subunits to facilitate rapid excretion. In this present study, we demonstrate acid and macrophage lysosomal degradation of nanorose via loss of the near-infrared optical shift, and clearance of the nanorose in vivo following i.v. administration in C57BL/6 mice by showing gold concentration is significantly reduced in 11 murine tissues in as little as 31days (P < 0.01). Hematology and chemistry show no toxicity of nanorose injected mice up to 14 days after administration. We conclude that the clustering design of nanorose does enhance the excretion of these nanoparticles, and that this could be a viable strategy to limit the potential toxicity of gold nanoparticles for clinical applications. From the Clinical Editor: The potential toxicity of nanomaterials is a critically important limiting factor in their more widespread clinical application. Gold nanoparticles have been classically considered bio-inert, but recent studies have questioned their safety. The authors of this study have developed a clustering gold and iron oxide nanoparticle (nanorose), which biodegrades into subunits to facilitate rapid excretion, resulting in reduced toxicity. [Copyright &y& Elsevier]

Abstract: Objectives: Poor treatment response is an important factor contributing to lack of treatment adherence. The goals of this research were to determine whether improvements in Positive and Negative Syndrome Scale (PANSS) symptom domains predict the likelihood of staying on treatment and whether differential responses to treatment with various atypical antipsychotics in specific symptom domains account for differences in discontinuation rates or treatment adherence. Methods: We conducted a post-hoc analysis of pooled data from 5 randomized, double-blind, 24- to 28-week clinical trials in 1103 olanzapine-treated and 1090 risperidone-, quetiapine-, ziprasidone-, or aripiprazole-treated adult patients with schizophrenia. The 5 PANSS factors were tested as potential predictors of treatment adherence for all treatment groups combined. Treatment differences in the 5 PANSS factors and individual items were assessed between olanzapine and the other atypical antipsychotics combined. Secondary analyses repeated for the 21 Heinrichs Quality of Life Scale (QLS) items. Results: Improvement in PANSS positive factor was the strongest predictor of treatment adherence, irrespective of medication (based on standardized scores, hazard ratio [HR], 1.58; 95% confidence interval [CI], +1.40 to +1.79; P < .001). Improvement in PANSS hostility (HR, 1.23; 95% CI, +1.11 to +1.37; P < .001) and depressive (HR, 1.15; 95% CI, +1.05 to +1.27; P = .002) factors was also a significant predictor; negative and disorganized thoughts factors were not. All QLS items had significant predictive effects. Olanzapine-treated patients showed significantly greater improvements than all other groups at week 24 on all 5 PANSS factors (P = .028 for negative; P < .001 for all others) and on 3 QLS items. Conclusion: Significant improvement in positive symptoms, regardless of treatment, followed by significant improvement in hostility and depressive symptoms, may best predict treatment adherence. Olanzapine-treated patients experienced significantly greater improvements in these specific symptoms than patients treated with the other atypical antipsychotics examined. These findings may further explain why olanzapine-treated patients continue treatment more often. [Copyright &y& Elsevier]

Objectives: To examine the efficacy and tolerability of atomoxetine (ATX) in improving cognitive performance of patients with Alzheimer dementia. Design: A randomized, double-blind, placebo (PLA)-controlled, parallel-groups study, starting with a 5-33-day screening and evaluation period, followed by a 6-month treatment period. Setting Eight independent or academic outpatient clinics in the United States. Participants: Male or female patients, aged 55 years and older, with mild-to-moderate Alzheimer disease (Mini-Mental State Examination score between 10 and 26) at baseline. Intervention ATX (25-80 mg/day) or PLA for up to 6 months, added to ongoing cholinesterase-inhibitor therapy. Measurements: Alzheimer Disease Assessment Scale—Cognitive Portion (ADAS-Cog, primary measure), Clinician's Interview-Based Impression of Change score at endpoint, Neuropsychiatric Inventory, and Alzheimer's Disease Cooperative Study Inventory—Activities of Daily Living Inventory total score, safety measures (secondary measures). Results: Patients' (N = 92) scores on assessments of cognitive function, global clinical impression, and neuropsychiatric symptoms were not significantly different between treatment groups. Neither group showed significant changes from baseline on the primary measure of efficacy, the ADAS-Cog The ATX group showed significantly greater increase of heart rate, and the mean increase in diastolic blood pressure and decrease in weight differed significantly from the decrease in pressure and weight increase in the PLA group. No other clinically meaningful safety results were obtained Conclusions: Addition of AIX to ongoing cholinesterase-inhibitor therapy was generally well tolerated but did not significantly improve cognitive function. [ABSTRACT FROM AUTHOR]

Abstract: In factitious disorder, an individual feigns, exaggerates, or actually self-induces physical or psychiatric illness to achieve ends such as mobilizing care and concern, ventilating aggression, diminishing guilty feelings, or gratifying dependency wishes. We present 2 new cases of factitious binocular blindness, which has rarely been reported but readily illustrates the dramatic range of factitious illness behaviors. Psychiatric and behavioral correlates culled from these cases include extravagant claims about the impairment and ludicrous claims for nonvisual sensory abilities. These patients typically refuse psychiatric care, but earlier detection can help abort the illness deceptions and forestall iatrogenic complications. [Copyright &y& Elsevier]

"Big Data" studies are extremely important in orthopedic research, as randomized controlled trials with extremely large sample sizes are nearly impossible to perform. But, as always, the devil is in the details. Databases are only as good as the information that is put into them. And when evaluating these studies, let's not forget how to interpret them. Many factors-patient insurance status, age, socioeconomic status, ethnicity, and comorbidities; regional variations; hospital status (inpatient/outpatient); clerical errors, recording biases, and omission of relevant orthopedic outcome measures; temporal changes in billing codes; payer mix; population demographics and catchment area; and data collection methodology-mean that the results of a specific big data study may or may not be generalizable to other populations. [ABSTRACT FROM AUTHOR]

Some studies have reported no difference between autograft and hybrid anterior cruciate ligament reconstructions. However, other studies have shown a significantly greater revision rate. Consequently, surgeons are reluctant to perform hybrid reconstructions in younger patients with diminutive hamstring autografts and have turned to other autograft graft sources (e.g., quadriceps tendon, patellar tendon). Until we can perform high-quality prospective studies that can definitively answer this question, we should consider avoiding autograft hamstring reconstructions in patients younger than 25 years old so that we are not faced with the dilemma of implanting an undersized autograft or a hybrid graft, as both may be at increased risk for failure. [ABSTRACT FROM AUTHOR]

Although a spaced retraining schedule improved resident arthroscopic task completion time and camera path length on a virtual simulator, it did not improve the degree of cartilage injury. To quote former Green Bay Packer Head Coach Vince Lombardi: "Practice does not make perfect. Only perfect practice makes perfect." [ABSTRACT FROM AUTHOR]

Traditional teaching has told us that arthroscopic ankle arthrodesis is reserved for those patients with severe osteoarthrosis but minimal deformity. However, it is not the size of the deformity that matters; rather, it is the ability to correct the deformity intraoperatively that leads to satisfactory results. Preoperative identification of those patients with significant deformity that can be corrected with an arthroscopic approach would allow for improved selection and likely lead to better patient-reported outcomes and fewer complications. [ABSTRACT FROM AUTHOR]

Repetitive throwing in the adolescent athlete often leads to long-term problems. Strict pitch counts and limitation of pitches (e.g., curve balls) that place extreme stress on the immature elbow must be monitored closely. And until our outcomes for osteochondritis dissecans of the capitellum in adolescent baseball players improve, it may be wise to counsel those pitchers and catchers who are symptomatic to consider switching to another position or sport. [ABSTRACT FROM AUTHOR]

Most everything in life has a cost, and for the academic orthopaedic sports medicine physician, it is time. But if it is to improve the skill set of the next generation of arthroscopic or sports medicine surgeons (who someday may perform surgery on me!), then I believe it is worth it. [ABSTRACT FROM AUTHOR]

Abstract: The use of self-assembled monolayers (SAMs) on medical devices offers a methodology for the incorporation of nanotechnology into medicine. SAMs are highly ordered nanosized molecular coatings, adding 1 to 10 nm thickness to a surface. This work is part of an overall goal to deliver therapeutic drugs from the surface of metal coronary stents using SAMs. In this study the oxidative and in vitro stability of functional alkylthiol SAMs on 316L stainless steel (SS) has been demonstrated. SAMs of 11-mercaptoundecanoic acid (-COOH SAM) and 11-mercapto-1-undecanol (-OH SAM) were formed on 316L SS. X-ray photoelectron spectroscopy (XPS), Fourier transform infrared spectroscopy (FTIR), and contact angle (CA) measurements collectively confirmed the formation of functional alkylthiol SAMs on 316L SS. Well-formed SAMs (CA: 82 deg ± 9 deg) were achieved within 48 hours of immersion in ethanolic solutions, after which no significant improvement in CA was observed. The ratio of the thiolate peak (163.5 eV) to the oxidized sulfur (sulfonates) peak (166.5 eV) gives us an indication of the percentage SAMs that would bind to the metal and serve as a drug reservoir in vivo; which in turn represents the stability and viability of these SAMs, keeping in mind the cardiovascular application under consideration. Oxidative and in vitro stability studies showed that alkanethiol SAMs oxidized completely within 14 days. The SAMs tend to desorb and leave the metal surface after longer time periods (21 days) in phosphate-buffered saline (PBS) immersion, whereas for oxidative exposure the SAMs continue to remain on the metal surface in the form of sulfonates. Although the chemistry of bonding of alkylthiol with the 316L SS is not well understood, the nanosized alkylthiol SAMs demonstrate sufficient stability to justify further study on these systems for potential in vivo drug delivery in the chosen coronary artery stent applications. [Copyright &y& Elsevier]

Objective: To determine the efficacy and safety of atomoxetine in adolescent subjects treated for attention-deficit/hyperactivity disorder (ADHD) for up to 2 years. Study design: Data from 13 atomoxetine studies (6 double-blind, 7 open-label) were pooled for subjects age 12 to 18 with ADHD as defined by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders IV. Results: Of the 601 atomoxetine-treated subjects in this meta-analysis, 537 (89.4%) completed 3 months of acute treatment. A total of 259 subjects (48.4%) are continuing atomoxetine treatment; 219 of these subjects have completed at least 2 years of treatment. The mean dose of atomoxetine at endpoint was 1.41 mg/kg/day. Mean ADHD Rating Scale IV, parent version, investigator-administered and -scored total scores showed significant improvement (P < .001) over the first 3 months. Symptoms remained improved up to 24 months without dosage escalation. During the 2-year treatment period, 99 (16.5%) subjects discontinued treatment due to lack of effectiveness, and 31 (5.2%) subjects discontinued treatment due to adverse events. No clinically significant abnormalities in height, weight, blood pressure, pulse, mean laboratory values, or electrocardiography parameters were found. Conclusions: Two-year data from this ongoing study indicate that atomoxetine maintains efficacy among adolescents with ADHD, with no evidence of drug tolerance and no new or unexpected safety concerns. [Copyright &y& Elsevier]

: BackgroundUnlike myxomatous degeneration in Marfan syndrome, which has been reported to result from a mutation in the gene that codes for the extracellular structural protein fibrillin, no specific molecular abnormality has been documented to be the underlying cause of myxomatous degeneration in mitral valve prolapse syndrome (MVPS). The present study examined the distribution of fibrillin and other extracellular matrix proteins in patients with isolated MVPS.: MethodsMitral valve leaflets from 7 MVPS patients and 5 rheumatic heart disease (RHD) patients were characterized immunohistochemically for fibrillin, elastin, collagen I, and collagen III distribution, and compared with five normal mitral valves.: ResultsIn normal mitral valve leaflets immunostaining for fibrillin, elastin, collagen I, and collagen III revealed a fibrillary and laminar pattern in the atrialis and the spongiosa. In addition, both the collagens were present in the ventricularis, and the coarse bundles in the fibrosa exhibited alternating bandlike collagen I immunoreactivity. The staining patterns of fibrillin, elastin, and collagens I and III revealed distinctly different distribution in MVPS relative to the normal and RHD leaflets. MVPS leaflets in areas of myxoid degeneration displayed a more diffuse, weaker, and nonlaminar pattern of staining for fibrillin. Similar, but less severe abnormality of elastin, collagen I, and collagen III was also observed. Unlike diffuse abnormality in MVPS, the disruption of extracellular proteins in RHD only occurred at the site of the inflammatory damage, but the overall architecture was preserved.: ConclusionsThe results of the current study suggest a primary role for abnormal fibrillin and other matrix proteins in producing myxoid degeneration of mitral valve leaflets in MVPS. [Copyright &y& Elsevier]

With the desire to remain athletically competitive, many adolescent athletes with shoulder instability are turning to early surgical invention. But is surgical repair always necessary and are all Bankart lesions identical? Using 3-dimensional, frequency-selective, fat-suppressed gradient recalled echo magnetic resonance imaging (MRI) scans, the authors noted that the anterior glenoid rim secondary ossification center peaks at age 16 years in male patients but is only fused in 70% of male patients at age 17 years. Therefore, relying on MRI alone to guide surgical treatment may result in procedures that may otherwise be avoided because normal glenoid development may be mistaken for a bony Bankart lesion. A thorough history and physical examination are still essential in adolescents with shoulder injuries. Relying on MRI alone to guide surgical treatment may result in procedures that may otherwise be avoided. [ABSTRACT FROM AUTHOR]

Unlike an orchestra conductor, whose fundamental goal is to bring a written score to life through exaggerated arm and body motion, the arthroscopist's goal is to enhance his or her surgical procedure by minimizing wasteful motion. So, the next time you are in the operating room observing or assisting with an arthroscopic procedure, do not just watch the monitor. Look at the surgeon's arm motion and see if you can distinguish between the maestro and the novice! [ABSTRACT FROM AUTHOR]

The optimal duration and extent of immobilization during the immediate postoperative period after arthroscopic rotator cuff repair are unknown. The current noninferiority study has shown that early active motion to tolerance can be just as effective as immobilization without increasing the failure rate, allowing for convenience and comfort in performing activities of daily living in the early postoperative period. However, further study is needed to determine which factors are most important to maintain repair integrity to optimize outcomes. [ABSTRACT FROM AUTHOR]

Although the exact function of the subacromial bursa as it relates to rotator cuff repair is still debatable, most surgeons would agree that the more invasive the procedure, the more likely there will be scarring and/or adhesions, which can lead to decreased motion. So, when performing subacromial bursectomy during rotator cuff repair, "Observe due measure, moderation is best in all things [subacromial]." [ABSTRACT FROM AUTHOR]

Corresponding Author [ABSTRACT FROM AUTHOR]

For the treatment of large to massive rotator cuff repairs, not all partial repairs are equivalent. The technique of rotator cuff repair in large to massive rotator cuff tears matters. By using mobilization techniques to mobilize the rotator cuff to obtain anatomic or near anatomic coverage, double-row techniques to increase footprint coverage, and medial mobilization to decrease tension on the repair, exposure of the humeral head can be minimized, which can improve outcomes. [ABSTRACT FROM AUTHOR]

Lateral femoral cutaneous nerve injury after shoulder arthroscopy in the beach chair position is an uncommon, but irritating complication for patients. Taking an extra minute to ensure a safe beach chair position will likely minimize the occurrence and prevent a disheartening conversation at the first postoperative visit. [ABSTRACT FROM AUTHOR]

Loss of shoulder motion, especially to flexion and external rotation, may increase the risk of nontraumatic shoulder and elbow injuries in elite pitchers. However, the etiology of these injuries is likely mulitifactorial, and before we direct our therapists to abandon sleeper stretches in favor of flexion and external rotation exercises, further research is needed to keep pitchers off the disabled list and on the mound. [ABSTRACT FROM AUTHOR]

Long-term energy supply for electronic systems is challenging for implantable biomedical devices, like cardiac pacemakers. Energy harvesting can significantly extend the lifetime of these devices, however, no clinical translational technologies can efficiently convert the mechanical energy of the heart into electrical power without a thoracotomy and interfering with the cardiovascular functions. Almost all reported implantable cardiac energy harvesting designs sutured devices directly onto the epicardium or pericardium with potential risks to the patients. Here, we report a cardiac energy harvesting strategy, which is integrated into part of the existing pacemaker lead and otherwise with no direct contact of heart, by utilizing porous piezoelectric thin films in a bioinspired self-wrapping helical configuration for flexible integration with existing implantable medical devices. We demonstrate that this compact design can be seamlessly coupled with current leads without introducing additional implantation surgeries. In vivo studies under various conditions (anchoring, pacing, and calcium chloride infusion) are presented that demonstrate clinical translation in a porcine model. Both theoretical studies and in vitro experiments are also presented to validate the energy harvesting process. The scalability of the design is discussed, and the reported results demonstrate a 10 × 10 array of helical EH devices wrapping all through the lead (a mixed pattern of in series and parallel connections) would extend the lifetime of the pacemaker battery by 1.5 years. This innovative cardiac energy harvesting strategy represents a significant step forward for clinical translation without a thoracotomy for patients, suggesting a paradigm for biomedical energy harvesting in vivo. Image 1 • Low profile thin film cardiac energy harvesting strategy with no direct contact of heart. • Bioinspired self-wrapping helical configuration for flexible integration with medical devices. • In vivo studies demonstrate clinical translation in a porcine model. • The device converts the complex vibrational, and bending/twisting motions of a pacemaker lead. • An energy harvesting device yields an electrical output of 0.65 V in vivo. [ABSTRACT FROM AUTHOR]

Summary The interaction between the immune system and endocrine cells in the pancreas is crucial for the initiation and progression of type 1 diabetes (T1D). Imaging mass cytometry (IMC) enables multiplexed assessment of the abundance and localization of more than 30 proteins on the same tissue section at 1-μm resolution. Herein, we have developed a panel of 33 antibodies that allows for the quantification of key cell types including pancreatic exocrine cells, islet cells, immune cells, and stromal components. We employed this panel to analyze 12 pancreata obtained from donors with clinically diagnosed T1D and 6 pancreata from non-diabetic controls. In the pancreata from donors with T1D, we simultaneously visualized significant alterations in islet architecture, endocrine cell composition, and immune cell presentation. Indeed, we demonstrate the utility of IMC to investigate complex events on the cellular level that will provide new insights on the pathophysiology of T1D. Graphical Abstract Highlights • Imaging mass cytometry enables multiplexed histological analyses at 1-μm resolution • Islets are altered in architecture and composition during T1D progression • Islet cells show changes in protein expression during T1D progression • Immune cells are highly proliferative in T1D pancreata Wang et al. use imaging mass cytometry (IMC) to profile the pancreata of type 1 diabetes donors at varying stages of disease progression. They see significant alterations in islet architecture, endocrine cell composition, and immune cell presentation, highlighting the utility of IMC to dissect cellular events underlying disease pathology. [ABSTRACT FROM AUTHOR]

Anterior inferior tibial fibular ligament tenderness to palpation, a positive squeeze test, and a positive external rotation test correlate well with syndesmosis instability after high ankle sprain. However, it is still unknown whether subtle unstable high ankle sprains (grade IIB) could heal satisfactorily with nonoperative treatment and whether their recovery would be prolonged compared with operative treatment. [ABSTRACT FROM AUTHOR]

Forecasting the future questions that need to be answered while collecting prospective data makes the design of long-term studies challenging. But, with the current focus in health care to report outcomes, more information will now be prospectively collected, likely providing the necessary data to more critically analyze our results with higher-level of evidence studies. [ABSTRACT FROM AUTHOR]

For the treatment of osteochondral lesions of the talus, the addition of concentrated bone marrow aspirate to marrow stimulation procedures results in repair tissue that, by magnetic resonance imaging, appears to be similar to native articular cartilage. But, functional outcomes are no different when compared with marrow stimulation alone. Moreover, the true "gold" is that the repair tissue not only has the magnetic resonance imaging appearance of native articular cartilage but also should have the same organizational structure and composition so that it may function like native articular cartilage. [ABSTRACT FROM AUTHOR]