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Abstract Background Exercise-induced bronchoconstriction (EIB) is common in children with asthma but can be present also in children without asthma, especially athletes. Differential diagnosis includes several conditions such as exercise-induced laryngeal obstruction (EILO), cardiac disease, or physical deconditioning. Detailed medical history, clinical examination and specific tests are mandatory to exclude alternative diagnoses. Given the high prevalence of EIB in children and its potential impact on health, sport performance, and daily levels of physical activity, health care professionals should be aware of this condition and able to provide a specific work-up for its identification. The aims of the present study were: (a) to assess the agreement among hospital pediatricians and primary care pediatricians of Emilia-Romagna Region (Italy) about the management of EIB in children and (b) formulate statements in a consensus document to help clinicians in daily clinical practice. Methods According to Delphi method, a panel of specialists scored 40 statements that were then revised and discussed during online meetings to reach full consensus. Statements were then formulated. Results To obtain full consensus, the questionnaire was administered in two rounds after full discussion of the uncertain topics on the basis of the latest evidence on EIB published over the last 10 years. Despite an overall agreement on EIB management, some gaps emerged in the sections dedicated to diagnosis and treatment. Nine summary statements on definition, pathogenesis, diagnostic work-up, treatment, and follow-up were eventually formulated. Conclusions This study describes the knowledge of EIB in a group of pediatricians and highlights gaps and uncertainties in diagnosis and treatment. The creation of statements shared by the specialists of the same area may improve the management of EIB in children. However, more research and evidence are needed to better clarify the best treatment and to standardize the best diagnostic protocol limiting useless examinations but at the same time assuring the best management.

Category: Bunion Introduction/Purpose: The purpose of this study was to determine the minimal clinically important difference (MCID) and the patient acceptable symptom state (PASS) threshold for the Visual Analogue Scale (VAS) and Foot and Ankle Ability Measure (FAAM) Scores after Hallux Valgus surgery. Methods: A retrospective review of prospective collected data was performed in patients undergoing hallux valgus surgery at a single institution from January 2021 through December 2022. Patient-reported outcome measures (PROMs) were collected pre-operatively and 1 year post-operatively. The specific PROMs utilized were the FAAM- Activities of Daily Living (FAAM-ADL), Single Assessment Numeric Evaluation (SANE), and VAS scale. The study measured change in PROMs from before surgery to one year after surgery to determine delta. Two methods were used to calculate MCID and PASS thresholds: A distribution-based approach and an anchor-based approach using responses to a one-year postoperative satisfaction question. The analysis identified optimal cut-off points that maximized sensitivity and specificity based on the Youden index. The percentage of patients reaching these optimal MCID and PASS thresholds was also determined. Results: Overall, 86% (136/158) completed baseline PROMs, and 72.7% (99/136) completed 1-year PROMs. The distribution-based MCID for FAAM-ADL, FAAM-ADL-SANE, , and VAS were calculated to be 10.8, 14.1, and 1.2 respectively. The rate of patients who achieved MCID thresholds was 54% for FAAM-ADL, 42% for FAAM-ADL-SANE, and 95.8% for VAS. The PASS threshold for FAAM-ADL, FAAM-ADL-SANE, and VAS were ≥78.5, ≥85, and ≤ 2, respectively. The rate of patients who achieved PASS thresholds was 77.5% for FAAM-ADL, 71.4% for FAAM-ADL-SANE, and 68.7% for VAS. Conclusion: This study identified useful values for the MCID and PASS thresholds at 1-year follow-up for patient undergoing hallux valgus surgery of FAAM-ADL, FAAM-ADL-SANE, and VAS scores.

Category: Other Introduction/Purpose: Non-orthopaedic surgical specialties have demonstrated steady increases in female resident composition. Female participation in orthopaedics continues to lag behind. Prior surveys disseminated only to female orthopaedic surgeons have attempted to understand this deficit through an internal review approach. A survey of current female surgical residents across all specialties attempting to understand this discrepancy, to our knowledge, has not been conducted. We sought to address the following questions 1) What factors are most influential towards selection of surgical subspecialty? 2) What salient experiences and exposures among orthopaedic residents differ from those observed in the general surgery and other subspecialty cohorts? 3) What actionable steps can we as a profession take to ensure orthopaedic surgery is an open avenue to all who would like to pursue it? Methods: A 38-item survey was developed with the following subsections: Demographics, Pre-Clinical Exposures to Orthopaedics, Attitudes Towards Surgical Environments, Factors Influencing Specialty Choice, Dissuaders to a Career in Orthopaedics, and Work Experiences Related to Gender. Surveys were disseminated to current and incoming female surgical residents at university-affiliated surgical residencies in Ohio. Data collection occurred over 45 days during the 2022-2023 academic year. Continuous outcome measures were assessed using ANOVA. Categorical outcomes were compared using chi-square testing. Results: 76 surveys were included for final analysis with a response rate of 23.5% (76/324) including 23 (30.3%) orthopaedic surgery residents, 33 (43.4%) general surgery residents, and 20 (26.3 %) from other surgical subspecialties. Orthopaedic residents were more likely to have attended medical schools that offered orthopaedics as an elective rotation during their third year (p=0.04) and expressed more interest in the application of biomechanical principles to surgery compared to general surgery residents (p< 0.01) and other subspecialties (p=0.03). Low interest in orthopaedic conditions was the most cited dissuader to pursuing orthopaedics amongst general surgery (33.3%) and other subspecialties (40.9%). Interest in surgical techniques unique to specialty and exposure to them in medical school were uniformly ranked as the top two influential factors on specialty choice. Conclusion: Choosing a residency is a complex and multifactorial process. Lack of interest in orthopaedic pathology was found to be a primary driver in the decision not to pursue the field, though lack of exposure to orthopaedics was also ranked as a common dissuader. All female orthopaedic residents reported having the option for an elective third year medical school rotation in orthopaedic surgery. This option was relatively deficient amongst non-orthopaedic residents. Such findings may suggest that early exposure and purposeful mentorship incorporated into the fabric of medical school curricula, may result in increased consideration of orthopaedics as a future career.

Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS) and Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) are broad diagnoses that encompass a range of sudden-onset neuropsychiatric symptoms in children, which can include obsessive-compulsive disorder (OCD), tics, anxiety, emotional instability, and cognitive difficulties. Unlike PANDAS, PANS is not strictly linked to group A streptococcal infections but can be triggered by various infectious or environmental factors. Lights and shadows remain upon the management of children with PANS and PANDAS and there is no clear consensus regarding definition, diagnostic criteria, treatment, and follow-up. The aim of the present study was to evaluate the level of agreement on PANS and PANDAS definition, diagnostic criteria, treatment and follow-up and to assess on the basis of recent studies whether there is a need to modify the current recommendations used by primary care pediatricians and hospital pediatricians in clinical practice in order to improve outcomes. Using the Delphi method, this consensus provides shared indications on PANS and PANDAS management in pediatric age, based on the most updated literature. This work represents, in our opinion, the most complete and up-to-date information on the diagnosis of PANS and PANDAS, as well as consensus statements about several aspects of clinical care. Undoubtedly, more randomized and controlled trials are needed in the pediatric population to better define the best management, also in terms of adequate follow-up examinations and period of observation.

Background: This study aims to determine the effect of time and imaging modality (three-dimensional (3D) CT vs. 3D magnetic resonance imaging (MRI)) on the surgical procedure indicated for shoulder instability. The hypothesis is there will be no clinical difference in procedure selection between time and imaging modality. Methods: Eleven shoulder surgeons were surveyed with the same ten shoulder instability clinical scenarios at three time points. All time points included history of present illness, musculoskeletal exam, radiographs, and standard two-dimensional MRI. To assess the effect of imaging modality, survey 1 included 3D MRI while survey 2 included a two-dimensional and 3D CT scan. To assess the effect of time, a retest was performed with survey 3 which was identical to survey 2. The outcome measured was whether surgeons made a “major” or “minor” surgical change between surveys. Results: The average major change rate was 14.1% (standard deviation: 7.6%). The average minor change rate was 12.6% (standard deviation: 7.5%). Between survey 1 to the survey 2, the major change rate was 15.2%, compared to 13.1% when going from the second to the third survey (P = .68). The minior change rate between the first and second surveys was 12.1% and between the second to third interview was 13.1% (P = .8). Discussion: The findings suggest that the major factor related to procedural changes was time between reviewing patient information. Furthermore, this study demonstrates that there remains significant intrasurgeon variability in selecting surgical procedures for shoulder instability. Lastly, the findings in this study suggest that 3D MRI is clinically equivalent to 3D CT in guiding shoulder instability surgical management. Conclusion: This study demonstrates that there is significant variability in surgical procedure selection driven by time alone in shoulder instability. Surgical decision making with 3D MRI was similar to 3D CT scans and may be used by surgeons for preoperative planning.

BackgroundThe use of Non-Pharmaceutical Interventions (NPIs) during the COVID-19 pandemic is debated. Understanding the consequences these measures may have on vulnerable populations including children and adolescents is important.MethodsThis is a multicenter, quasi-experimental before-after study involving 12 hospitals of the North Italian Emilia-Romagna Region, with NPI implementation as the intervention event. The 3 years preceding NPI implementation (in March 2020) constituted the pre-pandemic phase. The subsequent 2 years were further subdivided into a school closure phase (SC) and a subsequent mitigation measures phase (MM) with milder restrictions. Interrupted Time Series (ITS) regression analysis was used to calculate PED Standardized Incidence Rate Ratios (SIRR) on the diagnostic categories exhibiting the greatest frequency and/or variation.ResultsIn the 60 months of the study there were 765,215 PED visits. Compared to the pre-pandemic rate, overall PED presentations dropped by 58 and 39% during SC and MM, respectively. “Symptoms, signs and Ill-defined conditions,” “Injury and poisoning” and “Diseases of the Respiratory System” accounted for 74% of the reduction. A different pattern was instead seen for “Mental Disorders,” which exhibited the smallest decrease during SC, and is the only category which rose already at the end of SC. ITS analysis confirmed the strong decrease during SC (level change, IRR 0.17, 95%CI 0.12–0.27) and a significant increase in MM (slope change, IRR 1.23, 95%CI 1.13–1.33), with the sharpest decline (−94%) and rise (+36%) observed in the “Diseases of the Respiratory System” category. Mental Disorders showed a significant increasing trend of 1% monthly over the whole study period exceeding pre-pandemic levels at the end of MM. Females and adolescents showed higher increasing rates both in SC and MM.ConclusionNPIs appear to have influenced PED attendance in different ways according to diagnostic categories, mirroring different mechanisms of action. These effects are beneficial in some cases and harmful in others, and establishing a clear balance between pros and cons is a difficult task for public health decision makers. The role of NPIs on PED use appropriateness deserves investigation. The rise in pediatric mental disorders independent of the pandemic makes interventions addressing these issues urgent.

Stress profoundly affects physical and mental health, particularly when experienced early in life. Early-life stress (ELS) encompasses adverse childhood experiences such as abuse, neglect, violence, or chronic poverty. These stressors can induce long-lasting changes in brain structure and function, impacting areas involved in emotion regulation, cognition, and stress response. Consequently, individuals exposed to high levels of ELS are at an increased risk for mental health disorders like depression, anxiety, and post-traumatic stress disorders, as well as physical health issues, including metabolic disorders, cardiovascular disease, and cancer. This review explores the biological and psychological consequences of early-life adversity paradigms in rodents, such as maternal separation or deprivation and limited bedding or nesting. The study of these experimental models have revealed that the organism’s response to ELS is complex, involving genetic and epigenetic mechanisms, and is associated with the dysregulation of physiological systems like the nervous, neuroendocrine, and immune systems, in a sex-dependent fashion. Understanding the impact of ELS is crucial for developing effective interventions and preventive strategies in humans exposed to stressful or traumatic experiences in childhood.

Abstract The modulation of dopamine release from midbrain projections to the striatum has long been demonstrated in reward-based learning, but the synaptic basis of aversive learning is far less characterized. The cerebellum receives axonal projections from the locus coeruleus, and norepinephrine release is implicated in states of arousal and stress, but whether aversive learning relies on plastic changes in norepinephrine release in the cerebellum is unknown. Here we report that in mice, norepinephrine is released in the cerebellum following an unpredicted noxious event (a foot-shock) and that this norepinephrine release is potentiated powerfully with fear acquisition as animals learn that a previously neutral stimulus (tone) predicts the aversive event. Importantly, both chemogenetic and optogenetic inhibition of the locus coeruleus-cerebellum pathway block fear memory without impairing motor function. Thus, norepinephrine release in the cerebellum is modulated by experience and underlies aversive learning.

In this paper, the ability of a metasurface made of resonant elliptical pillars to focus flexural Lamb waves in the sub-wavelength regime is investigated. We report on the influence of the ellipticity parameter on the local resonances of the pillars, in particular the monopolar compressional and dipolar bending modes that are responsible for the desired focusing effect. We also discuss how the transmission through a line of pillars reveals these modes when the orientation of the pillars is changed with respect to the incident wave. Both the resonances can be superimposed for a particular choice of the ellipticity parameter, allowing a phase shift of 2π in the transmission coefficient for an incident antisymmetric Lamb wave, which is a necessary condition for the design of the metasurface. Finally, a gradient design for the pillar ellipticity is investigated, and its capacity to choose the focusing directionality of the transmitted wave at different targeted points is demonstrated.

BackgroundThe use of Non-Pharmaceutical Interventions (NPIs), such as lockdowns, social distancing and school closures, against the COVID-19 epidemic is debated, particularly for the possible negative effects on vulnerable populations, including children and adolescents. This study therefore aimed to quantify the impact of NPIs on the trend of pediatric hospitalizations during 2 years of pandemic compared to the previous 3 years, also considering two pandemic phases according to the type of adopted NPIs.MethodsThis is a multicenter, quasi-experimental before-after study conducted in 12 hospitals of the Emilia-Romagna Region, Northern Italy, with NPI implementation as the intervention event. The 3 years preceding the beginning of NPI implementation (in March 2020) constituted the pre-pandemic phase. The subsequent 2 years were further subdivided into a school closure phase (up to September 2020) and a subsequent mitigation measures phase with less stringent restrictions. School closure was chosen as delimitation as it particularly concerns young people. Interrupted Time Series (ITS) regression analysis was applied to calculate Hospitalization Rate Ratios (HRR) on the diagnostic categories exhibiting the greatest variation. ITS allows the estimation of changes attributable to an intervention, both in terms of immediate (level change) and sustained (slope change) effects, while accounting for pre-intervention secular trends.ResultsOverall, in the 60 months of the study there were 84,368 cases. Compared to the pre-pandemic years, statistically significant 35 and 19% decreases in hospitalizations were observed during school closure and in the following mitigation measures phase, respectively. The greatest reduction was recorded for “Respiratory Diseases,” whereas the “Mental Disorders” category exhibited a significant increase during mitigation measures. ITS analysis confirms a high reduction of level change during school closure for Respiratory Diseases (HRR 0.19, 95%CI 0.08–0.47) and a similar but smaller significant reduction when mitigation measures were enacted. Level change for Mental Disorders significantly decreased during school closure (HRR 0.50, 95%CI 0.30–0.82) but increased during mitigation measures by 28% (HRR 1.28, 95%CI 0.98–1.69).ConclusionOur findings provide information on the impact of COVID-19 NPIs which may inform public health policies in future health crises, plan effective control and preventative interventions and target resources where needed.

Background: This study’s purpose was to investigate the extent to which differences among operating surgeons may influence 1-year patient-reported outcome measures (PROMs) in patients undergoing rotator cuff repair (RCR) surgery, after controlling for general and disease-specific patient factors. We hypothesized that surgeon would be additionally associated with 1-year PROMs, specifically the baseline to 1-year improvement in Penn Shoulder Score (PSS). Methods: We used mixed multivariable statistical modeling to assess the influence of surgeon (and alternatively surgical case volume) on 1-year PSS improvement in patients undergoing RCR at a single health system in 2018, controlling for eight patient- and six disease-specific preoperative factors as possible confounders. Contributions of predictors to explaining variation in 1-year PSS improvement were measured and compared using Akaike’s Information Criterion. Results: 518 cases performed by 28 surgeons met inclusion criteria, with median (quartiles) baseline PSS of 41.9 (31.9, 53.9) and 1-year PSS improvement of 42 (29.1, 55.3) points. Contrary to expectation, surgeon and surgical case volume were neither statistically significantly nor clinically meaningfully associated with 1-year PSS improvement. Baseline PSS and mental health status (VR-12 MCS) were the dominant and only statistically significant predictors of 1-year PSS improvement, with lower baseline PSS and higher VR-12 MCS predicting larger 1-year PSS improvement. Conclusion: Patients generally reported excellent 1-year outcomes following primary RCR. This study did not find evidence that the individual surgeon or surgeon case volume influences 1-year PROMs, independently of case-mix factors, following primary RCR in a large employed hospital system.

Acoustic noise production during Magnetic Resonance Imaging is an important source of patient discomfort and leads to verbal communication problems, difficulties in sedation, and hearing impairment. To address these issues, in this paper we present a systematic characterization of the acoustic field distribution in a MRI cavity in a last generation 7 T scanner, in different spatial locations, with and without a phantom head. Analysis and comparison of various MRI sequences like Echo-planar imaging”, “Gradient echo”, “Spin echo” are carried out. Sound pressure levels are measured using standard statistical descriptors (Leq,Lmean, L90, and Lmode) using two prepolarized free-field microphones measuring pressure levels generated inside scanner cavities in a 50 Hz to 10 kHz range. Acoustic eigenmodes of the cavity are derived numerically in finite element simulations and compared to measurements. Equivalent sound pressure levels exceed 85 dB in the range between 500 and 3,000 Hz, and peak levels are consistently above 100 dB, i.e., the noise levels of 7 T scanners are higher than 3T and 1.5 T counterparts. The presence of the phantom head in the MRI scanner leads to increased noise levels (by 5–10 dB) in its vicinity, as a result of reflections occurring between the head and the bore reflective walls. Numerical finite element simulations allow to extrapolate the noise distribution in the entire cavity and to interpret experimental results and indicate that the frequencies at which the highest noise levels occur correspond to azimuthal or radial resonant modes of the MRI cavity, i.e., with a radially and azimuthally varying pressure field. These results can be useful for the design of future acoustic noise mitigation solutions.

Background: Shoulder osteoarthritis (OA) with eccentric (B) glenoids has generally been associated with poor patient-reported outcomes and increased complications. The purpose of this study was to outline all the described treatment options and their outcomes and complications in order to better guide treatment. Methods: This systematic review was performed according to the Preferred Reporting Items for Systematic review and Meta-analysis guidelines. Searches were performed up to December 19, 2019, using Medline, EMBASE, Scopus, and Cochrane databases. Inclusion criteria included studies for glenohumeral OA reporting posterior humeral head subluxation and/or posterior glenoid erosion. Studies were excluded if they were review papers, abstracts, or conference papers; had heterogeneity of included Walch types; or were not written in English. Results: Twenty-one studies met inclusion criteria. The mean follow-up duration was 47.5 months (range, 14-300), and the mean patient age 62 years (38-88). Six different discernible techniques were identified: asymmetric reaming with onlay glenoid (AROG) in 267 shoulders, posterior glenoid bone grafting (PGBG) with onlay glenoid in 79 shoulders, augmented glenoid (AG) in 160 shoulders, reverse shoulder arthroplasty (RSA) with or without bone grafting in 118 shoulders, hemiarthroplasty with concentric reaming (HACR) in 57 shoulders, and humeral head arthroplasty with inlay glenoid (HAIG) in 36 shoulders. All techniques reported improved patient outcomes and range of motion. Short-term (5 years) studies demonstrated increased rates of glenoid loosening with AROG (14.5%), PGBG (21% loose, 23.8% “at risk”), and AG (18.9% “at risk”), as well as increased rates of subluxation or revision due to instability. HAIG did not demonstrate loosening, subluxation, or revision at 55.2 months Conclusion: Various techniques exist to manage complex primary glenohumeral OA with posterior subluxation and posterior glenoid erosion. Glenoid component survival is a concern with ASOG, PGBG, and AG. HACR has the highest early revision rate. RSA offers promising short-term and midterm results likely due to the advantage of more secure fixation as well as a constrained design to prevent posterior subluxation. HAIG has the lowest complication and revision rates although further long-term studies are needed.

Low frequency ground-borne vibrations generated by transport infrastructure are one of the most serious causes of disturbance to the general population. One possibility to reduce this problem is to use the wave filtering properties of elastic metamaterials. However, their integration in the soil complicates the prediction of their response, and the influence of soil-structure interaction needs to be correctly evaluated for an efficient design. The aim of this work is to experimentally evaluate the efficiency of metamaterial trench barriers set in soil in attenuating vibrations, using low-frequency local resonance mechanisms. A lab scale model is proposed comprising different resonating structures and a cylindrical encasement is adopted to couple the structure to the soil. The influence of various parameters is evaluated, such as metamaterial structure, geometrical characteristics of the resonator, and constituent materials. Finite Element simulations are used to develop a suitable design, analysing mode shapes and resonance frequencies of structures with and without the surrounding encasement. Experimental modal analysis is then performed on the corresponding fabricated samples, providing both model validation and out-of-soil mechanical characterization. Finally, vibration transmission loss measurements are performed in a setup in which different resonant metamaterial barriers are embedded into the soil sample, allowing the evaluation of barrier performance. Results indicate that the metamaterial structures provide good attenuation of vibrations in selected intervals in the low to high frequency range (1–5 kHz), demonstrating the feasibility of the approach in a scaled sample. Preliminary data regarding the structures providing preferable design characteristics is also obtained. These results can be useful for the design of trench barriers scaled to large dimensions in more realistic applicative settings. [ABSTRACT FROM AUTHOR]

Background: Although clinically relevant thresholds such as minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) have been widely described across orthopaedics, their application in hallux valgus surgery remains scarce. The purpose of this study was to determine the MCID and PASS thresholds for the visual analog scale (VAS) and Foot and Ankle Ability Measure (FAAM) scores after hallux valgus surgery. Methods: A retrospective review was performed in patients undergoing hallux valgus surgery at a single institution from January 2021 through December 2022. Patient-reported outcome measures (PROMs) were collected preoperatively and 1 year postoperatively. The specific PROMs used were the FAAM–activities of daily living (FAAM-ADL), Single Assessment Numeric Evaluation (SANE), and VAS scale. Two methods were used to calculate MCID and PASS thresholds: a distribution-based approach for MCID and an anchor-based approach using responses to a 1-year postoperative satisfaction question for PASS. The analysis identified optimal cutoff points that maximized sensitivity and specificity based on the Youden index. Overall, 86% (136/158) completed baseline PROMs, and 73% (99/136) completed 1-year PROMs. Results: The distribution-based MCID for FAAM-ADL, SANE, and VAS were calculated to be 10.8, 14.1, and 1.2, respectively. The percentage of patients who achieved MCID thresholds was 54% for FAAM-ADL, 42% for SANE, and 96% for VAS. The PASS threshold for FAAM-ADL, SANE, and VAS were ≥78.5, ≥85, and ≤ 2, respectively. The percentage of patients who achieved PASS thresholds was 78% for FAAM-ADL, 72% for SANE, and 69% for VAS. Conclusion: This study identified useful values for the MCID and PASS thresholds of FAAM-ADL, SANE, and VAS scores at 1-year follow-up for patients undergoing hallux valgus surgery. Overall, despite not meeting the MCID thresholds, patients undergoing hallux valgus surgery were still likely to be satisfied with their surgery. [ABSTRACT FROM AUTHOR]