Medial Patellofemoral Ligament Repair for Recurrent Patellar Instability: Successful Outcomes Among Patients With Low Coronal Malalignment and Normal Patellar Height.

Medial patellofemoral ligament (MPFL) repair is discouraged for the treatment of chronic, recurrent patellar instability (RPI) because of high reported failure rates. However, the senior author uses MPFL repair for chronic RPI in the setting of low tibial tubercle-trochlear groove (TT-TG) distance. In this retrospective case series, we report results and evaluate outcome predictors. We used billing records to identify all patients, 14 years or older, who underwent isolated repair for chronic RPI performed by a single surgeon between September 2010 and February 2019. The TT-TG distance, patellar height (Caton-Deschamps Index [CDI]), and trochlear depth were measured on preoperative magnetic resonance imaging; postoperative reports were reviewed; and post hoc Kuala scores were obtained to extend outcome length. Patellar dislocation or revision surgery was considered a failure. Nonfailures were categorized as excellent or fair, based on the most recent report. Univariable generalized estimating equation models were used to evaluate associations of predictors (radiographic parameters, age, ligamentous laxity, primary presenting complaint) with failure and/or success. A total of 93 isolated MPFL repairs were performed. After exclusions were made for workers' compensation insurance (n=4), substance abuse (n=3), major secondary trauma less than 3 months postoperatively (n=3), and follow-up of less than 12 months (n=42), 41 knees (38 patients) had median follow-up of 32 months (interquartile range, 19-48 months). All repairs were patellar sided. Outcomes for 4 knees were considered failures, 23 were excellent, and 14 were fair. Only increased CDI was associated with increased risk of failure (odds ratio, 1.70; 95% CI, 0.98-2.92; P=.06). Mean CDI was 1.23 mm (SD, 0.13 mm) for failures vs 1.08 mm (SD, 0.16 mm) for nonfailures. Failure rate was less than 10% following patellar-sided MPFL repair for treatment of chronic RPI among patients with low TT-TG distance. Increased patellar height was associated with higher risk of failure. [Orthopedics. 2022;45(1):e23-e29.].

Features of primary care practice influence emergency care-seeking behaviors by caregivers of persons with dementia: A multiple-perspective qualitative study.

BACKGROUND: Persons with dementia use emergency department services at rates greater than other older adults. Despite risks associated with emergency department use, persons with dementia and their caregivers often seek emergency services to address needs and symptoms that could be managed within primary care settings. As emergency departments (EDs) are typically sub-optimal environments for addressing dementia-related health issues, facilitating effective primary care provision is critical to reduce the need for, or decision to seek, emergency services. The aim of this study is to explore how features of primary care practice influence care-seeking decisions by community-dwelling persons with dementia and familial caregivers. METHODS: Semi-structured qualitative interviews were conducted with 27 key dementia-care stakeholders (10 primary care/geriatrics providers, 5 caregivers, 4 emergency medicine physicians, 5 aging service providers, and 3 community paramedics) from multiple health systems. Transcripts from audio recordings were analyzed using a thematic analysis framework to iteratively code and develop emergent themes. Features of primary care were also synthesized into lists of tangible factors leading to emergency care-seeking and those that help prevent (or decrease the need for) ED use. FINDINGS: Stakeholders identified eight categories of features of primary care encompassing the clinical environment and provision of care. These collapsed into four major themes: (1) clinic and organizational features-including clinic structure and care team staffing; (2) emphasizing proactive approaches to anticipate needs and avoid acute problems-including establishing goals of care, preparing for the future, developing provider-patient/provider-caregiver relationships, and providing caregiver support, education, and resources to help prevent emergencies; (3) health care provider skills and knowledge of dementia-including training and diagnostic capabilities; and (4) engaging appropriate community services/resources to address evolving needs. CONCLUSIONS: Features of primary care practice influence decisions to seek emergency department care at the system, organizational/clinic, medical, and interpersonal levels, particularly regarding proactive and reactive approaches to addressing dementia-related needs. Interventions for improving primary care for persons with dementia and their caregivers should consider incorporating features that facilitate proactive family-centered dementia care across the four identified themes, and minimize those leading to caregiver decisions to utilize emergency services.

Factors Influencing Emergency Care by Persons With Dementia: Stakeholder Perceptions and Unmet Needs.

BACKGROUND/OBJECTIVES: People with dementia (PwD) frequently use emergency care services. To mitigate the disproportionately high rate of emergency care use by PwD, an understanding of contributing factors driving reliance on emergency care services and identification of feasible alternatives are needed. This study aimed to identify clinician, caregiver, and service providers' views and experiences of unmet needs leading to emergency care use among community-dwelling PwD and alternative ways of addressing these needs. DESIGN: Qualitative, employing semistructured interviews with clinicians, informal caregivers, and aging service providers. SETTING: Wisconsin, United States. PARTICIPANTS: Informal caregivers of PwD (n = 4), emergency medicine physicians (n = 4), primary care physicians (n = 5), geriatric healthcare providers (n = 5), aging service providers (n = 6), and community paramedics (n = 3). MEASUREMENTS: Demographic characteristics of participants and data from semistructured interviews. FINDINGS: Four major themes were identified from interviews: (1) system fragmentation influences emergency care use by PwD, (2) informational, decision-making, and social support needs influence emergency care use by PwD, (3) emergency departments (EDs) are not designed to optimally address PwD and caregiver needs, and (4) options to prevent and address emergency care needs of PwD. CONCLUSION: Participants identified numerous system and individual-level unmet needs and offered many recommendations to prevent or improve ED use by PwD. These novel findings, aggregating the perspectives of multiple dementia-care stakeholder groups, serve as the first step to developing interventions that prevent the need for emergency care or deliver tailored emergency care services to this vulnerable population through new approaches. J Am Geriatr Soc 67:711-718, 2019.

Promoting Antimicrobial Stewardship by Incorporating it in Undergraduate Medical Education Curricula.

BACKGROUND: Education related to antimicrobial stewardship-the judicious use of antimicrobials-is essential to stem the rising tide of resistance. METHODS: Using a scoping review method that includes a consultation component, we explored the extent to which antimicrobial stewardship is incorporated in undergraduate medical education. RESULTS: We found 4 studies evaluating stewardship content in undergraduate medical school curricula along with 2 studies assessing the effectiveness of specific stewardship training programs in medical education. DISCUSSION: We highlight three recommendations: (1) if applicable, identify an institutional "champion" and incorporate antibiotic stewardship-related content into medical school curriculum; (2) evaluate the status and effectiveness of antibiotic stewardship curricular components in medical education; (3) conduct research evaluating the long-term outcomes of antibiotic stewardship training in medical education.

Dissection and lateral mounting of zebrafish embryos: analysis of spinal cord development.

The zebrafish spinal cord is an effective investigative model for nervous system research for several reasons. First, genetic, transgenic and gene knockdown approaches can be utilized to examine the molecular mechanisms underlying nervous system development. Second, large clutches of developmentally synchronized embryos provide large experimental sample sizes. Third, the optical clarity of the zebrafish embryo permits researchers to visualize progenitor, glial, and neuronal populations. Although zebrafish embryos are transparent, specimen thickness can impede effective microscopic visualization. One reason for this is the tandem development of the spinal cord and overlying somite tissue. Another reason is the large yolk ball, which is still present during periods of early neurogenesis. In this article, we demonstrate microdissection and removal of the yolk in fixed embryos, which allows microscopic visualization while preserving surrounding somite tissue. We also demonstrate semipermanent mounting of zebrafish embryos. This permits observation of neurodevelopment in the dorso-ventral and anterior-posterior axes, as it preserves the three-dimensionality of the tissue.