Diagnostic Value of MRI and Radiographs of the Knee to Identify Osteochondral Lesions in Acute Patellar Instability.

The purpose of this study was to define the diagnostic value of magnetic resonance imaging (MRI) and plain radiographs (X-ray [XR]) in identifying an osteochondral defect or loose body in patients undergoing operative treatment for patellar instability. A total of 87 patients treated operatively for patellar instability with medial patellofemoral ligament (MPFL) reconstruction between 2015 and 2019 were identified. Inclusion criteria were evidence of clinical patellar instability, preoperative XR and MRI studies, and concomitant diagnostic knee arthroscopy and MPFL reconstruction performed to address patellar instability. Patients were excluded if they had a history of prior procedure for patellar instability on the surgical knee, underwent MPFL reconstruction without concomitant diagnostic knee arthroscopy, or had an anterior cruciate ligament or posterior cruciate ligament deficient knee. Operative notes and arthroscopic images were reviewed to identify osteochondral or chondral injuries and loose bodies noted during diagnostic arthroscopy. The primary outcome was the identification of intra-articular loose bodies, chondral injury, or osteochondral defect on preoperative plain radiographs and MRI in patients with patellar instability. All MRIs were performed on a 3T MRI. The sensitivity and specificity of identifying loose bodies on MRI were 0.52 and 0.92 and on XR were 0.23 and 0.98, respectively. The sensitivity and specificity of identifying osteochondral lesions on MRI were 0.43 and 0.81 and on XR were 0.08 and 0.97, respectively. Of the 87 available reports, 45 (51%) described performing chondroplasty for Outerbridge grade II/III chondral lesions on diagnostic arthroscopy. In conclusion, MRI and XR are poorly sensitive at identifying loose bodies or osteochondral defects after patellar dislocations. The poor sensitivity of imaging studies must be considered when determining whether or not to recommend operative management to a patient with patellar instability. This is a Level IV, diagnostic study.

Midarch Foot Pain: Entrapment Neuropathy of the Distal Medial Plantar Nerve and Its Branches.

Medial forefoot pain, or midarch pain, is usually attributed to plantar fasciitis. The authors present their findings of a previously unreported nerve entrapment of the medial proper plantar digital nerve (MPPDN). Ten fresh-frozen cadaveric specimens were analyzed for anatomical variance in the nerve distribution of the MPPDN. In addition, clinical results from a retrospective review of nine patients who underwent surgical nerve decompression of the MPPDN are presented. Significant anatomical variance was found for the MPPDN in the cadaveric dissection of 10 fresh-frozen specimens. Nine patients with a clinical diagnosis of entrapment of the MPPDN all obtained excellent pain relief with surgical external neurolysis. Only one complication occurred: a hypertrophic scar formation that was successfully treated with intralesional steroid injections. The authors believe that this MPPDN entrapment is often overlooked or misdiagnosed as plantar fasciitis. Surgical peripheral nerve decompression of this nerve can provide positive outcomes for patients suffering from midarch foot pain caused by this pain generator.

Suture Tape Augmentation Has No Effect on Anterior Tibial Translation, Gap Formation, or Load to Failure of Anterior Cruciate Ligament Repair: A Biomechanical Pilot Study.

PURPOSE: The purpose of our pilot study was to assess the effect of augmenting anterior cruciate ligament (ACL) repair with suture tape on biomechanical parameters including anterior tibial translation, gap formation, and load to failure. METHODS: Ten fresh-frozen nonpaired cadaveric knees were dissected, and baseline anterior-posterior stability of both ACL-intact and -deficient knees was obtained. The specimens were randomized to undergo ACL repair either with or without suture tape reinforcement, and anterior tibial translation, as well as gap formation, was measured after cyclic loading. Finally, all specimens were subjected to a single pullout force to determine maximum load to failure. We performed t test analysis to compare means between groups, and significance was defined as P < .05. RESULTS: On t test analysis, no statistically significant difference was found regarding anterior tibial translation between the ACL-intact group and either repair group or between the repair group without suture tape augmentation and the repair group with suture tape augmentation. No significant difference in gap formation was detected between the repair groups with and without suture tape augmentation at 100 cycles (1.25 mm vs 1.02 mm, P = .6), 250 cycles (2.87 mm vs 2.12 mm, P = .3), and 500 cycles (4.5 mm vs 4.55 mm, P = .5). The average load to failure of the repairs without suture tape augmentation was not significantly different from that of the repairs with suture tape augmentation (725.9 N vs 725.7 N, P = .99). CONCLUSIONS: In this pilot study, we did not identify a difference between ACL repairs with and without suture tape augmentation regarding anterior tibial translation, gap formation, or maximum load to failure. CLINICAL RELEVANCE: Treatment of ACL tears with primary ACL repair is a highly debated topic, and studies such as this study to further our understanding of the biomechanical properties of augmented ACL repairs are important for surgeons when deciding the best treatments for their patients.

Impact of a community health conversation upon advance care planning attitudes and preparation intentions.

Background: Advance care planning conversations and preparations do not occur as frequently as they should. Framing advance care planning as a health behavior and an opportunity for community engagement can help improve community-dwellers' intentions to have discussions and preparations regarding facing serious illness, death and dying.Methods: A multi-setting confidential pre/post paper survey assessing advance care planning discussions and preparation intentions was given to community-dwelling citizens residing in the New York metropolitan area. Survey items were adapted from a previous end of life survey to include questions on chronic illnesses, important conversations, comfort levels and concerns about end of life. The intervention was a 1-hour presentation on advance care planning (importance, laws, effective communication and audience questions)Results: Our study found significant interest in discussing advanced care planning across age groups. There were significant changes for participant intentions regarding: having conversations with loved ones, a health care proxy or similar document and none; as well as differences in participant intentions for discussions with caregiver, family, friends, primary physician and no-one.Conclusion: Educating individuals on the importance of advance care planning may be effective in changing community dwellers' intentions to start the conversation and put advanced care planning measures in place.Abbreviations: ACP: Advance Care Planning; CHAT: Conversations Health and Treatments; EoL: End of Life; HCP: Health Care Proxy; MOLST: Medical Orders for Life-Sustaining Treatments; PCP: Primary Care Physician.

Endoscopic Proximal Hamstring Repair and Ischial Bursectomy Using Modified Portal Placement and Patient Positioning.

Endoscopic management has become an effective method to repair proximal hamstring injuries. However, due to the complexity of such a procedure, the dissemination of the technique of endoscopic hamstring repair has occurred slowly among orthopaedic surgeons. This Technical Note with a video modifies previously described techniques and provides safer and more simplified endoscopic management of proximal hamstring injuries.

How Accurate Are We in Estimating True Stone Volume? A Comparison of Water Displacement, Ellipsoid Formula, and a CT-Based Software Tool.

INTRODUCTION: To compare the accuracy and reliability of stone volume estimated by ellipsoid formula (EFv) and CT-based algorithm (CTv) to true volume (TV) by water displacement in an in vitro model. MATERIALS AND METHODS: Ninety stone phantoms were created using clay (0.5-40 cm3, 814 HU ±91) and scanned with CT. For each stone, TV was measured by water displacement, CTv was calculated by the region-growing algorithm in the CT-based software AGFA IMPAX Volume Viewer, and EFv was calculated by the standard formula π × L × W × H × 0.167. All measurements were repeated thrice, and concordance correlation coefficient (CCC) was calculated for the whole group, as well as subgroups based on volume (<1.5 cm3, 1.5-6 cm3, and >6 cm3). RESULTS: Mean TV, CTv, and EFv were 6.42 cm3 ± 6.57 (range: 0.5-39.37 cm3), 6.24 cm3 ± 6.15 (0.48-36.1 cm3), and 8.98 cm3 ± 9.96 (0.49-47.05 cm3), respectively. When comparing TV to CTv, CCC was 0.99 (95% confidence interval [CI]: 0.99-0.995), indicating excellent agreement, although TV was slightly underestimated at larger volumes. When comparing TV to EFv, CCC was 0.82 (95% CI: 0.78-0.86), indicating poor agreement. EFv tended to overestimate the TV, especially as stone volume increased beyond 1.5 cm3, and there was a significant spread between trials. CONCLUSIONS: An automated CT-based algorithm more accurately and reliably estimates stone volume than does the ellipsoid formula. While further research is necessary to validate stone volume as a surrogate for stone burden, CT-based algorithmic volume measurement of urinary stones is a promising technology.

Cost-effectiveness comparison of response strategies to a large-scale anthrax attack on the chicago metropolitan area: impact of timing and surge capacity.

Rapid public health response to a large-scale anthrax attack would reduce overall morbidity and mortality. However, there is uncertainty about the optimal cost-effective response strategy based on timing of intervention, public health resources, and critical care facilities. We conducted a decision analytic study to compare response strategies to a theoretical large-scale anthrax attack on the Chicago metropolitan area beginning either Day 2 or Day 5 after the attack. These strategies correspond to the policy options set forth by the Anthrax Modeling Working Group for population-wide responses to a large-scale anthrax attack: (1) postattack antibiotic prophylaxis, (2) postattack antibiotic prophylaxis and vaccination, (3) preattack vaccination with postattack antibiotic prophylaxis, and (4) preattack vaccination with postattack antibiotic prophylaxis and vaccination. Outcomes were measured in costs, lives saved, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). We estimated that postattack antibiotic prophylaxis of all 1,390,000 anthrax-exposed people beginning on Day 2 after attack would result in 205,835 infected victims, 35,049 fulminant victims, and 28,612 deaths. Only 6,437 (18.5%) of the fulminant victims could be saved with the existing critical care facilities in the Chicago metropolitan area. Mortality would increase to 69,136 if the response strategy began on Day 5. Including postattack vaccination with antibiotic prophylaxis of all exposed people reduces mortality and is cost-effective for both Day 2 (ICER=$182/QALY) and Day 5 (ICER=$1,088/QALY) response strategies. Increasing ICU bed availability significantly reduces mortality for all response strategies. We conclude that postattack antibiotic prophylaxis and vaccination of all exposed people is the optimal cost-effective response strategy for a large-scale anthrax attack. Our findings support the US government's plan to provide antibiotic prophylaxis and vaccination for all exposed people within 48 hours of the recognition of a large-scale anthrax attack. Future policies should consider expanding critical care capacity to allow for the rescue of more victims.

Linking drugs to obscure illnesses: lessons from pure red cell aplasia, nephrogenic systemic fibrosis, and Reye's syndrome. a report from the Southern Network on Adverse Reactions (SONAR).

Identification of serious adverse drug reactions (sADRS) associated with commonly used drugs can elude detection for years. Reye's syndrome (RS), nephrogenic systemic fibrosis (NSF), and pure red cell aplasia (PRCA) among chronic kidney disease (CKD) patients were recognized in 1951, 2000, and 1998, respectively. Reports associating these syndromes with aspirin, gadodiamide, and epoetin, were published 29, 6, and 4 years later, respectively. We obtained primary information from clinicians who identified causes of these sADRs and reviewed factors contributing to delayed identification of these toxicities. Overall, 3,500 aspirin-associated RS cases in the United States, 1,605 gadolinium-associated NSF cases, and 181 epoetin-associated PRCA cases were reported. Delays in FDA regulation of over-the- counter medications and administration of aspirin to children contributed to development of RS. For NSF, in 1996, the Danish Medicine Agency approved high-dose gadodiamide administration to chronic kidney disease (CKD) patients undergoing MR scans. Overall, 88 % of Danish NSF cases were from two hospitals and 97 % of United States' NSF cases were from 60 hospitals. These hospitals frequently administered high-doses of gadodiamide to CKD patients. Another factor was the decision to administer linear chelated contrast agents versus lower risk macrocyclic chelated agents. For PRCA, increased use of subcutaneous epoetin formulations to CKD patients, in part due to convenience and cost-savings considerations, and a European regulatory requirement requiring removal of albumin as a stabilizer, led to toxicity. Overall, 81, 13, and 17 years elapsed between drug introduction into practice and identification of a causal relationship for aspirin, erythropoietin, and gadodiamide, respectively. A substantial decline in new cases of these sADRs occurred within two years of identification of the offending drug. Clinicians should be vigilant for sADRs, even for frequently-prescribed pharmaceuticals, particularly in settings where formulation or regulatory changes have occurred, or when over-the-counter, off-label, or pediatric use is common.

A tale of two citizens: a State Attorney General and a hematologist facilitate translation of research into US Food and Drug Administration actions--a SONAR report.

PURPOSE: Pharmaceutical safety is a public health issue. In 2005, the Connecticut Attorney General (AG) raised concerns over adverse drug reactions in off-label settings, noting that thalidomide was approved to treat a rare illness, but more than 90% of its use was off label. A hematologist had reported thalidomide with doxorubicin or dexamethasone was associated with venous thromboembolism (VTE) rates of 25%. We review US Food and Drug Administration (FDA) and manufacturer responses to a citizen petition filed to address these thalidomide safety issues. METHODS: Case study. RESULTS: The AG petitioned the FDA requesting thalidomide-related safety actions. Coincidentally, the manufacturer submitted a supplemental New Drug Approval (sNDA), requesting approval to treat multiple myeloma with thalidomide-dexamethasone. FDA safety officers reviewed the petition and the literature and noted that VTE risks with thalidomide were not appropriately addressed in the existing package insert. In the sNDA application, the manufacturer reported thalidomide-associated toxicities for multiple myeloma were primarily somnolence and neurotoxicity, and a proposed package insert did not focus on VTE risks. In October, the FDA informed the Oncology Drug Division that VTE risks with thalidomide were poorly addressed in the existing label. After reviewing this memorandum, an Oncology Drug Division reviewer informed the manufacturer that approval of the sNDA would be delayed until several thalidomide-associated VTE safety actions, including revisions of the package insert, were implemented. The manufacturer and FDA agreed on these actions, and the sNDA was approved. CONCLUSION: New approaches addressing off-label safety are needed. The conditions that facilitated the successful response to this citizen petition are uncommon.

High data-rate 6.7 GHz wireless ASIC transmitter for neural prostheses.

A high-frequency transmitter has been designed for high data-rate biomedical telemetry. Although high frequencies face greater attenuation, transcutaneous transmission was successfully tested and verified using a 3.76 mm thick sample of porcine skin. The structure transmits over 440 microW of power, consumes about 4.9 mA of current from a 1.8 V supply, and achieves a phase noise of -72 dBc/Hz at 100 KHz. The transmitter operates at around 6.7 GHz with a 50 MHz tuning range and is fully integrated on the CMOS IBM7RF 0.18 microm process.

Systematic review of piperacillin-induced neutropenia.

Because penicillin agents are implicated in granulopoiesis inhibition, healthcare professionals frequently consider discontinuation of such therapy in patients with decreasing white blood cell counts. No systematic review to date has described piperacillin and the patient population at risk for this adverse drug reaction (ADR). This review sought to assess the occurrence of piperacillin-induced neutropenia, describe characteristics of affected patients and assess the reporting modalities that most accurately classify this ADR. Case reports, cohort studies and clinical trials identified by comprehensive searches of PubMed and the US FDA Adverse Event Reporting System (AERS) database were reviewed for patient demographics, duration and dose of piperacillin or piperacillin-tazobactam treatment and the occurrence of neutropenia. Causality assessments were performed. Six published case reports, three cohort studies, 178 clinical trials and two compilations of phase I-III trials were reviewed. Review of case reports was notable in that the duration of beta-lactam therapy prior to the noting of leukopenia always exceeded 15 days. No deaths were recorded in this group. Among 13,816 patients enrolled in non-neutropenic fever studies, the occurrence of piperacillin-induced neutropenia was rare: five patients (0.04%) developed neutropenia; none died. The demographics for this group were poorly documented. Through the AERS database, we identified 366 unique cases of piperacillin or piperacillin-tazobactam-induced haematological abnormalities, including neutropenia (n = 183, 50.0%), leukopenia, (n = 99, 27%), agranulocytosis (n = 58, 15.8%) and others. In 62 cases, patients received between 1 and 14 days of therapy (mean 7.7 + 4.1 days). Overall, there were 82 (22.4%) deaths. Reports of haematological ADRs among patients receiving piperacillin or piperacillin-tazobactam are rare. Report of neutropenia associated with piperacillin usage prior to 15 days of therapy is a novel finding that requires further evaluation. Current reporting methods poorly characterise patient groups at risk.