Operative fixation of rib fracture nonunions.

INTRODUCTION: Rib fractures are common injuries in trauma patients that often heal without intervention. Infrequently, symptomatic rib fracture nonunions are a complication after rib fractures. There is a paucity of literature on the surgical treatment of rib fracture nonunion. The purpose of this study was to describe the efficacy of rib fracture nonunion operative fixation with particular focus on surgical technique, healing rates, and complications. MATERIALS AND METHODS: Patients aged ≥ 18 years with symptomatic rib fracture nonunions treated with open reduction and internal fixation (ORIF) with locking plates at a single urban level 1 trauma center were retrospectively reviewed. Pertinent demographic, clinical, radiographic, and surgical data were collected and analyzed. RESULTS: A total of 18 patients met inclusion criteria. The mean time from injury to undergoing ORIF for rib fracture nonunion was just under a year and the number of ribs plated was 2.95 ± 1.16 (1-5 ribs) with bone grafting used in six cases. All patients (100%) showed evidence of healing at an average of 2.65 ± 1.50 months (2-8 months). All patients reported a decrease in pain. No narcotic pain medication was used at an average of 3.88 ± 3.76 weeks (0-10 weeks) post-operatively. Intraoperative and postoperative complications were found in 4 (22.2%) patients. CONCLUSION: This study concluded that operative fixation of symptomatic rib fracture nonunion demonstrated favorable outcomes with reduction in preoperative pain levels, decreased use of narcotic pain medication, minimal complications, and a high rate of fracture union. This described method provides symptomatic relief, reduction in pain, and promotes bony healing of the fracture nonunion without development of major complications. We suggest that operative fixation should be considered as the primary method of treatment of symptomatic rib nonunions.

Intramedullary Screw Fixation Versus Traditional Plating for Distal Fibula Fractures.

The traditional method of treating fibular fractures in unstable ankle injuries involves open reduction and internal fixation with a plate and screw construct. Less invasive percutaneous fixation techniques with intramedullary fibular screws have been utilized for many years to reduce wound and implant complications while maintaining a stable ankle mortise. However, there have been no direct case-control studies comparing percutaneous intramedullary fibular screw fixation to the traditional open reduction and internal fixation with plates and screws. In our study, we compared radiographic and clinical outcomes for unstable ankle fractures in which the fibula fracture was treated with either a percutaneous intramedullary screw or by open reduction and internal fixation with a plate and screw construct. We retrospectively reviewed 69 consecutive patients from 2011 to 2019 with unstable ankle fractures treated with intramedullary fibular screws and compared them to 216 case-control patients treated with traditional plate and screw construct over the same time period. The average follow-up for the intramedullary screw group was 11.5 months and 15.2 months for the plate and screw group. We collected general demographic data, measured intraoperative and final follow-up talocrural angles, Kellgren-Lawrence osteoarthritis grade, union rates, implant removal rates, infection rates, and American Orthopedic Foot and Ankle Society ankle-hindfoot scores. The intramedullary screw group had a statistically significant lower rate of delayed implant removal (8.7% vs 23.6%) and there was no detectable difference in other measures.

Spatiotemporal control of laser intensity through cross-phase modulation.

Spatiotemporal pulse shaping provides control over the trajectory and range of an intensity peak. While this control can enhance laser-based applications, the optical configurations required for shaping the pulse can constrain the transverse or temporal profile, duration, or orbital angular momentum (OAM). Here we present a novel technique for spatiotemporal control that mitigates these constraints by using a "stencil" pulse to spatiotemporally structure a second, primary pulse through cross-phase modulation (XPM) in a Kerr lens. The temporally shaped stencil pulse induces a time-dependent focusing phase within the primary pulse. This technique, the "flying focus X," allows the primary pulse to have any profile or OAM, expanding the flexibility of spatiotemporal pulse shaping for laser-based applications. As an example, simulations show that the flying focus X can deliver an arbitrary-velocity, variable-duration intensity peak with OAM over distances much longer than a Rayleigh range.

Napping on the night shift and its impact on blood pressure and heart rate variability among emergency medical services workers: study protocol for a randomized crossover trial.

BACKGROUND: There is an emerging body of evidence that links exposure to shift work to cardiovascular disease (CVD). The risk of coronary events, such as myocardial infarction, is greater among night shift workers compared to day workers. There is reason to believe that repeated exposure to shift work, especially night shift work, creates alterations in normal circadian patterns of blood pressure (BP) and heart rate variability (HRV) and that these alterations contribute to increased risk of CVD. Recent data suggest that allowing shift workers to nap during night shifts may help to normalize BP and HRV patterns and, over time, reduce the risk of CVD. The risk of CVD related to shift work is elevated for emergency medical services (EMS) shift workers due in part to long-duration shifts, frequent use of night shifts, and a high prevalence of multiple jobs. METHODS: We will use a randomized crossover trial study design with three study conditions. The targeted population is comprised of EMS clinician shift workers, and our goal enrollment is 35 total participants with an estimated 10 of the 35 enrolled not completing the study protocol or classified as lost to attrition. All three conditions will involve continuous monitoring over 72 h and will begin with a 36-h at-home period, followed by 24 total hours in the lab (including a 12-h simulated night shift), ending with 12 h at home. The key difference between the three conditions is the intra-shift nap. Condition 1 will involve a simulated 12-h night shift with total sleep deprivation. Condition 2 will involve a simulated 12-h night shift and a 30-min nap opportunity. Condition 3 will involve a simulated 12-h night shift with a 2-h nap opportunity. Our primary outcomes of interest include blunted BP dipping and reduced HRV as measured by the standard deviation of the inter-beat intervals of normal sinus beats. Non-dipping status will be defined as sleep hours BP dip of less than 10%. DISCUSSION: Our study will address two indicators of cardiovascular health and determine if shorter or longer duration naps during night shifts have a clinically meaningful impact. TRIAL REGISTRATION: ClinicalTrials.gov NCT04469803 . Registered on 9 July 2020.

Nonlinear spatiotemporal control of laser intensity.

Spatiotemporal control over the intensity of a laser pulse has the potential to enable or revolutionize a wide range of laser-based applications that currently suffer from the poor flexibility offered by conventional optics. Specifically, these optics limit the region of high intensity to the Rayleigh range and provide little to no control over the trajectory of the peak intensity. Here, we introduce a nonlinear technique for spatiotemporal control, the "self-flying focus," that produces an arbitrary trajectory intensity peak that can be sustained for distances comparable to the focal length. The technique combines temporal pulse shaping and the inherent nonlinearity of a medium to customize the time and location at which each temporal slice within the pulse comes to its focus. As an example of its utility, simulations show that the self-flying focus can form a highly uniform, meter-scale plasma suitable for advanced plasma-based accelerators.

Drive-through Satellite Testing: An Efficient Precautionary Method of Screening Patients for SARS-CoV-2 in a Rural Healthcare Setting.

The first documented case of COVID-19 in the United States occurred on January 30th, 2020. Soon after, a global pandemic was declared in March 2020 with each state issuing stay at home orders based on population, risk for community transmission and current number of positive cases. A priority for each region was to develop efficient systems for testing large patient volumes in a safe manner to reduce the risk of community transmission. A community based United States health care system in the upper mid-west implemented a drive through testing site in an attempt to divert suspected cases of COVID-19 away from larger patient areas while protecting staff and patients. This commentary outlines the planning, work flow and challenges of implementing this drive through testing site in a rural community setting.

Stochastic approximation Monte Carlo with a dynamic update factor.

We present a Monte Carlo algorithm based on the stochastic approximation Monte Carlo (SAMC) algorithm for directly calculating the density of states. The proposed method is stochastic approximation with a dynamic update factor (SAD), which dynamically adjusts the update factor γ_{t} during the course of the simulation. We test this method on a square-well fluid and a 31-atom Lennard-Jones cluster and compare the convergence behavior of several related Monte Carlo methods. We find that both the SAD and 1/t-Wang-Landau (1/t-WL) methods rapidly converge to the correct density of states without the need for the user to specify an arbitrary tunable parameter t_{0} as in the case of SAMC. SAD requires as input the temperature range of interest, in contrast with 1/t-WL, which requires that the user identify the interesting range of energies. The convergence of the 1/t-WL method is very sensitive to the energy range chosen for the low-temperature heat capacity of the Lennard-Jones cluster. Thus, SAD is more powerful in the common case in which the range of energies is not known in advance.

Validation of a commercial inertial sensor system for spatiotemporal gait measurements in children.

Although inertial sensor systems are becoming a popular tool for gait analysis in both healthy and pathological adult populations, there are currently no data on the validity of these systems for use with children. The purpose of this study was to validate spatiotemporal data from a commercial inertial sensor system (MobilityLab) in typically-developing children. Data from 10 children (5 males; 3.0-8.3 years, mean=5.1) were collected simultaneously from MobilityLab and 3D motion capture during gait at self-selected and fast walking speeds. Spatiotemporal parameters were compared between the two methods using a Bland-Altman method. The results indicate that, while the temporal gait measurements were similar between the two systems, MobilityLab demonstrated a consistent bias with respect to measurement of the spatial data (stride length). This error is likely due to differences in relative leg length and gait characteristics in children compared to the MobilityLab adult reference population used to develop the stride length algorithm. A regression-based equation was developed based on the current data to correct the MobilityLab stride length output. The correction was based on leg length, stride time, and shank range-of-motion, each of which were independently associated with stride length. Once the correction was applied, all of the spatiotemporal parameters evaluated showed good agreement. The results of this study indicate that MobilityLab is a valid tool for gait analysis in typically-developing children. Further research is needed to determine the efficacy of this system for use in children suffering from pathologies that impact gait mechanics.

Evaluation of an inertial sensor system for analysis of timed-up-and-go under dual-task demands.

Functional tests, such as the timed-up-and-go (TUG), are routinely used to screen for mobility issues and fall risk. While the TUG is easy to administer and evaluate, its single time-to-completion outcome may not discriminate between different mobility challenges. Wearable sensors provide an opportunity to collect a variety of additional variables during clinical tests. The purpose of this study was to assess a new wearable inertial sensor system (iTUG) by investigating the effects of cognitive tasks in a dual-task paradigm on spatiotemporal and kinematic variables during the TUG. No previous studies have looked at both spatiotemporal variables and kinematics during dual-task TUG tests. 20 healthy young participants (10 males) performed a total 15 TUG trials with two different cognitive tasks and a normal control condition. Total time, along with spatiotemporal gait parameters and kinematics for all TUG subtasks (sit-to-stand, walking, turn, turn-to-sit), were measured using the inertial sensors. Time-to-completion from iTUG was highly correlated with concurrent manual timing. Spatiotemporal variables during walking showed expected differences between control and cognitive dual-tasks while trunk kinematics appeared to show more sensitivity to dual-tasks than reported previously in straight line walking. Non-walking TUG subtasks showed only minor changes during dual-task conditions indicating a possible attentional shift away from the cognitive task. Stride length and some variability measures were significantly different between the two cognitive tasks suggesting an ability to discriminate between tasks. Overall, the use of the iTUG system allows the collection of both traditional and potentially more discriminatory variables with a protocol that is easily used in a clinical setting.

Validity of a questionnaire in estimating restorative treatment need among young adults.

OBJECTIVE: There are no verified anamnestic sets of questions for assessing restorative treatment need. Finnish conscripts responded to a computer-based questionnaire on oral health during their oral health screening in 2011. This study compared the outcomes of the screening and the questionnaire concerning restorative treatment need with the aim of finding and validating a set of questions with the best association between the two methods. CLINICAL SETTING: The study group comprised 8,566 conscripts. Of 50 original questions, 22 questions were chosen for closer analysis. The generalised linear mixed model was used to calculate the OR values (95% CI) for each of these questions, using restorative treatment need at individual level as the response variable. Questions with the best association (Q1-Q10) were selected for the final set; the inclusion criterion was p < 0.05. The area under curve (AUC) value was calculated for the sum function of these 10 questions. RESULTS: Among the final set of 10 questions, the OR values varied between 1.12 and 4.61. The AUC value was 0.75. By increasing the number of positive responses to 8 questions, the odds for restorative treatment need were OR 69.27 and increased to infinity with 10 questions. CONCLUSIONS: A selected set of questions together with clinical screening, or even alone, can be a valid instrument for screening people for restorative treatment need. The method is particularly useful in large populations. This statistical method might identify appropriate sets of questions for different contexts.

Geographical distribution of dental caries prevalence and associated factors in young adults in Finland.

Oral health of the young has been reported to be associated with the place of residence, due to differences in socio-economic status. The results of studies on the effect of fluoride in drinking water on caries prevalence have been contradictory. The main aim of our study was to investigate the geographical distribution of dental caries prevalence in Finland and analyse possible regional, associated factors. Oral health of 13,564 men born between 1990 and 1992 was screened using a method based on criteria of the World Health Organization for epidemiological studies by 15 calibrated dentists in 20/24 garrisons of the Finnish Defence Forces in 2011. Mean DMFT and DT values in provinces were calculated. Multilevel analysis was applied to the data using generalized linear mixed models and a logit link function. The binary outcome variable was the cariological treatment need (yes/no) and the garrison was treated as random effect. Mean DMFT and DT values varied significantly between provinces in Finland. Increased levels of fluoride in drinking water, Swedish as the main language in the municipality, and living in urban areas were protective factors against cariological treatment need. Dentist density did not affect caries prevalence. The geographical distribution of dental caries further supported estimates of the protective effects of high fluoride levels in drinking water, Swedish as the main language in the municipality, as well as living in urban areas. Effect of fluoride on caries prevalence still exists, and association with the socio-economic status was confirmed.

Web-based SBIRT skills training for health professional students and primary care providers.

The authors have developed and assessed 2 innovative, case-based, interactive training programs on substance abuse, one for health professional students on alcohol and one for primary care providers on screening, brief intervention, and referral to treatment (SBIRT). Both programs build skills in substance abuse SBIRT. Real-world effectiveness trials involving medical students (n = 10) and nursing students (n = 60) were completed; trials involving primary care providers (n = 65) are in progress during 2011. Medical students and nursing students had similarly low baseline scores on assessments that benefited from training: knowledge, confidence, and clinical performance measured via an online standardized patient case and encounter note all improved post-training. Preliminary results indicate that practicing providers improved on knowledge, attitude, and brief intervention skill performance after a similar training. Results suggest that SBIRT skills can be improved with this model for case-based interactive training programs, and thus, that this training has the potential to impact patient outcomes.

Triclosan-resistant bacteria isolated from feedlot and residential soils.

Triclosan is an antimicrobial agent that is currently incorporated into hundreds of consumer and medical products. It can be either a bacteriostatic or bactericidal agent, depending on its formulation. It has activity against Gram-positive and Gram-negative bacteria, as well as some viruses and protists. The purpose of this study was to determine whether triclosan-resistant bacteria could be isolated from the soil. Soils from cattle feedlots and residential lawns were collected and assayed for the presence of these organisms by plating samples on growth media containing triclosan. Organisms were subsequently identified by partial 16S rRNA sequencing analysis. All the organisms isolated in this study were Gram-negative rods, with members of genus Pseudomonas being particularly well represented. This result may not be surprising because Gram-negative organisms are generally more resistant to triclosan, and since Pseudomonas bacteria are known to have numerous efflux mechanisms for dealing with harmful substances.

Effectiveness of an online curriculum for medical students on genetics, genetic testing and counseling.

BACKGROUND: It is increasingly important that physicians have a thorough understanding of the basic science of human genetics and the ethical, legal and social implications (ELSI) associated with genetic testing and counseling. METHODS: The authors developed a series of web-based courses for medical students on these topics. The course modules are interactive, emphasize clinical case studies, and can easily be incorporated into existing medical school curricula. RESULTS: Results of a 'real world' effectiveness trial indicate that the courses have a statistically significant effect on knowledge, attitude, intended behavior and self-efficacy related to genetic testing (p<0.001; N varies between 163 and 596 for each course). CONCLUSIONS: The results indicate that this curriculum is an effective tool for educating medical students on the ELSI associated with genetic testing and for promoting positive changes in students' confidence, counseling attitudes and behaviors.

An iGen approach to teaching medical students.

Medical school class sizes are set to increase, yet resources are not. The use of Internet based supplemental education modules and standardized patients (SP) is one answer to this imbalance. We have prototyped and assessed Internet modules and an SP on the topic of substance abuse. Effectiveness is supported by a small pilot study. A larger study is in process during 2008.

Developing an Internet-based practice tool to assist physicians associated with buprenorphine treatment of opioid addiction.

The Buprenorphine Practice Advisor (BPA) is a new web-based tool for primary care physicians who see opioid-dependent patients in their practices. The website (BupPractice.com) provides physicians with information and resources on referring patients for buprenorphine treatment, medical management of patients on buprenorphine, and setting up and managing office-based buprenorphine treatment.

Delivering drugs by the transdermal route: review and comment.

BACKGROUND: There are many advantages to administering drugs by routes that bypass the gastrointestinal tract. One such route is the transdermal in which the drug agent is applied to the skin in a patch or device of some type so that sufficient quantity penetrates the skin to exert a systemic effect. There are several theoretical advantages to this approach not the least of which is that the drug avoids being metabolized by the liver after absorption and that gastrointestinal irritation is avoided. AIMS: To discuss the various ways in which drugs can be persuaded to cross the skin barrier and also to discuss the adverse effects of transdermal administration. Technical advances have permitted an increasing number of drugs to be offered in the transdermal format.

The androgen receptor DNA-binding domain determines androgen selectivity of transcriptional response.

The AR (androgen receptor) is a hormone-dependent transcription factor that translates circulating androgen hormone levels into a physiological cellular response by directly regulating the expression of its target genes. It is the key molecule in e.g. the development and maintenance of the male sexual characteristics, spermatocyte production and prostate gland development and growth. It is also a major factor in the onset and maintenance of prostate cancer and a first target for pharmaceutical action against the further proliferation of prostate cancer cells. The AR is a member of the steroid hormone receptors, a group of steroid-inducible transcription factors sharing an identical consensus DNA-binding motif. The problem of how specificity in gene activation is achieved among the different members of this nuclear receptor subfamily is still unclear. In this report, we describe our investigations on how the AR can specifically activate its target genes, while the other steroid hormone receptors do not, despite having the same consensus monomeric DNA-binding motif. In this respect, we describe how the AR interacts with a newly identified class of steroid-response elements to which only the AR and not, for example, the glucocorticoid receptor can bind.