Screening Cobalt-based Catalysts on Multicomponent CdSe@CdS Nanorods for Photocatalytic Hydrogen Evolution in Aqueous Media.

We present CdSe@CdS nanorods coated with a redox-active polydopamine (PDA) layer functionalized with cobaloxime-derived photocatalysts for efficient solar-driven hydrogen evolution in aqueous environments. The PDA-coating provides reactive groups for the functionalization of the nanorods with different molecular catalysts, facilitates charge separation and transfer of electrons from the excited photosensitizer to the catalyst, and reduces photo-oxidation of the photosensitizer. X-ray photoelectron spectroscopy (XPS) confirms the successful functionalization of the nanorods with cobalt-based catalysts, whereas the catalyst loading per nanorod is quantified by total reflection X-ray fluorescence spectrometry (TXRF). A systematic comparison of different types of cobalt-based catalysts was carried out, and their respective performance was analyzed in terms of the number of nanorods and the amount of catalyst in each sample [turnover number, (TON)]. This study shows that the performance of these multicomponent photocatalysts depends strongly on the catalyst loading and less on the specific structure of the molecular catalyst. Lower catalyst loading is advantageous for increasing the TON because the catalysts compete for a limited number of charge carriers at the nanoparticle surface. Therefore, increasing the catalyst loading relative to the absolute amount of hydrogen produced does not lead to a steady increase in the photocatalytic activity. In our work, we provide insights into how the performance of a multicomponent photocatalytic system is determined by the intricate interplay of its components. We identify the stable attachment of the catalyst and the ratio between the catalyst and photosensitizer as critical parameters that must be fine-tuned for optimal performance.

Nonoperative Management, Repair, or Reconstruction of the Medial Collateral Ligament in Combined Anterior Cruciate and Medial Collateral Ligament Injuries-Which Is Best? A Systematic Review and Meta-analysis.

BACKGROUND: Combined injury of the anterior cruciate ligament (ACL) and the medial collateral ligament (MCL) is a common injury pattern and accounts for 20% of all ligamentous knee injuries. Despite advancements in surgical technique, there is no up-to-date consensus regarding the superiority of nonoperative versus operative management in higher-grade MCL tears of combined ACL-MCL injuries. PURPOSE: To interpret recent literature on treatment options and to provide an updated evidence-based approach for management of combined ACL-MCL knee injuries. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: We performed a systematic review on outcomes following treatment of concomitant ACL and MCL injuries. A computerized search was conducted in PubMed, Embase.com, and Scopus.com. Authors independently assessed eligible studies and screened titles and abstracts. Articles reporting on patients with concomitant ACL and MCL injuries with or without concomitant procedures were included. Data regarding study design, sample size, patient age and sex, length of follow-up, timing of surgery, indications, surgical methods, concomitant procedures, outcomes, and complications were recorded. Patient-reported outcomes (PROs) and functional outcomes, including Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee scores, Lysholm and Tegner scores, and range of motion, were estimated via meta-analysis and compared statistically by surgical approach. RESULTS: In total, 18 studies were included in the systematic review with level 1 to level 4 evidence, with a total of 1,534 cases, were included in the systematic review. Of these, 16 studies with sufficient statistical reporting including 997 cases with sufficient follow-up were included in meta-analysis. Three different approaches to combined ACL-MCL injuries were identified: ACL reconstruction with (1) nonoperative MCL, (2) MCL repair, and (3) MCL reconstruction. There was no statistical difference between nonoperative versus surgically managed MCL injuries for PROs, range of motion at final follow up, or quadriceps strength. CONCLUSION: Reconstruction of combined injury in a delayed fashion facilitates return of range of motion and may allow time for low-grade MCL tears to heal. If residual valgus or anteromedial rotatory laxity remains after a period of rehabilitation, then concomitant surgical management of ACL and MCL injuries is warranted. Avulsion MCL injuries and Stener-type lesions may benefit from early repair techniques.

Safely Reducing Unnecessary Radiographs in Suspected Pediatric Musculoskeletal Injuries: A Multidisciplinary Developed Algorithm.

BACKGROUND: While radiographs are a critical component of diagnosing musculoskeletal (MSK) injuries, they are associated with radiation exposure, patient discomfort, and financial costs. Our study initiative was to develop a system to diagnose pediatric MSK injuries efficiently while minimizing unnecessary radiographs. METHODS: This was a quality improvement trial performed prospectively at a single level one trauma center. A multidisciplinary team with leaders from pediatric orthopedics, trauma surgery, emergency medicine, and radiology created an algorithm delineating which x-rays should be obtained for pediatric patients presenting with MSK injuries. The intervention was performed in the following 3 stages: stage 1: retrospective validation of the algorithm, stage 2: implementation of the algorithm, and stage 3: sustainability evaluation. Outcomes measured included number of extra radiographs per pediatric patient and any missed injuries. RESULTS: In stage 1, 295 patients presented to the pediatric emergency department with MSK injuries. A total of 2148 radiographs were obtained, with 801 not indicated per the protocol, for an average of 2.75 unnecessary radiographs per patient. No injuries would have been missed using the protocol. In stage 2, 472 patients had 2393 radiographs with 339 not indicated per protocol, averaging 0.72 unnecessary radiographs per patient, a significant reduction from stage 1 ( P < 0.001). There were no missed injuries identified on follow-up. In stage 3, improvement was sustained for the subsequent 8 months with an average of 0.34 unnecessary radiographs per patient ( P < 0.05). CONCLUSIONS: Sustained reduction of unnecessary radiation to pediatric patients with suspected MSK injuries was accomplished through the development and implementation of a safe and effective imaging algorithm. The multidisciplinary approach, widespread education of pediatric providers, and standardized order sets improved buy-in and is generalizable to other institutions.Level of Evidence: III.

Telehealth Physical Therapy for Sports Medicine Rehabilitation: What Is Its Role in the Postpandemic Era?

Background: The adoption of telehealth visits for physical therapy (PT) has accelerated because of the COVID-19 pandemic. Patient reception of virtual PT at the outbreak of the pandemic was positive, but it is unclear how telehealth visits compare to in-person visits in the postpandemic era. Purpose: To evaluate utilization trends and patient satisfaction with virtual PT compared with in-person PT during and after the COVID-19 pandemic. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We identified 59,461 in-person and 2016 telehealth visits at a single physical rehabilitation center between March 2020 and December 2021. Patient socioeconomic and demographic variables, including insurance status, were compared between telehealth users and in-person visitors. A total of 1012 patient satisfaction surveys were available and analyzed using the top-box method. Univariable statistics (t test or Mann-Whitney U and chi-square tests) were used for group comparisons. Results: Overall, telehealth users when compared with in-person visitors were older (median age, 47 vs 42 years, respectively; P < .001), and a higher proportion was female (60.6% vs 54.8%; P < .001), was White (69.7% vs 66.6%; P = .023), spoke English as their primary language (99.2% vs 98.1%; P = .001), and had Medicare insurance (20.3% vs 16.1%; P < .001). Telehealth patients more often lived out-of-county (50.7% vs 45.8%; P < .001) and in small towns rather than in urban areas (1.0% vs 0.3%; P < .001). When we compared telehealth use before and after official reopening of the PT center in September 2020, telehealth users in the postpandemic era had an out-of-county rate of 58.7%, and 68.7% were female. Patient satisfaction survey results demonstrated that telehealth patients compared with in-person patients were less likely to recommend visits to others (75.0% vs 89.1%, respectively; P = .008) and had lower overall assessment of their visits (71.7% vs 88.6%; P = .001). Accordingly, there was a significant reduction in telehealth visits from 2020 to 2021 (from 6.9% to 0.9% of visits; P < .001). Conclusion: We noted a decline in telehealth PT use during the postpandemic era, consistent with reduced patient satisfaction when compared with in-person visits. Telehealth is a useful option for populations with limited time or access to care and may serve a role in a hybrid care model. Further studies on long-term outcomes after telehealth PT are warranted to evaluate its efficacy.

Comparison of computed tomography and 3D magnetic resonance imaging in evaluating glenohumeral instability bone loss.

BACKGROUND: To determine whether the addition of 3-dimensional (3D) magnetic resonance imaging (MRI) to standard MRI sequences is comparable to 3D computed tomographic (CT) scan evaluation of glenoid and humeral bone loss in glenohumeral instability. METHODS: Eighteen patients who presented with glenohumeral instability were prospectively enrolled and received both MRI and CT within 1 week of each other. The MRI included an additional sequence (volumetric interpolated breath-hold examination [VIBE]) that underwent postprocessing for reformations. The addition of a VIBE protocol, on average, is an additional 4-4.5 minutes in the scanner. CT data also underwent 3D postprocessing, and therefore each patient had 4 imaging modalities (2D CT, 2D MRI, 3D CT reformats, and 3D MRI reformats). Each sequence underwent the following measurements from 2 separate reviewers: glenoid defect, glenoid defect percentage, humeral defect, humeral defect percentage, and evaluation of glenoid track and version. Paired t tests were used to assess differences between imaging modalities and χ2 for glenoid track. Intra- and interobserver reliability were evaluated. Bland-Altman tests were also performed to assess the agreement between CT and MRI. In addition, we determined the cost of each imaging modality at our institution. RESULTS: 3D MRI measurements for glenoid and humeral bone loss measurements were comparable to 3D CT (Table 1). There were no significant differences for glenoid defect size and percentage, or humeral defect size and percentage (P > .05) (Table 2). Bland-Altman analysis demonstrated strong agreement, with small measurement errors for 3D CT and 3D MRI percentage glenoid bone loss. There was also no difference in evaluation for determining on vs. off track between any of the imaging modalities. Inter- and intrarater reliability was good to excellent for all CT and MRI measurements (r ≥ 0.7). CONCLUSION: 3D MRI measurements for bone loss in glenohumeral instability through use of VIBE sequence were equivalent to 3D CT. At our institution, undergoing MRI with 3D reconstruction was 1.67 times cheaper than MRI and CT with 3D reconstructions. 3D MRI may be a useful adjuvant to standard MRI sequences to allow concurrent soft tissue and accurate assessment of glenoid and humeral bone loss in glenohumeral instability.

Long-Term Health-Related Quality of Life After Harrington Instrumentation and Fusion for Adolescent Idiopathic Scoliosis: A Minimum 40-Year Follow-up.

BACKGROUND: Despite its importance for clinical decisions, the long-term consequences of posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS), particularly in the lower lumbar spine, remain unclear. This study evaluates the long-term health-related quality of life and the need for a further surgical procedure in patients treated with Harrington instrumentation from 1961 to 1977 according to the lowest instrumented vertebra (LIV) and in comparison with age-matched norms. METHODS: A search was performed to identify and contact the 314 identified patients with AIS treated with PSIF by Dr. L.A. Goldstein. The assessment included identified subsequent spine surgery, the Oswestry Disability Index (ODI), Scoliosis Research Society-7 (SRS-7), EuroQol-5 Dimensions (EQ-5D), and Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29). The health-related quality of life was compared with U.S. norms and, within the cohort, was compared by patient factors, LIV, and subsequent spine surgery. RESULTS: In this study, 134 patients (42.7%) were identified; 24 (7.6%) had died, 81 (25.8%) consented to participate in the study, and 29 (9.2%) declined participation. The mean follow-up was 45.4 years (range, 40 to 56 years). There were 81 patients who completed the surveys, 77 patients who completed the SRS-7, 77 patients who completed the ODI, and 76 patients who completed the PROMIS-29 and EQ-5D. There were 12.8% of patients with LIV L3 or proximal and 36.4% with LIV L4 or distal who had an additional surgical procedure (odds ratio, 3.98). Comparing the ODI of patients who had undergone an additional surgical procedure with those who had not showed 42% and 73% minimal disability, 53% and 23% moderate disability, and 5% and 2% severe disability. Of the patients who had not undergone an additional surgical procedure, those with LIV L3 or proximal had mean scores of 14.12 points for the ODI and 23.3 points for the SRS-7 and those with LIV L4 or distal had mean scores of 17.9 points for the ODI and 22.7 points for the SRS-7; these differences were not significant. The mean PROMIS-29 and EQ-5D scores were not different from normal U.S. age-based means. CONCLUSIONS: Patients with AIS treated with PSIF at a mean 45-year follow-up and LIV L4 or distal had a higher rate of undergoing an additional surgical procedure than those with LIV L3 or proximal. Patients undergoing an additional surgical procedure had lower health-related quality of life than those who did not. Despite this, there was no difference in health-related quality of life for patients with LIV L4 or distal compared with patients with LIV L3 or proximal. This cohort of patients with AIS treated with PSIF demonstrates normal self-reported health-related quality of life compared with the age-matched general population. These long-term outcomes of PSIF for AIS are encouraging. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Venous Thromboembolism Prophylaxis and Hormonal Contraceptive Management Practice Patterns in the Perioperative Period for Anterior Cruciate Ligament Reconstruction.

Purpose: To evaluate the venous thromboembolism (VTE) prophylaxis practices of surgeons performing anterior cruciate ligament reconstruction (ACLR) in female patients using hormonal contraceptives. Methods: Our research team designed an investigational survey using branching logic that was made available to the AANA membership. The survey was designed to identify clinical decision making regarding VTE prophylaxis after ACLR in patients without risk factors for VTE, the counseling of patients about VTE risk associated with hormonal contraceptives, and the use of VTE prophylaxis after ACLR in patients taking hormonal contraceptives. Results: Ninety-four respondents completed the survey. Eighty-nine respondents identified their gender (63% male and 37% female respondents). Respondents reported performing the following number of ACLRs annually: more than 50 (40%), 30 to 50 (29%), 15 to 30 (29%), and fewer than 15 (2%). Of the respondents, 62 (67%) reported that VTE developed after ACLR in their patients (male patients only, 32%; female patients only, 24%; and both male and female patients, 34%). Sixty-seven percent used chemoprophylaxis after ACLR. Surgeons who asked about hormonal contraceptive use were more likely to be women (P = .01; odds ratio [OR], 4.2). Surgeons who changed their VTE prophylaxis plan as a result of asking about hormonal contraceptive use were more likely to be women (P = .02; OR, 2.8). Surgeons who asked about hormonal contraceptive use were more likely to have female patients with VTE after ACLR (P = .03; OR, 2.9). Surgeons who changed their VTE prophylaxis plan as a result of asking about hormonal contraceptive use were more likely to have female patients with VTE after ACLR (P = .001; OR, 4.6). Conclusions: There is no standard of care for VTE prophylaxis after ACLR. A surgeon's own gender and prior clinical experience with VTE after ACLR may influence his or her likelihood to consider a patient's hormonal contraceptive use regarding VTE risk after ACLR. Clinical Relevance: The use of hormonal contraception is a risk factor for VTE in female patients undergoing ACLR. It is important to identify current practice patterns and the need for a standard of care.

Outcomes of Patients with and without Nighttime Awakening Symptoms After Carpal Tunnel Release.

Background: A common symptom associated with carpal tunnel syndrome (CTS) is nighttime awakening (NTA), which typically resolves quickly following carpal tunnel release (CTR). The early improvement in those who do not wake-up at night is less clear. This study investigates outcomes following CTR in patients with preoperative NTA symptoms compared to those without at 6 weeks and 3 months. Methods: Patients diagnosed with CTS who proceeded with CTR and agreed to participate in a prospective study completed the Boston Carpal Tunnel Questionnaire (BCTQ) and Michigan Hand Outcome Questionnaire (MHQ) at their preoperative appointment and 6-week and 3-month follow-ups. We compared outcomes between time points for improvement. Results: Of 45 patients, 37 patients with NTA had BCTQ scores of 3.09, 1.86, and 1.50 at preoperative, 6-week, and 3-month follow-up, respectively, and MHQ scores of 56.68, 74.91, and 81.01. NTA patients had improvement of both BCTQ and MHQ at 6 weeks and 3 months. Nonawakening patients had BCTQ scores of 2.58, 2.15, and 1.86 and MHQ scores of 57.94, 62.71, and 72.16, respectively. This cohort did not have significant improvement of MHQ at 6 weeks, but did at 3 months. The BCTQ severity scores in the nonawakening patients had significant improvement at both 6 weeks and 3 months, but did not at either time point for the BCTQ functionality scores. At 6 weeks, 2/37 patients continued to have NTA and no patients had NTA at 3 months. Conclusion: Patients with CTS and NTA symptoms had significant improvements in BCTQ and MHQ at 6 weeks and 3 months. Patients who did not awaken at night did not have significant improvements when evaluating BCTQ functional results, although they did improve when analyzing for BCTQ for symptom severity and MHQ, but not to the same level as those that do awaken and improvement was slower based on MHQ scores.

Mismatch Between Pelvic Incidence and Lumbar Lordosis is the Key Sagittal Plane Determinant of Patient Outcome at Minimum 40 Years After Instrumented Fusion for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective review. OBJECTIVE: Assess measures of spinal-pelvic balance in predicting functional outcome in patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis (AIS) at minimum 40-year follow-up. SUMMARY OF BACKGROUND DATA: Back pain and long-term function are considered when choosing levels for surgery in AIS patients. Three hundred and fourteen patients underwent fusion for AIS between 1961 and 1977. One hundred and thirty-four patients were located for potential long-term follow-up. METHODS: With Institutional Review Board approval, medical records and public resources were used to locate patients. Patients completed health-related quality of life (HRQoL) instruments, and returned for assessment including full radiographs. Radiographs were analyzed for scoliosis measures, and recognized spinal-pelvic measures including the lumbar lordosis, sagittal vertical axis (SVA), pelvic incidence, and pelvic tilt (PT). Bivariate and multivariable analyses were performed to assess the association between spinal-pelvic measures and patient-reported outcomes. RESULTS: Thirty-five of 134 patients agreed to return for complete HRQoL and radiographic follow-up. There were no differences at baseline between those agreeing and declining participation. The cohort was 94% female, had an average age of 60.5 years, and average follow-up of 46 years. In bivariate analysis, pelvic incidence and lumbar lordosis difference (PI-LL) was the only spinal-pelvic parameter which statistically discriminated between patients doing well and not, as assessed by the Oswestry Disability Index and the Patient-reported Outcomes Measurement Information System (PROMIS) Pain Interference and Fatigue instruments. In multivariable analysis, (PI-LL > 9°) was associated with worse scores in PROMIS-Pain Interference, Physical Function, Depression, Fatigue, Social Function and the total Oswestry score. An SVA > 50 mm was associated with worse scores in the Scoliosis Research Society-7. CONCLUSION: In a cohort of 35 patients with average follow-up of 46 years after posterior spinal instrumentation with Harrington rods (PSIF) for AIS, spinal-pelvic mismatch as identified by (PI-LL > 9°) was associated with inferior HRQoL outcomes. Other spinal-pelvic measures (SVA and PT) were not reliably associated with inferior HRQoL.Level of Evidence: 4.

Mortality Rates of Humerus Fractures in the Elderly: Does Surgical Treatment Matter?

INTRODUCTION: Multiple studies have shown the impact of hip fractures on geriatric mortality. Few evaluate mortality after proximal humerus (PH) or distal humerus (DH) fractures, and fewer determine differences in mortality based on management. We aim to evaluate a statewide cohort of elderly patients with PH or DH fractures to evaluate mortality, length of stay, discharge data, readmission, and differences based on management. METHODS: The New York Statewide Planning and Research Cooperative System database was used to identify patients 60 years and older admitted with a PH or DH fracture. Patient demographics, including age, gender, sex, race, weight, and insurance status, along with comorbid conditions using the Charlson Comorbidity Index, were determined. Seven-day, 30-day, and 1-year mortality was determined for operative and nonoperative cohorts. Logistic regression determined the competing risk of mortality when controlling for patient demographics, comorbid conditions, and treatment. RESULTS: Forty-two thousand five hundred eleven PH and 7654 DH fractures were evaluated. PH fractures had higher mortality than DH. Nonoperative treatment occurred in 76.2% of PH fractures and 53% of DH fractures. There were more comorbid conditions, longer length of stay, and higher mortality at 7 days, 30 days, and 1 year in patients treated nonoperatively. After controlling for patient demographics and comorbid conditions, there was no difference in mortality between PH and DH fractures, but operative treatment for either PH or DH was associated with lower mortality at all time points. DISCUSSION: Fewer PH than DH fractures were treated operatively. Operative treatment was associated with improved survival in patients hospitalized with PH or DH fracture even after controlling for patient demographic and comorbid factors. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Dynamic Functional Assessment of Hand Motion Using an Animation Glove: The Effect of Stenosing Tenosynovitis.

BACKGROUND: The aim of the present study is to determine whether an animation glove can be utilized to provide a reliable and reproducible assessment of dynamic hand function and whether this assessment is altered in the setting of hand pathology. METHODS: Ten subjects without known hand pathology and 11 subjects with known stenosing tenosynovitis were assessed on tasks involving hand function at varied speeds, including forceful and gradual making of a fist and the quick and slow grip of a baseball using an animation glove to record range of motion and measures of velocity (CyberGlove II). RESULTS: In normal subjects, peak extension and flexion velocity of the index and middle finger was highest in the metacarpophalangeal and lowest in the distal interphalangeal; however, the converse was true in the ring finger. In those subjects with stenosing tenosynovitis, the animation glove was able to detect a triggering event during assessment. Furthermore, there was a significant decrease in the maximum velocity of the proximal interphalangeal joint observed with the slow fist task in both flexion and extension (55%, P < .01) in the affected hand when compared with the unaffected hand. CONCLUSIONS: The CyberGlove II can be utilized in the dynamic functional analysis of the hand and is able to detect a triggering event in subjects with known stenosing tenosynovitis. Those subjects demonstrate a significant decrease in maximum velocity in slow fist tasks, highlighting the need for comprehensive assessment to ascertain the full extent of functional limitations that can occur in the setting of hand pathology.

Social Media in Pediatric Orthopaedics.

BACKGROUND: Internet searches and social media utilization in health care has exploded over the past 5 years, and patients utilize it to gain information on their health conditions and physicians. Social media has the potential to serve as a means for education, communication, and marketing in all health care specialties. Physicians are sometimes reluctant to engage because of concerns of privacy, litigation, and lack of experience with this modality. Many surgical subspecialties have capitalized on social media but no study to date has examined the specific footprint of pediatric orthopaedic surgeons in this realm. We aim to quantify the utilization of individual social media platforms by pediatric orthopaedic surgeons, and identify any differences between private and hospital-based physicians, but also regional differences. METHODS: Using the Pediatric Orthopaedic Society of North America Member Directory, each active member's social media presence was reviewed through an Internet search. Members were stratified on the basis of practice model and geographic location. Individual Internet searches, social media sites, and number of publications were reviewed for social media presence. RESULTS: Of 987 Pediatric Orthopaedic Society of North America members, 95% had a professional webpage, 14.8% a professional Facebook page, 2.2% a professional Twitter page, 36.8% a LinkedIn profile, 25.8% a ResearchGate profile, 33% at least 1 YouTube. Hospital-based physicians had a lower mean level of utilization of social media compared with their private practice peers, and a higher incidence of Pubmed publications. Private practice physicians had double the social media utilization. Regional differences reveal that practicing Pediatric Orthopaedists in the Northeast had increased utilization of ResearchGate and LinkedIn and the West had the lowest mean social media utilization levels. CONCLUSIONS: The rapid expansion of social media usage by patients and their family members is an undeniable force affecting the health care industry. The Internet and social media platforms provide all physicians with a means to educate patients, collaborate with colleagues, and promote their practice and areas of interest. Our survey indicates that pediatric orthopaedic surgeons may be underutilizing their potential social media presence. LEVELS OF EVIDENCE: Level IV.

The MD Blues: Under-Recognized Depression and Anxiety in Medical Trainees.

BACKGROUND: Mental health disease is under recognized in medical professionals. OBJECTIVE: To screen medical students (MS), residents and fellows for major depressive disorder (MDD) and generalized anxiety disorder (GAD) under the new era of work hour reform with age-matched controls from a large representative cross-sectional survey. METHODS: We conducted an anonymous online survey at a medical university in 2013-2014. We incorporated the Patient Health Questionnaire 2 (PHQ-2) to screen for MDD and the generalized anxiety disorder scale (GAD-7) to screen for GAD, along with additional questions on life stressors and academic performance. We compared these results to age-matched controls from the National Health and Nutrition Examination Survey (NHANES) database. RESULTS: 126 residents/fellows and 336 medical students participated voluntarily. 15.1% and 15.9% of postgraduates as well as 16.4% and 20.3% of MS screened positive for MDD and GAD, respectively. When compared to national estimates, the prevalence of a positive screen for MDD was over five-fold higher in medical trainees compared to age-matched controls (16% vs. 2.8%, p<0.0001). Similarly, the prevalence of a positive screen for GAD was over eight-fold higher in medical trainees (19% vs. 2.3%, p<0.0001).The prevalence was consistently higher within age strata. 33.3% of postgraduates and 32% of MS believe there is a significant impact of depression or anxiety on their academic performance. For stress relief, one fifth of residents/fellows as well as MS reported alcohol use. CONCLUSIONS: The stresses of medical education and practice may predispose trainees to psychopathological consequences that can affect their academic performance and patient care. The current study showed a significantly higher rate of MDD and GAD positive screens in medical trainees than the prevalence in an age-matched U.S. population, despite significant work hour reform for medical trainees. Increased awareness and support services are required at all levels of medical training. We propose that the ACGME and the Institute of Medicine may consider these findings when implementing future changes to work hour regulations.

A Peculiar Primary Paraganglioma of the Distal Thumb.

A paraganglioma is a highly vascularized neuroendocrine tumor most commonly found within the adrenal gland as a pheochromocytoma. Extra-adrenal paragangliomas are frequently located in the head, neck, thorax, and abdomen. We report the first documented case of a primary paraganglioma found within the appendicular skeleton. Only 2 additional cases of paragangliomas in the extremities have been documented, one in the soft tissue of the forearm and other within the median nerve. Our patient underwent amputation of the distal phalanx, with no sign of recurrence at greater than 1 year of follow-up. Because of the geographic and clinical similarity to a benign enchondroma, radiographic imaging alone may not be sufficient to rule out malignancies inside bones. Thus paraganglioma should remain in the differential and immunohistochemistry is both vital and necessary to confirm the diagnosis. Vigilant and appropriate follow-up is necessary to detect metastases early in these patients.