Relationship of vitamin D levels with clinical presentation and recurrence of BPPV in a Southeastern United States institution.

OBJECTIVE: To examine the relationship of 25hydroxyvitamin D serum levels with BPPV incidence and recurrence rates. METHODS: A retrospective cross-sectional, case-controlled study with follow-up phone survey was performed on patients diagnosed with BPPV between 05/2017-05/2020, who had available 25hydroxyvitamin D serology. Patients were seen at a multidisciplinary, vestibular-focused, neurotology clinic at a tertiary referral center. Controls consisted of subjects from the National Health and Nutrition Examination Survey (NHANES), and a locoregional age, sex, and race-matched group of patients from our institution. RESULTS: Our BPPV cohort consisted of 173 patients (mean age 66.2 ± 11.8 years), who were predominately female (75.7%) and Caucasian (76.3%). Almost all age subgroups (BPPV, NHANES, and locoregional groups) ≤60 years old had insufficient levels of vitamin D. However, the overall BPPV cohort had a significantly higher vitamin D level than the NHANES control (31.4 ± 16.5 v. 26.0 ± 11.2 ng/mL, d=0.474 [0.323, 0.626]). There was no significant difference when compared to the overall locoregional control (31.4 ± 20.5 ng/mL). Migraines were significantly correlated to increased BPPV recurrence rates on univariate (beta=0.927, p=0.037, 95% CI: [0.057, 1.798]) and multiple regression analyses (beta=0.231, 95% CI: [0.024, 2.029], p=0.045). Furthermore, patients with BPPV recurrences had significantly lower levels of vitamin D at initial presentation when compared to patients with no recurrences (29.0 ± 12.0 v. 37.6 ± 18.3 ng/mL, d=0.571[0.139,1.001]). CONCLUSION: Many BPPV patients in our cohort had insufficient vitamin D levels, and patients with BPPV recurrences had insufficient and significantly lower vitamin D levels than those without. As a readily available and affordable supplement, vitamin D may be used as an adjunct treatment but prospective studies should be done to confirm if it can prevent or reduce recurrence.

Innovations in osteomyelitis research: A review of animal models.

Infection of bone tissue, or osteomyelitis, has become a growing concern in modern healthcare due in no small part to a rise in antibiotic resistance among bacteria, notably Staphylococcus aureus. The current standard of care involves aggressive, prolonged antibiotic therapy combined with surgical debridement of infected tissues. While this treatment may be sufficient for resolving a portion of cases, recurrences of the infection and associated risks including toxicity with long-term antibiotic usage have been reported. Therefore, there exists a need to produce safer, more efficacious options of treatment for osteomyelitis. In order to test treatment regimens, animal models that closely mimic the clinical condition and allow for accurate evaluation of therapeutics are necessary. Establishing a model that replicates features of osteomyelitis in humans continues to be a challenge to scientists, as there are many variables involved, including choosing an appropriate species and method to establish infection. This review addresses the refinement of animal models of osteomyelitis to reflect the clinical disease and test prospective therapeutics. The aim of this review is to explore studies regarding the use of animals for osteomyelitis therapeutics research and encourage further development of such animal models for the translation of results from the animal experiment to human medicine.

Autoclaving of Poloxamer 407 hydrogel and its use as a drug delivery vehicle.

With antibiotic-resistant bacteria becoming increasingly prevalent, biomaterials capable of targeted, in situ drug delivery are urgently needed. The synthetic polymer Poloxamer 407 (P407) is of particular interest due to its thermoreversible gelation. Clinical use of P407 typically involves sterilization via autoclaving, but the effects of these extreme environmental conditions on hydrogel water content, rheological properties and efficacy as a drug delivery vehicle remain unknown. The aim of this study was to investigate the effects of autoclaving on the properties of P407 hydrogel. Autoclaving reduced hydrogel water content due to evaporation, thus increasing the polymer weight fraction of the hydrogels. In contrast, except for a reduction in gelation temperature following autoclaving, autoclaved hydrogels had similar rheological properties as nonautoclaved hydrogels. In vitro, autoclaving did not hinder the hydrogel's efficacy as a carrier for vancomycin antibiotic, and P407 (with and without vancomycin) had a bactericidal effect on planktonic Staphylococcus aureus. An in vivo pilot study using P407 to deliver bacteriophage highlighted the need for additional understanding of the functionality of the hydrogel for surgical applications. In conclusion, P407 hydrogel water content and gelation temperature were reduced by autoclave sterilization, while other rheological properties and the efficacy of the biomaterial as a delivery vehicle for vancomycin in vitro were unaffected.

Improved Clinical and Functional Outcomes in Crouch Gait Following Minimally Invasive Hamstring Lengthening and Serial Casting in Children With Cerebral Palsy.

BACKGROUND: Serial extension casting represents a novel solution for addressing residual knee flexion contractures following hamstring lengthening in children with cerebral palsy. The purpose of this study was to investigate postoperative changes in patients following hamstring lengthening with a serial casting protocol. METHODS: Measures from preoperative and postoperative gait analyses were reviewed retrospectively for 19 patients with cerebral palsy who underwent hamstring lengthening followed by serial extension casting. Postoperative changes in clinical, functional, and kinematic parameters were assessed using paired parametric methods. RESULTS: Improvements were measured in popliteal angle, knee contracture, peak stance phase knee extension, sagittal plane range of motion of the knee during walking, Gait Deviation Index, and pediatric outcomes data collection instrument Global score. Nearly 80% of the cohort (15/19 patients) demonstrated a significant or moderate response to the intervention, whereas 20% demonstrated no improvement. Of note, significantly increased anterior pelvic tilt was also observed. CONCLUSIONS: Hamstring lengthening combined with a serial casting protocol was associated with significant postoperative improvements in a range of clinical (eg, knee contracture), functional (eg, pediatric outcomes data collection instrument Global), and kinematic (eg, knee extension in stance) parameters. Improvements following this minimally invasive surgery were comparable to outcomes from procedures with higher complication rates. LEVEL OF EVIDENCE: This is a Level III Therapeutic Study (retrospective study investigating the results of a treatment).

Therapeutics and delivery vehicles for local treatment of osteomyelitis.

Osteomyelitis, or the infection of the bone, presents a major complication in orthopedics and may lead to prolonged hospital visits, implant failure, and in more extreme cases, amputation of affected limbs. Typical treatment for this disease involves surgical debridement followed by long-term, systemic antibiotic administration, which contributes to the development of antibiotic-resistant bacteria and has limited ability to eradicate challenging biofilm-forming pathogens including Staphylococcus aureus-the most common cause of osteomyelitis. Local delivery of high doses of antibiotics via traditional bone cement can reduce systemic side effects of an antibiotic. Nonetheless, growing concerns over burst release (then subtherapeutic dose) of antibiotics, along with microbial colonization of the nondegradable cement biomaterial, further exacerbate antibiotic resistance and highlight the need to engineer alternative antimicrobial therapeutics and local delivery vehicles with increased efficacy against, in particular, biofilm-forming, antibiotic-resistant bacteria. Furthermore, limited guidance exists regarding both standardized formulation protocols and validated assays to predict efficacy of a therapeutic against multiple strains of bacteria. Ideally, antimicrobial strategies would be highly specific while exhibiting a broad spectrum of bactericidal activity. With a focus on S. aureus infection, this review addresses the efficacy of novel therapeutics and local delivery vehicles, as alternatives to the traditional antibiotic regimens. The aim of this review is to discuss these components with regards to long bone osteomyelitis and to encourage positive directions for future research efforts.

Fracture obliquity is a predictor for loss of reduction in supracondylar humeral fractures in older children.

Supracondylar humeral fractures in older children have different biomechanical characteristics and surgical outcomes when compared to the same fractures in younger children. We aimed to analyze the fracture's architecture in a large group of older children and investigate the correlation between patients' variables, fracture patterns, fixation techniques and the rate of loss of reduction (LOR). A retrospective review study was conducted. We collected the records of 240 consecutive patients aged 8-14 years that sustained Gartland type 2/3 supracondylar humeral fractures between 2004 and 2014 and were operated at our hospital. We excluded patients with intra-articular or pathological fractures. Following the radiographical analysis and chart review, we conducted a multivariable regression analysis. Fracture obliquity on the sagittal plane ( > 20°) occurred in 33% of the cases and was found to be the only factor related to LOR (P = 0.01). Gartland type 3 fractures and more than two lateral pin configuration did not correlate to fixation failure (P = 0.69 and 0.14, respectively). The incidence of flexion-type fractures (5.8%) was found to be higher than in the total pediatric population. The sagittal oblique supracondylar humeral fracture is common and is related to fixation instability and LOR. This pattern needs to be considered when investigating different pin configurations, complication rates, and biomechanical properties. Subclassifying Gartland type 2/3 supracondylar humeral fractures as 'oblique' or 'transverse' might offer more comprehensive information about the anticipated operative results, lead to applying more stable pin constructs to these fractures and allow improved outcomes following surgical fixation.

CRISPR-Cas9 modified bacteriophage for treatment of Staphylococcus aureus induced osteomyelitis and soft tissue infection.

Osteomyelitis, or bone infection, is often induced by antibiotic resistant Staphylococcus aureus strains of bacteria. Although debridement and long-term administration of antibiotics are the gold standard for osteomyelitis treatment, the increase in prevalence of antibiotic resistant bacterial strains limits the ability of clinicians to effectively treat infection. Bacteriophages (phages), viruses that in a lytic state can effectively kill bacteria, have gained recent attention for their high specificity, abundance in nature, and minimal risk of host toxicity. Previously, we have shown that CRISPR-Cas9 genomic editing techniques could be utilized to expand temperate bacteriophage host range and enhance bactericidal activity through modification of the tail fiber protein. In a dermal infection study, these CRISPR-Cas9 phages reduced bacterial load relative to unmodified phage. Thus we hypothesized this temperate bacteriophage, equipped with the CRISPR-Cas9 bactericidal machinery, would be effective at mitigating infection from a biofilm forming S. aureus strain in vitro and in vivo. In vitro, qualitative fluorescent imaging demonstrated superiority of phage to conventional vancomycin and fosfomycin antibiotics against S. aureus biofilm. Quantitative antibiofilm effects increased over time, at least partially, for all fosfomycin, phage, and fosfomycin-phage (dual) therapeutics delivered via alginate hydrogel. We developed an in vivo rat model of osteomyelitis and soft tissue infection that was reproducible and challenging and enabled longitudinal monitoring of infection progression. Using this model, phage (with and without fosfomycin) delivered via alginate hydrogel were successful in reducing soft tissue infection but not bone infection, based on bacteriological, histological, and scanning electron microscopy analyses. Notably, the efficacy of phage at mitigating soft tissue infection was equal to that of high dose fosfomycin. Future research may utilize this model as a platform for evaluation of therapeutic type and dose, and alternate delivery vehicles for osteomyelitis mitigation.