Magnetic Resonance Arthrogram Improves Visualization of Hip Capsular Defects in Patients Undergoing Previous Hip Arthroscopy.

Purpose: To compare magnetic resonance imaging (MRI) with magnetic resonance arthrogram (MRA) in the identification of hip capsular defects in patients who previously underwent hip arthroscopy. Methods: Patients who underwent revision hip arthroscopy for capsular insufficiency by a single surgeon between March 2014 and December 2019 were identified by Current Procedural Terminology code. Patients with arthroscopically confirmed capsular defects treated surgically who underwent both MRI and MRA between their primary and revision surgeries were identified. Imaging studies were blinded, randomized, and distributed to two fellowship-trained musculoskeletal radiologists. Radiologists evaluated 14 components of different anatomic structures, including the presence of capsular defect and defect grading, over 2 months, with a 2-week washout period between 4 sets of reads to obtain 2 complete reads from each radiologist. Data were analyzed in R version 4.0.2. Results: Two hundred thirty patients underwent revision hip arthroscopy between March 2014 and December 2019. Twelve patients had both an MRI and an MRA of the operated hip performed between their primary and revision surgeries. Time between primary and revision hip arthroscopy was 2.0 ± 1.5 years (R: .3-6.3). Time between MRI and MRA was .6 ± .6 years (R: .0-1.6). Sensitivity for detecting hip capsular defects was significantly higher for MRA than for MRI (87.5%, 95% CI: [68,96] vs 50%, 95% CI: [31,69], respectively; P = .008). Conclusions: This retrospective review demonstrates that MRA has higher sensitivity than MRI in detecting surgically confirmed capsular defects. MRA may be more helpful in identifying capsular defects in patients presenting with hip instability symptoms who have had a previous hip arthroscopy. Level of Evidence: Level IV, diagnostic case series.

PLASMA CONCENTRATION AND PHARMACODYNAMICS OF INTRAMUSCULAR ADMINISTRATION OF ALFAXALONE IN INDIAN PEAFOWL (PAVO CRISTATUS).

Alfaxalone, a neuroactive steroid with anesthetic properties, is considered safe when used alone or in combination with other drugs for anesthesia at recommended species doses, and its use has been studied in numerous species. The objective of this study was to assess the pharmacokinetics and pharmacodynamics of IM alfaxalone in Indian peafowl (Pavo cristatus; hereafter peafowl). Eight female peafowl from one zoological institution were used. A control blood sample was obtained before administration of either 10 mg/kg (n = 4) or 20 mg/kg (n = 4) alfaxalone. Blood was collected at 5, 10, 15, 30, and 60 min after alfaxalone injection, with monitoring of sedation score, heart rate, and respiratory rate at each time point. Four peahens receiving a 10 mg/ kg dose had subjectively smoother inductions and recoveries, although sedation level was generally scored as low, with no adverse reactions noted. They were considered fully recovered by the 60-min postinjection time point, although measurable alfaxalone plasma concentrations remained present. Four peahens receiving 20 mg/kg IM experienced adverse effects including seizure-like episodes and hypersensitivity to stimuli throughout the study. This dosing group experienced prolonged recoveries consistent with high plasma concentrations (>3,000 ng/ml). Based on these results, use of 20 mg/kg IM alfaxalone as the sole anesthetic agent is not recommended in this species. Further studies should determine whether alfaxalone in conjunction with other anesthetic or analgesic agents could provide better sedation and smoother induction and recovery for peafowl and to assess the pharmacokinetics and pharmacodynamics of alfaxalone in other avian species.

Retrospective evaluation of cardiopulmonary arrest and resuscitation in hospitalized birds: 41 cases (2006-2019).

OBJECTIVE: To describe circumstances and outcomes following cardiopulmonary arrest (CPA) in hospitalized birds. DESIGN: Retrospective case study. SETTING: Academic medical center. METHODS: The hospital medical records system was searched for avian cases that underwent CPR. Medical records were reviewed; data retrieved included association of CPA with anesthesia or handling, use of external compressions and intubation, drug administration, rates of return of spontaneous circulation (ROSC), and outcome. Cases with incomplete medical records were excluded. RESULTS: Forty-one cases of avian CPR were identified. Anesthesia-related arrest was reported in 26 of 41 cases. The remainder of CPA events occurred during an examination (6/41) or were observed during hospitalization for treatment of disease or injury (11/41). Compressions were performed in 14 birds and manual ventilation performed in 21 of 41 cases via intubation (19/21), tight-fitting face mask (1/21), or air sac cannulation (1/21). Vascular access was achieved in 24 of 41 cases. Emergency drug administration was documented in 22 of 41 cases and included epinephrine (20/22), atropine (19/22), glycopyrrolate (3/22), doxapram (2/22), dextrose (3/22), mannitol (1/22), and furosemide (1/22). Fluid therapy was administered in 24 of 41 cases. There were 3 documented cases of ROSC (7%), all in patients under general anesthesia, and 1 (2%) CPA survivor. CONCLUSIONS: There was no standardized approach to avian CPR in this study, and ROSC was rare. When ROSC was achieved, birds were under general anesthesia with direct monitoring by a clinician, were ventilated, and were administered anesthetic reversals and anticholinergic or catecholamine emergency medications. These poor outcomes suggest that further research and an updated standardized approach to avian CPR, with special consideration of the physiological differences from mammals, are needed.

Development and Validation of a Universal Science Writing Rubric That is Applicable to Diverse Genres of Science Writing.

It is critical for science, technology, engineering, and mathematics (STEM) students to develop competencies in science communication, including science writing. However, it can be difficult for instructors and departments to assess the quality of their students' science writing. Many published science writing rubrics are specific to certain genres like lab reports. We thus developed a Universal Science Writing Rubric (USWR) that is usable regardless of the genre or audience of science writing. This tool enables students, instructors, and departments to assess science writing written to lay or scientific audiences, focusing on important rhetorical concerns like science content and interpretation rather than simply surface features like grammar. We demonstrate the use of our USWR on various life science lab reports, scientific review articles, grant proposals, and news articles, showing that the USWR is sensitive enough to highlight statistically significant differences between groups of student writing samples and valid enough to produce results that echo published and anecdotal observations of STEM student science writing skills. Thus, the USWR is a useful tool for assessment of STEM student science writing that is widely applicable in the classroom and laboratory.

Concepts in Musculoskeletal Bone and Soft Tissue Biopsy.

Imaging-guided needle biopsy of musculoskeletal lesions is a high-yield and low-risk procedure that can be used for definitive characterization of indeterminate bone and soft tissue lesions. Familiarity with the preprocedural, technical, and postprocedural steps is vital for the appropriate management of these cases. Biopsy request triage requires an awareness of definitively benign conditions and other tumor mimics. A complete clinical, laboratory, and imaging work-up is essential for procedural planning and determining pathologic concordance. Consultation with an orthopaedic oncologist is a requisite step to ensure maximizing biopsy yield and to avoid interference with any future limb-sparing surgical intervention. Knowledge of the equipment, pertinent medications, and appropriate biopsy technique can minimize the risk of periprocedural complications. Finally, the radiologist may be required to discuss the concordance of histopathology with preprocedure imaging, perform repeat image-guided biopsy, and carefully interpret sarcoma surveillance imaging examinations.

Smartphone display size can cause distortions in perceptual estimates of size.

Everyday we consume massive amounts of visual information on mobile devices like smartphones. However, are there consequences for viewing information on these devices? In 2 experiments, participants viewed several target objects on two differently sized virtual smartphone displays, and then made a judgment of the size of each target item. Results from both experiments confirm that smartphone display size does impact user perceptions of size, such that larger displays cause users to significantly underestimate the size of objects. This effect held when target items were presented alone, or concurrently with a non-target referent. This is the first study to confirm such an effect and suggests that the size of a smartphone display can negatively influence the accuracy of users' visual perception. Thus, beyond aesthetics or cost, it must be realized that the choice of device might have additional perceptual consequences for consumers.

MRI of the Wrist Ligaments.

Technological advances in magnetic resonance imaging (MRI) have improved radiologists' ability to evaluate wrist ligaments. MRI interpretation often guides clinical management. This article aims to review the normal and pathologic appearance of intrinsic and extrinsic wrist ligaments with a focus on MRI. Variant anatomy, imaging pearls, and clinical significance are also discussed. Special attention is paid to key wrist ligaments that play a role in carpal stability.

Septic Arthritis: An Evidence-Based Review of Diagnosis and Image-Guided Aspiration.

OBJECTIVE. The purpose of this evidence-based review is to equip radiologists to discuss and interpret findings obtained with various imaging modalities, guide patient selection for percutaneous aspiration, and safely perform arthrocentesis to assess for infection in both native and prosthetic joints. CONCLUSION. Septic arthritis is an emergency that can lead to rapidly progressive, irreversible joint damage. Despite the urgency associated with this diagnosis, there remains a lack of consensus regarding many aspects of the management of native and periprosthetic joint infections.

Using a simplified version of a common surgical grading scale for acetabular labral tears improves the utility of preoperative hip MRI for femoroacetabular impingement.

OBJECTIVE: To evaluate whether a commonly used surgical grading scale, when applied to acetabular labral findings on MRI, could improve preoperative planning and counseling for patients undergoing hip arthroscopy. MATERIALS AND METHODS: We evaluated 76 clinical MRIs performed on patients with femoroacetabular impingement. Three musculoskeletal radiologists and one musculoskeletal fellow reviewed each scan in a blinded fashion, classifying the acetabular labrum from 12:00 to 4:00 using the Beck scale, a common surgical grading scale. Clinical correlation was provided via surgical examination and classification. Reliability was determined between readers and between reader and surgical data using Cohen's kappa and Krippendorff's alpha at each clock position and for the worst grading for each scan. In addition, a simplified version of the scale comprised of only two grades, potentially reparable and not potentially reparable, was evaluated. RESULTS: When the scale was simplified into categories of potentially reparable and not potentially reparable, the sensitivity was excellent, ranging from 85.5 to 96%. Observer agreement when using individual Beck grades was found to range from poor to fair; Kappa ranged from 0.03 to 0.19, and Alpha ranged from - 0.27 to 0.22. CONCLUSION: The simplified version of the Beck labral scale when applied to MRI is a highly sensitive predictor of potentially reparable labral pathology while excluding normal and grossly degenerative tissue. Use of this scale provides clinically relevant information that can drive preoperative planning and improve patient counseling. It does so in a standardized fashion that can be applied across practice sites and without additional cost.

Clinical decision support in a hospital electronic prescribing system informed by local data: experience at a tertiary New Zealand centre.

BACKGROUND: An electronic prescribing and administration (ePA) system has been progressively rolled out to Canterbury District Health Board (CDHB, Christchurch, New Zealand) public hospitals since 2014, and is currently used for around 1300 tertiary beds. ePA data can be used to monitor user behaviour, and to evaluate and inform the local customisation of clinical decision support (CDS) tools within the ePA system. AIMS: To describe retrospectively illustrative vignettes of CDHB ePA analyses that have been used for CDS. METHODS: Alerts were developed according to a set of common principles agreed upon by the CDHB CDS Working Group. Alerts were informed and evaluated by extracting and parsing data for various time periods during 2016 to 2018 from the CDHB ePA database. RESULTS: There was a median of 74 000 prescriptions a month. After examining 525 spironolactone prescriptions, the high dose alert threshold was set at 100 mg with an expected alert burden of 3%. The presence of a ceftriaxone shortage prescribing alert for 1 week was associated with a prescribing rate that was lower than 95% of the preceding 52 weeks. Following review of 367 fentanyl patch alerts, revision of the alert led to false positives falling from 43% to 3% (P < 0.0001). At the point of firing, 6% of antithrombotic drug interactions alerts led to immediate changes in prescriptions (94% overridden), and a further 22% were changed within 30 min after the alert. CONCLUSIONS: Local data extracts from ePA systems can inform iterative configuration of the software and monitor user behaviour.

Methylsulfonylmethane for treatment of low back pain: A safety analysis of a randomized, controlled trial.

OBJECTIVE: To ensure that 16 weeks of methylsulfonylmethane (MSM) does not cause adverse effects in patients with the musculoskeletal disorders of osteoarthritis and back pain. DESIGN: We carried out a subgroup analysis on data from a randomized, double-blind, placebo-controlled trial, "The use of Methylsulfonylmethane (MSM) in the treatment of low back pain," to determine the safety of taking 6 g daily of MSM (OptiMSM®, Bergstrom Nutrition). We monitored metabolic parameters to determine whether MSM altered hematologic, liver or kidney function. We also monitored physiologic parameters of blood pressure and weight. SETTING: Family Medicine Residency, Mike O'Callaghan Military Medical Center. MAIN OUTCOME MEASURES: Metabolic parameters as measured by hematologic function - white blood cells (WBC), platelets, hemoglobin (Hb), glucose; liver function as measured by - total bilirubin, alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Physiologic parameters as measured by weight, diastolic (DBP) and systolic blood pressure (SBP); kidney function as measured by creatinine. RESULTS: Analysis of outcome measures showed no significant difference between MSM and placebo (p < 0.05) safety values. CONCLUSION: MSM has no effects on WBC, platelets, Hb, total bilirubin, AST, ALT, creatinine weight, DBP, or SBP in this study.

Iridocorneal angle assessment of companion rabbits using gonioscopy, spectral-domain optical coherence tomography (Optovue iVue® ), high-resolution ultrasound, and Pentacam® HR imaging.

OBJECTIVE: Iridocorneal angle (ICA) narrowing is a known risk factor for primary glaucoma in multiple species, but has not been described in companion rabbits. This study aimed to develop an ICA grading scheme for companion rabbits to enable early glaucoma predisposition diagnosis. ANIMALS STUDIED: Twenty healthy rabbits of varying breeds and ages. PROCEDURES: Rabbits received complete ophthalmic examinations, including gonioscopy, and imaging of the ICA using spectral-domain optical coherence tomography (SD-OCT), Scheimpflug imaging (Pentacam® HR), and high-resolution ultrasound (HRUS). Angle opening distance (AOD) and angle recess area (ARA) of the ICA were measured and assessed for agreement using a Bland-Altman analysis. A five-stage gonioscopy grading scheme was created, and Spearman-rank test assessed for correlation between gonioscopy grades and ICA measurements. Differences among age and sex were analyzed with a nonparametric ANOVA and Wilcoxon rank-sum test, respectively. RESULTS: Analysis revealed AOD medians of 0.28mm for SD-OCT [95% CI: 0.24-0.31], 0.20mm for Pentacam® HR [95% CI: 0.18-0.21], and 0.25mm for HRUS [95% CI: 0.22-0.28]. The median ARA was 0.14mm2 for SD-OCT [95% CI: 0.117-0.163], 0.09mm2 for Pentacam® HR [95% CI: 0.082-0.100], and 0.06mm2 for HRUS [95% CI: 0.046-0.054]. The association between gonioscopy grade and SD-OCT ARA was significant (P < 0.05), and there was a significant difference (P < 0.001) between imaging modalities for both ARA and AOD. CONCLUSIONS: Gonioscopy grade correlated well with SD-OCT ARA. Therefore, SD-OCT is recommended as a noncontact method for evaluating companion rabbit ICA. Each imaging device should not be used interchangeably for ICA evaluation.

Early Postoperative Actigraphy Poorly Predicts Hypoactive Delirium.

STUDY OBJECTIVES: Delirium is a postoperative complication accompanied by disturbances in attention, cognition, arousal, and psychomotor activity. Wrist actigraphy has been advocated to study inactivity and inferred sleep patterns during delirium. We hypothesized that altered patterns of motor activity or immobility, reflective of disordered sleep and wakefulness patterns, would serve as predictive markers of hypoactive postoperative delirium. METHODS: Eighty-four elderly surgical patients were classified into three groups based on the timing of hypoactive delirium following surgery: intact with no delirium throughout postoperative days (POD) 0-5 (n = 51), delirium during POD 0-1 (n = 24), and delirium during POD 2-5 (n = 13). Delirium was detected on daily Confusion Assessment Method evaluations and chart review. Actigraphy measures were calculated from accelerometry signals acquired on the first postoperative day (POD 0, 16:00-23:00) and night (POD 0, 23:00-POD 1, 06:00). RESULTS: Actigraphy metrics showed substantial interpatient variability. Among the three patient groups, only those without delirium showed greater movement during the day compared to night and also fewer minutes of night immobility (P = .03 and P = .02, Wilcoxon rank-sum tests). These patients were poorly discriminated from those with delirium during either POD 0-1 or POD 2-5, using differences in day and night activity (C-statistic, 95% confidence interval [CI]: 0.66 [0.53-0.79] and C-statistic, 95% CI: 0.71 [0.55-0.87], respectively). Inclusion of low-frequency signals improved performance of immobility measures without affecting those based on activity. Cognitively intact patients during POD 0-5 were distinguished from those with delirium during POD 0-1, based on differences in the number of day and night immobile minutes (C-statistic 0.65, 95% CI: [0.53-0.78]). Actigraphy metrics with the strongest association to delirium incidence were not reliably correlated with an increased risk during POD 0-5, when accounting for patient age, sex, intensive care unit admission, and Charlson Comorbidity Index (adjusted odds ratio of 1.7, 95% CI: [1.0-3.0], P = .09, likelihood ratio test). CONCLUSIONS: Early postoperative wrist actigraphy metrics that serve as markers of sleep and wakefulness offer limited capacity as sole predictors or markers of hypoactive delirium. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Title: Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) Study; Identifier: NCT02241655; URL: https://clinicaltrials.gov/ct2/show/NCT02241655.

Modified Battlefield Acupuncture Does Not Reduce Pain or Improve Quality of Life in Patients with Lower Extremity Surgery.

INTRODUCTION: This study seeks to determine if modified Battlefield Acupuncture is more effective at relieving acute extremity pain, reducing medication use, and improving quality of life than placebo acupuncture or standard care after lower extremity surgery. METHODS: We conducted a multi-site 3-arm randomized, double-blind controlled trial of standard care alone versus standard care + placebo auricular acupuncture with semi-permanent needles versus standard care + modified battlefield acupuncture with semi-permanent needles for lower extremity surgery at two Air Force hospitals. Subjects reported pain level immediately after acupuncture, 24, 48, 168, and 720 hours later to a blinded research associate. Additionally, subjects completed a PIQ-6 30 days post-operatively, and opioid use was tracked for 30 days post-operatively. RESULTS: Two hundred thiry-three subjects >18 years old (92 females and 141 males) with a mean age of 44.5 years were randomized with 81 randomized to modified BFA, 74 randomized to placebo acupuncture, and 78 randomized to standard care. Overall pain levels were unchanged at each time point between groups. Outcomes showed unchanged pain, opioid and quality of life between groups. CONCLUSION: The use of modified battlefield acupuncture protocol does not change pain opioid use or quality of life in those with lower extremity surgery.

Effect of water-soluble cinnamon extract on electrocardiographic parameters: An analysis of the CiNNaMON trial.

OBJECTIVE: To ensure that cinnamon extract does not cause electrocardiographic (ECG) effects in patients with prediabetes. DESIGN: A subgroup analysis was carried out on data from 103 prediabetic patients participating in the "Effect of Lifestyle Intervention Plus Water-Soluble Cinnamon Extract on Lowering Blood Glucose in Prediabetics" trial. The trial was a randomized, double-blind, placebo-controlled trial comparing cinnamon extract versus placebo in prediabetic adults who committed to participate in a standard-of-care, aggressive lifestyle therapy program. SETTING: Family Medicine Residency, Mike O'Callaghan Military Medical Center; Family Medicine Residency, David Grant Medical Center, Travis AFB; Wilford Hall Ambulatory Surgical Center, Family Medicine Residency; Eglin AFB, Family Medicine residency; Offutt AFB, Family Medicine Residency. MAIN OUTCOME MEASURES: QTc interval, QT interval, PR interval, QRS duration and heart rate from ECGs at baseline, 3 months, and 6 months. RESULTS: Analysis of the ECGs showed no time-matched intra-group differences in any of the ECG parameters (QTc interval, QT interval, PR interval, QRS duration and heart rate; all p-values >0.05). CONCLUSIONS: Use of cinnamon extract in prediabetic patients does not affect electrocardiographic measures.

Edema from Taking Cinnamon for Treatment of Diabetes: Similar Biochemistry and Pathophysiology to Thiazolidinedione Medications.

We present a report of cinnamon bark powder 1000 mg daily associated with edema that resolved after stopping the supplement in an adult male. Thiazolidinediones (TZDs) cause fluid retention in those with diabetes or prediabetes. Some medications in this class have been implicated in increased cardiac deaths from this side effect. While medications are effective for diabetes, many people have turned to natural remedies to treat their diabetes instead of conventional pharmaceuticals. Cinnamon is a common agent used, and it has received extensive lay press attention. Chemically, cinnamon bark powder activates peroxisome proliferated activated receptors similar to TZDs. It is reasonable to hypothesize that cinnamon bark powder can cause edema. This case demonstrates that cinnamon bark powder may have a similar side effect profile. Physicians should be aware that consumption of cinnamon bark powder could cause fluid retention and possibly worsen congestive heart failure.

Magnetic Resonance Imaging of Osteochondritis Dissecans: Validation Study for the ICRS Classification System.

RATIONALE AND OBJECTIVES: In this retrospective case series, we utilize arthroscopy as the gold standard to determine if magnetic resonance imaging (MRI) of the knee can predict osteochondritis dissecans (OCD) lesion stability, the most important information to guide patient treatment decisions. It is hypothesized that the classification system of the International Cartilage Repair Society (ICRS) will allow for improved assessment of lesion grade and stability in OCD. MATERIALS AND METHODS: Routine MRI studies of 46 consecutive patients with arthroscopically proven OCD lesions (mean age: 23.7 years; 26 male, 16 female) were assessed by three radiologists who were blinded to arthroscopic results. Arthroscopic images were evaluated by two orthopedic surgeons in consensus. The OCD criteria of the ICRS were applied to arthroscopy and imaging interpretations. Inter-rater correlation statistics and accuracy of magnetic resonance (MR) grading with respect to arthroscopy were determined. RESULTS: Only 56% of the available MR reports assigned a label of stable or unstable to the lesion description. Of these, 58% of the lesions were deemed unstable and 42% were stable. Accuracy was 53% when reports addressed stability. Utilizing the ICRS classification system, for all three readers combined, the respective sensitivity, specificity, and accuracy of MR imaging to determine lesion stability were 70%, 81%, and 76%. When compared to the original MRI report, the overall accuracy increased from 53% to 76% when readers were given the specific criteria of the OCD ICRS classification. However, inter-reader variability remained high, with Krippendorf's alpha ranging from 0.48 to 0.57. CONCLUSIONS: In this paper, we utilize arthroscopy as the gold standard to determine if MRI can predict OCD lesion stability, the most important information to guide patient treatment decisions. To our surprise, the analysis of the existing radiology reports that addressed stability revealed an overall accuracy in defining OCD lesion stability of about 53%. The classification system of the ICRS, created by an international multidisciplinary, multi-expert consortium, did markedly improve the accuracy, but consistency among different readers was lacking. This retrospective study on OCD reporting and classification highlights the inadequacy of existing classification schemes, and emphasizes the critical need for improved diagnostic MRI protocols in musculoskeletal radiology in order to propel it toward evidence-based medicine.