Comparative efficacy of low-volume retrobulbar anesthesia using three commercial local anesthetics in adult horses

OBJECTIVE

To compare the efficacy of low-volume (5-mL) locoregional retrobulbar anesthesia ("retrobulbar block") by use of 3 commercial local anesthetic formulations.

ANIMALS

8 healthy adult mares.

METHODS

A block-randomized, masked, controlled design was used. A single ultrasound-guided retrobulbar block was performed with 2% lidocaine, 2% mepivacaine, or 0.5% bupivacaine (n = 5 eyes/group). Contralateral eyes served as untreated controls. End points performed at baseline and time intervals up to 24 hours postblock included the following: assessment of neurophthalmic reflexes/responses, intraocular pressure, and vertical pupil diameter measurement, corneal and periocular esthesiometry, and observation for adverse effects.

RESULTS

Low-volume block did not result in increased intraocular pressure or other adverse effects at any time point in any treatment group. Statistically significant corneal anesthesia (P < .001) was observed 1 minute after block in all groups, persisting through 4 hours after lidocaine or mepivacaine block and through 24 hours after bupivacaine block. Clinically significant periocular anesthesia was not observed in any group. Significant vertical pupil diameter increase (P < .05) was observed for up to 4 hours after lidocaine or mepivacaine block and 6 hours after bupivacaine block.

CLINICAL RELEVANCE

Low-volume retrobulbar block with any of the 3 local anesthetic drugs evaluated was not associated with adverse effects. In terms of efficacy, mepivacaine block showed no clinical advantage over lidocaine block. However, bupivacaine block induced comparatively rapid and sustained corneal anesthesia. In comparison to published findings using a larger injection volume, low-volume retrobulbar block with lidocaine produced clinically comparable corneal anesthesia. However, periocular soft tissue anesthesia was not achieved with any local anesthetic drug at low volume.

The effect of feeding on serum concentrations of cobalamin, folate, trypsin-like immunoreactivity, and pancreatic lipase immunoreactivity in dogs with signs of chronic gastrointestinal disease

BACKGROUND

It is unknown if serum concentrations of cobalamin, folate, canine pancreatic lipase immunoreactivity (cPLI), and canine trypsin-like immunoreactivity (cTLI) obtained postprandially are equivalent to measurements obtained after withholding food in dogs with suspected gastrointestinal disease.

HYPOTHESIS/OBJECTIVES

Measurements of serum concentrations of cobalamin, folate, cPLI, and cTLI postprandially will be equivalent to measurements after 12 hours of withholding food in dogs with signs of chronic gastrointestinal disease. Changes observed will not alter clinical interpretation.

ANIMALS

51 client-owned dogs with signs of gastrointestinal disease.

METHODS

Prospective single arm clinical trial. Serum concentrations of cobalamin, folate, cPLI and cTLI 2, 4, and 8 hours postprandially were compared by equivalence testing to values after withholding food for 12 hours (baseline).

RESULTS

Mean serum cobalamin concentrations 2 hours (498.1 ± 213.1 ng/L; P = 0.024) and 4 hours (501.9 ± 207.4 ng/L; P = 0.008) postprandial were equivalent to baseline (517.3 ± 211.5 ng/L). Mean serum cTLI 2 hours (31.3 ± 14 μg/L; P < 0.001) and 4 hours (29.6 ± 13.1 μg/L; P = 0.027) postprandial were equivalent to baseline (31.1 ± 15 μg/L). Mean serum folate concentration 2 hours postprandial (15 ± 7.7 μg/L) was equivalent to baseline (13.7 ± 8.3 μg/L; P < 0.001). Equivalence could not be assessed for cPLI due to results below the lower limit of quantification. Feeding altered the clinical interpretation in 27% (cobalamin), 35% (folate), 20% (cTLI), and 12% (cPLI) of dogs.

CONCLUSIONS AND CLINICAL IMPORTANCE

The clinical interpretation for a substantial number of samples changed after feeding, therefore withholding food before sample collection is prudent.

Antimicrobial effects of blue light therapy against cutibacterium acnes: optimal dosing and impact of serial treatments

Background

Blue light therapy (BLT) is a Food and Drug Administration cleared modality used in dermatology as an effective treatment of acne. The primary purpose of this study is to determine if there are dose-dependent antimicrobial effects of BLT against Cutibacterium acnes (C. acnes).

Methods

A known strain of C. acnes was grown on chocolate agar in a controlled laboratory environment under anaerobic conditions for 1 week. After 1 week, 2-3 colonies of C. acnes were isolated and transferred to broth medium to incubate for 2 or 7 days. Broth vials (treatment arm) then underwent 1 of 6 different blue light dosing treatment regimens and a duplicate broth vial served as a control left open to the same environment. The BLT regimens were a single treatment of 25 J/cm2, 50 J/cm2, 75 J/cm2, 100 J/cm2, 2 serial treatments of 50 J/cm2 separated by 24 hours, or 2 serial treatments of 75 J/cm2 separated by 24 hours. The Omnilux Blue device (415 nm wavelength) was used for all BLT treatments and delivered, on average, 1.68 ± 0.004 J/min. Following treatment, the control and treatment broth samples were plated on chocolate agar and allowed to grow for 7 days. After 7 days, plates were counted and colony forming units (CFUs) were calculated. Six trials were completed for each BLT dosing regimen based on an a priori power analysis of 6 individual 2-sided t-tests. Comparisons in the primary outcome were made via mixed-effects analysis of variance with replicate as a random effect.

Results

All BLT treatment regimens resulted in significantly fewer CFUs than their aggregate control plate CFUs (P < .05 for all). Furthermore, in 2-way comparison of CFUs between BLT treatment groups, a single treatment of 75 J/cm2 did lead to significantly less growth than 25 J/cm2 (P = .017) and 50 J/cm2 (P = .017). There were no improved antimicrobial effects with serial treatments when comparing 2 doses of 50 J/cm2 with a single dose of 100J/cm2, nor were 2 doses of 75 J/cm2 more efficacious than 100 J/cm2. Using the Omnilux Blue device, it took 44.8 minutes to deliver a 75 J/cm2 dose.

Conclusion

BLT is an effective antimicrobial agent against this single virulent strain of C. acnes. Treatment dosing of 75 J/cm2 was identified to be the most effective dose per unit time. Serial treatments did not lead to superior antimicrobial effects over a single, high-dose treatment.

Radiographic Comparison of Virtual Surgical Corrective Options for Excessive Tibial Plateau Angle in the Dog

OBJECTIVE

 The main aim of this study is to compare the impact of six proximal tibial osteotomies on the geometry and alignment of tibias with and without excessive tibial plateau angle (TPA).

STUDY DESIGN

 Mediolateral radiographs of 30 canine tibias were divided into three groups (n = 10/group): moderate TPA (≤34 degrees), severe TPA (34.1-44 degrees) and extreme TPA (>44 degrees). Six proximal tibial osteotomies were simulated on each tibia using orthopaedic planning software: cranial closing wedge ostectomy (CCWO), modified CCWO (mCCWO), isosceles CCWO (iCCWO), neutral isosceles CCWO (niCCWO), tibial plateau levelling osteotomy with CCWO (TPLO/CCWO) and coplanar centre of rotation of angulation-based levelling osteotomy (coCBLO). All tibias were reduced to a standard target TPA. Pre- and postoperative measurements were obtained for each virtual correction. Compared outcome measures included tibial long axis shift (TLAS), cranial tibial tuberosity shift (cTTS), distal tibial tuberosity shift (dTTS), tibial shortening and osteotomy overlap.

RESULTS

 Across all TPA groups, TPLO/CCWO had the lowest mean TLAS (1.4 mm) and dTTS (6.8 mm); coCBLO had the largest TLAS (6.5 mm) and cTTS (13.1 mm); CCWO had the largest dTTS (29.5 mm). CCWO had the largest degree of tibial shortening of 6.5 mm, while mCCWO, niCCWO and coCBLO resulted in minimal tibial lengthening (1.8-3.0 mm). These trends were generally conserved across different TPA groups. All findings had a p-value less than 0.05.

CONCLUSION

 mCCWO balances moderate alterations to tibial geometry while preserving osteotomy overlap. The TPLO/CCWO has the least effect on tibial morphology alteration, whereas the coCBLO results in the largest alteration.

Blood pressure changes in gestational hypertension, preeclampsia, and chronic hypertension from preconception to 42-day postpartum

OBJECTIVE

To investigate blood pressure changes from preconception to 42-day postpartum in patients with gestational hypertension, preeclampsia, and chronic hypertension.

STUDY DESIGN

Secondary analysis of patients diagnosed with a hypertensive disorder of pregnancy (HDP) antenatally or postpartum, who were enrolled prospectively in a postpartum remote blood pressure (BP) monitoring program between March 2017 and May 2020. BP were collected at 47 time points: preconception, each trimester, delivery day, and every postpartum day through 42-days postpartum. The primary outcome of the study was to examine changes in BP over time and between the types of HDP for 42 days postpartum. Secondary outcomes included the difference in timing of BP stabilization (BPs < 140/90 mmHg for ≥ 48 h), BP resolution (stabilized without antihypertensive medication use), and antihypertensive medication usage at 42-day postpartum between the HDP groups.

RESULTS

A total of 1,194 patients were included in the cohort; 224 (18.8 %) had chronic hypertension (CHTN), 525 (43.9 %) had gestational hypertension (GHTN), 153 (12.8 %) had preeclampsia, and 292 (24.5 %) had preeclampsia with severe features. Postpartum BP peaked on days 5-7 postpartum with rapid decrease from postpartum day 7 until postpartum day 14, followed by very small resolution/stabilization in BP values between day 15 and 42 postpartum. By 6 weeks postpartum, 60.5 % of patients with CHTN still required antihypertensive medications to maintain BP < 140/90 mmHg. In the group of patients with preeclampsia with severe features, 32.6 % still required antihypertensive medications to maintain BP < 140/90 mmHg. Finally, 16.1 % patients with GHTN and 23.8 % of patients with preeclampsia without severe features required antihypertensive use at 6 weeks postpartum. The groups of CHTN and GHTN had significant reduction in SBPs at 42-days postpartum compared to their pre-conception BP (p < 0.001 for both groups). While diastolic BP at 42-days postpartum were not different in CHTN, GHTN and preeclampsia groups, compared to preconception, women with preeclampsia with severe features had higher diastolic BP at the end of 6-weeks postpartum period compared to preconception readings (p = 0.007).

CONCLUSION

Our study adds new information by examining BP trajectories through 42 days postpartum and demonstrates that all types of HDP are at risk of BP spikes and intervention through 42 days postpartum. We found that patients with CHTN had slower stabilization and resolution of their BP compared to patients with GHTN and preeclampsia with and without severe features. In addition, even at 42 days postpartum, a substantial proportion of patients with HDP, including GHTN, required antihypertensive treatment to maintain BP within stage I hypertension.

Morphological quantification of the maxillary canine tooth in the domestic dog (Canis lupus familiaris)

Canine tooth shape is known to vary with diet and killing behavior in wild animals and the relationship between form and function is driven in part by selective pressure. However, comparative investigation of the domestic dog (Canis lupus familiaris) is of interest. How do they compare to their wild counterparts? This study sought to quantify and characterize the morphology of the canine tooth in the domestic dog, and to provide a preliminary investigation into the variance in canine tooth morphology across individual dogs of varying breeds. Three-dimensional (3D) models generated from micro-computed tomography (µ-CT) studies of 10 mature maxillary canine teeth from the domesticated dog (Canis lupus familiaris) were used to quantify key morphological features and evaluate variance among dogs. Results show that, utilizing modern imaging and model building software, the morphology of the canine tooth can be comprehensively characterized and quantified. Morphological variables such as second moment of area and section modulus (geometrical parameters related to resistance to bending), as well as aspect ratio, ridge sharpness, cusp sharpness and enamel thickness are optimized in biomechanically critical areas of the tooth crown to balance form and function. Tooth diameter, second moment of area, section modulus, cross sectional area, tooth volume and length as well as enamel thickness are highly correlated with body weight. In addition, we found preliminary evidence of morphological variance across individual dogs. Quantification of these features provide insight into the balance of form and function of the canine tooth in wild and domesticated canids. In addition, results suggest that variance between dogs exist in some morphological features and most morphological features are highly correlated with body weight.

Correlation of mineral density and elastic modulus of dog dentin using μ-CT and nanoindentation

This study sought to 1) investigate the spatial distribution of mineral density of dog dentin using µ-CT and 2) characterize the relationship between the elastic modulus and mineral density of dog dentin using nanoindentation and µ-CT. Maxillary canine teeth of 10 mature dogs were scanned with a µ-CT then sectioned in the transverse and vertical planes and tested using nanoindentation. Spatial distribution of mineral density and elastic modulus was quantified. Results demonstrated significant spatial variation in mineral density and elastic modulus. Mineral density and elastic modulus generally increased from the dentin-pulp interface to the dentino-enamel junction and from the crown base to the crown tip. Significant site dependent correlations between mineral density and elastic modulus were determined (0.021 > R2 > 0.408). The results of this study suggest that while mineral density is a mediator of elastic modulus, other mediators such as collagen content may contribute to the mechanical behavior of dog dentin.

Perinatal Outcomes Associated With Institutional Changes Early in the COVID-19 Pandemic

OBJECTIVE

Many institutions implemented policy changes to protect patients and clinicians during the COVID-19 pandemic. This study examines how institutional policy changes and patient behaviors affected perinatal outcomes. We hypothesized that obstetric practice changes occurred and that these changes affected perinatal outcomes.

METHODS

We conducted a retrospective cohort study of singleton pregnancies delivered at a single institution with low incidence of COVID-19. Deliveries occurring from December 15, 2019 through March 14, 2020 were designated as the pre-COVID-19 group. Those occurring from March 15, 2020, through June 15, 2020, were designated the COVID-19 group. The primary outcome is a perinatal composite defined as delivery ≥ 41 weeks, hypertensive disorder of pregnancy at term, unplanned Cesarean delivery, term neonatal intensive care unit admission, 42-day maternal readmission, and 7-day neonatal readmission. Additional maternal, neonatal, and delivery composites also were analyzed, and we evaluated all individual outcomes secondarily.

RESULTS

Of 2,268 deliveries, 1,210 occurred during the COVID-19 period. Four of the 1,210 (0.3%) were diagnosed with COVID-19. Women during the COVID-19 period were more likely to present in spontaneous labor and less likely to undergo induction. Maternal and neonatal length of stay was also shorter. There was no difference in the perinatal composite between the 2 groups (36.3% vs 36.7% [OR 1.05; 95% CI, 0.86-1.21]). There was a significant increase in deliveries occurring at or after 41 weeks (4.7% vs 6.9% [OR 1.83; 95% CI, 1.00-3.34]). There was no difference in maternal, neonatal, and delivery composites or the outcomes assessed individually.

CONCLUSIONS

We demonstrated significant changes in clinical practice secondary to policy changes and patient behaviors during the COVID-19 pandemic. As an institution that globally adopted ARRIVE (A Randomized Trial of Induction Versus Expectant Management) practices, we noted fewer inductions, more women presenting in labor and more women delivering at or after 41 weeks. We also noted a shorter length of hospital stay for the mother-baby dyad. Overall, these changes in clinical practice did not affect perinatal outcomes.

Association between spine injury and opioid misuse in a prospective cohort of Level I trauma patients

Objective

To explore patient and treatment factors explaining the association between spine injury and opioid misuse.

Design

Prospective cohort study.

Setting

Level I trauma center in a Midwestern city.

Participants

English speaking patients aged 18 to 75 on Trauma and Orthopedic Surgical Services receiving opioids during hospitalization and prescribed at discharge.

Exposure

Spine injury on the Abbreviated Injury Scale.

Main outcome measures

Opioid misuse was defined by using opioids: in a larger dose, more often, or longer than prescribed; via a non-prescribed route; from someone other than a prescriber; and/or use of heroin or opium. Exploratory factor groups included demographic, psychiatric, pain, and treatment factors. Multivariable logistic regression estimated the association between spine injury and opioid misuse when adjusting for each factor group.

Results

Two hundred eighty-five eligible participants consented of which 258 had baseline injury location data and 224 had follow up opioid misuse data. Most participants were male (67.8%), white (85.3%) and on average 43.1 years old. One-quarter had a spine injury (25.2%). Of those completing follow-up measures, 14 (6.3%) developed misuse. Treatment factors (injury severity, intubation, and hospital length of stay) were significantly associated with spine injury. Spine injury significantly predicted opioid misuse [odds ratio [OR] 3.20, 95% confidence interval [CI] (1.05, 9.78)]. In multivariable models, adjusting for treatment factors attenuated the association between spine injury and opioid misuse, primarily explained by length of stay.

Conclusion

Spine injury exhibits a complex association with opioid misuse that predominantly operates through treatment factors. Spine injury patients may represent a subpopulation requiring early intervention to prevent opioid misuse.

Structure-function relationships in dog dentin

Investigations into teeth mechanical properties provide insight into physiological functions and pathological changes. This study sought to 1) quantify the spatial distribution of elastic modulus, hardness and the microstructural features of dog dentin and to 2) investigate quantitative relationships between the mechanical properties and the complex microstructure of dog dentin. Maxillary canine teeth of 10 mature dogs were sectioned in the transverse and vertical planes, then tested using nanoindentation and scanning electron microscopy (SEM). Microstructural features (dentin area fraction and dentinal tubule density) and mechanical properties (elastic modulus and hardness) were quantified. Results demonstrated significant anisotropy and spatial variation in elastic modulus, hardness, dentin area fraction and tubule density. These spatial variations adhered to a consistent distribution pattern; hardness, elastic modulus and dentin area fraction generally decreased from superficial to deep dentin and from crown tip to base; tubule density generally increased from superficial to deep dentin. Poor to moderate correlations between microstructural features and mechanical properties (R² = 0.032-0.466) were determined. The results of this study suggest that the other constituents may contribute to the mechanical behavior of mammalian dentin. Our results also present several remaining opportunities for further investigation into the roles of organic components (e.g., collagen) and mineral content on dentin mechanical behavior.

Patients With Generalized Joint Hypermobility Have Thinner Superior Hip Capsules and Greater Hip Internal Rotation on Physical Examination

Purpose

To compare preoperative hip range of motion (ROM), hip capsular thickness on magnetic resonance imaging (MRI), and bony morphology on radiographs and computed tomography (CT) between patients with and without joint hypermobility as measured by the Beighton Test score (BTS), with subanalysis based on sex and age.

Methods

Consecutive patients who underwent hip arthroscopy for a diagnosis of femoroacetabular impingement syndrome with or without dysplasia were retrospectively reviewed. Patient BTS, hip ROM, demographics, surgical data, morphologic measures on radiographs and CT, and MRI findings including hip capsule thickness at various locations were compiled. Multiple statistical tests were performed, including multivariable linear or logistic regression models, while controlling for BTS, age, and sex.

Results

In total, 99 patients were included with a mean age of 29 ± 9.9 years; 62 (62.6%), were female. Forty patients (40.4%) had a BTS ≥4. Female patients (P < .001) and younger patients (26.7 vs 30.9 years, P = .030) were more likely to have a BTS ≥4. Male patients had significantly thicker superior capsules (3.4 mm vs. 2.8 mm, P = .034). BTS was not associated with capsular thickness when controlling for sex. On CT, femoral version (18.9° vs 11.4°, P < .001), and McKibben index (37.8° vs. 28.2°, P < .001) were significantly greater in those with a BTS ≥4. Patients with a BTS ≥4 had more hip internal rotation at 90° of flexion (15.0° vs 10.0°, P < .001), when prone (30.0° vs 20.0°, P = .004), and in extension (10.0° vs. 5.0°, P < .001).

Conclusions

All female patients, regardless of Beighton score, and all patients with a BTS ≥4 indicated for primary hip arthroscopy for femoroacetabular impingement syndrome with or without dysplasia were more likely to have thinner superior hip capsules on MRI and greater hip internal rotation on exam. Bony morphologic differences exist between sexes and between patients with and without hypermobility, likely contributing to differences in ROM.

Level of Evidence

III, retrospective cohort study.

Comparing diagnostic criteria for the diagnosis of neurocognitive disorders in multiple sclerosis

BACKGROUND

People with multiple sclerosis (MS) commonly experience cognitive impairment associated with the disease, but there is currently no agreed-upon operational definition for identifying the presence of that impairment, in either research or clinic contexts. The International MS Cognition Society (IMSCOGS) established a task force to begin to examine this issue and this paper represents the results of an initial pilot investigation. The aim of this paper was to compare two criterion sets to determine how to identify cognitive impairment among people with MS: the general Diagnostic and Statistical Manual (DSM-5) Criteria for neurocognitive disorders and criteria derived from existing MS research (scores in two domains fall 1.5 standard deviations below normative controls).

METHODS

Two hundred and ten people with MS presented for a brief cognitive evaluation in an MS Multidisciplinary Clinic at a midwestern academic medical center in the United States. Participants were generally middle aged (average 51.5 years), female (73.8%), and white (93.3%). McNemar's test was computed to compare the number of individuals whose cognitive test score performance was deemed cognitively normal, mildly impaired, or more significantly impaired.

RESULTS

DSM-5 criteria classified 87.2% of the sample as cognitively impaired, where 66.7% were more mildly impaired and 20.5% more significantly impaired. By contrast, research-based criteria classified 63.3% of the sample as cognitively impaired, with 49.5% as mildly impaired and 13.8% as more significantly impaired.

CONCLUSIONS

These findings indicate that compared to research criteria, the DSM-5 criteria classified far more people with MS as having cognitive impairment secondary to the disease. The paper discusses the potential benefits and drawbacks of the two diagnostic methods, highlighting that more work will be needed in order to establish a standardized and validated method for characterizing these impairments.

Impact of the Surgical Environment on the Incidence, Timing, and Severity of Complications Associated With Oromaxillofacial Oncologic Surgery in Dogs

Numerous reports describe complication rates associated with oromaxillofacial oncologic surgery in dogs, however, investigation regarding the impact of the surgical environment on the incidence of complications is under reported. The objective of this retrospective cohort study, including 226 dogs surgically treated for oromaxillofacial tumors between January 1, 1997 and December 31, 2018, is to evaluate the impact of the surgical environment on the incidence of complications in oromaxillofacial oncologic surgery in dogs. A secondary objective is to report the incidence of local complications in oromaxillofacial oncologic surgery and characterize the type, timing, and severity of complications encountered. Incidence of complications was identified to be 69.9%. No significant association was identified between the incidence, timing, or severity of complications and the training background of the clinician, physical location of the procedure, or the ostectomy instrument used. These results suggest that the surgical environment has little impact on the incidence, timing, and severity of complications in dogs undergoing oromaxillofacial oncologic surgery. The results also emphasize the importance of preparing the surgical team and the client for a high incidence of complications associated with oromaxillofacial oncologic surgery in dogs and indicate that both short-term and long-term follow up is important in these cases. Oromaxillofacial surgery performed by residents-in-training within a veterinary teaching environment with adequate supervision appears to be safe.

High School Sports During the COVID-19 Pandemic: The Effect of Sport Participation on the Health of Adolescents

CONTEXT

During the fall of 2020, some high schools across the United States allowed their students to participate in interscholastic sports while others cancelled or postponed their sport programs due to concerns regarding COVID-19 transmission. What effect this has had on the physical and mental health of adolescents is unknown.

OBJECTIVE

To identify the effect of playing a sport during the COVID-19 pandemic on the health of student-athletes.

DESIGN

Cross-sectional study.

SETTING

Sample recruited via email.

PATIENTS OR OTHER PARTICIPANTS

A total of 559 Wisconsin high school athletes (age = 15.7 ± 1.2 years, female = 43.6%, male = 56.4%) from 44 high schools completed an online survey in October 2020. A total of 171 (30.6%) athletes played (PLY) a fall sport, while 388 (69.4%) did not play (DNP).

MAIN OUTCOME MEASURE(S)

Demographic data included sex, grade, and sport(s) played. Assessments were the General Anxiety Disorder-7 Item for anxiety, Patient Health Questionnaire-9 Item for depression, the Hospital for Special Surgery Pediatric Functional Activity Brief Scale for physical activity, and the Pediatric Quality of Life Inventory 4.0 for quality of life. Univariable comparisons between the 2 groups were made via t tests or χ2 tests. Means for each continuous outcome measure were compared between groups using analysis-of-variance models that controlled for age, sex, teaching method (virtual, hybrid, or in person), and the percentage of students eligible for free or reduced-price lunch.

RESULTS

The PLY group participants were less likely to report moderate to severe symptoms of anxiety (PLY = 6.6%, DNP = 44.1%, P < .001) and depression (PLY = 18.2%, DNP = 40.4%, P < .001). They also demonstrated higher (better) Pediatric Functional Activity Brief Scale scores (PLY = 23.2 [95% CI = 22.0, 24.5], DNP = 16.4 [95% CI = 15.0, 17.8], P < .001) and higher (better) Pediatric Quality of Life Inventory total scores (PLY = 88.4 [95% CI = 85.9, 90.9], DNP = 79.6 [95% CI = 76.8, 82.4], P < .001).

CONCLUSIONS

Adolescents who played a sport during the COVID-19 pandemic described fewer symptoms of anxiety and depression and had better physical activity and quality-of-life scores compared with adolescent athletes who did not play a sport.

Longitudinal blood pressure patterns of women with hypertensive disorders of pregnancy: preconception through postpartum

OBJECTIVE

To investigate the longitudinal blood pressure (BP) pattern of women with hypertensive disorders of pregnancy (HDP) preconception through the postpartum day (PPD) 42.

STUDY DESIGN

A retrospective study of women (≥15 years old) diagnosed with an HDP antenatally or postpartum, who were enrolled prospectively in a postpartum remote BP monitoring program between 3/2017 and 5/2020. BPs were collected from 47-time points: preconception, each trimester, delivery day, and 42 days postpartum. Analysis was conducted utilizing a mixed-effects longitudinal model.

MAIN OUTCOME MEASURES

Primary outcome was the longitudinal BP patterns. Secondary outcomes were the timing of BP stabilization (BPs < 140/90 mmHg for ≥48 h) and resolution (stabilized without antihypertensive medication use).

RESULTS

Our final analysis included 897 of the 964 eligible women. The peak systolic and diastolic BPs were on PPDs 3, 4, 5, and 5, 6, 7, respectively. Systolic BP fell below the preconception level after PPD15; diastolic BP reached its plateau after PPD17 and remained above the preconception level till PPD42 (p < .001). Postpartum BP peaked with the highest percentage of BP spikes on PPDs 4-7. The median survival times to BP stabilization and resolution were PPDs 11 (95% CI: 10-12) and 23 (95% CI: 21-25), respectively. By PPD42, 91.0% and 74.1% of women achieved BP stabilization and resolution, respectively.

CONCLUSION

This study data could be used to develop evidence-based recommendations for women with an HDP. Diastolic BPs remaining significantly higher than the preconception level indicates the long-term risk of cardiovascular disease. In our cohort, 26% of women had unresolved hypertension by PPD42, which reinforces the necessity to ensure long-term follow-up.

Efficacy of combinational therapy using blue light and benzoyl peroxide in reducing Cutibacterium acnes bioburden at the deltopectoral interval: a randomized controlled trial

BACKGROUND

The purpose of this study was to compare the efficacy of blue light therapy (BLT) and 5% topical benzoyl peroxide (BPO) gel in combination with standard chlorhexidine (CHX) preparation in eradicating Cutibacterium acnes at the deltopectoral interval measured by positive, quantitative culture findings.

METHODS

Adult male volunteers were randomized to 1 of 3 treatment groups: BPO, BLT, and BPO followed by BLT. Contralateral shoulders served as matched controls. Volunteers randomized to BPO applied the gel for a total of 5 treatments. In the BLT group, a single 23-minute treatment was administered at an estimated irradiance of 40 mW/cm² (radiant exposure, 55.2 J/cm²). In the BPO-BLT group, volunteers received both treatments as described earlier. After treatment with either BPO, BLT, or both, a single swab culture was taken from the treatment shoulder. Next, control and treatment shoulders were prepared with CHX, and cultures were taken from each shoulder. Cultures were sent for anaerobic quantitative growth analysis with both polymerase chain reaction and Sanger sequencing confirmation of presumptive C acnes colonies.

RESULTS

This study enrolled 60 male volunteers, 20 per group, with no loss to follow-up. After treatment but prior to CHX administration, all culture samples in the BPO group and BLT group grew C acnes. Prior to CHX, 16 samples (80%) in the BPO-BLT group grew C acnes. On quantitative analysis, the BPO group and BPO-BLT group had significantly less growth of C acnes compared with the BLT group after treatment but prior to CHX (P < .05 for each). Following CHX administration, the BPO and BPO-BLT groups had significantly fewer positive culture findings (odds ratios of 0.03 and 0.29, respectively) and less quantity of growth compared with their control arms (P < .05). This was not seen in the BLT group. For quantitative between-group analysis, no significant synergistic effects were seen with BPO-BLT compared with BPO alone (P = .688). There was no difference in side effects between groups.

CONCLUSION

The combination of topical BPO and CHX was effective at eliminating C acnes in most cases. BLT alone did not demonstrate effective antimicrobial properties against C acnes at the radiant exposure administered in this study. Combining BPO and BLT did not lead to significant synergistic antimicrobial effects. Both BPO and BLT are safe with few, transient side effects reported. More work is needed to determine whether BLT at higher radiant exposures or serial treatment results in bactericidal effects against C acnes in vivo.

Do intra-articular knee injuries detected by preoperative MRI affect the clinical management of extensor mechanism ruptures?

OBJECTIVES

We sought to determine the prevalence of intra-articular findings at the time of extensor mechanism injury that required subsequent surgical intervention.

DESIGN

Retrospective cohort study.

SETTING

Level 1 academic trauma center.

PATIENTS/PARTICIPANTS

Sixty-seven knees in 66 nonconsecutive patients (mean age 53.6 years, 95.6% male) with extensor mechanism injury and preoperative magnetic resonance imaging (MRI) before undergoing open primary surgical repair.

MAIN OUTCOME MEASUREMENTS

Patellar or quadriceps tendon rupture, high or low injury energy level, and age above or below 45 years were used to stratify patients. The primary outcome was additional surgery for intra-articular injury. Demographics, comorbidities, mechanism and location of injury, and internal derangements based on MRI findings were also collected.

RESULTS

Fifty-one knees (76.1%) had quadriceps tendon injury, 13 knees (19.4%) had patellar tendon injury, and 3 knees (4.6%) had both. Thirty-four knees (50.7%) had intra-articular pathology and 3 (4.5%) required additional surgery, including 1 knee (7.7%) with patellar tendon injury and 2 knees (3.9%) with quadriceps tendon injury. Patellar tendon injuries were more commonly associated with cruciate ligament injury (P < .01) and occurred in younger patients (P < .001) than quadriceps tendon injury.

CONCLUSIONS

50.7% of cases with extensor mechanism injury had intra-articular pathology but only 4.5% required additional surgery. The results of our study suggest that preoperative MRI is unlikely to be of significant clinical utility in most extensor mechanism injuries but should be considered in cases of patellar tendon rupture in younger patients where the incidence of concomitant cruciate ligament injury is higher.

LEVEL OF EVIDENCE

Diagnostic Level III.

Pitching Behaviors in Youth Baseball: Comparison With the Pitch Smart Guidelines

Background

The Pitch Smart guidelines aim to limit youth baseball pitching behaviors associated with overuse injuries. Despite many youth baseball leagues being compliant with the guidelines, during tournaments, pitch count restrictions or guidelines are often not followed.

Purpose

To perform a quantitative analysis of pitch counts in youth baseball players and evaluate compliance with regard to the Pitch Smart guidelines in the tournament setting.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Included in the analysis were 100 youth baseball teams that competed in the 8-and-under to 14-and-under age divisions during the 2019 tournament season. Pitching data were compared with the Pitch Smart guidelines. Violations were identified as (1) exceeding maximum daily pitch count, (2) inadequate rest between pitching events, and (3) pitching more than 1 event on the same day. Pitcher and game factors were analyzed for possible relationships to guideline violations using mixed-effects negative binomial regression models, with comparisons of violations using rate ratios (RRs).

Results

Analysis included 1046 pitchers and 2439 games. There were 1866 total Pitch Smart guideline violations, with 48.6% of pitchers having at least 1 violation. Inadequate rest was the most common reason for violation, with noncompliance occurring in 43.3% of pitchers. The highest rate of any violation (0.32 per appearance) occurred in the 8-and-under age division. High-volume pitchers had increased violation rates in each category compared with low-volume pitchers (P < .001). Violation rates were increased more than twice the rate when pitchers participated in ≥5 consecutive games without a rest day when compared with a single game (RR, 2.48; P < .001).

Conclusion

Noncompliance with Pitch Smart guidelines in tournament settings occurred in more than 90% of teams and almost half of all pitchers. Factors associated with noncompliance included younger pitcher age, high-volume pitching, and pitching in multiple consecutive games. Education of tournament directors, coaches, parents, and athletes regarding pitching guidelines is warranted in order to limit the risk of injury.

Incidence and Risk Factors for Surgical Site Infections Following Oromaxillofacial Oncologic Surgery in Dogs

Antibiotic stewardship in veterinary medicine is essential to help prevent resistant bacterial infections. Critical evaluation into the benefits of prophylactic use of antibiotics during veterinary surgical procedures is under reported and additional investigation is warranted. The objectives of this paper were to determine the incidence of surgical site infection in dogs that underwent oromaxillofacial oncologic surgery and to identify risk factors for the development of surgical site infection. In this retrospective cohort study including 226 dogs surgically treated for oromaxillofacial tumors between January 1, 1997 and December 31, 2018, the incidence of surgical site infection was determined to be 7.5%. Univariable logistical regression models were used to evaluate potential risk factors for development of surgical site infections including signalment, tumor type, antibiotic protocol, time under anesthesia, location of surgical procedure (dental suite vs. sterile operating room), specific comorbidities, and surgical margins obtained. Anesthetic events lasting greater than 6 h were significantly associated with development of infection. Signalment, comorbidities, administration of anti-inflammatory and immunosuppressive medications, tumor type, histological margin evaluation, surgical procedure location, and antibiotic protocols were not significant contributors to development of infection. Use of antibiotic therapy in this cohort was not protective against development of infection and may not be routinely indicated for all oromaxillofacial oncologic surgeries despite common promotion of its use and the contaminated nature of the oral cavity. Anesthetic time significantly contributed towards the development of infection and use of perioperative antibiotics for surgical procedures lasting >6 h may be routinely warranted.

Liposomal Bupivacaine Versus Standard Bupivacaine in the Adductor Canal for Total Knee Arthroplasty: A Randomized, Controlled Trial

Peripheral nerve blocks are commonly used in total knee arthroplasty (TKA). Liposomal bupivacaine is an extended-release anesthetic medication that maintains efficacy upwards of 72 hours. This study compared single-shot liposomal bupivacaine (LB) with the standard single-shot bupivacaine (SB) in a preoperative adductor canal block in TKA patients. A double-blind randomized, controlled trial at a single institution was performed in patients undergoing TKA. A standard preoperative single-shot adductor canal nerve injection was performed in 31 patients using 266 mg of liposomal bupivacaine (20 mL), whereas 32 patients received a standard formulation of 0.5% bupivacaine hydrogen chloride (20 mL). The primary outcome measure was postoperative gait velocity. Secondary outcomes included knee range of motion, pain scores, patient satisfaction, knee extension strength, opioid consumption, length of stay, and adverse events. There were no differences in baseline measures between groups. Improved pain ratings with activity (P=.009) were noted on postoperative day 1 with LB (mean, 4.4; SD, 2.0) compared with SB (mean, 5.9; SD, 2.6). Fewer opioids were used with LB compared with SB on postoperative day 1 (mean, 51.2 vs 66.1; P=.020) and on postoperative day 2 (mean, 39.5 vs 54.8; P=.016). No statistically significant differences in gait velocity, knee range of motion, knee extension strength, or patient satisfaction occurred. Peripheral nerve blockade with a single-shot adductor canal injection demonstrated improved pain scores with activity and diminished postoperative narcotic use when using LB compared with SB in TKA patients. There may be early postoperative advantages with LB as a single-shot injection in adductor canal blockade for patients undergoing TKA. [Orthopedics. 2021;44(4):249-255.].

Interrater Reliability of the Prone Apprehension Relocation Test

Background:

The Prone Apprehension Relocation Test (PART) augments existing radiographic measures and clinical provocative maneuvers in diagnosing hip instability. One measure of the potential clinical utility of the PART depends on the reproducibility of test results by evaluating providers including physicians, licensed athletic trainers, and physical therapists.

Purpose:

To determine the interrater reliability of the PART among health care providers.

Study Design:

Cohort study (diagnosis); Level of evidence, 3.

Methods:

We retrospectively identified patients in our institution’s hip preservation registry who presented between September 2017 and June 2019 for evaluation of hip pain. Patients included in the study had the PART performed by a single physician as well as 1 of 12 physician extenders (a licensed athletic trainer or a physical therapist). The providers were blinded to the findings of the other examining professional. Interrater reliability was assessed using the Cohen κ (≥0.75 was considered excellent; between 0.75 and 0.40, moderate; and ≤0.40, poor).

Results:

A total of 96 patients (190 hips) were included in this study (61 women and 35 men, average age 32 ± 12.1 years). A total of 23 hips had a positive PART from both examiners. Interrater reliability was excellent between health care professionals for the PART when evaluating the right hip (κ = 0.80), left hip (κ = 0.82), and when combining the results for left and right (κ = 0.81). A subanalysis of patients with a positive PART from both raters demonstrated that 19 of the 23 hips had a lateral center-edge angle >25°.

Conclusion:

Our study demonstrated excellent interrater reliability of the PART, supporting its use in the physical evaluation of painful hips.

Retrobulbar lidocaine injection via the supraorbital fossa is safe in adult horses but produces regionally variable periocular anaesthesia

BACKGROUND

Injection techniques for retrobulbar anaesthesia are published in horses, but neither safety nor anaesthetic efficacy and duration have been evaluated objectively in vivo.

OBJECTIVE

To characterise the safety and efficacy of one published technique for retrobulbar anaesthesia.

STUDY DESIGN

Randomised, controlled descriptive experiment.

METHODS

Unilateral retrobulbar injection with 10 mL lidocaine (2%) was performed in eight sedated adult mares. Contralateral eyes served as untreated controls. Neurophthalmic parameters, intraocular pressure (IOP), and corneal and periocular sensation were measured awake, post-sedation and at periodic time points for 24 hours following injection. Adverse effects were documented.

RESULTS

Injection of 10 mL lidocaine significantly increased IOP for up to 2 hours (P < .05) maximally at 30 min (mean [95% CI]: 6.0 [2.7, 9.2] mm Hg, P < .001). Six of the eight treated eyes developed mild to moderate reversible chemosis for 2 to 24 hours. One eye developed severe chemosis and superficial corneal ulceration at 24 and 48 hours following injection respectively. Corneal sensitivity significantly decreased for 6 hours (P < .05), maximally at 10 min (-44.4 [-34.6, -54.1] mm, P < .001). Periocular sensitivity (measured as increase in applied force) significantly decreased dorsally and medially for up to 2 hours (maximal at 2 hours (367.1 [238.5, 495.7] g, P < .001, and at 30 min: 345.8 [202.6, 488.9] g, P < .001) respectively). Ventral and lateral sensitivity were not effectively decreased beyond 30 min. Optic nerve function was not consistently reduced following injection.

MAIN LIMITATIONS

Investigators were not masked to the treated eye.

CONCLUSIONS

Retrobulbar injection using 10 mL lidocaine is safe in normal eyes of adult horses, but carries risk in structurally compromised or glaucomatous eyes due to transient IOP increase. Reversible chemosis commonly develops 2-4h following injection, and may be severe in some horses with risk for corneal ulceration. Corneal anaesthesia is rapid and prolonged, but all periocular regions are not consistently anaesthetised. Retrobulbar injection should be combined with other local anaesthetic injections for eyelid surgeries or enucleations.

Occupational segregation by gender in veterinary specialties: Who we are choosing, or who is choosing us

OBJECTIVE

Gender demographics vary across specialties including surgery, internal medicine, cardiology, neurology, and oncology. Our objective was to determine whether residency selection or the decision to apply for training drives these differences.

STUDY DESIGN

Retrospective cohort study.

SAMPLE POPULATION

Matched and unmatched residents lists from Veterinary Internship and Residency Matching Program (VIRMP) from 2011 to 2020. Comparative Data Reports from the American Association of Veterinary Medical Colleges from 2010 to 2019.

METHODS

Names for matched and unmatched residents with addresses in the United States or Canada were coded for gender for seven programs: large and small animal surgery, large and small animal medicine, cardiology, neurology, and oncology. Match rate by gender was compared using chi-square tests. Gender demographics of applicants were compared to demographics of graduates using tests of two proportions.

RESULTS

No differences were observed between genders for the likelihood of successfully matching into each residency program evaluated except in large animal internal medicine. Women (44.2%) were slightly more likely to match, overall, than men (39.0%, p = .003). The proportions of women applying for residencies overall (70.7%), in large and small animal surgery (66.1%, 62.2%), cardiology (70.2%), and neurology (70.7%) were lower than the proportion of female graduates (79%; p's < .001).

CONCLUSION

No evidence for gender bias was detected in the VIRMP resident selection process. Female veterinary graduates seemed less likely to apply for residencies than their male counterparts.

IMPACT

Occupational segregation seems to stem from the decision to apply for residency. Interventions aimed at altering gender demographics in specialized medicine should target potential applicants.

Intraoperative Conversion to Five-Strand Hamstring Autograft Configuration Significantly Increases Anterior Cruciate Ligament Graft Diameter Independent of Patient Characteristics

Intraoperative conversion of a four-strand hamstring autograft to a five-strand configuration during an anterior cruciate ligament (ACL) reconstruction has been reported. However, the expected change in graft size and the dependence on patient characteristics are currently not well described. The purpose of this study was to determine the effective change in hamstring graft diameter and reliance on patient characteristics when intraoperatively converting a four-strand hamstring autograft into a five-strand configuration during an ACL reconstruction. A prospective, paired cohort study design was used to measure individual hamstring autograft diameter intraoperatively using traditional four-strand configuration followed by a five-strand configuration. All hamstring tendons included were long enough to consider a five-strand configuration. Five-strand hamstring autograft increased graft diameter in all patients. Hamstring tendon graft diameter increased by an average of 0.99 mm (95% confidence interval [CI]: 0.84-1.11) in the five-strand configuration compared with the traditional four-strand configuration (mean: 7.8 mm). There was no significant difference in the average increase in graft diameter between males (1.04 mm) and females (0.92 mm) (p = 0.323). Eighty-three percent (95% CI: 57.8-95.6) of average graft diameters ≤ 8 mm in the four-strand configuration achieved an average graft diameter of >8 mm in the five-strand configuration, and 70% (95% CI: 35.4- 91.9) of four-strand configuration average diameters < 8 mm achieved an average graft diameter > 8.0 mm in the five-strand configuration. Five-strand hamstring autograft reliably increased intraoperative hamstring tendon autograft diameter, with an average of 1 mm, compared with traditional four-strand configuration. This increase in diameter is independent of sex and remained significant when controlling for age, laterality, body mass index, and semitendinosus length.

Effect of withholding food on serum concentrations of cobalamin, folate, trypsin-like immunoreactivity, and pancreatic lipase immunoreactivity in healthy dogs

OBJECTIVE

To evaluate the effects of withholding food on the results for measurements of serum concentrations of cobalamin, folate, canine pancreatic lipase immunoreactivity (cPLI), and canine trypsin-like immunoreactivity (cTLI) in healthy dogs.

ANIMALS

11 healthy employee- or student-owned dogs.

PROCEDURES

Food was withheld from the dogs for 12 hours, baseline blood samples were collected, then dogs were fed. Postprandial blood samples collected 1, 2, 4, and 8 hours later were assessed. A mixed-effects ANOVA model with fasting duration (time) as a fixed factor and dog as a random effect was fit for each analyte variable. Additionally, a mixed-effects ANOVA model controlling for the variable of time was fit to assess whether lipemia affected serum concentrations of the analytes.

RESULTS

The median serum cobalamin concentration was lower at 4 hours (428 ng/L) and 8 hours (429 ng/L) postprandially, compared with baseline (479 ng/L), but this difference was not clinically meaningful. Although there were no substantial differences in serum concentrations of folate, cPLI, or cTLI, postprandial changes in serum concentrations of cTLI or folate could potentially affect diagnoses in some dogs.

CONCLUSIONS AND CLINICAL RELEVANCE

Although results indicated that feedings rarely resulted in clinically important differences in the median serum concentrations of cobalamin, folate, cPLI, or cTLI in healthy dogs, given the further processing required for lipemic samples, withholding food for at least 8 hours is an appropriate recommendation when measuring these analytes. Similar research is needed in dogs with gastrointestinal disease to determine whether the withholding of food is necessary when measuring these analytes in affected dogs.

Changes in the Health of Adolescent Athletes: A Comparison of Health Measures Collected Before and During the CoVID-19 Pandemic

CONTEXT

In the spring of 2020, schools closed to in-person teaching and sports were cancelled to control the transmission of CoVID-19. The changes that took place to the physical and mental health among young athletes during this time remain unknown, however.

OBJECTIVE

Identify changes in the health (mental health, physical activity and quality of life) of athletes that occurred during the CoVID-19 pandemic.

DESIGN

Cross-sectional study.

SETTING

Sample recruited via social media.

PATIENTS OR OTHER PARTICIPANTS

3243 Wisconsin adolescent athletes (age=16.2±1.2 yrs., female=58% female) completed an online survey in May 2020 (DuringCoVID-19). Health measures for this cohort were compared with previously reported data for Wisconsin adolescent athletes (n=5231, age=15.7±1.2, 47% female) collected in 2016-2018 (PreCoVID-19).

MAIN OUTCOME MEASURE(S)

Demographic information included: sex, grade and sports played. Health assessments included the Patient Health Questionnaire-9 Item (PHQ-9) to identify depression symptoms, the Pediatric Functional Activity Brief Scale (PFABS) for physical activity, and the Pediatric Quality of Life Inventory 4.0 (PedsQL) for health related quality of life (HRQoL). Univariable comparisons of these variables between groups were made via t-tests or chi-square tests. Means and 95% confidence intervals (CI) for each group were estimated by survey weighted ANOVA models.

RESULTS

Compared to PreCoVID-19, a larger proportion of the During-CoVID-19 participants reported rates of moderate to severe levels of depression (9.7% vs 32.9%, p<0.001). During-CoVID-19 participants reported 50% lower (worse) PFABS scores (mean:12.2 [95%CI: 11.9, 12.5] vs 24.7 [24.5, 24.9] p<0.001) and lower (worse) PedsQL total scores compared to the PreCoVID-19 participants (78.4 [78.0, 78.8] vs. 90.9 [90.5, 91.3] p<0.001).

CONCLUSIONS

During the CoVID-19 pandemic, adolescent athletes reported increased symptoms of depression, decreased physical activity and decreased quality of life compared to adolescent athletes in previous years.

3D-printed models for periacetabular osteotomy surgical planning

The purpose of this study was to determine the feasibility and clinical benefits of using 3D-printed hemipelvis models for periacetabular osteotomy preoperative planning in the treatment of hip dysplasia. This retrospective study included 28 consecutive cases in 26 patients, with two bilateral cases, who underwent periacetabular osteotomy between January 2017 and February 2020 and had routine radiographs, CT and MR imaging. Of these, 14 cases [mean patient age 30.7 (SD 8.4) years, 11 female] had routine preoperative imaging, and 14 cases [mean patient age 28.0 (SD 8.7) years, 13 female] had routine preoperative imaging and creation of a full-scale 3D-printed hemipelvis model from the CT data. The expected surgical cuts were performed on the 3D-printed models. All patients underwent Bernese periacetabular osteotomy. Operative times, including time to achieve proper acetabular position and total periacetabular osteotomy time, fluoroscopy radiation dose and estimated total blood loss were compiled. ANOVA compared outcome variables between the two patient groups, controlling for possible confounders. On average, patients who had additional preoperative planning using the 3D-printed model had a 5.5-min reduction in time to achieve proper acetabular position and a 14.5-min reduction in total periacetabular osteotomy time; however, these changes were not statistically significant (P = 0.526 and 0.151, respectively). No significant difference was identified in fluoroscopy radiation dose or total blood loss. Detailed surgical planning for periacetabular osteotomy using 3D-printed models is feasible using widely available and affordable technology and shows promise to improve surgical efficiency.

Effect of Repetitive Administration of a Next-generation Sensory Organization Test in Adults With and Without Vestibular Dysfunction

HYPOTHESIS

The overall aim was to assess the effects of repetitive testing on performance on a next-generation Sensory Organization Test (NG-SOT).

BACKGROUND

The psychometric properties of sensory organization assessment with a next-generation posturography device are not fully characterized. Thus, a better understanding of the reliability of the NG-SOT is required to support its use as an outcome measure.

METHODS

Forty adults (20 vestibular-impaired) participated. Test-retest reliability was determined using the interclass correlation coefficient [ICC (3,1)] for the composite, somatosensory, vision, vestibular, and visual preference scores. Learning effects were assessed by analyzing the change in the composite score over time.

RESULTS

Analyzing the NG-SOT scores across all participants produced the following interclass correlation coefficients [95% confidence interval (CI)]: composite = 0.95 (0.92, 0.97), somatosensory = 0.20 (-0.06, 0.44), vision = 0.93 (0.88, 0.96), vestibular = 0.91 (0.85, 0.94), and visual preference = 0.19 (-0.07, 0.43). The mean differences (95% CI; p value) for the composite score between administrations were: 2.7 (1.0, 4.4; 0.002) for visits 1 and 2; 1.4 (-0.3, 3.1; 0.099) for visits 2 and 3; 0.7 (-1.0, 2.4; 0.403) for visits 3 and 4; and 0.4 (-1.3, 2.1; 0.653) for visits 4 and 5.

CONCLUSIONS

Test-retest reliability was excellent for the composite, vision, and vestibular scores, but it was poor for the somatosensory and visual preference scores. A learning effect for the composite score was identified, but performance was stable after two administrations. Changes in the composite score that are greater than 6.5 points exceed the measurement error for the test.

Evaluation of the effect of disposable tonometer cover brand on performance of Tono-Pen Vet in canine eyes

PRIMARY OBJECTIVE

To evaluate the effect of latex tip cover manufacturer on accuracy and repeatability of Tono-Pen Vet™ in canine eyes.

ANIMAL STUDIED

Twelve enucleated globes from six dogs.

PROCEDURES

The anterior chamber was cannulated and connected to a calibrated manometer. Intraocular pressure (IOP) measurements were obtained using the Tono-Pen Vet and TONOVET Plus at manometric IOP ranging from 5 to 80 mmHg. At each IOP, the Tono-Pen Vet was used with a new Ocu-Film™ latex tip cover (the only manufacturer-approved brand of cover) followed by a new Softips™ latex tip cover. For comparison, the TONOVET Plus was also used at each IOP with a new disposable rebound probe. Measured IOP values were analyzed by linear regression and intraclass correlation coefficient (ICC).

RESULTS

Tono-Pen Vet accuracy was unaffected by tip cover manufacturer or by frequent change in cover. Using ICC analysis, repeatability of measurements using either tonometer was good to excellent at physiologic IOP levels but variably decreased with both devices at supraphysiologic IOP.

CONCLUSIONS

Neither tip cover manufacturer nor frequent changes in tip cover adversely affect Tono-Pen Vet accuracy. Measurement repeatability with Tono-Pen Vet and TONOVET Plus is widely variable at supraphysiologic IOP. Therefore, minor changes in IOP >25 mmHg should not be used to make clinical decisions without considering this variability.

Validation of a next-generation sensory organization test in adults with and without vestibular dysfunction

BACKGROUND

The traditional Sensory Organization Test (T-SOT) is a gold standard balance test; however, the psychometric properties of assessing sensory organization with a virtual-reality-based posturography device have not been established.

OBJECTIVE

Our overall aims were to assess the criterion, concurrent, and convergent validity of a next-generation Sensory Organization Test (NG-SOT).

METHODS

Thirty-four adults (17 vestibular-impaired) participated. We compared the area under the curve (AUC) for receiver operator characteristic (ROC) analysis for the T-SOT and NG-SOT composite scores. Between-group and between-test differences for the composite and sensory analysis scores from each SOT were assessed using Wilcoxon Rank Sum tests. Additionally, we ran Spearman correlations between the NG-SOT composite score and outcomes of interest.

RESULTS

The AUCs for the NG-SOT and T-SOT were 0.950 (0.883, 1) and 0.990 (0.969, 1) respectively (p = 0.168). The median composite, vision, and visual preference scores were lower on the NG-SOT compared to the T-SOT; whereas, the median somatosensory score was higher on the NG-SOT compared to the T-SOT. Associations between the composite score and patient-reported or performance-based outcomes ranged from poor to strong.

CONCLUSIONS

The NG-SOT is a valid measure of balance in adults. However, the results of the NG-SOT and T-SOT should not be used interchangeably.

Association of lower extremity injuries and injury mechanism with previous concussion history in adolescent athletes

OBJECTIVE

Determine the association between concussion and subsequent contact, non-contact, and overuse lower extremity (LE) injuries in a cohort of adolescent athletes. Secondarily, to identify this association between males and females.

STUDY DESIGN

Cross-sectional.

SETTING

Summer athletic events with participants ages 12-18.

MAIN OUTCOME

Anonymous survey included sport-related injuries (injury month/year) and participants classified injuries as a contact, non-contact, overuse injury, or concussion. Multivariable logistic regression analyses were used to examine associations between a concussion event and a subsequent LE injury while controlling for age and any previous LE injury.

RESULTS

A concussion was reported in 219 athletes (Female = 96, 44%) and were matched with 219 non-concussed athletes (438 total participants). Concussion was not association with a specific injury mechanism but was significant for any subsequent LE injury (OR = 1.58 95%CI = [1.03-2.41]; p < 0.05). Concussed females were more likely to report any subsequent LE injury compared to non-concussed female athletes (2.49[1.31, 4.74]; p < 0.01). This relationship was not observed between concussed and non-concussed males (1.11[0.62-1.99]; p > 0.5).

CONCLUSION

A history of concussion was associated with any subsequent LE injury, but not associated with a specific mechanism of injury. The association with concussion and a subsequent LE injury was different between males and females.

Mental Health, Physical Activity, and Quality of Life of US Adolescent Athletes During COVID-19-Related School Closures and Sport Cancellations: A Study of 13 000 Athletes

CONTEXT

In the spring of 2020, US schools closed to in-person teaching and sports were cancelled to control the transmission of coronavirus disease 2019 (COVID-19). It is critical to understand the mental and physical health of adolescent athletes during this time.

OBJECTIVE

To describe the health of athletes during COVID-19-related school closures and sport cancellations.

DESIGN

Cross-sectional study.

SETTING

A national sample recruited via social media.

PATIENTS OR OTHER PARTICIPANTS

A total of 13 002 US adolescent athletes (age = 16.3 ± 1.2 years, females = 52.9%, males = 47.0%) completed an anonymous online survey.

MAIN OUTCOME MEASURE(S)

Demographic information collected was sex, grade, sport(s) played, and zip code. Assessments used were the General Anxiety Disorder 7-Item for anxiety, Patient Health Questionnaire 9-Item for depression, the Pediatric Functional Activity Brief Scale for physical activity, and the Pediatric Quality of Life Inventory 4.0 for quality of life. Mental health, physical activity, and health-related quality-of-life variables were compared among sex, grade, sport(s) played, and poverty level using means and 95% confidence intervals (CIs) from the survey-weighted analysis of variance.

RESULTS

Females reported a higher prevalence of moderate to severe anxiety symptoms (females = 43.7% versus males = 28.2%). The Pediatric Functional Activity Brief Scale score was highest (best) for grade 9 (mean = 14.5, 95% CI = 14.0, 15.0) and lowest for grade 11 (mean = 10.9, 95% CI = 10.5, 11.3). The prevalence of depression symptoms was highest in team sport (74.1%) and lowest in individual sport (64.9%) participants. The total Pediatric Quality of Life Inventory score was lowest (worst) for athletes from counties with the highest poverty levels (high: mean = 74.5, 95% CI = 73.7, 75.3; middle: mean = 78.9, 95% CI = 78.0, 79.8; and low: mean = 78.3, 95% CI = 77.4, 79.1).

CONCLUSIONS

The health of US adolescents during the COVID-19-related school closures and sport cancellations varied to differing degrees depending on sex, grade level, type of sport participation, and level of poverty. Health policy experts should consider these findings in the future when creating and implementing policies to improve the health of adolescents in the United States.

Reference ranges ("normal values") for cardiovascular magnetic resonance (CMR) in adults and children: 2020 update

Cardiovascular magnetic resonance (CMR) enables assessment and quantification of morphological and functional parameters of the heart, including chamber size and function, diameters of the aorta and pulmonary arteries, flow and myocardial relaxation times. Knowledge of reference ranges ("normal values") for quantitative CMR is crucial to interpretation of results and to distinguish normal from disease. Compared to the previous version of this review published in 2015, we present updated and expanded reference values for morphological and functional CMR parameters of the cardiovascular system based on the peer-reviewed literature and current CMR techniques. Further, databases and references for deep learning methods are included.

Interobserver variance and patient heterogeneity influencing the treatment of grade I spondylolisthesis

BACKGROUND CONTEXT

Despite well done randomized clinical trials, the role of fusion as an adjunct to decompression for the treatment of patients with degenerative spondylolisthesis remains controversial. There is substantial variation in the use of fusion as well as the techniques used for fusion for a population of patients all described by a single ICD10 code.

PURPOSE

We sought to investigate the source of the variation in the perceived role of fusion by looking at surgeon as well as patient-specific factors.

STUDY DESIGN

Prospective cohort study examining the variability of recommendations from an expert panel of surgeons-based imaging and clinical vignettes.

PATIENT SAMPLE

Patients with degenerative spondylolisthesis and stenosis.

OUTCOME MEASURES

A six-category treatment schema based on level of invasiveness of proposed surgeries with one through three representing nonfusion strategies and categories four through six representing fusion strategies.

METHODS

The authors are conducting the ongoing spinal laminectomy vs instrumented pedicle screw II study in which patients with grade one degenerative spondylolisthesis and stenosis are randomized to two groups: a review group in which patients are treated as per recommendations of an expert panel and a nonreview group in which patients are treated as per the referring surgeon's preference. In the former (review group), clinical vignettes and radiographic studies were evaluated by an expert panel of spine surgeons. The panel then provided these recommendations to the referring surgeon. We investigated the underlying variability by looking both at the number of similar or different recommendations received by an individual patient (surgeon-related variability) as well as the number of similar or different recommendations offered by individual surgeons across the population of patients (patient heterogeneity). Agreement between surgeons for fusion vs nonfusion (Categories 1-3 vs 4-6) was calculated using a Kappa value from a mixed effects logistic regression model. We looked at Kappa for agreement and weighted Kappa for association of ratings on the ordinal 1 to 6 scale with a mixed effects linear regression model. Additionally, we analyzed the summary of data between patients after averaging the rater scores within patients. Similarly, we summarized the data between surgeons after averaging their scores over the patients that each surgeon reviewed.

RESULTS

One hundred and fourteen patients received 1,463 treatment recommendations. On average, fusion was recommended 58.5% of the time. Overall agreement was low, and perfect agreement on the need for fusion was seen in only 24 (21.1%) of patients. Kappa statistic for agreement on fusion was 0.378 (95% confidence interval 0.324-0.432). The average score across surgeons was 4.2 (0.6) with a range of 3 to 5.3. The most common single recommendation was for fusion with interbody fusion (40.8%) and the lowest was for decompression with noninstrumented fusion (0.5%).

CONCLUSIONS

We demonstrated variability in surgical approach when individual patients were evaluated by a panel of surgeons indicating that even "expert" surgeons disagree with each other regarding the need for fusion in individual patients. We were also able to demonstrate that individual patients received consistent recommendations that were very different from those received by other individuals evaluated by the same surgeons. This indicates that there is patient-related heterogeneity driving variability independent of surgeon factors.

Opioid Use in Robotic-Arm Assisted Total Knee Arthroplasty: A Comparison to Conventional Manual Total Knee Arthroplasty

INTRODUCTION

Opioids are frequently prescribed in the postoperative management of total knee arthroplasty (TKA) with multiple factors influencing postoperative opioid use. Robotic-arm-assisted TKA (raTKA) was developed with the goal of improving alignment and outcomes while decreasing soft tissue injury. The purpose of this study was to compare postoperative opioid consumption in raTKA and conventional manual TKA (mTKA) cohorts.

MATERIALS AND METHODS

A consecutive series of unilateral primary TKAs performed 1/1/16 to 12/31/17 were included. Patients with major procedures requiring opioids occurring within one year of TKA were excluded. A single-surgeon raTKA cohort of 127 patients (Group 1) was compared to a same-surgeon cohort of 119 mTKAs (Group 2) using the same cemented implant design and a two-surgeon cohort of 410 mTKA (Group 3). Groups were subdivided into opioid naïve (ON) and opioid exposed (OE). Length of hospitalization and postoperative opioid utilization up to one year were compared between groups and collectively without separating raTKA and mTKA. Statistical analysis included Chi-square, Student's t-test, and Wilcoxon rank sum tests.

RESULTS

For both ON and OE patients, Group 1 demonstrated reduced inpatient mean daily oral morphine milligram equivalent (MME) compared to Group 3 (ON p=0.007; OE p=0.034), a shorter hospitalization compared to Group 2 (ON p=0.02; OE p=0.012), and fewer opioids prescribed at discharge compared to Group 2 (ON p=0.005; OE p=0.081) and Group 3 (ON p<0.001; OE p=0.036). No differences in opioid prescriptions were seen at three months or after. Regardless of surgical technique OE patients had higher inpatient opioid utilization (p<0.001) as well as cumulative outpatient prescription quantity (MME 1050 ON, 2660 OE) and duration (ON 0.5%; OE 28.3%) at one year (p<0.001).

CONCLUSION

Less opioids were prescribed at discharge and used during hospitalization in raTKA compared to mTKA though no differences in opioid use were seen at further time points. Preoperative opioid use remains a dominant factor in postoperative opioid utilization regardless of TKA surgical technique.

The Health Of Us Adolescent Athletes During Covid-19 Related School Closures And Sport Cancellations

CONTEXT

In the spring of 2020, US schools closed to in-person teaching and sports were cancelled to control the transmission of COVID-19. It is critical to understand the mental and physical health of adolescent athletes during this time.

OBJECTIVE

Describe the health of athletes during COVID-19 related school closures and sport cancellations.

DESIGN

Cross sectional.

SETTING

A national sample recruited via social media.

PATIENTS OR OTHER PARTICIPANTS

13,002 US adolescent athletes (age=16.3+1.2 yrs., female=53.1%) completed an anonymous online survey.

MAIN OUTCOME MEASURE(S)

Demographic information included: sex, grade, sports played and zip code. Assessments included the: General Anxiety Disorder-7 Item (GAD-7) for anxiety, Patient Health Questionnaire-9 Item (PHQ-9) for depression, the Pediatric Functional Activity Brief Scale (PFABS) for physical activity, and the Pediatric Quality of Life Inventory 4.0 (PedsQL) for quality of life. Mental health, physical activity and quality of life variables were compared between sex, grade, sports played and poverty level using means and 95%CI from the survey weighted ANOVA.

RESULTS

Females reported a higher prevalence of moderate to severe anxiety symptoms (females=43.7% vs. males=28.2%). The PFABS score (mean [95%CI] was highest (best) for grade 9 (14.5 [14.0,15.0]) and lowest for grade 11 (10.9 [10.5,11.3]. The prevalence of depression symptoms was highest in team sport (74.1%) and lowest for individual sport participants (64.9%). The total PedsQL score was lowest (worst) for athletes from counties with the highest poverty levels (high=74.5[73.7,75.3], middle=78.9[78.0,79.8], low=78.3 [77.4,79.1]).

CONCLUSIONS

The health of US adolescents during the COVID-19 related school closures and sport cancellations varied to differing degrees depending on sex, grade level, type of sport participation and level of poverty. Health policy experts should consider these findings when creating and implementing policies to improve the health of adolescents in the US in the future.

Does an intrathecal baclofen pump impact scoliosis progression and complicate posterior spine fusion in patients with cerebral palsy?

STUDY DESIGN

Retrospective comparative study.

OBJECTIVES

In patients with cerebral palsy (CP), we determine the impact of intrathecal baclofen pumps (ITBPs) on scoliosis curve progression before posterior spine fusion (PSF) and its effects on surgical outcome.

BACKGROUND

Children with CP can have rapid scoliosis progression, and high rates of surgical complications can be encountered. It is unknown whether the presence of pre-existing ITBP results in more difficult surgery and higher complication rates in similarly affected children.

METHODS

This is a single-center retrospective study of CP patients undergoing PSF over a 15-year period. Demographics, comorbidities, curve magnitudes, and surgical methods were compared between patients with ITBP and those without. Postoperative complications, length of intensive care unit/hospital stay, drain use and output volume, and need for further surgery were also compared. Curve progression analysis after ITBP placement was performed on a subgroup of patients with high-quality consistent radiographs.

RESULTS

Nineteen patients with ITBP and 49 patients without ITBP met inclusion criteria. Age, comorbidities, number of levels fused, and fixation techniques during PSF were not significantly different between cohorts. ITBP patients were more likely to have PSF with osteotomy (p = 0.022). Increased intraoperative neurosurgical consultations were found for patients with ITBP (42.1% vs. 4.0%; p < 0.001). Median surgical time was 1.2 h greater in patients with ITBP (6.7 vs. 5.5 h, p = 0.039). There was no difference in hospital course and complications in patients with ITBP and those without ITBP. Thirty-one patients without ITB were compared with 15 ITBP patients for curve progression before PSF, demonstrating a mean rate of scoliosis progression of 9.6° ± 6.7°/year and 14.8° ± 9.1°/year (p = 0.0346), respectively.

CONCLUSION

The presence of an ITBP appears to be associated with the increase in scoliosis progression; and these patients will likely have a more challenging spine fusion. Fortunately, the final outcome is not affected by ITBP.

LEVEL OF EVIDENCE

Level III.

Use of a Laryngeal Mask Airway Decreases Radiation Exposure During Computed Tomography-Guided Percutaneous Glycerol Rhizotomy for Trigeminal Neuralgia

BACKGROUND

We have been using computed tomography (CT) guidance for percutaneous glycerol rhizotomy (PGR) for the last 7 years. As a quality improvement exercise, we recently began using general anesthesia (GA) with the use of a laryngeal mask airway (LMA) because of our perception that the procedure went faster and that there was less radiation exposure because of less patient movement. We aim to compare PGR radiation exposure and procedural time between patients receiving local anesthetic with sedation and those receiving GA/LMA.

METHODS

A single-center historical cohort study was performed using patients treated with PGR between 2017 and 2019. Ninety-two surgeries were conducted during the study period: 64 surgeries had local anesthetic with intravenous sedation, and 28 surgeries had deeper anesthetic with LMA. Data analyzed included the number of CT sequences obtained, needle placement time, and total radiation dose.

RESULTS

Use of GA/LMA resulted in a 23% decrease in mean radiation dose (565.5 vs. 436.1 μGy × cm, P = 0.014), number of CT sequences required (7.4 vs. 5.7, P = 0.003), and needle placement time (12.8 vs. 9.8 minutes, P = 0.006). Additionally, 10 patients underwent multiple glycerol rhizotomies during the collection period with both anesthetic types being used at least once. Seven of 10 patients (70.0%) had a reduction in total radiation dose, number of CT sequences obtained, and needle placement time when GA/LMA was used. There were no procedure- or anesthetic-related complications in this patient cohort.

CONCLUSIONS

The use of GA/LMA during PGR is associated with decreased radiation exposure without increased anesthetic complications.

CD8β Depletion Does Not Prevent Control of Viral Replication or Protection from Challenge in Macaques Chronically Infected with a Live Attenuated Simian Immunodeficiency Virus

We evaluated the contribution of CD8αβ+ T cells to control of live-attenuated simian immunodeficiency virus (LASIV) replication during chronic infection and subsequent protection from pathogenic SIV challenge. Unlike previous reports with a CD8α-specific depleting monoclonal antibody (mAb), the CD8β-specific mAb CD8β255R1 selectively depleted CD8αβ+ T cells without also depleting non-CD8+ T cell populations that express CD8α, such as natural killer (NK) cells and γδ T cells. Following infusion with CD8β255R1, plasma viremia transiently increased coincident with declining peripheral CD8αβ+ T cells. Interestingly, plasma viremia returned to predepletion levels even when peripheral CD8αβ+ T cells did not. Although depletion of CD8αβ+ T cells in the lymph node (LN) was incomplete, frequencies of these cells were 3-fold lower (P = 0.006) in animals that received CD8β255R1 than in those that received control IgG. It is possible that these residual SIV-specific CD8αβ+ T cells may have contributed to suppression of viremia during chronic infection. We also determined whether infusion of CD8β255R1 in the LASIV-vaccinated animals increased their susceptibility to infection following intravenous challenge with pathogenic SIVmac239. We found that 7/8 animals infused with CD8β255R1, and 3/4 animals infused with the control IgG, were resistant to SIVmac239 infection. These results suggest that infusion with CD8β255R1 did not eliminate the protection afforded to LASIV vaccination. This provides a comprehensive description of the impact of CD8β255R1 infusion on the immunological composition in cynomolgus macaques, compared to an isotype-matched control IgG, while showing that the control of LASIV viremia and protection from challenge can occur even after CD8β255R1 administration.IMPORTANCE Studies of SIV-infected macaques that deplete CD8+ T cells in vivo with monoclonal antibodies have provided compelling evidence for their direct antiviral role. These studies utilized CD8α-specific mAbs that target both the major (CD8αβ+) and minor (CD8αα+) populations of CD8+ T cells but additionally deplete non-CD8+ T cell populations that express CD8α, such as NK cells and γδ T cells. In the current study, we administered the CD8β-specific depleting mAb CD8β255R1 to cynomolgus macaques chronically infected with a LASIV to selectively deplete CD8αβ+ T cells without removing CD8αα+ lymphocytes. We evaluated the impact on control of virus replication and protection from pathogenic SIVmac239 challenge. These results underscore the utility of CD8β255R1 for studying the direct contribution of CD8αβ+ T cells in various disease states.

The Influence of Athletic Trainers on the Incidence and Management of Concussions in High School Athletes

CONTEXT

In many US high schools, the athletic trainer (AT) has the responsibility to identify and manage athletes with concussions. Although the availability of ATs varies a great deal among schools, how the level of AT availability in high schools affects the reported incidence and management of sport-related concussions (SRCs) is unknown.

OBJECTIVE

To determine how the presence of an AT affects the reporting and management of SRCs.

DESIGN

Prospective cohort study.

PATIENTS OR OTHER PARTICIPANTS

A total of 2459 (female = 37.5%, age = 16.1 ± 1.2 years) athletes from 31 Wisconsin high schools were categorized as having low availability (LoAT), mid availability (MidAT), or high availability (HiAT) of ATs. Athletic trainers recorded the incidence, days lost from sport, and postconcussion management through return to sport. The incidence of SRC reporting among categories was examined using a multivariate Cox proportional hazards model. Fisher exact tests were used to determine if postconcussion management differed based on AT availability.

RESULTS

The incidence of reported SRCs was lower for the LoAT schools (2.4%) compared with the MidAT (5.6%, hazard ratio = 2.59, P = .043) and HiAT (7.0%, hazard ratio = 3.33, P = .002) schools. The median time before the first AT interaction was longer for LoAT schools (24.0 hours) than for MidAT (0.5 hours, post hoc P = .012) and HiAT (0.2 hours, post hoc P = .023) schools. The number of post-SRC interactions was different in all groups (LoAT = 2 interactions, MidAT = 3, and HiAT = 4; all post hoc P values < .05). Days lost were greater for MidAT and HiAT (both 14 days lost) schools compared with LoAT schools (11.5 days lost, post hoc P = .231 and P = .029, respectively). Athletes at LoAT schools were less likely to undergo a return-to-play protocol (9/18 SRCs, 50.0%) than athletes at MidAT (44/47 SRCs, 93.6%; post hoc P = .001) or HiAT (64/64 SRCs, 100%; post hoc P < .001) schools.

CONCLUSIONS

The level of AT availability positively influenced the reported incidence of SRCs as well as postconcussion management activities in this sample of high schools.

School and Community Socioeconomic Status and Access to Athletic Trainer Services in Wisconsin Secondary Schools

CONTEXT

Secondary schools have made significant progress in providing athletic trainer (AT) coverage to their student-athletes, but the levels of access at schools with ATs may vary widely. Socioeconomic disparities in medical coverage and access have been noted in other health care fields, but such disparities in the level of access to AT services have not been thoroughly examined.

OBJECTIVE

To determine if (1) access to AT services or (2) the level of access (AT hours per week and athletes per AT hour) differed based on the socioeconomic characteristics of secondary schools.

DESIGN

Cross-sectional study.

SETTING

Mailed and e-mailed surveys.

PATIENTS OR OTHER PARTICIPANTS

High school athletic directors and ATs from 402 Wisconsin high schools.

MAIN OUTCOME MEASURE(S)

Respondents provided information as to whether their school used the services of an AT and the number of hours per week that their school had an AT on-site. The number of athletes per AT hour was calculated by dividing the total number of athletes at the school by the number of hours of AT coverage per week. The socioeconomic status of each school was determined using the percentage of students with free or reduced-cost lunch and the county median household income (MHI).

RESULTS

Schools without an AT on-site were in lower MHI counties ( P < .001) and had more students eligible for a free or reduced-cost lunch ( P < .001). Lower levels of AT access (fewer hours of AT access per week and more athletes per AT hour) were observed at schools in the lowest third of the county MHI and with the highest third of students eligible for a free or reduced-cost lunch ( P < .001).

CONCLUSIONS

Socioeconomic disparities were present in access to AT services. New models are needed to focus on providing a high level of AT access for all student-athletes, regardless of socioeconomic status.

Physical Therapist, Physical Therapist Assistant, and Student Response to Inappropriate Patient Sexual Behavior: Results of a National Survey

BACKGROUND

A recent survey found that 84% of physical therapist, physical therapist assistant, and student respondents experienced inappropriate patient sexual behavior (IPSB) over their careers and 47% over the prior 12 months. Prevalence data justify consideration of how to address IPSB.

OBJECTIVE

The objective was to determine how physical therapist clinicians (used here to mean physical therapists, physical therapist assistants, and students) address IPSB and examine strategy impact.

DESIGN

The design was observational and cross-sectional.

METHODS

Several sections of the American Physical Therapy Association and selected education programs fielded the electronic survey. Respondents reported on the frequency and effect of IPSB response strategy. Response-strategy impact was tested for statistical significance. Open-ended comments were analyzed using qualitative methods.

RESULTS

Of 1027 respondents, 396 had experienced IPSB over the prior 12 months; 391 provided data on the frequency and effect of response strategies used. Common informal responses included distraction, ignoring IPSB, and altering treatment to avoid physical contact or being alone. Common formal responses included reporting the behavior within the facility and documenting the behavior. Successful strategies included distraction, avoidance, direct confrontation, behavioral contracts, transfer of care, and chaperone use. Experienced clinicians were more likely to be direct, whereas novice clinicians were more likely to engage in unsuccessful actions of ignoring and joking.

LIMITATIONS

Limitations included self-report, clinician memory, and convenience sampling.

CONCLUSIONS

The first findings in 20 years on physical therapist, physical therapist assistant, and student response to IPSB provide direction for the profession. Results indicate a need for clear workplace policies coupled with training for managers and supervisors to support clinicians in resolving IPSB. Policies on using behavioral contracts, chaperones, and transfer of care could empower staff to consider these successful options. Professional education and training for all physical therapy professionals on assertive communication and redirection strategies with IPSB appears warranted.

Associations between pain coping and opioid use: One-month follow-up results of a prospective study in a cohort of traumatic injury patients

OBJECTIVE

To examine associations between Pain Catastrophizing Scale (PCS) scores and daily opioid dosage in traumatic injury patients.

DESIGN

This was a prospective cohort study with patient assessments at baseline and 1-month following discharge.

SETTING

Study visits were conducted at a Regional Level I Trauma Center and by phone at follow-up.

PATIENTS

Forty-nine injured inpatients completed baseline PCS. A subsample of 23 patients continued to take prescribed opioid medication at 1-month postdischarge and were included in the current analyses.

MAIN OUTCOME MEASURED

Associations between baseline PCS and morphine equivalent daily dose (MEDD) at 1-month follow-up.

RESULTS

Controlling for baseline MEDD, baseline PCS score was positively associated with MEDD at 1-month postdischarge (β= 0.577 [0.399, 1.535]; p = 0.002; R² of PCS = 0.395).

CONCLUSIONS

In the current sample of traumatic injury inpatients, findings indicated that a baseline measure of pain catastrophizing predicts ongoing opioid medication use and dosage at 1-month postdischarge from an inpatient trauma unit.

Effects of losartan and allopurinol on cardiorespiratory regulation in obstructive sleep apnoea

NEW FINDINGS

What is the central question of this study? In sleep apnoea, a putative link between intermittent hypoxia and hypertension is the generation of oxygen radicals by angiotensin II and xanthine oxidase within the chemoreflex arc and vasculature. We tested whether chemoreflex control of sympathetic outflow, hypoxic vasodilatation and blood pressure are altered by angiotensin blockade (losartan) and/or xanthine oxidase inhibition (allopurinol). What is the main finding and its importance? Both drugs lowered blood pressure without altering sympathetic outflow, reducing chemoreflex sensitivity or enhancing hypoxic vasodilatation. Losartan and allopurinol are effective therapies for achieving blood pressure control in sleep apnoea.

ABSTRACT

Chemoreflex sensitization produced by chronic intermittent hypoxia in rats is attenuated by angiotensin II type 1 receptor (AT₁ R) blockade. Both AT₁ R blockade and xanthine oxidase inhibition ameliorate chronic intermittent hypoxia-induced endothelial dysfunction. We hypothesized that treatment with losartan and allopurinol would reduce chemoreflex sensitivity and improve hypoxic vasodilatation in patients with obstructive sleep apnoea. Eighty-six hypertensive patients with apnoea-hypopnoea index ≥25 events h^-1 and no other cardiovascular, pulmonary, renal or metabolic disease were randomly assigned to receive allopurinol, losartan or placebo for 6 weeks. Treatment with other medications and/or continuous positive airway pressure remained unchanged. Tests of chemoreflex sensitivity and hypoxic vasodilatation were performed during wakefulness before and after treatment. Ventilation (pneumotachography), muscle sympathetic nerve activity (microneurography), heart rate (electrocardiography), arterial oxygen saturation (pulse oximetry), blood pressure (sphygmomanometry), forearm blood flow (venous occlusion plethysmography) and cerebral flow velocity (transcranial Doppler ultrasound) were measured during eupnoeic breathing and graded reductions in inspired O₂ tension. Losartan and allopurinol lowered arterial pressure measured during eupnoeic breathing and exposure to acute hypoxia. Neither drug altered the slopes of ventilatory, sympathetic or cardiovascular responses to acute hypoxia. We conclude that losartan and allopurinol are viable pharmacotherapeutic adjuncts for achieving blood pressure control in hypertensive obstructive sleep apnoea patients, even those who are adequately treated with continuous positive airway pressure.

Prospective Comparison of the Diagnostic Accuracy of MR Imaging versus CT for Acute Appendicitis

Purpose To compare the accuracy of magnetic resonance (MR) imaging with that of computed tomography (CT) for the diagnosis of acute appendicitis in emergency department (ED) patients. Materials and Methods This was an institutional review board-approved, prospective, observational study of ED patients at an academic medical center (February 2012 to August 2014). Eligible patients were nonpregnant and 12- year-old or older patients in whom a CT study had been ordered for evaluation for appendicitis. After informed consent was obtained, CT and MR imaging (with non-contrast material-enhanced, diffusion-weighted, and intravenous contrast-enhanced sequences) were performed in tandem, and the images were subsequently retrospectively interpreted in random order by three abdominal radiologists who were blinded to the patients' clinical outcomes. Likelihood of appendicitis was rated on a five-point scale for both CT and MR imaging. A composite reference standard of surgical and histopathologic results and clinical follow-up was used, arbitrated by an expert panel of three investigators. Test characteristics were calculated and reported as point estimates with 95% confidence intervals (CIs). Results Analysis included images of 198 patients (114 women [58%]; mean age, 31.6 years ± 14.2 [range, 12-81 years]; prevalence of appendicitis, 32.3%). The sensitivity and specificity were 96.9% (95% CI: 88.2%, 99.5%) and 81.3% (95% CI: 73.5%, 87.3%) for MR imaging and 98.4% (95% CI: 90.5%, 99.9%) and 89.6% (95% CI: 82.8%, 94.0%) for CT, respectively, when a cutoff point of 3 or higher was used. The positive and negative likelihood ratios were 5.2 (95% CI: 3.7, 7.7) and 0.04 (95% CI: 0, 0.11) for MR imaging and 9.4 (95% CI: 5.9, 16.4) and 0.02 (95% CI: 0.00, 0.06) for CT, respectively. Receiver operating characteristic curve analysis demonstrated that the optimal cutoff point to maximize accuracy was 4 or higher, at which point there was no difference between MR imaging and CT. Conclusion The diagnostic accuracy of MR imaging was similar to that of CT for the diagnosis of acute appendicitis.

Increased Leg Bone Mineral Density and Content During the Initial Years of College Sport

Scerpella, JJ, Buehring, B, Hetzel, SJ, and Heiderscheit, BC. Increased leg bone mineral density and content during the initial years of college sport. J Strength Cond Res 32(4): 1123-1130, 2018-Bone mineral density (BMD) and bone mineral content (BMC) data are useful parameters for evaluating how training practices promote bone health. We used dual-energy X-ray absorptiometry (DXA) to longitudinally assess sport-specific growth in leg and total body BMD/BMC over the initial 2 years of collegiate training. Eighty-five Division 1 collegiate basketball, hockey, and soccer athletes (50 males and 35 females; age 19.0 [0.8] years) underwent annual DXA scans. Leg and total body BMD/BMC were compared within and across two 1-year intervals (periods 1 and 2) using repeated-measures analysis of variance, adjusting for age, sex, race, and sport. Leg BMD, leg BMC, and total body BMC all increased over period 1 (0.05 g·cm [p = 0.001], 0.07 kg [p = 0.002], and 0.19 kg [p < 0.001] respectively). Changes in period 2 compared with period 1 were smaller for leg BMD (p = 0.001), leg BMC (p < 0.001), leg fat mass (p = 0.028), and total BMC (p = 0.005). Leg lean mass increased more during period 2 than period 1 (p = 0.018). Sports participation was the only significant predictor of change in leg BMD. Significant increases in both leg BMD and BMC were demonstrated over both 2-year periods, with greater gains during period 1. These gains highlight the importance of attentive training procedures, capitalizing on attendant physical benefits of increased BMD/BMC. Additional research in young adults, evaluating bone mass acquisition, will optimize performance and decrease risk of bone stress injury among collegiate athletes.

Iron Deficiency and Anemia among Collegiate Athletes: A Retrospective Chart Review

PURPOSE

To describe the prevalence of anemia among incoming female college athletes and to characterize the results and expenses of iron-related testing at one National Collegiate Athletic Association Division I institution.

METHODS

In this retrospective medical record review, hemoglobin (Hgb) and ferritin laboratory values were obtained for student-athletes at a single institution, 2002 to 2014. Laboratories were collected either as part of the preparticipation examination (PPE) for female athletes, routine screening for cross-country athletes, or as needed for medical evaluation. Anemia was defined as Hgb < 11.6 g·dL for females and < 13.6 g·dL for male athletes. Iron deficiency was defined as Fer < 20 ng·mL for both sexes.

RESULTS

A total of 5674 laboratory draws were obtained for 2749 individuals (56% female) from 25 different teams. The prevalence of low Hgb among female athletes at PPE was 5.7% (95% confidence interval, 4.4%-6.9%). At PPE, the incidence of anemia was not significantly higher for any sport when compared with the group mean. Ferritin and Hgb were collected together in approximately one third of all blood draws from females (n = 1059) and one sixth of blood draws from males (n = 411). For female athletes, 2.2% indicated iron deficiency anemia and 30.9% indicated iron deficiency without anemia. For male athletes, 1.2% indicated iron deficiency anemia and 2.9% indicated iron deficiency without anemia. The median cost of iron testing exceeded US $20,000 annually for the institution.

CONCLUSIONS

One in 20 incoming female athletes was identified with anemia at the PPE. Given the costs of testing, screening practices at each institution should be thoughtfully selected and routinely reassessed.

Isokinetic Strength Deficit 6 Months After Adductor Canal Blockade for Anterior Cruciate Ligament Reconstruction

Background

Recent evidence shows a delayed return to sport in children and delayed quadriceps recovery in both adults and children who have undergone anterior cruciate ligament (ACL) reconstruction with concomitant femoral nerve blockade (FNB) compared with those who had no blockade. We evaluated the use of adductor canal blockade (ACB), as an alternative to FNB, at the time of ACL reconstruction.

Hypothesis

Patients who receive ACB will have greater isokinetic strength at 6 months postoperative compared with patients who receive FNB at the time of ACL reconstruction.

Study Design

Cohort study; Level of evidence, 3.

Methods

A retrospective record review was performed at a single academic medical center to identify all patients aged ≥16 years who had undergone ACL reconstruction with blockade between January 2010 and January 2015. Exclusion criteria included (1) non-sports medicine fellowship-trained surgeon performing the procedure, (2) continuous nerve catheter or concurrent epidural used, (3) revision ACL reconstruction or multiligament reconstruction as the index procedure, (4) previous contralateral ACL reconstruction, (5) concurrent microfracture, and (6) additional surgery within the 6-month outcome period that affected recovery. Isokinetic strength testing was performed using a computerized dynamometer, measuring total work at fast speed and peak torque at slow speed at 6 months; results were evaluated as a percentage of the nonoperative side. Multivariate regression analysis was used to evaluate the effect of block type on isokinetic strength outcome variables, controlling for age, sex, body mass index, graft type, and surgeon.

Results

There were 230 patients receiving FNB and 30 patients receiving ACB included in the study. The multivariate regression analysis identified a greater side-to-side deficit in extension total work for the ACB group compared with the FNB group (P = .040), after controlling for age, sex, body mass index, graft type, and surgeon.

Conclusion

Compared with FNB, ACB for ACL reconstruction is associated with a persistent fast-activation isokinetic strength deficit at 6 months after surgery. This is the first study to compare FNB to ACB, and results are concerning for patients planning an early return to sport.