Cardiovascular Medicine

Are women really more affected by vasovagal syncope than men? It is commonly reported that vasovagal syncope (VVS) is more frequent in women. Presently, this issue has never been investigated. The purpose of this review was to evaluate, through an extensive review of the literature, whether women are really more affected by VVS than men. The gender distribution was investigated in individuals with classical and nonclassical VVS. The database PubMed was searched using the terms 'syncope', 'vasovagal syncope', 'neurally mediated syncope' and 'tilt testing'. Twelve studies dealing with classical and 75 with nonclassical VVS were eligible. In the individuals with classical (N = 1861) and nonclassical VVS (N = 9696), a trend towards a greater percentage of women emerged (P = 0.14 and 0.07, respectively). In the total population with VVS (N = 11 557), the percentage of women was significantly higher than that of men (58 versus 42%, P = 0.03). Most of the individuals were young or middle-aged. In 84% of the studies, the percentage of women was greater than that of men. A separate analysis was carried out in older VVS patients (≥60 years) and only two studies were eligible to be evaluated. Considering that almost all the studies were carried out in the western nations, where the number of men and women is almost superimposable until the age of 65 years and a bias by gender has never been reported in the management of VVS, these data strongly suggest that young and middle-aged women are more affected by VVS than their male counterparts. At present, data are too scant to draw a definitive conclusion in older VVS patients.

Pathophysiology and management of recreational drug-related acute coronary syndrome: ANMCO position statement Recreational drug use may cause coronary artery disease through several mechanisms. An increasing number of young patients with drug-related acute coronary syndrome have been reported over recent years. The present position statement reports the most recent epidemiological data on acute coronary syndrome in the setting of drug abuse, describes the main pathophysiological mechanisms underlying coronary artery disease and acute events in these patients, and provides practical recommendations on management and an overview of prognosis.

Cardiac resynchronization therapy: variations across Europe in implant rates and types of implanted devices No abstract available

Clinical performance of a novel sirolimus-coated balloon in coronary artery disease: EASTBOURNE registry Aims The purpose of the EASTBOURNE registry is to evaluate the immediate and long-term clinical performance of a novel sirolimus-coated balloon (SCB) in a real-world population of patients with coronary artery disease. We here present the prespecified interim analysis after the enrollment of the first 642 patients who obtained 1-year clinical follow-up. Methods EASTBOURNE is a prospective, international, multicenter, all-comer investigator-driven clinical registry, which is enrolling consecutive patients treated with SCB at 42 European and Asiatic centers. Primary study endpoint is target-lesion revascularization (TLR) at 12 months. Secondary endpoints are procedural success and major adverse cardiac events through 36 months. Results Diabetes mellitus was present in 41% of patients. Acute coronary syndrome was present in 45% of patients and de novo lesions were 55%; 83% of the in-stent restenosis (ISR) patients had drug-eluting stents restenosis. Lesion predilatation was performed in 95% of the cases and bailout stenting occurred in 7.5%. So far, 642 patients have a complete 12-month follow-up. TLR occurred in 2.5%, myocardial infarction in 2.3%, total death in 1% and major adverse cardiac events in 5.8% of patients. A prespecified analysis of comparison between ISR and de-novo lesions showed a significantly higher occurrence of TLR in the ISR population (5.4 vs. 0.2%, P = 0.0008). Conclusion The current interim analysis of 12-month follow-up of the EASTBOURNE registry shows good immediate performance and an adequate and encouraging safety profile through 12 months for this novel SCB.

Sirolimus-coated balloons: ready for primetime in real world patients? No abstract available

Clinical and electrocardiographic features of patients with myocardial infarction with non-obstructive coronary artery disease (MINOCA) Aims Myocardial infarction with non-obstructive coronary artery disease (MINOCA) is often an underdiagnosed and undertreated condition. This study aimed to evaluate clinical and ECG characteristics of MINOCA in a large cohort of patients admitted for acute coronary syndrome. Methods All coronary angiograms performed at the University Heart Center in Zurich (Switzerland) between 2012 and 2016 were investigated. MINOCA was defined according to European Society of Cardiology guidelines and patients were divided into two groups, based on the presence or absence of coronary sclerosis at angiogram[nonobstructive coronary artery disease (noCAD) and normal coronary arteries (NCA)]), after exclusion of myocarditis and Takotsubo syndrome. Results Out of 13 669 angiographic studies, 3695 were diagnosed with acute coronary syndrome; of these, 244 patients presented MINOCA (6.6%). Patients with noCAD were more likely to be older (67.9 vs. 59.2 years, P < 0.001) with higher prevalence of traditional cardiovascular risk factors (hypertension 64.1 vs. 41.2%, P = 0.002; diabetes 19.7 vs. 10.8%, P = 0.036; hypercholesterolemia 36.6 vs. 23.5%, P = 0.037). On surface ECG, anterior ST- segment elevation was more frequent in NCA patients (13.7 vs. 5.0%, P = 0.016). Secondary prevention therapy was significantly more prescribed in noCAD compared with NCA patients (acetylsalicylic acid 68.3 vs. 21.6%, P less than 0.001; statins 76.1 vs. 22.5%, P less than 0.001; angiotensin-converting enzyme inhibitor–AT1 blockers 51.4 vs. 31.3%, P = 0.006). One-year mortality was very low (0.4% for noCAD patients). Conclusion noCAD patients were older, with higher prevalence of cardiovascular risk factors and more frequently discharged with secondary prevention therapy. NCA patients presented more frequently anterior ST- segment elevation. Further diagnostic tests should be highly recommended to determine the underlying mechanism of MINOCA.

Arrhythmic event prediction in patients with heart failure and reduced ejection fraction Aims Implantable cardioverter defibrillator (ICD) is an effective treatment to reduce mortality in patients with symptomatic heart failure and left ventricular ejection fraction (LVEF) 35% or less. LVEF presents a low sensitivity for predicting arrhythmic events. Aim of this study was to identify predictors of sustained ventricular arrhythmias (SVAs), overall and according to the cause of heart failure. Methods Single-center, retrospective, cohort study of 193 patients (51 nonischemic and 142 ischemic) with chronic heart failure and LVEF less than 35% who had received ICD for primary prevention of sudden cardiac death. We collected clinical data, echocardiographic parameters and SVAs detected by the ICD. Results During a median follow-up of 1440 days, 32 (16.2%) patients had SVAs. SVAs incidence was similar in patients with nonischemic (15.6%) and ischemic cause of heart failure (16.9%). Hypertension, diabetes, chronic renal failure, atrial fibrillation, chronic obstructive pulmonary disease, New York Heart Association class at least III were predictors at univariate analysis of SVAs. A clinical score, assigning one point to each of these variables, was associated with a significantly increased risk of SVAs [odds ratio for each point increase = 1.92, 95% confidence interval 1.40–2.65, P < 0.0001, area under the curve (AUC) 0.73], with 72% sensitivity and 60% specificity for a cutoff at least three and remained significant in nonischemic (AUC 0.84) and ischemic (AUC 0.68) patients. Conclusion Our study shows the benefit of ICD implantation in primary prevention and its independency of cause. A simple clinical score, based on comorbidities, identifies patients with more benefits from ICD implantation.

Frequency, predictors and prognostic impact of implantable cardioverter defibrillator shocks in a primary prevention population with heart failure and reduced ejection fraction Aims The role of the implantable cardioverter defibrillator (ICD) in primary prevention real-world population is debated. We sought to evaluate the incidence, predictors and prognostic impact of ICD shocks in consecutive heart failure patients implanted for primary prevention at our tertiary institution. Methods and results We retrospectively selected a sample of 497 patients (mean age 64.8 years, 82.1% men, average left ventricular ejection fraction, LVEF, 27.1%). At long-term follow-up (median time 70.4 months), total mortality was 40.8%, and 16.5% of patients had received at least one appropriate shock (3.12%/year). Inappropriate shock [odds ratio (OR) 1.93, 95% confidence interval (95% CI) 1.08–3.47; P = 0.027] and length of follow-up (1 year, OR 1.01, 95% CI 1.00–1.01; P = 0.0031) were associated with the occurrence of appropriate shock, whereas atrial fibrillation (OR 2.65, 95% CI 1.55–4.51, P < 0.001), length of follow-up (1-year OR 1.01, 95% CI 1.00–1.01, P < 0.001) and appropriate shock (OR 1.93, 95% CI 1.08–3.47, P = 0.027) were associated with the occurrence of inappropriate shock. Neither appropriate nor inappropriate shock independently increased mortality risk, whereas older age (hazard ratio 1.05; 95% CI 1.04–1.07; P < 0.001), atrial fibrillation (hazard ratio 2.25; 95% CI 1.67–3.02; P < 0.001) and lower LVEF (hazard ratio 0.97; 95% CI 0.94–0.99; P = 0.004) did. Conclusion Incidence of shocks in real-world primary prevention ICD recipients might be lower than expected, and the association between ICD shocks and prolongation of survival is not as clear-cut as might be perceived. Further investigations from larger real-world samples are warranted.

A cohort study examining urgent and emergency treatment for decompensated severe aortic stenosis Aims We compared strategies in the treatment of decompensated severe aortic stenosis. The hypothesis was that undertaking urgent or emergency transcatheter aortic valve implantation (TAVI) directly in such patients is safer and more effective than urgent or emergency balloon aortic valvuloplasty (BAV) followed by elective TAVI or surgical aortic valve replacement (SAVR). Methods This was a single-centre retrospective study including all consecutive patients who underwent urgent or emergency BAV or TAVI for decompensated severe aortic stenosis between September 2014 and February 2018. Primary endpoints were 30-day and 1-year mortality. Results Fifty-two patients underwent urgent or emergency BAV and 87 underwent TAVI. Baseline characteristics of the two groups were well matched. Significant differences were noted between the two groups in 30-day all-cause mortality (88.5% BAV patients alive at 30 days, 97.7% TAVI patients; P < 0.05) and 1-year all-cause mortality (44.2% BAV patients alive at 1 year, 88.5% TAVI patients; P < 0.001). At 1 year, the estimated hazard ratio for patients undergoing BAV was 11.2 (95% confidence interval: 4.67–26.9; P < 0.001) when adjusted for potential confounding variables. Patients in the BAV group who successfully underwent subsequent TAVI or SAVR all survived for 365 days, but there was no significant 1-year mortality difference compared with those who underwent urgent or emergency TAVI (100 vs. 88.5%; P > 0.155). Conclusion Our results suggest treatment of decompensated severe aortic stenosis with urgent or emergency TAVI may be associated with improved survival outcomes when compared with a strategy of performing BAV as a bridge to subsequent TAVI or SAVR.

Pacemaker need after sutureless aortic valve replacement: the role of the learning curve Aim Aortic valve replacement (AVR) using sutureless prosthesis is a reasonable alternative in those patients with aortic stenosis who would benefit from reduced cross clamp time, such as elderly and high-risk patients. Actually, excellent performances have been demonstrated in hemodynamic outcomes and safety, but some questions remain open regarding long-term durability and the need for postoperative pacemaker implantation. Methods Between January 2014 and August 2019, all 436 patients [male 40.6%, median age 78 years interquartile range (73–82)] treated with sutureless AVR with a Perceval prosthesis were included in our analysis. Results The univariate logistic regression showed previous aortic valve surgery [P = 0.028; odds ratio (OR) 3.248], dialysis (P = 0.036; OR 6.435), renal insufficiency (P = 0.021; OR 2.75), EuroSCORE II (P = 0.016; OR 1.051) and year of operation (P < 0.01; OR 0.658) as factors associated with the development of atrioventricular type II or type III block or junctional block requiring pacemaker implantation. The overall incidence of pacemaker implantation after sutureless AVR was 7.1% in the current study, but it dropped to 3.8 and 4.7%, respectively, in 2018 and 2019. Conclusion The Perceval aortic valve is associated with encouraging postoperative results. The incidence of pacemaker implantation is strictly linked to the surgeons' experience, decreasing year by year after an adequate sizing, reaching a percentage comparable with sutured valve.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Reproductive and Developmental Medicine

Luteotropic roles of glucocorticoids in rat granulosa cells Xin-Yan Huang, Yin-Yan Xu, Juan Xie, Li Wang Reproductive and Developmental Medicine 2020 4(4):195-203 Objective: The study objective was to investigate whether endogenous glucocorticoids directly impact the functions and proliferation/apoptosis of ovarian granulosa cells. Methods: Primary rat ovarian granulosa cells were cultured and treated with graded concentrations of corticosterone either alone or in the presence of the indicated drugs. After 48 h of treatment, the cells and growth media were collected to measure intracellular and extracellular progesterone/estradiol concentrations, and steroid secretion ratios were obtained by parameter calculation. The number of granulosa cells was determined by Cell Counting Kit-8. To determine the impact on cell numbers, granulosa cell proliferation was detected using the BrdU incorporation method and cell apoptosis was detected by flow cytometry. Results: First, high corticosterone concentrations significantly stimulated progesterone synthesis/secretion and inhibited estradiol synthesis in cultured granulosa cells. Second, accompanied by follicle-stimulating hormone, high corticosterone concentrations promoted progesterone synthesis/release and estradiol release. Last, high corticosterone concentrations increased the cell number and suppressed apoptosis but did not induce cell proliferation. Conclusions: These indicate that high glucocorticoid concentrations may play luteotropic roles in the functions and number of corpora lutea.

Benzyl alcohol-benzyl benzoate clearing reveals the dose-dependent effect of cyclophosphamide on follicle damage in mice Qi-Wang Lin, He Fei, Yun-Feng Jin, Kun-Peng Wu, Xin Dai, Ying Qu, Hua Jiang Reproductive and Developmental Medicine 2020 4(4):204-211 Objective: Cyclophosphamide (CTX), which is commonly used in clinical chemotherapy, has a damaging effect on ovarian follicles. This study aimed to establish a new method to count the number of follicles in mouse ovaries using benzyl alcohol–benzyl benzoate (BABB)-based tissue-clearing technology and evaluate the follicle-damaging effects of different doses of CTX. Methods: C57BL/6 mice were divided into four groups and administered intraperitoneal injections of 0, 40, 80, or 120 mg/kg CTX. The serum levels of estradiol (E2) and follicle-stimulating hormone (FSH) were detected using an ELISA kit. Mouse ovaries were subjected to BABB clearing and labeled with DAPI, β-actin, and DDX4 to observe the ovarian structure and follicles. A three-dimensional software, Imaris, was used to reconstruct the ovarian structure and automatically count the number of follicles. The effects of different CTX doses on the total follicle number and estrous cycle were determined. Results: As the CTX dose increased, E2 levels in CTX mice declined from 212.3 to 57.7 pg/mL; the FSH levels increased from 3.2 to 29 ng/mL. Mouse ovaries became transparent after BABB treatment. After fixation, microscopy, and Imaris processing, immunofluorescence signals of β-actin and DAPI from all levels in intact ovaries could be obtained and follicle number in half ovaries could be automatically counted using anti-DDX4 antibody labeling. In the NC, CTX40, CTX80, and CTX120 groups, the proportion of mice in the diestrus phase was 26.67%, 51.67%, 73.33%, and 95.00%, respectively, and the total follicle number was 2,603, 1,761, 1,043, and 262, respectively. E2 levels were positively correlated with follicle number and FSH levels were negatively correlated with follicle number, indicating that the damaging effect of CTX on follicle number may be dose dependent. Conclusion: BABB can be used to clear intact ovaries from adult mice, and follicle number in half ovaries can be automatically counted. The damaging effect of CTX on follicles and the endocrine system is dose dependent.

Selection and evaluation of optimal reference genes for quantitative reverse transcription-polymerase chain reaction analyses of gene expression in human spermatozoa Chun-Hai Luo, Yun-Ge Tang, Shi-Hao Hong, Yuan Tang, Ying Zhang, Fei Sun Reproductive and Developmental Medicine 2020 4(4):212-218 Objective: Optimal reference genes are critical for accurate normalization and reliable interpretation of gene expression quantification data. Recently, several strategies have been utilized for validating reference genes in different human tissues. However, no universal reference genes have been described that accurately summarize transcriptional activity in human spermatozoa. Methods: Using quantitative reverse transcription-polymerase chain reaction (RT-qPCR), we evaluated ten commonly used candidate reference genes between two groups of human cryopreserved donor sperm with different pregnancy rates. We assessed the stability of reference genes using three different algorithms, namely geNorm, NormFinder, and BestKeeper. We then identified the most stable reference genes. Results: Male-enhanced antigen 1 (MEA1) was identified as the most stably expressed reference gene, followed by testis-enhanced gene transcript (TEGT). Conclusions: We comprehensively identified MEA1 and TEGT as the most stably expressed reference genes for the normalization of gene expression data in human spermatozoa.

Alteration of apoptotic gene expression and reproductive parameters through Thymus vulgaris administration following paclitaxel-induced testopathy in micea Shiva Roshankhah, GholamReza Hassanzadeh, Azita Faramarzi, Mohammad Reza Salahshoor Reproductive and Developmental Medicine 2020 4(4):219-227 Objective: Paclitaxel (PAC) is a chemotherapy drug and has an active role in the treatment of lung, breast, and ovarian cancers; however, its use causes increased levels of free radicals, leading to severe and irreversible organ damage. Thymus vulgaris is a species of flowering plant that contains various antioxidant chemical compounds. This study aimed to investigate the effect of T. vulgaris on PAC-induced oxidative damage in mice testis and sperm parameters. Methods: In this study, 40 BALB/c mice were divided into five groups: normal control (NC); positive control (20 mg/kg of PAC); and three treatment groups (4.5, 9, and 18 mg/kg doses of T. vulgaris extract + 20 mg/kg PAC). Treatments were administered intraperitoneally daily for 50 days. Finally, the levels of serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), and testosterone were measured using immunoassay method. Testicular stereological features and sperm parameters were also calculated. Antioxidant parameters were measured using nitrite oxide (NO) and perioxidation levels and ferric-reducing ability of plasma assay. The expressions of p53, caspase-3, Bax, and Bcl-2 were measured through real-time quantitative polymerase chain reaction. Results: T. vulgaris + PAC treatments at all doses significantly increased all parameters in NC and three treatment groups compared with the positive control group (20 mg/kg of PAC) (P < 0.05), except the LH, FSH, and NO levels, which were decreased. Further, significantly downregulated levels of p53, caspase-3, and Bax genes and? upregulated levels of Bcl-2 gene expression were noted in NC and three treatment groups in comparison with the positive control group (P < 0.05). Conclusions: T. vulgaris administration attenuates the toxic effects of PAC on male reproductive parameters.

Potential application of anti-müllerian hormone in polycystic ovary syndrome according to chinese classification criteria: A retrospective analysis Ling-Li Tang, Ling-Shan Zhang, Xiao-Yong Zhu, Ying-Li Shi Reproductive and Developmental Medicine 2020 4(4):228-232 Objective: Anti-Müllerian hormone (AMH) expression is elevated in patients with polycystic ovary syndrome (PCOS), however, its clinical significance is not clear. Owing to the strong correlation between AMH and polycystic ovarian morphology (PCOM), some studies believe that AMH alone can be used to diagnose PCOS. The aim of this study was to explore whether AMH can be used to diagnose PCOS and to differentiate the various PCOS subtypes. Methods: This was a retrospective study of 503 patients with PCOS. Patients were divided into eight subtypes based on the presence/absence of hyperandrogenemia (HA), insulin resistance (IR), or obesity (OB). The expression characteristics of AMH in each subtype were analyzed. Due to the small number of patients with subtypes 7 and 8, only patients with subtypes 1–6 were included in the analysis. Results: AMH showed a good positive correlation with PCOM (P = 0.000) and negative correlations with OB (P = 0.000) and IR (P = 0.003). The free testosterone index showed no correlation with AMH (P = 0.803). The percentages of patients with each subtype (excluding subtypes 7–8) and their respective AMH levels were as follows: Type 1 (HA + NIR + OB) 4.77% and 9.12 ng/mL; Type 2 (HA + IR + NOB) 20.68% and 10.34 ng/mL; Type 3 (HA + NIR + NOB) 23.66% and 9.47 ng/mL; Type 4 (HA + IR + OB) 30.82% and 8.32 ng/mL; Type 5 (NHA + NIR + NOB) 11.73% and 10.0 ng/mL; and Type 6 (NHA + IR + NOB) 6.16% and 9.76 ng/mL. The diagnostic rates of AMH (>8.09 ng/mL) and ultrasound for PCOM were 60.10% and 85.60%, respectively, suggesting that AMH did not completely predict PCOM. Conclusions: High AMH levels can be used to evaluate the incidence trend of PCOS. However, due to clinical heterogeneity, accurately evaluating the severity of PCOS and identifying the subtype of PCOS in Chinese patients are difficult. Individualized treatment should be administered based on accurate clinical subtypes and other clinical characteristics.

Prediction of cumulative live birth rate in women aged 40 years and over undergoing In vitro fertilization/intracytoplasmic sperm injectiona Lei Jia, Pan-Yu Chen, Ying-Chun Guo, Zhi-Qiang Zhang, Xiao Gong, Jing-Bo Chen, Cong Fang Reproductive and Developmental Medicine 2020 4(4):233-238 Objective: To investigate cumulative live birth rate (cLBR) per oocyte retrieval in infertile patients aged 40 years and over undergoing their first in vitro fertilization/intracytoplasmic sperm injection cycles and to identify the possible predictors. Methods: A total of 1,613 patients at a university hospital in China from January 2013 to May 2017 were enrolled in this retrospective study. All data for fresh and subsequent frozen-thawed cycles were analyzed. Multivariate logistic regression analysis with stepwise selection of possible predictors for cLBR was performed, and Loess curve was constructed to determine the association between cLBR and the number of oocytes retrieved. Results: cLBR significantly increased with the number of oocytes retrieved and reached up to 75% when > 20 oocytes were retrieved ( P < 0.001). Variables of antral follicle count (AFC) and the number of oocytes retrieved were selected using multiple logistic regression analysis with stepwise selection to predict the significance of cLBR. cLBR demonstrated an obvious upward trend as the number of oocytes retrieval increased in the Loess curve. Conclusions: For patients aged 40 years and over, AFC and the number of oocytes retrieved were two key predictors for cLBR and maximization of ovarian reserve exploitation was pivotal to increase the chance of live birth.

Consensus on infertility management and fertility preservation related to polycystic ovary syndrome Expert Group of Consensus on Infertility Managemen and Fertility Preservation Related to Polycystic Ovary Syndrome Reproductive and Developmental Medicine 2020 4(4):239-248 There is currently no universally accepted unified diagnostic standard for infertility treatment and maternity protection related to polycystic ovary syndrome (PCOS) worldwide, and the treatment options vary greatly. To improve the understanding of PCOS-related infertility among Chinese obstetricians and gynecologists at all levels for better patient diagnosis and management, we have referred to the international expert recommendations and literature and taken into account the Chinese clinical practice to develop the “Consensus on infertility management and fertility preservation related to PCOS.”

Toll-like receptor-dependent antiviral responses at the maternal–fetal interface Xiao-Rui Liu, Xiao-Wei Wei, Yi Lin Reproductive and Developmental Medicine 2020 4(4):249-256 The maternal–fetal interface is a key barrier to protect the fetus from infection. Toll-like receptors (TLRs) at the maternal–fetal interface are involved in antiviral responses. TLRs are expressed in both maternal decidua and fetal trophoblasts. Virus-induced activation of TLR signaling pathways triggers the release of interferon-related antiviral molecules and other inflammatory cytokines and/or chemokines by the host innate immune system, which may disrupt immune tolerance at the maternal–fetal interface and lead to pregnancy complications. In this review, we summarize the state of knowledge on the most common viral infections during pregnancy, antiviral TLR responses at the maternal–fetal interface, and TLR-associated pregnancy complications.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Urology

Robotic assistance helps low-volume surgeons deliver better outcomes to their patients Sridhar Panaiyadiyan, Rajeev Kumar Indian Journal of Urology 2021 37(1):1-3

Round up Anil Mandhani Indian Journal of Urology 2021 37(1):4-5

The Urological Society of India Guidelines for the management of urethral stricture (Executive Summary) Sanjay B Kulkarni, Amilal Bhat, Hardev S Bhatyal, Gyanendra R Sharma, Deepak D Dubey, Nikhil Khattar, Arabind Panda, Anujdeep Dangi, Vikram Shah Batra, Pankaj M Joshi Indian Journal of Urology 2021 37(1):6-9

The Urological Society of India Guidelines for the management of pediatric urinary tract infection (Executive Summary) MS Ansari, P Ashwin Shekar, Chandra Singh, Shriram S Joshi Indian Journal of Urology 2021 37(1):10-12

The current role of cytoreductive nephrectomy for metastatic renal cell carcinoma Eric C Umbreit, Andrew G McIntosh, Chalairat Suk-Ouichai, Jose A Karam, Christopher G Wood Indian Journal of Urology 2021 37(1):13-16 The management of metastatic renal cell carcinoma (mRCC) continues to be a therapeutic challenge; however, the options for systemic therapy in this setting have exploded over the past 20 years. From the advent of toxic cytokine therapy to the subsequent discovery of targeted therapy (TT) and immune checkpoint inhibitors, the landscape of viable treatment options continues to progress. With the arrival of cytokine therapy, two randomized trials demonstrated a survival benefit for upfront cytoreductive nephrectomy (CN) plus interferon therapy and this approach became the standard for surgical candidates. However, it was difficult to establish the role and the timing of CN with the subsequent advent of TT, just a few years later. More recently, two randomized phase III studies completed in the TT era questioned the use of CN and brought to light the role of risk stratification while selecting patients for CN. Careful identification of the mRCC patients who are likely to have a rapid progression of the disease is essential, as these patients need prompt systemic therapy. With the continued advancement of systemic therapy using the immune checkpoint inhibitors as a first line therapy, the role of CN will continue to evolve.

Optimizing biopsy strategy for prostate cancer: Bayesian framework of network meta-analysis and hierarchical summary receiver operating characteristic model for diagnostic accuracy Ilham Akbar Rahman, Ilham Fauzan Nusaly, Syakri Syahrir, Harry Nusaly, Firdaus Kasim Indian Journal of Urology 2021 37(1):20-31 Overdiagnosis and overtreatment are well known problems in prostate cancer (PCa). The transrectal ultrasound (TRUS) Guided biopsy (GB) as a current gold standard investigation has a low positive detection rate resulting in unnecessary biopsies. The choice of optimal biopsy strategy needs to be defined. Therefore, we undertook a Bayesian network meta analysis (NMA) and Bayesian prediction in the hierarchical summary receiver operating characteristic (HSROC) model to present a method for optimizing biopsy strategy in PCa. Twenty eight relevant studies were retrieved through online databases of EMBASE, MEDLINE, and CENTRAL up to February 2020. Markov chain Monte Carlo simulation and Surface Under the Cumulative RAnking curve were used to calculate the rank probability using odds ratio with 95% credible interval. HSROC model was used to formulate the predicted true sensitivity and specificity of each biopsy strategy. Six different PCa biopsy strategies including transrectal ultrasound GB (TRUS GB), fusion GB (FUS GB), fusion + transrectal ultrasound GB (FUS + TRUS GB), magnetic resonance imaging GB (MRI GB), transperineal ultrasound GB (TPUS GB), and contrast enhanced ultrasound GB were analyzed in this study with a total of 7584 patients. These strategies were analyzed on five outcomes including detection rate of overall PCa, clinically significant PCa, insignificant PCa, complication rate, and HSROC. The rank probability showed that the overall PCa detection rate was higher in FUS + TRUS GB, MRI GB, and FUS GB. In terms of clinically significant PCa detection, FUS + TRUS GB and FUS GB had a relatively higher clinically significant PCa detection rate, whereas TRUS GB had a relatively lower rate for clinically significant PCa detection rate. MRI GB (91% and 81%) and FUS GB (82% and 83%) had the highest predicted true sensitivity and specificity, respectively, whereas TRUS GB (62% and 83%) had a lower predicted true sensitivity and specificity. MRI GB, FUS GB, and FUS + TRUS GB were associated with lower complication rate, whereas TPUS GB and TRUS GB were more associated with higher complication rate. This NMA and HSROC model highlight the important finding that FUS + TRUS GB, FUS GB, and MRI GB were superior compared with other strategies to avoid the overdiagnosis and overtreatment of PCa. FUS GB, MRI GB, and FUS + TRUS GB had lower complication rates. These results may assist in shared decision making between patients, carers, and their surgeons.

Role of laparoscopy in the era of robotic surgery in urology in developing countries Devanshu Bansal, Samit Chaturvedi, Ruchir Maheshwari, Anant Kumar Indian Journal of Urology 2021 37(1):32-41 With the rapid expansion of robotic platforms in urology, there is an urgent and unmet need to review its cost and benefits in comparison to the traditional laparoscopy, especially in reference to a developing country. A nonsystematic review of the literature was conducted to compare the outcomes of pure laparoscopic and robot-assisted urologic procedures. Available literature over the past 30 years was reviewed. Robot-assisted surgery and laparoscopy were found to have similar outcomes in the areas of radical prostatectomy, partial and radical nephrectomy, radical cystectomy, retroperitoneal lymph node (LN) dissection, inguinal LN dissection, donor nephrectomy, and kidney transplantation. Robot-assisted surgery was found to be significantly costlier than pure laparoscopy. In the absence of a clear advantage of robot-assisted surgery over pure laparoscopy, lack of widespread availability and the currently prohibitive cost of robotic technology, laparoscopic urological surgery has a definite role in the developing world.

Robot-assisted laparoscopic ureteral reimplant: A single-center experience Vipin Tyagi, Mrinal Pahwa, Praveen Lodha, Tejas Mistry, Sudhir Chadha Indian Journal of Urology 2021 37(1):42-47 Introduction: Open ureteral reimplant has been the gold standard for management of lower ureteric strictures. With the widespread acceptance of robotic surgery, robotic-assisted laparoscopic ureteral reimplant (RALUR) is becoming the preferred choice for performing ureteral reimplant. We present our single-institution and single-surgeon experience of performing RALUR. Materials and Methods: We performed a retrospective analysis of 40 patients who underwent RALUR at our institute in the last 5 years. Demographic data were recorded along with presenting complaint and diagnosis. Intraoperative variables included operative and docking time, blood loss, intraoperative complications, technique, and procedure performed. Postoperative data that were analyzed included complications, hospital stay, and outcomes. Patient satisfaction score was calculated using a numerical scale of points 1–6. Results: The mean age of patients was 31.5 ± 9.8 years (r = 4–45). Male: female ratio was 3:5. The most common presenting symptom was flank pain, and the most common etiology was iatrogenic strictures in adults and congenital vesicoureteral reflux in children. The mean operative time and blood loss were 135.3 ± 45.1 min (r = 84–221) and 67.7 ± 31.4 ml (r = 32–118), respectively. There were no intraoperative complications and nil conversion to open surgery. The mean length of hospital stay was 4.5 ± 2.3 days (r = 3–9). Radiographic success was achieved in 41 out of 44 ureters. Eighty-five percent of the patients were completely satisfied with robotic approach and its outcomes. Conclusion: RALUR is a minimally invasive, safe, feasible, less morbid technique with good outcome.

Retrograde intrarenal surgery for renal stones in children <5 years of age Vaddi Chandramohan, PM Siddalingaswamy, Paidakula Ramakrishna, Ganesan Soundarya, Babu Manas, Anandan Hemnath Indian Journal of Urology 2021 37(1):48-53 Introduction: There are very few studies in the literature describing retrograde intrarenal surgery (RIRS) in preschool children. We have evaluated the feasibility, stone-free rate, and complications of RIRS in children &#60;5 years of age. Methods: All children &#60;5 years of age and stone size &#60;2 cm (renal/proximal ureteric), who underwent RIRS at our hospital from February 2010 to May 2020 were included in this retrospective study. All children were prestented for the passive dilatation of ureter. A 7.5 Fr flexible ureterorenoscope was introduced over the ureteral access sheath (UAS) or over a guidewire. At 2 weeks, the stent was removed and at 2 months the child was evaluated for residual stones. Results: A total of 62 children with 67 renal units met the inclusion criteria. The mean age was 42.11 months (4&#8211;60 months). Mean weight was 13.31 kg (6&#8211;16.3 kg). Mean stone size was 11.9 mm (7.3&#8211;18.2 mm). Majority of the stones were in pelvis (37.8&#37;). UAS 9.5/11.5 Fr was placed in 40 (63.5&#37;) children. Mean operative time was 55.2 min; mean hospitalization was 61 h. Four out of the 67 renal units (5.9&#37;) required conversion to minipercutaneous nephrolithotomy in the same sitting, due to access failure. Two cases who developed post-operative fever required a change of antibiotics. Two cases required ureteroscopy for steinstrasse postoperatively. Stone-free rate at 2 months for stones size =2 mm was 76.3&#37;. Conclusion: Pediatric RIRS is a promising option in young children as it offers acceptable stone-free rates and a low incidence of high-grade complications. However, it requires expertise and should be offered in tertiary care centres.

Tubeless mini-percutaneous nephrolithotomy for renal stones larger than 20 mm Sanjay Khadgi, Maitrey Darrad, Ahmed R EL-Nahas, Abdullatif AL-Terki Indian Journal of Urology 2021 37(1):54-58 Introduction: The aim of this study is to evaluate the outcomes of tubeless mini- percutaneous nephrolithotomy (PCNL) for the treatment of large (&#62;20 mm) renal stones. Patients and Methods: This study included consecutive patients who underwent single-session tubeless mini-PCNL (tract size 16&#8211;20 F) for large (&#62;20 mm) renal stones. Stone-free status meant complete clearance or residual fragments &#60;4 mm. Complications were recorded and classified according to modified Clavien-Dindo classifications. Risk variables for significant residuals were determined with univariate (Chi-square and t-test) and multivariate logistic regression analyses. Results: Between July 2015 and November 2018, 225 patients were included. The mean age was 42.9 years; the mean stone size was 30.2 &#177; 9.6 mm and 75&#37; of patients were males. A single renal stone was present in 54 patients (24&#37;), multiple stones in 108 (48&#37;), and staghorn stones in 63 (28&#37;). The stone-free rate was 87.6&#37;. The complication rate was 8.4&#37; (Grade I&#8211;II in 7.5&#37;, III in 0.9&#37;). Three patients (1.3&#37;) required blood transfusion. Independent risk factor for significant residual fragments was the presence of stones in multiple sites inside the pelvicalyceal system (relative risk: 13.44, 95&#37; confidence interval: 1.78&#8211;101.43, P &#61; 0.012). Conclusions: Mini-PCNL is an effective and safe treatment option for patients with large renal stones (&#62;20 mm). Stones located in multiple sites is the only predictor of significant residual stones.

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Emergency Medicine

News: ODs Often the Cause of Sudden Cardiac Death No abstract available

Emergentology: Every System is Perfectly Designed to Get the Results It Gets No abstract available

Special Report: Lessons Learned in Clinical Adjustments at an ED at a COVID-19 Pandemic Epicenter No abstract available

News: Exorcising the CMG Demons of Emergency Medicine No abstract available

News: Does Bretylium Have a Place in Cardiac Arrest? No abstract available

First Person: A Nation Infected No abstract available

First Person: Students and Residents Saved My Career, and I Will Never Stop Paying Them Back No abstract available

First Person: Things to Think about Before You Get COVID-19 from an Emergency Physician Who Has Been There No abstract available

First Person: Words of Advice from Four Longtime EPs No abstract available

News: New Felon Etiology: Occult Subungual Infection No abstract available

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Addiction Medicine

Sildenafil Misuse for its Psychoactive Properties? A Case Report Sildenafil is a widely used drug for the treatment of erectile dysfunction in a dosage ranging from 50 to 100 mg per day. Recreational use is reported among youth for its sexual function enhancing effects. To date, however, no study has reported the use of sildenafil for its nonsexual, psychoactive effects. We report a case of a 38-year-old male with opioid and sedative use disorder who self-administered sildenafil orally in a dose of up to 2000 mg per day for its psychoactive effects (primarily) for 10 years before seeking treatment and discuss the literature relevant to the case. Send correspondence to Roshan Bhad, MBBS, MD, DNB (Psychiatry), All India Institute of Medical Sciences, New Delhi, India. E-mail: drroshansindia@gmail.com. Received 11 July, 2020 Accepted 21 November, 2020 The authors report no conflicts of interest. © 2020 American Society of Addiction Medicine

The Role of Cannabis Use in Suicidal Ideation Among Patients With Opioid Use Disorder Objectives: Cannabis use is associated with suicide risk in the general population; however, it is unknown if this association is also present in patients with opioid use disorder (OUD). The purpose of this study is to investigate the association between cannabis use and suicidal ideation in patients with OUD. Methods: We conducted a multivariable logistic regression analysis to assess the association between cannabis use and suicidal ideation, amongst a large cohort of patients with OUD. Current cannabis use and suicidal ideation over the past 30 days were obtained by self-report. Results: Cross-sectional data from 2335 participants with OUD were included in the analysis, of whom 51% report current cannabis use. We found a positive association between cannabis use and suicidal ideation (OR = 1.41, 95% CI 1.11, 1.80, P = 0.005). We found that men (OR = 1.84, 95% CI 1.44, 2.35, P < 0.001), younger individuals (OR = 1.02, 95% CI 1.01, 1.03), P = 0.004), and that those with more symptoms of anxiety or depression (OR = 1.16, 95% CI 1.15, 1.18, P < 0.001) were more likely to report suicidal ideation. Conclusions: Cannabis use is associated with a heightened propensity for suicidal ideation amongst patients with OUD, who are already a high-risk population. Further research into the potential harms of cannabis use in this population is required given the prevalence of its use and potential benefits in mitigating opioid withdrawal. Send correspondence to Zainab Samaan, MBChB, MSc, DMMD, MRCPSych, PhD, Associate Professor Psychiatry and Behavioural Neurosciences, McMaster University Director, Clinician Investigator Program, Mood Disorders Program, St. Joseph's Healthcare Hamilton, 100 West 5th St, G104, Hamilton, Ontario L8N 3K7, Canada. E-mail: samaanz@mcmaster.ca. Received 29 June, 2020 Accepted 30 October, 2020 Dr. Samaan is supported by grants from CIHR Awards #156306 and #155404. The authors report no conflicts of interest. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 © 2020 American Society of Addiction Medicine

Low Uptake of Secure Messaging Among Veterans With Experiences of Homelessness and Substance Use Disorders Objectives: Persons who are homeless have significant health challenges and barriers accessing care. Secure messaging supports communication between patients and their providers through a web-based portal, but the acceptability of this technology among patients with high prevalence of substance use disorders (SUDs) is unknown. We examined secure messaging use among veterans with experiences of homelessness (VEHs), and determined factors associated with messaging use. Methods: We conducted a cross-sectional analysis of responses to a national survey of VEHs, administered by mail from March to October 2018 (response rate = 40.2%). One item assessed secure messaging use and satisfaction. We used multivariable logistic regressions to model secure messaging use, controlling for sociodemographics, medical conditions, housing indicators, and mental health and SUD diagnoses. Results: Of 5072 VEHs, 21% had ever used secure messaging and 87% of the subsample found messaging to be useful. Secure messaging was more commonly used by VEHs who were female, had some college education, those with ≥3 chronic medical conditions, depression, or posttraumatic stress disorder (all P < 0.001). Messaging was much less common for VEHs ages 55 to 64 or older, non-Latino Blacks, those receiving homeless-tailored primary care, and those with SUDs (all P < 0.001). VEHs with opioid use disorder were even less likely than those with other SUDs to use secure messaging (P = 0.047). Conclusions: Persons with homeless experiences might require assistance to engage with secure messaging technology. As health systems limit in-person care during a national pandemic, alternative solutions may be needed to facilitate health communications and prevent care disruptions for patients experiencing homelessness and SUDs. Send correspondence to Audrey L. Jones, PhD, Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, 500 Foothill Drive, MC151 Research, Salt Lake City, UT 84148. E-mail: Audrey.Jones3@va.gov. Received 6 May, 2020 Accepted 8 November, 2020 Supported by the Department of Veterans Affairs (VA) Health Services Research and Development (IIR 15–095); the VA, Veterans Health Administration, National Center on Homelessness Among Veterans; and the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR002538 and KL2TR002539. Dr. Varley reported receiving income from Heart Rhythm Clinical Research Solutions. Dr. Kertesz and Dr. Gordon reported receiving personal fees from UpToDate, the California Society of Addiction Medicine, the Howard Center, the Centre for Addiction and Mental Health, and Ascension/St. Vincent's Health System; owning stock in CVS Health, Thermo Fisher Scientific, and Zimmer Biomet; and that his spouse privately owns stock in Abbott, Merck and Co, and Johnson & Johnson. No other disclosures were reported. The authors thank Ms. April Hoge (VA Birmingham Medical Center) and Dr. Young-il Kim (University of Alabama at Birmingham School of Medicine) for project assistance, data management, and statistical guidance. The supporting organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, the National Institutes of Health, or the United States government. Audrey L. Jones ORCID ID: 0000-0003-1533-7469; Adam J. Gordon ORCID ID: 0000-0002-2453-8871; Stefan G. Kertesz ORCID ID: 0000-0001-6101-8421. The authors report no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.journaladdictionmedicine.com). © 2020 American Society of Addiction Medicine

Use of Electronic Health Record Data to Estimate the Probability of Alcohol Withdrawal Syndrome in a National Cohort of Hospitalized Veterans Objectives: Inpatient alcohol withdrawal syndrome (AWS) is common and early treatment improves outcomes, but no prior study has used electronic health record (EHR) data, available at admission, to predict the probability of inpatient AWS. This study estimated the probability of inpatient AWS using prior-year EHR data, hypothesizing that documented alcohol use disorder (AUD) and AWS would be strongly associated with inpatient AWS while exploring associations with other patient characteristics. Methods: The study investigated patients hospitalized ≥24 hours on medical services in the Veterans Health Administration during 2013 using EHR data extracted from the Veterans Health Administration Corporate Data Warehouse. ICD-9-CM diagnosis code, demographic, and healthcare utilization data documented in the year before admission defined prior-year AUD, AWS, and other factors associated with inpatient AWS. The primary outcome, inpatient AWS, was defined by inpatient ICD-9-CM codes. Results: The unadjusted probability of AWS was 5.0% (95% CI 4.5%–5.4%) among 209,151 medical inpatients overall, 26.4% (95% CI 24.4%–28.4%) among those with prior-year AUD, and 62.5% (95% CI 35.2%–39.7%) among those with prior-year AWS. Of those with AWS, 86% had documented prior-year AUD and/or AWS. Other patient characteristics associated with increased probability of inpatient AWS (P < 0.001) were: male sex, single relationship status, homelessness, seizure, and cirrhosis. Conclusions: Although inpatient providers often use history to predict AWS, this is the first study in hospitalized patients to inform and validate this practice, showing that prior-year diagnosis of AUD and/or AWS in particular, can identify the majority of inpatients who should be monitored for AWS. Send correspondence to Tessa L. Steel, MD, MPH, Seattle-Denver Center of Innovation (COIN), VA Puget Sound Health Care System, Seattle Division, 1660 South Columbian Way S-152, Seattle, WA 98108. E-mail: tessita@uw.edu, @tessaLsteel. Received 14 September, 2020 Accepted 8 November, 2020 Supported by VA Puget Sound Health Care System Research & Development Associate Chief of Staff (ACOS) Pilot Grant Program, the Center of Excellence for Substance Abuse Treatment & Education (CESATE), and K24AA022128. The authors report no conflicts of interest. All authors had access to the data supporting this study and a role in writing the manuscript. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.journaladdictionmedicine.com). © 2020 American Society of Addiction Medicine

COVID-19 and Cannabidiol (CBD) COVID-19 pandemic has resulted in devastating mortality and morbidity consisting of socioeconomic and health effects that have included respiratory/pulmonary, cardiovascular, mental health and neurological consequences such as anxiety, depression, and substance use. Extensive efforts are underway to develop preventive vaccines and therapeutics such as remdesivir, dexamethasone, convalescent plasma, and others to treat COVID-19 but many report residual mental health problems after recovery. Cannabis products such as cannabidiol (CBD) are being advertised for the treatment of COVID-19 associated mental health problems and substance use disorders. This commentary will briefly clear the myth that CBD can ameliorate a wide range of COVID-19 associated health effects including anxiety, depression, or any substance use disorder, and show that there is a clear lack of sufficient unbiased clinical evidence from well-designed double-blind, placebo-controlled clinical trials to prove the antianxiety or antidepression therapeutic properties of CBD and support its wide use as medicine to treat COVID-19- associated mental health conditions or substance use disorders. Finally, we suggest that addiction physicians must play an important role in dealing with their patients requesting CBD prescription for treating any of these conditions. Send correspondence to Jag H. Khalsa, MS, PhD, 24924 McNair Place, ALDIE, VA 20105-5572. E-mail: jkhalsa@yahoo.com; jag.khalsa@gmail.com; jag.khalsa@nih.gov. Received 12 July, 2020 Revised 8 October, 2020 Accepted 14 October, 2020 Support by GB: Samaritan/Day Top Village; SBM: R01NS066801; R01AG 054325; SK: Grant 5R01DA 043396. Research grants to the institution from Merck, Inc., Gillead Sciences, and Airbutus pharmaceuticals. Other authors report no conflicts of interest. © 2020 American Society of Addiction Medicine

COVID-19 Social Distancing and Online Mutual Help Engagement for Alcohol Use Recovery Introduction: COVID-19 and associated social distancing has presented challenges for individuals engaging in face-to-face mutual help groups (MHGs) such as Alcoholics Anonymous for alcohol use recovery. Online MHGs may be particularly appealing to individuals with limited access or inclination to attend in-person MHGs. We examined engagement within the popular "StopDrinking" online MHG, hypothesizing that engagement would increase due to demand for virtual peer support as COVID-19 social distancing progressed. Methods: We collected publicly available engagement data for StopDrinking from February 19, 2018 through April 30, 2020 while considering March and April of 2020 as months initially impacted by voluntary or mandated COVID-19 social distancing. Using seasonal autoregressive integrated moving average models, we predicted daily engagement for this social distancing time period based on all available engagement data collected before April 2020. Kalman filtering with 95% prediction limits was employed to define significant thresholds for observed data to reside within. Results: All days of observed engagement in March and April 2020 were lower than corresponding predicted values. Observed engagement fell below the lower 95% prediction limit for 36% of days, with 15 days in March and 7 days in April having significantly lower than predicted engagement. Conclusions: Relatively low activity on StopDrinking may signal broader population trends of problematic alcohol use and recovery disengagement during the initial COVID-19 social distancing timeframe. Continued investigation of online MHGs is needed to understand their potential for monitoring population health trends and to understand how such groups might support alcohol use recovery in contexts of crisis and isolation. Send correspondence to Jason B. Colditz, MEd, 230 McKee Place, #600, Pittsburgh, PA 15213. E-mail: colditzjb@pitt.edu. Received 23 July, 2020 Accepted 21 November, 2020 The authors report no conflicts of interest. © 2020 American Society of Addiction Medicine

Understanding Contraceptive Needs of Women Who Inject Drugs in Orange County: A Qualitative Study Objectives: Women with opioid use disorder experience higher rates of unintended pregnancy compared with the general US population. Our aim was to examine the factors that may affect access to desired contraception for women who use injection drugs. Methods: Using purposive sampling, we conducted semi-structured interviews pertaining to contraceptive use with 14 women ages 18 to 44 who were current users of injection drugs living in Orange County, CA between March and December 2019. Interviews were transcribed, coded, and analyzed using grounded theory. Results: Participants discussed logistical barriers, including homelessness and lack of transportation, as well as perceived barriers, such as a belief in the inability to become pregnant while using drugs, that affect access to contraceptive care. Women also discussed the factors that motivate them to use contraception despite these barriers, including the desire for sobriety before becoming pregnant and fear of harming a fetus while using substances. Some participants expressed feeling uncomfortable disclosing substance use to their healthcare providers out of concern for stigmatization. Several points of access for contraceptive care were elucidated, including visits for primary and postpartum care, as well as in carceral spaces. Finally, participants expressed a desire to obtain contraceptive services at a local syringe exchange program due to trusting relationships with providers and increased ease of access. Conclusions: Our findings highlight several causative factors for the unmet contraceptive need among women who use injection drugs, and suggest that syringe exchange programs represent a unique access point for the provision of contraceptive care for this population. Send correspondence to Orli K. Florsheim, MD, University of New Mexico School of Medicine, Department of Family and Community Medicine, 1 University of New Mexico, Albuquerque, NM 87131, United States. E-mail: oflorsheim@salud.unm.edu. Received 15 August, 2020 Accepted 15 November, 2020 This work was supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant UL1TR0001414. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The authors have no conflicts of interest to disclose. © 2020 American Society of Addiction Medicine

Cannabis Use During the COVID-19 Pandemic in Canada: A Repeated Cross-sectional Study Objectives: In the context of the ongoing coronavirus disease pandemic in Canada, we aimed to (1) characterize trends in cannabis use in the overall population; and (2) characterize patterns of and identify risk characteristics associated with an increase in cannabis use among those who used cannabis. Methods: Data were obtained from three waves of an online, repeated cross-sectional survey of adults residing in Canada (May 08–June 23, 2020; N = 3012). Trends were assessed using Cochran-Armitage and chi-square tests, and risk characteristics were identified using logistic regression analyses. Results: Cannabis use in the overall population remained stable during the months of May and June. Among those who used cannabis, about half increased their cannabis use compared to before the start of the pandemic. This proportion of an increase in cannabis use among those who used cannabis remained consistent across the survey waves. Risk characteristics associated with higher odds of an increase in cannabis use included residence in the central region (Odds ratio, 95% confidence intervals: 1.93, 1.03–3.62), being 18 to 29 years old (2.61, 1.32–5.17) or 30 to 49 years old (1.85, 1.07–3.19), having less than college or university education (1.86, 1.13–3.06) and being somewhat worried about the pandemic's impact on personal finances (1.73, 1.00–3.00). Conclusions: A large proportion of those who used cannabis have increased cannabis use during the pandemic, suggesting a need for interventions to limit increased cannabis use, policy measures to address cannabis-attributable harms, and continued monitoring of cannabis use during and after the pandemic. Send correspondence to Sameer Imtiaz, PhD, Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 2035B - 33 Russell Street, Toronto, Ontario, M5S 2S1, Canada. E-mails: sameer.imtiaz@camh.ca, sameer.imtiaz@gmail.com. Received 16 July, 2020 Accepted 21 November, 2020 Delvinia provided in-kind support for the data collection. Sameer Imtiaz, Samantha Wells, Hayley Hamilton, and Tara Elton-Marshall acknowledge funding from the Canadian Institutes of Health Research and Canadian Centre on Substance Use and Addiction (Partnerships for Cannabis Policy Evaluation Team Grant), and Sameer Imtiaz, Jürgen Rehm and Tara Elton-Marshall acknowledge funding from the Canadian Institutes of Health Research's Institute of Neurosciences, Mental Health and Addiction (Canadian Research Initiative on Substance Misuse Ontario Node Grant [SMN-13950]). The funders had no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript. The authors report no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.journaladdictionmedicine.com). © 2020 American Society of Addiction Medicine

Barriers and Facilitators to Buprenorphine Prescribing for Opioid Use Disorder in the Veterans Health Administration During COVID-19 No abstract available

Discontinuing Methadone and Buprenorphine: A Review and Clinical Challenges This paper offers a review and recommendations for clinicians working with patients interested in discontinuing opioid agonist treatment. As buprenorphine/naloxone has gained widespread acceptance for opioid addiction, many treatment providers and patients have a range of hopes and expectations about its optimal use. A surprising number assume buprenorphine/naloxone is primarily useful as a medication to transition off illicit opioid use, and success is partially defined by discontinuing the medication. Despite accumulating evidence that a majority of patients will need to remain on medication to preserve their gains, clinicians often have to address a patient's fervent desire to taper. Using the concept of "recovery capital," our review addresses (1) the appropriate duration of opioid agonist treatment, (2) risks associated with discontinuing, (3) a checklist that guides the patient through self-assessment of the wisdom of discontinuing opioid agonist treatment, and (4) shared decision making about how to proceed. Send correspondence to Joan E. Zweben, PhD, 714 Spruce Street Berkeley, CA 94707; E-mail: joan.zweben@gmail.com Received 21 April, 2020 Accepted 10 November, 2020 Supported in part by the second author's Fulbright-Canada Fellowship while at the University of Calgary, Calgary, Alberta, Canada. Additional support through NIH U10DA15815, R25DA028567, and R25DA035163. The authors report no conflicts of interest. Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a "work of the United States Government" for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government. © 2020 American Society of Addiction Medicine

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Critical Care

Extracorporeal membrane oxygenation in COVID-19: The Saudi ECLS-Chapter perspective Saudi Critical Care Journal 2020 4(4):115-118

Development of critical care nursing research in Saudi Arabia: 10 years' perspective Saudi Critical Care Journal 2020 4(4):119-122 Nursing research is a scientific method that provides evidence to support nursing practices. Investigation of the critical care nursing research in Saudi Arabia has not been well established. This review aims to examine the numbers, and the characteristics of PubMed-cited critical care nursing articles contributed from Saudi Arabia over the past decade. We conducted a PubMed search to analyze nursing publications in the field of critical care published or contributed in Saudi Arabia for over 10 years (2010–2019). We investigated the number of publications per year, specialty, study design, journal impact factor, and international collaboration. A total of 94 critical care nursing publications were included in this review. International collaborations were noted in 49 (52.1%) articles. The majority 53 (56.4%) of the critical care nursing publications were related to the nursing field and 66 (70.2%) of these articles were classified as clinical practice topics. Observation cohort study was the most used study design 64 (68.1%). The median impact factor for the journals of these publications was 1.76 (1.48, 2.52). Despite the lower rate of published researches, critical care nursing research in Saudi Arabia is increasing over the years. International collaborations had contributed dramatically in the published articles. Developing local strategy for critical care nursing research and promoting local and international collaboration to conduct and use research according to the critical care nursing priority are also warranted. More interventional nursing researches are needed in critical care settings in Saudi Arabia.

Exploring factors affecting critical care response team service at a tertiary hospital in Riyadh: A retrospective cohort study Saudi Critical Care Journal 2020 4(4):123-129 Background: Critical care response team (CCRT) is a proactive department of intensive care unit (ICU) that consists of an intensivist, a staff physician, a critical care nurse, and a respiratory therapist. The purpose of this team is to manage patients in their wards to avoid unnecessary ICU bed occupancies. The aim of the study is to explore factors affecting CCRT service in terms of patient disposition and mortality rate and to analyze interventions provided to the patients by the team. Materials and Methods: This is a retrospective cohort study conducted at a tertiary hospital in Riyadh. All CCRT event data collection forms from the period between February 2018 and April 2019 were reviewed. Patients meeting our criteria were included. Outcome measures were as follows: (1) patient disposition. (2) mortality rate. Factors that were tested for effect on CCRT service were patient age, activation time, and reasons for activation. All statistical analyses were done using SAS software 9.4. Results: A total of 1088 CCRT events were considered during the period of the study. Out of all deaths, the mean age was 70.90 ± 16.67 compared to the mean age of survivors 61.21 ± 20.65 (P < 0.0001). Furthermore, older patients had higher chances for ICU transfer (P = 0.0399). CCRT service was not affected by activation time as patient disposition and mortality rates were almost the same in activations during and out of work hours. The most common reason for CCRT activation was tachypnea (28.49%). Majority of patients within each reason for activation were not transferred to the ICU, except for low oxygen saturation (50.54% transferred to the ICU) (P = 0.0001), decreased level of consciousness (DLOC) (49.40% transferred to ICU) (P = 0.0001). Patients not transferred to the ICU had lower mortality rate (15.18%) than those transferred to the ICU (55.41%) (P < 0.0001). Conclusion: Given these results, increased vigilance and quick responses to CCRT calls for older patients, and those with low oxygen saturation and DLOC, must be considered. Increased vigilance is also needed for those spending more time in ICUs.

Herpes zoster coinfection and the current COVID-19 pandemic Saudi Critical Care Journal 2020 4(4):130-133 Clinical presentation of COVID-19 infection can be variable in the current pandemic, even in patients presenting to the clinic with mild history of upper respiratory complaints. Various cutaneous manifestations have been noticed in COVID-19 patients with herpes zoster (HZ) being one among them. HZ is an infection that results when varicella zoster virus reactivates from its latent state in a posterior dorsal root ganglion. Here, we aim to expand our knowledge by reporting three cases of associated zoster infection in COVID-19 patients admitted to our intensive care unit in view of respiratory complaints. All the three patients admitted had revealed lymphocytopenia at the time of HZ diagnosis and were managed conservatively throughout the course. In all the cases, acyclovir/valacyclovir led to the resolution of lesions in 10 days. No postherpetic sequelae were observed. We hereby suggest that the clinical presentation of HZ at the time of current pandemic should be considered as an alarming sign for a latent subclinical SARS-CoV-2 infection and thorough follow-up of such patients should be adopted.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Bone and Joint Surgery

• A Treatment Pathway Variation for Chronic Prosthesis-Associated Infections

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Brügger, Jan; Saner, Simon; Nötzli, Hubert P.

  Background: Periprosthetic joint infections (PJIs) are relatively rare but are on the rise because of the increasing total number of implantations performed. Treatment of PJI remains individualized and involves both surgical and medical treatment, with variations depending on the time of implantation, the duration and severity of the infection, tissue damage, and the underlying microorganism. In this case series study, we investigated clinical and functional outcomes of a variation of the Liestal algorithm in patients with PJI following total hip arthroplasty. Methods: This study included 32 patients (33 cases) who were treated for chronic PJI with 2-stage exchange using a cement spacer during the period of 2003 to 2014. In contrast to other treatment pathways, antibiotic therapy was targeted to the causative microorganism as early as possible despite the presence of a cement spacer. Second-look surgery was performed 4 days after removal of the primary implant and a 4-week antibiotic-free window was interposed before definitive reimplantation. Thereafter, antibiotic treatment continued for approximately 6 weeks. All patients were followed for a minimum of 2 years. Parameters investigated were the duration of infection-free survival, functional outcome, and epidemiological data. Results: At 2 years of follow-up and at the most recent follow-up (on average, 7 years after reimplantation), 100% of the patients were free of signs of infection, and the mean Harris hip score (HHS) was 89 at the latest follow-up. Conclusions: A meticulously performed 2-stage exchange for PJI with early targeted antibiotic treatment, second-look surgery, an antibiotic-free window before reimplantation, and antibiotic treatment post-reimplantation of medium duration is associated with excellent infection-related and good functional outcome after ≥2 years of follow-up even in cases of chronic PJI. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

• Anterolateral Versus Posterolateral Approach for Lateral Condylar Fractures of the Humerus in Children

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Tomori, Yuji; Nanno, Mitsuhiko; Takai, Shinro

  Background: Two surgical approaches, an anterolateral and a posterolateral approach, have been advocated for lateral condylar fractures (LCFs) of the humerus in children. The purpose of this study was to evaluate the radiographic and clinical outcomes of the 2 surgical approaches. Methods: We retrospectively analyzed the data of consecutive patients <15 years of age with an LCF treated via open reduction and internal fixation through 1 of 2 surgical approaches during the period of April 2000 to March 2019. Patients were classified into the anterolateral (AL) and posterolateral (PL) groups, according to the surgical approach used. Postoperative complications and radiographic and clinical findings (including range of motion and findings on the basis of the Flynn criteria) were investigated. To investigate humeral deformity, the Baumann angle and the carrying angle were measured on anteroposterior radiographs. Results: Sixty-one of 82 patients met the inclusion criteria. The AL group included 17 patients (13 male, 4 female), and the PL group included 44 patients (28 male, 16 female). In the PL group, 7 patients had cubitus varus deformity, 3 had malunion due to unacceptable reduction of fracture fragments, and 6 had elbow joint contracture. In the AL group, the overall clinical results were excellent for 15 patients and good for 2. In the PL group, the clinical results were excellent for 12 patients, good for 14, fair for 6, and poor for 12. Conclusions: An anterolateral approach would be the optimal approach for an LCF in pediatric patients. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

• Predictors of Successful Treatment 1 Year After Arthroscopic Partial Meniscectomy: Data from the OME Cohort

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Cleveland Clinic Sports Health

  Background: Arthroscopic partial meniscectomy (APM) is one of the most common orthopaedic procedures. Understanding factors that predict better patient-reported outcomes is important for guiding patient and clinician decision-making. The purpose of this study was to evaluate predictors of pain and function after APM in a large, multisite, academic health system cohort. Methods: We prospectively enrolled 665 patients who were ≥40 years of age and who had APM without any concomitant ligament or cartilage-resurfacing procedures. There were 486 subjects (73%) who completed baseline and follow-up questionnaires including demographic variables (age, sex, body mass index [BMI], education level), surgical findings (meniscal tear type, articular cartilage grade), and patient-reported outcomes (Knee injury and Osteoarthritis Outcome Score [KOOS] Pain, Physical Function Short Form [PS], and knee-related Quality of Life [QOL]; and Veterans RAND 12-Item [VR-12] Mental Component Score [MCS] and Physical Component Score [PCS]). We constructed multivariable statistical models to assess predictors of improvement in patient-reported outcomes, as well as a model to assess predictors of a successful improvement of at least 10 points in either KOOS Pain or KOOS-PS. Results: The mean age was 55 years, 46% of patients were female, and the mean BMI was 30 kg/m2. There were clinically important and significant improvements (p < 0.001) in all patient-reported outcomes from baseline to the 1-year follow-up. The following factors predicted less improvement in at least 1 patient-reported outcome: higher baseline score, higher BMI, older age, less education, current smoking, lower VR-12 MCS, prior ipsilateral surgical procedure, bipolar medial compartment cartilage lesions, and a lateral meniscal tear. Eighty-three percent of subjects had a successful improvement of 10 points in either KOOS Pain or KOOS-PS. The odds of successful improvement were lower in patients with a medial meniscal root tear, a lateral meniscal tear, or higher baseline KOOS Pain score. Conclusions: Eighty-three percent of patients improved by at least 10 points in pain and function after APM. Patients with a medial meniscal root tear or a lateral meniscal tear had decreased odds of a clinically important improvement in pain or function after APM. Increased BMI, smoking, and worse VR-12 MCS are potentially modifiable risk factors that predict less improvement after APM and warrant further study. Level of Evidence: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

• Application of a Customized Total Talar Prosthesis for Revision Total Ankle Arthroplasty

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Morita, Shigeki; Taniguchi, Akira; Miyamoto, Takuma; Kurokawa, Hiroaki; Tanaka, Yasuhito

  Background: The rate of revision surgery for total ankle arthroplasty (TAA) is higher than for hip and knee arthroplasties. Tibiotalocalcaneal arthrodesis is widely used; however, it requires a large allograft. Thus, the use of a customized total talar prosthesis in combination with the tibial component of TAA (combined TAA) may be an effective strategy for talar component subsidence. This study aimed to evaluate the clinical and radiographic effectiveness of the combined TAA in such revision cases. Methods: Between 2000 and 2015, 10 patients (10 women; 10 ankles) were treated using the combined TAA for revision after standard TAA or combined procedures that included the use of a talar body prosthesis. In 6 patients, the tibial component was concurrently replaced. The median follow-up period was 49 months (interquartile range [IQR], 24.5 to 90 months). The Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale score, a numerical rating scale (NRS) pain score, passive range of motion of the ankle, and the presence of osteophytes and degenerative changes in the adjacent joints were assessed preoperatively and at final postoperative follow-up. Results: The median NRS pain score improved significantly, from 7 (IQR, 6.25 to 8.75) to 2 (IQR, 1 to 3). The median JSSF ankle-hindfoot scale total score improved significantly, from 64 (IQR, 56.25 to 71.5) to 88.5 (IQR, 79.75 to 96). In the subcategories of this scale, the median pain score improved from 20 (IQR, 20 to 27.5) to 35 (IQR, 30 to 40), and the median function score improved from 34 (IQR, 26.5 to 37) to 43.5 (IQR, 39.75 to 46). The median range of motion improved from 29° (IQR, 25.5° to 35°) to 35° (IQR, 31.25° to 43.75°). No significant difference in osteophyte formation was found. Degenerative changes in the adjacent joint were found only in the talonavicular joint. Conclusions: The combined TAA, used in revision for postoperative complications after standard TAA or combined procedures including the use of a talar body prosthesis, was associated with improved objective JSSF ankle-hindfoot scale scores, subjective pain assessment, and range of motion in the ankle. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

• A Novel Method for Accurate Preoperative Templating for Total Hip Arthroplasty Using a Biplanar Digital Radiographic (EOS) System

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Huang, Jun; Zhu, Ye; Ma, Wenxia; Zhang, Zhigang; Shi, Weidong; Lin, Jun

  Background: Accurate preoperative planning for total hip arthroplasty (THA) relies on conventional anteroposterior radiographs. The difficulty of determining the magnification factor of radiographs is a major limitation. Despite the use of markers for calibration, identifying the plane of the hip joint is a major challenge. The aim of this study was to evaluate the accuracy of a novel method for image calibration and preoperative planning in THA involving the use of a biplanar radiographic (EOS imaging) system and a self-designed coin device. Methods: Biplanar radiographs (with the self-designed coin device) and a conventional anteroposterior radiograph (with a coin) were made for 26 patients after primary THA. The agreement between the actual and calculated diameters for each method was assessed using the concordance correlation coefficient (CCC) and Bland-Altman plots. In addition, 15 patients undergoing primary THA were prospectively enrolled to evaluate the EOS imaging-based method (EOS method), with biplanar radiographs made with use of the coin device. The accuracy of the preoperative predicted size of the implants was evaluated. Results: Both the EOS and conventional anteroposterior radiograph-based methods were reliable in repeated measurements of the diameter of the artificial femoral head in the reproducibility study, with the average CCCs for both methods >0.990. The agreement between the actual and EOS-based calculated diameters of the artificial femoral head was excellent, with a CCC of >0.990, while the agreement was poor between the actual and anteroposterior radiograph-based calculated diameters, with a CCC of <0.75. The EOS method exhibited a lower absolute difference (0.09 ± 0.07 mm) between the actual and calculated diameters compared with conventional anteroposterior radiography (1.26 ± 0.86 mm) (p < 0.001). EOS-based preoperative plans also exhibited excellent performance on the accuracy of the planning of the cups and stems; only 1 patient (6.7%) had a final implanted cup that differed by 1 size from the predicted size. Two patients (13.3%) had final implanted stems that differed by 1 size from the predicted size, and for 1 patient (6.7%), the stem size was off by ≥2 sizes. Conclusions: We describe a novel and easy-to-use method for the accurate calibration of radiographs and preoperative planning for THA. The EOS method evaluated in this study is an alternative method for preoperative planning in clinical practice.

• Anatomic Total Shoulder Arthroplasty with All-Polyethylene Glenoid Component for Primary Osteoarthritis with Glenoid Deficiencies

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Matsen, Frederick A. III; Whitson, Anastasia J.; Somerson, Jeremy S.; Hsu, Jason E.

  Background: This study evaluated the ability of shoulder arthroplasty using a standard glenoid component to improve patient self-assessed comfort and function and to correct preoperative humeral-head decentering on the face of the glenoid in patients with primary glenohumeral arthritis and type-B2 or B3 glenoids. Methods: We identified 66 shoulders with type-B2 glenoids (n = 40) or type-B3 glenoids (n = 26) undergoing total shoulder arthroplasties with a non-augmented glenoid component inserted without attempting to normalize glenoid version and with clinical and radiographic follow-up that was a minimum of 2 years. The Simple Shoulder Test (SST), the percentage of humeral-head decentering on the glenoid face, and bone ingrowth into the central peg were the main outcome variables of interest. Similar analyses were made for concurrent patients with type-A1, A2, B1, and D glenoid pathoanatomy to determine if the outcomes for type-B2 and B3 glenoids were inferior to those for the other types. Results: The SST score (and standard deviation) improved from 3.2 ± 2.1 points preoperatively to 9.9 ± 2.4 points postoperatively (p < 0.001) at a mean time of 2.8 ± 1.2 years for type-B2 glenoids and from 3.0 ± 2.5 points preoperatively to 9.4 ± 2.1 points postoperatively (p < 0.001) at a mean time of 2.9 ± 1.5 years for type-B3 glenoids; these results were not inferior to those for shoulders with other glenoid types. Postoperative glenoid version was not significantly different (p > 0.05) from preoperative glenoid version. The mean humeral-head decentering on the glenoid face was reduced for type-B2 glenoids from −14% ± 7% preoperatively to −1% ± 2% postoperatively (p < 0.001) and for type-B3 glenoids from −4% ± 6% preoperatively to −1% ± 3% postoperatively (p = 0.027). The rates of bone integration into the central peg for type-B2 glenoids (83%) and type-B3 glenoids (81%) were not inferior to those for other glenoid types. Conclusions: Shoulder arthroplasty with a standard glenoid inserted without changing version can significantly improve patient comfort and function and consistently center the humeral head on the glenoid face in shoulders with type-B2 and B3 glenoids, achieving >80% osseous integration into the central peg. These clinical and radiographic outcomes for type-B2 and B3 glenoids were not inferior to those outcomes for other glenoid types. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

• The Impact of Patient Age on Foot and Ankle Arthrodesis Supplemented with Autograft or an Autograft Alternative (rhPDGF-BB/β-TCP)

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Berlet, Gregory C.; Baumhauer, Judith F.; Glazebrook, Mark; Haddad, Steven L.; Younger, Alastair; Quiton, Jovelyn D.; Fitch, David A.; Daniels, Timothy R.; DiGiovanni, Christopher W.

  Background: A recent survey of orthopaedic surgeons asking about risk factors for nonunion following foot and ankle arthrodesis revealed that patient age is considered to be a relatively low risk factor, despite the potential for autologous graft quality to deteriorate with increasing age. The purpose of the current study was to evaluate the impact of patient age and graft type on fusion rates following hindfoot and ankle arthrodesis. Methods: In this study, we analyzed data from a previously published clinical trial, comparing fusion success in 397 subjects who underwent hindfoot or ankle arthrodesis (597 joints) supplemented with either autograft or an osteoinductive autograft alternative, recombinant human platelet-derived growth factor-BB homodimer carried in beta-tricalcium phosphate (rhPDGF-BB/β-TCP). The odds of fusion success were compared among subjects older or younger than age thresholds of 55, 60, 65, 70, and 75 years. The odds of fusion success were also compared between autograft and rhPDGF-BB/β-TCP among subjects older than each age threshold. Results: In the autograft group, the joints of subjects who were younger than the age thresholds of 60 and 65 years had >2 times the odds of successful fusion compared with those of older subjects. There was no significant difference in the odds of fusion success between the older and younger subjects at the age threshold of 55 years. In the rhPDGF-BB/β-TCP group, there was no significant difference in the odds of successful fusion between older and younger subjects at any age threshold. When the odds of fusion success were compared between the 2 graft materials in subjects who were older than each age threshold, rhPDGF-BB/β-TCP had approximately 2 times the odds of fusion success compared with autograft for all thresholds, except 55 years. Conclusions: The presented evidence suggests that age is an identifiable and concerning risk factor for hindfoot and ankle arthrodesis nonunion, a finding in contrast to the wider perception in the surgeon community. Notably, patients ≥60 years of age had significantly lower odds of fusion success with the use of autograft. The data reveal that use of rhPDGF-BB/β-TCP as an alternative bone-healing adjunct may help mitigate the risk of nonunion when these procedures are performed in the elderly population. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

• Elective Orthopaedic Surgery During COVID-19: A Safe Way to Get Back on Track

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Zorzi, Claudio; Piovan, Gianluca; Screpis, Daniele; Natali, Simone; Marocco, Stefania; Iacono, Venanzio

  Background: The novel coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has greatly changed our way of living and working. We have developed a method to treat urgent patients in a safe way, and we applied the same protocol to resume elective surgical procedures. Methods: We reorganized the system and the management of our orthopaedic department to perform elective surgical procedures in a safe way. During the COVID-19 lockdown, 614 patients underwent elective orthopaedic procedures. Results: No major postoperative complications were recorded. None of the orthopaedic surgeons, health-care personnel, or hospitalized patients was infected in this period of activity. Conclusions: During COVID-19, it is possible to perform elective surgical procedures in a safe way.

• Mortality in Patients with Proximal Femoral Fracture During the COVID-19 Pandemic: A U.K. Hospital's Experience

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Mamarelis, Georgios; Oduoza, Uche; Chekuri, Ravi; Estfan, Rami; Greer, Tony

  Background: Coronavirus disease 2019 (COVID-19) is a worldwide pandemic, with a case mortality ratio of approximately 6.4% at the time of writing (May 2020). Mortality increases in elderly patients with comorbidities. Patients with hip fracture have an average age of 80 years, with an estimated 2.8 comorbidities per patient. Evidence is lacking regarding the mortality rate of patients with hip fracture admitted during the COVID-19 pandemic. Our aim was to investigate the mortality rate among patients with a proximal femoral fracture who were admitted to our hospital during the COVID-19 pandemic. Methods: We conducted a retrospective review of all patients with a proximal femoral fracture admitted to Southend University Hospital in the U.K. from March to April 2020 (during the COVID-19 pandemic). Data collected included demographics (patient age, body mass index, sex), comorbidities, and blood test values along with COVID-19 diagnosis (based on positive microbiological sample and clinical and radiographic findings) and operative characteristics (time to operation, length of stay, American Society of Anesthesiologists [ASA] classification, Nottingham Hip Fracture Score). The primary outcome was the 30-day mortality rate for patients with a hip fracture who were COVID-19 positive or negative. Kaplan-Meier survival analysis was conducted along with Mann-Whitney U tests and Fisher exact tests. Results: Forty-one patients were included in the study, of whom 37 had an available SARS-CoV-2 (severe acute respiratory syndrome-coronavirus 2) swab test result. The overall 30-day mortality was 22%. Eleven patients tested positive for COVID-19. There was a significant difference in the mortality rate between those who tested positive and those who tested negative (54.5% versus 7.69%, respectively; Fisher exact test, p = 0.004) and between the operative patients who tested positive and the operative patients who tested negative (37.5% versus 4.34%, respectively; Fisher exact test, p = 0.043). Conclusions: Patients with a proximal femoral fracture may be at higher risk for mortality during the COVID-19 pandemic. We noted that patients with a proximal femoral fracture who tested positive for COVID-19 had a higher 30-day mortality rate compared with those who tested negative. Additional research is required to ascertain the benefits of a reduction in time to operation. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

• Combined Transfer of the Gluteus Maximus and Tensor Fasciae Latae for Irreparable Gluteus Medius Tear Using Contemporary Techniques: Short-Term Outcomes

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Maldonado, David R.; Annin, Shawn; Chen, Jeffrey W.; Yelton, Mitchell J.; Shapira, Jacob; Rosinsky, Philip J.; Lall, Ajay C.; Domb, Benjamin G.

  Background: Combined transfer of the gluteus maximus and tensor fasciae latae (TFL) has been acknowledged as a treatment for irreparable full-thickness gluteus medius tears; yet, there is a paucity of reports on outcomes for this topic in the current literature. The purpose of the present study was to report short-term patient-reported outcome scores in patients who underwent combined transfer of the gluteus maximus and TFL in the setting of an irreparable gluteus medius tear. Methods: Data for patients who underwent hip preservation and hip arthroplasty between July 2011 and November 2017 were prospectively collected and retrospectively reviewed. Patients were considered for this study if they had undergone combined transfer of the gluteus maximus and TFL for irreparable gluteus medius tears. Inclusion criteria consisted of patients who had a minimum 1-year follow-up for the modified Harris hip score, Non-Arthritic Hip Score, Hip Outcome Score Sports Specific Subscale, visual analog scale score for pain, and patient satisfaction. The exclusion criterion was Workers' Compensation status. Results: The study included 18 hips in 18 patients who underwent combined transfer of the gluteus maximus and TFL, with a mean follow-up of 39.75 months (range, 12.04 to 93.88 months). The average age was 68.48 ± 11.05 years, the average body mass index was 29.54 ± 6.23 kg/m2, and 13 patients were female. Abductor strength improved in 7 of 17 patients, with abduction data unavailable for 1 patient. Significant improvements were observed in modified Harris hip score from 49.73 ± 16.85 to 74.94 ± 17.91 (p < 0.001), Non-Arthritic Hip Score from 55.02 ± 22.53 to 72.78 ± 19.17 (p = 0.032), and visual analog scale for pain from 5.42 ± 3.42 to 1.57 ± 1.68 (p = 0.0004). No secondary surgeries were reported. Conclusions: Significant improvements in patient-reported outcomes were observed in patients who underwent combined transfer of the gluteus maximus and TFL for the treatment of irreparable full-thickness gluteus medius tears at short-term follow-up. Level of Evidence: Level IV. See Instructions for Authors for a complete description of levels of evidence.

• Preoperative Skin Cultures Predict Periprosthetic Infections in Revised Shoulder Arthroplasties: A Preliminary Report

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Matsen, Frederick A. III; Whitson, Anastasia; Hsu, Jason E.

  Background: Current approaches do not provide a practical method for the accurate prediction of a Cutibacterium periprosthetic joint infection (PJI) in failed arthroplasties. Thus, surgeons revising failed arthroplasties must decide whether to exchange the implants and to institute antibiotic treatment without knowing the results of cultures of deep specimens obtained at the revision procedure. This study tests the hypothesis that the results of preoperative culture specimens of the skin surface obtained in the clinic can predict the presence of culture-positive Cutibacterium PJIs. Methods: Revision shoulder arthroplasties performed between October 3, 2017, and February 4, 2020, that had both preoperative clinic culture specimens and surgical culture specimens were included in this analysis. Culture results were assigned a value from 0 to 4. The percentage of the total skin bacterial load contributed by Cutibacterium (Cutibacterium percentage) was determined. To reduce concern about contamination, a robust criterion for culture-positive Cutibacterium PJI was applied: ≥2 surgical specimens with a Cutibacterium value of ≥1. The predictive values for a culture-positive Cutibacterium PJI were determined for a clinic skin culture Cutibacterium value of >1 and a clinic skin percentage of Cutibacterium of ≥75%. Results: Eighteen cases met the inclusion criteria; of these, 7 (6 male patients) met our criterion for a culture-positive Cutibacterium PJI. For all patients, a preoperative clinic skin Cutibacterium value of >1 predicted the presence of a culture-positive Cutibacterium PJI with an accuracy of 89%, and a clinic skin Cutibacterium percentage of ≥75% predicted the presence of a culture-positive Cutibacterium PJI with an accuracy of 94%. For male patients, a preoperative clinic skin Cutibacterium value of >1 predicted the presence of a culture-positive Cutibacterium PJI with an accuracy of 91%, and a clinic skin Cutibacterium percentage of ≥75% predicted the presence of a culture-positive Cutibacterium PJI with an accuracy of 100%. Conclusions: A simple culture specimen of the unprepared skin surface obtained in a clinic prior to revision shoulder arthroplasty may provide valuable assistance to surgeons planning a revision arthroplasty. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

• Surgical Approach to Total Hip Arthroplasty Affects the Organism Profile of Early Periprosthetic Joint Infections

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Buchalter, Daniel B.; Teo, Greg M.; Kirby, David J.; Aggarwal, Vinay K.; Long, William J.

  Background: The optimal approach for total hip arthroplasty (THA) remains hotly debated. While wound complications following the direct anterior approach are higher than with other approaches, the organism profile of periprosthetic joint infections (PJIs) by approach remains unknown. Our goal was to compare the organism profiles of PJIs following direct anterior and non-anterior THA. Methods: We retrospectively reviewed 12,549 primary THAs (4,515 direct anterior and 8,034 non-anterior) that had been performed between January 2012 and September 2019 at a university-affiliated single-specialty orthopaedic hospital to identify patients with an early postoperative PJI. Criteria used for the diagnosis of a PJI were the National Healthcare Safety Network, which screens for PJI that occurs within 90 days of index arthroplasty, and the Musculoskeletal Infection Society guidelines. Patient demographic information and organism characteristics were recorded for analysis. Results: We identified 84 patients (38 who underwent the direct anterior approach and 46 who underwent the non-anterior approach) with an early postoperative PJI following primary THA (0.67% total THA PJI rate, 0.84% direct anterior THA PJI rate, and 0.57% non-anterior THA PJI rate). The direct anterior THA cohort had a significantly lower body mass index and American Society of Anesthesiologists score than the non-anterior THA cohort (29.5 versus 35.2 kg/m2, p < 0.0001; 2.29 versus 2.63, p = 0.016, respectively). Regarding organism profile, patients in the direct anterior THA cohort had significantly more monomicrobial gram-negative infections than the non-anterior THA cohort (4 versus 0, p = 0.038). We did not identify any demographic risk factors other than approach for gram-negative PJI. There were no significant differences in methicillin-resistant Staphylococcus aureus, methicillin-sensitive Staphylococcus aureus, coagulase-negative Staphylococcus, obligate anaerobes, polymicrobial, or PJIs due to other organisms by approach. Conclusions: Direct anterior THA approaches have a greater risk of monomicrobial gram-negative PJI, likely due to the unique microbiome of the inguinal region. While targeted infection prophylaxis may reduce these infections, it is not entirely effective on its own. Future studies with larger sample sizes are required to help us develop more targeted perioperative infection prophylaxis. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

• Exchange of Modular Components Improves Success of Debridement, Antibiotics, and Implant Retention: An Observational Study of 575 Patients with Infection After Primary Total Hip Arthroplasty

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Svensson, Karin; Rolfson, Ola; Nauclér, Emma; Lazarinis, Stergios; Sköldenberg, Olof; Schilcher, Jörg; Johanson, Per-Erik; Mohaddes, Maziar; Kärrholm, Johan

  Background: Debridement, antibiotics, and implant retention (DAIR) is a surgical treatment for periprosthetic joint infection (PJI). DAIR is a desirable treatment option from an economic and patient perspective, if successful. The aim of this observational study was to compare the rates of success, defined as no additional reoperations due to PJI, between DAIR with exchange of modular components and DAIR without exchange in patients who had first-time PJI after primary total hip arthroplasty (THA). Methods: Patients with PJI at the site of a primary THA who were treated with DAIR in Sweden between January 1, 2009, and December 31, 2016, were identified in the Swedish Hip Arthroplasty Register. Supplementary questionnaires were sent to orthopaedic departments for additional variables of interest related to PJI. The primary end point was another reoperation due to PJI within 2 years after the first-time DAIR. DAIR with exchange was compared with DAIR without exchange using Kaplan-Meier survival analysis and Cox regression analysis. Results: A total of 575 patients treated with DAIR for a first-time PJI at the site of a primary THA were analyzed; 364 underwent component exchange and 211 did not. The exchange of components was associated with a lower rate of reoperations due to PJI after DAIR (28.0%) compared with non-exchange (44.1%). The Kaplan-Meier implant survival estimate for exchange was 71.4% (95% confidence interval [CI] = 66.9% to 76.3%) compared with 55.5% (95% CI = 49.1% to 62.7%) for non-exchange. With the analysis adjusted for confounders, DAIR with exchange was associated with a significantly decreased risk of another reoperation due to PJI compared with non-exchange (hazard ratio [HR] = 0.51 [95% CI = 0.38 to 0.68]). Conclusions: In patients with a first-time PJI at the site of a primary THA, DAIR with exchange of modular components was superior to non-exchange DAIR. Surgeons should strive to exchange components when they perform DAIR, but there is a need to further identify how DAIR best should be practiced and which patients benefit from it. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

• The Use of Porous Titanium Coating and the Largest Possible Head Do Not Affect Early Cup Fixation: A 2-Year Report from a Randomized Controlled Trial

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Tsikandylakis, Georgios; Mortensen, Kristian R.L.; Gromov, Kirill; Troelsen, Anders; Malchau, Henrik; Mohaddes, Maziar

  Background: Cups are more frequently revised than stems after uncemented total hip arthroplasty, which warrants the development of cup surfaces that provide long-lasting, stable fixation. Large heads have become popular with the aim of reducing dislocation rates, but they generate greater frictional torque that may compromise cup fixation. We aimed to investigate (1) if a novel porous titanium surface provides superior cup fixation when compared with a porous plasma spray (PPS) surface and (2) if the use of the largest possible head compromises cup fixation when compared with a 32-mm head. Methods: Ninety-six patients were randomized to receive either a cup with a porous titanium coating (PTC) or a cup with PPS. A second randomization was performed to either the largest possible (36 to 44-mm) or a 32-mm head in metal-on-vitamin-E-infused polyethylene bearings. Roentgen stereophotogrammetric analysis (RSA) examinations were obtained postoperatively at 3, 12, and 24 months. The primary outcome was proximal cup migration when comparing the 2 cup surfaces and also when comparing the largest possible head with the 32-mm head. The patients were followed for 2 years. Results: The median (and interquartile range) proximal cup migration was 0.15 mm (0.02 to 0.32 mm) for the PTC cup and 0.21 mm (0.11 to 0.34 mm) for the PPS cup. The largest possible head had a proximal cup migration of 0.15 mm (0.09 to 0.31 mm), and the 32-mm head had a proximal cup migration of 0.20 mm (0.04 to 0.35 mm). There were no significant differences between the cup surface (p = 0.378) or the head size (p = 0.693) groups. Conclusions: Early cup fixation was not superior with the novel PTC cup; the use of the largest possible head (36 to 44 mm) did not compromise early cup fixation. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

• The Effect of Body Mass Index Class on Patient-Reported Health-Related Quality of Life Before and After Total Hip Arthroplasty for Osteoarthritis: Registry-Based Cohort Study of 64,055 Patients

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Mukka, Sebastian; Rolfson, Ola; Mohaddes, Maziar; Sayed-Noor, Arkan

  Background: Overweight status and obesity represent a global epidemic, with serious consequences at the individual and community levels. The number of total hip arthroplasties (THAs) among overweight and obese patients is expected to rise. Increasing body mass index (BMI) has been associated with a higher risk of mortality and reoperation and lower implant survival. The evaluation of perioperative health-related quality of life (HRQoL) has recently gained importance because of its direct relation to, and impact on, patients' physical, mental, and social well-being as well as health-service utilization. We sought to evaluate the influence of BMI class on HRQoL preoperatively and at 1 year following THA in a register-based cohort study. Methods: This observational cohort study was designed and conducted on the basis of registry data derived from the Swedish Hip Arthroplasty Register (SHAR) and included 64,055 primary THAs registered between January 1, 2008, and December 31, 2015. Patients' baseline preoperative and 1-year postoperative EuroQol-5 Dimension-3 Level (EQ-5D-3L) responses were documented by the treating department and reported to the SHAR through the patient-reported outcome measures program. The EQ-5D-3L includes a visual analogue scale (EQ VAS), which measures the patient's overall health status. Results: At 1 year of follow-up, all BMI classes showed significant and clinically relevant improvements in all HRQoL measures compared with preoperative assessment (p < 0.05). Patients reported improved perception of current overall health status for the EQ VAS. Underweight, overweight, and all obesity classes showed increasingly worse 1-year HRQoL compared with normal weight, both with unadjusted and adjusted calculations. Conclusions: In this study, we found that all BMI classes had significant improvement in HRQoL at 1 year following THA. Patients who were underweight, overweight, or obese (classes I to III), compared with those of normal weight, reported worse hip pain and EQ-5D-3L and EQ VAS responses prior to THA and at 1 year postoperatively. These results can assist both health-care providers and patients in establishing reasonable expectations about THA outcomes. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

• Epiphyseal Angulation and Related Spatial Orientation in Slipped Capital Femoral Epiphysis: Theoretical Model and Biomechanical Explanation of Varus and Valgus Slip

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Gautier, Emanuel; Passaplan, Caroline; Gautier, Lucienne

  Background: The management of slipped capital femoral epiphysis (SCFE) is controversial. Surgical decision-making is based regularly on the chronicity, stability, and severity of the slip. The purpose of this study was to determine the true angulation and spatial orientation of the epiphysis in hips with SCFE and contralateral hips. Methods: Eighteen hips in 18 patients with SCFE were included in the analysis. Trigonometric calculations, based on angle measurements using 2 conventional radiographs in planes that are perpendicular to each other, were used to determine the angulation of the epiphysis and its orientation in space. Results: The mean absolute epiphyseal obliquity of the SCFE hips was 56.2° and the spatial orientation was 36.5°. The mean obliquity of the contralateral side was 34.0°, with a related spatial orientation of 16.8°. The maximum error can reach up to 9.9° (or 41%) when comparing the calculated angles with the angle measurements on radiographs. Conclusions: On standard radiographs, the epiphyseal angulation in SCFE is consistently underestimated. As a consequence, the assigned classification of some patients may be 1 severity group too low, which impacts the value of traditional severity classification for surgical decision-making. The analysis of the spatial orientation of the slip with the concomitant direction of the resultant shear can partially explain varus and valgus slip in SCFE. Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

• Nonoperative Treatment of Anterior Glenoid Rim Fractures After First-Time Traumatic Anterior Shoulder Dislocation: A Study with 9-Year Follow-up

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Wieser, Karl; Waltenspül, Manuel; Ernstbrunner, Lukas; Ammann, Elias; Nieuwland, Arend; Eid, Karim; Gerber, Christian

  Background: Primary traumatic anterior shoulder dislocations can be associated with displaced anterior glenoid rim fractures. Nonoperative treatment of such fractures has been shown to have excellent results in a small cohort of patients; as such, we have been treating these fractures nonoperatively, regardless of fragment size and degree of displacement, provided that post-reduction computed tomography scans revealed an anteroposteriorly centered humeral head. The aim of this study was to analyze the medium- to long-term results of nonoperative treatment of displaced anterior glenoid rim fractures, assessing in particular the residual instability and development of osteoarthritis. Methods: In a 2-center study, 30 patients with a mean age of 48 years (range, 29 to 67 years) were evaluated clinically with use of the Subjective Shoulder Value, Constant score, American Shoulder and Elbow Surgeons score, and Western Ontario Shoulder Instability index, as well as radiographically with use of radiographs and computed tomography scans at a mean follow-up of 9 years (range, 5 to 14 years). Results: Fracture-healing was documented in all patients. Seven patients (23%) had post-fracture onset of osteoarthritis (5 with Samilson grade I and 2 with Samilson grade IV). Of these, 1 patient had recurrent instability that was successfully treated with hemiarthroplasty 9 years after the index injury (relative Constant score, 101%), and was excluded from further analysis. No other patient had a recurrent redislocation, subluxation, or positive apprehension. The other 6 patients with new-onset radiographic osteoarthritis were pain-free (mean Constant score pain scale, 15 points) with good shoulder function (relative Constant score, 84% to 108%). A total of 26 patients (90%) rated their functional outcome as good or very good, and 3 patients (10%) rated it as fair. The mean relative Constant score was 97% (range, 61% to 108%), the mean American Shoulder and Elbow Surgeons score was 92 points (range, 56 to 100 points), and the mean Western Ontario Shoulder Instability index score was 126 points (range, 0 to 660 points). All patients returned to full-time work. Conclusions: Nonoperative treatment of anterior glenoid rim fractures following primary traumatic anterior shoulder dislocation results in excellent clinical outcomes with a very low rate of residual instability and, thus, treatment failure. Asymptomatic radiographic osteoarthritis occurred in roughly 1 of 4 patients. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

• Motorized Internal Limb-Lengthening (MILL) Techniques Are Superior to Alternative Limb-Lengthening Techniques: A Systematic Review and Meta-Analysis of the Literature

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Sheridan, Gerard A.; Falk, David P.; Fragomen, Austin T.; Rozbruch, S. Robert

  Background: The field of limb lengthening has undergone substantial advancement in recent years with respect to the subjective patient experience, the rate of surgical complications, and the time required to achieve regenerate consolidation. We aimed to assess the performance of motorized internal limb lengthening (MILL) devices when compared with alternative methods of limb lengthening through systematic review and meta-analysis. Methods: Studies comparing MILL methods with alternative forms of limb lengthening were included for systematic review. Medical Subject Headings (MeSH) terms, specifically "PRECICE," "STRYDE," "FITBONE," "limb lengthening," "Ilizarov," "distraction osteogenesis," and "motorized internal limb lengthening," were used to search a number of electronic bibliographic databases, including PubMed, the International Clinical Trials Registry Platform (World Health Organization), the Cochrane Library, ClinicalTrials.gov, and the EU Clinical Trials Register. The primary outcome measures were time to union and total length (centimeters) achieved. Kaplan-Meier survivorship curves were generated, and the 2-sample t test with equal variances was utilized to compare groups. Secondary outcomes including problems, obstacles, and sequelae were compared using a random-effects meta-analysis. To detect any evidence of publication bias, the Egger test for small-study effects was used. A number of bone-healing indices, when reported, were compared between groups. Results: A total of 143 limbs were lengthened using MILL techniques. These were compared with 98 limbs that were lengthened with the use of alternative techniques. The MILL cohort was found to have significantly fewer problems (p < 0.001; relative risk [RR] = 0.31; 95% confidence interval [CI], 0.19 to 0.52) and sequelae (p = 0.002; RR = 0.57; 95% CI, 0.40 to 0.81) on random-effects meta-analysis. Both deep and superficial infectious complications were fewer for MILL procedures across all of the studies. Conclusions: MILL is associated with fewer complications than alternative methods of limb lengthening. Because of the advancements in the field of limb lengthening toward fully implantable remote-controlled internal limb-lengthening devices, MILL techniques are likely to dominate the field of limb lengthening in the foreseeable future. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

• In-Bundle Surgeons More Likely Select Cemented Femoral Fixation in Total Hip Arthroplasty for At-Risk Patients: The Medicare Comprehensive Care for Joint Replacement Bundled Model

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Edelstein, Adam I.; Hume, Eric L.; Pezzin, Liliana E.; McGinley, Emily L.; Dillingham, Timothy R.

  Background: Bundled payment models for lower-extremity arthroplasty have been shown to lower costs but have not reliably improved quality. It is unknown how the bundled payment model may affect surgeons' decisions that impact the quality of arthroplasty care. The purpose of this study was to compare the utilization of femoral component fixation modes by surgeons performing total hip arthroplasties (THAs) in at-risk patients in areas subject to Medicare's Comprehensive Care for Joint Replacement (CJR) bundled payment model compared with patients treated by surgeons in areas exempt from the policy. Methods: Elective, primary THAs among elderly persons were identified from Medicare claims during 2017 and 2018, including the use of cemented or cementless femoral fixation. Multivariable regression models, applied to samples stratified by sex, were used to assess the association between CJR bundle participation and the use of femoral fixation mode. Analyses were adjusted for patient age, race or ethnicity, comorbidity burden, low-income status, and Census division of the hospital. Results: Of 118,676 Medicare patients who underwent THA, 9.1% received cemented femoral components, and use of cement varied significantly by geographic region (p < 0.001). Patients who received cemented fixation, compared with patients who received cementless fixation, had significant differences in mean age (and standard deviation) at 78.3 ± 6.9 years compared with 74.5 ± 6.1 years (p < 0.001) for female patients and 77.3 ± 6.8 years and 74.2 ± 5.9 years (p < 0.001) for male patients; were more likely to be White at 94.0% compared with 92.7% (p < 0.001) for female patients and 95.1% compared with 93.8% (p = 0.046) for male patients; and had higher mean Elixhauser comorbidity index at 2.6 ± 2.2 compared with 2.3 ± 2.0 (p < 0.001) for female patients and 2.8 ± 2.4 compared with 2.4 ± 2.1 (p < 0.001) for male patients. In adjusted analyses, female patients in the CJR bundled payment model were more likely to have cemented fixation compared with female patients not in the CJR model (odds ratio [OR], 1.11 [95% confidence interval (CI), 1.05 to 1.16]; p < 0.001), whereas male patients in the CJR bundled payment model were less likely to have cemented fixation compared with male patients not in the CJR model (OR, 0.91 [95% CI, 0.83 to 0.99]; p = 0.029). Conclusions: In the bundled environment, surgeons were more likely to choose cemented femoral fixation for elderly female patients. This may be due to in-bundle surgeons being more risk-averse and avoiding cementless fixation in patients at risk for fracture or implant-related complications. Further research is needed to directly examine the impact of the bundle on surgeon decision-making.

• Failure Rates of Autograft and Allograft ACL Reconstruction in Patients 19 Years of Age and Younger: A Systematic Review and Meta-Analysis

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Cruz, Aristides I. Jr.; Beck, Jennifer J.; Ellington, Matthew D.; Mayer, Stephanie W.; Pennock, Andrew T.; Stinson, Zachary S.; VandenBerg, Curtis D.; Barrow, Brooke; Gao, Burke; Ellis, Henry B. Jr.

  Background: Graft choice for pediatric anterior cruciate ligament reconstruction (ACLR) is determined by several factors. There is limited information on the use and outcomes of allograft ACLR in pediatric patients. The purpose of this systematic review and meta-analysis was to quantify reported failure rates of allograft versus autograft ACLR in patients ≤19 years of age with ≥2 years of follow-up. We hypothesized that there would be higher rates of failure for allograft compared with autograft ACLR in this population. Methods: PubMed/MEDLINE and Embase databases were systematically searched for literature regarding allograft and autograft ACLR in pediatric/adolescent patients. Articles were included if they described a cohort of patients with average age of ≤19 years, had a minimum of 2 years of follow-up, described graft failure as an outcome, and had a Level of Evidence grade of I to III. Qualitative review and quantitative meta-analysis were performed to compare graft failure rates. A random-effects model was created to compare failure events in patients receiving allograft versus autograft in a pairwise fashion. Data analysis was completed using RevMan 5.3 software (The Cochrane Collaboration). Results: The database search identified 1,604 studies; 203 full-text articles were assessed for eligibility. Fourteen studies met the inclusion criteria for qualitative review; 5 studies were included for quantitative meta-analysis. Bone-patellar tendon-bone (BTB) represented 58.2% (n = 1,012) of the autografts, and hamstring grafts represented 41.8% (n = 727). Hybrid allografts (autograft + supplemental allograft) represented 12.8% (n = 18) of all allograft ACLRs (n = 141). The unweighted, pooled failure rate for each graft type was 8.5% for BTB, 16.6% for hamstring, and 25.5% for allograft. Allografts were significantly more likely than autografts to result in graft failure (odds ratio, 3.87; 95% confidence interval, 2.24 to 6.69). Conclusions: Allograft ACLR in pediatric and adolescent patients should be used judiciously, as existing studies revealed a significantly higher failure rate for allograft compared with autograft ACLR in this patient population. Additional studies are needed to improve the understanding of variables associated with the high ACLR failure rate among pediatric and adolescent patients. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

• Restructuring of an Orthopaedic Surgery Residency Research Rotation Correlates with Increased Academic Productivity in Teaching Faculty

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Granger, Caroline J.; Rothy, Alexander; Nigh, Evan; Hernandez, Victor H.; Baraga, Michael; Conway, Sheila Ann

  Introduction: Contribution toward clinical research is paramount to the education of physician trainees and is required by the Accreditation Council for Graduate Medical Education. From 1987 through 2015, our single institution orthopaedic surgery residency research experience included 2 dedicated research rotations. Because few resident projects were pursued to completion, feedback was used to restructure the curriculum, including the appointment of 2 clinical orthopaedic faculty to serve as codirectors, development of a revised curriculum, use of research teams, and a centralized research database. Our group previously displayed increased resident productivity within 2 years after the 2015 implementation. The aim of this study was to investigate the impact of orthopaedic residency curricular changes on scholarly activity of orthopaedic teaching faculty. Methods: The curriculum vitae (CVs) of a single institution's orthopaedic teaching faculty were collected and retrospectively reviewed from 2014 through 2018 to determine academic productivity of clinical faculty. Indicators of academic productivity included peer-reviewed publications (including journal impact factors) and podium or poster presentations. Results: Twenty-three of 27 faculty members responded to our request for CVs. One hundred three CVs were reviewed on 23 faculty. All academic indicators increased over 5 years. Multivariate analysis of variance (MANOVA) using a multivariate repeated measures analysis was completed. A sphericity χ2 test was violated for all measures, precluding us from using unadjusted univariate analysis. Univariate MANOVA with repeated measures displays significance regarding impact factor (f < 0.02, p < 0.05) and journal publications (f < 0.004, p < 0.05). Subsequent multivariate analysis shows similar results regarding impact factor (f < 0.0008), journal publications (0.0005), and poster presentations (f < 0.016). Conclusions: Improved structure of an established resident research rotation combined with enhanced faculty mentorship resulted in a significant increase in academic productivity for clinical teaching faculty of the department of orthopaedic surgery. This increase parallels that seen in orthopaedic resident research productivity; indicating a positive impact on teaching faculty scholarly activity. Level of Evidence: III.

• The Content and Accessibility of Orthopaedic Residency Program Websites

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Sherman, Nathan C.; C. Sorenson, Jacob; M. Khwaja, Ansab; L. DeSilva, Gregory

  Background: Applicants to orthopaedic surgery residency programs face a competitive match. Internet resources such as program websites allow prospective applicants to gauge interest in particular programs. This study evaluated the content and accessibility of orthopaedic surgery residency program websites. Methods: Existing orthopaedic surgery residency programs for the 2020 application cycle were identified on the Electronic Residency Application Service (ERAS) website. Individual program websites were accessed through links directly from the ERAS website, and a Google search for each program was performed to corroborate accessibility. Programs websites were then reviewed and evaluated on the presence of 20 criteria selected for their potential to influence resident recruitment (10) and education (10), respectively. The results were compared with the lone 2001 study and with orthopaedic fellowship website analyses. Results: One hundred eighty-nine orthopaedic surgery residency programs were accredited at the time of the study. Only 6 programs (3.2%) did not have a website identifiable through ERAS or Google searches, leaving a final sample size of 183 websites. Approximately 73.3% of all recruitment content and 44.9% of education content were present on the websites available. There was a significant increase in all available recruitment and education content (p < 0.05) when compared with the lone 2001 study. Orthopaedic residency program websites provide comparable recruitment content at a higher rate (71.1%) than orthopaedic fellowship websites (59.6%) but fall slightly below average in presentation of education content (44.9% vs 45.9%). Conclusion: This is the first study in nearly 20 years to assess the content and accessibility of orthopaedic residency program websites. There is noticeable variability in the presentation of website content, but approximately 73.3% of recruitment content and 44.9% of the educational content were easily accessible through internet search. Orthopaedic surgery residency programs and their applicants may benefit from standardization of program websites and an increase in recruitment and education content.

• Use of the Behavior Assessment Tool in 18 Pilot Residency Programs

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Armstrong, April D.; Agel, Julie; Beal, Matthew D.; Bednar, Michael S.; Caird, Michelle S.; Carpenter, James E.; Guthrie, Stuart T.; Juliano, Paul; Karam, Matthew; LaPorte, Dawn; Marsh, J. Lawrence; Patt, Joshua C.; Peabody, Terrance D.; Wu, Karen; Martin, David F.; Harrast, John J.; Van Heest, Ann E.

  Background: The purpose of this study was to determine the feasibility and evaluate the effectiveness of the American Board of Orthopaedic Surgery Behavior Tool (ABOSBT) for measuring professionalism. Methods: Through collaboration between the American Board of Orthopaedic Surgery and American Orthopaedic Association's Council of Residency Directors, 18 residency programs piloted the use of the ABOSBT. Residents requested assessments from faculty at the end of their clinical rotations, and a 360° request was performed near the end of the academic year. Program Directors (PDs) rated individual resident professionalism (based on historical observation) at the outset of the study, for comparison to the ABOSBT results. Results: Nine thousand eight hundred ninety-two evaluations were completed using the ABOSBT for 449 different residents by 1,012 evaluators. 97.6% of all evaluations were scored level 4 or 5 (high levels of professional behavior) across all of the 5 domains. In total, 2.4% of all evaluations scored level 3 or below reflecting poorer performance. Of 431 residents, the ABOSBT identified 26 of 32 residents who were low performers (2 or more < level 3 scores in a domain) and who also scored "below expectations" by the PD at the start of the pilot project (81% sensitivity and 57% specificity), including 13 of these residents scoring poorly in all 5 domains. Evaluators found the ABOSBT was easy to use (96%) and that it was an effective tool to assess resident professional behavior (81%). Conclusions: The ABOSBT was able to identify 2.4% low score evaluations (

• Applicant Fit and Diversity in the Orthopaedic Surgery Residency Selection Process: Defining and Melding to Create a More Diverse and Stronger Residency Program

  Thu, 01 Oct 2020 00:00:00 GMT-05:00
  Modest, Jacob M.; Cruz, Aristides I. Jr; Daniels, Alan H.; Lemme, Nicholas J.; Eberson, Craig P.

  No abstract available

  

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