Morton's neuroma: review of anatomy, pathomechanism, and imaging

Morton's neuroma is a commonly encountered cause of forefoot pain, which may limit weight-bearing activities and footwear choices. Although the aetiology and pathomechanism of this condition is controversial, the histological endpoint is well established as benign perineural fibrosis of a common plantar digital nerve, typically within the third intermetatarsal space. The diagnosis of Morton's neuroma is mainly based on characteristic symptoms and clinical findings, but may be confirmed by ultrasonography. Although ultrasound is a highly accurate diagnostic tool for Morton's neuroma, it is subject to interoperator variability due to differences in technique and level of experience. In this paper, the authors review the anatomy of the common plantar digital nerves and surrounding structures in the forefoot, which are deemed relevant to the understanding of Morton's neuroma, especially from a sonographic point of view. Several theories of the pathomechanism of Morton's neuroma are briefly discussed. The main purpose of this article is to illustrate the ultrasound techniques for evaluating Morton's neuroma and performing ultrasound-guided corticosteroid injections.

Fight Against COVID-19: ARCI's Technologies for Disinfection

COVID-19 (SARS-CoV-2) is causing a huge concern to the global population due to its highly contagious properties. The SARS-CoV-2 is a new variant in the coronavirus family. The world is focussing on several methods to battle against this novel corona virus, including control of its spread. In this context, ARCI has quickly made efforts to develop disinfection systems including a UVC-based disinfection trolley, honeycomb air heater and a fogging chamber using UVC germicidal lamps, dry heat sterilization and HOCl-based chemical disinfectant to provide rapid and effective inactivation of microorganisms causing the pandemic. These systems have been successfully deployed at different hospitals for their validation.

Impact of the size of the lesion in prenatal neural tube defect repair on imaging, neurosurgical and motor outcomes: a retrospective cohort study

OBJECTIVES

(1) To compare brain findings between large and non-large neural tube defect (NTD); (2) to evaluate the impact of large lesion on the surgical parameters; (3) to study any associations between the size of the lesions and brain findings 6 weeks postoperatively and neurological short-term outcomes.

DESIGN

Retrospective cohort study.

SETTING

Texas Children's Hospital, between 2011 and 2018.

POPULATION

Patients who underwent prenatal NTD repair.

METHODS

Large lesion was defined when the lesion's surface was >75th centile of our cohorts' lesions.

MAIN OUTCOME MEASURES

Time of referral: ventriculomegaly and anatomical level of the lesion; surgery: duration and need for relaxing incisions. 6 weeks postoperative: hindbrain herniation (HBH) and ventriculomegaly. After delivery: dehiscence, need for hydrocephalus treatment and motor function.

RESULTS

A total of 99 patients were included, 25 of whom presented with large lesions. Type of lesion and ventriculomegaly were comparable between individuals with large and non-large lesions. Individuals with large lesions were associated with increased need for relaxing incisions by 5.4 times (95% CI 1.3-23.2, P = 0.02). Six weeks postoperatively, having a large lesion decreased by ten times the likelihood of having a postoperative reversal of HBH (odds ratio = 0.1, 95% CI 0.1-0.4, P < 0.01). At birth, larger lesions increased the risk for repair dehiscence by 6.1 times (95% CI 1.6-22.5, P < 0.01) and the risk of dehiscence or leakage of cerebrospinal fluid at birth by 5.5 times (95% CI 1.6-18.9, P < 0.01).

CONCLUSION

Prenatal repair of patients with large NTD presents a lower proportion of HBH reversal 6 weeks after the surgery, a higher risk of dehiscence and a higher need for postnatal repair.

TWEETABLE ABSTRACT

Evaluation of the size of fetal NTD can predict adverse neurological outcomes after prenatal NTD repair.

THU0408 EFFECT OF NEW-ONSET GOUT ON KIDNEY TRANSPLANT OUTCOMES: A RETROSPECTIVE COHORT ANALYSIS OF THE UNITED STATES RENAL DATA SYSTEM

Background:

Gout is a frequent comorbidity in kidney transplant (KT) recipients. However, assessing the independent effect of gout on KT outcomes is difficult because of multiple confounders (e.g., temporal changes in estimated glomerular filtration rate [eGFR], cyclosporine or tacrolimus dose, urate-lowering medication use) that obscure a clear picture of gout’s potential impact.

Objectives:

This investigation assessed if the development of new-onset gout after KT was an independent risk factor for loss of graft function, as assessed by the need for maintenance hemodialysis following KT.

Methods:

This retrospective cohort study analyzed data on patients in the United States Renal Data System (USRDS) who received a primary KT between 1/1/2008 and 12/31/2015. The date of transplantation was the ‘index’ date. Eligible patients were required to have ≥24 months of Medicare coverage and no prior history of gout, defined as ≥1 claim with a gout diagnosis code in the 24 months prior to the index date. All patients were also required to have ≥12 months of coverage post index. Patients who died, experienced graft failure, or returned to dialysis <12 months post index were excluded. Because the first year following transplant is associated with the highest frequency of rejections, we evaluated subjects beginning 1 year after transplant. The exposure of interest was new-onset gout, defined as the presence of ≥2 claims for gout post index, and the primary endpoint was return to dialysis >12 months post index. Baseline time-invariant confounders included recipient and donor demographics and clinical characteristics at index. Time-varying confounders included body mass index (BMI) adjusted tacrolimus and cyclosporine dose, eGFR, and urate-lowering medication use post index. Patients who died or lost Medicare coverage >12 months post index were censored; all patients remaining at the end of the study period (12/31/2016) were also censored. A marginal structural model (MSM) was fitted to determine the relative risk of new-onset gout on return to dialysis, while controlling for both time-invariant and time-varying confounders.

Results:

18,525 of 466,589 KT recipients in the USRDS met study eligibility. Within the observation period, 1,399 (7.6%) developed new-onset gout and 1,420 (7.7%) returned to dialysis >12 months post index. Median time from index to new-onset gout and from index to return to dialysis was 16.2 months (IQR: 33.4) and 32.8 months (IQR: 28.4), respectively. Adjusting for baseline time-invariant and time-varying confounders via the MSM showed new-onset gout was associated with a 51% increased risk of return to dialysis >12 months post index (RR: 1.51, 95% CI: 1.03, 2.20).

Conclusion:

New-onset gout was independently associated with a 51% increased risk of return to dialysis >12 months after primary KT compared to a control cohort without gout. To our knowledge, this is the first observation of this outcome in an appropriately controlled cohort study of KT recipients with gout. Results from this analysis may have important implications for the monitoring and management of new-onset gout in the kidney transplant population.

References:

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Disclosure of Interests: :

Justin Li: None declared, David Yin: None declared, Zheng Wang: None declared, Mark Brigham: None declared, Brian LaMoreaux Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Jeffrey Kent Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Megan Francis-Sedlak Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Richard Johnson Shareholder of: Colorado Research Partners LLC, XORTX Therapeutics, Consultant of: Horizon Therapeutics, Eli Lilly, Speakers bureau: Horizon Therapeutics, Nandini Hadker: None declared, Kevin Francis: None declared, Herman Sanchez: None declared, Gavin Miyasato: None declared

Comparative dynamic aerosol efficiencies of three emergent coronaviruses and the unusual persistence of SARS-CoV-2 in aerosol suspensions

The emergent coronavirus, designated severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), is a zoonotic pathogen that has demonstrated remarkable transmissibility in the human population and is the etiological agent of a current global pandemic called COVID-191. We measured the dynamic (short-term) aerosol efficiencies of SARS-CoV-2 and compared the efficiencies with two other emerging coronaviruses, SARS-CoV (emerged in 2002) and Middle Eastern respiratory syndrome CoV (MERS-CoV; emerged starting in 2012). We also quantified the long-term persistence of SARS-CoV-2 and its ability to maintain infectivity when suspended in aerosols for up to 16 hours.

S, Anthony C, Coleman P, Cottingham B, Culmo R, Curtis R, Dingman L, Johnson R, Lehman G, Loughran J, Martinez S, Moody J, Paisley C, Radloff H, John AS, Schrader E, Sizemore J, Wenger J, White G. Combustion Method for Determination of Crude Protein in Meat and Meat Products: Collaborative Study

Twelve laboratories participated in a collaborative study to compare a combustion method with the AOAC mercury catalyst Kjeldahl method (928.08) for the determination of crude protein in meat and meat products. Three different combustion instruments were used; consequently, the combustion method for this study is written in generic terms describing the principle, the apparatus specifications, and the performance requirements needed. Fifteen sample pairs were used for the study; each pair consisted of the same commercial meat product from each of 2 different manufacturers. Protein content of all samples ranged from about 10 to 20%. In addition, nicotinic acid and lysine monohydrochloride were used as standards to assess combustion equipment performance. All laboratories and all instruments performed the combustion method satisfactorily on the basis of results for the standards. For the meat samples, repeatability standard deviations (sr) ranged from 0.11 to 0.40 for the Kjeldahl method and from 0.12 to 0.41 for the combustion method; the repeatability relative standard deviations (RSDr) ranged from 0.82 to 2.41% and from 0.60 to 2.23% for the Kjeldahl and combustion methods, respectively. Reproducibility standard deviations (SR) ranged from 0.20 to 0.49 for the Kjeldahl method and from 0.18 to 0.46 for the combustion method, whereas the reproducibility relative standard deviations (RSDR) ranged from 1.59 to 2.84% for the Kjeldahl method and from 1.32 to 3.35% for the combustion method. Overall grand means were 15.59% protein for the Kjeldahl method and 15.75% protein for the combustion method. The combustion method was adopted first action by AOAC International.

Engaging patients and families to transform heart failure care

For patients with advanced heart failure involvement as a member of the healthcare team is critical to safe, high-quality and goal-directed care. While recognized as an important aspect of care, patient engagement is not yet a standard practice. This presents an opportunity for professional education and development in team-based care. This short report describes the development of a Community and Patient Advisory Team (CPAT) formed to support patient involvement in interprofessional collaborative practice. The CPAT, composed of patient and family advisors, researchers, care team members, and grant operations staff, served as a core team within the structure of a project to shape a new vision of care delivery. This was accomplished through participation in quarterly leadership workshops and facilitation of team training focused on patient-provider communication strategies to improve patient safety. The advisory team led the co-development of patient materials to support patient engagement during the new implementation of structured interprofessional bedside rounds. Involving community members as partners helped shape our work to more effectively and directly address gaps in current patient care.

Evaluating the impact of cycle helmet use on severe traumatic brain injury and death in a national cohort of over 11000 pedal cyclists: a retrospective study from the NHS England Trauma Audit and Research Network dataset

OBJECTIVES

In the last 10 years there has been a significant increase in cycle traffic in the UK, with an associated increase in the overall number of cycling injuries. Despite this, and the significant media, political and public health debate into this issue, there remains an absence of studies from the UK assessing the impact of helmet use on rates of serious injury presenting to the National Health Service (NHS) in cyclists.

SETTING

The NHS England Trauma Audit and Research Network (TARN) Database was interrogated to identify all adult (≥16 years) patients presenting to hospital with cycling-related major injuries, during a period from 14 March 2012 to 30 September 2017 (the last date for which a validated dataset was available).

PARTICIPANTS

11 patients met inclusion criteria. Data on the use of cycling helmets were available in 6621 patients.

OUTCOME MEASURES

TARN injury descriptors were used to compare patterns of injury, care and mortality in helmeted versus non-helmeted cohorts.

RESULTS

Data on cycle helmet use were available for 6621 of the 11 192 cycle-related injuries entered onto the TARN Database in the 66 months of this study (93 excluded as not pedal cyclists). There was a significantly higher crude 30-day mortality in un-helmeted cyclists 5.6% (4.8%-6.6%) versus helmeted cyclists 1.8% (1.4%-2.2%) (p<0.001). Cycle helmet use was also associated with a reduction in severe traumatic brain injury (TBI) 19.1% (780, 18.0%-20.4%) versus 47.6% (1211, 45.6%-49.5%) (p<0.001), intensive care unit requirement 19.6% (797, 18.4%-20.8%) versus 27.1% (691, 25.4%-28.9%) (p<0.001) and neurosurgical intervention 2.5% (103, 2.1%-3.1%) versus 8.5% (217, 7.5%-9.7%) (p<0.001). There was a statistically significant increase in chest, spinal, upper and lower limb injury in the helmeted group in comparison to the un-helmeted group (all p<0.001), though in a subsequent analysis of these anatomical injury patterns, those cyclists wearing helmets were still found to have lower rates of TBI. In reviewing TARN injury codes for specific TBI and facial injuries, there was a highly significant decrease in rates of impact injury between cyclists wearing helmets and those not.

CONCLUSIONS

This study suggests that there is a significant correlation between use of cycle helmets and reduction in adjusted mortality and morbidity associated with TBI and facial injury.

Soft-sheath, stiff-core microfiber hydrogel for coating vascular implants

Vascular implants remain clinically challenged due to often-occurring thrombosis and stenosis. Critical to addressing these complications is the design of implant material surfaces to inhibit the activities of platelets, smooth muscle cells (SMCs) and inflammatory cells. Recent mechanobiology studies accentuate the significance of material elasticity to cells and tissues. We thus developed and characterized an implant coating composed of hybrid, viscoelastic microfibers with coaxial core-sheath nanostructure. The coating over metallic stent material was formed by first depositing coaxially-electrospun fibers of poly(L-lactic acid) core and polyethylene glycol dimethacrylate sheath, and then polymerizing fibers with various UV times. Material characterizations were performed to evaluate the coating structure, mechanical property and biocompatibility. Results showed that coaxial microfibers exhibited arterial-like mechanics. The soft surface, high water content and swelling ratio of the coaxial fibers resemble hydrogels, while they are mechanically strong with an elastic modulus of 172-729 kPa. The coating strength and surface elasticity were tunable with the photopolymerization time. Further, the elastic fibers, as conformal coating on stent metal, strongly reduced SMC overgrowth and discouraged platelet adhesion and activation, compared to bare metals. Importantly, after 7-day subcutaneous implantation, coaxial fiber-coated implants showed more favorable in vivo responses with reduced tissue encapsulation, compared to bare stent metals or those coated with a two-layered fiber mixture composed of fibers from individual polymers. The excellent biocompatibility aroused from nanostructural interfaces of hybrid fibers offering hydrated, soft, nonfouling microenvironments. Such integrated fiber system may allow creation of advanced vascular implants that possess physico-mechanical properties of native arteries.

Examining Differences in Recovery Outcomes between Male and Female Hip Fracture Patients: Design and Baseline Results of a Prospective Cohort Study from the Baltimore Hip Studies

BACKGROUND

Incidence of hip fractures in men is expected to increase, yet little is known about consequences of hip fracture in men compared to women. It is important to investigate differences at time of fracture using the newest technologies and methodology regarding metabolic, physiologic, neuromuscular, functional, and clinical outcomes, with attention to design issues for recruiting frail older adults across numerous settings.

OBJECTIVES

To determine whether at least moderately-sized sex differences exist across several key outcomes after a hip fracture.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study (Baltimore Hip Studies 7th cohort [BHS-7]) was designed to include equal numbers of male and female hip fracture patients to assess sex differences across various outcomes post-hip fracture. Participants were recruited from eight hospitals in the Baltimore metropolitan area within 15 days of admission and were assessed at baseline, 2, 6 and 12 months post-admission.

MEASUREMENTS

Assessments included questionnaire, functional performance evaluation, cognitive testing, measures of body composition, and phlebotomy.

RESULTS

Of 1709 hip fracture patients screened from May 2006 through June 2011, 917 (54%) were eligible and 39% (n=362) provided informed consent. The final analytic sample was 339 (168 men and 171 women). At time of fracture, men were sicker (mean Charlson score= 2.4 vs. 1.6; p<0.001) and had worse cognition (3MS score= 82.3 vs. 86.2; p<0.05), and prior to fracture were less likely to be on bisphosphonates (8% vs. 39%; p<0.001) and less physically active (2426 kilocalories/week vs. 3625; p<0.001).

CONCLUSIONS

This paper provides the study design and methodology for recruiting and assessing hip fracture patients and evidence of baseline and pre-injury sex differences which may affect eventual recovery one year later.

95 N-Acetyl cysteine as a potential treatment for equine persistent breeding-induced endometritis

Persistent breeding-induced endometritis (PBIE) is a major cause of infertility in mares. Transient uterine inflammation is a normal response to breeding; however, PBIE-susceptible mares do not clear this inflammation in a timely fashion. Uterine inflammation at the time of embryonic descent from the oviducts ultimately results in early embryonic death and is seen clinically as infertility. Several risk factors for PBIE have been identified and include age, parity, anatomical conformation, such as poor perineal conformation and cervical fibrosis, as well as other reproductive tract abnormalities. N-Acetyl cysteine (NAC), a mucolytic used to treat endometritis in mares, has anti-inflammatory properties, affects inflammatory cytokines, and is a mild inhibitor of nitric oxide synthase. Increased nitric oxide, causing smooth muscle relaxation and alterations in inflammatory cytokines, has been documented in PBIE mares. The objective of our study was to determine if NAC treatment would lower nitric oxide and inflammatory cytokine levels, thereby resolving PBIE. A randomised, blinded, crossover design clinical trial was performed utilising PBIE-susceptible mares (n=10). Mares were screened for bacterial endometritis before enrolment in the study and only mares that had negative bacterial cultures were used. No other treatments were given to mares while they were enrolled in the study. Intrauterine infusion of 180mL of 3.3% NAC was performed 12h before insemination, when a follicle &gt;35mm was present. Mares were sampled for endometrial cytology and endometrial fluid to determine inflammatory cytokine (ELISA) and nitric oxide (colourimetric assay) levels at 12 and 72h post-insemination. Endometrial biopsies were taken at the same time points post-insemination to determine gene expression of inflammatory cytokines by qPCR. Clinical signs of endometrial oedema and intrauterine fluid volumes were assessed at 12 and then every 24h post-breeding. Statistical assessment of the data was performed using a repeated-measures ANOVA. Uterine inflammation, as determined by percent number of neutrophils on endometrial cytology (P=0.0006), and interleukin 6 gene expression (P=0.003) were highest at 12h. Uterine oedema was greatest at 12 and 24h (P=0.02) and uterine fluid volumes were highest at 24h (P=0.02). Interestingly, interleukin-6 protein levels were not in accordance with gene expression, and were highest at 72h. In this clinical trial, pre-breeding intrauterine treatment with NAC did not affect nitric oxide levels, cytokine gene expression, or clinical signs of PBIE. However, the pattern of inflammation noted in this study is consistent with that described in PBIE mares. Nevertheless, the assessment of inflammatory cytokines, both at the gene and protein level at different time points post-AI, in combination with clinical signs will add to the understanding of the alterations in inflammatory cytokine levels in mares susceptible to PBIE.

Evaluation of tetracycline in milk following extra-label administration of topical tetracycline for digital dermatitis in dairy cattle

Digital dermatitis (DD) is a painful infectious foot lesion commonly treated topically with extra-label tetracycline. Our objectives were to determine the concentrations of tetracycline in milk and plasma and to calculate a withdrawal interval following topical application at various doses. Another objective was to evaluate agreement between tests for measuring tetracycline in milk. A randomized block trial was conducted on 2 farms, where 50 cows with active DD lesions on 2 feet were allocated to 1 of 5 treatment groups (n = 10 cows per group). Treatment groups consisted of topical applications of tetracycline hydrochloride, in a paste or as a powdered form under a bandage, at 3 different dosing levels (2, 5, and 25 g) on each of the 2 affected feet. Following enrollment and treatment, samples were collected from milk, teat skin, and blood every 8 to 24 h for up to 7 d postdosing. Concentrations of tetracycline were measured by liquid chromatography-mass spectrometry and milk samples were further tested using the Charm ROSA TET test (Charm Sciences Inc., Lawrence, MA). Tetracycline was present in milk, plasma, and teat skin from all treatment groups. Tetracycline concentrations varied depending on time of sampling, method of application, and dosing level. At 8 h post-treatment, 11% of cows had tetracycline present in milk higher than 100 ng/mL (ppb) but none higher than 300 ng/mL. The 25-g treatment group had the longest estimated withdrawal interval, the highest observed concentrations (210-244 ng/mL) of tetracycline present in milk, and the longest observed consecutive period of tetracycline presence (from 8 to 72 h) among all treatment groups. Compared with liquid chromatography-mass spectrometry, the Charm test had a sensitivity of 77 and 100% for measuring tetracycline in milk at ≥30 and ≥100 ng/mL, respectively. Post-treatment samples of the teat skin were taken from 15 cows on 6 occasions, and every cow had tetracycline present in at least 1 of those 6 samples. This confirms an association between topical DD treatment with tetracycline and contamination of the teat. A total of 22% of blood samples had detectable tetracycline, and the majority (63%) occurred at 8 h post-treatment. At 100 ng/mL, the estimated cow-level milk withdrawal interval ranged from 0 to 70 h. At 300 ng/mL, the estimated cow-level withdrawal interval ranged from 0 to 34 h, and was 0 h at the bulk tank level. We recommend that conservative measures be adopted after extra-label use of topical tetracycline for DD treatment, including using a low dose and strategic post-treatment testing for tetracycline-class drugs in milk.