Decreased costs with maintained patient satisfaction after total joint arthroplasty in a physician-owned hospital

Objective

Comparing total joint arthroplasty (TJA) costs and patient-reported outcomes between a physician-owned hospital (POH) and a non-POH.

Methods

Costs for each 90-day TJA episode at both facilities were determined, and patients were asked to complete a patient satisfaction questionnaire.

Results

Average TJA episode cost was $19,039 at the POH, compared to $21,302 at the non-POH, a difference of $2,263 (p = 0.03), largely driven by decreased skilled nursing facility utilization in the POH group. There were no differences between groups for patient satisfaction.

Conclusion

TJA can be performed at reduced cost with comparable patient satisfaction at POHs, compared to non-POH facilities.

Exploring thoracic kyphosis and incident fracture from vertebral morphology with high-intensity exercise in middle-aged and older men with osteopenia and osteoporosis: a secondary analysis of the LIFTMOR-M trial

Our aim was to explore change in kyphosis and vertebral fracture incidence following 8 months of high-intensity resistance and impact training (HiRIT) or machine-based isometric axial compression (IAC) training in men with osteopenia and osteoporosis. HiRIT and IAC improved posture. HiRIT participants did not experience progression or incident vertebral fracture. IAC participants did experience progression and incident vertebral fracture.

INTRODUCTION

The Lifting Intervention For Training Muscle and Osteoporosis Rehabilitation for Men (LIFTMOR-M) trial examined efficacy and safety of an eight-month, supervised, high-intensity progressive resistance and impact training (HiRIT) program compared with machine-based isometric axial compression (IAC) training in middle-aged and older men with low areal bone mineral density (aBMD). The primary purpose of the current work was to explore change in thoracic kyphosis and incident fracture from vertebral morphology following eight-months of HiRIT or IAC training. The secondary purpose was to explore change in clinical kyphosis measures for HiRIT, IAC and a non-randomized, matched control group.

METHODS

Men (≥ 45 yrs), with low aBMD, were recruited and randomized to HiRIT or IAC, or designated control. Clinical measures of thoracic kyphosis with inclinometry were determined. Cobb angle of kyphosis and vertebral fracture assessment using the Genant semi-quantitative method were determined from lateral thoracolumbar DXA (Medix DR, Medilink, France). Per-protocol (n = 40) and intention-to-treat (n = 93) analyses were conducted.

RESULTS

Forty participants (HiRIT n = 20, IAC n = 20; 66.1 ± 7.8 yrs.; lumbar spine T-score - 0.1 ± 0.8; femoral neck T-score - 1.5 ± 0.5) underwent clinical kyphosis measures and thoracolumbar DXA at baseline and follow-up. No between-group differences were detected in kyphosis change, however, within-group improvements in neutral (HiRIT - 2.3 ± 0.8°; IAC - 2.5 ± 0.8°) and 'standing tall' (HiRIT - 2.4 ± 0.8°; IAC - 2.0 ± 0.8°) postures were observed (p < 0.05). HiRIT improved Cobb angle (- 3.5 ± 1.5°, p = 0.027) from baseline. Over the 8 months, no incident vertebral fractures nor progression of prevalent vertebral fractures occurred for HiRIT participants. Five incident fractures of thoracic vertebrae occurred for IAC and one wedge fracture progressed. Ninety-three participants underwent clinical kyphosis measures at both time-points (HiRIT n = 34, IAC n = 33, control n = 26). HiRIT exhibited a reduction in 'standing tall' kyphosis compared to control (- 2.3 ± 0.6° versus 1.4 ± 0.7°, p < 0.05), but no other between-group differences were detected.

CONCLUSIONS

Although there was no difference in change between intervention groups, thoracic kyphosis appeared to improve in both HiRIT and IAC with exercise exposure. HiRIT improved 'standing tall' posture in comparison to usual activities. HiRIT was not associated with vertebral fracture progression or incident vertebral fracture, but for some IAC participants there was evidence of progression of vertebral fracture severity and incident vertebral fractures, in our small sample. Larger trials are required to confirm the observations of the current work, which was exploratory in nature.

Acute Workplace Hazards in Orthopedic Surgery: Resident Survey Regarding Splash and Workplace Violence Events

INTRODUCTION

Orthopedic surgery residents are at risk for daily work-related hazards and exposures. Hazards related specific to this specialty includes radiation exposure, smoke inhalation (from electrocautery), and disease transmission through contact with surgical instruments or sharps during procedures. However, minimal research has been focused on other occupational hazard risks in orthopedic surgery including surgical splash events and workplace violence. This study focused on determining (1) whether or not use of protective eyewear in the workplace would be related to the availability of personal protective equipment (PPE); (2) resident education; and (3) the rate of workplace violence toward orthopedic surgery residents during their training.

METHODS

An invitation to participate in a web-based, anonymous survey to 46 US allopathic orthopedic surgery residency programs (1207 potential resident respondents). The survey was conceptually divided into the following areas: (1) demographics; (2) training and attitudes concerning occupational hazards; (3) PPE provision and use; (4) sharps injuries and reporting; and (5) general safety knowledge and violence in the workplace. Those who answered yes to having a splatter event or receiving a threat at the hospital were compared to those who did not. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between these outcomes and selected independent variables of interest. p-Values of <0.05 were considered statistically significant.

RESULTS

From January 18 to March 31, 2016, 518 surveys were received and included for analysis for a response rate of 42.9% (518/1207). One survey was excluded from analysis due to <50% completed response items. Self-reported program types were 64.5% (334/518) public university-affiliated, 23.2% (120/518) private university affiliated, 7.1% (37/518) community, and 5.2% (27/518) military. Residents were 83.0% = male and 17.0% = female. Overall, reported eye protection usage was 95% amongst all residents and 22% of residents reported experiencing a violent threat in the workplace. The risk of experiencing a splatter event was not statistically associated with residency type, gender, or geographic region. Senior residents were at an increased likelihood of experiencing a splatter event (OR 1.22, [95% CI 1.06-1.41], p = 0.006) when compared to PGY-1 residents. The risk of a violent experience at work was not statistically associated with residency type, year of residency training, or gender. Residents in the Northeast were more likely to have a violent experience (OR 2.78 [95% CI 1.41-5.49] p = 0.003). Overall, residents felt that they had adequate training to prevent occupational hazards (mean of 3.9/5 on Likert scale) and respond to hazards (mean of 3.7/5 Likert).

CONCLUSIONS

Occupational hazards are not uncommon in orthopedic surgery training with high rates of improper eyewear PPE use and poor awareness of Occupational Safety and Health Administration and AAOS guidelines. Violence in the workplace impacts over one in 4 residents and training programs and hospitals should improve education and report efforts. Continual yearly PPE training and awareness of AAOS guidelines could be intertwined with duty hour and/or case logs in order to ensure residents are exposed to this material on a regular basis.

High-intensity exercise did not cause vertebral fractures and improves thoracic kyphosis in postmenopausal women with low to very low bone mass: the LIFTMOR trial

Our aim was to assess risk of vertebral fracture during high-intensity resistance and impact training (HiRIT) for postmenopausal women with low bone mass. HiRIT did not induce vertebral fracture, as evidenced by a reduction in kyphosis following 8 months of training and a lack of change in vertebral morphology.

INTRODUCTION

The LIFTMOR trial demonstrated a novel, HiRIT program notably improved bone mass in postmenopausal women with osteopenia and osteoporosis. While no clinical signs or symptoms of vertebral crush fracture were evident during the trial, anecdotal feedback suggests that concerns about safety of HiRIT in the osteoporosis demographic remain. The aim of the current work was to assess vertebral body morphology, Cobb angle, and clinical measures of thoracic kyphosis in participants in the LIFTMOR trial for evidence of vertebral fracture following 8 months of supervised HiRIT.

METHODS

Participants were randomized to either 8 months of 30-min, twice-weekly, supervised HiRIT or unsupervised, low-intensity, home-based exercise (CON). Lateral thoracolumbar DXA scans (Medix DR, Medilink, France) were performed at baseline and follow-up. Cobb angle was determined, and vertebral fracture identification was performed using the semiquantitative Genant method. Clinical kyphosis measurements were performed in relaxed standing (neutral posture) and standing tall using an inclinometer and a flexicurve.

RESULTS

The HiRIT group exhibited a reduction in inclinometer-determined standing tall thoracic kyphosis compared to CON (- 6.7 ± 8.2° vs - 1.6 ± 8.1°, p = 0.031). Both the HiRIT and CON groups exhibited within-group improvement in kyphosis in relaxed standing as measured by both inclinometer and flexicurve (p < 0.05). There were no changes in vertebral fracture classification in the HiRIT group post-intervention. A single, new, wedge deformity was observed for CON.

CONCLUSIONS

Supervised HiRIT was not associated with an increased risk of vertebral fracture in postmenopausal women with low bone mass. Indeed, a clinically relevant improvement in thoracic kyphosis was observed following 8 months of supervised HiRIT, further supporting its efficacy as an osteoporosis intervention for postmenopausal women with low to very low bone mass.

Trends and Risk Factors in Orthopedic Lawsuits: Analysis of a National Legal Database

Orthopedic surgeons frequently encounter medical malpractice claims. The purpose of this study was to assess trends and risk factors in lawsuits brought against orthopedic surgeons using a national legal database. A legal research service was used to search publicly available settlement and verdict reports between 1988 and 2013 by terms "orthopaedic or orthopedic" and "malpractice." Temporal trends were evaluated, and logistic regression was used to identify independent risk factors for case outcomes. A total of 1562 publicly reported malpractice cases brought against orthopedic surgeons, proceeding to trial during a 26-year period, were analyzed. The plaintiffs won 462 (30%) cases, with a mean award of $1.4 million. The frequency of litigation and pay-outs for plaintiffs increased 215% and 280%, respectively, between the first and last 5-year periods. The mean payout for plaintiff-favorable verdicts was highest in pediatrics ($2.6 million), followed by spine ($1.7 million) and oncology ($1.6 million). Fracture fixation (363 cases), arthroplasty (290 cases), and spine (231 cases) were the most commonly litigated procedures, while plaintiffs were most successful for fasciotomy (48%), infection-treating procedures (43%), and carpal tunnel release (37%). When analyzing data by state and region, adjusted for population, northeastern states had a higher frequency of lawsuits. Malpractice liability has increased during the past 3 decades while orthopedic surgeons continue to win most of the cases making it to court. As patients search for medical care via publicly available information, it is important for orthopedic surgeons to understand what aspects of their own practice carry different risks of litigation. [Orthopedics. 2019; 42(2):e260-e267.].

Adoption of Intramedullary Nail Fixation for Proximal Humerus Fractures: Assessment of Surgical Efficiency and Complications

Fixation of proximal humerus fractures (PHFs) with intramedullary (IM) nails potentially is a newer, less invasive technique. The purpose of this study was to report on the early adoption results of IM nail use for PHF. Retrospective chart reviews were performed on the first 60 patients treated with IM nails for acute PHFs by two shoulder surgeons. The first 15 patients treated by each surgeon were compared with the subsequent 15 patients. Surgical and fluoroscopic times, fracture type, union, and varus collapse were compared. The average operating time decreased (p = .002). Fluoroscopy time, radiographic alignment, union rate, complications, and reoperations were not influenced. Three- and four-part fractures had a higher complication rate than two-part fractures (53% vs. 20%). When considering implementing use of IM nails for treatment of PHFs, initial cases can have outcomes and complications similar to those performed with greater experience. IM nailing appears a good treatment option for two-part PHFs. (Journal of Surgical Orthopaedic Advances 28(2):121-126, 2019).

Metabolic syndrome and hip fracture: Epidemiology and perioperative outcomes

INTRODUCTION

Hip fractures and metabolic syndrome (MetS) are becoming major global healthcare burdens as populations age. This study sought to determine the impact of MetS in hip fracture patients on perioperative outcomes following operative fixation or arthroplasty.

METHODS

Data from the 2004-2014 Nationwide Inpatient Sample was used to select 3,348,207 discharges with hip fracture. MetS patients were identified by having at least 3 of 4 component comorbidities: hypertension, dyslipidemia, obesity, and diabetes. Logistic regression was used to estimate odds ratios for the association between MetS and perioperative outcomes adjusted for age, gender, race, payer status, and comorbidities.

RESULTS

Overall, 32% of hip fracture patients were treated with open reduction internal fixation (ORIF), 28% hemiarthroplasty (HA), 18% closed reduction with internal fixation (CRPP), and 3% primary total hip arthroplasty (THA). The remaining 19% of cases were either treated via unspecified procedure of hip repair (9%), managed non-operatively (2%), underwent multiple procedures during the hospital stay (6%), or the surgical procedure data was missing (2%) and were excluded from procedural analyses. The prevalence of MetS was 7.9% and increased among minorities, patients treated at urban hospitals, with comorbidities (heart failure, kidney disease, peripheral vascular disease), and with Medicare coverage. MetS was associated with increased odds of any adverse event (p < 0.0001), specifically: acute renal failure, myocardial infarction, acute posthemorrhagic anemia. MetS was also associated with increased LOS (p < 0.0001) and increased total charges (p < 0.0001). However, MetS was associated with reduced odds of postoperative pneumonia, deep vein thrombosis and pulmonary embolism, surgical site infection, septicemia, and in-hospital mortality (p < 0.0001). The above associations were maintained for MetS patients stratified according to their treatment groups: HA, CRPP, and ORIF.

CONCLUSIONS

MetS is associated with increased odds of complications in hip fracture patients but decreased odds of in-hospital mortality. This may be related to patients' nutritional status and catabolic states in the perioperative period.

Sternoclavicular joint palpation pain: the shoulder's Waddell sign?

BACKGROUND

Pain is a complex and subjective reality and can be magnified by nonorganic or nonanatomic sources. Multiple studies have demonstrated a correlation between psychological factors and patients' perceptions of musculoskeletal pain and disability. In addition, nonorganic findings as part of the physical examination are well and long recognized. The purpose of this study was to analyze the relationship between a shoulder examination test, palpation of the sternoclavicular joint (SCJ), and psychosocial conditions including chronic pain, depression, and anxiety.

METHODS

From June until October 2016, all new patients of 2 sports/shoulder fellowship-trained surgeons at an academic practice were screened for study enrollment. After their consent was obtained, patients were given a set of 5 surveys (Pain Catastrophizing Scale; Patient-Health Questionnaire 2; Pain Self-Efficacy Questionnaire; shortened Disabilities of the Arm, Shoulder and Hand questionnaire; and Shoulder Pain and Disability Index) to complete. The physician then completed a comprehensive standardized physical examination, with the examining physician being blinded to the patient's survey responses. Palpation of the SCJ was done with the examiner's thumbs and was accompanied by the question "Does this hurt?" If a positive pain response was given, clarification as to the correct side of the pain was made.

RESULTS

A total of 132 patients were enrolled and completed the surveys and physical examination. Of the patients, 26 (19.7%) reported SCJ pain with SCJ palpation. Patients with and without confirmed pain on SCJ palpation had significantly different (P < .001) mean scores for all 5 surveys. A review of the medical histories between the 2 groups identified a significantly increased prevalence of chronic pain and mental health disorders, such as anxiety and depression, in SCJ palpation-positive patients.

CONCLUSIONS

Patients who confirmed pain on SCJ palpation had significantly higher scores on various psychological surveys than those who denied pain on palpation, indicating that a portion of their pain was stemming from a nonorganic source. Inclusion of SCJ palpation during a routine shoulder or upper extremity physical examination may improve selection of treatment options for patients.

What Leads to Lead: Results of a Nationwide Survey Exploring Attitudes and Practices of Orthopaedic Surgery Residents Regarding Radiation Safety

BACKGROUND

Excessive radiation to health-care providers has been linked to risks of cancer and cataracts, but its negative effects can be substantially reduced by lead aprons, thyroid shields, and leaded glasses. Hospitals are required to provide education and proper personal protective equipment, yet discrepancies exist between recommendations and compliance. This article presents the results of a survey of U.S. orthopaedic surgery residents concerning attitudes toward radiation exposure and personal protective equipment behavior.

METHODS

An invitation to participate in a web-based, anonymous survey was distributed to 46 U.S. allopathic orthopaedic surgery residency programs (1,207 potential resident respondents). The survey was conceptually divided into the following areas: demographic characteristics, training and attitudes concerning occupational hazards, personal protective equipment provision and use, and general safety knowledge. Prevalence ratios (PRs) and 95% confidence intervals (CIs) were calculated for the association between these characteristics and compliance with thyroid shield or lead gown wear.

RESULTS

In this study, 518 surveys were received, with 1 survey excluded because of insufficient response, leaving 517 surveys for analysis (42.8% response rate). Ninety-eight percent of residents believed that personal protective equipment should be provided by the hospital or residency program. However, provision of personal protective equipment was not universal, with 33.8% reporting none and 54.2% reporting provision of a gown and thyroid shield. The prevalence of leaded glasses usage was 21%. Poor lead gown compliance and thyroid shield wear were associated with difficulty finding the corresponding equipment: PR, 2.51 (95% CI, 1.75 to 3.62; p < 0.001) for poor lead gown compliance and PR, 2.14 (95% CI, 1.46 to 3.16; p < 0.0001) for poor thyroid shield wear. Not being provided with personal protective equipment was also significantly associated with low compliance with both lead gowns (PR, 1.47 [95% CI, 1.04 to 2.08]; p = 0.03) and thyroid shields (PR, 1.69 [95% CI, 1.18 to 2.41]; p = 0.004). Respondents from the Southeast, West, or Midwest had lower compliance with lead gown usage. Forgetting was the number 1 reason to not wear a lead apron (42%).

CONCLUSIONS

Radiation exposure is associated with increased risk of serious health problems. Our findings identified that the availability of lead personal protective equipment leads to increased compliance among residents surveyed. In addition to yearly occupational hazard training specific to orthopaedic surgery, greater efforts by residency programs and hospitals are needed to improve access to lead personal protective equipment and compliance for orthopaedic residents.

Trends in Joint Replacement Surgery in Patients with Rheumatoid Arthritis

Objective.

This study analyzed trends in large total joint arthroplasties (TJA) and in the proportion of these procedures performed on patients with rheumatoid arthritis (RA).

Methods.

The US Nationwide Inpatient Sample (2002–2012) was used to identify the incidences of total shoulder (TSA), elbow (TEA), knee (TKA), hip (THA), and ankle (TAA) arthroplasty and the proportion of these performed with coexisting RA.

Results.

The prevalence of RA among patients with TJA increased 3.0%. The prevalence of RA among cases of TEA and TSA decreased by 50% (p < 0.0001) and 18% (p = 0.0016), respectively; a 38.0% decrease occurred in the prevalence of RA among TAA (p = 0.06); and nonsignificant increases were seen among THA and TKA. The average age difference between RA and non-RA patients undergoing TJA narrowed by 2 years (p < 0.0001). There was a greater reduction in the proportion of TSA, TEA, and TAA groups among women with RA than men with RA. In the TSA and TEA groups, there was a reduction in the proportion of whites with RA, but not blacks. The proportion of privately insured TSA and TAA patients with RA decreased, while patients with RA undergoing TSA, TEA, or TAA who were receiving Medicaid (government medical insurance) remained relatively stable over time.

Conclusion.

The prevalence of RA has decreased among TSA and TEA patients. A nonsignificant decline occurred among TAA patients. The average age of TJA patients with RA is beginning to mirror those without RA. Sex ratios for TSA, TEA, and TAA patients are following a similar pattern. These results may be evidence of the success of modern RA treatment strategies.

Arthroscopic Versus Open Rotator Cuff Repair: Which Has a Better Complication and 30-Day Readmission Profile?

PURPOSE

To provide a comparative 30-day postoperative analysis of complications and unplanned readmission rates, using the National Surgical Quality Improvement Program database, after open or arthroscopic rotator cuff repair (RCR).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for postoperative complications after open or arthroscopic RCR over an 8-year period, from 2007 through 2014. Patients were identified by use of Current Procedural Terminology codes. The open group contained 3,590 cases (21.8%) and the arthroscopic group had 12,882 cases (78.2%), for a total of 16,472 patients undergoing RCR. The risk of complications was compared between the 2 groups, along with patient demographic characteristics, operative time, length of stay, and unplanned readmission within 30 days. We compared dichotomous variables using the Fisher exact test and continuous variables with 1-way analysis of variance. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated when appropriate.

RESULTS

The open RCR group had a higher prevalence of patients aged 65 years or older and comorbidities such as hypertension, diabetes, chronic obstructive pulmonary disease, smoking, and alcoholism (P < .05). Patients undergoing open RCR had a higher risk of any adverse event when compared with arthroscopic RCR patients (1.48% vs 0.84%; RR, 1.17; 95% CI, 1.05-1.30; P = .0010). They were also at higher risk of return to the operating room within 30 days (0.70% vs 0.26%; RR, 1.36; 95% CI, 1.09-1.69; P = .0004). Open RCR was associated with a longer average hospital stay (0.48 ± 2.7 days vs 0.23 ± 4.2 days, P = .0007), whereas arthroscopic RCR had a longer average operative time (90 ± 45 minutes vs 79 ± 45 minutes, P < .0001).

CONCLUSIONS

Although both open and arthroscopic approaches to RCR had low morbidity, arthroscopy was associated with lower risks of any adverse event and return to the operating room during the initial 30-day postoperative period.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Competitive bass anglers: a new concern in sports medicine

OBJECTIVE

Competitive bass angling involves sport fishing against other anglers while targeting a species of fish known as the black basses. Due to the rapidly growing popularity of high school competitive bass angling in Alabama and the nature of the casting motion similar to that of overhead athletes, we sought to examine the prevalence of sports type injuries in this population.

METHODS

In spring 2016, an anonymous survey was distributed across two large scale competitive high school fishing tournaments, allowing for a broad sampling of anglers throughout the state of Alabama. Survey items included demographic information, relevant past medical history, and various pains associated with the shoulder, elbow and wrist. Results were recorded and analyzed electronically using Microsoft Excel and IBM SPSS statistical software.

RESULTS

A total of 257 surveys were recorded. The response rate was 61%. The mean age of participating anglers was 15 ± 1.61 years. The majority (42%) of anglers fished year round. On average, anglers casted nearly 1,000 more times while competing versus fishing recreationally. Approximately 15% of anglers experienced shoulder, elbow, and wrist pain. The most common factors associated with pain included higher tournament cast counts, number of competitive years, number of tournaments/year, number of tournaments, and use of light weight lures.

CONCLUSION

A large portion of high school competitive anglers experience upper extremity pain. Knowledge of angling factors associated with pain allow for the creation of a modifiable routine to help reduce pain in affected anglers and prevent pain in healthy anglers.

Psychomotor Testing for Orthopedic Residency Applicants: A Pilot Study

OBJECTIVE

The purpose of this study was to develop an objective motor skills testing system to aid in the evaluation of potential orthopedic residents.

DESIGN

Participants attempted a battery of 5 motor skills tests (4 novel tests and the Grooved Pegboard [GPT] Test) in one 10-minute session. A percentile-based scoring system was created for each test based on raw scores. One-way analysis of variance was used to compare testing scores among 3 cohorts. Each novel test and overall scores were compared with GPT scores as a relative measure of validity.

SETTING

The 2015 orthopedic surgery residency interview season at an academic institution.

PARTICIPANTS

Thirty orthopedic residents and 72 nonresidents (15 community volunteers and 57 orthopedic surgery residency applicants).

RESULTS

Overall, residents performed better than nonresidents (p < 0.0001) and applicants performed worse than residents or volunteers (p < 0.0001). There were positive correlations between the GPT score and overall battery score (r = 0.63), screw and nut test (r = 0.40), and mimic a structure test (r = 0.26). The fracture reduction test and drilling test scores did not correlate to performance on the GPT.

CONCLUSIONS

Psychomotor testing for surgical applicants is an area in need of study. This investigation successfully piloted a novel battery of tests, which is easily reproducible and thus may be feasible for use in the orthopedic surgery residency interview setting. Longitudinal evaluation is required to explore correlation with future operative skill.

Readability of Orthopaedic Patient-reported Outcome Measures: Is There a Fundamental Failure to Communicate?

BACKGROUND

Patient-reported outcome measures (PROMs) are increasingly used to quantify patients' perceptions of functional ability. The American Medical Association and NIH suggest patient materials be written at or below 6th to 8th grade reading levels, respectively, yet one recent study asserts that few PROMs comply with these recommendations, and suggests that the majority of PROMs are written at too high of a reading level for self-administered patient use. Notably, this study was limited in its use of only one readability algorithm, although there is no commonly accepted, standard readability algorithm for healthcare-related materials. Our study, using multiple readability equations and heeding equal weight to each, hopes to yield a broader, all-encompassing estimate of readability, thereby offering a more accurate assessment of the readability of orthopaedic PROMS.

QUESTIONS/PURPOSES

(1) What proportion of orthopaedic-related PROMs and orthopaedic-related portions of the NIH Patient Reported Outcomes Measurement Information System (PROMIS®) are written at or below the 6th and 8th grade levels? (2) Is there a correlation between the number of questions in the PROM and reading level? (3) Using systematic edits based on guidelines from the Centers for Medicare and Medicaid Services, what proportion of PROMs achieved American Medical Association and NIH-recommended reading levels?

METHODS

Eighty-six (86) independent, orthopaedic and general wellness PROMs, drawn from commonly referenced orthopaedic websites and prior studies, were chosen for analysis. Additionally, owing to their increasing use in orthopaedics, four relevant short forms, and 11 adult, physical health question banks from the PROMIS®, were included for analysis. All documents were analyzed for reading grade levels using 19 unique readability algorithms. Descriptive statistics were performed using SPSS Version 22.0.

RESULTS

The majority of the independent PROMs (64 of 86; 74%) were written at or below the 6th grade level, with 81 of 86 (94%) written at or below the 8th grade level. All item banks (11 of 11) and short forms (four of four) of the PROMIS® were written below the 6th grade reading level. The median reading grade level of the 86 independent PROMs was 5.0 (interquartile range [IQR], 4.6-6.1). The PROMIS® question banks had a median reading grade level of 4.1 (IQR, 3.5-4.8); the Adult Short Forms had a median reading grade level of 4.2 (IQR, 4.2-4.3) There was no correlation appreciated between the median reading grade level and the number of questions contained in a PROM (r = -0.081; p = 0.460). For PROMs above NIH-recommended levels, following edits, all (five of five) achieved NIH reading level goals and three (three of five) achieved American Medical Association goals. Editing of these PROMs improved readability by 4.3 median grade level (before, 8.9 [IQR, 8.4-9.1], after 4.6 [IQR, 4.6-6.4], difference of medians, 4.3; p = 0.008).

CONCLUSIONS

Patient literacy has great influence on healthcare outcomes, and readability is an important consideration in all patient-directed written materials. Our study found that more than 70% of PROMs commonly used in orthopaedics, and all orthopaedic-related portions of the PROMIS® are written at or below the most stringent recommendations (≤ 6th grade reading level), and more than 90% of independent PROMs and all PROMIS® materials are written at or below an 8th grade level. Additionally, the use of the Centers for Medicare and Medicaid Services guidelines for editing high reading level PROMs yields satisfactory results.

CLINICAL RELEVANCE

Fears of widely incomprehensible PROMs may be unfounded. Future research to identify the most appropriate readability algorithm for use in the healthcare sector, and revalidation of PROMs after readability-improving edits is warranted.

Telemedicine with mobile devices and augmented reality for early postoperative care

Advanced features are being added to telemedicine paradigms to enhance usability and usefulness. Virtual Interactive Presence (VIP) is a technology that allows a surgeon and patient to interact in a "merged reality" space, to facilitate both verbal, visual, and manual interaction. In this clinical study, a mobile VIP iOS application was introduced into routine post-operative orthopedic and neurosurgical care. Survey responses endorse the usefulness of this tool, as it relates to The virtual interaction provides needed virtual follow-up in instances where in-person follow-up may be limited, and enhances the subjective patient experience.

The Burden of the Fellowship Interview Process on General Surgery Residents and Programs

OBJECTIVES

This study evaluated the effect of the fellowship interview process in a cohort of general surgery residents. We hypothesized that the interview process would be associated with significant clinical time lost, monetary expenses, and increased need for shift coverage.

DESIGN

An online anonymous survey link was sent via e-mail to general surgery program directors in June 2014. Program directors distributed an additional survey link to current residents in their program who had completed the fellowship interview process.

SETTING

United States allopathic general surgery programs.

PARTICIPANTS

Overall, 50 general surgery program directors; 72 general surgery residents.

RESULTS

Program directors reported a fellowship application rate of 74.4%. Residents most frequently attended 8 to 12 interviews (35.2%). Most (57.7%) of residents reported missing 7 or more days of clinical training to attend interviews; these shifts were largely covered by other residents. Most residents (62.3%) spent over $4000 on the interview process. Program directors rated fellowship burden as an average of 6.7 on a 1 to 10 scale of disruption, with 10 being a significant disruption. Most of the residents (57.3%) were in favor of change in the interview process. We identified potential areas for improvement including options for coordinated interviews and improved content on program websites.

CONCLUSIONS

The surgical fellowship match is relatively burdensome to residents and programs alike, and merits critical assessment for potential improvement.

Heavy resistance training is safe and improves bone, function, and stature in postmenopausal women with low to very low bone mass: novel early findings from the LIFTMOR trial

The aim of the LIFTMOR (Lifting Intervention For Training Muscle and Osteoporosis Rehabilitation) trial is to determine the safety and efficacy of brief, bone-targeted, high-intensity progressive resistance training (HiPRT) with impact loading for postmenopausal women with low bone mass. Preliminary findings indicate the LIFTMOR program is safe and effective.

INTRODUCTION

Despite a lack of notable efficacy, exercise guidelines for osteoporosis typically recommend moderate-intensity exercises, owing to a perceived risk of fracture from high-intensity loading. Indeed, safety concerns alone have prevented the well-recognised preferential response of bone tissue to high-intensity loads from being applied to those who stand to benefit the most. To progress from this therapeutic stalemate, a challenge to conventional wisdom was required. Our goal was to examine the safety and efficacy of HiPRT and impact loading for risk factors of osteoporotic fracture in postmenopausal women with low to very low bone mass.

METHODS

Participants have been randomised to either 8 months of twice-weekly 30-min supervised HiPRT and impact loading or a low-intensity home-based exercise program of the same duration and dose. Testing at baseline and follow-up has included anthropometry; bone, muscle, and fat mass; and functional performance.

RESULTS

Twenty-eight women (66.1 ± 4.8 years, mean lumbar spine T-score -2.15 ± 0.72) have completed the study. HiPRT and impact loading (n = 12) improved height (0.4 ± 0.2 cm vs -0.3 ± 0.1 cm, p = 0.003), femoral neck bone mineral density (0.3 ± 0.5 % vs -2.5 ± 0.8 %, p = 0.016), lumbar spine bone mineral density (1.6 ± 0.9 % vs -1.7 ± 0.6 %, p = 0.005), and functional performance (p < 0.05), compared to controls (n = 16). Compliance has been >87 %. There have been no injuries.

CONCLUSIONS

Brief supervised HiPRT with impact loading is a safe and effective exercise therapy for postmenopausal women with low to very low bone mass.

Adenosine A₁ receptors in mouse pontine reticular formation modulate nociception only in the presence of systemic leptin

Human obesity is associated with increased leptin levels and pain, but the specific brain regions and neurochemical mechanisms underlying this association remain poorly understood. This study used adult male C57BL/6J (B6, n=14) mice and leptin-deficient, obese B6.Cg-Lep(ob)/J (obese, n=10) mice to evaluate the hypothesis that nociception is altered by systemic leptin levels and by adenosine A₁ receptors in the pontine reticular formation. Nociception was quantified as paw withdrawal latency (PWL) in s after onset of a thermal stimulus. PWL was converted to percent maximum possible effect (%MPE). After obtaining baseline PWL measures, the pontine reticular formation was microinjected with saline (control), three concentrations of the adenosine A₁ receptor agonist N(6)-p-sulfophenyladenosine (SPA), or super-active mouse leptin receptor antagonist (SMLA) followed by SPA 15 min later, and PWL was again quantified. In obese, leptin-deficient mice, nociception was quantified before and during leptin replacement via subcutaneous osmotic pumps. SPA was administered into the pontine reticular formation of leptin-replaced mice and PWL testing was repeated. During baseline (before vehicle or SPA administration), PWL was significantly (p=0.0013) lower in leptin-replaced obese mice than in B6 mice. Microinjecting SPA into the pontine reticular formation of B6 mice caused a significant (p=0.0003) concentration-dependent increase in %MPE. SPA also significantly (p<0.05) increased %MPE in B6 mice and in leptin-replaced obese mice, but not in leptin-deficient obese mice. Microinjection of SMLA into the pontine reticular formation before SPA did not alter PWL. The results show for the first time that pontine reticular formation administration of the adenosine A₁ receptor agonist SPA produced antinociception only in the presence of systemic leptin. The concentration-response data support the interpretation that adenosine A₁ receptors localized to the pontine reticular formation significantly alter nociception.

Clinical study of therapeutic ocular surface medium for persistent epithelial defect

PURPOSE

To investigate therapeutic ocular surface medium (TOSM), a potential physiological tear replacement therapy, for persistent epithelial defect (PED).

METHODS

11 eyes of 10 patients with PED for ≥ 2 weeks without improvement despite conventional treatment were enrolled in a prospective pilot study of TOSM over 1 month.

RESULTS

Healing of the PED occurred in 3 out of the 11 eyes at 1, 2 and 4 weeks, respectively. At week 4, 2 eyes were almost healed (PED area ≤ 0.5 mm(2)). In 4 of the remaining 6 eyes, the PED area was reduced. Failure occurred in 1 case with end-stage ocular cicatricial pemphigoid and severe dry eye, and 1 patient withdrew due to a mild allergic reaction. There were no serious or irreversible side effects with TOSM.

CONCLUSIONS

TOSM is a potential novel physiological therapy for PED that, unlike autologous serum, has the potential to be easily manufactured and widely available.

Delayed presentation of severe ocular injury from a button battery

A 2-year-old girl presented to the emergency department at 3:00 h with severe pain in her right eye and a rust coloured, blood stained frothy discharge that had woken her. An examination of her eye revealed a shiny metallic looking foreign body, which was immediately removed by the on-call ophthalmologist. That morning the patient underwent ocular examination under anaesthesia and was found to have severe tissue necrosis resulting from an electrochemical burn. She was treated with daily rodding for 3 days and betamethasone ointment four times a day, which was gradually tapered. At 3 months her only eye pathology was a mild symblepharon between the bulbar and tarsal conjunctiva. This is the first case of delayed symptoms after placement of a button battery into the conjunctival fornix. This case highlights the serious nature of button battery injuries to the eye and the potential to miss the diagnosis owing to a delayed onset of symptoms.

The effect of mesenchymal stem cell conditioned media on corneal stromal fibroblast wound healing activities

AIMS

To investigate the effects of conditioned media from mesenchymal stem cells (MSC) on the wound healing activities of corneal stromal fibroblasts.

METHODS

Cell cycle analysis and early stage activation of apoptosis, chemotactic chambers and fibroblast-populated type I collagen gels were used to assess corneal stromal fibroblast proliferation, migration and contraction, respectively. Fibroblasts were obtained from human donor corneas and MSC from fresh rat bone marrow. MSC conditioned media and fibroblast culture medium (FCM), with and without calf serum supplementation, were compared.

RESULTS

MSC conditioned media and serum-free FCM had an inhibitory effect on the progression of corneal fibroblasts through the cell cycle. There was a significant increase in the number of cells in the G0-G1 phase for MSC conditioned media and serum-free FCM (p=0.001, p=0.97 respectively). Fibroblast migration and relaxed and stressed gel contraction were significantly inhibited by MSC conditioned media and serum-free FCM compared with FCM with serum (all p=0.001). Glucose and lactate analysis confirmed that these factors were not contributing to this effect.

CONCLUSION

MSC conditioned media was found to inhibit the wound healing activities of corneal stromal fibroblasts in vitro. Putative factors secreted by MSC could be developed for therapeutic use in corneal repair.

Characterization of cerebrospinal fluid monoamine metabolites in peripubertal chimpanzees (Pan troglodytes)

BACKGROUND

Assessment of cerebrospinal (CSF) monoamine metabolites 5-hydroxyindoeacetic acid (5-HIAA) and homovanillic acid (HVA), and the serotonin precursor tryptophan (TRP), in chimpanzees may help in understanding the neurobiology underlying aggressive, impulsive behavior in humans and non-human primates.

METHODS

Two CSF samples were obtained from 11 peripubertal chimpanzees 8 months apart and were assayed for monoamine metabolite and TRP concentrations.

RESULTS

Substantial inter-individual stability was observed for 5-HIAA (n = 11; r = 0.83, P < 0.001) and HVA (r = 0.91, P < 0.001). Females had significantly higher concentrations of 5-HIAA compared to males (F(1,8) = 7.31; P < 0.05). Levels of 5-HIAA (r = -0.62, P < 0.05), HVA (r = -0.86, P < 0.001) and TRP levels (r = -0.67; P < 0.05) decreased with age.

CONCLUSION

Close parallels were observed between chimpanzees and humans with respect to absolute levels, sex effects, ontogeny, and 5-HIAA-HVA correlations, supporting the potential utility of the measures in understanding relationships between monoamine functioning and behavior in chimpanzees and humans.

Interventions for recurrent corneal erosions

BACKGROUND

Recurrent corneal erosion is a common cause of disabling ocular symptoms and predisposes the cornea to infection. It may follow corneal trauma. Measures to prevent the development of recurrent corneal erosion following corneal trauma have not been firmly established. Once recurrent corneal erosion develops simple medical therapy (standard treatment) may lead to resolution of the episode. However some patients continue to suffer when such therapy fails and once resolved further episodes of recurrent erosion may occur. A number of treatment and prophylactic options are then available but there is no agreement as to the best option.

OBJECTIVES

To assess the effectiveness and safety of prophylactic and treatment regimens for recurrent corneal erosion.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE, EMBASE and LILACS in June 2007. The NRR was searched in April 2005. We also contacted researchers in the field.

SELECTION CRITERIA

We included randomised and quasi-randomised trials that compared a prophylactic or treatment regimen with another prophylaxis/ treatment or no prophylaxis/ treatment for patients with recurrent corneal erosion.

DATA COLLECTION AND ANALYSIS

Both authors independently extracted data and assessed trial quality. We contacted study authors for additional information.

MAIN RESULTS

Five randomised and one quasi-randomised controlled trial were included in the review. The trials were heterogenous and of poor quality. Safety data presented were incomplete. For the treatment of recurrent corneal erosion there was limited evidence that oral tetracycline 250 mg twice daily for 12 weeks or topical prednisolone 0.5% four times daily for one week or both in addition to standard treatment; and excimer laser ablation in addition to mechanical debridement may be effective. Therapeutic contact lens wear was inferior to lubricant drops and ointment in abolishing the symptoms of recurrent corneal erosion and had a high complication rate. For prophylaxis of further episodes of recurrent corneal erosion there was no difference in the occurrence of objective signs of recurrent erosion between hypertonic saline ointment versus tetracycline ointment or lubricating ointment. Lubricating ointment at night in addition to standard treatment following traumatic corneal abrasion (erosion) caused by fingernail injury to prevent recurrence led to increased symptoms of recurrent corneal erosion compared to standard therapy alone.

AUTHORS' CONCLUSIONS

Well-designed masked randomised controlled trials using standardised methods are needed to establish the benefits of new and existing prophylactic and treatment regimes for recurrent corneal erosion.

Legeais BioKpro III keratoprosthesis implantation: long term results in seven patients

AIMS

The long term results of the Legeais BioKpro III keratoprosthesis are presented for seven patients with severe corneal scarring.

METHODS

The study took place at Moorfields Eye Hospital, London. Patients had either end stage ocular surface disease or corneal opacification after multiple failed graft surgery, with the potential for significant visual improvement. After insertion the device was covered with a conjunctival flap or buccal mucous membrane graft, which was later opened to expose the optic. The outcome measures were vision, complications, and retention of the device.

RESULTS

The BioKpro III was inserted into seven patients with severe corneal scarring: ocular cicatricial pemphigoid, measles keratitis, thermal injury, Stevens-Johnson syndrome, aniridia, chemical injury, and congenital rubella. The follow up was 18-48 months. The keratoprosthesis failed in six, because of extrusion occurring 2-28 months postoperatively. Retroprosthetic membranes occurred in three patients, and endophthalmitis in one. Vision improved from hand movements to 6/12 in the only patient who retained the KPro; however he was troubled by mucus accumulation on the optic.

CONCLUSIONS

The one success has been in a patient with thermal burns. The remaining results have been poor, with the KPro extruding in six of the seven patients.

Influence of estradiol on cortisol secretion in ovariectomized cynomolgus macaques (Macaca fascicularis)

In an investigation of cortisol secretion in fully mature, ovariectomized cynomolgus monkeys (Macaca fascicularis), we compared monkeys that were given either placebo (OVX, n = 26) or 17beta estradiol (E(2 )) (EST, n = 26) in a daily oral dose. Serum cortisol concentrations were measured prior to the experimental manipulation and 3, 6, 9, and 12 months following initiation of treatment. Pretreatment cortisol values did not differ between groups. Assessment of the treatment period values revealed that cortisol concentrations were significantly higher ( approximately 10%) in the EST than in the OVX monkeys. Cortisol also varied significantly across periods of sampling. This time-dependent variation was attributable to elevations in months 6 and 9 (when daylight was generally long), relative to months 3 and 12 (when daylight was relatively short). The modest stimulatory effect of estrogen on corticosteroid production observed in this study is consistent with what has been seen in women, and contrasts with the more robust effects observed in New World monkeys. The possible relationship between season and cortisol secretion observed here has not been previously described in monkeys.

Treatment of infants with lymphoblastic leukaemia: results of the UK Infant Protocols 1987-1999

One hundred and twenty-six infants with acute lymphoblastic leukaemia (ALL) were treated on two consecutive protocols, Infant 87 (n = 40) and Infant 92 (n = 86), in an attempt to improve the poor prognosis of this disease. Both included intensive induction and consolidation with intrathecal and high-dose systemic therapy for central nervous system (CNS) protection. Intensification therapy was modified and high-dose chemotherapy with bone marrow transplantation in first remission was permitted in Infant 92. Four-year event-free survival was superior in Infant 92 (33%; 95% CI 23-44%) compared with Infant 87 (22.5%; 95% CI 12-37%) (P = 0.04) and survival at 4 years was also superior, 46% (95% CI 35-57%) c.f. 32.5% (95% CI 20-48%) (P = 0.01), largely as a result of a significant reduction in remission deaths. Twelve patients in Infant 92 underwent bone marrow transplantation (BMT) in first remission, but their survival was no better than that of patients receiving chemotherapy. Multivariate analysis of prognostic factors showed the adverse influence of younger age, CNS involvement at diagnosis and a high initial leucocyte count, but not of CD10 expression. Cytogenetic analysis, available in 93% of patients in Infant 92, showed that 67% had chromosomal rearrangements involving 11q23 of which 39% had the translocation t(4;11) (q21;q23). There was no significant difference in event-free survival between cytogenetic subgroups, although no children under 6 months of age with 11q23 abnormalities, other than the t(4;11), survived. In conclusion, infants with lymphoblastic leukaemia remain a high-risk group, but it is unclear whether their adverse prognosis can be attributed to unfavourable cytogenetics alone. The role of high-dose therapy and BMT in first remission remains uncertain.

Dominance, cortisol, and behavior in small groups of female cynomolgus monkeys (Macaca fascicularis)

The relationships among social rank, basal cortisol concentrations, and social behavior were assessed in adult female cynomolgus monkeys (Macaca fascicularis). Subjects were 157 unrelated, reproductively intact animals housed in 30 small groups. Rank determinations were made monthly. Blood samples were collected on two occasions, 4.5 and 7.5 months following initial group formation. Regular behavioral observations were conducted on a subset of animals over a period of 4 weeks, 9 months following group formation. Analyses revealed that serum cortisol values were significantly correlated across the two sampling periods, with no significant change in absolute values. While social rank was positively correlated across both samples, there was no relationship between rank and cortisol. However, dominant and subordinate animals did differ in the rates of performance of aggressive and submissive behaviors. These data suggest that social rank does not influence baseline serum cortisol in adult female cynomolgus monkeys, despite stability in measures of rank and cortisol and the presence of the usual behavioral differences between dominants and subordinates.

Can puzzle feeders be used as cognitive screening instruments? Differential performance of young and aged female monkeys on a puzzle feeder task

Conventional cognitive testing of monkeys is time-consuming and involves single-caging and food or water deprivation. Here we report a novel test of global cognitive performance that can be completed in a short time period without food/water or social restrictions. Nine mazes of increasing difficulty were developed using a standard puzzle feeder, and the maze-solving performance of ten young and five aged female cynomolgus monkeys (Macaca fascicularis) was tested. The young monkeys solved maze configurations at higher levels of difficulty and solved the first level of difficulty more quickly than aged monkeys. This task discriminated performance by age in nonhuman primates as do more conventional forms of cognitive testing and indicates that this task may be a quick and easy assessment of global cognitive function.

Scent-marking and cortisol response in the small-eared bushbaby (Otolemur garnettii)

Among prosimians, some types of scent-marking may serve as displacement activities that reduce physiological arousal in stressful situations. Type and frequency of scent-marking was measured for 22 male small-eared or Garnett's bushbabies (Otolemur garnettii) exposed to a novel open field environment, with and without novel objects. Rates of foot rubbing, chest rubbing, urine washing, flank rubbing, and ano-genital marking were measured. Foot and chest rubbing constituted 92.5% of responses. Type and frequency of scent-marking was compared to the magnitude of the animals' cortisol responses in a separate test of restraint stress. Only foot and chest rubbing were systematically related to cortisol levels. The animals that performed these behaviors more in the novel environment also exhibited lower cortisol responses to restraint stress. These results suggest that bushbabies that characteristically employ behavioral coping strategies have a reduced physiological response to psychological stressors.

Can I drive after those drops, doctor?

PURPOSE

To document the experience of patients driving after drops to dilate the pupils. There are no documented guidelines on driving after pupillary dilatation. This is a study of patients who drove a car after attending the eye casualty for an ocular examination during which their pupils were dilated.

METHODS

Thirty patients were identified who felt confident to drive after their pupils were dilated. Distant visual acuities, colour vision and confrontation visual fields were assessed before and after pupillary dilatation with 2.5% phenylephrine and 1% tropicamide. These patients met the legal requirements for driving after pupillary dilatation. The patients completed a questionnaire that recorded their subjective experiences of driving while their pupils were dilated.

RESULTS

The mean age of the patients was 51.9 +/- 19.7 years (range 20-73 years). Twenty-seven of the 30 patients undertook the journey on familiar roads, and 14 of 30 wore spectacles. The mean spherical equivalent was +2.00 dioptre sphere for distance and a mean additional spherical equivalent of 1.75 dioptre sphere for near. Twenty patients experienced glare, which was severe enough to cause difficulty driving in three cases. Two of these patients drove in sunny weather conditions and one in light (not sunny) weather. Six patients had difficulty with road signs, two had difficulty judging distances and one reported difficulty with traffic lights.

CONCLUSIONS

Dilating the pupils did not reduce distance visual acuity. However, it would seem appropriate to warn patients of the problems associated with glare and, if driving is their only option for transport home, recommend that they allow sufficient time to adapt to a dilated pupillary state, drive only on familiar roads and avoid driving in sunny weather.

Surgically induced necrotizing scleritis in a patient with ankylosing spondylitis

We present the case of a 75-year-old man with ankylosing spondylitis who developed surgically induced necrotizing scleritis (SINS) more than 3 years after uneventful extracapsular cataract extraction and posterior chamber intraocular lens implantation. The patient presented with a painful eye and increasing vertical diplopia. To our knowledge, neither the association of SINS and ankylosing spondylitis nor vertical diplopia as its presenting complaint has been described.

Behavioral responses to ovariectomy and chronic anabolic steroid treatment in female cynomolgus macaques

A pilot study was conducted to investigate the effects of ovariectomy on rates of aggressive and affiliative behavior, as well as body size, in 38 young adult female cynomolgus monkeys (Macaca fascicularis) living in isosexual social groups of four to five animals. In addition, we assessed the effects of nandrolone decanoate (an anabolic steroid used for postmenopausal hormone replacement therapy) on indices of aggression, submission, and body size. Animals were randomized into three experimental conditions: 1) sham ovariectomized, untreated (SHAM); 2) ovariectomized, untreated (OVX); and, 3) ovariectomized, treated with nandrolone decanoate for 24 months (NAN). Each individual was observed for 10 min, one to two times per month, and all instances of agonistic and affiliative behavior were recorded by means of focal animal sampling. Ovariectomized, untreated animals exhibited a two- to threefold increase in aggression compared to SHAM or NAN animals; F(2, 32) = 4.09, p = 0.026; however, the expression of prosocial or affiliative behaviors as measured by rates of grooming and initiating friendly behavior was unaffected. At an i.m. dose of 25 mg every 2 weeks, nandrolone decanoate caused a 60% increase in body weight of the animals compared to untreated intact and ovariectomized animals, F(2, 31) = 161.57, p < 0.0001.

Effects of chronic social separation on cardiovascular disease risk factors in female cynomolgus monkeys

A lack of social support is associated with increased risk of coronary heart disease morbidity and mortality in human beings. Similarly, chronic social separation (single cage housing) potentiates atherosclerosis in female monkeys. Under the hypothesis that autonomic arousal and/or ovarian impairment may mediate this effect (as both are associated with increased atherosclerosis), heart rate and luteal phase plasma progesterone concentrations were measured in 12 female cynomolgus monkeys that were first socially housed, then individually housed, and finally returned to their original social groups. Afternoon heart rates increased during social separation compared to the social groupings (P < 0.001). Increased heart rates could not be explained by activity levels, which were lower during social separation than in social groupings (P < 0.001). Ovarian function (i.e. luteal-phase progesterone concentrations) was not influenced by housing condition. Single caging reduced the extent of social signaling, even though animals were in visual and auditory contact. Rates of affiliative behaviors increased and time spent alone decreased in post-reunion social groups compared to pre-separation social groups (P's < 0.01). The results indicate that chronic social separation in this group-living species may exacerbate atherosclerosis via altered autonomic activity, as evidenced by higher heart rates during social separation.

Acute administration of phenylpropanolamine fails to affect resting energy expenditure in men of normal weight

Studies have consistently found that dieters using over-the-counter weight control products containing phenylpropanolamine (PPA) are more successful at losing weight than those who do not. To explore the possibility that drug-induced metabolic changes contribute to weight loss associated with this compound, this study investigated the effects of PPA on resting metabolic rate in 20 healthy men of normal weight between the ages of 18 and 29. After the arrival of the subjects to the laboratory, blood pressure was taken and resting energy expenditure (REE) and respiratory quotient (RQ) were assessed for 20 minutes (Baseline) via indirect calorimetry. Half of the subjects were then given 75 mg of immediate-release PPA (administered orally via a gelatin capsule), while the other half received placebo. Immediately after drug administration, metabolic rate was measured for an additional 95 minutes (During Drug). After this assessment, blood pressure was again measured. Although significant increases in both systolic and diastolic blood pressure were observed after PPA administration, the drug had no effect on REE or RQ. These results, consistent with that previously reported in mildly overweight women, further establish that it is unlikely that drug-induced metabolic changes contribute to PPA-induced weight loss in humans.

An electrophysiological and histological study of trypsin induced demyelination

Ten-microliters quantities of trypsin or saline were injected into rat tibial nerve and the physiological and histological changes evaluated and compared to the focal demyelinating lesions induced by intraneural injection of rabbit EAN serum and proteinase K. The injection of trypsin produced progressive conduction block that was maximal on day 4, and a slowing of motor nerve conduction. Early retraction of myelin at paranodes, vesicular change, and macrophage stripping of myelin from nerve axons were seen on histological examination. At day 4, the first groups of completely demyelinated axons were seen, typically in a perivascular distribution. These changes were similar to those seen in the positive controls and thus support the postulate that proteolytic enzymes from macrophages--the dominant cellular species within the demyelinating lesion, play a central role in degradation of the myelin sheath in demyelinating diseases.

Continence following electrical stimulation and EMG biofeedback in a teenager with imperforate anus

A teenage boy with repaired high imperforate anus relied on daily enemas for social continence. After treatment with low intensity transcutaneous electrical stimulation and electromyographic biofeedback home programs, he achieved improved fecal continence requiring only one enema per month.

Alterations in T lymphocyte subpopulations associated with renal allograft rejection

The peripheral blood OKT3 (total T), OKT4 (T helper/inducer), and OKT8 (T suppressor/cytotoxic) cells were determined by flow cytometry on twenty consecutive recipients of HLA-nonidentical cadaveric renal allografts. The absolute number of cells in all three populations decreased significantly posttransplantation, but no differences were found between patients experiencing rejection and those in quiescence. An OKT4/OKT8 ratio of greater than or equal to 1.7, either pretransplant or posttransplant, uniformly identified patients who subsequently experienced rejection. However, an OKT4/OKT8 ratio of less than 1.7 did not identify patients with a low risk of rejection. Pretransplant splenectomy was performed in 6 of 7 patients who rejected despite a low ratio. Serial monitoring of the OKT4/OKT8 ratio posttransplantation determined that an increase in the ratio of greater than or equal to 0.5 was a sensitive (81%) and specific (91%) indicator of a rejection episode. Graft survival was improved in patients with a high posttransplant OKT4/OKT8 ratio. These results indicate that the balance of helper and suppressor cell function may be of critical importance to the fate of an allograft, and that the alterations in this balance can be used to assist in the clinical management of allograft recipients.