Sanford Medical Center

Simvastatin is among the most commonly used prescription medications for cholesterol reduction. A single coding single-nucleotide polymorphism, rs4149056T>C, in SLCO1B1 increases systemic exposure to simvastatin and the risk of muscle toxicity. We summarize evidence from the literature supporting this association and provide therapeutic recommendations for simvastatin based on SLCO1B1 genotype. This article is an update to the 2012 Clinical Pharmacogenetics Implementation Consortium guideline for SLCO1B1 and simvastatin-induced myopathy.

PURPOSE: A pre-post analysis of an antimicrobial stewardship program (ASP) involving the use of data-mining software to prospectively identify cases for ASP intervention was conducted. METHODS: The investigators evaluated clinical outcomes and cost metrics before and after implementation of the ASP, which entailed daily physician review of summary reports on all adult inpatients receiving antimicrobial therapy. The primary outcome measures were annual antimicrobial expenditures and rates of infections due to common nosocomial pathogens; secondary outcome measures included patient survival and length of stay (LOS) in cases involving the indicator diagnoses of pneumonia and abdominal sepsis. RESULTS: Antimicrobial expenditures, which had increased by an average of 14.4% annually in the years preceding ASP implementation, decreased by 9.75% in the first year of the program and remained relatively stable in subsequent years, with overall cumulative cost savings estimated at $1.7 million. Rates of nosocomial infections involving Clostridium difficile, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant enterococci all decreased after ASP implementation. A pre-post comparison of survival and LOS in patients with pneumonia (n = 2186) or abdominal sepsis (n = 225) showed no significant differences in those outcomes in either patient group, possibly due to the hospital's initiation of other, concurrent infection-control programs during the study period. CONCLUSION: A prospective collaborative ASP employed automated reports to efficiently identify key data for ASP review. After ASP implementation, antimicrobial expenditures and rates of nosocomial infections caused by resistant pathogens dropped without significant changes in patient survival, LOS, and readmissions for the two studied illness categories.

PURPOSE: To evaluate the effects of retensioning and knot tying on the biomechanical properties of an adjustable loop anterior cruciate ligament (ACL) reconstruction device. METHODS: Testing consisted of 3 phases, which used both adjustable loop devices (ALD) and closed loop devices (CLD) tested under cyclic loading to 4,500 cycles. Phase 1 consisted of implant-only testing using cyclic loading from 50 to 250 N. Phase 2 used relatively unloaded cyclic loading of 10 to 250 N. Phase 3 used a tendon/bone/implant model. Subsets of the ALD implants were subjected to isolated retensioning, isolated knot tying, or a combination of both to allow for independent examination of these interventions. RESULTS: In phase 1, retensioning and knot tying reduced final ALD elongation by 60% (0.38 v 0.96 mm; P = .00004). In phase 2, retensioning and knot tying reduced final ALD elongation by 88% (0.51 v 4.22 mm, P = .014). In phase 3, retensioning and knot tying reduced final ALD elongation by 45% (1.5 v 2.7 mm; P = .001), which was half of the elongation of the CLD (3.0 mm; P = .0007). CONCLUSIONS: The ALD did demonstrate an increase in cyclic elongation as compared with the CLD during both extended loading conditions. The phase 1 ALD elongation (0.96 mm), while statistically greater than the CLD (0.52 mm), was likely not of clinical importance. However, the ALD elongation in phase 2 (4.22 mm) could be of clinical concern. Both of these increased elongations were eliminated by retensioning and knot tying. Furthermore, when evaluating in a graft-femur construct, retensioning and knot tying of the ALD reduced final cyclic elongation by 50% when compared with CLD. CLINICAL RELEVANCE: Retensioning and knot tying after initial reduction of the tendon graft with an adjustable loop ACL fixation device may help to further reduce concerns of loop slippage and displacement with cyclic loading during postoperative rehabilitation.

PURPOSE: A case of apparent gabapentin withdrawal symptoms after discontinuation of gabapentin therapy is reported. SUMMARY: A 53-year-old woman had coffee ground emesis, a two-day history of black tarry stools, and abdominal pain. The patient did have an elevated ethanol concentration (323 mg/dL), with the last reported ingestion of ethanol about 12 hours before admission. Her medical history included liver cirrhosis secondary to ethanol abuse, ascites, portal hypertension, esophageal varices (with previous band ligation three weeks prior), anemia, gastroesophageal reflux disease, neuropathic pain, and depression. Her home medications included spironolactone, nadolol, lactulose, ursodiol, ferrous sulfate, omeprazole, gabapentin, citalopram, and trazodone. She was admitted to the intensive care unit, and upper gastrointestinal endoscopy was performed, with 12 band ligations applied. After the procedure, she ingested nothing orally, including home medications, for the first two days. On day 3 of hospitalization, she developed restlessness, disorientation, confusion, agitation, and anxiety. She was presumed to be suffering from ethanol withdrawal and was treated with benzodiazepines but had no improvement in symptoms. During days 4 and 5, the patient became increasingly confused, agitated, and anxious, with complaints of headache, light sensitivity, and increasing nervousness. On day 5, gabapentin was reinitiated, and the patient's confusion and agitation improved that evening. The next morning, the patient was calm, alert, and cooperative. Her symptoms resolved, and she was discharged on hospital day 7. CONCLUSION: A patient developed apparent withdrawal symptoms beginning two days after gabapentin therapy was discontinued. The symptoms were unresponsive to treatment with benzodiazepines but completely resolved with the reinitiation of gabapentin therapy.

PURPOSE: To compare the effect of independent suture tape reinforcement on the dynamic elongation and stiffness behavior as well as ultimate strength of tripled smaller-diameter and quadrupled soft-tissue grafts for anterior cruciate ligament reconstruction (ACLR) with tibial screw fixation in a biomechanical in vitro study. METHODS: Tripled smaller-diameter (8 mm) and quadrupled (9 mm) bovine tendon grafts with and without suture tape reinforcement (n = 8 in each group) were tested using femoral suspensory and tibial interference screw fixation. The suture tape was femoral sided and fixed independent from the graft by passing it through the suspensory button and securing the 2 open tibial strands with a secondary interference screw. Dynamic testing was performed in position and force control at 250 N and 400 N, followed by pull to failure with the mode of failure noted. Dynamic elongation, stiffness, and ultimate strength were analyzed. RESULTS: Tripled constructs showed a significantly worse structural performance than quadrupled constructs at higher loads. Reinforcement of tripled and quadrupled grafts substantially decreased total elongation by 56% (4.54 ± 0.75 mm vs 2.01 ± 0.50 mm, P < .001) and 39% (3.25 ± 0.49 mm vs 1.98 ± 0.51 mm, P < .001), respectively, by significantly increasing dynamic stiffness. No statistical significance was found between the reinforced groups. Failure loads of reinforced tripled (1,074 ± 148 N vs 829 ± 100 N, P = .003) and quadrupled (1,125 ± 157 N vs 939 ± 76 N, P = .023) grafts were also significantly improved. CONCLUSIONS: Independent reinforcement of soft-tissue grafts with suture tape strengthened the performance especially of tripled smaller-diameter grafts for ACLR with tibial screw fixation by significantly improving dynamic elongation at increased stiffness and ultimate strength. Quadrupled reinforced grafts showed no over-constraining and structurally behaved similarly to tripled grafts with reinforcement. CLINICAL RELEVANCE: Independent reinforcement for ACLR may provide an option for protecting autografts or allografts against irreversible lengthening during the maturation and remodeling phases of healing.

BACKGROUND AND PURPOSE: Complex wide-neck intracranial aneurysms are challenging to treat. We report a multicenter experience using the LVIS Jr stent for "Y-stent"-assisted coiling embolization of wide-neck bifurcation aneurysms. METHODS: Seven centers provided retrospective data on patients who underwent Y-stenting. Technical complications, immediate posttreatment angiographic results, clinical outcomes, and imaging follow-up were assessed. RESULTS: Thirty patients/aneurysms were treated: 15 basilar tip, 8 middle cerebral artery, 4 anterior communicating artery, 1 pericallosal, and 2 posterior inferior cerebellar artery aneurysms. The mean aneurysm size was 11 mm and the mean dome-to-neck ratio was 1.3 mm. Twenty-four aneurysms were unruptured and treated electively, and 6 were acutely ruptured. Fifty-eight LVIS Jr stents were successfully deployed without any technical issue. One pro-cedural and transient in-stent thrombosis resolved with the intravenous infusion of a glycoprotein IIb/IIIa inhibitor. Five periprocedural complications (within 30 days) occurred: 2 periprocedural neurological complications (1 small temporal stroke that presented with transient aphasia and 1 posterior cerebral artery infarct) and 3 nonneurological periprocedural complications (2 retroperitoneal hematomas, and 1 patient developed a disseminated intravascular coagulopathy). One permanent complication (3.3%) directly related to Y-stenting was reported in the patient who suffered the posterior cerebral artery infarct. Immediate complete obliteration (Raymond-Roy Occlusion Classification [RROC] I-II) was achieved in 26 cases (89.6%). Twenty-four patients had clinical and imaging follow-up (mean 5.2 months). Complete angiographic occlusion (RROC I-II) was observed in 23 patients (96%). A good functional outcome with a modified Rankin Scale score ≤2 was achieved in 26 cases. CONCLUSIONS: In this multicenter case series, Y-stent-assisted coiling of wide-neck aneurysms with the LVIS Jr device was feasible and relatively safe. Follow-up imaging demonstrated very low recanalization rates.

This article investigates the extent to which a proactive two-phased recruitment approach resulted in recruitment of a representative sample of older adults from two lower income congregate housing facilities into a physical activity promotion program. Enrollees were similar to nonenrollees with respect to education, gender, marital status, race/ethnicity, self-rated health, physical functioning, psychological distress, exercise frequency, level of social contact, having a confidant, use of alcohol, and smoking status. However, enrollees were younger, more likely to speak English as a primary language, less likely to be completely sedentary, and more likely to be overweight. Overall, 21% of the target population were recruited into the program. Recruitment strategies such as those used in this study appeared to enable enrollment of a reasonably representative sample of a small well-defined population.

Traumatic brain injury (TBI) contributes to almost one third of all trauma-related deaths, and those that survive often suffer from long-term physical and cognitive deficits. Ciclosporin (cyclosporine, cyclosporin A) has shown promising neuroprotective properties in pre-clinical TBI models. The Copenhagen Head Injury Ciclosporin (CHIC) study was initiated to establish the safety profile and pharmacokinetics of ciclosporin in patients with severe TBI, using a novel parenteral lipid emulsion formulation. Exploratory pharmacodynamic study measures included microdialysis in brain parenchyma and protein biomarkers of brain injury in the cerebrospinal fluid (CSF). Sixteen adult patients with severe TBI (Glasgow Coma Scale 4-8) were included, and all patients received an initial loading dose of 2.5 mg/kg followed by a continuous infusion for 5 days. The first 10 patients received an infusion dosage of 5 mg/kg/day whereas the subsequent 6 patients received 10 mg/kg/day. No mortality was registered within the study duration, and the distribution of adverse events was similar between the two treatment groups. Pharmacokinetic analysis of CSF confirmed dose-dependent brain exposure. Between- and within-patient variability in blood concentrations was limited, whereas CSF concentrations were more variable. The four biomarkers, glial fibrillary acidic protein, neurofilament light, tau, and ubiquitin carboxy-terminal hydrolase L1, showed consistent trends to decrease during the 5-day treatment period, whereas the samples taken on the days after the treatment period showed higher values in the majority of patients. In conclusion, ciclosporin, as administered in this study, is safe and well tolerated. The study confirmed that ciclosporin is able to pass the blood-brain barrier in a TBI population and provided an initial biomarker-based signal of efficacy.

The efficacy and safety of esmolol, a titratable intravenous beta-adrenergic blocking agent with a short elimination half-life (t 1/2 = 9.0 min) was evaluated in a multicenter open-label study for the treatment of supraventricular tachyarrhythmias (heart rate greater than 100 bpm). The study also investigated the feasibility of transferring patients from esmolol to alternate oral antiarrhythmic agents without loss of therapeutic response. Of the 113 patients studied, 95 (84%) achieved therapeutic response (reduction in heart rate of 15% or more or conversion to sinus rhythm). Most of these patients (93%) achieved the therapeutic response at esmolol doses of 200 micrograms/kg/min or lower. Transfer from esmolol to an oral antiarrhythmic agent(s) was studied in 76 patients. Alternate antiarrhythmic agents used in this study were digoxin (N = 25), propranolol (N = 21), verapamil (N = 10), metoprolol (N = 11), quinidine (N = 2), and a combination of two antiarrhythmic agents (N = 7). Sixty-seven (88%) patients were successfully transferred to oral antiarrhythmic agents without loss of the therapeutic response obtained with esmolol. The most frequent adverse effect observed during the study was hypotension, which resolved quickly (16 +/- 14 min) either by decreasing the dose or by discontinuation of esmolol infusion. This study supports previous observations concerning the safety and efficacy of esmolol in the treatment of supraventricular tachyarrhythmias. Furthermore, it demonstrates that the majority of patients successfully treated with esmolol can be safely and effectively transferred to oral therapy with alternate antiarrhythmic agents.

The College of American Pathologists offers these templates to assist pathologists in providing clinically useful and relevant information when reporting results of biomarker testing. The College regards the reporting elements in the templates as important elements of the biomarker test report, but the manner in which these elements are reported is at the discretion of each specific pathologist, taking into account clinician preferences, institutional policies, and individual practice.The College developed these templates as educational tools to assist pathologists in the useful reporting of relevant information. It did not issue them for use in litigation, reimbursement, or other contexts. Nevertheless, the College recognizes that the templates might be used by hospitals, attorneys, payers, and others. The College cautions that use of the templates other than for their intended educational purpose may involve additional considerations that are beyond the scope of this document.Completion of the template is the responsibility of the laboratory performing the biomarker testing and/or providing the interpretation. When both testing and interpretation are performed elsewhere (eg, a reference laboratory), synoptic reporting of the results by the laboratory submitting the tissue for testing is also encouraged to ensure that all information is included in the patient's medical record and thus readily available to the treating clinical team.Select a single response unless otherwise indicated.Note: Use of this template is optional. Reporting on the data elements in this template is not required.___ Negative (score 0)___ Negative (score 1+)___ Equivocal (score 2+)___ Positive (score 3+)___ Indeterminate (explain): ___________________________ Negative (not amplified)___ Positive (amplified)___ Indeterminate (explain): ________________________Number of observers: ______Number of invasive cancer cells counted: _________ Using dual-probe assay Average number of HER2 (ERBB2) signals per cancer cell: ______ Average number of CEP17 signals per cancer cell:______ HER2 (ERBB2):CEP17 ratio: _________ Using single-probe assay Average number of HER2 (ERBB2) signals per cancer cell: _________ US Food and Drug Administration (FDA) cleared (specify test/vendor): _______________________ Laboratory-developed test___ 4B5___ HercepTest___ A0485___ SP3___ CB11___ Other (specify): _____________________________ FDA cleared (specify test/vendor): __________________ Laboratory-developed test (specify probe):_______________Gene names should follow the recommendations of The Human Genome Organisation (HUGO) Nomenclature Committee (www.genenames.org; accessed June 25, 2014).All reported gene sequence variations should be identified following the recommendations of the Human Genome Variation Society (www.hgvs.org/rec; accessed June 25, 2014).HER2 (ERBB2) is a proto-oncogene located on chromosome 17 that encodes a 185-kDa tyrosine kinase receptor belonging to the epidermal growth factor receptor (EGFR) family whose phosphorylation initiates signaling pathways that lead to cell division, proliferation, differentiation, and apoptosis.1–3The HUGO Nomenclature Committee (HGNC) has designated ERBB2 as the approved symbol and CD340, HER-2, HER2, and NEU as synonyms (http://www.genenames.org/cgi-bin/gene_symbol_report?hgnc_id=3430; accessed June 25, 2014). HER2 gene product is expressed in normal epithelial cells, and amplification and/or overexpression of this gene has been reported in up to 30% of breast cancers4 and in 9% to 27% of patients with gastric cancer. Overexpression in stomach cancer varies with histologic type (intestinal type greater than diffuse type) and differentiation (moderately differentiated greater than poorly differentiated).5For patients with inoperable locally advanced, recurrent, or metastatic adenocarcinoma of the stomach or esophagogastric junction for whom trastuzumab (Herceptin) is under consideration for therapy, assessment for tumor HER2 overexpression using immunohistochemistry (IHC) or in situ hybridization (ISH) is recommended by the National Comprehensive Cancer Network (NCCN).5 Results of an open-label, international phase 3 randomized controlled trial in 2010 (Trastuzumab for Gastric Cancer [ToGA]) showed that the anti-HER2 humanized monoclonal antibody trastuzumab is effective in prolonging survival compared with chemotherapy alone in patients with HER2-positive adenocarcinoma of the stomach and the esophagogastric junction.6 HER2 (ERBB2) appears to be an important prognostic factor in gastric cancer, although the literature is conflicting, and not all studies have shown an association between HER2 overexpression and poor prognosis.4,7 Clinical trials with antibodies to HER2 in gastric cancer patients are in progress.HER2 (ERBB2) status is assessed by testing either biopsy or surgical resection specimens. Immunohistochemistry evaluates membranous protein expression of cancer cells. Both intensity and percentage of immunoreactive cancer cells are assessed, with scores ranging from 0 to 3+ (Table). In situ hybridization, which encompasses fluorescence ISH (FISH), chromogenic ISH, and silver-enhanced ISH, identifies the presence or absence of gene amplification. Some assays use a single HER2 (ERBB2) probe to determine the number of HER2 (ERBB2) gene copies present, but most assays include a chromosome enumeration probe (CEP17) to determine the ratio of HER2 (ERBB2) signals to copies of chromosome 17. In situ hybridization has been used to verify IHC-equivocal cases.5 HER2-positive gastric cancer has been defined as IHC 3+ or ISH positive in the United States and Japan, and IHC 3+ or 2+ with ISH positivity in Europe.4,8 In the United States, the FDA has approved trastuzumab in association with chemotherapy for metastatic gastric cancer using the eligibility criteria of the ToGA trial, limited to patients with a score of IHC 3+ or 2+ and ISH positivity. No significant survival benefit was seen for patients who were IHC 0 or 1+ and FISH positive.9HER2 protein expression is more heterogeneous in gastric cancers than in breast cancers.7,8,10 The completeness of membrane staining required for positivity in breast cancers is infrequent in gastric adenocarcinomas, which often exhibit a basolateral staining pattern. Detection of HER2 (ERBB2) gene amplification by FISH is similar to that in breast cancer according to the American Society of Clinical Oncology/College of American Pathologists 2013 guidelines, in which HER2 (ERBB2) amplification is defined as HER2 (ERBB2):CEP17 ratio of ≥2.11 Hofmann et al7 developed a 4-tier scoring system for IHC (Table), also used in the ToGA trial, for gastric cancer by using the assessment area cutoff of at least 10% stained tumor cells for resection specimens and a small cluster of cells (≥5 neoplastic cells) for biopsy specimens. The NCCN guidelines recommend that assessment for HER2 status be performed first using IHC following the modified scoring system used in the ToGA trial. A score of 0 or 1+ is considered to be negative for HER2 expression. A score of 2+ is considered equivocal and should be confirmed with FISH or other ISH techniques. The NCCN panel recommends FISH only for cases with IHC 2+, although some institutions routinely perform both IHC and FISH on all cases. The guidelines recommend trastuzumab with chemotherapy only for patients with IHC 3+ and IHC 2+ with evidence of HER2 (ERBB2) amplification by ISH (HER2 [ERBB2]:CEP17 ratio ≥2). Trastuzumab is not recommended if the IHC score is 0 or 1+.5

BACKGROUND: Antimicrobial resistance is a growing concern, and in recent years, there has been increased interest in ambulatory antimicrobial stewardship. Acute rhinosinusitis (ARS) is one of the most common outpatient diagnoses that results in an antibiotic prescription. OBJECTIVE: To determine if a best practice alert (BPA) will affect the percentage of oral antibiotic prescriptions for adults with ARS. METHODS: A prospective, pre/post study was initiated to evaluate the percentage of oral antibiotic prescriptions for ARS in 117 primary care clinics in the Midwest. Included in the study results were 16,570 adults who had an office visit for ARS: 8,106 patients from December 1, 2015, to February 28, 2016, were in the pre-intervention group without an active BPA, and 8,464 patients from December 1, 2016, to February 28, 2017, were in the post-intervention group when the BPA was active. The primary outcome was the number of oral antibiotic prescriptions for ARS compared with the number of office visits for ARS in the pre- and postintervention groups. RESULTS: The percentage of oral antibiotics prescribed for the pre- and postintervention groups were 94.8% and 94.3%, respectively (P = 0.152). The BPA displayed for 7,780 visits, prompting discontinuation of an antibiotic for 10 (0.1%) visits in the postintervention group. CONCLUSIONS: This study suggests that, although an electronic alert may be attractive to facilitate antimicrobial stewardship, it may be ineffective. These results warrant alternative measures to facilitate ambulatory antimicrobial stewardship. DISCLOSURES: No outside funding supported this study. The authors have no conflicts of interest to declare. Study concept and design were contributed by Hansen, D. Leedahl, and N. Leedahl. Hansen and N. Leedahl took the lead in data collection, with assistance from Carson and D. Leedahl. Data interpretation was performed by all the authors. The manuscript was written by Hansen, along with the other authors, and revised by all the authors.

Antibiotics are a known cause of idiosyncratic drug-induced liver injury (DILI). According to the Centers for Disease Control and Prevention, the five most commonly prescribed antibiotics in the United States are azithromycin, ciprofloxacin, cephalexin, amoxicillin, and amoxicillin-clavulanate. We quantified the frequency of acute DILI for these common antibiotics in the All of Us Research Program, one of the largest electronic health record (EHR)-linked research cohorts in the United States. Retrospective analyses were conducted applying a standardized phenotyping algorithm to de-identified clinical data available in the All of Us database for 318,598 study participants. Between February 1984 and December 2022, more than 30% of All of Us participants (n = 119,812 individuals) had been exposed to at least 1 of our 5 study drugs. Initial screening identified 591 potential case patients that met our preselected laboratory-based phenotyping criteria. Because DILI is a diagnosis of exclusion, we then used phenome scanning to narrow the case counts by (i) scanning all EHRs to identify all alternative diagnostic explanations for the laboratory abnormalities, and (ii) leveraging International Classification of Disease 9th revision (ICD)-9 and ICD 10th revision (ICD)-10 codes as exclusion criteria to eliminate misclassification. Our final case counts were 30 DILI cases with amoxicillin-clavulanate, 24 cases with azithromycin, 24 cases with ciprofloxacin, 22 cases with amoxicillin alone, and < 20 cases with cephalexin. These findings demonstrate that data from EHR-linked research cohorts can be efficiently mined to identify DILI cases related to the use of common antibiotics.

Adolescent and young adult (AYA) oncology is caught between the pediatric and adult oncology settings and, therefore, poorly defined. Unfortunately, progress in overall survival for this age cohort has been stagnant while children and older adults have seen significant improvements. Reasons for the lack of progress are multifactorial, with biologic and psychosocial explanations. The current article will detail the unique features of AYA patients with cancer in terms of outcomes, psychosocial issues, and recommendations. Literature pertaining to AYA patients with cancer from 2006-2012 was reviewed. Findings suggested that recognizing AYAs as a subspecialty that requires holistic, multidisciplinary care may improve outcomes. Nurses at all levels are adept at providing holistic care and are, therefore, excellent potential advocates for a specialized care delivery model that AYAs with cancer deserve.

Ice hockey is a fast, physical sport with unique associated biomechanical demands often placing the hip in forced and repetitive supraphysiological ranges of motion. Ice hockey players commonly endure and are sidelined by nebulous groin injury or hip pain. Underlying causes can be chronic or acute and extra-articular, intra-articular, or "hip-mimicking." This article serves to review common hip-related injuries in ice hockey. For each, we define the particular condition; comment on risk factors and preventive strategies; discuss key historical, physical examination, and imaging findings; and finally, suggest nonoperative and/or operative treatment plans.

BACKGROUND: The procedures that rural general surgeons perform may be changing. It is important to recognize the trends and practices of the current rural general surgeon in efforts to better prepare general surgeons who desire to enter a practice in a rural environment. The aim of this review is to detail the recent operative case volumes of 6 rural locations in the upper Midwest where general surgery is practiced. METHODS: The Enterprise Data and Analytics department of Sanford Health compiled all surgical procedures performed within the Sanford Health System between January 1, 2013 and August 31, 2018. Procedures performed by a total of 58 general surgeons in locations of under 50 000 people are included in this review. RESULTS: From January 1, 2013 to August 31, 2018, 38 958 surgical procedures were performed in rural locations. Endoscopic procedures made up 61.6% of a rural general surgeon's practice. Cholecystectomy (6.3%), hernia repair (6.3%), and appendectomy (3.7%) were the principle nonendoscopic procedures performed by rural surgeons, comprising 16.3% of the case volume. Added together, endoscopy, cholecystectomy, hernia repair, and appendectomy made up 77.9% of the rural general surgeon's caseload. Vascular procedures (2.5%), breast procedures (1.8%), obstetrics (0.4%), and urology procedures (0.2%) are also included in this review. CONCLUSIONS: Rural general surgeons are vital to the surgical workforce in the United States. Recognizing a trend that rural general surgeons perform less subspecialty procedures and more endoscopic procedures will provide direction for those interested in pursuing a career in rural general surgery.

Study Design Controlled laboratory study. Background Plantar heel pain is one of the most common foot and ankle conditions seen in clinical practice, and many individuals continue to have persisting or recurrent pain after treatment. Impaired foot plantar flexor muscle performance is a factor that may contribute to limited treatment success, but reliable methods to identify impairments in individuals with plantar heel pain are needed. In addition, foot orthoses are commonly used to treat this condition, but the implications of orthosis use on muscle performance have not been assessed. Objectives To assess ankle plantar flexor and toe flexor muscle performance in individuals with plantar heel pain using clinically feasible measures and to examine the relationship between muscle performance and duration of foot orthosis use. Methods The rocker-board plantar flexion test (RBPFT) and modified paper grip test for the great toe (mPGTGT) and lesser toes (mPGTLT) were used to assess foot plantar flexor muscle performance in 27 individuals with plantar heel pain and compared to 27 individuals without foot pain who were matched according to age, sex, and body mass. Pain ratings were obtained before and during testing, and self-reported duration of foot orthosis use was recorded. Results Compared to the control group, individuals with plantar heel pain demonstrated lower performance on the RBPFT (P = .001), the mPGTGT (P = .022), and the mPGTLT (P = .037). Longer duration of foot orthosis use was moderately correlated to lower performance on the RBPFT (r = -0.52, P = .02), the mPGTGT (r = -0.54, P = .01), and the mPGTLT (r = -0.43, P = .03). Conclusion Ankle plantar flexor and toe flexor muscle performance was impaired in individuals with plantar heel pain and associated with longer duration of self-reported foot orthosis use. J Orthop Sports Phys Ther 2016;46(8):681-688. Epub 3 Jul 2016. doi:10.2519/jospt.2016.6482.

Metoprolol is a medication commonly utilized in select patients to achieve a reduction in heart rate, systolic blood pressure, or other indications. A majority of metoprolol metabolism occurs via CYP2D6. Decreased expression of the CYP2D6 enzyme increases the concentration of metoprolol. Current pharmacogenomics guidelines by the Dutch Pharmacogenomics Working Group recommend slower titrations and dose decreases to minimize adverse effects from poor metabolizers or normal metabolizers taking concomitant medications that are strong inhibitors of CYP2D6 (phenoconverters). This study aimed to evaluate adverse effects such as bradycardia, hypotension, and syncope in patients who are expected to have absent CYP2D6 enzyme activity due to drug–drug or drug–gene interactions. The secondary aims of this study were to evaluate heart rate measurements for the included participants. Retrospective data were collected for individuals with CYP2D6 genotyping results obtained for clinical purposes. Three categories (CYP2D6 normal metabolizers, poor metabolizers, and phenoconverters) were assigned. A total of 325 participants were included. There was no statistically significant difference found in the primary composite outcome between the three metabolizer groups (p = 0.054). However, a statistically significant difference was identified in the incidences of bradycardia between the poor metabolizers and the normal metabolizers or phenoconverters (p &lt; 0.0001). The average heart rates were 2.8 beats per minute (bpm) and 2.6 bpm lower for the poor metabolizer and phenoconverter groups, respectively, compared to the normal metabolizers (p &lt; 0.0001 for both comparisons). This study further supports the role of genetic testing in precision medicine to help individualize patient care as CYP2D6 poor metabolizers taking metoprolol were found to have an increase in bradycardia. Additional research is needed to clarify the dose relationship in this drug–gene interaction.

PURPOSE: To evaluate the effect of preconditioning according to intraoperative workflow on initial tension and elongation behavior for femoral adjustable loop devices (ALDs) and closed loop devices (CLDs) in suspensory anterior cruciate ligament reconstruction (ACLR) with tibial screw fixation in a biomechanical in vitro study. METHODS: Three ACLR groups with tibial screw fixation were biomechanically tested in a full-construct setup using porcine tibias. Groups (n = 8 per group) varied by femoral fixation method and consisted of a CLD (group 3) and ALD fixation with (group 2) and without simulated intraoperative preconditioning (group 1). The change in tension after screw insertion and the displacement to restore the initial loading situation were measured. Grafts underwent dynamic cycling (1,000 cycles at 0.75 Hz) using both a position and a force control mode. RESULTS: Data are presented as mean [standard deviation]. Placement of an interference screw induced a graft tension loss of 62% (49.4 [0.4] N vs 19.0 [10.0] N, P < .001) by introducing a laxity of 0.53 [0.26] mm. Intraoperative preconditioning led to a higher initial load level (228.3 [19.8] N) compared with unconditioned ALD (156.1 [25.5] N, P < .001) and CLD groups (156.6 [12.8] N, P < .001) with less force decrease over position-controlled cyclic loading. Furthermore, initial (-0.22 [0.16] mm) and dynamic elongation (0.88 [0.23] mm) were reduced compared with the unconditioned ALD (0.65 [0.35] mm, P < .001; and 1.56 [0.19] mm, P < .001) and CLD groups (0.16 [0.26] mm, P < .001; and 1.64 [0.24] mm, P < .001). CONCLUSIONS: ACLR with femoral ALD fixation and intraoperative preconditioning allows for restoration of time-zero screw-imparted slack and leads to significantly reduced cyclic elongation in accordance with native ACL function. Both ALD and CLD control groups behaved similarly, with total elongation less than 3 mm including time-zero slack. CLINICAL RELEVANCE: Although the clinical relevance of time-zero graft tension loss is uncertain, the use of an ALD in concert with tibial screw fixation may be favorable to allow for tension optimization.

The first known case of endocarditis caused by Kingella indologenes is reported. A review of the literature reveals only seven cases of endocarditis caused by the other two species of the genus Kingella (Kingella kingae, six cases; Kingella denitrificens, one case). Kingella organisms appear to be sensitive to a wide variety of antimicrobial agents. The available data suggest that endocarditis caused by Kingella species occurs rarely and is associated with a benign clinical course.

Abstract Background and study aims Biliary access following Roux-en-Y gastric bypass (RYGB) anatomy presents a significant challenge. Long-term outcomes of laparoscopic-assisted trans-gastric ERCP (LA-ERCP) including sphincter of Oddi dysfunction (SOD) subtypes have not been thoroughly examined. Our study aims to present our overall outcomes of trans-gastric LAERCP and examine a significant subgroup of patients with SOD after RYGB. Patients and methods A retrospective review of RYGB patients who underwent LA-ERCP between 2009 and 2016 identified 51 patients. A subgroup of 22 patients with SOD were examined and contacted by phone survey to determine long-term symptom resolution. Results Post-procedure length of stay was 1.9 days (SD 3.0). There was one conversion from laparoscopic to open procedure. Selective cannulation rate was 100 %. Mean follow-up was 14.6 months. There were two major operative complications, two major ERCP-related complications, and five wound infections (9.8 %). No deaths or episodes of pancreatitis occurred. Seventeen patients had biliary SOD (Type I = 9, Type II = 8). The remaining four had pancreatic SOD (Type I = 1, Type II = 4). SOD subgroup follow-up was 21.4 months (SD 18.1). All patients with Type I biliary and 75 % with Type I pancreatic SOD reported complete resolution of their symptoms. Conclusions Consistent with other published series, LA-ERCP yields excellent cannulation rates after RYGB. Successful treatment of pancreatic and Type 1 biliary SOD suggests that there is significant symptomatic benefit to treating this patient population. However, an overall complication rate of approximately 15 % with LAERCP leaves open the possibility for improvements in access techniques in post-RYGB patients.