Texas Health Harris Methodist Hospital Fort Worth

BACKGROUND: Studies showing that drugs that inhibit cyclooxygenase-2 (COX-2) reduce the number of colorectal adenomas in animals and patients with familial adenomatous polyposis suggest that COX-2 inhibitors may also prevent sporadic colorectal neoplasia. METHODS: We randomly assigned patients who had adenomas removed before study entry to receive placebo (679 patients) or 200 mg (685 patients) or 400 mg (671 patients) of celecoxib twice daily. Randomization was stratified for the use of low-dose aspirin. Follow-up colonoscopies were performed at one and three years after randomization. The occurrence of newly detected colorectal adenomas was compared among the groups with the life-table extension of the Mantel-Haenszel test. RESULTS: Follow-up colonoscopies were completed at year 1 in 89.5 percent of randomized patients, and at year 3 in 75.7 percent. The estimated cumulative incidence of the detection of one or more adenomas by year 3 was 60.7 percent for patients receiving placebo, as compared with 43.2 percent for those receiving 200 mg of celecoxib twice a day (risk ratio, 0.67; 95 percent confidence interval, 0.59 to 0.77; P<0.001) and 37.5 percent for those receiving 400 mg of celecoxib twice a day (risk ratio, 0.55; 95 percent confidence interval, 0.48 to 0.64; P<0.001). Serious adverse events occurred in 18.8 percent of patients in the placebo group, as compared with 20.4 percent of those in the low-dose celecoxib group (risk ratio, 1.1; 95 percent confidence interval, 0.9 to 1.3; P=0.5) and 23.0 percent of those in the high-dose group (risk ratio, 1.2; 95 percent confidence interval, 1.0 to 1.5; P=0.06). As compared with placebo, celecoxib was associated with an increased risk of cardiovascular events (risk ratio for the low dose, 2.6; 95 percent confidence interval, 1.1 to 6.1; and risk ratio for the high dose, 3.4; 95 percent confidence interval, 1.5 to 7.9). CONCLUSIONS: These findings indicate that celecoxib is an effective agent for the prevention of colorectal adenomas but, because of potential cardiovascular events, cannot be routinely recommended for this indication. (ClinicalTrials.gov number, NCT00005094 [ClinicalTrials.gov].).

BACKGROUND: After a person has been injured, prehospital administration of plasma in addition to the initiation of standard resuscitation procedures in the prehospital environment may reduce the risk of downstream complications from hemorrhage and shock. Data from large clinical trials are lacking to show either the efficacy or the risks associated with plasma transfusion in the prehospital setting. METHODS: To determine the efficacy and safety of prehospital administration of thawed plasma in injured patients who are at risk for hemorrhagic shock, we conducted a pragmatic, multicenter, cluster-randomized, phase 3 superiority trial that compared the administration of thawed plasma with standard-care resuscitation during air medical transport. The primary outcome was mortality at 30 days. RESULTS: A total of 501 patients were evaluated: 230 patients received plasma (plasma group) and 271 received standard-care resuscitation (standard-care group). Mortality at 30 days was significantly lower in the plasma group than in the standard-care group (23.2% vs. 33.0%; difference, -9.8 percentage points; 95% confidence interval, -18.6 to -1.0%; P=0.03). A similar treatment effect was observed across nine prespecified subgroups (heterogeneity chi-square test, 12.21; P=0.79). Kaplan-Meier curves showed an early separation of the two treatment groups that began 3 hours after randomization and persisted until 30 days after randomization (log-rank chi-square test, 5.70; P=0.02). The median prothrombin-time ratio was lower in the plasma group than in the standard-care group (1.2 [interquartile range, 1.1 to 1.4] vs. 1.3 [interquartile range, 1.1 to 1.6], P<0.001) after the patients' arrival at the trauma center. No significant differences between the two groups were noted with respect to multiorgan failure, acute lung injury-acute respiratory distress syndrome, nosocomial infections, or allergic or transfusion-related reactions. CONCLUSIONS: In injured patients at risk for hemorrhagic shock, the prehospital administration of thawed plasma was safe and resulted in lower 30-day mortality and a lower median prothrombin-time ratio than standard-care resuscitation. (Funded by the U.S. Army Medical Research and Materiel Command; PAMPer ClinicalTrials.gov number, NCT01818427 .).

OBJECTIVES: Locked plating has become a standard method to treat supracondylar femur fractures. Emerging evidence indicates that this method of treatment is associated with modest failure rates. The goals of this study were to determine risk factors for complications and to provide technical recommendations for locked plating of supracondylar femur fractures. DESIGN: Retrospective review. SETTING: Three level I or II trauma centers. PATIENTS/PARTICIPANTS: Three hundred twenty-six patients with 335 distal femur fractures (OTA 33A or C, 33% open) treated with lateral locked plates were studied. The average patient age was 57 years (range 17-97 years), 55% were women, 34% were obese, 19% were diabetic, and 24% were smokers. INTERVENTION: All patients were managed with open reduction internal fixation using a lateral distal femoral locked plate construct that included locked screws in the distal fragment and nonlocked, locked, or a combination of locked and nonlocked screws in the proximal fragment. MAIN OUTCOME MEASUREMENTS: Risk factors for reoperation to promote union, deep infection, and implant failure. RESULTS: After the index procedure, 64 fractures (19%) required reoperation to promote union, including 30 that had a planned staged bone grafting because of the metaphyseal defect after debridement of an open fracture. Independent risk factors for reoperation to promote union and deep infection included diabetes and open fracture. Risk factors for proximal implant failure included open fracture, smoking, increased body mass index, and shorter plate length. CONCLUSIONS: The identified risk factors for reoperation to promote union and complications included open fracture, diabetes, smoking, increased body mass index, and shorter plate length. Most factors are out of surgeon control but are useful when considering prognosis. Use of relatively long plates is a technical factor that can reduce risk for fixation failure. LEVEL OF EVIDENCE: Prognostic level II. See instructions for authors for a complete description of levels of evidence.

Importance: Traumatic brain injury (TBI) is the leading cause of death and disability due to trauma. Early administration of tranexamic acid may benefit patients with TBI. Objective: To determine whether tranexamic acid treatment initiated in the out-of-hospital setting within 2 hours of injury improves neurologic outcome in patients with moderate or severe TBI. Design, Setting, and Participants: Multicenter, double-blinded, randomized clinical trial at 20 trauma centers and 39 emergency medical services agencies in the US and Canada from May 2015 to November 2017. Eligible participants (N = 1280) included out-of-hospital patients with TBI aged 15 years or older with Glasgow Coma Scale score of 12 or less and systolic blood pressure of 90 mm Hg or higher. Interventions: Three interventions were evaluated, with treatment initiated within 2 hours of TBI: out-of-hospital tranexamic acid (1 g) bolus and in-hospital tranexamic acid (1 g) 8-hour infusion (bolus maintenance group; n = 312), out-of-hospital tranexamic acid (2 g) bolus and in-hospital placebo 8-hour infusion (bolus only group; n = 345), and out-of-hospital placebo bolus and in-hospital placebo 8-hour infusion (placebo group; n = 309). Main Outcomes and Measures: The primary outcome was favorable neurologic function at 6 months (Glasgow Outcome Scale-Extended score >4 [moderate disability or good recovery]) in the combined tranexamic acid group vs the placebo group. Asymmetric significance thresholds were set at 0.1 for benefit and 0.025 for harm. There were 18 secondary end points, of which 5 are reported in this article: 28-day mortality, 6-month Disability Rating Scale score (range, 0 [no disability] to 30 [death]), progression of intracranial hemorrhage, incidence of seizures, and incidence of thromboembolic events. Results: Among 1063 participants, a study drug was not administered to 96 randomized participants and 1 participant was excluded, resulting in 966 participants in the analysis population (mean age, 42 years; 255 [74%] male participants; mean Glasgow Coma Scale score, 8). Of these participants, 819 (84.8%) were available for primary outcome analysis at 6-month follow-up. The primary outcome occurred in 65% of patients in the tranexamic acid groups vs 62% in the placebo group (difference, 3.5%; [90% 1-sided confidence limit for benefit, -0.9%]; P = .16; [97.5% 1-sided confidence limit for harm, 10.2%]; P = .84). There was no statistically significant difference in 28-day mortality between the tranexamic acid groups vs the placebo group (14% vs 17%; difference, -2.9% [95% CI, -7.9% to 2.1%]; P = .26), 6-month Disability Rating Scale score (6.8 vs 7.6; difference, -0.9 [95% CI, -2.5 to 0.7]; P = .29), or progression of intracranial hemorrhage (16% vs 20%; difference, -5.4% [95% CI, -12.8% to 2.1%]; P = .16). Conclusions and Relevance: Among patients with moderate to severe TBI, out-of-hospital tranexamic acid administration within 2 hours of injury compared with placebo did not significantly improve 6-month neurologic outcome as measured by the Glasgow Outcome Scale-Extended. Trial Registration: ClinicalTrials.gov Identifier: NCT01990768.

Importance: Both military and civilian clinical practice guidelines include early plasma transfusion to achieve a plasma to red cell ratio approaching 1:1 to 1:2. However, it was not known how early plasma should be given for optimal benefit. Two recent randomized clinical trials were published, with apparently contradictory results. The Prehospital Air Medical Plasma (PAMPer) clinical trial showed a nearly 30% reduction in mortality with plasma transfusion in the prehospital environment, while the Control of Major Bleeding After Trauma (COMBAT) clinical trial showed no survival improvement. Objective: To facilitate a post hoc combined analysis of the COMBAT and PAMPer trials to examine questions that could not be answered by either clinical trial alone. We hypothesized that prehospital transport time influenced the effects of prehospital plasma on 28-day mortality. Design, Setting, and Participants: A total of 626 patients in the 2 clinical trials were included. Patients with trauma and hemorrhagic shock were randomly assigned to receive either standard care or 2 U of thawed plasma followed by standard care in the prehospital environment. Data analysis was performed between September 2018 and January 2019. Interventions: Prehospital transfusion of 2 U of plasma compared with crystalloid-based resuscitation. Main Outcomes and Measures: The main outcome was 28-day mortality. Results: In this post hoc analysis of 626 patients (467 men [74.6%] and 159 women [25.4%]; median [interquartile range] age, 42 [27-57] years) who had trauma with hemorrhagic shock, a Cox regression analysis showed a significant overall survival benefit for plasma (hazard ratio [HR], 0.65; 95% CI, 0.47-0.90; P = .01) after adjustment for injury severity, age, and clinical trial cohort (COMBAT or PAMPer). A significant association with prehospital transport time was detected (from arrival on scene to arrival at the trauma center). Increased mortality was observed in patients in the standard care group when prehospital transport was longer than 20 minutes (HR, 2.12; 95% CI, 1.05-4.30; P = .04), while increased mortality was not observed in patients in the prehospital plasma group (HR, 0.78; 95% CI, 0.40-1.51; P = .46). No serious adverse events were associated with prehospital plasma transfusion. Conclusions and Relevance: These data suggest that prehospital plasma is associated with a survival benefit when transport times are longer than 20 minutes and that the benefit-risk ratio is favorable for use of prehospital plasma. Trial Registration: ClinicalTrials.gov identifiers: NCT01838863 (COMBAT) and NCT01818427 (PAMPer).

BACKGROUND: Guidelines currently recommend targeting light sedation with dexmedetomidine or propofol for adults receiving mechanical ventilation. Differences exist between these sedatives in arousability, immunity, and inflammation. Whether they affect outcomes differentially in mechanically ventilated adults with sepsis undergoing light sedation is unknown. METHODS: In a multicenter, double-blind trial, we randomly assigned mechanically ventilated adults with sepsis to receive dexmedetomidine (0.2 to 1.5 μg per kilogram of body weight per hour) or propofol (5 to 50 μg per kilogram per minute), with doses adjusted by bedside nurses to achieve target sedation goals set by clinicians according to the Richmond Agitation-Sedation Scale (RASS, on which scores range from -5 [unresponsive] to +4 [combative]). The primary end point was days alive without delirium or coma during the 14-day intervention period. Secondary end points were ventilator-free days at 28 days, death at 90 days, and age-adjusted total score on the Telephone Interview for Cognitive Status questionnaire (TICS-T; scores range from 0 to 100, with a mean of 50±10 and lower scores indicating worse cognition) at 6 months. RESULTS: Of 432 patients who underwent randomization, 422 were assigned to receive a trial drug and were included in the analyses - 214 patients received dexmedetomidine at a median dose of 0.27 μg per kilogram per hour, and 208 received propofol at a median dose of 10.21 μg per kilogram per minute. The median duration of receipt of the trial drugs was 3.0 days (interquartile range, 2.0 to 6.0), and the median RASS score was -2.0 (interquartile range, -3.0 to -1.0). We found no difference between dexmedetomidine and propofol in the number of days alive without delirium or coma (adjusted median, 10.7 vs. 10.8 days; odds ratio, 0.96; 95% confidence interval [CI], 0.74 to 1.26), ventilator-free days (adjusted median, 23.7 vs. 24.0 days; odds ratio, 0.98; 95% CI, 0.63 to 1.51), death at 90 days (38% vs. 39%; hazard ratio, 1.06; 95% CI, 0.74 to 1.52), or TICS-T score at 6 months (adjusted median score, 40.9 vs. 41.4; odds ratio, 0.94; 95% CI, 0.66 to 1.33). Safety end points were similar in the two groups. CONCLUSIONS: Among mechanically ventilated adults with sepsis who were being treated with recommended light-sedation approaches, outcomes in patients who received dexmedetomidine did not differ from outcomes in those who received propofol. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01739933.).

Patients with various rheumatologic and inflammatory disease states commonly require drugs known to decrease the inflammatory or autoimmune response for adequate control of their condition. Such drugs include nonsteroidal antiinflammatory drugs (NSAIDs), cyclooxygenase (COX)-2 inhibitors, corticosteroids, disease-modifying antirheumatic drugs (DMARDs), and biologic response modifiers. These drugs affect inflammation and local immune responses, which are necessary for proper wound healing in the perioperative setting, thereby potentially resulting in undesirable postoperative complications. Such complications include wound dehiscence, infection, and impaired collagen synthesis. The end result is delayed healing of soft tissue and bone wounds. The current literature provides insight into the effect of some of these drugs on wound healing. For certain drugs, such as methotrexate, trials have been conducted in humans and direct us on what to do during the perioperative period. Whereas with other drugs, we must rely on either small-animal studies or extrapolation of data from human studies that did not specifically look at wound healing. Unfortunately, no clear consensus exists on the need and optimum time for withholding therapy before surgery. Likewise, clinicians are often uncertain of the appropriate time to resume therapy after the procedure. For those drugs with limited or no data in this setting, the use of pharmacokinetic properties and biologic effects of each drug should be considered individually. In some cases, discontinuation of therapy may be required up to 4 weeks before surgery because of the long half-lives of the drugs. In doing so, patients may experience an exacerbation or worsening of disease. Clinicians must carefully evaluate individual patient risk factors, disease severity, and the pharmacokinetics of available therapies when weighing the risks and benefits of discontinuing therapy in the perioperative setting.

BACKGROUND: Adhesions are fibrous bands of scar tissue, often a result of surgery, that form between internal organs and tissues, joining them together abnormally. Postoperative adhesions frequently occur following abdominal surgery, and are associated with a large economic burden. This study examines the inpatient burden of adhesiolysis in the United States (i.e., number and rate of events, cost, length of stay [LOS]). METHODS: Hospital discharge data for patients with primary and secondary adhesiolysis were analyzed using the 2005 Healthcare Cost and Utilization Project's Nationwide Inpatient Sample. Procedures were aggregated by body system. RESULTS: We identified 351,777 adhesiolysis-related hospitalizations: 23.2% for primary and 76.8% for secondary adhesiolysis. The average LOS was 7.8 days for primary adhesiolysis. We found that 967,332 days of care were attributed to adhesiolysis-related procedures, with inpatient expenditures totaling $2.3 billion ($1.4 billion for primary adhesiolysis; $926 million for secondary adhesiolysis). Hospitalizations for adhesiolysis increased steadily by age and were higher for women. Of secondary adhesiolysis procedures, 46.3% involved the female reproductive tract, resulting in 57,005 additional days of care and $220 million in attributable costs. CONCLUSIONS: Adhesiolysis remain an important surgical problem in the United States. Hospitalization for this condition leads to high direct surgical costs, which should be of interest to providers and payers.

OBJECTIVE: To assess the ability of transvaginal ultrasound to detect cesarean scars and their defects in the nonpregnant state. METHODS: Asymptomatic, parous volunteers underwent transvaginal ultrasound of the cervix, uterus, and adnexa. Uterine measurements, the presence or absence of a cesarean scar, and the presence of a scar defect, defined as fluid within the scar, were recorded. All subjects completed a self-report questionnaire regarding obstetric history. Sonographers and investigators were blinded to subject history. RESULTS: A total of 70 subjects were enrolled. Of these, 38 women had a prior vaginal delivery and 32 women a prior cesarean delivery. One woman with a bicornuate uterus and three cesarean deliveries was excluded from data analysis. Real-time transvaginal ultrasound proved 100% sensitive (exact 95% confidence interval [CI] 88.8, 100) and 100% specific (exact 95% CI 90.7, 100). Stored image review had a sensitivity of 87% (exact 95% CI 70.2, 96.4) and a specificity of 100% (exact 95% CI 90.7, 100). Fluid was visualized within the scars of 13 of 31 subjects (42%) with a prior cesarean delivery. All 13 were found among the 23 subjects (56%) who had labored prior to cesarean delivery. Moreover, women with cesarean scar defects had a greater number of cesarean deliveries (P <.04) than women without scar defects. CONCLUSIONS: Transvaginal ultrasound is highly accurate in detecting cesarean hysterotomy scars. Cesarean scar defect, defined by the presence of fluid within the incision site, was more common when labor preceded cesarean delivery and with multiple cesarean deliveries.

OBJECTIVES/HYPOTHESIS: To assess balloon dilation of the Eustachian tube with Eustachian tube balloon catheter in conjunction with medical management as treatment for Eustachian tube dilatory dysfunction. STUDY DESIGN: In this prospective, multicenter, randomized, controlled trial, we assigned, in a 2:1 ratio, patients age 22 years and older with Eustachian tube dilatory dysfunction refractory to medical therapy to undergo balloon dilation of the Eustachian tube with balloon catheter in conjunction with medical management or medical management alone. METHODS: The primary endpoint was normalization of tympanogram at 6 weeks. Additional endpoints were normalization of Eustachian Tube Dysfunction Questionaire-7 symptom scores, positive Valsalva maneuver, mucosal inflammation, and safety. RESULTS: Primary efficacy results demonstrated superiority of balloon dilation of the Eustachian tube with balloon catheter + medical management compared to medical management alone. Tympanogram normalization at 6-week follow-up was observed in 51.8% (72/139) of investigational patients versus 13.9% (10/72) of controls (P < .0001). Tympanogram normalization in the treatment group was 62.2% after 24 weeks. Normalization of Eustachian Tube Dysfunction Questionaire-7 Symptom scores at 6-week follow-up was observed in 56.2% (77/137) of investigational patients versus 8.5% (6/71) controls (P < .001). The investigational group also demonstrated substantial improvement in both mucosal inflammation and Valsalva maneuver at 6-week follow-up compared to controls. No device- or procedure-related serious adverse events were reported for those who underwent balloon dilation of the Eustachian tube. CONCLUSIONS: This study demonstrated superiority of balloon dilation of the Eustachian tube with balloon catheter + medical management compared to medical management alone to treat Eustachian tube dilatory dysfunction in adults. LEVEL OF EVIDENCE: 1b. Laryngoscope, 128:1200-1206, 2018.

OBJECTIVE: Management of vertical femoral neck fractures in young adults has been a challenging clinical problem, resulting in mixed clinical outcomes. A thorough understanding of the fracture morphology for this injury pattern is lacking, which may contribute to frequent failures of treatment. This study is designed to produce a detailed description of the pathoanatomy of these fractures, which may ultimately be helpful in developing more informed reduction and fixation strategies. DESIGN: Retrospective study of patient records, plain radiographs, and computed tomography scans to determine the morphology the Pauwels III femoral neck fractures (coronal angle >50 degrees) in young adults. SETTING: Two level I and 1 level II regional trauma centers. PATIENTS: All patients 18-49 years of age with a surgically repaired, high-energy high shear angle (>50 degrees) femoral neck fracture from January 1, 2007, to December 31, 2010. METHODS: One hundred thirty-six adult patients younger than 50 years were identified with a femoral neck fracture in the study period, of whom 33 met all study criteria. We evaluated plain radiography and computed tomography data including fracture orientation, comminution, deformity, characteristics of the inferomedial fracture spike, and the associated inferomedial calcar's cortical buttress. RESULTS: The vertical (coronal) fracture averaged 60 degrees and axial fracture obliquity averaged 24 degrees with relative deficiency of the posterior neck on the head-neck fragment. Major femoral neck comminution (>1.5 cm in any dimension) was identified in 96% of cases, mostly located in the inferior (94%) and posterior (82%) quadrants. The apical fracture spike of the head segment was found to be in line (within 10 degrees) of the neck-shaft axis on the proximal femur 63% of the time. Deformity in external rotation averaged 44 degrees (range, 10-68 degrees) and shortening of the femur averaged 1.8 cm (range, 0.9-4.4 cm). CONCLUSIONS: This study investigated the fracture morphology of isolated, high shear angle femoral neck fractures in young adults, which may ultimately lead to improved operative reduction and fixation tactics. Given this injury's characteristic findings, including fracture orientation, deformity, and comminution, surgeons should be cognizant of this pattern's innate instability and potential for treatment failure with typical implant constructs.

The four main types of appendiceal neoplasms are carcinoid tumors (CT), mucinous cystadenocarcinomas, colonic adenocarcinomas (CAC), and adenocarcinoid tumors. They have different clinical features and require different therapy. They are rarely diagnosed before or during surgery and frequently require a secondary operation for proper treatment. A series of 14 patients treated between 1979 and 1989 at Harris Methodist Fort Worth Hospital are described. There are six important points of management. (1) A frozen section should be done whenever the appendiceal findings are atypical. Then a diagnosis of malignancy can be made during surgery and appropriate surgery can be done primarily. (2) All patients with appendiceal neoplasms should be followed because a second malignancy will develop in 15% to 20% of them. (3) Appendectomy is recommended for patients whose CT are less than or equal to 1.0 cm in diameter and for most patients whose tumors are between 1.0 and 2.0 cm in diameter. Right hemicolectomy is preferred for those patients whose CT are 2.0 cm or more in diameter or between 1.0 and 2.0 cm with heavy lymphatic and mesenteric invasion. (4) Mucinous cystadenocarcinomas are slowly progressive and are best treated by means of right hemicolectomy with aggressive debulking added if pseudomyxoma peritonei is present. (5) CAC require a right hemicolectomy and have the same prognosis as have other colon adenocarcinomas. (6) Adenocarcinoid tumors have a dual cell origin, a predilection for developing ovarian metastases, and a malignant potential between CT and CAC. They are best treated by means of right hemicolectomy with concomitant oophorectomy in postmenopausal women.

OBJECTIVE: Evaluation of clinical results and outcomes of low metaphyseal distal tibia fractures with minimal or no intra-articular involvement. These were treated using the minimally invasive plate osteosynthesis concept with a 3.5-mm locked medial tibial plafond plate and hybrid (locking and nonlocking) screw construct. SETTING: Level II regional trauma center. DESIGN: Consecutive case series of clinical outcomes using limb-specific and whole-person measures. INTERVENTION: Minimally invasive medial plating using hybrid locking and nonlocking techniques. MAIN OUTCOME MEASUREMENT: The following were applied at a minimum of 2 years: limb assessment--Olerud and Molander's ankle rating scale and the American Orthopaedic Foot and Ankle Surgeon's (AOFAS) ankle-hindfoot instrument, whole-person assessment--the Short Form 36 (SF-36). RESULTS: Thirty-eight patients were followed an average of 32 months (range, 12-48 months). Mean fracture healing time was 21 weeks (range, 9-60 weeks). Acceptable alignment and length were restored (angulation <or=5 degrees or shortening <or=1 cm) in all but one case. One patient (3%) had loss of fixation and two (5%) underwent secondary surgeries to achieve union. In 30 patients at >2 years, the AOFAS and the Olerud and Molander ankles scores averaged good-excellent. SF-36 outcomes scores were lower than that of normative data in patients with uninjured limbs but only significantly diminished in physical function. CONCLUSIONS: Minimally invasive medial plating using a hybrid locking plate technique in metaphyseal fractures of the distal tibia predictably restored limb alignment with a 5% reoperation rate and yielded mostly good-excellent ankle scores. There were residual impairments seen on whole-body outcomes measures.

PURPOSE: Robotically-assisted total knee arthroplasty (TKA) has been shown to improve alignment and decrease outliers, an important goal in TKA procedures. The purpose of this cadaveric study was to compare the accuracy and reproducibility of a recently introduced TKA robotic system to conventional instrumentation for bone resections. METHODS: This cadaveric study compared 14 robotically-assisted TKA with 20 conventional TKAs. Four board-certified high volume arthroplasty surgeons with no prior experience in robotics (except one) performed the procedures with three different implant systems. Angle and level of bone resections obtained from optical navigation or calliper measurements were compared to the intra-operative plan to determine accuracy. Group comparison was performed using Student t test (mean) and F test (variance), with significance at p < 0.05. RESULTS: The robotic group demonstrated statistically more accurate results (p < 0.05) and fewer outliers (p < 0.05) than conventional instrumentation when aiming for neutral alignment. Final limb alignment (HKA) had an accuracy of 0.8° ± 0.6° vs 2.0° ± 1.6°, with 100% vs 75% of cases within 3° and 93% vs 60% within 2°. For the robotically-assisted knees, the accuracy of bone resection angles was below 0.6° with standard deviations below 0.4°, except for the femur flexion (1.3° ± 1.0°), and below 0.7 mm with standard deviations below 0.7 mm for bone resection levels. CONCLUSION: This in vitro study has demonstrated that this novel TKA robotic system produces more accurate and more reproducible bone resections than conventional instrumentation. It supports the clinical use of this new robotic system. LEVEL OF EVIDENCE: Cadaveric study, Level V.

BACKGROUND: Nurses have an essential role in implementing evidence-based practices (EBP) that contribute to high-quality outcomes. It remains unknown how healthcare facilities can increase nurse engagement in EBP. PURPOSE: To determine whether individual or organizational qualities could be identified that were related to registered nurses' (RNs') readiness for EBP as measured by their reported EBP barriers, ability, desire, and frequency of behaviors. METHODS: A descriptive cross-sectional survey was used in which a convenience sample of 2,441 nurses within one United States healthcare system completed a modified version of the Information Literacy for Evidence-Based Nursing questionnaire. Descriptive statistics, t tests, one-way ANOVA, and regression modeling were used to analyze the data. RESULTS: RNs employed by facilities designated by the American Nurses Credentialing Center (ANCC) as Magnet® or Pathway to Excellence® reported significantly fewer barriers to EBP than those RNs employed by non designated facilities. RNs in Magnet organizations had higher desire for EBP than Pathway to Excellence or non designated facilities. RNs educated at the baccalaureate level or higher reported significantly fewer barriers to EBP than nurses with less education; they also had higher EBP ability, desire, and frequency of behaviors. A predictive model found higher EBP readiness scores among RNs who participated in research, had specialty certifications, and engaged in a clinical career development program. LINKING EVIDENCE TO ACTION: Education, research, and certification standards promoted by the Magnet program may provide a nursing workforce that is better prepared for EBP. Organizations should continue structural supports that increase professional development and research opportunities so nurses are empowered to practice at their full capacity.

Points out that, if high performance is to be sustained in metal‐industrial organizations, co‐operative action among personnel becomes essential ‐ the explosion of information today and the complexity of our times demand it. Maintains that team management, then, is vital to achieve and maintain high output at a time of fast growth. Stresses that thinking managers must be committed to learning the skills of group dynamics, including how to influence team processes and activities, norms and values, and task and maintenance functions. Discusses group leadership which implies clarifying roles and relationships; sharing of unique talents and decision making; and acquiring new tools such as the computer to control the diverse elements involved in matrix, project or product management. Discusses the creation of an effective team culture which improves performance beyond the sum of individual member efforts. Suggests that behavioural scientists can provide team building to ensure group productiveness and synergy. Determines that successful management actively not only promotes a team spirit, but installs team mechanisms and the means to develop in team skills.

Recent publications have suggested that intra-ocular pressure (IOP) may be an indirect assessment of intra-cranial pressure (ICP). Both IOP and ICP have similar physiologic pressure ranges and similar responses to changes in intra-abdominal, intra-thoracic and aortic pressure. Previous studies have demonstrated the relationships between retinal arterial pressure and aortic pressure, intra-ocular pressure and retinal venous pressure, intra-cranial pressure and retinal venous pressure. Power athletes routinely utilize the Valsalva maneuver during weightlifting. In fact there are reports of stroke, cerebral hemorrhage, subarachnoid hemorrhage, conjunctival, foveal and retinal hemorrhage, retinal detachment, hiatal hernia and pneumothorax associated with weightlifting. These events are thought to occur secondary to the extreme pressure elevations that occur in the intra-abdominal, intra-thoracic, intra-cranial, intra-ocular and vascular compartments. To date no human studies have examined the IOP changes that may occur with heavy resistance exercise. Therefore, we recruited power athletes (n = 11), who had participated in prior studies, from the local metropolitan area. The athletes had blood pressure status, drug screening and medical histories performed during previous investigations. Intra-ocular pressure was measured by noncontact tonometry at rest and during maximal isometric contraction. All subjects resting IOP were within normal ranges (mean 13 +/- 2.8 mmHg). Intra-ocular pressures were significantly (p < 0.0001) elevated in each subject during maximal contraction (mean 28 +/- 9.3 mmHg). One subject's IOP reached 46 mmHg during maximal contraction. Linear regression analysis demonstrated a significant linear relationship (r = 0.62, p < 0.0001) in the net change of IOP from rest to maximal contraction for each subject. This study demonstrates that IOP elevates to pathophysiologic levels during resistance exercise. The findings of conjunctival hemorrhages in two subjects further supports IOP being reflective of retinal venous pressure. The enormous pressures generated by power athletes during weightlifting leads to elevations in ICP which obstruct venous outflow leading to hemorrhage and elevations in IOP. The question remains as to whether these intermittent bursts of elevated IOP can lead to long-term pathological sequelae.

STUDY DESIGN: Cross-sectional. OBJECTIVES: To compare lower extremity balance and shoulder range of motion in baseball players with ulnar collateral ligament (UCL) tears to a healthy cohort. Background Throwing is a complex motion that requires balance and coordination to effectively transfer energy through the kinetic chain. In theory, poorer balance could negatively affect throwing mechanics and lead to injury. METHODS: Thirty baseball players (mean ± SD age, 18.5 ± 1.9 years) with a diagnosis of a UCL tear of their throwing arm were compared to 30 players (age, 19.0 ± 1.1 years) without a UCL tear. All participants were competing at either the high school or collegiate level and reported an average ± SD of 13.5 ± 1.7 years of playing experience. The Y Balance Test composite scores were calculated for the stance and lead lower extremities of all players. Shoulder range of motion was used to calculate glenohumeral internal rotation deficit and side-to-side differences in total rotational motion. Group comparisons were made between participants with and without UCL tears using independent t tests. RESULTS: Baseball players with UCL tears scored significantly lower on the Y Balance Test for both the stance (P<.001) and lead (P<.001) lower extremities compared to the noninjured cohort. No between-group differences were noted in glenohumeral internal rotation deficit (P = .453), whereas the mean ± SD side-to-side difference in total rotational motion was -6.0° ± 9.6° for the injured group, compared to -0.4° ± 9.6° for the control group (P = .028). CONCLUSION: Participants with a UCL tear demonstrated decreased performance for their stance and lead lower extremities during the Y Balance Test. These data are consistent with a clinical hypothesis of a potential association between impaired balance and UCL tears in high school and collegiate baseball players. The lower total rotational motion of the dominant shoulder in participants with UCL tears needs to be considered in the interpretation of those results.

Background: The Surgical Infection Society (SIS) Guidelines for the treatment of complicated skin and soft tissue infections (SSTIs) were published in October 2009 in Surgical Infections. The purpose of this project was to provide a succinct update on the earlier guidelines based on an additional decade of data. Methods: We reviewed the previous guidelines eliminating bite wounds and diabetic foot infections including their associated references. Relevant articles on the topic of complicated SSTIs from 2008–2020 were reviewed and graded individually. Comparisons were then made between the old and the new graded recommendations with review of the older references by two authors when there was disparity between the grades. Results: The majority of new studies addressed antimicrobial options and duration of therapy particularly in complicated abscesses. There were fewer updated studies on diagnosis and specific operative interventions. Many of the topics addressed in the original guidelines had no new literature to evaluate. Conclusions: Most recommendations remain unchanged from the original guidelines with the exception of increased support for adjuvant antimicrobial therapy after drainage of complex abscess and increased data for the use of alternative antimicrobial agents.

OBJECTIVE: The treatment of some pelvic injuries has evolved recently to include the use of a subcutaneous anterior pelvic fixator (INFIX). We present 8 cases of femoral nerve palsy in 6 patients after application of an INFIX to highlight this potentially devastating complication to pelvic surgeons using this technique and discuss how it might be avoided in the future. DESIGN: Retrospective chart review. Case series. SETTING: Five level 1 and 2 trauma centers, tertiary referral hospitals. PATIENTS/PARTICIPANTS: Six patients with anterior pelvic ring injury treated with an INFIX who experienced 8 femoral nerve palsies (2 bilateral). INTERVENTION: Removal of internal fixator, treatment for femoral nerve palsy. MAIN OUTCOME MEASUREMENTS: Clinical and electromyographic evaluation of patients. RESULTS: All 6 patients with a total of 8 femoral nerve palsies had their INFIX removed. Variable resolution of the nerve injuries was observed. CONCLUSIONS: Application of an INFIX for the treatment of pelvic ring injury carries a potentially devastating risk to the femoral nerve(s). Despite early implant removal after detection of nerve injury, some patients had residual quadriceps weakness, disturbance of the thigh's skin sensation, and/or gait disturbance attributable to femoral nerve palsy at the time of early final follow-up. LEVEL OF EVIDENCE: Therapeutic level IV. See Instructions for Authors for a complete description of levels of evidence.