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Objectives: Tibial tubercle osteotomy (TTO) can be used to treat patellar instability, patellar maltracking/compression, and patellofemoral cartilage damage. Reported complication rates following TTO range from 1% to 46%, with varied definitions of complication. The purpose of our study was to define the incidence of complications following TTO in a large cohort at a tertiary-care institution. Methods: Patients who underwent TTO between 2011 and 2023 were retrospectively identified. Patients who did not have at least 30 days of follow-up were excluded. Revision cases were excluded. Information about complications was obtained through review of the electronic medical record. Major complications included intraoperative fracture, postoperative fracture, loss of fixation, delayed union, non-union, pulmonary embolism (PE), patella tendon rupture, deep infection, painful hardware requiring removal, arthrofibrosis requiring reoperation, re-dislocation, reoperation for other indications, readmission, and revision. Minor complications included superficial infection, deep venous thrombosis (DVT), wound dehiscence, and postoperative neurapraxia. Chi-square tests were used for categorical variables, t tests for continuous variables. Results: Four hundred and seventy-six TTOs in 436 patients were included in the final cohort with a mean follow-up of 1.9 years. Patients were 68.5% female with average age 28.3 years.The overall complication rate was 27.5 percent. Major complications were recorded in 23.7% of patients, and minor complications in 8.4% of patients. Reoperation was required in 16.6% of patients at an average of 14 months after index procedure. The most common complications were painful hardware requiring removal (6.5%), superficial infection (5.7%), and arthrofibrosis requiring return to the operating room (5.0%). These and other complications are reported in Table 1 at 30 days, 90 days, 1 year, and final follow-up. Table 2 compares patient characteristics for those who had a major complication versus those who did not. Patients who had a major complication were older than those who did not (30.2 vs 27.7, p = .013). A higher proportion of patients who had a major complication had a previous ipsilateral surgery (57.5% vs. 36.6%, p < .001), had an indication of cartilage lesion/arthritis (71.7% vs. 60.6%, p = .034), and underwent a concomitant cartilage reconstruction/repair procedure (51.8% vs. 39.1%, p = .012). A lower proportion of patients who had a major complication had an indication of instability (56.6% vs. 67.2%, p = .043) and underwent a soft tissue reconstruction (46.4% vs. 60.1%, p = .012). There were no differences in the proportion of major complications by sex or American Society of Anesthesiologists score. Mean body mass index (BMI) did not differ significantly between patients who had a major complication and those who did not. Hardware removal was required in 6.5% of patients. More patients with headed as compared to headless screws required hardware removal (13.2% vs. 1.7%, p < .001). Arthrofibrosis requiring reoperation was observed in 5.7% of patients. A significantly higher proportion of patients who underwent a concomitant cartilage restoration/repair procedure had arthrofibrosis postoperatively (10.0% vs. 2.5%, p < 001). There was no difference in arthrofibrosis requiring reoperation by race, sex, age, BMI, smoking status, prior ipsilateral surgery, or other concomitant procedures. Conclusions: The complication rate following TTO was 27.5%, with painful hardware requiring removal (6.5%) as the most common complication, and a reoperation rate of 16.6% at a mean follow-up of 1.9 years. Major complications were observed in 23.7% of patients and were more common in older patients, patients with an indication of cartilage lesion/arthritis, patients who underwent a cartilage restoration/repair procedure, and patients with a previous ipsilateral surgery. Hardware removal was more common in patients with headed screws. Arthrofibrosis was more common in patients who underwent a concomitant cartilage restoration/repair procedure.

Background: Sleep issues are commonly reported in athletes after a sport-related concussion (SRC). Further studies are needed to evaluate screening methods for sleep disturbances and the risk of persisting symptoms after an SRC. Purpose: To evaluate the association between the Sport Concussion Assessment Tool 5 (SCAT5) symptoms of trouble falling asleep, fatigue (or low energy), and drowsiness and the risk of persisting symptoms (≥28 days to recovery) in adolescent athletes. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 519 athletes aged 13 to 18 years reported any sleep-related symptoms with an SRC, scored as none (0), mild (1-2), moderate (3-4), or severe (5-6), at their initial office visit (median, 5.4 days after an SRC). Scores were correlated with the risk of persisting symptoms. A composite “sleep cluster” score (range, 0-18) was calculated by summing the SCAT5 component items for trouble falling asleep, fatigue, and drowsiness. Results: The results indicated that, compared with athletes who reported that they did not have each symptom, (1) athletes who reported mild, moderate, or severe trouble falling asleep were 3.0, 4.6, and 6.7 times more likely to have persisting symptoms, respectively; (2) athletes reporting mild, moderate, or severe fatigue (or low energy) were 2.6, 4.8, and 7.6 times more likely to have persisting symptoms, respectively; and (3) athletes reporting mild, moderate, or severe drowsiness were 1.9, 4.6, and 6.8 times more likely to have persisting symptoms, respectively (P < .001 for all). For every 1-point increase in the sleep cluster score, there was a 1.2-fold increased risk of persisting symptoms and an additional 2.4 days of recovery required (P < .001 for both). Conclusion: Athletes who reported mild, moderate, or severe sleep-related symptoms on the SCAT5 were at a proportionally increased risk of persisting symptoms at the initial office visit.

Foreign body ingestions are a common problem in the emergency department. Patients often undergo invasive interventions that require significant resources. Current recommendations based on limited studies, are to attempt endoscopic removal of objects that are sharp or greater than 2.5 cm at or above the proximal duodenum. We hypothesized that many small and sharp objects will pass spontaneously without complication. We performed a retrospective study of all foreign bodies ingested by adults that were not removed initially by endoscopy over five years. We recorded foreign body size, shape and location, radiographic results, interventions performed, and demographic data. Regression analysis was used to determine any significant associations with the outcome of late intervention. 117 patients with 171 encounters met inclusion criteria with an average age of 33 years. 74 % of patients had a known psychiatric history. The most common foreign body was a razorblade. Fifteen patients had late intervention with twelve endoscopies and three exploratory laparotomies. 87 % of these late interventions were for failure to progress determined by the treatment team. There were no small bowel obstructions. One patient had a recto-sigmoid perforation from a pencil. Analysis indicates that size and sharpness were not significant risk factors for later intervention. Our study indicates that small objects, even sharp foreign bodies including razorblades, can pass spontaneously without intervention. If larger, future studies show the same conclusion, there should be a reconsideration of current guidelines. •Recommendations for ingested foreign body removal are based on limited studies.•The most common reason for ingested foreign body removal when distal to the esophagus is failure to progress.•Complications such as perforation or small bowel obstruction are exceedingly rare

Fever following immunizations is a common presenting chiefcomplaint among infants. The 2021 American Academy of Pediatrics (AAP) febrile infant clinical practice guidelines exclude recently immunized (RI) infants. This is a challenge for clinicians in the management of the febrile RI young infant. The objective of this study was to assess the prevalence of SBI in RI febrile young infants between 6 and 12 weeks of age. This was a retrospective chart review of infants 6–12 weeks who presented with a fever ≥38 °C to two U.S. military academic Emergency Departments over a four-year period. Infants were considered recently immunized (RI) if they had received immunizations in the preceding 72 h prior to evaluation and not recently immunized (NRI) if they had not received immunizations during this time period. The primary outcome was prevalence of serious bacterial infection (SBI) further delineated into invasive-bacterial infection (IBI) and non-invasive bacterial infection (non-IBI) based on culture and/or radiograph reports. Of the 508 febrile infants identified, 114 had received recent immunizations in the preceding 72 h. The overall prevalence of SBI was 11.4% (95% CI = 8.9–14.6) in our study population. The prevalence of SBI in NRI infants was 13.7% (95% CI = 10.6–17.6) compared to 3.5% (95% CI = 1.1–9.3) in RI infants. The relative risk of SBI in the setting of recent immunizations was 0.3 (95% CI = 0.1–0.7). There were no cases of invasive-bacterial infections (IBI) in the RI group with all but one of the SBI being urinary tract infections (UTI). The single non-UTI was a case of pneumonia in an infant who presented with respiratory symptoms within 24 h of immunizations. The risk of IBI (meningitis or bacteremia) in RI infants aged 6 to 12 weeks is low. Non-IBI within the first 24 h following immunization was significantly lower than in febrile NRI infants. UTIs remain a risk in the RI population and investigation with urinalysis and urine culture should be encouraged. Shared decision making with families guide a less invasive approach to the care of these children. Future research utilizing a large prospective multi-center data registry would aid in further defining the risk of both IBI and non-IBI among RI infants. •Post-immunization fever in young infants is common.•Recently immunized infants are not included in fever guidelines.•Risk of IBI is extremely low in recently immunized young infants.•Obtain a urine sample and urine culture in febrile recently immunized young infants.•Consider a less invasive approach with shared decision-making in well-appearing recently immunized young infants.

The diagnosis of cardiac amyloidosis (CA) often necessitates invasive myocardial biopsy. We sought to evaluate whether late gadolinium enhancement (LGE) of the atrial myocardium by cardiac magnetic resonance imaging was associated with impaired left atrial (LA) function and whether the extent of LA LGE may enhance diagnostic differentiation of CA from other cardiomyopathies. Twenty-two patients with biopsy-proven CA, 37 with systemic hypertension (SH), and 22 with nonischemic dilated cardiomyopathy (NIDC) underwent cardiac magnetic resonance imaging and echocardiographic evaluation. Patients with CA had greater minimal LA volume (57 ± 53 vs 24 ± 18 in SH and 19 ± 25% in NIDC, p = 0.003), and significantly lower total LA emptying function (19 ± 14 vs 40 ± 14 in SH and 33 ± 20% in NIDC, p = 0.0006). The mean proportion of atrial enhancement (LGELA%) was significantly greater in patients with CA than with SH and NIDC (59 ± 36% vs 7.4 ± 2.1 and 2.9 ± 9.0%, p <0.0001, respectively). There was also a strong inverse correlation between both active and total atrial emptying (r = −0.69, p = 0.001; r = −0.67, p = 0.01, respectively) with LGELA% for patients with CA. In multivariate regression analysis, LGELA% was the strongest adjusted predictor for CA diagnosis. Using receiver operating characteristic analysis, LGELA% ≥33% produced the greatest diagnostic utility for CA (sensitivity 76%, specificity 94%). Patients with CA may have extensive LGE of the LA myocardium, which is associated with marked reduction in LA emptying function. The extent of LA LGE was highly predictive for the diagnosis of CA.

Guidelines endorse intravenous (IV) and intraosseous (IO) medication administration for cardiac arrest treatment. Limited clinical evidence supports this recommendation. A multiagency, retrospective study was performed to determine the association between parenteral access type and return of spontaneous circulation (ROSC) in out of hospital cardiac arrest. This was a structured, retrospective chart review of emergency medical services (EMS) records from three agencies. Data was analyzed from adults who suffered OHCA and received epinephrine through EMS established IV or IO access during the 18-month study period. Per regional EMS protocols, choice of parenteral access type was at the provider's discretion. Non-inferiority analysis was performed comparing the association between first access type attempted and ROSC at time of emergency department arrival. 1310 subjects met inclusion criteria and were included in the analysis. Providers first attempted parenteral access via IV route in 788 (60.15%) subjects. Providers first attempted parenteral access via IO route in 552 (39.85%) subjects. Rates of ROSC at time of ED arrival were 19.67% when IV access was attempted first and 19.92% when IO access was attempted first. An IO first approach was non-inferior to an IV first approach based on the primary end point ROSC at time of emergency department arrival (p=0.01). An IO first approach was non-inferior to an IV first approach based on the end point ROSC at time of emergency department arrival.

To characterize performance among ED sites participating in the Emergency Quality Network (E-QUAL) Avoidable Imaging Initiative for clinical targets on the American College of Emergency Physicians Choosing Wisely list. This was an observational study of quality improvement (QI) data collected from hospital-based ED sites in 2017–2018. Participating EDs reported imaging utilization rates (UR) and common QI practices for three Choosing Wisely targets: Atraumatic Low Back Pain, Syncope, or Minor Head Injury. 305 ED sites participated in the initiative. Among all ED sites, the mean imaging UR for Atraumatic Low Back Pain was 34.7% (IQR 26.3%–42.6%) for XR, 19.1% (IQR 11.4%–24.9%) for CT, and 0.09% (IQR 0%–0.9%) for MRI. The mean CT UR for Syncope was 50.0% (IQR 38.0%–61.4%). The mean CT UR for Minor Head Injury was 72.6% (IQR 65.6%–81.7%). ED sites with sustained participation showed significant decreases in CT UR in 2017 compared to 2018 for Syncope (56.4% vs 48.0%; 95% CI: −12.7%, −4.1%) and Minor Head Injury (76.3% vs 72.1%; 95% CI: −7.3%, −1.1%). There was no significant change in imaging UR for Atraumatic Back Pain for XR (36.0% vs 33.3%; 95% CI: −5.9%, −0;5%), CT (20.1% vs 17.7%; 95% CI: −5.1%, −0.4%) or MRI (0.8% vs 0.7%, 95% CI: −0.4%, −0.3%). Early data from the E-QUAL Avoidable Imaging Initiative suggests QI interventions could potentially improve imaging stewardship and reduce low-value care. Further efforts to translate the Choosing Wisely recommendations into practice should promote data-driven benchmarking and learning collaboratives to achieve sustained practice improvement. •Survey data from a large national sample of volunteer hospital-based EDs shows wide variation in imaging utilization•ED sites with sustained participation in a national QI initiative showed significant reductions in imaging utilization•Imaging utilization rates from top-performing ED sites can serve as performance improvement targets for future QI efforts•Efforts to translate the Choosing Wisely campaign into practice should utilize benchmarking to sustain practice improvements