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Abstract Objectives To advance knowledge in using the ex vivo method to identify factor sensitivity of the activated partial thromboplastin time (APTT), using data from a hemophilia and reference hemostasis laboratory; to evaluate application of inclusion and exclusion criteria to eliminate data outliers; and to discuss outcomes with reference to comparable studies. Methods An ex vivo, retrospective analysis was performed on patient samples with conjointly ordered APTT and intrinsic pathway factors (VIII, IX, XI, XII) for application to a large network of laboratories. The relationship between factor levels and APTT, before and after application of exclusion criteria, is demonstrated. Results Curvilinear relationships were found between all factor levels and APTTs, which demonstrated both similarities and differences with available studies. Factor sensitivity data are presented. Study strengths include large sample size and use of real-world data. Limitations include inability to exclude all residual outliers and paucity of patient samples singularly deficient in factors other than FVIII. Conclusions This ex vivo, retrospective analysis of the sensitivity of the APTT assay to intrinsic pathway factor deficiencies using real-world data from a hemophilia and reference hemostasis laboratory contains the largest sample size using this approach to date. The outcomes assist in informing practice in this area and can be used as a reference for further studies.

Concussions are becoming a growing concern in society today with one out of every five adolescents being affected. This accounts for 1.6 to 3.8 million emergency department visits annually. The current standard of care involves an initial period of mental rest with symptomatic care and symptom-based return to daily activities/sports. High dose IV magnesium has been proven to be neuroprotective in severe TBI. We hypothesized that oral magnesium replacement following a concussion will decrease the overall symptomatic period allowing a quicker return to functional baseline. We used a randomized cohort study involving patients aged 12–18 who presented within 48 h after a concussion. Our study design had a treatment arm including acetaminophen, ondansetron, and magnesium PO and a placebo arm of acetaminophen and ondansetron. We then utilized the Post- Concussion Severity Score (PCSS) to evaluate the extent of the patient's symptoms. This score was collected immediately prior to obtaining medications, 1 h, 48 h, and 120 h after starting the study. The study relied on outpatient follow up through phone conversations, and a Sports Medicine clinic locally. Our data shows that there was a statistically significant decrease in the PCSS at 48 h (p = 0.016) in the magnesium group relative to the placebo treatment arm. This study does imply that magnesium supplementation has potential benefit in treatment of concussions acutely. Oral magnesium replacement decreases symptoms acutely following a concussion and should be provided with symptomatic management following a concussion in the emergency setting.

Objective To investigate the accuracy of preoperative and intraoperative diagnosis via comparison to pathologic diagnosis in spontaneous intestinal perforation (SIP) vs. necrotizing enterocolitis (NEC). Study design A retrospective review of neonates <1500 g treated for pneumoperitoneum between 07/2004-09/2022 was conducted. Patients treated for NEC medically prior to diagnosis and those treated with drain only were excluded. Fleiss’ Kappa analysis assessed agreement between all three diagnoses: preoperative, intraoperative, and pathologic. Result Overall, 125 patients were included with mean birthweight 834.2 g (SD:259.2) and mean gestational age 25.8 weeks (SD:2.2). Preoperative and intraoperative diagnoses agreed in 90.3%, intraoperative and pathologic agreed in 71.1%, and preoperative and pathologic agreed in 75.2% of patients. Fleiss’ Kappa was 0.55 (95% CI:0.43,0.68), indicating moderate agreement between the three diagnoses. Conclusion Our study shows moderate agreement between preoperative, intraoperative, and pathologic diagnoses. Further studies investigating the clinical characteristics of SIP and NEC are needed to improve diagnostic accuracy and management.

Endotracheal intubation is commonly performed in the Emergency Department. Traditional measures for estimating and confirming the endotracheal tube (ETT) depth may be inaccurate or lead to delayed recognition. Ultrasound may offer a rapid tool to confirm ETT depth at the bedside. This was a randomized trial assessing the diagnostic accuracy of ultrasound to confirm ETT depth. Three cadavers were intubated in a random sequence with the ETT placed high (directly below the vocal cords), middle (2 cm above the carina), or deep (ETT at the carina). Seven blinded sonographers assessed the depth of the ETT using ultrasound. Outcomes included diagnostic accuracy of sonographer identification, time to identification, and operator confidence based upon ETT location. A subgroup analysis was performed to assess diagnostic accuracy by operator confidence. 441 total assessments were performed (154 high, 154 middle, and 133 deep ETT placements). Overall accuracy was 84.8% (95% CI 81.1% to 88.0%). When placed high, ultrasound was 82.5% sensitive (95% CI 75.5% to 88.1%) and 92.3% specific (95% CI 88.6% to 95.1%) with a mean time to identification of 15.3 s (95% CI 13.6–17.0) and a mean operator confidence of 3.9/5.0 (95% CI 3.7–4.1). When the ETT was placed in the middle, ultrasound was 83.8% sensitive (95% CI 77.0% to 89.2%) and 92.3% specific (95% CI 88.6% to 95.1%) with a mean time to identification of 16.7 s (95% CI 14.6–18.8) and a mean operator confidence of 3.7/5.0 (95% CI 3.5–3.9). When the ETT was placed deep, ultrasound was 88.0% sensitive (95% CI 81.2% to 93.0%) and 92.2% specific (95% CI 88.6% to 94.6%) with a mean time to identification of 19.0 s (95% CI 17.3–20.7) and a mean operator confidence of 3.4/5.0 (95% CI 3.2–3.6). Sonographers were significantly more accurate when they reported a higher confidence score. Ultrasound was moderately accurate for identifying the ETT location in a cadaveric model and was more accurate when sonographers felt confident with their visualization. Future research should determine the accuracy of combining transtracheal ultrasound with lung sliding and other modifications to improve the accuracy.

Francofonia is Alexander Sokurov's portrait of the real-life collaboration that saved the Louvre Museum under the Nazi Occupation, a stunning and urgently relevant meditation on the essential relationship between art, culture, and history.

Category: Other Introduction/Purpose: Foot and ankle (FA) pain can be found in up to 20% of the adult population.1 Etiologies are multifactorial and include neurologic injury, trauma, deformity, tendinopathies and psychological factors. The purpose of this investigation is to assess psychological factors contributing to FA pain in surgical and nonsurgical patients. By identifying how psychological factors influence patient reported pain and disability, clinicians may be able to develop interventions to decrease catastrophic thinking and improve psychological well-being prior to considering surgical intervention Methods: All patients seen in a FA clinic by a single fellowship trained orthopaedic surgeon from August 2016 to October 2016 were included. All patients completed 5 functional assessments prior to their visit (PHQ-2, VAS Pain Scale, FAAM, PSEQ, PCS). We divided the patients into two groups based on their performance on the PHQ (PHQ < 3, or PHQ = 3), which measures depression. Scores = 3 are indicative of clinical depression. Nonparametric Wilcoxon testing was used to determine whether the distributions of the other scores (VAS Pain Scale, FAAM, PSEQ and PCS) were significantly different between these two groups. Results: Of the 225 patients included in our analysis, there were 175 (88%) had PHQ-2 depression scores of < 3 (Group 1) and 50 (22%) had scores = 3 (Group 2). Group 2 demonstrated a statistically significant increase in VAS Pain Scale and PCS. In addition, patients in Group 2 showed statistically significant decreases in FAAM and PSEQ. Patients in Group 2 were statistically more likely to be obese, use tobacco, and be unemployed. Conclusion: In patients with common FA complaints, those with clinical depression, as assessed by the PHQ-2, demonstrated increased pain scores, decreased ability to cope with pain, and lower functional outcome scores compared to patients without depression. Tobacco use, obesity and employment status were found to independently affect pain, coping, and function of patients. These data suggest that depression can significantly affect a patient’s ability to cope with pain and to achieve a higher functional outcome. This data suggests patients with depression may have increased difficulty coping with their FA ailment leading to the need for increased counseling regarding expected outcomes.

Purpose To identify prior studies of arthroscopic glenoid component removal after total shoulder arthroplasty (TSA) and understand indications, techniques and patient outcomes. Methods A search of the English language literature on arthroscopic removal of the glenoid component (ARGC) after TSA published between 2005 and 2021 was performed from MEDLINE and EMBASE databases. Articles with ARGC after TSA were identified and we recorded article characteristics as well as patient demographics and outcomes contained within the studies. Results A total of six publications (two case reports and four retrospective case series) detailing the outcome of ARGC performed on twenty-five shoulders were identified. The average time from index procedure to glenoid removal was 117 months and mean age at time of ARGC was 75 years. Although patient reported outcomes measures (PROMs) varied in type and reporting style, all articles reported improvements in PROMs. Twenty patients in this systematic review were evaluated for post-operative complications and the complication rate was found to be 15% (n = 3). There were 2 cases (18%) of superior migration of the humeral head relative to the glenoid and no reported cases of anterior or posterior humeral head subluxation. Two of 25 patients (8%) underwent subsequent open revision procedures. Conclusions The limited number of publications in this systematic review demonstrates that ARGC after TSA can result in improvements in both pain and PROMs. This less-invasive arthroscopic technique may be an alternative to open revision for lower demand patients; however, future prospective, comparative studies are necessary to better define indications.

Background: At present, the geographic distribution of orthopedic foot and ankle (OFA) surgeons in the United States is poorly defined. The purpose of this investigation is to determine the geographic distribution of OFA surgeons in the United States. We hypothesize that there will be differences in OFA surgeon density throughout the United States and that economic factors may play a role in access to subspecialty OFA care. Methods: A current membership list was obtained from the American Orthopaedic Foot & Ankle Society (AOFAS). Active members were categorized relative to states and US congressional districts, using publicly available census data. The relationship between income and surgeon density was determined using a Pearson correlation. Results: We identified a list of 1103 active AOFAS members. There was an average of 0.38 and 0.40 OFA surgeons per 100 000 people in each state and congressional district, respectively. We found a weak negative relationship demonstrating that regions with higher levels of poverty had fewer OFA surgeons, with a Pearson correlation coefficient of –0.14 (95% CI: –0.24, –0.04), P = .008. Conclusion: There is wide geographic variation of OFA surgeon density throughout the United States. Regions with higher levels of poverty were weakly associated with decreased population density of OFA surgeons compared to regions with lower poverty levels. Understanding these trends may aid in developing both recruitment and referral strategies for complex foot and ankle care in underserved regions. Level of Evidence: Level V.

Este trabalho teve como objectivo a implementação de um servidor de mundos virtuais (OpenSimulator), com funcionalidade de voz no contexto da rede interna de uma empresa (podendo eventualmente permitir acesso a partir do exterior se pretendido). Assim, foi necessário ter em conta vários aspectos que rodeiam a presença de uma empresa num mundo virtual, tal como, possibilitar o uso de voz entre utilizadores OpenSimulator ou automaticamente reencaminhar chamadas para outros locais que não OpenSimulator, recorrendo a tecnologias por software como o GTalk ou softphones, caso a chamada por voz não fosse atendida dentro do mundo virtual. É ainda possível aos utilizadores usarem as suas contas OpenSimulator em softphones, ou seja, efectuarem chamadas para utilizadores que se encontrem no mundo virtual.Também se teve em conta aspectos relevantes em meio empresarial tais como a realização de cópias de segurança diárias, para permitir a recuperação de todos os dados do servidor em caso de falhas de software ou hardware; ou a necessidade de agilização de procedimentos quotidianos, tendo para o efeito sido desenvolvidas ferramentas que permitem a criação e manutenção de contas de utilizadores, bem como a gestão do servidor OpenSimulator através de um website.