bluuebunny/crossref_metadata_2025 huggingface dataset:
Recognising small image quality differences for ultrasound probes and the potential of misdiagnosis due to undetected side lobes
Authors: Doblhoff Georg , Satrapa Jaroslav , Coulthard Philip
Published: January 2017

Background

Ultrasonic imaging is an integral and routine procedure in many medical applications. An increased awareness of the need for quality assurance in this field has led to numerous tests being proposed. Due to the complexity of the problem, the tests directly measuring the important parameters of resolution and contrast of low-echoic structures are not unified, often more qualitative than quantitative, and are performed at large periodic intervals. Uniform sensitivity of an array transducer is a necessary but insufficient requirement for imaging quality of an ultrasound probe. Good probe uniformity should in no way be confused with meaning the ultrasound probe is working as it should.

Methods

In this paper, side lobes in the elevation direction and side and grating lobes in the lateral direction are discussed. Both may provide uniform element response across the scanner, yet result in a loss of resolution and contrast. To resolve problems of these resolution and contrast-relevant parameters being overlooked, a crossed filament phantom is introduced.

Results

The cross-filament phantom provides the determination of resolution- and contrast-relevant parameters of a scanner, by directly measuring the main, side and grating-lobes of the beam in 3D. The main lobe 3D-data allows the determination of lateral and elevational resolution at different depths and thus the focal settings. In combination with the side and grating lobe information, the contrast for a small non-echoic object (i.e. a cyst) in an echoic environment may be explained.

Conclusion

We argue that regarding system acceptance, system baseline quality assurance and routine quality assurance, the analysis of the beam shape should be part of the comprehensive assessment. Combining the results with void resolution and contrast measurements is recommended.
The feasibility of implementation of ultrasound equipment standards set by United Kingdom professional bodies
Authors: Dudley Nicholas J , Harries Debbie , Wardle Jessica
Published: January 2017

Introduction

The Royal College of Radiologists and the Society and College of Radiographers in the United Kingdom published ‘Standards for the provision of an ultrasound service’, including application-specific limiting values for resolution and penetration. No measurement methods were detailed. We aimed to explore a possible theoretical basis for the standards and to develop a measurement protocol.

Methods

Since application-specific standards fail to account for probes of different frequencies used for similar applications and no evidence for the standards was provided, we developed generic standards based on theoretical considerations. In a trial implementation of the published standards, automated measurements were made on four recently purchased scanners with a total of eight probes, results being assessed against the standards. Measurements were made on 15 modern probes and used to develop our generic standards.

Results

Automated measurements showed less inter- and intra-observer variability than manual/visual measurements. Four new ultrasound scanners with a total of eight probes all failed to meet the published axial and lateral resolution standards; three failed to meet the penetration standard. Our generic standards were tested on 15 probes, four probes failing to meet the revised standards.

Conclusions

Automated methods are essential for measurements against standards. New generic standards with a theoretical basis have been proposed. Further work is required to refine standards and methods and to determine the appropriate contributions of objective and subjective equipment selection methods.
When Fair Is Not Equal
Authors: Zhao Kun , Ferguson Eamonn , Smillie Luke D.
Published: January 2017

Growing evidence has highlighted the importance of social norms in promoting prosocial behaviors in economic games. Specifically, individual differences in norm adherence—captured by the politeness aspect of Big Five agreeableness—have been found to predict fair allocations of wealth to one’s partner in the dictator game. Yet, most studies have used neutrally framed paradigms, where players may default to norms of equality in the absence of contextual cues. In this study ( N = 707), we examined prosocial personality traits and dictator allocations under salient real-world norms of equity and need. Extending on the previous research, we found that—in addition to politeness—the compassion aspect of agreeableness predicted greater allocations of wealth when they were embedded in real-world norms. These results represent an important step in understanding the real-world implications of laboratory-based research, demonstrating the importance of both normative context and prosocial traits.
Resource Availability and Explicit Memory Largely Determine Evaluative Conditioning Effects in a Paradigm Claimed to be Conducive to Implicit Attitude Acquisition
Authors: Mierop Adrien , Hütter Mandy , Corneille Olivier
Published: January 2017

In three experiments, we investigated how preventing the explicit encoding of conditioned stimulus–unconditioned stimulus (CS–US) pairings by imposing a secondary task at learning influences evaluative conditioning (EC) effects in a paradigm claimed to be conducive to implicit EC. We additionally used a multinomial processing tree model to examine how the resource depletion manipulation affects explicit and implicit memory contributions to EC. In all experiments, the EC effect largely vanished when a secondary task was employed that severely reduced participants’ explicit memory for the CS–US pairings. Furthermore, no evidence obtained for an implicit memory contribution to EC effects. In conclusion, the present research yields evidence for explicit learning, but no support for the contribution of implicit processes to EC in a paradigm claimed to facilitate implicit EC.
Decellularized bone matrix grafts for calvaria regeneration
Authors: Lee Dong Joon , Diachina Shannon , Lee Yan Ting , Zhao Lixing , Zou Rui , Tang Na , Han Han , Chen Xin , Ko Ching-Chang
Published: January 2017

Decellularization is a promising new method to prepare natural matrices for tissue regeneration. Successful decellularization has been reported using various tissues including skin, tendon, and cartilage, though studies using hard tissue such as bone are lacking. In this study, we aimed to define the optimal experimental parameters to decellularize natural bone matrix using 0.5% sodium dodecyl sulfate and 0.1% NH4OH. Then, the effects of decellularized bone matrix on rat mesenchymal stem cell proliferation, osteogenic gene expression, and osteogenic differentiations in a two-dimensional culture system were investigated. Decellularized bone was also evaluated with regard to cytotoxicity, biochemical, and mechanical characteristics in vitro. Evidence of complete decellularization was shown through hematoxylin and eosin staining and DNA measurements. Decellularized bone matrix displayed a cytocompatible property, conserved structure, mechanical strength, and mineral content comparable to natural bone. To study new bone formation, implantation of decellularized bone matrix particles seeded with rat mesenchymal stem cells was conducted using an orthotopic in vivo model. After 3 months post-implantation into a critical-sized defect in rat calvaria, new bone was formed around decellularized bone matrix particles and also merged with new bone between decellularized bone matrix particles. New bone formation was analyzed with micro computed tomography, mineral apposition rate, and histomorphometry. Decellularized bone matrix stimulated mesenchymal stem cell proliferation and osteogenic differentiation in vitro and in vivo, achieving effective bone regeneration and thereby serving as a promising biological bone graft.
Optimal conjugation of catechol group onto hyaluronic acid in coronary stent substrate coating for the prevention of restenosis
Authors: Lih Eugene , Choi Seul Gi , Ahn Dong June , Joung Yoon Ki , Han Dong Keun
Published: January 2017

Although endovascular stenting has been used as an interventional therapy to treat cardio- and cerebro-vascular diseases, it is associated with recurrent vascular diseases following stent thrombosis and in-stent restenosis. In this study, a metallic stent was coated with dopamine-conjugated hyaluronic acid with different ratios of catechol group to improve hemocompatibility and re-endothelialization. Especially, we were interested in how much amount of catechol group is appropriate for the above-mentioned purposes. Therefore, a series of dopamine-conjugated hyaluronic acid conjugates with different ratios of catechol group were synthesized via a carbodiimide coupling reaction. Dopamine-conjugated hyaluronic acid conjugates were characterized with 1H-nuclear magnetic resonance and Fourier transform infrared spectroscopy, and the amount of catechol group in dopamine-conjugated hyaluronic acid was measured by ultraviolet spectrometer. Co-Cr substrates were polished and coated with various dopamine-conjugated hyaluronic acid conjugates under pH 8.5. Dopamine-conjugated hyaluronic acid amounts on the substrate were quantified by micro-bicinchoninic acid assay. Surface characteristics of dopamine-conjugated hyaluronic-acid-coated Co-Cr were evaluated by water contact angle, scanning electron microscopy, and atomic force microscopy. The hemocompatibility of the surface-modified substrates was assessed by protein adsorption and platelet adhesion tests. Adhesion and activation of platelets were confirmed with scanning electron microscopy and lactate dehydrogenase assay. Human umbilical vein endothelial cells were cultured on the substrates, and the viability, adhesion, and proliferation were investigated through cell counting kit-8 assay and fluorescent images. Obtained results demonstrated that optimal amounts of catechol group (100 µmol) in the dopamine-conjugated hyaluronic acid existed in terms of various properties such as hemocompatibility and cellular responses.
Tubular organ epithelialisation
Authors: Saksena Rhea , Gao Chuanyu , Wicox Mathew , de Mel Achala
Published: January 2017

Hollow, tubular organs including oesophagus, trachea, stomach, intestine, bladder and urethra may require repair or replacement due to disease. Current treatment is considered an unmet clinical need, and tissue engineering strategies aim to overcome these by fabricating synthetic constructs as tissue replacements. Smart, functionalised synthetic materials can act as a scaffold base of an organ and multiple cell types, including stem cells can be used to repopulate these scaffolds to replace or repair the damaged or diseased organs. Epithelial cells have not yet completely shown to have efficacious cell–scaffold interactions or good functionality in artificial organs, thus limiting the success of tissue-engineered grafts. Epithelial cells play an essential part of respective organs to maintain their function. Without successful epithelialisation, hollow organs are liable to stenosis, collapse, extensive fibrosis and infection that limit patency. It is clear that the source of cells and physicochemical properties of scaffolds determine the successful epithelialisation. This article presents a review of tissue engineering studies on oesophagus, trachea, stomach, small intestine, bladder and urethral constructs conducted to actualise epithelialised grafts.
A clinically relevant in vivo model for the assessment of scaffold efficacy in abdominal wall reconstruction
Authors: Chan Jeffrey CY , Burugapalli Krishna , Huang Yi-Shiang , Kelly John L , Pandit Abhay
Published: January 2017

An animal model that allows for assessment of the degree of stretching or contraction of the implant area and the in vivo degradation properties of biological meshes is required to evaluate their performance in vivo. Adult New Zealand rabbits underwent full thickness subtotal unilateral rectus abdominis muscle excision and were reconstructed with the non-biodegradable Peri-Guard®, Prolene® or biodegradable Surgisis® meshes. Following 8 weeks of recovery, the anterior abdominal wall tissue samples were collected for measurement of the implant dimensions. The Peri-Guard and Prolene meshes showed a slight and obvious shrinkage, respectively, whereas the Surgisis mesh showed stretching, resulting in hernia formation. Surgisis meshes showed in vivo biodegradation and increased collagen formation. This surgical rabbit model for abdominal wall defects is advantageous for evaluating the in vivo behaviour of surgical meshes. Implant area stretching and shrinkage were detected corresponding to mesh properties, and histological analysis and stereological methods supported these findings.
Changing Paradigms in the Management of Rejection in Kidney Transplantation
Authors: Maier Mirela , Takano Tomoko , Sapir-Pichhadze Ruth
Published: January 2017

Purpose of review:

P4 medicine denotes an evolving field of medicine encompassing predictive, preventive, personalized, and participatory medicine. Using the example of kidney allograft rejection because of donor-recipient incompatibility in human leukocyte antigens, this review outlines P4 medicine’s relevance to the various stages of the kidney transplant cycle.

Sources of information:

A search for English articles was conducted in Medline via OvidSP (up to August 18, 2016) using a combination of subject headings (MeSH) and free text in titles, abstracts, and author keywords for the concepts kidney transplantation and P4 medicine. The electronic database search was expanded further on particular subject headings.

Findings:

Available histocompatibility methods exemplify current applications of the predictive and preventive domains of P4 medicine in kidney transplant recipients’ care. Pharmacogenomics are discussed as means to facilitate personalized immunosuppression regimens and promotion of active patient participation as a means to improve adherence.

Limitations:

For simplicity, this review focuses on rejection. P4 medicine, however, should more broadly address health concerns in kidney transplant recipients, including competing outcomes such as infections, malignancies, and cardiovascular disease. This review highlights how biomarkers to evaluate these competing outcomes warrant validation and standardization prior to their incorporation into clinical practice.

Implications:

Consideration of all 4 domains of the P4 medicine framework when caring for and/or studying kidney transplant recipients has the potential of increasing therapeutic efficiency, minimizing adverse effects, decreasing health care costs, and maximizing wellness. Technologies to gauge immune competency, immunosuppression requirements, and early/reversible immune-mediated injuries are required to optimize kidney transplant care.
Are metric parameters sufficient alone in evaluation of the patellar instability? New angular measuring parameters
Authors: Deveci Alper , Cankaya Deniz , Yilmaz Serdar , Celen Ersin , Sakman Bulent , Bozkurt Murat
Published: January 2017

Purposes:

When the evaluation of patellar instability is examined from the aspect of the conical-cylindrical anatomy of the tibia, metric measurement parameters such as the tuberositas tibia (TT)–trochlear groove (TG) and patellar tendon (PT) insertion–trochlear groove (TG) distances are not sufficient. We asked whether defined angular parameters reveal the rotational movement of the tuberositas tibia on the tibia shaft, additional to the metric parameters and there is a correlation between the metric and angular parameters.

Methods:

19 patients with patellar instability and 22 patients without patellar instability were evaluated. For all patients, two angle and three length parameters were evaluated on the slices taken. Evaluations were made of the TT-TG, the midpoint of the PT insertion-TG distances, the anatomic midpoint of the dome of the TT-TG, the TG-PT angle, and the TG-dome angle (DA). The Pearson correlation test was used for the statistical analysis of correlations between groups.

Results:

A statistically significant increase was determined in the patellar instability group in the TG-DA and TG-PT angle values compared to the group without patellar instability ( p < 0.05). In both groups, a positive and strong correlation was determined between the TT-TG and the TG-PT and dome of the TT-TG distances, but no statistically significant correlation was determined between the tuberositas TT-TG and TG-PT angle and TG-DA.

Conclusion:

Metric parameters may not be sufficient alone in the evaluation of patellar instability. Metric parameters should be supported by additional angular parameters which reveal the rotational movement of the TT on the tibia shaft.
Color Doppler ultrasound assessment for identifying perforator arteries of the second dorsal metacarpal flap
Authors: Nanno Mitsuhiko , Kodera Norie , Tomori Yuji , Hagiwara Yusuke , Takai Shinro
Published: January 2017

Purpose:

The second dorsal metacarpal (SDMC) perforator flap has been widely used for the soft tissue reconstruction of the hand. However, it is difficult to identify the depth and branches of the perforators of the second dorsal metacarpal artery (SDMA) using only handheld acoustic Doppler flowmetry (HADF), which is the most common method. The purpose of this study was to compare the results of examination by color Doppler ultrasonography (CDU) with those of HADF and to evaluate the efficacy of CDU for detection of the perforators to be used in the design of the SDMC flap.

Methods:

Twenty-two healthy volunteers (42 hands) were examined using both CDU and HADF. All locations identified as the perforators of the SDMA by the two examinations were mapped respectively.

Results:

The total perforator arteries detected with CDU in all hands were 111 branches, 49 branches of which could not be identified with HADF. The average number of perforators of the SDMA per hand found with CDU was 2.8 branches, while that for HADF was only 1.8 branches. The detection rates of the cutaneous perforators of the SDMA by CDU were 100% in the proximal one-third of the second metacarpal and 95% in the distal one-fourth of the second metacarpal.

Conclusion:

This study demonstrated the superiority of CDU compared with HADF for detection of the perforators of the SDMA. The CDU examination could easily identify the locations of the cutaneous perforators and help in the useful assessment of vascularity for the SDMC flap.
Potential of a Pharmacogenetic-Guided Algorithm to Predict Optimal Warfarin Dosing in a High-Risk Hispanic Patient
Authors: Hernandez-Suarez Dagmar F. , Claudio-Campos Karla , Mirabal-Arroyo Javier E. , Torres-Hernández Bianca A. , López-Candales Angel , Melin Kyle , Duconge Jorge
Published: January 2017

Deep abdominal vein thrombosis is extremely rare among thrombotic events secondary to the use of contraceptives. A case to illustrate the clinical utility of ethno-specific pharmacogenetic testing in warfarin management of a Hispanic patient is reported. A 37-year-old Hispanic Puerto Rican, non-gravid female with past medical history of abnormal uterine bleeding on hormonal contraceptive therapy was evaluated for abdominal pain. Physical exam was remarkable for unspecific diffuse abdominal tenderness, and general initial laboratory results—including coagulation parameters—were unremarkable. A contrast-enhanced computed tomography showed a massive thrombosis of the main portal, splenic, and superior mesenteric veins. On admission the patient was started on oral anticoagulation therapy with warfarin at 5 mg/day and low-molecular-weight heparin. The prediction of an effective warfarin dose of 7.5 mg/day, estimated by using a recently developed pharmacogenetic-guided algorithm for Caribbean Hispanics, coincided with the actual patient’s warfarin dose to reach the international normalized ratio target. We speculate that the slow rise in patient’s international normalized ratio observed on the initiation of warfarin therapy, the resulting high risk for thromboembolic events, and the required warfarin dose of 7.5 mg/day are attributable in some part to the presence of the NQO1*2 (g.559C>T, p.P187S) polymorphism, which seems to be significantly associated with resistance to warfarin in Hispanics. By adding genotyping results of this novel variant, the predictive model can inform clinicians better about the optimal warfarin dose in Caribbean Hispanics. The results highlight the potential for pharmacogenetic testing of warfarin to improve patient care.
Multifocal Gastric Ulcers Caused by Diffuse Large B Cell Lymphoma in a Patient With Significant Weight Loss
Authors: Gromski Mark A. , Peng Jennifer L. , Zhou Jiehao , Masuoka Howard C. , Suvannasankha Attaya , Liangpunsakul Suthat
Published: January 2017

Primary gastrointestinal (GI) lymphoma is a heterogeneous disease with varied clinical presentations. The stomach is the most common GI site and accounts for 70% to 75% of GI lymphomas. We present a patient with gastric diffuse large B cell lymphoma (DLBCL) who presented with significant weight loss, early satiety, and multifocal ulcerated gastric lesions. Esophagoduodenoscopy should be performed in patients presenting with warning symptoms as in our case. Diagnosis is usually made by endoscopic biopsies. Multiple treatment modalities including surgery, radiotherapy, and chemotherapy have been used. Advancements in endoscopic and pathologic technology decrease turnaround time for diagnosis and treatment initiation, thus reducing the need for surgery. Health care providers should maintain a high level of suspicion and consider gastric DLBCL as part of the differential diagnosis, especially in those with warning symptoms such as weight loss and early satiety with abnormal endoscopic findings.
Evolutionary History of Multiple Dural Fistula
Authors: Martinez-Burbano Braulio , Correa Diaz Edgar Patricio , Jácome Sánchez Carolina
Published: January 2017

Intracranial dural arteriovenous fistulas (DAVFs) are abnormal communications between arteries and veins or dural venous sinuses, which sit between the sheets of the dura. They represent 10% to 15% of intracranial vascular malformations. Clinical manifestations and prognosis depend on the pattern of venous drainage and location. The clinical presentation of DAVF may be mistaken for vascular or nonvascular brain pathologies. For that reason, within the differential diagnosis come a wide range of conditions, such as secondary headaches, encephalopathies, dementias including those with rapid progression, neurodegenerative diseases, inflammatory processes, or tumors typically at the orbital level or in the cavernous sinus. Diagnosis requires a high degree of suspicion because of the multiplicity of symptoms and presentations, making this pathology an entity that provides a major challenge for clinicians, yet early and multidisciplinary treatment of high-grade fistulas improve the possibility of avoiding poor or unfavorable outcomes for the patient.
Symptomatic Type IV Dual Left Anterior Descending Coronary Artery
Authors: Papadopoulos Kyriacos , Georgiou Georgios M. , Nicolaides Evagoras
Published: January 2017

Dual left anterior descending coronary artery is a rare congenital anomaly with 4 subtypes. Double left anterior descending coronary artery originating from the left main stem and the right coronary artery (type IV dual left anterior descending artery) has been reported to occur in 0.01% to 0.7% of patients undergoing cardiac catheterization. We report a case of a 49-year-old woman who was found to have this anomaly during coronary angiography. The patient had been complaining of chest pain that mimics angina pectoris and exercise tolerance test was positive for myocardial ischemia.
Multiple Brain Abscesses in an Immunocompetent Patient With Factor V Leiden Mutation
Authors: Zafar Saeed Zubair , Pervin Najwa , Manthri Sukesh , Bhattarai Mukul
Published: January 2017

Multiple brain abscesses in an immunocompetent patient is a challenging clinical problem in the medical world despite advances in imaging techniques, laboratory diagnostics, surgical interventions, and antimicrobial treatment. It is a clinical entity that typically tends to occur in the presence of known predisposing factors. Clinicians seek to determine the potential risk factors responsible for the development of brain abscess because it is very crucial for management of this life-threatening condition. At times, like in our case, there are clinical situations where it is difficult to reveal any traditional risk factors. We report a case of multiple brain abscesses in a 51-year-old female with a past medical history significant only for factor V Leiden mutation, and deep vein thrombosis on chronic anticoagulation. She underwent thorough evaluation but no predisposing factors were found. Based on our extensive literature review, this is the index case of multiple brain abscesses in a patient with history of factor V Leiden mutation and the absence of any conventional risk factors. We also postulate a possible mechanism of infection in such patients.
Ebstein Anomaly With QRS Fragmentation on Electrocardiogram
Authors: Acharya Prakash , Ang Jonathan Ross , Gitler Bernard
Published: January 2017

Ebstein anomaly is a rare congenital disorder that involves the tricuspid valve and the right ventricle. It is associated with interatrial communication, which allows for paradoxical embolization causing unilateral blindness. Abnormal conduction through the atrialized right ventricle leads to QRS fragmentation on electrocardiogram. Its presence suggests a more severe abnormality and a higher risk of arrhythmia. The QRS fragmentation disappears after corrective surgery with resection of the atrialized right ventricle.
Perception of Health Problems Among Competitive Runners
Authors: Jelvegård Sara , Timpka Toomas , Bargoria Victor , Gauffin Håkan , Jacobsson Jenny
Published: January 2017

Background:

Approximately 2 of every 3 competitive runners sustain at least 1 health problem each season. Most of these problems are nontraumatic injuries with gradual onset. The main known risk indicator for sustaining a new running-related injury episode is a history of a previous injury, suggesting that behavioral habits are part of the causal mechanisms.

Purpose:

Identification of elements associated with purposeful interpretations of body perceptions and balanced behavioral responses may supply vital information for prevention of health problems in runners. This study set out to explore competitive runners’ cognitive appraisals of perceived symptoms on injury and illness and how these appraisals are transformed into behavior.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

The study population consisted of Swedish middle- and long-distance runners from the national top 15 list. Qualitative research methods were used to categorize interview data and perform a thematic analysis. The categories resulting from the analysis were used to construct an explanatory model.

Results:

Saturation of the thematic classification required that data from 8 male and 6 female runners (age range, 20-36 years) were collected. Symptoms interpreted to be caused by illness or injury with a sudden onset were found to lead to immediate action and changes to training and competition programs (activity pacing). In contrast, perceptions interpreted to be due to injuries with gradual onset led to varied behavioral reactions. These behavioral responses were planned with regard to short-term consequences and were characterized by indifference and neglect of long-term implications, consistent with an overactivity behavioral pattern. The latter pattern was consistent with a psychological adaptation to stimuli that is presented progressively to the athlete.

Conclusion:

Competitive runners appraise whether a health problem requires immediate withdrawal from training based on whether the problem is interpreted as an illness and/or has a sudden onset. The ensuing behaviors follow 2 distinct patterns that can be termed “activity pacing” and “overactivity.”
Plantaris Excision Reduces Pain in Midportion Achilles Tendinopathy Even in the Absence of Plantaris Tendinosis
Authors: Calder James D. F. , Stephen Joanna M. , van Dijk C. Niek
Published: January 2017

Background:

It is becoming increasingly apparent that the plantaris can contribute to symptoms in at least a subset of patients with midportion Achilles tendinopathy. However, the nature of its involvement remains unclear.

Purpose:

To determine whether excised plantaris tendons from patients with midportion Achilles tendinopathy display tendinopathic changes and whether the presence of such changes affect clinical outcomes.

Study Design:

Case series; Level of evidence, 4.

Methods:

Sixteen plantaris tendons in patients with midportion Achilles tendinopathy recalcitrant to conservative management underwent histological examination for the presence of tendinopathic changes. All patients had imaging to confirm the presence of the plantaris tendon adherent to or invaginated into the focal area of Achilles tendinosis. Visual analog scale (VAS) and Foot and Ankle Outcome Score (FAOS) results were recorded pre- and postoperatively.

Results:

Sixteen patients (mean age, 26.2 years; range, 18-47 years) underwent surgery, with a mean follow-up of 14 months (range, 6-20 months). The plantaris tendon was histologically normal in 13 of 16 cases (81%). Inflammatory changes in the loose peritendinous connective tissue surrounding the plantaris tendon were evident in all cases. There was significant improvement in mean VAS scores ( P < .05) and all domains of the FAOS postoperatively ( P < .05).

Conclusion:

The absence of any tendinopathic changes in the excised plantaris of 13 patients who clinically improved suggests plantaris involvement with Achilles tendinopathy may not yet be fully understood and supports the concept that this may be a compressive or a frictional phenomenon rather than purely tendinopathic.
Axial-Plane Biomechanical Evaluation of 2 Suspensory Cortical Button Fixation Constructs for Acromioclavicular Joint Reconstruction
Authors: Struhl Steven , Wolfson Theodore S. , Kummer Frederick
Published: January 2017

Background:

Although numerous suture-button fixation techniques for acromioclavicular (AC) joint reconstruction have been validated with biomechanical testing in the superior direction, clinical reports continue to demonstrate high rates of construct slippage and breakage.

Purpose:

To compare the stability of a novel closed-loop double Endobutton construct with a commercially available cortical button system in both the axial and superior directions.

Study Design:

Controlled laboratory study.

Methods:

Six matched pairs of fresh-frozen cadaveric upper extremities were anatomically dissected and prepared to simulate a complete AC joint dislocation. One side of each pair was reconstructed with the double Endobutton (DE) construct and other side with the dog bone button (DB) construct. The specimens were then tested using a materials testing machine, determining initial superior and axial displacements with a preload, and then cyclically loaded in the axial direction with 70 N for 5000 cycles. Displacement was again measured with the same preloads at fixed cycle intervals. The specimens were then loaded superiorly to failure.

Results:

At 5000 cycles, the mean axial displacement was 1.7 mm for the DB group and 1.2 mm for the DE group ( P = .19), and the mean superior displacement was 1.1 mm for the DB group and 0.7 mm for the DE group ( P = .32). Load at failure was similar (558 N for DE, 552 N for DB; P = .96). There was no statistically significant difference in the modes of failure.

Conclusion:

Biomechanical testing of both constructs showed similar fixation stability after cyclical axial loading and similar loads to failure.

Clinical Relevance:

The strength of both constructs after cyclical loading in the axial plane and load-to-failure testing in the superior plane validate their continued clinical use for achieving stability in AC joint reconstruction procedures.
Responsiveness Comparison of the EQ-5D, PROMIS Global Health, and VR-12 Questionnaires in Knee Arthroscopy
Authors: Oak Sameer R. , Strnad Gregory J. , Bena James , Farrow Lutul D. , Parker Richard D. , Jones Morgan H. , Spindler Kurt P.
Published: January 2017

Background:

The EuroQol 5 dimensions questionnaire (EQ-5D), Patient-Reported Outcomes Measurement Information System (PROMIS) 10 Global Health, and Veterans RAND 12-Item Health Survey (VR-12) are generic patient-reported outcome (PRO) questionnaires that assess a patient’s general health. In choosing a PRO to track general health status, it is necessary to consider which measure will be the most responsive to change after treatment. To date, no studies exist comparing responsiveness among the EQ-5D, PROMIS 10 Global Health, and the Veterans Rand 12-Item Health Survey (VR-12).

Purpose:

To determine which of the generic PROs are most responsive internally and externally in the setting of knee arthroscopy.

Study Design:

Cohort study (diagnosis); Level of evidence, 3.

Methods:

Fifty patients who underwent knee arthroscopy were surveyed preoperatively and a mean 3.6 months postoperatively, with 90% follow-up. PROs included the EQ-5D, EQ-5D visual analog scale, PROMIS 10 Global Health (PROMIS 10) physical and mental components, VR-12 physical and mental components, and the Knee injury and Osteoarthritis Outcome Score (KOOS)–pain subscale. Internal responsiveness was evaluated by performing paired t tests on the changes in measures and calculating 2 measures of effect size: Cohen d and standardized response mean (SRM). External responsiveness was evaluated by comparing Pearson correlation measures between the disease-specific reference KOOS-pain and generic PROs.

Results:

For internal responsiveness, 3 PROs showed a statistically significant improvement in score after treatment (EQ-5D: +0.10 [95% CI, 0.06-0.15], VR-12 physical: +7.2 [95% CI, 4.0-10.4]), and PROMIS 10 physical: +4.4 [95% CI, 2.6-6.3]) and effect size statistics with moderate change (Cohen d and SRM, 0.5-0.8). Assessing external responsiveness, a high correlation with the disease-specific reference (KOOS-pain score) was found for EQ-5D (0.65), VR-12 physical (0.57), and PROMIS 10 physical (0.77). For both internal and external responsiveness, the EQ-5D, VR-12 physical, and PROMIS 10 physical showed significantly greater responsiveness compared with the other general PRO measures but no statistical differences among themselves.

Conclusion:

There is no statistical difference in internal or external responsiveness to change among the EQ-5D, VR-12 physical, and PROMIS 10 physical instruments. In tracking longitudinal patient health, researchers and administrators have the flexibility to choose any of the general PROs among the EQ-5D, VR-12 physical, and PROMIS 10 physical. We recommend that any study tracking PROs in knee arthroscopy include 1 of these generic instruments.
Analysis of Platelet-Rich Plasma Extraction
Authors: Fitzpatrick Jane , Bulsara Max K. , McCrory Paul Robert , Richardson Martin D. , Zheng Ming Hao
Published: January 2017

Background:

Platelet-rich plasma (PRP) has been extensively used as a treatment in tissue healing in tendinopathy, muscle injury, and osteoarthritis. However, there is variation in methods of extraction, and this produces different types of PRP.

Purpose:

To determine the composition of PRP obtained from 4 commercial separation kits, which would allow assessment of current classification systems used in cross-study comparisons.

Study Design:

Controlled laboratory study.

Methods:

Three normal adults each donated 181 mL of whole blood, some of which served as a control and the remainder of which was processed through 4 PRP separation kits: GPS III (Biomet Biologics), Smart-Prep2 (Harvest Terumo), Magellan (Arteriocyte Medical Systems), and ACP (Device Technologies). The resultant PRP was tested for platelet count, red blood cell count, and white blood cell count, including differential in a commercial pathology laboratory. Glucose and pH measurements were obtained from a blood gas autoanalyzer machine.

Results:

Three kits taking samples from the “buffy coat layer” were found to have greater concentrations of platelets (3-6 times baseline), while 1 kit taking samples from plasma was found to have platelet concentrations of only 1.5 times baseline. The same 3 kits produced an increased concentration of white blood cells (3-6 times baseline); these consisted of neutrophils, leukocytes, and monocytes. This represents high concentrations of platelets and white blood cells. A small drop in pH was thought to relate to the citrate used in the sample preparation. Interestingly, an unexpected increase in glucose concentrations, with 3 to 6 times greater than baseline levels, was found in all samples.

Conclusion:

This study reveals the variation of blood components, including platelets, red blood cells, leukocytes, pH, and glucose in PRP extractions. The high concentrations of cells are important, as the white blood cell count in PRP samples has frequently been ignored, being considered insignificant. The lack of standardization of PRP preparation for clinical use has contributed at least in part to the varying clinical efficacy in PRP use.

Clinical Relevance:

The variation of platelet and other blood component concentrations between commercial PRP kits may affect clinical treatment outcomes. There is a need for standardization of PRP for clinical use.
Why Do Authors Differ With Regard to the Femoral and Meniscal Anatomic Parameters of the Knee Anterolateral Ligament?
Authors: Helito Camilo Partezani , do Amaral Carlos , Nakamichi Yuri da Cunha , Gobbi Riccardo Gomes , Bonadio Marcelo Batista , Natalino Renato José Mendonça , Pécora José Ricardo , Cardoso Tulio Pereira , Camanho Gilberto Luis , Demange Marco Kawamura
Published: January 2017

Background:

No consensus exists regarding the anatomic characteristics of the knee anterolateral ligament (ALL). A critical analysis of the dissections described in previous studies allows the division of the ALL into 2 groups with similar characteristics. The presence of considerable variability suggests that the authors may not be referring to the same structure.

Purpose/Hypothesis:

To perform a lateral anatomic dissection, by layers, seeking to characterize the 2 variants described for the ALL on the same knee. We hypothesized that we would identify the 2 variants described for the ALL and that these variants would have distinct characteristics.

Study Design:

Descriptive laboratory study.

Methods:

Thirteen unpaired cadaveric knees were used in this study. The dissection protocol followed the parameters described in previous studies. Immediately below the iliotibial tract, we isolated a structure designated as the superficial ALL, whereas between this structure and the articular capsule, we isolated a structure designated as the deep ALL. The 2 structures were measured for length at full extension and at 90° of flexion and for distance from the tibial insertion relative to the Gerdy tubercle. Potential contact with the lateral meniscus was also evaluated. After measurements were obtained, the 2 dissected structures underwent histologic analysis.

Results:

The superficial ALL presented a posterior and proximal origin to the center of the lateral epicondyle, its length increased on knee extension, and it exhibited no contact with the lateral meniscus. The deep ALL was located in the center of the lateral epicondyle, its length increased on knee flexion, and it presented a meniscal insertion. Both structures had a similar tibial insertion site; however, the insertion site of the deep ALL was located more posteriorly. The analysis of the histological sections for both structures indicated the presence of dense and well-organized collagen fibers.

Conclusion:

This anatomic study clearly identified 2 structures, described as the superficial and deep ALL, which were consistent with previous but conflicting descriptions of the ALL.

Clinical Relevance:

This study clarifies numerous controversies encountered in anatomic studies of the ALL. Knowledge regarding the existence of 2 distinct structures in the anterolateral knee will allow more accurate evaluation of their functions and characteristics.
Utilization of Platelet-Rich Plasma for Musculoskeletal Injuries
Authors: Zhang Joanne Y. , Fabricant Peter D. , Ishmael Chad R. , Wang Jeffrey C. , Petrigliano Frank A. , Jones Kristofer J.
Published: January 2017

Background:

Platelet-rich plasma (PRP) has emerged as a popular biologic treatment for musculoskeletal injuries and conditions. Despite numerous investigations on the efficacy of PRP therapy, current utilization of this treatment within the United States is not widely known.

Purpose:

To investigate the national utilization of PRP, including the incidence and conditions for which it is used in the clinical setting, and to determine the current charges associated with this treatment.

Study Design:

Descriptive epidemiology study.

Methods:

Using a national database (PearlDiver) of private insurance billing records, we conducted a comprehensive search using Current Procedural Terminology (CPT) codes to identify patients who received PRP injections over a 2-year period (2010-2011). Associated International Classification of Diseases, 9th Revision (ICD-9) codes were identified to determine the specific conditions the injection was used to treat. The aggregate patient data were analyzed by yearly quarter, practice setting, geographic region, and demographics. PRP therapy charges were calculated and reported as per-patient average charges (PPACs).

Results:

A total of 2571 patients who received PRP injections were identified; 51% were male and 75% were older than 35 years. The overall incidence ranged from 5.9 to 7.9 per 1000 patients over the study period. PRP was most commonly administered in hospitals (39%) and ambulatory surgical centers (37%) compared with in private offices (26%). The most common conditions treated were knee meniscus/plica disorders, followed by unspecified shoulder conditions, rotator cuff injuries, epicondylitis, and plantar fasciitis. Further evaluation revealed that 25% of all patients received injections for cartilage-related conditions, 25% meniscus, 25% unspecified, 12% tendon, 8% glenoid labrum, and 5% ligament. The PPAC for PRP treatment was US$1755 per injection.

Conclusion:

Despite a lack of consensus regarding PRP indications and efficacy, we observed widespread application of this treatment for a myriad of musculoskeletal injuries. Most treated patients were older than 35 years, and the most commonly treated conditions included cartilage and meniscus disorders. Given the current controversy surrounding this treatment, further studies are necessary to guide clinicians on the value of this therapy for each clinical diagnosis.
Surgeon-Directed Cost Variation in Isolated Rotator Cuff Repair
Authors: Terhune E. Bailey , Cannamela Peter C. , Johnson Jared S. , Saad Charles D. , Barnes John , Silbernagel Janette , Faciszewski Thomas , Shea Kevin G.
Published: January 2017

Background:

As value becomes a larger component of heath care decision making, cost data can be evaluated for regional and physician variation. Value is determined by outcome divided by cost, and reducing cost increases value for patients. “Third-party spend” items are individual selections by surgeons used to perform procedures. Cost data for third-party spend items provide surgeons and hospitals with important information regarding care value, potential cost-saving opportunities, and the total cost of ownership of specific clinical decisions.

Purpose:

To perform a cost review of isolated rotator cuff repair within a regional 7-hospital system and to document procedure cost variation among operating surgeons.

Study Design:

Economic and decision analysis; Level of evidence, 4.

Methods:

Current Procedural Terminology (CPT) codes were used to retrospectively identify subjects who received an isolated rotator cuff repair within a 7-hospital system. Cost data were collected for clinically sensitive third-party spend items and divided into 4 cost groups: (1) suture anchors, (2) suture-passing devices and needles, (3) sutures used for cuff repair, and (4) disposable tools or instruments.

Results:

A total of 62 isolated rotator cuff repairs were performed by 17 surgeons over a 13-month period. The total cost per case for clinically sensitive third-party spend items (in 2015 US dollars) ranged from $293 to $3752 (mean, $1826). Four surgeons had a mean procedure cost that was higher than the data set mean procedure cost. The cost of an individual suture anchor ranged from $75 to $1775 (mean, $403). One disposable suture passer was used, which cost $140. The cost of passing needles ranged from $140 to $995 (mean, $468). The cost per repair suture (used to repair cuff tears) varied from $18 to $298 (mean, $61). The mean suture (used to close wounds) cost per case was $81 (range, $0-$454). A total of 316 tools or disposable instruments were used, costing $1 to $1573 per case (mean, $624).

Conclusion:

This study demonstrates significant cost variation with respect to cost per case and cost of individual items used during isolated rotator cuff repair. Suture anchors represent the most expensive and variable surgeon-directed cost. The wide cost variation seen in all cost categories illustrates both the effect of surgeon choice in procedure cost and the opportunity for significant cost savings in cases of isolated rotator cuff repair. Engaging surgeons in discussion on cost can positively influence the value of care provided to patients if costs can be reduced without affecting the quality of patient outcomes.