Consumer Prices for Surgical Management of Ankle Arthritis: Limited Availability and Wide Variability.

Background: Healthcare costs for the surgical management of ankle arthritis continue to rise. Patients are generally unaware of the prices of the services they use. Understanding the costs associated with surgical management of ankle arthritis is an important facet of patient care. The purposes of this study were to (1) determine the access to the surgical cost of total ankle arthroplasty (TAAs) and ankle arthrodesis and (2) the variability of the price between the two procedures. Methods: Fifty foot and ankle centers (25 academic, 25 private) that perform TAAs and ankle arthrodeses were contacted using a standardized patient script. The described patient was a 63-year-old man who had failed conservative treatment of ankle arthritis. Each institution was contacted up to three times in an attempt to obtain a full-bundled surgical quote for a TAA and an ankle arthrodesis. Results: Twenty-one centers (42%, 14 academic, 7 private) were able to provide a quote for a TAA and an ankle arthrodesis. The mean bundled price for a TAA was $50,332 (SD ±$25,744), with the mean academic and private center quote being $56,529 and$37,937, respectively. The mean bundled price for an ankle arthrodesis was $41,756 (SD ±$26,033), with the mean academic and private center quote being $48,116 and$29,037, respectively. No statistically significant difference was found between the bundled prices for TAA and ankle arthrodesis. Discussion: This study demonstrated limited availability of consumer prices for TAA and ankle arthrodesis. When comparing different institutions for surgical management of ankle arthritis, there was a wide range of quotes for both TAA and ankle arthrodesis. When comparing the choice of surgical management for ankle arthritis, no statistically significant difference was observed in price between TAA and ankle arthrodesis

Localization of type 1 diabetes susceptibility to the MHC class I genes HLA-B and HLA-A

The major histocompatibility complex (MHC) on chromosome 6 is associated with susceptibility to more common diseases than any other region of the human genome, including almost all disorders classified as autoimmune. In type 1 diabetes the major genetic susceptibility determinants have been mapped to the MHC class II genes HLA-DQB1 and HLA-DRB1 (refs 1-3), but these genes cannot completely explain the association between type 1 diabetes and the MHC region. Owing to the region's extreme gene density, the multiplicity of disease-associated alleles, strong associations between alleles, limited genotyping capability, and inadequate statistical approaches and sample sizes, which, and how many, loci within the MHC determine susceptibility remains unclear. Here, in several large type 1 diabetes data sets, we analyse a combined total of 1,729 polymorphisms, and apply statistical methods - recursive partitioning and regression - to pinpoint disease susceptibility to the MHC class I genes HLA-B and HLA-A (risk ratios >1.5; Pcombined = 2.01 × 10-19 and 2.35 × 10-13, respectively) in addition to the established associations of the MHC class II genes. Other loci with smaller and/or rarer effects might also be involved, but to find these, future searches must take into account both the HLA class II and class I genes and use even larger samples. Taken together with previous studies, we conclude that MHC-class-I-mediated events, principally involving HLA-B*39, contribute to the aetiology of type 1 diabetes. ©2007 Nature Publishing Group

Myth or Memory? Recollections of Penal Times in Irish Folklore

Stories of priests being hunted down and murdered at Mass Rocks by priest catchers and soldiers during the Penal era in Ireland persist to the present day. Using Ó Ciosáin’s (2004) tripartite taxonomy of memory this paper explores the reasons why these images continue to dominate and reflect persecuted nature of Catholicism

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Introduction: Why Are There so Many Different Surgeries for Hallux Valgus?

Hallux valgus is a common pathology of the foot and ankle. Surgical correction of the condition has been described as early as 1836. Since then, numerous different surgical techniques have been documented in the literature. One of the explanations as to why there are so many different surgeries for hallux valgus is the variety of etiologies attributed to causing the condition. This article discusses the etiologies associated with hallux valgus and describes a few of the surgeries commonly used to treat the deformity

Recovery of fatigue life using laser peening on 2024‐T351 aluminium sheet containing scratch damage: The role of residual stress

The aim of the current work was to study the effect of laser shock peening (LSP) when applied to 2‐mm thick 2024‐T351 aluminium samples containing scratch‐like defects in the form of V‐shaped scribes 50 to 150μm deep. The scribes decreased fatigue life to 5% of that of the pristine material. The effect of laser peening on fatigue life was dependent on the specifics of the peen treatment, ranging from further reductions in life to restoration of the fatigue life to 61% of pristine material. Fatigue life was markedly sensitive to near‐surface tensile residual stress, even if a compressive residual stress field was present at greater depth. Fatigue life after peening was also dependent on sample distortion generated during the peening process. Sample distortion modified local stresses generated by externally applied loads, producing additional life changes. Models based on residual stress intensity and crack closure concepts were successfully applied to predict fatigue life recovery

Operative Reports in Orthopaedic Surgery: The Need for Assessment and Education

The ability to complete an operative report is a vital skill for an orthopaedic surgeon. We hypothesized that most programs do not have formal operative report teaching, that resident operative reports at our institution are incomplete, and that a formal teaching program would improve operative reports. A survey of residencies in the United States was conducted assessing the state of operative report education. In addition, resident operative reports were collected at our institution both pre and post a formal educational session. Scores were given for each report out of a possible 35 points. Total 54 institutions responded to the survey, of which 83% indicated that they had no formal resident operative report teaching. Within our institution, 100 resident operative dictations were assessed prior to instituting a formal education session, with a mean score of 24.5. The most commonly missed items in the report were preoperative antibiotics, deep venous thrombosis prophylaxis, and tourniquet time. The mean score of 100 resident operative dictations following the educational session improved to 31.8. Most residency programs do not conduct formal resident operative report teaching. Formal instruction on how to complete a comprehensive operative report resulted in a significant improvement in their quality

Risk factors for periprosthetic joint infection following total ankle replacement

•A total of 8 studies met the inclusion criteria, all were determined to be of low quality.•A limited strength of recommendation can be made that certain patient characteristics are associated with an increased risk of PJI.•Inflammatory arthritis, prior ankle surgery, age <65 years, BMI <19, PVD, chronic lung disease, hypothyroidism, and low preoperative AOFAS scores.•There is conflicting evidence in the literature regarding the effect of obesity, tobacco use, diabetes, and duration of surgery.•High quality evidence is needed to further determine the risk factors associated with a PJI following TAR. Identifying preoperative patient characteristics that correlate with an increased risk of periprosthetic joint infection (PJI) following total ankle replacement (TAR) is of great interest to orthopaedic surgeons, as this may assist with appropriate patient selection. The purpose of this study is to systematically review the literature to identify risk factors that are associated with PJI following TAR. Utilizing the terms “(risk factor OR risk OR risks) AND (infection OR infected) AND (ankle replacement OR ankle arthroplasty)” we searched the PubMed/MEDLINE electronic databases. The quality of the included studies was then assessed using the AAOS Clinical Practice Guideline and Systematic Review Methodology. Recommendations were made using the overall strength of evidence. Eight studies met the inclusion criteria. A limited strength of recommendation can be made that the following preoperative patient characteristics correlate with an increased risk of PJI following TAR: inflammatory arthritis, prior ankle surgery, age less than 65 years, body mass index less than 19, peripheral vascular disease, chronic lung disease, hypothyroidism, and low preoperative AOFAS hindfoot scores. There is conflicting evidence in the literature regarding the effect of obesity, tobacco use, diabetes, and duration of surgery. Several risk factors were identified as having an association with PJI following TAR. These factors may alert surgeons that a higher rate of PJI is possible. However, because of the low level of evidence of reported studies, only a limited strength of recommendation can be ascribed to regard these as risk factors for PJI at this time

Consumer Prices for Surgical Management of End-Stage Hallux Rigidus

Category: Midfoot/Forefoot, Healthcare economics Introduction/Purpose: Hallux rigidus is the most prevalent arthritic condition of the foot. Treatment of end-stage disease traditionally consists of a first metatarsophalangeal joint (MTPJ) arthrodesis, however the use of a synthetic cartilage implant is becoming more common. With the high prevalence of disease and implementation of new treatment modalities, healthcare consumers should be aware of the costs associated with management. The purpose of this study was to determine access to the cost and variability in price of first MTPJ arthrodesis and synthetic cartilage implantation. Methods: Forty academic centers were contacted using a standardized patient script. The patient was a 59-year-old female who had failed conservative treatment of hallux rigidus. Each institution was contacted up to three times in an attempt to obtain a full bundled operative quote for a first MTPJ arthrodesis and synthetic cartilage implantation. Results: Twenty centers (50%) provided a quote for first MTPJ arthrodesis and 15 centers (38%) provided a quote for synthetic cartilage implantation. Only 14 centers (35%) were able to provide a quote for both procedures. The mean bundled price for MTPJ arthrodesis was $21,767 (range,$8,417 – $39,265). The mean bundled price for synthetic cartilage implantation was$21,546 (range, $4,903 –$74,145). There was no statistically significant difference between the bundled price for first MTPJ arthrodesis and synthetic cartilage implantation. Conclusion: There was limited availability of consumer prices for first MTPJ arthrodesis and synthetic implantation, therefore impeding healthcare consumers’ decision making. There was a wide range of quotes for both procedures, indicating potential cost savings