Treatment of Partial Thickness Rotator Cuff Tears in Overhead Athletes

Purpose of Review

To review the etiology, classification, presentation, evaluation, treatment strategy, and outcomes in overhead athletes with partial thickness rotator cuff tears.

Recent Findings

Despite advances in surgical repair techniques, return to play following surgical repair of partial rotator cuff tears remains modest at best.

Summary

Overhead athletes may be particularly prone to rotator cuff pathology due to the supraphysiological strains within the tendon during the throwing motion, as well as mechanical stress with contact between the undersurface of the rotator cuff and the glenoid. The true prevalence of partial tears may be underestimated given the high incidence of asymptomatic tears. Both dynamic ultrasound and enhanced contrast MRI have improved our understanding of this pathology. For most overhead athletes, nonoperative management is the most common course. Despite advances in imaging, diagnosis, and surgical techniques, our ability to return these patients to their elite level is modest at best when nonoperative management fails and surgical treatment is performed. If a surgical route is needed, debridement alone is the most frequent procedure given concerns of over constraint and poor return to play with surgical repair of the partial thickness rotator cuff tear.

     

Integrated Cardiac and Lung Ultrasound (ICLUS) in the Cardiac Intensive Care Unit

Purpose of Review

This review highlights the use of basic lung ultrasound and introduces the concept of integrated cardiac and lung ultrasound (ICLUS) in the care of patients in the cardiac intensive care unit (ICU).

Recent Findings

Cardiac ultrasound is a fundamental imaging modality that is the gold standard for the diagnosis of cardiac pathology at the bedside. However, the demographics of the modern cardiac ICU are evolving to encompass patients with complex multi-organ system dysfunction in addition to acute cardiovascular disease. Therefore, a more comprehensive diagnostic approach is needed to allow the cardiologist to unravel the potential interplay of multiple pathologic processes. Literature on lung ultrasound has expanded dramatically in recent years as it has proven to be a feasible and accurate exam that provides rapid diagnosis of pulmonary pathology including pneumothorax, pleural effusion, pneumonia, and pulmonary edema. Furthermore, combined cardiac and lung sonography exposes the interaction of circulatory and pulmonary physiology that is central to the diagnosis and management of acute cardiovascular disease. ICLUS provides valuable information for the diagnosis and management of conditions such as respiratory failure, shock, and heart failure.

Summary

Numerous studies in recent years have illustrated the utility of lung ultrasound in various clinical settings. Integration of lung and cardiac ultrasound provides the cardiologist with a more holistic examination of the medically complex patients that are admitted to the modern cardiac ICU.

     

ADARRI: a novel method to detect spurious R-peaks in the electrocardiogram for heart rate variability analysis in the intensive care unit

We developed a simple and fully automated method for detecting artifacts in the R-R interval (RRI) time series of the ECG that is tailored to the intensive care unit (ICU) setting. From ECG recordings of 50 adult ICU-subjects we selected 60 epochs with valid R-peak detections and 60 epochs containing artifacts leading to missed or false positive R-peak detections. Next, we calculated the absolute value of the difference between two adjacent RRIs (adRRI), and obtained the empirical probability distributions of adRRI values for valid R-peaks and artifacts. From these, we calculated an optimal threshold for separating adRRI values arising from artifact versus non-artefactual data. We compared the performance of our method with the methods of Berntson and Clifford on the same data. We identified 257,458 R-peak detections, of which 235,644 (91.5%) were true detections and 21,814 (8.5%) arose from artifacts. Our method showed superior performance for detecting artifacts with sensitivity 100%, specificity 99%, precision 99%, positive likelihood ratio of 100 and negative likelihood ratio <0.001 compared to Berntson’s and Clifford’s method with a sensitivity, specificity, precision and positive and negative likelihood ratio of 99%, 78%, 82%, 4.5, 0.013 for Berntson’s method and 55%, 98%, 96%, 27.5, 0.460 for Clifford’s method, respectively. A novel algorithm using a patient-independent threshold derived from the distribution of adRRI values in ICU ECG data identifies artifacts accurately, and outperforms two other methods in common use. Furthermore, the threshold was calculated based on real data from critically ill patients and the algorithm is easy to implement.     

Post-operative Weaning of Opioids After Ambulatory Surgery: the Importance of Physician Stewardship

Purpose of Review

We performed a systematic review to elucidate the current guidelines on weaning patients from opioids in the post-operative ambulatory surgery setting, and how pain management intraoperatively can impact this process.

Design

The review highlights the most up-to-date research from clinical trials, patient reports, and retrospective studies regarding both the current guidelines and weaning of opioid analgesia in ambulatory surgery setting.

Recent Findings

A striking paucity of convincing evidence exists on ambulatory postoperative pain management discontinuation or weaning of pain medications. However, retrospective and patient-reported studies suggest our approach should be similar to acute pain management strategies. The first steps include identifying high-risk patients and devising an appropriate pain plan. This may be accomplished by implementing multimodal analgesia, anticipating opioid needs, and the proper use of regional anesthesia. The increasing roles for Transitional Pain Service (TPS), Perioperative Surgical Home (PSH), and Enhanced Recovery After Surgery (ERAS) may also guide us in this process.

Summary

Patients discharged from same-day surgery may lack the additional infrastructure of a hospital or medical establishment to monitor postoperative recovery. As such, weaning of pain medications in ambulatory surgery settings requires teams that are adept at treating varied patient populations through a tailored, novel means that invoke multimodal analgesia. Given the growth of surgeries moving toward the ambulatory sector, more data and practice guidelines are needed to direct postoperative pain regimen titration for the patients.

     

Gene-Specific Differential DNA Methylation and Chronic Arsenic Exposure in an Epigenome-Wide Association Study of Adults in Bangladesh

Background: Inorganic arsenic is one of the most common naturally occurring contaminants found in the environment. Arsenic is associated with a number of health outcomes, with epigenetic modification suggested as a potential mechanism of toxicity.Objective: Among a sample of 400 adult participants, we evaluated the association between arsenic exposure, as measured by blood and urinary total arsenic concentrations, and epigenome-wide white blood cell DNA methylation.Methods: We used linear regression models to examine the associations between arsenic exposure and methylation at each CpG site, adjusted for sex, age, and batch. Differentially methylated loci were subsequently examined in relation to corresponding gene expression for functional evidence of gene regulation.Results: In adjusted analyses, we observed four differentially methylated CpG sites with urinary total arsenic concentration and three differentially methylated CpG sites with blood arsenic concentration, based on the Bonferroni-corrected significance threshold of p < 1 × 10^–7. Methylation of PLA2G2C (probe cg04605617) was the most significantly associated locus in relation to both urinary (p = 3.40 × 10^–11) and blood arsenic concentrations (p = 1.48 × 10^–11). Three additional novel methylation loci—SQSTM1 (cg01225779), SLC4A4 (cg06121226), and IGH (cg13651690)—were also significantly associated with arsenic exposure. Further, there was evidence of methylation-related gene regulation based on gene expression for a subset of differentially methylated loci.Conclusions: We observed significant associations between arsenic exposure and gene-specific differential white blood cell DNA methylation, suggesting that epigenetic modifications may be an important pathway underlying arsenic toxicity. The specific differentially methylated loci identified may inform potential pathways for future interventions.Citation: Argos M, Chen L, Jasmine F, Tong L, Pierce BL, Roy S, Paul-Brutus R, Gamble MV, Harper KN, Parvez F, Rahman M, Rakibuz-Zaman M, Slavkovich V, Baron JA, Graziano JH, Kibriya MG, Ahsan H. 2015. Gene-specific differential DNA methylation and chronic arsenic exposure in an epigenome-wide association study of adults in Bangladesh. Environ Health Perspect 123:64–71; http://dx.doi.org/10.1289/ehp.1307884     

Differences in COVID-19 Preventive Behavior and Food Insecurity by HIV Status in Nigeria

AIDS and Behavior - The aim of the study was to assess if there were significant differences in the adoption of COVID-19 risk preventive behaviors and experience of food insecurity by people living...