The worsening opioid epidemic in the United States, exacerbated by the COVID-19 pandemic, necessitates innovative approaches to pain management. Buprenorphine, a long-acting opioid, has gained ...popularity due to its safety profile and accessibility. Orthopaedic surgeons, encountering an increasing number of patients on buprenorphine, face challenges in perioperative management. This article will update orthopaedic surgeons on new developments in the understanding of buprenorphine as a pain reliever and share evidence-based practice guidelines for buprenorphine management. For patients on buprenorphine for opioid use disorder or chronic pain, the updated recommendation is to continue their home dose of buprenorphine through the perioperative period. The patient’s buprenorphine prescriber should be contacted and notified of any impending surgery. The continuation of buprenorphine should be accompanied by a multimodal approach to analgesia, including a preoperative discussion about expectations of pain and pain control, regional anesthesia, standing acetaminophen, Nonsteroidal anti-inflammatory drugs when possible, gabapentinoids at night for patients under 65 years, cryotherapy, elevation, and early mobilization. Patients can also be prescribed short-acting, immediate-release opioids for breakthrough pain. Transdermal buprenorphine is emerging as an excellent option for the management of acute perioperative pain in both elective and nonelective orthopaedic patients. A single patch can provide a steady dose of pain medication for up to 1 week during the postoperative period. A patch delivery method can help combat patient nonadherence and ultimately provide better overall pain control. In the future, transdermal buprenorphine patches could be applied in virtually all fracture surgery, spinal surgery, total joint arthroplasty, ligament reconstructions with bony drilling, etc. As the stigma surrounding buprenorphine decreases, further opportunities for perioperative use may develop.
•Groundwater flooding in Irish lowland karst has been accurately simulated.•Spring discharge from the lowland karst to the sea has been estimated.•Groundwater flood alleviation options have been ...simulated.•Impacts of flood alleviation on the salinity of Kinvara Bay has been assessed.•Impacts of flood alleviation on eco-hydrology of the turloughs was assessed.
Groundwater flooding is a phenomenon which has become recognised as a significant natural hazard in recent years. The Gort lowland karst catchment situated in south Co. Galway on the western coast of Ireland has experienced two extreme groundwater flood events in the past decade leading to considerable damage and disruption. Groundwater flooding in the catchment typically occurs following periods of sustained heavy rainfall when sufficient capacity is not available in the bedrock to store and convey water to the sea. The underground karst conduit system therefore surcharges to the ground surface through a system of estavelles and floods low-lying areas of ground known as turloughs (ephemeral lakes). A 1D/2D pipe network model of the karst conduit system of the Gort lowland karst was developed in order to simulate the flooding mechanisms across the catchment as well as to assess flood alleviation options. The nature of the underground karstic connections in the system has been determined from a combination of available field data (dye tracing, water chemistry data etc.) and cross-frequency analysis on the turlough fluctuation time series data over several years. The availability of high accuracy LiDAR data of the catchment then allowed the flooding regime to be accurately simulated on the ground surface. The model was calibrated using historic continuous water level data for a number of turloughs in the catchment and then validated using historic peak spot flood levels. The model was then used to identify appropriate potential groundwater flood alleviation measures for the catchment. The impacts of such measures on both the salinity of Kinvara bay, through increased freshwater discharges, and eco-hydrology of the protected wetland habitats within the turloughs was also investigated. The study demonstrated that the measures proposed can be developed without inducing undesirable impacts to either salinity in Kinvara Bay (and thus mariculture) or to the protected turlough habitats. The study has also demonstrated the suitability and functionality of such karst models for examining groundwater flood management options and eco-hydrology in karst catchments.
Cervical disc displacement (CDD) may disqualify pilots from flying and have a profound impact on military unit capability. The objective of this retrospective database review is to characterize the ...incidence and demographic predictors of symptomatic cervical spine disc displacement in pilots of fixed- and rotary-wing aircraft and ground-based controls.
The Defense Military Epidemiology Database was queried for first-occurrence ICD-9 code 722.0: CDD cases from 2007 to 2015. Injury count rates among aircraft groups and overall incidence per 1,000 person-years were calculated and standardized for age, gender, and military rank, and 95% confidence intervals (CIs) were compared to determine significance.
There were 934 new cases of CDD among active duty U.S. Military pilots during the study period. The overall incidence of CDD in all pilots during this time frame was 2.715 per 1,000 person-years (95% CI, 2.603-2.830). Helicopter pilots had a significantly higher incidence compared to all other aircraft pilots and crew at 3.79 per 1,000 person-years (95% CI, 3.48-4.13). This finding remained statistically significant after standardizing for age, gender, and rank. Among all military officers, increasing age was a risk factor for CDD.
The U.S. Military helicopter pilots have an increased risk compared to fixed-wing pilots and non-pilot controls. CDD remains a rare, though career-threatening, condition. Increased education and awareness training are warranted for both helicopter pilots and flight physicians to recognize signs and symptoms of cervical pathology. Continued investigations into preventive measures to minimize injury and time unfit for flight are warranted.
Spinopelvic dissociation is a rare injury associated with 2% to 3% of transverse sacral fractures and 3% of sacral fractures associated with pelvic ring injuries. When spinopelvic dissociation is ...expediently identified and treated appropriately, patient outcomes can be maximized, highlighting the importance of early diagnosis and treatment. Because of its rarity and complexity, there remains a paucity of high-level evidence-based guidance on treating this complex issue. No consensus exists on fixation techniques or reduction maneuvers to achieve stability, allowing for early functional rehabilitation. The purpose of this article is to review the current body of literature to better understand this injury pattern to help establish a treatment algorithm that appropriately guides the treating surgeons in the surgical planning and perioperative care of these patients.
Dark-matter-only simulations predict that dark matter halos have steep, cuspy inner density profiles, while observations of dwarf galaxies find a range of inner slopes that are often much shallower. ...There is debate whether this discrepancy can be explained by baryonic feedback or if it may require modified dark matter models. In Paper I of this series, we obtained high-resolution integral field H observations for 26 dwarf galaxies with M* = 108.1−109.7 . We derived rotation curves from our observations, which we use here to construct mass models. We model the total mass distribution as the sum of a generalized Navarro-Frenk-White (NFW) dark matter halo and the stellar and gaseous components. Our analysis of the slope of the dark matter density profile focuses on the inner 300-800 pc, chosen based on the resolution of our data and the region resolved by modern hydrodynamical simulations. The inner slope measured using ionized and molecular gas tracers is consistent, and it is additionally robust to the choice of stellar mass-to-light ratio. We find a range of dark matter profiles, including both cored and cuspy slopes, with an average of , shallower than the NFW profile, but steeper than those typically observed for lower-mass galaxies with M* ∼ 107.5 . Simulations that reproduce the observed slopes in those lower-mass galaxies also produce slopes that are too shallow for galaxies in our mass range. We therefore conclude that supernova feedback models do not yet provide a fully satisfactory explanation for the observed trend in dark matter slopes.
The specifics of how galaxies form from, and are fuelled by, gas from the intergalactic medium remain uncertain. Hydrodynamic simulations suggest that 'cold accretion flows'--relatively cool ...(temperatures of the order of 10(4) kelvin), unshocked gas streaming along filaments of the cosmic web into dark-matter halos--are important. These flows are thought to deposit gas and angular momentum into the circumgalactic medium, creating disk- or ring-like structures that eventually coalesce into galaxies that form at filamentary intersections. Recently, a large and luminous filament, consistent with such a cold accretion flow, was discovered near the quasi-stellar object QSO UM287 at redshift 2.279 using narrow-band imaging. Unfortunately, imaging is not sufficient to constrain the physical characteristics of the filament, to determine its kinematics, to explain how it is linked to nearby sources, or to account for its unusual brightness, more than a factor of ten above what is expected for a filament. Here we report a two-dimensional spectroscopic investigation of the emitting structure. We find that the brightest emission region is an extended rotating hydrogen disk with a velocity profile that is characteristic of gas in a dark-matter halo with a mass of 10(13) solar masses. This giant protogalactic disk appears to be connected to a quiescent filament that may extend beyond the virial radius of the halo. The geometry is strongly suggestive of a cold accretion flow.
We present Keck Cosmic Web Imager spectroscopy of the four putative images of the lensed quasar candidate J014710+463040 recently discovered by Berghea et al. The data verify the source as a ...quadruply lensed, broad absorption-line quasar having . We detect intervening absorption in the Fe ii λλ2586, 2600, Mg ii λλ2796, 2803, and/or C iv λλ1548, 1550 transitions in eight foreground systems, three of which have redshifts consistent with the photometric-redshift estimate reported for the lensing galaxy (zL 0.57). The source images probe these absorbers over transverse physical scales of 0.3-22 kpc, permitting assessment of the variation in metal-line equivalent width as a function of sight-line separation. We measure differences in of <40% across most of the sight-line pairs subtending 8-22 kpc, suggestive of a high degree of spatial coherence for the Mg ii-absorbing material. varies by >50% over the same scales across the majority of sight-line pairs, while C iv absorption exhibits a wide range in differences of 5%-80% within transverse distances of 3 kpc. These spatial variations are consistent with those measured in intervening absorbers detected toward lensed quasars drawn from the literature, in which and vary by ≤20% in 35 7% and 47 6% of sight lines separated by <10 kpc, respectively. J014710+463040 is one of only a handful of z > 2 quadruply lensed systems for which all four source images are very bright (r = 15.4-17.7 mag) and are easily separated in ground-based seeing conditions. As such, it is an ideal candidate for higher-resolution spectroscopy probing the spatial variation in the kinematic structure and physical state of intervening absorbers.
Ulnohumeral arthroplasty, also known as the Outerbridge-Kashiwagi procedure, was popularized after reports of successful results in 1978, and has long been a means of management for ulnohumeral ...arthritis. However, there are concerns over the loss of integrity of the distal humerus as a result of fenestration. The purpose of this study was to examine the relationship between the size of fenestration and fracture risk.
Using a validated fourth-generation sawbones model, load to failure and site of fracture were investigated following incrementally increasing distal humeral fenestration sizes. Each sample was subjected to a uniform extension stress on a materials testing system, with 5 samples run for each group. The experimental groups began with a fenestration size of 10 mm and increased by 3 mm increments up to 31 mm. Load at failure and site of fracture were recorded for each sample.
Forty-five fourth-generation sawbones samples were tested. Average load at sample failure was equivalent for each fenestration group up to 25 mm. At 28 mm, average load to failure began to decrease, and was statistically significant beginning between 28 mm and 31 mm. At 28 mm, 4 of 5 samples fractured through the fenestration, and at 31 mm, all 5 samples fractured through the fenestration. This change in fracture site became statistically significant between 25 mm and 28 mm.
Distal humeral fenestration does compromise its structural integrity; however, for resection in the range of 10–25 mm, there is no increased risk of fracture.
On the basis of this biomechanical model, the authors do not recommend any activity limitations after initial surgical recovery, but do recommend against distal humeral fenestrations larger than 25 mm when performing this procedure.
The incidence of both myocardial infarction (MI) and sudden cardiac death increases with age. Here, we describe the development of a minimally invasive large animal model of MI that can be applied to ...young or aged animals. We demonstrate that rabbit coronary anatomy is highly variable, more so than described in previous literature. In this work, we categorize the coronary pattern of 37 young rabbits and 64 aged rabbits. Aged rabbits had a higher degree of branching from the left main coronary artery. Standardizing the model across age cohorts required a new approach, targeting an area of myocardium rather than a specific vessel. Here, we present a method for achieving a reproducible infarct size, one that yielded a consistent scar encompassing ~30% of the apical left ventricular free wall. The model's consistency allowed for more valid comparisons of MI sequelae between age cohorts.
This study describes the coronary angiographic imaging of young and aged rabbits. We developed and improved a novel minimally invasive approach for coil embolization that targets a specific area of myocardium and yielded a consistent scar encompassing ~30% of the left ventricular free wall of young and aged rabbit hearts.
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