Background Effective tuberculosis (TB) control in HIV-prevalent settings is hindered by absence of accurate, rapid TB diagnostic tests. We evaluated the accuracy of a urine lipoarabinomannan (LAM) test for TB diagnosis in South Africa. Methods Hospitalized adults with signs and/or symptoms of active TB were enrolled. Sputum smear microscopy and mycobacterial culture, mycobacterial blood culture, and HIV testing were performed. A spot urine specimen was tested for LAM. Results 499 participants were enrolled; 422 (84.6%) were HIV-infected. In microbiologically-confirmed TB patients, the LAM test was positive in 114/193 (sensitivity 59%, [95% CI 52, 66]), including 112/167 (67% [59, 74]) who were HIV-infected. Among individuals classified as “not TB”, the LAM test was negative in 117/122 (specificity 96% [91, 99]), including 83/88 (94% [87, 98]) who were HIV-infected. In confirmed TB patients, the LAM test was more sensitive than sputum smear microscopy (42%, 82/193, p<0.001) and detected 56% (62/111) of those who were sputum smear-negative. HIV-infection (AOR 13.4), mycobacteremia (AOR 3.21), and positive sputum smear (AOR 2.42) were risk factors for a positive LAM test. Conclusions The urine LAM test detected a subset of HIV-infected patients with severe TB in whom sputum smear microscopy had suboptimal sensitivity. The combination of urine LAM testing and sputum smear microscopy is attractive for use in settings with high HIV burden.

Level IV, case series.

Patient reported outcome measures (PROMs) are key tools when performing clinical research and PROM data are increasingly used to inform clinical decision-making, patient-centered care, health policy and more recently, reimbursement decisions. PROMs must possess particular properties before they are used. Thus purpose of this paper is to give an overview of PROMs, their definition, how their evidence can be assessed, how they should be reported in clinical research, how to choose PROMs, the types of PROMs available in orthopaedics, where these measures can be found, PROMs in orthopaedic clinical practice and what are some key next steps in this field. If PROMs are used in accordance with the guidance in this article, I believe we will gain considerable insight into PROMs in orthopaedics and will advance this field in a way that can contribute to science, improve patient care and save considerable resources. Why Patient Reported Outcome Measures? The development, testing and implementation of tools to aid in the measurement of phenomena in medicine are central to clinical practice and clinical research. Measurements in clinical practice form the basis of diagnosis, prognosis, evaluation and follow-up. Measurements in clinical research allow for the collection of data that afford us the information needed to test specific hypotheses [1]. The field of measurement in medicine includes both psychometrics and clinimetrics [2-4]. But, it has been argued thatthere is little distinction between these two areas [3]. Throughout this paper the term psychometrics will be used and more generally the term measurement to refer to these fields.

Our goal was to determine whether there were age-related differences in pain, opiate use, and opiate side effects after total hip or knee arthroplasty in patients 60 years old or older. We hypothesized that there would be no significant differences between age groups in (1) mean pain score, (2) opiate use after adjusting for pain, or (3) opiate side effects after adjusting for opiate use and pain score. We retrospectively reviewed the electronic and paper charts of all patients undergoing total joint replacements at our institution over 3 years who met the following criteria: (1) 60 years old or older, (2) primary single total knee or total hip replacement, and (3) no preoperative dementia. Preoperative, intraoperative, and postoperative course data were collected using a customized data entry process and database. We divided the patients into 2 age groups, those 60 to 79 years old and those 80 years old or older. Using a marginal model with the panel variable of postoperative day, we investigated the associations between age group and pain, age group and pain adjusting for opiate use, and age group and complications (respiratory depression, naloxone usage as a measure of respiratory arrest, delirium, constipation, and urinary retention) adjusting for opiate use (Xtgee, Stata10, Stata Corp. LP, College Station, Texas). Significance was set at P < .05. We found no significant difference in pain scores between groups, but the older group had significantly fewer opiates prescribed yet significantly more side effects, including delirium (odds ratio 4.2), than did the younger group, even after adjusting for opiate dose and pain score.

Electron transport, the proton gradient and ATP synthesis were determined in thylakoids that had been briefly exposed to a low concentration of trypsin during illumination. This treatment cleaves the gamma subunit of the ATP synthase into two large fragments that remain associated with the enzyme. Higher rates of electron transport are required to generate a given value of the proton gradient in the trypsin-treated membranes than in control membranes, indicating that the treated membranes are proton leaky. Since venturicidin restores electron transport and the proton gradient to control levels, the proton leak is through the ATP synthase. Remarkably, the synthesis of ATP by the trypsin-treated membranes at saturating light intensities is only slightly inhibited even though the proton gradient is significantly lower in the treated thylakoids. ATP synthesis and the proton gradient were determined as a function of light intensity in control and trypsin-treated thylakoids. The trypsin-treated membranes synthesized ATP at lower values of the proton gradient than the control membranes. Cleavage of the gamma subunit abrogates inhibition of the activity of the chloroplast ATP synthase by the epsilon subunit. Our results suggest that overcoming inhibition by the epsilon subunit costs energy.

Background: Commercially available suture anchors for rotator cuff repairs can differ significantly in architecture and material. Clinical data on their osseous integration and its effect on patient-reported outcomes is scarce. Preclinical investigations indicated a higher rate of osseous integration for the open-architecture design of the Healicoil Regenesorb anchor than the closed-threaded design of the Twinfix (Smith & Nephew). The purpose of this study was to investigate these 2 anchors with different architecture and material to determine their effect on osseous integration and clinical outcomes after rotator cuff repair. Methods: A prospective randomized controlled trial was performed from 2014 to 2019. Sixty-four patients (39 females, 25 males) with an average age of 58.7 years who underwent arthroscopic rotator cuff repair by one of 4 board-certified, fellowship-trained surgeons were randomized to receive Healicoil Regenesorb (PLGA/ß-TCP/Calcium Sulfate) or Twinfix Ultra HA (PLLA/HA) anchors. Thirty-two patients had Healicoil anchors implanted, and 32 patients had Twinfix anchors implanted. Of the 64 patients, 51 returned at 24 months for computed tomographic (CT) examination (25 Twinfix and 26 Healicoil) to determine osteointegration of the anchors. Patient-reported outcomes, including Penn Shoulder Score (PENN), Western Ontario Rotator Cuff Index, visual analog scale, EQ-5D, Single Assessment Numeric Evaluation, Global Rating of Change, were collected at baseline, 6 weeks, 3 months, 6 months, 12 months, and 24 months. Ultrasonography was used to assess rotator cuff integrity after 6 months. Two board-certified, fellowship-trained orthopedic surgeons, blinded to the type of anchors, analyzed the CT scans to assess the anchor osteointegration at 24 months using a previously published grading scale. Results: There were no differences in demographics, preoperative outcomes, or baseline characteristics such as tear size, number of anchors, Goutallier classification, or smoking status between groups. There was no difference in osseous integration between the 2 anchors at 24 months (P ¼ .117). Eight patients had rotator cuff retears, of which 2 patients had Twinfix anchors and 6 patients had Healicoil anchors (P ¼ .18). There were no statistically significant differences in patient-reported outcomes or complications between groups. The 2-year PENN scores were 89 with the Twinfix and 88 with Healicoil anchors (P ¼ .55).

Background: Patients with gluteus medius tendinopathy present with laterally based hip pain that can be diagnosed under the greater trochanteric pain syndrome diagnosis. Magnetic resonance imaging (MRI) can assist in diagnosing pathology of the symptomatic hip, and when a pelvic MRI that includes both hips, the clinician may identify asymptomatic tears in the nonsurgical hip. In patients who undergo unilateral gluteus medius repairs, little is known about the prevalence or subsequent onset of clinical symptoms in the nonsurgical hip. Purpose: To describe (1) the prevalence of asymptomatic contralateral gluteus medius tears in patients with unilateral symptoms, (2) the presentation and time before symptom onset, and (3) the morphological characteristics on MRI of future symptomatic tears. Study Design: Case series; Level of evidence, 4. Methods: A total of 51 consecutive patients who underwent gluteus medius tear surgery were reviewed for contralateral hip pathology; of these, 43 patients were 2 years out from index surgery with reviewable preoperative MRI scans. A musculoskeletal radiologist reviewed the MRI scans for tear size, tendon retraction, and fatty infiltration using the Goutallier-Fuchs grading system. Medical record review identified contralateral hips requiring subsequent treatment. Results: Of the original 43 patients, 10 (23%) had no contralateral tear, 19 (44%) had low-grade partial tears, 9 (20%) had high-grade partial tears, and 5 (11%) had full-thickness tears. Thirty-seven patients had unilateral symptoms; the other 6 had mild contralateral hip pain at enrollment. Of the 37 patients with unilateral symptoms, 27 (73%) had a contralateral tear; of those, 10 became symptomatic at an average of 24 months after index presentation (range, 6-50 months). In patients with symptomatic progression, 7 had low-grade partial tears, 1 had a high-grade partial tear, and 2 had full-thickness tears, with an average retraction of 17 mm. Tendon tear grade on MRI did not always correlate with symptoms or future presentation. All symptomatic progression remained mild to moderate. Seven patients required a corticosteroid injection, and none needed contralateral hip surgery within 2 years. Conclusion: Of patients who underwent surgery for a gluteus medius tear, 73% (27/37) had an incidental MRI-confirmed contralateral hip abductor tear. Of these, 37% (10/27) developed symptoms consistent with greater trochanteric pain syndrome during the 2-year study period.

Currently, the only standardized evaluation of trauma knowledge throughout orthopedic training is found in the Orthopaedic In-Training Examination, which is administered annually to all residents by the American Academy of Orthopaedic Surgeons. Our goals were to assess the Orthopaedic In-Training Examination to (1) determine the content of the trauma questions, (2) identify the content of the 3 most frequently referenced journals on the answer keys, and (3) evaluate the correlation between those contents.We reviewed the trauma-related Orthopaedic In-Training Examination questions and answer keys for 2002 through 2007. Content for test questions and cited literature was assessed with the same criteria: (1) category type, (2) anatomic location, (3) orthopedic focus, and (4) treatment type. For each of the 3 most frequently referenced journals, we weighted content by dividing the number of times it was referenced by the number of its trauma-related articles. We then compared the journal data individually and collectively to the data from the Orthopaedic In-Training Examination trauma questions. A chi-square analysis with Yates correction was used to determine differences. Questions and literature were similar in the most frequently addressed items in each of the 4 areas: category type (taxonomy 3, treatment), 52.4% and 60.7%, respectively; anatomic location (femur), 23.3% and 27.7%, respectively; orthopedic focus (fracture), 51.0% and 56.5%, respectively; and treatment type (multiple/nonspecific), 39.0% and 35.4%, respectively.The content correlation found between the questions and literature supports the idea that reviewing current literature may help prepare for the trauma content on the Orthopaedic In-Training Examination.