Traumatic brain injury (TBI) is one of the most prevalent causes of morbidity in the United States and is associated with numerous chronic sequelae long after the point of injury. One of the most common long-term complaints in patients with TBI is sleep dysfunction. It is reported that alterations in melatonin follow TBI and may be linked with various sleep and circadian disorders directly (via cellular signaling) or indirectly (via free radicals and inflammatory signaling). Work over the past two decades has contributed to our understanding of the role of melatonin as a sleep regulator and neuroprotective anti-inflammatory agent. Although there is increasing interest in the treatment of insomnia following TBI, a lack of standardization and rigor in melatonin research has left behind a trail of non-generalizable data and ambiguous treatment recommendations. This narrative review describes the underlying biochemical properties of melatonin as they are relevant to TBI. We also discuss potential benefits and a path forward regarding the therapeutic management of TBI with melatonin treatment, including its role as a neuroprotectant, a somnogen, and a modulator of the circadian rhythm.

Objectives: To compare objective costs between an in-house developed arthroscopy simulator and commercially available options. Design: Cost analysis. Setting: Orthopaedic graduate medical education. Patients/Participants: Eight board-certified orthopaedic surgeons and nineteen novice learners. Intervention: Simulation Training. Main outcome measurement: Cost difference between an in-house developed simulator and a commercially available simulator. Results and conclusions: Significant price differences exist between in-house simulator production cost and commercially available simulators. Low-cost, in-house simulators improve access to arthroscopic simulation training for novice learners by reducing up front cost by 29% and reducing recurring costs by over 90% when compared to a similar commercially available option. Level of Evidence: IV; Cost Analysis Keywords: Education; Simulation; Orthopaedics; Arthroscopy; Simulation Based Learning Theory (J Ortho Business Jan 2022;2(1):7-9)

Objectives: To develop and validate a novel, low-cost shoulder arthroscopy partial task trainer. Study Design: Cross-sectional study Methods: A low-cost arthroscopy model was created to simulate navigation and triangulation skills in conjunction with ABOS-certified Orthopaedic surgeons' input. Each participant performed three trials of simulated labral repair and performance data was compared between experienced surgeons and novice medical students. Results: A total of 8 orthopaedic surgeons in the experienced group and 18 medical students in the novice group participated in the study. The average age of the experienced group was 43.1 years old, with 8.3 years of post-residency experience. The average age of the novice group was 24.3 years. The experienced group completed the simulation task faster than the novice group (16.6±7.6 vs. 96.4 ±102.2 seconds; p<0.001). Conclusion: The shoulder arthroscopy model demonstrated significant differences in performance between experienced orthopaedic surgeons and novices when used to assess a standardized basic arthroscopic technical skill. This low-cost trainer discriminates between varying skill levels and may be an effective option for simulation training of arthroscopic fundamentals to novice learners. Level of Evidence: III, Case Control Keywords: Arthroscopy, Simulation, Validity Evidence, Orthopaedics, Graduate Medical Education (J Ortho Business 2022; Volume 2, Issue 4:pages 1-4)

An 82-year-old woman with multiple medical problems was hospitalized for respiratory failure after failing outpatient antibiotic therapy for community-acquired pneumonia. Imaging revealed a right upper lobe consolidation with extension beyond the pleural margin into the endothoracic fascia and intercostal musculature, consistent with empyema necessitans (EN). Extensive microbiologic evaluation, including Coccidioides spp. serology, was negative. Plasma microbial cell-free DNA (cfDNA) testing (Karius assay) was obtained and identified Coccidioides immitis. The patient was treated with isavuconazole rather than typical first-line therapy due to potential drug interactions and underlying renal dysfunction. She subsequently demonstrated steady clinical and radiographic improvement and was discharged with continued recovery. This case highlights EN as a rare complication of pulmonary coccidioidomycosis and a successful alternative treatment regimen. It also underscores the limitations of early serologic testing, particularly in immunocompromised patients and illustrates the utility of plasma microbial cfDNA testing in establishing a diagnosis when conventional studies are inconclusive.