A Dose-Finding, Biomarker Validation, and Effectiveness Study of Transcranial Magnetic Stimulation for Adolescents With Depression.

OBJECTIVE: Research and clinical application of transcranial magnetic stimulation (TMS) for adolescents with major depressive disorder (MDD) has advanced slowly. Significant gaps persist in our understanding of optimized, age-specific protocols and dosing strategies. This study aimed to compare the clinical effects of 1 Hz versus 10 Hz TMS regimens and examine a biomarker-informed treatment approach with glutamatergic intracortical facilitation (ICF). METHOD: Participants with moderate-to-severe symptoms of MDD were randomized to 30 sessions of left prefrontal 1 Hz or 10 Hz TMS, stratified by baseline ICF measures. The primary clinical outcome measure was the Children's Depression Rating Scale, Revised (CDRS-R). The CDRS-R and ICF biomarker were collected weekly. RESULTS: Forty-one participants received either 1 Hz (n = 22) or 10 Hz (n = 19) TMS treatments. CDRS-R scores improved compared to baseline in both 1 Hz and 10 Hz groups. For participants with low ICF at baseline, the overall least squares means of CDRS-R scores over the 6-week trial showed that depressive symptom severity was lower for the group treated with 1 Hz TMS than for those who received 10 Hz TMS. There were no significant changes in weekly ICF measurements across the 6 weeks of TMS treatment. CONCLUSION: Low ICF may reflect optimal glutamatergic N-methyl-d-aspartate (NMDA) receptor activity that facilitates the therapeutic effect of 1 Hz TMS through long-term depression-like mechanisms on synaptic plasticity. The stability of ICF suggests that it is a tonic, trait-like measure of NMDA receptor-mediated neurotransmission, with potential utility to inform parameter selection for therapeutic TMS in adolescents with MDD.

A retrospective, naturalistic study of deep brain stimulation and vagal nerve stimulation in young patients.

INTRODUCTION: Invasive neuromodulation interventions such as deep brain stimulation (DBS) and vagal nerve stimulation (VNS) are important treatments for movement disorders and epilepsy, but literature focused on young patients treated with DBS and VNS is limited. This retrospective study aimed to examine naturalistic outcomes of VNS and DBS treatment of epilepsy and dystonia in children, adolescents, and young adults. METHODS: We retrospectively assessed patient demographic and outcome data that were obtained from electronic health records. Two researchers used the Clinical Global Impression scale to retrospectively rate the severity of neurologic and psychiatric symptoms before and after patients underwent surgery to implant DBS electrodes or a VNS device. Descriptive and inferential statistics were used to examine clinical effects. RESULTS: Data from 73 patients were evaluated. Neurologic symptoms improved for patients treated with DBS and VNS (p < .001). Patients treated with DBS did not have a change in psychiatric symptoms, whereas psychiatric symptoms worsened for patients treated with VNS (p = .008). The frequency of postoperative complications did not differ between VNS and DBS groups. CONCLUSION: Young patients may have distinct vulnerabilities for increased psychiatric symptoms during treatment with invasive neuromodulation. Child and adolescent psychiatrists should consider a more proactive approach and greater engagement with DBS and VNS teams that treat younger patients.

Hip Preservation Surgery in Patients With Femoroacetabular Impingement Syndrome and Acetabular Dysplasia Improves Functional Measures and Pain Catastrophizing.

Background Chronic hip pain is a debilitating condition that severely reduces one's quality of life. Prior studies uncovered a link between hip pathologies and pain catastrophizing, anxiety, and depression. The purpose of this study was to investigate whether hip preservation surgery in patients with femoroacetabular impingement syndrome (FAIS) and acetabular dysplasia (AD) improves functional outcomes and pain catastrophizing. Methods Patients with FAIS and AD were requested to complete a hip questionnaire both preoperatively and postoperatively at a single academic center (University of Texas Southwestern Medical Center, Dallas, Texas, USA). Pain catastrophizing was evaluated using the pain catastrophizing scale, and pain level was assessed using the visual analog scale. Assessments of hip functional outcomes included the hip outcome score (HOS) and the hip disability and osteoarthritis outcome score (HOOS). Outcome measures before and after treatment were compared using the dependent samples t-test. A correlation analysis, using the Spearman partial correlation coefficient (rs), was conducted to evaluate the relationship between variables. Results The results indicated a clinically significant improvement in functional measures and pain catastrophizing in patients who underwent hip preservation surgery. The most significant discovery was an inverse relationship between both HOOS quality of life (rs=-0.293, p=0.0065, false discovery rate (FDR)=0.0210) and HOS activities of daily living (rs=-0.242, p=0.0254, FDR=0.0423) and pain catastrophizing; however, similar improvements were seen in pain catastrophizing with improvements in other functional outcomes. Conclusion Undergoing hip preservation surgery for patients with AD or FAIS improved their hip functional measures and decreased pain catastrophizing postoperatively. The improvement of hip function, quality of life, and pain catastrophizing reveals an intricate link between the functional outcomes of hip preservation surgery and pain catastrophizing.

The effect of parent-adolescent discrepancies in reports of familial dysfunction and depression on suicidal ideation in adolescents.

INTRODUCTION: Parents and adolescents are often discrepant in their reports of adolescent psychosocial factors. Few studies have addressed parent-adolescent discrepancies in subjective ratings of familial dysfunction and depression as longitudinal predictor variables, and none have done so in a treatment setting for adolescents with acute suicidality. This study examined how parent-adolescent discrepancies in familial dysfunction and depression impact adolescent treatment response in an intensive outpatient program for suicidality. METHODS: Adolescents (N = 315) were assessed at treatment entry and exit for familial dysfunction, depression, and suicidal ideation. Parents received parallel assessments of familial dysfunction and adolescent depression at each time point. A polynomial regression was conducted to determine whether parent-adolescent discrepancies in reports of familial dysfunction and depression at entry related to the treatment outcome of adolescent-reported depression and suicide ideation at exit. RESULTS: Significant discrepancies were present with on average adolescents reporting more depression and familial dysfunction than parents. Entry discrepancy in familial dysfunction (but not depression) predicted suicide ideation at exit. CONCLUSIONS: Our results suggest that parent-adolescent discrepancies in perception of familial dysfunction is a risk factor for poor outcomes in suicidal youth and might be a fruitful target in treatment programs.

The Relationship Between Postoperative Patient-Reported Psychological Outcomes and Preoperative Pain Characteristics in Patients Who Underwent Periacetabular Osteotomy.

This study sought to investigate the relationship between multiple preoperative characteristics of pain (maximum pain severity location, the presence of pain in certain locations, the highest level of pain, and the number of pain locations) and psychological outcome measures as reported by patients. Fifty-four hips (50 patients) that underwent periacetabular osteotomy to treat acetabular dysplasia between February 2017 and July 2020 were reviewed using the Depression, Anxiety, and Stress Scale-21 (DASS21), Hospital Anxiety and Depression Scale (HADS), and Pain Catastrophizing Scale (PCS), radiographic analysis, and questionnaires concerning pain severity/location. Twenty-six hips had their worst pain in the groin, whereas 28 hips had greater or equal levels of pain at another location. There was no significant difference between these two locations on any of the postoperative psychological outcomes (HADS, P=.53; DASS21, P=.85; PCS, P=.97). Additionally, there was not a significant relationship between pain in any location other than the groin and any postoperative psychological outcomes (P≥.08). Finally, the highest level of preoperative pain and the number of locations of pain demonstrated no significant relationship with postoperative psychological outcomes (maximum severity: HADS, P=.28; DASS21, P=.49; PCS, P=.57; number of pain locations: HADS, P=.47; DASS21, P=.60; PCS, P=.35). Variance in preoperative pain location, severity, and number of pain locations seemingly does not result in any significant effect on postoperative psychological outcomes. Thus, a large range of patients with acetabular dysplasia may experience similar, favorable psychological outcomes from treatment with periacetabular osteotomy notwithstanding the characteristics of preoperative pain. [Orthopedics. 2024;47(1):28-33.].

Association between preoperative respiratory symptoms and perioperative respiratory adverse events in pediatric patients with positive viral testing.

STUDY OBJECTIVE: To determine the association between the presence of upper respiratory tract viral infection symptoms and occurrence of perioperative respiratory adverse events (PRAE) in children with positive viral screening, and to analyze the risk of PRAE in children with SARS-CoV-2 compared to non-SARS-CoV-2 infection. DESIGN: A prospective cohort study. SETTING: A tertiary, freestanding pediatric hospital in Dallas, Texas. PATIENTS: Children <18 years of age with positive respiratory viral testing who underwent general anesthesia. INTERVENTION: Measurement of incidence of PRAE and severe adverse events during the first 7 postoperative days. MEASUREMENTS: The primary outcome was a composite of PRAE: oxygen saturation < 90% for >5 min, supplemental oxygen for >2 h after anesthesia, laryngospasm, and bronchospasm. The secondary outcome was severe adverse events: high flow nasal cannula >6 l of oxygen per minute, admission to the ICU for escalation of respiratory support post-anesthetic, acute respiratory distress syndrome, postoperative pneumonia, cardiovascular arrest, extracorporeal life support, and death. MAIN RESULTS: In this convenience sample of 196 children, 83 were symptomatic and 113 were asymptomatic. The risk of PRAE was similar in children with active viral symptoms and asymptomatic children (risk difference: -1.9%; 95% CI: -10.9, 7.9%), but higher among children with documented fever within 48 h of the anesthetic (risk difference: 20.8%; 95% CI: 5.3, 39.7%). The multivariable adjusted odds ratio of PRAE was 0.68 (95% CI: 0.25, 1.85) for symptomatic compared to asymptomatic patients, and 0.46 (95% CI: 0.14, 1.44) for patients with SARS-CoV-2 compared to non-SARS-CoV-2 infection. CONCLUSIONS: There was no significant difference in the incidence of PRAE between symptomatic and asymptomatic children with laboratory confirmed viral respiratory infection, and between children with the Omicron variant of SARS-CoV-2 compared to non-SARS-CoV-2 respiratory viruses. However, the risk was increased in children with recent fever.

Predicting Remission From Depression in Youth Receiving Outpatient Medication Management.

Objective: To examine 6-month remission rates of adolescents treated for depression in a university-based clinic and examine predictors of eventual remission.Methods: All patients aged 11-18 years treated in the clinic completed self-report measures assessing depression, suicidal ideation, anxiety, and associated symptoms. Remission was operationalized as a total score of ≤ 4 on the Patient Health Questionnaire-9 (PHQ-9) within 6 months of entering treatment.Results: Of the 430 patients, (76.74% female, 65.34% Caucasian, mean ± SD age 14.65 ± 1.69 years), 26.74% achieved remission within 6 months. Mean ± SD scores on the PHQ-9 at visit 1 (clinic entry) were 11.97 ± 4.76 for remitters (n = 115) and 15.03 ± 5.21 for non-remitters (n = 315). Predicted odds of remitting decreased as depressive symptom severity at visit 1 increased (OR = 0.941; 95% CI, 0.886 to 1.000; P = .051) and as scores on the Concise Associated Symptoms Tracking scale at treatment entry increased (OR = 0.971; 95% CI, 0.948 to 0.995; P = .017). As depression severity increased between visits, odds of remitting decreased (OR = 0.873; 95% CI, 0.827 to 0.921; P < .0001). Finally, adolescent males were more likely to achieve remission than females within 6 months (OR = 2.257; 95% CI, 1.351 to 3.771; P = .002).Conclusions: This study reports remission rates for depressed youth receiving medication management in a naturalistic outpatient setting. Results confirm that depression severity at treatment initiation and over time is a strong predictor of remission status. Additionally, monitoring associated symptoms via measurement-based care can provide important clinical information to inform treatment decisions.

The Relationship Between Pelvic Tilt and Clinical Outcomes After Hip Preservation Surgery in Femoroacetabular Impingement Syndrome and Hip Dysplasia.

Pelvic tilt is thought to be a compensatory mechanism in hip pathology, specifically in patients with femoroacetabular impingement syndrome (FAIS) and hip dysplasia. This study investigated the relationship between preoperative pelvic tilt and postoperative outcomes in patients undergoing hip preservation surgery for FAIS or hip dysplasia. We reviewed a prospective hip preservation database for demographic, radiographic, and outcome data for 89 patients who underwent hip preservation surgery with a primary diagnosis of FAIS or dysplasia from 2016 to 2020. Pelvic tilt was assessed on the standing anteroposterior radiograph with the pubic symphysis to sacroiliac joint (PS-SI) distance measurement. The International Hip Outcome Tool 12 (iHOT-12), Hip Outcome Score, Harris Hip Score, UCLA activity score, and European Quality of Life-Visual Analog Scale were used to assess hip function and pain preoperatively and postoperatively. The mean pelvic tilt (PS-SI distance) was 86.4±18.3 mm for the FAIS group and 96.2±15.1 mm for the dysplasia group. The statistical analysis demonstrated a positive relationship between pelvic tilt and change in iHOT-12 score (rs=0.262, P=.019) for all 89 patients with hip pathology and, separately, a trend toward significance for the 42 patients with FAIS (rs=0.330, P=.056). No other significant relationships were observed. The improvement in iHOT-12 score was greater for patients with more anterior tilt and less for patients with posterior pelvic tilt, regardless of underlying hip etiology. These results provide intriguing insights into an initial investigation on pelvic tilt in patients undergoing hip preservation surgery. Further investigation is necessary to assess pelvic tilt preoperatively and postoperatively, spinal parameters, and longer-term outcomes. [Orthopedics. 2023;46(6):e341-e346.].

Sequential bilateral accelerated theta burst stimulation in adolescents with suicidal ideation associated with major depressive disorder: Protocol for a randomized controlled trial.

BACKGROUND: Suicide is a leading cause of death in adolescents worldwide. Previous research findings suggest that suicidal adolescents with depression have pathophysiological dorsolateral prefrontal cortex (DLPFC) deficits in γ-aminobutyric acid neurotransmission. Interventions with transcranial magnetic stimulation (TMS) directly address these underlying pathophysiological deficits in the prefrontal cortex. Theta burst stimulation (TBS) is newer dosing approach for TMS. Accelerated TBS (aTBS) involves administering multiple sessions of TMS daily as this dosing may be more efficient, tolerable, and rapid acting than standard TMS. MATERIALS AND METHODS: This is a randomized, double-blind, sham-controlled trial of sequential bilateral aTBS in adolescents with major depressive disorder (MDD) and suicidal ideation. Three sessions are administered daily for 10 days. During each session, continuous TBS is administered first to the right DPFC, in which 1,800 pulses are delivered continuously over 120 seconds. Then intermittent TBS is applied to the left DPFC, in which 1,800 pulses are delivered in 2-second bursts and repeated every 10 seconds for 570 seconds. The TBS parameters were adopted from prior research, with 3-pulse, 50-Hz bursts given every 200 ms (at 5 Hz) with an intensity of 80% active motor threshold. The comparison group will receive 3 daily sessions of bilateral sham TBS treatment for 10 days. All participants will receive the standard of care for patients with depression and suicidal ideation including daily psychotherapeutic skill sessions. Long-interval intracortical inhibition (LICI) biomarkers will be measured before and after treatment. Exploratory measures will be collected with TMS and electroencephalography for biomarker development. DISCUSSION: This is the first known randomized controlled trial to examine the efficacy of sequential bilateral aTBS for treating suicidal ideation in adolescents with MDD. Results from this study will also provide opportunities to further understand the neurophysiological and molecular mechanisms of suicidal ideation in adolescents. TRIAL REGISTRATION: Investigational device exemption (IDE) Number: G200220, ClinicalTrials.gov (ID: NCT04701840). Registered August 6, 2020. https://clinicaltrials.gov/ct2/show/NCT04502758?term=NCT04701840&draw=2&rank=1.

Dysplastic hips demonstrate increased joint translation at higher body mass index.

OBJECTIVE: To determine which radiographic measures used to define the severity of hip dysplasia are associated with hip joint translation and to investigate relationships between position, body mass index, and joint translation. MATERIALS AND METHODS: This is a cross-sectional retrospective study evaluating 10 validated radiographic measures of dysplasia on weight-bearing AP pelvis and supine 45-degree bilateral Dunn radiographs of 93 young adults with symptomatic hip dysplasia presenting to a single academic institution between October 2016 and May 2019. We determined the difference between standing and supine measurements for each hip and the correlation of each measure with the patient's body mass index. RESULTS: Femoral head extrusion index was 2.49% lower on supine X-ray (p = 0.0020). Patients with higher body mass index had higher center gap distance (p = 0.0274), femoral head extrusion (p = 0.0170), and femoral head lateralization (p = 0.0028) when standing. They also had higher Tönnis angle (pstanding = 0.0076, psupine = 0.0121) and lower lateral center-edge angle (pstanding = 0.0196, psupine = 0.0410) in both positions. The difference in femoral head lateralization between standing and supine positions increased with higher body mass index (p = 0.0081). CONCLUSION: Translation of the hip joint with position change is demonstrated by decreased femoral head extrusion index on supine X-ray. Patients with higher body mass index had more dysplastic hips, as measured by five of six radiographic outcomes of dysplasia, and experienced more translation with weight-bearing, reflected by increased femoral head lateralization.

A Systematic Review of Intramedullary Fixation in Midfoot Charcot Neuroarthropathy.

Charcot neuroarthropathy can cause severe deformity of the midfoot, and intramedullary use of beams and bolts has been utilized as a method of definitive stabilization. This systematic review evaluated the outcomes of intramedullary beaming in patients with Charcot neuroarthropathy and determined the methodological quality of the studies. Four online databases were searched: PubMed, MEDLINE (Clarivate Analytics), CINAHL (Cumulative Index to Nursing and Allied Health) and Web of Science (Clarivate Analytics). To assess the methodological quality of the studies, the Coleman Methodology Score was used. The data was pooled into 2 outcomes groups for comparison: (1) Studies that reported on the outcomes of Charcot specific implants (study group). (2) Studies that reported on the outcomes using non-Charcot specific implants (control group). After screening, 16 studies were included. Compared to our control group, our study group had significantly higher rates of overall hardware complications, hardware migration, surgical site infection, reoperation, and nonunion. The study group had significantly lower rates of limb salvage compared to the control group. Our study and control groups did not differ in the rates of hardware breakage, wound healing complications, or mortality. The limb salvage rate was 92% and 97% of patients were still alive at a mean follow-up of 25 months. The mean Coleman Methodology Score indicated the quality of the studies was poor and consistent with methodologic limitations. The quality of published studies on intramedullary implants for Charcot reconstruction is low. Complications when utilizing intramedullary fixation for Charcot reconstruction are high, whether or not Charcot specific implants are used.

Amputation and infection are the greatest fears in patients with diabetes foot complications.

AIMS: To determine the degree patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations fear complications (death, dialysis, heart attack, stroke, blindness, diabetic foot infection, minor and major lower extremity amputation [LEA]) that can occur and to assess if there is a difference between fears of patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations and diabetic patients without these complications. METHODS: 478 patients completed an eight question Likert scale survey. The study group was defined as non-infected foot ulcers, neuropathic fractures and Charcot neuroarthropathy. RESULTS: Of the 478 patients, 121 (25.3 %) had diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations and 357 (74.7 %) did not. The study group had significantly higher odds of reporting extreme fear of foot infection (OR 2.8, 95 % CI 1.8-4.5), major LEA (OR 2.8, 95 % CI 1.8-4.4), minor LEA (OR 2.3, 95 % CI 1.5-3.5), blindness (OR 2.0, 95 % CI 1.3-3.2), dialysis (OR 2.0, 95 % CI 1.1-3.3), and death (OR 2.4, 95 % CI 1.4-4.2). In the study group highest rated fear measures were foot infection (3.71, SD 1.23), minor amputation (3.67, SD 1.45) and major amputation (3.63, SD 1.52). There were no significant differences in the mean fear of infection, minor amputation or major amputation. CONCLUSION: Patients with diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations reported higher fear ratings of diabetes-related complications compared to those without these complications.

The relationship between pre-operative pain characteristics and periacetabular osteotomy outcomes in patients with acetabular dysplasia.

The aims of this study were to determine if pre-operative pain characteristics (location of maximum severity of pain, presence of non-groin pain, maximum severity of pain and number of pain locations) affect patient-reported outcome measures in patients undergoing periacetabular osteotomy (PAO) for acetabular dysplasia. We reviewed 52 hips (48 patients) treated with PAO for acetabular dysplasia from February 2017 to July 2020 using modified Harris Hip Score (mHHS), Hip Outcome Score (HOS) and international Hip Outcome Tool (iHOT-12) score, radiographic analysis and pain location/severity questionnaires. Descriptive statistics, analysis of covariance and Spearman partial correlation coefficients were implemented. Twenty-six hips experienced the most severe pre-operative pain in the groin, and 26 hips experienced equal or greater pain in a non-groin location. Outcome scores between these groups were not significantly different (mHHS P = 0.59, HOS P = 0.48, iHOT-12 P = 0.99). Additionally, the presence of pre-operative pain in any non-groin location had no significant relationship with PROM (all P-values ≥0.14). Furthermore, the maximum severity of pre-operative pain and number of pain locations showed no significant relationship with PROM (maximum severity: mHHS P = 0.82, HOS P = 0.99, iHOT-12 P = 0.36; number of pain locations: mHHS P = 0.56, HOS P = 0.10, iHOT-12 P = 0.62). Varying pre-operative pain characteristics do not appear to have any significant impact on outcomes. Therefore, a wide array of patients with acetabular dysplasia might expect similar, favourable outcomes from PAO regardless of pre-operative pain characteristics.

The relationship between patient-reported outcomes and preoperative pain characteristics in patients who underwent total hip arthroplasty.

AIMS: This study aims to answer the following questions in patients with hip osteoarthritis (OA) who underwent total hip arthroplasty (THA): are patient-reported outcome measures (PROMs) affected by the location of the maximum severity of pain?; are PROMs affected by the presence of non-groin pain?; are PROMs affected by the severity of pain?; and are PROMs affected by the number of pain locations? METHODS: We reviewed 336 hips (305 patients) treated with THA for hip OA from December 2016 to November 2019 using pain location/severity questionnaires, modified Harris Hip Score (mHHS), Hip Outcome Score (HOS), international Hip Outcome Tool (iHOT-12) score, and radiological analysis. Descriptive statistics, analysis of covariance (ANCOVA), and Spearman partial correlation coefficients were used. RESULTS: There was a significant difference in iHOT-12 scores between groups experiencing the most severe pain in the groin and the trochanter (p = 0.039). Additionally, more favourable mHHS scores were related to the presence of preoperative pain in trochanter (p = 0.049), lower back (p = 0.056), lateral thigh (p = 0.034), and posterior thigh (p = 0.005). Finally, the maximum severity of preoperative pain and number of pain locations had no significant relationship with PROMs (maximum severity: HHS: p = 0.928, HOS: p = 0.163, iHOT-12 p = 0.233; number of pain locations: HHS: p = 0.211; HOS: p = 0.801; iHOT-12: p = 0.112). CONCLUSION: Although there was a significant difference in iHOT-12 scores between patients with the most severe pain in the groin or trochanter, and the presence of pain in the trochanter, lower back, lateral thigh, or posterior thigh was related to higher mHHS scores, the majority of preoperative pain characteristics did not have a significant impact on outcomes. Therefore, a broad array of patients with hip OA might expect similar, favourable outcomes from THA notwithstanding preoperative pain characteristics. Cite this article: Bone Jt Open 2022;3(4):332-339.

Low rate of malalignment using the tibial traction triangle for infrapatellar nailing of distal tibia fractures.

OBJECTIVES: To report on the immediate postoperative alignment of distal tibia fractures (within 10 cm of the tibial plafond) treated with infrapatellar intramedullary nailing (IMN) using the tibial traction triangle (TTT). METHODS: We performed a retrospective cohort study at a Level-I academic trauma center, with eighty-one skeletally mature patients with closed distal tibia fractures treated over a 10-year period with closed infrapatellar intramedullary nailing, without fibula fixation, using the TTT. The primary outcome measure is primary malalignment ≥5°. RESULTS: Primary malalignment occurred in 4 (4.9%) patients, all in the coronal plane. Mean coronal plane alignment was 1.72° valgus (range 3° varus to 8° valgus). No sagittal malalignment occurred. The fibula was intact in 5 (6.2%) cases. No patients underwent fibula fixation or blocking screw placement. Intra-articular extension occurred in 28 (34.6%) cases. Mean fracture distance from the plafond was 5.98 cm. Thirty-one patients had a fracture within 5 cm of the plafond, where malalignment was noted in 2 (6.5%) patients. CONCLUSIONS: This is the first analysis of a large cohort of patients with distal tibia fractures treated with the TTT. Use of this device leads to a very low rate of primary malalignment with infrapatellar nailing, even in extremely distal fractures. We recommend consideration of this device as one more adjunct to help treat these difficult fractures successfully.

Identifying Risk Factors for Nonunion of the Modified Lapidus Procedure for the Correction of Hallux Valgus.

There is a paucity of literature characterizing risk factors for nonunion associated with the modified Lapidus procedure for correction of hallux valgus. The purpose of this study was to evaluate risk factors associated with nonunion for Lapidus bunionectomies. Patients who underwent modified Lapidus procedure from 2009 to 2018 were retrospectively reviewed. Patient's age, sex, body mass index, prior bunionectomy, history of tobacco use, presence of diabetes mellitus or hypothyroidism, and fixation method were recorded along with pre- and postoperative radiographic parameters. A multiple logistic regression analysis was implemented to estimate the odds of nonunion. Of the 222 patients who met inclusion criteria, nonunion with modified Lapidus procedure was observed in 20 patients (9.01%). Odds of nonunion with modified Lapidus procedure were greater for patients who had undergone previous bunionectomy (odds ratio [OR] = 3.957, 95% confidence interval [CI]: 1.021-15.338), as body mass index increased (OR = 1.091, 95% CI: 1.018-1.170), and as preoperative HV angle increased (OR = 1.108, 95% CI: 1.020-1.203). Odds of nonunion were lower for patients as preoperative intermetatarsal angle increased (OR = 0.739, 95% CI: 0.580-0.941). No significant increased odds of nonunion were found between fixation methods.

Sex differences in reporting of concussion symptoms in adults.

Objective: To examine differences in concussion symptom reporting between female and male adults considering current psychological symptoms such as anxiety and depression and pre-injury factors in order to identify sex differences which may guide treatment efforts. Method: This prospective study is part of the North Texas Concussion Registry (ConTex). Subjects (N = 132) age 19 to 78 years had sustained a concussion within 30 days of clinic visit. The independent variable was sex and covariates included age, ethnicity, current anxiety and depression ratings, history of attention deficit disorder, history of headache/migraine, and time to clinic. The dependent variables were 22 post-concussion symptoms as measured by the Sport Concussion Assessment Tool-5 Post-Concussion Symptom Scale. Results: Analysis of covariance and ordinal logistic regression results both revealed that females had a greater likelihood of reporting increased symptom severity for 15/22 concussion symptoms. The largest risk ratios (effect size) in symptom reporting between sexes (higher symptoms in females) included: feeling more emotional 4.05 (0.72), fatigue or low energy 4.05 (0.72), sensitivity to light 3.74 (0.69), headache 3.65 (0.57), balance problems 3.31 (0.53), pressure in head 3.06 (0.51), and neck pain 2.97 (0.60). Conclusions: Adult females in our sample reported higher levels of many concussion symptoms than males and showed an increased risk of developing these same symptoms following concussion. Examination of the magnitude of sex difference in concussion symptom reporting will better inform medical staff to anticipate and address symptoms that may present greater challenges for adult females.

Are Readmission and Reoperation Rates for Lower Extremity Necrotizing Fasciitis Different Between Patients With and Without Diabetes Mellitus?

Necrotizing fasciitis is a condition associated with high morbidity and mortality unless emergent surgery is performed. This study aims to understand the hospital course of diabetic and nondiabetic patients managed for lower-extremity necrotizing fasciitis by identifying factors contributing to readmissions and reoperations. About 562 patients treated for lower-extremity necrotizing fasciitis were selected from the American College of Surgeons-National Surgical Quality Improvement Program database between 2012 and 2017. The unplanned reoperation and readmission rates for all patients during the 30-day postoperative period were 9.4% and 5.3%, respectively. Out of 562 patients with lower-extremity necrotizing fasciitis, 326 (58.0%) patients had diabetes. Diabetes patients were more likely to undergo amputation (p < .00001). Neither readmission (6.1% vs 4.2%, p = .411) nor reoperation (8.6% vs 10.6%, p = .482) were significantly different between patients with and without diabetes. Neither readmission (7.2% vs 4.0%, p = .159) nor reoperation (4.1% vs 3.7%, p = .842) were significantly different between patients undergoing amputation and nonamputation procedures. In simple logistic regression, factors associated with unplanned reoperation included poorer renal function, thrombocytopenia, longer duration of surgery, longer hospital length of stay, postoperative surgical site infection, postoperative respiratory distress, and postoperative septic shock. Body mass index >30 kg/m2 was associated with decreased odds of readmission. In multiple logistic regression, surgical site infection was the only predictor of reoperation (adjusted odds ratio 7.32, 95% confidence interval 2.76-19.1), and any amputation was associated with readmission (adjusted odds ratio 4.53, 95% confidence interval 1.20-29.6). Further study is needed to understand patient characteristics to better direct management. However, the current study elucidates patient outcomes for a relatively rare condition.

The Impact of Hospitalization for Diabetic Foot Infection on Health-Related Quality of Life: Utilizing PROMIS.

Diabetic foot infections (DFI) are an increasingly common cause of hospitalizations. Once hospitalized with DFI, many patients require some level of amputation, often undergoing multiple operations. With increasing importance on patient-centered metrics, self-reported health-related quality of life (HRQOL) tools have been developed. This prospective cohort study aimed assessed the impact of DFI on HRQOL. Two hundred twenty-four patients completed the 29-item Patient-Reported Outcome Measurement Information System (PROMIS) and 12-Item Short Form (SF-12) survey. Secondary outcomes using the Foot and Ankle Ability Measures survey were obtained and included in the analysis. The study group was comprised of hospitalized patients with DFIs (n = 120), and the control group was comprised of patients with diabetes who were evaluated for routine outpatient foot care (n = 104); diabetic foot screening, wound care, onychomycosis, and/or callosities. Using this cohort, a propensity score-matched sample of hospitalized patients with DFI (n = 35) and control group patients (n = 35) was created for comparative analysis. The 2-independent sample t test was used to test for group differences on each of the PROMIS subscale outcomes. Using PROMIS, we found that hospitalized patients with DFI reported significantly worse HRQOL in 6 of 7 subscales (physical function, anxiety, depression, fatigue, social role, pain intensity; p value range: .0001-.02) compared to outpatients with diabetes evaluated for routine foot care. There was no significant difference between the 2 groups on sleep disturbance (p = .22). Patients hospitalized for DFI report lower HRQOL compared to patients with diabetes receiving routine outpatient foot care.

A Retrospective Examination of the Impact of Pharmacotherapy on Parent-Child Interaction Therapy.

Objective: Parent-child interaction therapy (PCIT) is an evidence-based approach for children aged 2-7 years with disruptive behavior problems. This study examined the effectiveness of PCIT with and without concurrent pharmacotherapy. Methods: A convenience sample was collected from a retrospective chart review of preschool-aged children treated with PCIT at the Mayo Clinic Young Child Clinic between 2016 and 2020. Quantitative and qualitative data were abstracted from all patients. The sample was divided into two groups based on psychotropic medications status (medicated and unmedicated) at the initiation of PCIT. Effectiveness of treatment was assessed with the change in Eyberg Child Behavior Inventory (ECBI) score. The change over time in ECBI score was compared between the two PCIT groups with and without concurrent pharmacotherapy using a linear mixed model. Results: Of the 62 youth, 38.71% were females. Mean age was 4.71 ± 1.17 years. The mean baseline ECBI score was 148.74 ± 30.86, indicating clinically significant disruptive behaviors. The mean number of PCIT sessions was 6.59 ± 3.82. There was no statistically significant difference in ECBI scores between the two groups at pre-PCIT (medication group: 149.68, standard error [SE] = 11.61 vs. unmedicated group: 147.92, SE = 10.93, p = 0.8904) and at post-PCIT (medication group: 116.27 [SE = 11.89] vs. unmedicated group: 128.86 [SE = 11.57], p = 0.3464). There was a statistically significant improvement in ECBI scores for both groups after completing therapy (medication group = -33.41 [-22.32%], SE = 6.27, p < 0.0001; d = 1.144; unmedicated group = -19.06 [-12.88%], SE = 5.78, p = 0.0022; d = 1.078). Conclusions: PCIT reduced disruptive behaviors in this sample of young children regardless of concurrent pharmacotherapy. Future prospective studies should consider one particular pharmacological agent and long-term outcomes of treatment. PCIT and certain pharmacological treatments could have complex and important bidirectional priming effects for both treatments.