A review of the use of patient reported outcome measures (PROMS) in temporomandibular joint (TMJ) surgery.

Temporomandibular joint (TMJ) surgery accounts for a significant number of patient episodes in oral and maxillofacial surgery, and treatment effectiveness is commonly assessed using measures of pain and mouth opening. Patient-reported outcome measures (PROMs) enable assessment of the patient's perspective and perception of the diseases and treatment outcomes. The purpose of this review was to assess the use of PROMs in TMJ surgery. A review of 3 databases (PubMed, OVID, Trip) was carried out to assess the use of PROMs when reporting on TMJ surgical interventions. Studies were limited to the English language, involving humans and at least one surgical intervention of the TMJ. A total of 214 articles met the inclusion and exclusion criteria, of which only 28 used 18 PROMs among them. Half of these PROMs were single-question visual analogue scales or Likert scales on quality of life and disability. The Oral Health Impact Profile and the Helkimo Clinical Dysfunction Index were the second most used (n = 3). PROMs were used most in studies on internal derangement (n = 9) and in cohort study designs (n = 26), but this was not statistically significant. In the majority of research on TMJ surgery, no PROMs are used, and when one is, there is a tendency to use weaker single-question PROMs as opposed to multi-question PROMs to assess outcomes. With the increasing importance of PROMs for assessing patients' perception of treatment outcomes, further research is needed to establish valid and reproducible PROMs for TMJ surgery.

Is anterior knee pain following anterior cruciate ligament reconstruction a consideration for graft choice, and the influence of COVID: a qualitative analysis in recreational athletes.

BACKGROUND: We set out to investigate whether anterior knee pain following anterior cruciate ligament reconstruction has a significant effect on patients, and whether it should influence graft choice. METHODS: This was a qualitative analysis of a set of recreational athletes treated at a university hospital at about 1 year following anterior cruciate ligament reconstruction surgery. Participants were interviewed by an orthopaedic fellow and resident using structured, open-ended questions. Inductive theme analysis was used to code the data. RESULTS: There were 4 major themes: (1) Our hypothesis was that patients would be given adequate information to make an appropriate graft choice. This hypothesis was rejected. Discussion took place, but with little details or rationale for the graft choice. The predominant theme was that the surgeon made the decision, and there was a lack of reliable information for the patient to make a choice. (2) The overall theme was that most patients had no anterior knee pain, and it did not interfere with activities of daily living. (3) One theme was that patients were able to resume all sports without restriction, but in some, the anterior knee pain interfered with the more demanding activities such as impact, cutting, and pivoting. A separate theme was that fear was a major impediment to return to sports and was not related to the anterior knee pain. (4) The overriding theme was that the generalized closures associated with the COVID-19 pandemic slowed the rehabilitation process. Although virtual care was available in general, it was not particularly satisfactory. Patients indicated that they had not been able to return to the gym or to their sporting activities as a result. CONCLUSIONS: Amongst non-competitive athletes, anterior knee pain post-anterior cruciate ligament reconstruction surgery does not significantly affect activities of daily living. Although there is a minor effect on sporting activities, the inability to return to sports is related to factors such as the COVID-19 pandemic, fear, or insufficient rehabilitation, rather than anterior knee pain. Overall, anterior knee pain is not a significant factor that plays a role in determining graft choice.

2-Octyl Cyanoacrylate (Dermabond®) Inhibits Bridging Bone Formation of Articular Fractures in a Rat Model.

One technique often used for small intraarticular fracture fixation involves the use of 2-octyl-cyanoacrylate (2-OCTA) (Dermabond®, Ethicon, Inc., Raritan, USA). The purpose of this study was to determine if 2-OCTA impedes bony healing. Osteochondral plugs in 38 retired Sprague-Dawley rats were created in both hind legs. Each rat had one plug dipped in 2-OCTA before fixation and one control plug. H&E staining was used to quantify bone bridging. The 2-OCTA group had a mean bridging bone circumference of 22.80%, significantly less than 67.75% in the control group (p<0.05). Our data suggests that 2-OCTA blocks bridging bone formation, making it a poor choice for fracture fixation.

Unfit Assessments of Class 1 Medical Certificate Holders.

INTRODUCTION: An aviation safety management system should consider and mitigate against all potential risks to flight safety. In addition to in-flight incapacitation, pilots falling below regulatory standards who are assessed as unfit may have represented a risk prior to that assessment. An analysis was undertaken of Class 1 certificate holders to determine factors correlated with unfit assessments.METHODS: Fitness assessments of pre-existing Class 1 certificate holders following medical examinations (to EASA Part-MED standards) or between medicals were studied between 1 January 2016 and 31 December 2019. Assessments where the outcome was 'fit' (N= 99,406) were compared with those where the outcome was 'unfit' (N= 7925). Analyses for correlation between unfit assessments against age, declared coexisting medical conditions, and the number of days since last assessed as fit were undertaken using SPSS.RESULTS: Unfit assessment likelihood and age were strongly correlated; there is, however, evidence for the 'healthy worker effect', with a fall in unfit assessments between 60-65 yr of age. There was no association between coexisting medical condition declaration and the likelihood of becoming unfit. The time interval between a fit and unfit assessment was significantly lower when comparing 20-60 and 61-63 yr old individuals.DISCUSSION: The analysis of unfit assessments shows strong correlation with increasing age and the possible presence of the healthy worker effect among commercial pilots. The decreased time from a previous fit assessment to an unfit assessment supports the reduced certificate validity period of Class 1 applicants over 60 yr of age.Cairns MK. Unfit assessments of Class 1 Medical certificate holders. Aerosp Med Hum Perform. 2021; 92(12):945-949.

Autologous Platelet Concentrates to improve post extraction outcomes.

Data sourcesElectronic search of Medline, Embase, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL). Manual search of multiple dental journals and review reference lists.Study selectionTwo authors searched studies without any language or follow-up duration restrictions. Randomised and controlled clinical trials with a minimum of five patients per group and a parallel or split-mouth design were included. Outcome variables assessed comparing APC use included: patient satisfaction, self-reported postoperative quality of life, radiographic bone healing, clinical and radiographic marginal bone remodelling, soft tissue healing and complications such as alveolar osteitis.Data extraction and synthesisMethodologic quality of research was assessed using the following parameters: random sequence generation method and allocation concealment, calibration and binding of outcome assessment, comparability of control and treatment groups at entry, clear definition of inclusion and exclusion criteria, clear definition of outcomes assessment and success criteria, completeness of the outcome data reported and explanation for dropouts/withdrawal, recall rate, sample size and number of surgeons involved. Meta-analysis was carried out with data from studies reporting the same outcome measurements at comparable observations times following tooth extraction. Dichotomous outcomes (ie development of alveolar osteitis) for different treatments were expressed as risk ratios with a 95% confidence interval and continuous outcomes (ie quantifiable bone changes) were expressed as mean differences with a 95% confidence interval. Study design risk of bias was assessed using sensitivity analysis.ResultsThirty three studies met the inclusion criteria. Soft tissue healing at seven days after extraction was better when APCs were used (mean difference of 1.01; 95% CI; 0.77 to 1.24). Three months postoperatively, the second mandibular molar distal probing depth was statistically better in the APC group, mean difference of -1.63; (95% CI; -2.05 to -1.22). There were no statistical differences between the APC and control groups for alveolar osteitis, acute inflammation or alveolar infection. Although the percentage of new bone and indirect measurement of bone metabolism were similar for both groups, bone density was statistically better for the APC group, mean difference of 5.06; (95% CI; 1.45 to 8.66). Qualitative analysis found decreased swelling in four of five studies and decreased trismus in two of three studies. The variations between different types of APCs were not evaluated as part of this review.ConclusionsAPCs including platelet-rich plasma (PRP), platelet-rich fibrin (PRF) and plasma rich in growth factors (PRGF) can be used following tooth extraction to improve soft tissue healing, probing depth and bone density, as well as to reduce swelling and trismus. However, their use in reducing other postoperative complications such as pain, alveolar osteitis, inflammation, infection, or in improving new bone percentage and metabolism cannot be recommended. Study heterogeneity made it impossible to perform meta-analysis for pain reduction; therefore further studies investigating the effect on pain are required.

Are Medicare's "Comprehensive Care for Joint Replacement" Bundled Payments Stratifying Risk Adequately?

BACKGROUND: Bundled payments are meant to reduce costs and improve quality of care. Without adequate risk adjustment, bundling may be inequitable to providers and restrict access for certain patients. This study examines patient factors that could improve risk stratification for the Comprehensive Care for Joint Replacement (CJR) bundled-payment program. METHODS: Ninety-five thousand twenty-four patients meeting the CJR criteria were retrospectively reviewed using administrative Medicare data. Multivariable regression was used to identify associations between patient factors and traditional (fee-for-service) Medicare reimbursement over the bundle period. RESULTS: Average reimbursement was $18,786 ± $12,386. Older age, male gender, cases performed for hip fractures, and most comorbidities were associated with higher reimbursement (P < .05), except dementia (lower reimbursement; P < .01). Stratification incorporating these factors displayed greater accuracy than the current CJR risk adjustment methods (R2 = 0.23 vs 0.17). CONCLUSION: More robust risk stratification could provide more equitable reimbursement in the CJR program. LEVEL OF EVIDENCE: Large database analysis; Level III.

Refining Risk Adjustment for the Proposed CMS Surgical Hip and Femur Fracture Treatment Bundled Payment Program.

BACKGROUND: The U.S. Centers for Medicare & Medicaid Services (CMS) has been considering the implementation of a mandatory bundled payment program, the Surgical Hip and Femur Fracture Treatment (SHFFT) model. However, bundled payments without appropriate risk adjustment may be inequitable to providers and may restrict access to care for certain patients. The SHFFT proposal includes adjustment using the Diagnosis-Related Group (DRG) and geographic location. The goal of the current study was to identify and quantify patient factors that could improve risk adjustment for SHFFT bundled payments. METHODS: We retrospectively reviewed a 5% random sample of Medicare data from 2008 to 2012. A total of 27,898 patients were identified who met SHFFT inclusion criteria (DRG 480, 481, and 482). Reimbursement was determined for each patient over the bundle period (the surgical hospitalization and 90 days of post-discharge care). Multivariable regression was performed to test demographic factors, comorbidities, geographic location, and specific surgical procedures for associations with reimbursement. RESULTS: The average reimbursement was $23,632 ± $17,587. On average, reimbursements for male patients were $1,213 higher than for female patients (p < 0.01). Younger age was also associated with higher payments; e.g., reimbursement for those ≥85 years of age averaged $2,282 ± $389 less than for those aged 65 to 69 (p < 0.01). Most comorbidities were associated with higher reimbursement, but dementia was associated with lower payments, by an average of $2,354 ± $243 (p < 0.01). Twenty-two procedure codes are included in the bundle, and patients with the 3 most common codes accounted for 98% of the cases, with average reimbursement ranging from $22,527 to $24,033. Less common procedures varied by >$20,000 in average reimbursement (p < 0.01). DRGs also showed significant differences in reimbursement (p < 0.01); e.g., DRG 480 was reimbursed by an average of $10,421 ± $543 more than DRG 482. Payments varied significantly by state (p ≤ 0.01). Risk adjustment incorporating specific comorbidities demonstrated better performance than with use of DRG alone (r = 0.22 versus 0.15). CONCLUSIONS: Our results suggest that the proposed SHFFT bundled payment model should use more robust risk-adjustment methods to ensure that providers are reimbursed fairly and that patients retain access to care. At a minimum, payments should be adjusted for age, comorbidities, demographic factors, geographic location, and surgical procedure.

Incidence, Severity, and Time Loss Associated With Collegiate Football Fractures, 2004-2005 to 2013-2014.

BACKGROUND: The inherent risk of any time loss from physical injury in football has been extensively discussed, with many such injuries having a profound effect on the lives of National Collegiate Athletic Association (NCAA) football players. However, the incidence of fractures in collegiate football has not been well established. PURPOSE: To examine the epidemiology of fractures in NCAA football. STUDY DESIGN: Descriptive epidemiology study. METHODS: Fracture data reported in college football during the 2004-2005 to 2013-2014 academic years were analyzed from the NCAA Injury Surveillance Program (NCAA-ISP). Fracture rates per 1000 athlete-exposures, surgery and time loss distributions, injury rate ratios, injury proportion ratios (IPRs), and 95% CIs were reported. RESULTS: Overall, 986 fractures were reported. The rate of competition fractures was larger than the rate of practice fractures (1.80 vs 0.17 per 1000 athlete-exposures; injury rate ratio = 10.56; 95% CI, 9.32-11.96). Fractures of the hand/fingers represented 34.6% of all injuries, while fibula fractures (17.2%) were also common. A majority (62.5%) of all fractures resulted in time loss >21 days. Altogether, 34.4% of all fractures required surgery, and 6.3% were recurrent. The proportion of fractures resulting in time loss >21 days was higher for fractures requiring surgery than fractures not requiring surgery (85.0% vs 50.7%; IPR = 1.68; 95% CI, 1.53-1.83). The proportion of recurrent and nonrecurrent fractures requiring surgery did not differ (35.5% vs 34.3%; IPR = 1.03; 95% CI, 0.73-1.46); however, recurrent fractures were more likely to require surgery than nonrecurrent fractures when restricted to the hand/fingers (66.7% vs 27.2%; IPR = 2.45; 95% CI, 1.36-4.44). CONCLUSION: Fractures in collegiate football were sustained at a higher rate in competition than practice and frequently required extended time lost from participation, particularly among those requiring surgery. Prevention strategies are warranted to reduce incidence and severity of fractures.

Impact of Body Mass Index and Bacterial Resistance in Osteomyelitis after Antibiotic Prophylaxis of Open Lower-Extremity Fractures.

BACKGROUND: We investigated the clinical effectiveness of antimicrobial prophylaxis in lower-extremity open fractures following the Eastern Association for the Surgery of Trauma Guidelines. METHODS: This observational, retrospective, single-center study included adults with lower-extremity open fractures of the ankle, tibia, fibula, or femur. The primary endpoint was the incidence of osteomyelitis within 12 months of the fracture. Secondary endpoint comparisons were the time of antibiotic initiation and drug selection. RESULTS: A total of 90 patients were included. Patients suffered from Gustilo and Anderson grades I (14%), II (54.7%), and III (31.3%) fractures. Almost all patients received cefazolin (98%). Among grade III fractures, 59.3% (16/27) of patients received additional gram-negative coverage as recommended by the guidelines. The osteomyelitis rate was 8.9%. There was no difference in osteomyelitis rates among patients with grade III fractures who received or did not receive additional gram-negative coverage: 18.8% (3/16) and 0 (0/11) (p = 0.248), respectively. There was no correlation between median antibiotic start time or antibiotic stop time after closure and the development of osteomyelitis, respectively. Resistant organisms caused 50% (4/8) of the osteomyelitis cases. On univariate analysis, obesity had the most significant association with osteomyelitis (p = 0.026). CONCLUSIONS: Bacterial resistance was common among cases of osteomyelitis in our cohort. Obesity was associated with a higher rate of osteomyelitis.

Blunt Cerebrovascular Injury in Cervical Spine Fractures: Are More-Liberal Screening Criteria Warranted?

Study Design Retrospective comparative study. Objective To compare strict Biffl criteria to more-liberal criteria for computed tomography angiography (CTA) when screening for blunt cerebrovascular injury (BCVI). Methods All CTAs performed for blunt injury between 2009 and 2011 at our institution were reviewed. All patients with cervical spine fractures who were evaluated with CTA were included; patients with penetrating trauma and atraumatic reasons for imaging were excluded. We then categorized the patients' fractures based on the indications for CTA as either within or outside Biffl criteria. For included subjects, the percentage of studies ordered for loose versus strict Biffl criteria and the resulting incidences of BCVI were determined. Results During our study period, 1,000 CTAs were performed, of which 251 met inclusion criteria. Of the injuries, 192 met Biffl criteria (76%). Forty-nine were found to have BCVIs (19.5%). Forty-one injuries were related to fractures meeting Biffl criteria (21.4%), and 8 were related to fractures not meeting those criteria (13.6%). The relative risk of a patient with a Biffl criteria cervical spine injury having a vascular injury compared with those imaged outside of Biffl criteria was 1.57 (p = 0.19). Conclusions Our data demonstrates that although cervical spine injuries identified by the Biffl criteria trend toward a higher likelihood of concomitant BCVI (21.4%), a significant incidence of 13.6% also exists within the non-Biffl fracture cohort. As a result, a more-liberal screening than proposed by Biffl may be warranted.

Gut barrier dysfunction in the Apc(Min/+) mouse model of colon cancer cachexia.

BACKGROUND: The Apc(Min/+) mouse, an animal model of colorectal cancer and cachexia, has a heterologous mutation in the Apc tumor suppressor gene, predisposing the mouse to intestinal and colon tumor development. This mouse develops intestinal polyps by ~4 weeks of age, and loses body weight gradually between ~14 and ~20 weeks of age. The strengths of this cachexia model derive from several features that mimic human cancer, including a gradual increase in tumor burden, chronic inflammation, and anemia. Little is known about the role of gut barrier dysfunction and endotoxemia in the development of cancer cachexia. We sought to determine how gut permeability and resultant endotoxemia change with the progression of cachexia. METHODS: Intestinal gut barrier integrity was assessed by permeability to FITC-dextran (MW(av)=4000kDa; FD4). Plasma glucose and triglycerides were measured by enzymatic assays, IL-6 by enzyme-linked immunosorbent assay, and endotoxin by the limulus amoebocyte assay. Body temperature was measured using a rectal probe. RESULTS: Progression of cachexia was accompanied by development of gut barrier dysfunction (permeability to FD4), hypertrophy of mesenteric lymph nodes, and an increase in plasma endotoxin concentration. Changes in blood glucose and glucose tolerance, plasma IL-6, triglycerides, and body temperature were characteristic of endotoxemia. CONCLUSION: We propose a role for gut barrier dysfunction (GBD) and subsequent endotoxemia in the development of inflammation and progression of cachexia in the Apc(Min/+) mouse.

Musculoskeletal changes in mice from 20-50 cGy of simulated galactic cosmic rays.

On a mission to Mars, astronauts will be exposed to a complex mix of radiation from galactic cosmic rays. We have demonstrated a loss of bone mass from exposure to types of radiation relevant to space flight at doses of 1 and 2 Gy. The effects of space radiation on skeletal muscle, however, have not been investigated. To evaluate the effect of simulated galactic cosmic radiation on muscle fiber area and bone volume, we examined mice from a study in which brains were exposed to collimated iron-ion radiation. The collimator transmitted a complex mix of charged secondary particles to bone and muscle tissue that represented a low-fidelity simulation of the space radiation environment. Measured radiation doses of uncollimated secondary particles were 0.47 Gy at the proximal humerus, 0.24-0.31 Gy at the midbelly of the triceps brachii, and 0.18 Gy at the proximal tibia. Compared to nonirradiated controls, the proximal humerus of irradiated mice had a lower trabecular bone volume fraction, lower trabecular thickness, greater cortical porosity, and lower polar moment of inertia. The tibia showed no differences in any bone parameter. The triceps brachii of irradiated mice had fewer small-diameter fibers and more fibers containing central nuclei. These results demonstrate a negative effect on the skeletal muscle and bone systems of simulated galactic cosmic rays at a dose and LET range relevant to a Mars exploration mission. The presence of evidence of muscle remodeling highlights the need for further study.