What leadership role should University Medical Centers take in regional primary prevention networks? An interdisciplinary, multi-method analysis of a crowded stakeholder environment.

Advancing public health through prevention necessitates collaboration among public, private, and community actors. Only together can these different actors amass the resources, knowledge, and community outreach required to promote health. Recent studies have suggested that university medical centres (UMCs) can play a key role in regional prevention networks, given their capacity to initiate, coordinate, drive, and monitor large partnerships. Yet, the literature often refers to prevention activities in general, leaving underexplored what UMCs can add to primary, universal prevention networks specifically. Moreover, UMCs operate in a crowded field of other organizations with extensive experience in primary prevention, who will already have an idea about what role UMCs should play in the network. This article presents a case study examining the potential role of a UMC within a densely interconnected stakeholder environment in the surroundings of a large city in the Netherlands. Combining insights from public health studies and network governance research, and integrating data from various methods, this study concludes that UMCs can enhance their contributions to prevention by assuming the role of network servants rather than network leaders. Stakeholders consider public health authorities or municipal governments as more logical candidates for coordinating the network. Moreover, partners often perceive-deservedly or not-UMCs as overly focused on the medical aspects of prevention, potentially neglecting social interventions, and as favouring universal treatments over tailor-made community interventions. At the same time, partner organizations hope that the UMCs join collaborations within the community, using their expertise to measure the impact of interventions and leveraging their prestige to generate attention for primary prevention. By synthesizing theoretical insights from multiple disciplines and analysing the empirics of network leaderships through multiple methods, this study offers UMCs a contextually-informed perspective on how to position themselves effectively within primary prevention networks.

Body length changes for Atlantic salmon (Salmo salar) over five decades exhibit weak spatial synchrony over a broad latitudinal gradient.

Understanding the factors that drive spatial synchrony among populations or species is important for management and recovery of populations. The range-wide declines in Atlantic salmon (Salmo salar) populations may be the result of broad-scale changes in the marine environment. Salmon undergo rapid growth in the ocean; therefore changing marine conditions may affect body size and fecundity estimates used to evaluate whether stock reference points are met. Using a dataset that spanned five decades, 172,268 individuals, and 19 rivers throughout Eastern Canada, we investigated the occurrence of spatial synchrony in changes in the body size of returning wild adult Atlantic salmon. Body size was then related to conditions in the marine environment (i.e., climate indices, thermal habitat availability, food availability, density-dependence, and fisheries exploitation rates) that may act on all populations during the ocean feeding phase of their life cycle. Body size increased during the 1980s and 1990s for salmon that returned to rivers after one (1SW) or two winters at sea (2SW); however, significant changes were only observed for 1SW and/or 2SW in some mid-latitude and northern rivers (10/13 rivers with 10 of more years of data during these decades) and not in southern rivers (0/2), suggesting weak spatial synchrony across Eastern Canada. For 1SW salmon in nine rivers, body size was longer when fisheries exploitation rates were lower. For 2SW salmon, body size was longer when suitable thermal habitat was more abundant (significant for 3/8 rivers) and the Atlantic Multidecadal Oscillation was higher (i.e., warmer sea surface temperatures; significant for 4/8 rivers). Overall, the weak spatial synchrony and variable effects of covariates on body size across rivers suggest that changes in Atlantic salmon body size may not be solely driven by shared conditions in the marine environment. Regardless, body size changes may have consequences for population management and recovery through the relationship between size and fecundity.

Neighborhood socioeconomic disadvantages associated with increased rates of revisions, readmissions, and complications after total joint arthroplasty.

INTRODUCTION: Low socioeconomic status based on neighborhood of residence has been suggested to be associated with poor outcomes after total joint arthroplasty (TJA). The area deprivation index (ADI) is a scale that ranks (zero to 100) neighborhoods by increasing socioeconomic disadvantage and accounts for median income, housing type, and family structure. We sought to examine the potential differences between high (national median ADI = 47) and low ADI among TJA recipients at a single institution. Specifically, we assessed: (1) 30-day emergency department visits/readmissions; (2) 90-day and 1-year revisions; as well as (3) medical and surgical complications. METHODS: A consecutive series of primary TJAs from September 21, 2015, through December 29, 2021, at a tertiary healthcare system were reviewed. A total of 3,024 patients who had complete ADI data were included. Patients were divided into groups below the national median ADI of 47 (n = 1,896) and above (n = 1,128). Multivariable regressions to determine independent risk factors accounting for ADI, race, age, sex, American Society of Anesthesiologists Classification grade, body mass index, diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease, hypertension, chronic kidney disease, alcohol abuse, substance abuse, and tobacco use. The primary outcomes of interest include evaluation of the independent association of ADI with total postoperative complications (at 30 days, 90 days, and 1 year) after adjusting for multiple relevant cofactors. RESULTS: After adjusting for multiple relevant cofactors, at 90 days, ADI > 47 (OR, 1.36, 95% CI 1.00-1.83, P = 0.04), men versus women (OR, 0.73, 95% CI 0.54-0.99, P = 0.039), and CHF (OR, 1.90, 95% CI 1.18-3.06, P = 0.009) were independently associated with increased total complications. The ADI was not associated with increased total complications at 30 days or 1-year (All P > 0.05). CONCLUSION: Our findings of higher complications of the ADI > 47 cohort at 90 days, reaffirm the complex relationship between ADI, patient demographics, and additional socioeconomic parameters that may influence postoperative outcomes and complications after TJA. This study utilizing ADI demonstrates potential areas of intervention and further investigation for assessing arthroplasty outcomes.

A case series of the Royal Perth Hospital cannula-first approach in the 'can't intubate, can't oxygenate' scenario.

At the Royal Perth Hospital, we have been developing and teaching a can't intubate, can't oxygenate (CICO) rescue algorithm for over 19 years, based on live animal simulation. The algorithm involves a 'cannula-first' approach, with jet oxygenation and progression to scalpel techniques if required in a stepwise fashion. There is little reported experience of this approach to the CICO scenario in humans. We present eight cases in which a cannula-first Royal Perth Hospital approach was successfully implemented during an airway crisis. We recommend that institutions teach and practice this approach; we believe it is effective, safe and minimally invasive when undertaken by clinicians who have been trained in it and have immediate access to the requisite equipment. The equipment is low cost, comprising a 14G Insyte cannula, saline, 5 ml syringe and a Rapid-O2. Training can be provided using low-fidelity manikins or part-task trainers.

Use and Application of Large Language Models for Patient Questions Following Total Knee Arthroplasty.

BACKGROUND: A consumer-focused health care model not only allows unprecedented access to information, but equally warrants consideration of the appropriateness of providing accurate patient health information. Nurses play a large role in influencing patient satisfaction following total knee arthroplasty (TKA), but they come at a cost. A specific natural language artificial intelligence (AI) model, ChatGPT (Chat Generative Pre-trained Transformer), has accumulated over 100 million users within months of launching. As such, we aimed to compare: (1) orthopaedic surgeons' evaluation of the appropriateness of the answers to the most frequently asked patient questions after TKA; and (2) patients' comfort level in answering their postoperative questions by using answers provided by arthroplasty-trained nurses and ChatGPT. METHODS: We prospectively created 60 questions based on the most commonly asked patient questions following TKA. There were 3 fellowship-trained surgeons who assessed the answers provided by arthroplasty-trained nurses and ChatGPT-4 to each of the questions. The surgeons graded each set of responses based on clinical judgment as: (1) "appropriate," (2) "inappropriate" if the response contained inappropriate information, or (3) "unreliable," if the responses provided inconsistent content. Patients' comfort level and trust in AI were assessed using Research Electronic Data Capture (REDCap) hosted at our local hospital. RESULTS: The surgeons graded 44 out of 60 (73.3%) responses for the arthroplasty-trained nurses and 44 out of 60 (73.3%) for ChatGPT to be "appropriate." There were 4 responses graded "inappropriate" and one response graded "unreliable" provided by the nurses. For the ChatGPT response, there were 5 responses graded "inappropriate" and no responses graded "unreliable." There were 136 patients (53.8%) who were more comfortable with the answers provided by ChatGPT compared to 86 patients (34.0%) who preferred the answers from arthroplasty-trained nurses. Of the 253 patients, 233 (92.1%) were uncertain if they would trust AI to answer their postoperative questions. There were 127 patients (50.2%) who answered that if they knew the previous answer was provided by ChatGPT, their comfort level in trusting the answer would change. CONCLUSIONS: One potential use of ChatGPT can be found in providing appropriate answers to patient questions after TKA. At our institution, cost expenditures can potentially be minimized while maintaining patient satisfaction. Inevitably, successful implementation is dependent on the ability to provide information that is credible and in accordance with the objectives of both physicians and patients. LEVEL OF EVIDENCE: III.

C. Difficile Infection within 6 Months before TKA Is Associated with Increased Short-Term Complications.

A history of Clostridium difficile infection (CDI) before total knee arthroplasty (TKA) may be a marker for poor patient health and could be used to identify patients with higher risks for complications after TKA. We compared the frequency of 90-day postoperative CDI, complications, readmissions, and associated risk factors in (1) patients experiencing CDIs more than 6 months before TKA, (2) patients experiencing CDIs in the 6 months before TKA, and (3) patients without a history of CDI. We identified patients who underwent primary TKAs from 2010 to 2019 and had a history of CDI before TKA (n = 7,195) using a national, all-payer database. Patients were stratified into two groups: those with CDIs > 6 months before TKA (n = 6,027) and those experiencing CDIs ≤ 6 months before TKA (n = 1,168). These patients were compared with the remaining 1.4 million patients without a history of CDI before TKA. Chi-square and unadjusted odds ratios (ORs) with 95% confidence intervals (CI) were used to compare complication frequencies. Prior CDI during either timespan was associated with higher unadjusted odds for postoperative CDI (CDI > 6 months before TKA: OR 8.03 [95% CI 6.68-9.63]; p < 0.001; CDI ≤ 6 months before TKA: OR 59.05 [95% CI 49.66-70.21]; p < 0.001). Patients with a history of CDI before TKA were associated with higher unadjusted odds for 90-day complications and readmission compared with patients without a history of CDI before TKA. Other comorbidities and health metrics were not found to be associated with postoperative CDI (i.e., age, obesity, smoking, antibiotic use, etc.). CONCLUSION: CDI before TKA was associated with higher odds of postoperative CDI compared with patients without a history of CDI. CDI ≤ 6 months before TKA was associated with the highest odds for postoperative complications and readmissions. Providers should consider delaying TKA after CDI, if possible, to allow for patient recovery and eradication of infection.

Comparative analysis of open versus endoscopic carpal tunnel release in a comprehensive national database.

PURPOSE: Carpal tunnel syndrome is the most common compressive neuropathy. There is limited evidence to support endoscopic compared to open carpal tunnel release according to the 2016 American Academy of Orthopaedic Surgeons Clinical Practice Guideline on carpal tunnel syndrome. The purpose of the present study was to assess differences between the two procedures by comparing 30- and 90-day complications and mean hospital costs in a large patient population. METHODS: Using the national Mariner15 Database by PearlDiver Technologies, we retrospectively studied 27,192 carpal tunnel syndrome patients who received carpal tunnel release using an endoscopic or open surgical approach from 2010 to 2019. Patients who met the inclusion criteria were grouped and case-matched at a 1:1 ratio through the corresponding International Classification of Diseases codes (n = 13,596) and assessed for 30- and 90-day complications such as median nerve injury, superficial palmar arch injury, and revision carpal tunnel release surgery. Univariate analysis was used to compare outcomes and a multivariate regression was performed to identify risk factors associated with each outcome. RESULTS: Endoscopic carpal tunnel release was associated with a higher rate of median nerve injury than open release at 30 days (0.3% vs. 0.1% odds ratio, 2.21; 95% confidence interval, 1.29-3.81; p < 0.05) and 90 days (0.4% vs. 0.3%; odds ratio, 1.77; 95% confidence interval, 1.16-2.70; p < 0.05). Endoscopic release was also associated with a higher rate of superficial palmar arch injury (0.1% vs. 0%; odds ratio, 25.02; 95% confidence interval, 1.48-423.0; p < 0.05). CONCLUSIONS: In the present study, risk of median nerve injury and vascular injury was higher after endoscopic than open carpal tunnel release. At 90 days, all-cause revision rates were similar between techniques. Surgeons should understand these differences, to optimize surgical decision-making. LEVEL OF EVIDENCE: Therapeutic, IIIa.

Spinal fusion and total hip arthroplasty: why timing is important.

BACKGROUND: There is increasing debate among orthopaedic surgeons over the temporal relationship between lumbar spinal fusion (LSF) and total hip arthroplasty (THA) for patients with hip-spine syndrome. Few large studies have directly compared the results of patients who undergo LSF prior to THA (LSF-THA) to those who undergo LSF after THA (THA-LSF). The current study matched THA patients with a prior LSF to patients who underwent LSF after THA to assess: 90-day and 1-year (1) medical/surgical complications; and (2) revisions. METHODS: We queried a national, all-payer database to identify all patients undergoing THA between 2010 and 2018 (n = 716,084). The LSF-THA patients and THA-LSF patients were then matched 1:1 on age, sex, Charleson Comorbidity Index, and obesity. Medical/surgical complications and revisions at 90 days and 1 year were recorded. Categorical and continuous variables were analysed utilising t-tests and chi-square, respectively. RESULTS: LSF-THA patients experienced significantly more postoperative dislocations at 90 days and 1 year compared to THA-LSF patients (p = 0.048 and p < 0.001). There were a similar number of revisions performed for LSF-THA and THA-LSF patients at both 90 days and 1 year (p = 0.183 and p = 0.426). Furthermore, at 1 year, LSF-THA patients experienced more pneumonia (p = 0.005) and joint infection (p = 0.020). CONCLUSIONS: Prior LSF has been demonstrated to increase the risk of postoperative dislocation in patients undergoing THA. The results of the present study demonstrate increased dislocations with LSF-THA compared to THA-LSF. For "hip spine syndrome" patients requiring both LSF and THA, it may be more beneficial to undergo THA prior to LSF. Arthroplasty surgeons may wish to collaborate with spinal surgeons to ensure optimal outcomes for this group of patients.

Postoperative Opioid Dependence in Patients Undergoing Either Total or Reverse Shoulder Arthroplasty for Proximal Humerus Fracture Fixation.

INTRODUCTION: In elderly patients who have proximal humerus fractures, treatment commonly involves total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (RSA). Following these procedures, patients often require opioids for postoperative analgesia. This common scenario is of clinical and societal importance, as increased postoperative opioid usage has been shown to worsen outcomes and increase the likelihood for dependence. We aimed to compare postoperative opioid use in patients undergoing either TSA or RSA for fixation of their proximal humerus fracture. Specifically, we assessed: (1) postoperative opioid use at two, four, six, eight, and greater than eight weeks postoperatively; (2) aseptic revision rates at 90-days, one year, and two years postoperatively; and (3) periprosthetic joint infection (PJI) rates at 90-days, one year, and two years postoperatively between patients undergoing TSA or RSA for the surgical management of their proximal humerus fractures. MATERIALS AND METHODS: For this review, we queried a national all-payer database from October 1, 2015 to October 31, 2020 (n=1.5 million) for all patients who had a "proximal humerus fracture" diagnosis who underwent either TSA or RSA. There were two cohorts: patients undergoing TSA (n=731) and patients undergoing RSA (n=731). Bivariate Chi-square analyses. RESULTS: We found no differences (p>0.05) in opioid use postoperatively in patients undergoing RSA for proximal humerus management compared to patients undergoing TSA after two weeks. There was not a significant difference in aseptic revision or PJI rates between the two cohorts (all p>0.05). CONCLUSION: The evidence comparing opioid use in patients undergoing either TSA or RSA for proximal humerus fracture fixation is lacking. Our study specifically showed no differences in opioid use postoperatively in patients undergoing RSA for proximal humerus management compared to patients undergoing TSA.

Inpatient vs outpatient arthroplasty: A in-state database analysis of 90-day complications.

Introduction: An increase in the number of policy initiatives, such as alternative payment models, have prompted healthcare providers to examine health-care expenditures while seeking to improve quality of care. Performing total joint arthroplasty (TJA) in the outpatient setting is an attractive option in driving costs down and providing psychological benefits to patients. Concerns regarding the safety and effectiveness of same-day discharge protocols warrants further investigation, especially on the state level. Due to the lack of consensus, we aimed to compare: (1) risk factors for outpatient arthroplasty and (2) incidences of postoperative complications between inpatient vs outpatient arthroplasty using an in-state database. Methods: Patients who underwent total knee or hip arthroplasty between January 1, 2022 and December 31, 2022 were identified. Data was drawn from the Maryland State Inpatient Database (SID) and Maryland State Ambulatory Surgery and Services Database (SASD). A total of 7817 patients had TJA within this time. Patients were divided into inpatient arthroplasty (n = 1429) and outpatient arthroplasty (n = 6338). Demographic variables, medical comorbidities, and 90-day complication rates were compared between inpatient and outpatient procedures. Additional independent variables included: marital status, primary language, race, and median household income. A multivariate logistic regression analysis was performed to identify independent risk factors for complications following TJA after controlling for risk factors and patient comorbidities. Results: Arthroplasty in the outpatient setting were more likely to be married (61.3% vs. 51.2%, p < 0.001), white (75.5% vs. 60.9%, <0.001), speak English as primary language (98.7% vs. 88.6%, p < 0.001), and have lower rates of diabetes (4.8% vs. 9.7%, p < 0.001), chronic obstructive pulmonary disease (16.3% vs. 21.8%, p < 0.001), and obesity (30.0% vs. 45.2%, p < 0.001) compared to arthroplasty in the inpatient setting, respectively. There were lower incidences of acute kidney injury (0.2 vs. 0.8%, p < 0.001) and infection (0.3% vs. 1.1%, p < 0.001) in the outpatient cohort compared to the inpatient cohort, respectively. Inpatient arthroplasty (Odds Ratio (OR) 1.98, 95% CI 1.30-3.02, p = 0.002) and hypertension (OR 2.12, 95% CI 1.23-3.64, p = 0.007) were independent risk factors for total complications following TJA. Conclusion: Arthroplasty in the outpatient setting showed fewer complications than compared to patients in the inpatient setting. Although multiple factors should guide the decision for arthroplasty, outpatient arthroplasty may be a safe option for select, healthier patients without the increased burden of increased complications.

The Bullying in Anaesthesia Registrars Survey (BARS): Does a validated questionnaire improve our understanding of bullying in Australian and New Zealand anaesthesia trainees?

Previous studies have established that bullying is a pervasive problem in healthcare. However, most investigations of bullying in anaesthesia use self-labelled survey questions in which respondents' subjective perceptions of bullying are central in defining prevalence. This study applied the validated revised Negative Acts Questionnaire (NAQ-r) for a more objective assessment of bullying prevalence and types of negative behaviours experienced by anaesthesia trainees in Australia and New Zealand.An online questionnaire was distributed by the Australian and New Zealand College of Anaesthetists (ANZCA) Clinical Trials Network to 990 randomly selected ANZCA trainees. Bullying prevalence was assessed using both a self-labelled survey tool and the NAQ-r, which requires respondents to select from a list of negative acts, with validated cut-offs that define bullying. Sources of bullying, impact on recipients and barriers to reporting were also examined. This design allowed comparison of the two methods for evaluating bullying prevalence.Twenty-six percent of trainees surveyed completed both bullying survey instruments. Thirty percent of these respondents self-labelled as having experienced bullying in the previous six months, with 8% reporting bullying at least monthly. With the NAQ-r, most respondents (96%) reported experiencing at least one negative act in the prior six months, with 54% reporting these on a monthly basis. The most frequent behaviours described were humiliation and intimidation. Using NAQ-r cut-offs, 36% of respondents experienced occasional bullying and 10% were victims of severe workplace bullying.The NAQ-r provides a more nuanced and objective insight into bullying faced by ANZCA trainees than do self-labelled surveys. The results of the present study provide a valuable baseline for ongoing assessment.

Inflammatory bowel disease is associated with increased complications after total knee arthroplasty.

BACKGROUND: Few studies investigate the influence of inflammatory bowel disease (IBD) on complications following total knee arthroplasty (TKA). Therefore, we compared complications and readmissions frequencies after TKA in patients with Crohn's disease (CD) and ulcerative colitis (UC) to patients without IBD. METHODS: A large administrative claims database was used to identify patients who underwent primary TKAs from 2010 to 2019 and had a diagnosis of IBD before TKA. Patients were stratified into two groups: those with CD (n = 8,369) and those with UC (n = 11,347). These patients were compared a control of 1.3 million patients without an IBD diagnosis. Chi-square and unadjusted odds ratios (OR) with 95% confidence intervals (CI) were used to compare complication frequencies. Multivariable logistic regression was used to evaluate independent risk factors for 90-day complications. RESULTS: Compared to patients without IBD, patients with IBD were associated with higher unadjusted 90-day odds for Clostridium difficile infection (CDI) (CD: OR 2.81 [95% CI 2.17 to 3.63]; p < 0.001; UC: OR 3.01 [95% CI 2.43 to 3.72]; p < 0.001) and two-year periprosthetic joint infection (CD: OR 1.34 [95% CI 1.18 to 1.52]; p < 0.001; UC: OR 1.26 [95% CI 1.13 to 1.41]; p < 0.001). After controlling for risk factors like obesity, tobacco use, and diabetes, both types of IBD were associated with higher 90-day odds for CDI and PJI (p < 0.001 for all). CONCLUSION: IBD is associated with higher 90-day postoperative CDI and PJI compared with patients without IBD. Providers should consider discussing these risks with patients who have a diagnosis of IBD.

Photobiomodulation therapy combined with static magnetic field in tibial fracture healing of a dog: A case report.

A 10-week-old male, Xoloitzcuintle (Mexican hairless dog), weighing 8.9 kg was presented after its owner accidentally stepped on its paw. The dog presented with acute pain, inflammation and grade IV lameness in the right hind paw. A complete transverse fracture in the right proximal tibia was diagnosed from radiography. The dog underwent a minimally invasive plate osteosynthesis (MIPO) procedure. After surgery, photobiomodulation therapy combined with static magnetic field (PBMT-sMF) was applied twice daily for 21 days. A multi-wavelength PBMT-sMF device was applied at three sites using different frequencies: proximal and distal of the fracture zone (3000 Hz, 40.35 J per site, and 300 s per site) and in the fracture zone (250 Hz, 39.11 J and 300 s per site). Follow up radiographies were performed after surgery and treatment with PBMT-sMF. Eighteen days post-surgery the healing process of bone was advanced. Fifty-five days post-surgery the callus was enlarged. In addition, radiographic union and clinical union was evidenced by closure of the fracture gap. This case report has reported the use of PBMT-sMF in order to accelerate and improve bone healing following a MIPO procedure on a complete transverse fracture in the proximal tibia of a puppy.

Preoperative Statin Exposure Reduces Periprosthetic Fractures and Revisions following Total Knee Arthroplasty.

The purpose of this study is to examine patients undergoing primary total knee arthroplasty (TKA) with and without prior history of statin use. We specifically evaluated (1) 90-day to 2-year periprosthetic fractures, (2) revisions, and (3) respective risk factors. We queried a national, all-payer database for patients undergoing primary TKA between 2010 and 2020. Chronic statin exposure was then identified and defined as more than three prescriptions filled within 1 year prior to TKA (statin users). A control cohort of patients undergoing TKA without the prior history of statin use was then created (statin naïve). Cohorts were matched 1:1 based on age range, Charlson Comorbidity Index, sex, diabetes, obesity, and tobacco use, yielding 579,136 patients. Multivariate logistic regression was performed to evaluate the risk factors for periprosthetic fractures and revisions, adjusted for demographics and comorbidities. Statin users had a lower incidence of periprosthetic fractures from 90 days to 2 years compared with the statin naïve (p < 0.001). Similarly, statin users had a lower incidence of revisions at 90 days to 2 years (p < 0.001). Using the statin-naïve cohort as a reference, statin use was independently associated with decreased odds of periprosthetic fractures and revisions. Statin use was associated with a reduced risk of periprosthetic fractures and revisions. These results may mitigate postoperative risks though statin therapy is currently not recommended for fracture-related benefits alone.

Intra-articular Hip Injections Prior to Total Hip Arthroplasty: Infection and Cost-Related Associations.

Intra-articular injections prior to total hip arthroplasty (THA) have been associated with postoperative infections. The purpose of this study was to determine whether a temporal relationship exists between hip injections prior to THA and infection. Specifically, we asked (1) Do patients who receive hip injections within 3 months of THA have a higher incidence of prosthetic joint infections (PJIs) or surgical site infections (SSIs)? and (2) Do these patients incur higher 90-day costs? Patients with hip injections prior to THA were identified using a national database from 2010 to 2019. Three laterality-specific groups (injection 0 to 3 months, 3 to 6 months, and 6 to 12 months prior to THA)were compared with a matched cohort without prior injection (n=277,841). Primary outcomes included PJIs, SSIs, and costs. Patients who had injections within 3 months of THA had a higher incidence of PJIs at 90 days (5.1% vs 1.6%, P<.01) and 1 year (6.8% vs 2.1%, P<.01), when compared with the matched cohort. They also had a higher incidence of SSIs at 90 days (2.8% vs 1.2%, P<.01) and 1 year (3.7% vs 1.7%, P<.01). Mean costs were 13.7% higher in this injection cohort. Patients who had injections between 3 and 6 months prior to THA had higher incidence and odds of postoperative PJIs at 90 days (2.6% vs 1.6%, P<.04), whereas those with injections beyond 6 months had no differences in PJIs (P≥.46). Patients who receive hip injections within 3 months of undergoing primary THA are at increased risk for postoperative PJIs, SSIs, and higher costs. This study reaffirms guidelines for when to perform THAs in these populations. [Orthopedics. 2023;46(1):19-26.].

Primary total hip arthroplasty complications and costs in liver transplant recipients: a matched analysis using a national database.

BACKGROUND: The number of liver transplant recipients (LTR) is worldwide increasing and, as the survival is improving as well, there is an increasing number of patients needing total hip arthroplasty (THA). There might be increased risks for this specific group of patients and due to their comorbidities costs might be higher too. Using a big national database outcome and cost of THA should be compared between liver transplant recipients and the general population. METHODS: The study was performed using a collection of Medicare, Medicaid, and private insurance claims. Length of stay (LOS), 30-day readmissions, complications rates up to 5 years, and 90-day total cost of care between liver transplant recipients and matched non-transplant patients should be compared. All primary THAs from 2010 to 2019 were identified. 513 patients with a liver transplant before their THA were matched to 10,759 patients without a history of solid organ transplant at a 1:20 ratio based on age, sex, Charlson Comorbidity Index, obesity, and diabetes status. RESULTS: LTR had a longer average LOS (4.2 vs. 3.4 days, p < 0.001). There was no difference in the thirty-day readmissions (5.7% vs. 4.1%, p = 0.117) and 90-day dislocation rates (2.9% vs. 2.4%, p = 0.600). Total costs in the first ninety days after THA were not different between the LTR and controls (p = 0.756). CONCLUSIONS: These findings suggest that complications and costs are no major point of concern in patients with liver transplant that are operated with THA.

Operative Versus Nonoperative Treatment for Closed Displaced Midshaft Clavicle Fractures.

BACKGROUND: Nonoperative treatment for clavicle fractures has historically been standard of care, but with a concomitant rise in recent operative fixation for displaced midshaft clavicle fractures (MCF), a re-evaluation of treatment modalities is necessary. The purpose of this study was to compare nonunion rates among operative and nonoperative treatment of closed displaced MCF. Specifically, we assessed the following between operative and nonoperative management: (1) 90-day to 1-year nonunion and malunion incidence; (2) 90-day medical complications; and (3) 90-day to 1-year total costs of care. METHODS: An all-payer national database was retrospectively reviewed for closed displaced MCF from 2010 to 2020 (n = 173 188). Of these, patients undergoing operative fixation within 30 days of a displaced MCF were identified (n = 17 452). Nonoperative displaced MCF patients were matched with operative patients at a 3:1 ratio. Outcomes at 90 days and 1 year included: nonunion, total cost, and complications. RESULTS: Closed displaced MCF with operative fixation resulted in significantly increased nonunion rates at 1 year compared with nonoperative treatment (3.97% vs 1.63%, odds ratio = 2.50 [2.26-2.77], P < .001). Kaplan-Meier survivorship and log-rank score demonstrated the same for a 1-year nonunion endpoint (P < .001). As expected, the operative cohort incurred higher median total costs of care at 90 days ($3255.00 vs $1024.00, P < .001) and 1 year ($1978.00 vs $4799.50, P < .001) compared with nonoperative treatment. CONCLUSION: Our study found higher nonunion incidence after operative fixation of displaced MCF. These results may serve as a catalyst for future high-quality prospective studies comparing treatment options for closed displaced MCF.

Phenotypic Frailty Score Predicts Perioperative Outcomes for Geriatric Total Joint Arthroplasty.

Various assessment tools are often used to predict perioperative morbidity among patients older than 75 years who undergo total joint arthroplasty. Yet, few studies describe the use of phenotypic frailty as a predictor for outcomes. The goal of this study was to assess phenotypic frailty with the Sinai Abbreviated Geriatric Evaluation (SAGE) and compare its utility with established assessment tools used in practice. We specifically asked: (1) Can SAGE predict 30-day outcomes, including postoperative delirium? (2) Can SAGE determine the risk of prolonged hospital length of stay? (3) Is SAGE predictive for 30-day readmissions? (4) Can SAGE determine the risk of discharge to a specialized facility? Patients undergoing total hip arthroplasty and total knee arthroplasty were evaluated with the American Association of Anesthesiologists Physical Status (ASA), Charlson Comorbidity Index (CCI), 5-point Modified Frailty Score (5-FS), and SAGE. Assessment scores were determined for each patient, and every incremental change in score was used to predict the likelihood of perioperative complications. A receiver operating characteristic analysis was also performed to calculate testing sensitivity for each assessment tool. The SAGE scores were more likely to predict 30-day complications (odds ratio [95 CI], 2.21 [1.32-3.70]), postoperative delirium (6.40 [1.78-23.03]), and length of stay greater than 2 days (3.90 [1.00-15.7]) compared with ASA, CCI, and 5-FS values. The SAGE scores were not predictive of readmission (1.77 [0.66-4.72]) or discharge to a specialized facility (1.48 [0.80-2.75]). The SAGE score was a more sensitive predictor (area under the curve, 0.700) for perioperative morbidity compared with ASA (0.638), CCI (0.662), and 5-FS (0.644) values. Therefore, SAGE scores can reliably assess risk of perioperative morbidity and may have better clinical utility than ASA, CCI, and 5-FS values for patients undergoing total joint arthroplasty. [Orthopedics. 2022;45(6):e315-e320.].

Ultrasensitive multiplexed chemiluminescent enzyme-linked immunosorbent assays in 384-well plates.

We have developed an ultrasensitive multiplexed immunoassay using 384-well microtiter plates capable of detecting proteins at subfemtomolar concentrations that requires as little as 2.5 µL of sample. Arrays of up to 4 capture antibodies were patterned on the bottom of the wells of a 384-well plate either by directly printing the capture antibodies or by printing anti-peptide tag anchor antibodies and incubating these arrays with capture antibodies conjugated to the corresponding peptide tags ("customized" assays). Samples were incubated with the antibody arrays and shaken orbitally at 2000 rpm to achieve the greatest sensitivity. Chemiluminescence (CL) from immunocomplexes labeled with horseradish peroxidase was imaged across the entire plate to quantify the amount of protein bound to each antibody spot of the arrays. The 384-well assay had a throughput 5-fold greater than 96-well plates that was achieved from simultaneous imaging of CL in all 384-wells and the use of automated pipettors to allow parallel processing of 384 assays. We developed 4 assays based on the 384-well CL ELISA: a direct print assay for IL-10 (limit of detection (LOD) = 0.075 fM); a customized assay for IL-6 (0.22 fM); a customized pharmacokinetic (PK) assay for measuring adalimumab (7.3 pg/mL); and a customized 4-plex assay for IL-5 (0.1 fM), IL-6 (0.52 fM), IL-10 (0.2 fM), and TNF-α (3.2 fM). The sensitivity and precision of the cytokine assays were comparable to current ultrasensitive protein detection methods in 96-well formats. The PK assay for adalimumab was 650 times more sensitive than a commercially available 96-well plate ELISA. We used the 384-well CL ELISAs to measure endogenous levels of the cytokines in the serum and plasma of healthy humans: the mean concentrations and precision were comparable to those from 96-well immunoassays. This 384-well format with subfemtomolar sensitivity will enable ultrasensitive multiplexed immunoassays to be performed with higher throughput and lower sample volumes than currently possible, a particularly important capability for clinical studies in drug development.

Has modern human immunodeficiency virus therapy decreased complications following total knee arthroplasty?

BACKGROUND: Anti-retroviral therapy (ART) remains the cornerstone of decreasing morbidity and mortality in human immunodeficiency virus (HIV) patients. However, a large study comparing HIV patients taking ART prior to total knee arthroplasty (TKA) is lacking. We sought to examine: (1) readmissions; (2) post-operative complications; and (3) revisions in ART-treated or untreated HIV patients compared with a non-HIV population. METHODS: We queried a national, all-payer database to identify TKA patients from 2010-2020 (n = 1,393,357). The presence or absence of ART was identified and matched with non-HIV patients based on age, sex, diabetes, obesity, and tobacco status resulting in 889 patients in each cohort. Readmissions, post-operative complications, and revisions were assessed. RESULTS: Readmissions were higher among all HIV patients and even higher in those not taking ART, as compared to the matching cohort (4.8 versus 1.6%, p < 0.01). Prosthetic joint infections (PJIs) at 1-year were higher among HIV patients who were either taking ART (4.0%; OR, 1.41 [0.82-2.45]) or not taking ART (5.1%; OR, 2.44 [1.42-4.21]) as compared to non-HIV patients (2.1%, all p < 0.03). Revision rates at 1-year trended higher in HIV patients who were taking ART (2.6%; Odds Ratio (OR), 1.94 [0.96-3.93]) and who did not take ART (3.1%; OR, 2.38 [1.20-4.70]), compared to non-HIV patients (1.3%, all p < 0.09). CONCLUSIONS: ART-treated HIV patients are associated with lower readmissions, post-operative complications, and revisions when compared to HIV patients not taking ART. The findings of this study underscore the utility of ART and patient optimization to reduce risk in HIV patients.