Comparative Analyses and Ablation Efficiency of Thulium Fiber Laser by Stone Composition.

PURPOSE: There are limited data on ablation effects of thulium fiber laser (TFL) settings with varying stone composition. Similarly, little is known surrounding the photothermal effects of TFL lithotripsy regarding the chemical and structural changes after visible char formation. We aim to understand the TFL's ablative efficiency across various stone types and laser settings, while simultaneously investigating the photothermal effects of TFL lithotripsy. MATERIALS AND METHODS: Human specimens of calcium oxalate monohydrate, calcium oxalate dihydrate, uric acid, struvite, cystine, carbonate apatite, and brushite stones were ablated using 13 prespecified settings with the Coloplast TFL Drive. Pre- and postablation mass, ablation time, and total energy were recorded. Qualitative ablative observations were recorded at 1-minute intervals with photographs and gross description. Samples were analyzed with Fourier-transform infrared spectroscopy pre- and postablation and electron microscopy postablation to assess the photothermal effects of TFL. RESULTS: Across all settings and stone types, 0.05 J × 1000 Hz was the best numerically efficient ablation setting. When selected for more clinically relevant laser settings (ie, 10-20 W), 0.2 J × 100 Hz, short pulse was the most numerically efficient setting for calcium oxalate dihydrate, cystine, and struvite stones. Calcium oxalate monohydrate ablated with the best numerical efficiency at 0.4 J × 40 Hz, short pulse. Uric acid and carbonate apatite stones ablated with the best numerical efficiency at 0.3 J × 60 Hz, short pulse. Brushite stones ablated with the best numerical efficiency at 0.5 J × 30 Hz, short pulse. Pulse duration impacted ablation effectiveness greatly with 6/8 (75%) of inadequate ablations occurring in medium or long pulse settings. The average percent of mass lost during ablation was 57%; cystine stones averaged the highest percent mass lost at 71%. Charring was observed in 36/91 (40%) specimens. Charring was most often seen in uric acid, cystine, and brushite stones across all laser settings. Electron microscopy of char demonstrated a porous melting effect different to that of brittle fracture. Fourier-transform infrared spectroscopy of brushite char demonstrated a chemical composition change to amorphous calcium phosphate. CONCLUSIONS: We describe the optimal ablation settings based on stone composition, which may guide urologists towards more stone-specific care when using thulium laser for treating renal stones (lower energy settings would be safer for ureteral stones). For patients with unknown stone composition, lasers can be preset to target common stone types or adjusted based on visual cues. We recommend using short pulse for all TFL lithotripsy of calculi and altering the settings based on visual cues and efficiency to minimize the charring, an effect which can make the stone refractory to further dusting and fragmentation.

Manhattan Vision Screening and Follow-Up Study (NYC-SIGHT): optometric exam improves access and utilization of eye care services.

PURPOSE: To describe the benefits of optometric evaluation for detection of vision-affecting conditions in the context of community-based eye health screenings and identify factors associated with having a recent dilated eye exam. METHODS: Enrolled participants were age 40 and older, living independently in affordable housing developments in New York City. Eye health screening failure and criteria for seeing the on-site study optometrist were defined as visual acuity 20/40 or worse in either eye, intraocular pressure 23-29 mmHg, or an unreadable fundus image. The optometrist conducted a manifest refraction using loose lenses and used a portable slit lamp and ophthalmoscope to perform a non-dilated anterior and posterior segment ocular health evaluation. Demographics, social determinants of health, eye health screening results, and rates of suspected ophthalmic conditions were recorded. To determine factors associated with having a recent dilated eye exam, which was the main outcome for this statistical analysis, a stepwise multivariate logistic regression was performed. RESULTS: A total of 708 participants were screened, 308 attended the optometric exam; mean age 70.7 ± 11.7 [standard deviation (SD)] years. Among this subgroup, 70.1% identified as female, 54.9% self-identified as African American, 39% as Hispanic/Latino, and 26.6% Dominican ethnicity; 78.2% (241/308) had not undergone a dilated eye exam within the last year, 71.4% reported they did not have an eye care provider. Stepwise multivariate logistic regression analysis indicated that participants who self-reported having cataracts (odds ratio (OR) 2.15; 95% confidence interval (CI) 1.03-4.47; p = 0.041), self-reported having glaucoma/glaucoma suspect (OR 5.60; 95% CI 2.02-15.43; p = 0.001), or spoke Spanish as their primary language (OR 3.25; 95% CI 1.48-7.11; p = 0.003) had higher odds of having a recent dilated eye exam. CONCLUSIONS: This community-based screening initiative demonstrated the effectiveness of optometric exams in detecting vision-affecting conditions and identified factors associated with having a recent dilated eye exam. Optometrists play a vital role in increasing access to eye care for high-risk, underserved populations. TRIAL REGISTRATION: ClinicalTrials.gov (NCT04271709).

Manhattan Vision Screening and Follow-Up Study: (NYC-SIGHT)Tele-Retinal Image Findings and Importance of Photography.

Purpose: To describe tele-retinal abnormality image findings from the Manhattan Vision Screening and Follow-up Study (NYC-SIGHT), which aims to investigate whether community-based eye health outreach strategies using telemedicine can improve visual outcomes among at-risk populations in Upper Manhattan. Methods: A 5-year prospective, cluster-randomized clinical trial was conducted. Eligible individuals aged 40 years and older were recruited from affordable housing developments and senior centers in New York City. Participants underwent on-site eye health screening (best-corrected visual acuity, intraocular pressure [IOP] measurements, and fundus photography). Fundus images were graded via telemedicine by a retina specialist. Multivariate logistic regression modeling was used to assess the factors associated with abnormal retinal findings requiring referral to ophthalmology. Results: Participants with a retinal abnormality on fundus photography (n = 157) were predominantly older adults, with a mean age of 68.4 ± 11.1 years, female (63.7%), African American (50.3%), and Hispanic (43.3%). A total of 32 participants in our study passed the vision and IOP screening but had an abnormal retinal image and ocular pathology that would have been missed without fundus photography. Individuals who self-identified as having preexisting glaucoma (odds ratio [OR] = 3.749, 95% confidence interval [CI] = 1.741-8.074, p = 0.0001) and had severe vision impairment (OR = 4.1034, 95% CI = 2.0740-8.1186, p = 0.000) at the screening had significantly higher odds of having an abnormal retinal image. Conclusion: This community-based study targeted populations at-risk for eye disease, improved access to eye care, detected a significant number of retinal image abnormalities requiring follow-up by using telemedicine, and provided evidence of the importance of fundus photography during eye health screenings. CTR number: NCT04271709.

The State of Urotrauma Education Among Residency Programs in the United States: A Systematic Review and Meta-Analysis.

PURPOSE OF REVIEW: Management of urotrauma is a crucial part of a urologist's knowledge and training. We therefore sought to understand the state of urotrauma education in the United States. RECENT FINDINGS: Using themes of "Urotrauma" and "Education," we performed a systematic review and meta-analysis by searching for studies in MEDLINE, all Cochrane libraries, EMBASE, BIOSIS, Scopus, and Web of Science through May 2023. The primary outcome was the pooled rate of urology trainee and program director attitudes toward urotrauma education. Secondary outcomes involved a descriptive summary of existing urotrauma curricula and an assessment of factors affecting urotrauma exposure. Of 12,230 unique records, 11 studies met the final eligibility criteria, and we included 2 in the meta-analysis. The majority of trainees and program directors reported having level 1 trauma center rotations (range 88-89%) and considered urotrauma exposure as an important aspect of residency education (83%, 95% CI 76-88%). Despite possible increases in trainee exposure to Society of Genitourinary Reconstructive Surgeons (GURS) faculty over the preceding decade, nearly a third of trainees and program directors currently felt there remained inadequate exposure to urotrauma during training (32%, 95% CI 19-46%). Factors affecting urotrauma education include the limited exposure to GURS-trained faculty and clinical factors such as case infrequency and non-operative trauma management. Urology resident exposure to urotrauma is inadequate in many training programs, underscoring the potential value of developing a standardized curriculum to improve urotrauma education for trainees. Further investigation is needed to characterize this issue and to understand how it impacts trainee practice readiness.

A national evaluation of the use and survival impact of adjuvant chemotherapy in Stage II colon cancer from the national cancer database.

AIM: Stage II colon cancers are a heterogeneous category, with controversy over use of adjuvant chemotherapy (AC). Patients with high-risk features may benefit from AC to improve overall survival (OS). Current guidelines do not routinely recommend AC in low-risk cases, but the actual use and benefit on OS in this cohort have not been fully examined on a national scale. We aimed to evaluate the use and impact of AC on OS in low-risk Stage II colon cancer. METHODS: The national cancer database was reviewed for Stage II colon cancers undergoing curative resection (2010-2015). Cases with preoperative radio-chemotherapy or high-risk features were excluded. Cases were stratified into 'AC' and 'no AC' cohorts, and then propensity score matched. Kaplan-Meier and Cox regression analysed OS. The main outcome measures were the incidence and impact of AC on OS in low-risk Stage II colon cancer. RESULTS: Of 39 926 patients evaluated, 8.2% (n = 3275) received AC. Matching resulted in 3275 cases per cohort. AC significantly improved 1-, 3- and 5-year OS versus no AC (P = 0.0017). The 5-year absolute risk reduction was 2.6%, relative risk reduction 12%, with a number needed to treat of 38. In the Cox model, AC remained significantly associated with increased OS (hazard ratio 0.816; 95% CI 0.713-0.934; P < 0.003). CONCLUSIONS: From this dataset, AC was associated with improved OS in low-risk Stage II disease. These findings from a large-scale sample question current guidelines and the need for better risk stratification. Further study with more robust variables is warranted to determine AC best practices.

Race, But Not Gender, Is Associated With Admissions Into Orthopaedic Residency Programs.

BACKGROUND: Orthopaedic surgery is one of the most competitive but least diverse surgical specialties, with ever-increasing academic achievements (such as test scores) shown by applicants. Prior research shows that white applicants had higher United States Medical Licensing Exam (USMLE) Step 1 and Step 2 Clinical Knowledge scores as well as higher odds of Alpha Omega Alpha status compared with Black, Hispanic, and other applicant groups. Yet, it still remains unknown whether differences in application metrics by race/ethnicity sufficiently explain the underrepresentation of certain racial or ethnic minority groups in orthopaedic residency programs. QUESTIONS/PURPOSES: In this study, we sought to determine (1) the relative weight of academic variables for admission into orthopaedic residency, and (2) whether race and gender are independently associated with admission into an orthopedic residency. METHODS: The Electronic Residency Application System (ERAS) data from the Association of American Medical Colleges (AAMC) and the National Board of Medical Examiners (NBME) of first-time MD applicants (n = 8966) for orthopaedic surgery residency positions in the United States and of admitted orthopaedic residents (n = 6218) from 2005 to 2014 were reviewed. This dataset is the first and most comprehensive of its kind to date in orthopaedic surgery. Academic metrics, such as USMLE Step 1 and Step 2 Clinical Knowledge scores, number of publications, Alpha Omega Alpha status, volunteer experiences, work experience, as well as race and gender, were analyzed using hierarchical logistic regression models. The first model analyzed the association of academic metrics with admission into orthopaedic residency. In the second model, we added race and gender and controlled for metrics of academic performance. To determine how well the models simulated the actual admissions data, we computed the receiver operating characteristics (ROC) including the area under curve (AUC), which measures the model's ability to simulate which applicants were admitted or not admitted, with an AUC = 1.0 representing a perfect simulation. The odds ratio and confidence interval of each variable were computed. RESULTS: When only academic variables were analyzed in the first model, Alpha Omega Alpha status (odds ratio 2.12 [95% CI 1.80 to 2.50]; p < 0.001), the USMLE Step 1 score (OR 1.04 [95% CI 1.03 to 1.04]; p < 0.001), the USMLE Step 2 Clinical Knowledge score (OR 1.01 [95% CI 1.01 to 1.02]; p < 0.001), publication count (OR 1.04 [95% CI 1.03 to 1.05]; p < 0.001), and volunteer experience (OR 1.03 [95% CI 1.01 to 1.04]; p < 0.001) were associated with admissions into orthopaedics while work and research experience were not. This model yielded a good prediction of the results with an AUC of 0.755. The second model, in which the variables of race and gender were added to the academic variables, also had a good prediction of the results with an AUC of 0.759. This model indicates that applicant race, but not gender, is associated with admissions into orthopaedic residency. Applicants from Asian (OR 0.78 [95% CI 0.67 to 0.92]), Black (OR 0.63 [95% CI 0.51 to 0.77], Hispanic (OR 0.48 [95% CI 0.36 to 0.65]), or other race groups (OR 0.65 [95% CI 0.55 to 0.77]) had lower odds of admission into residency compared with white applicants. CONCLUSION: Minority applicants, but not women, have lower odds of admission into orthopaedic surgery residency, even when accounting for academic performance metrics. Changes in the residency selection processes are needed to eliminate the lower admission probability of qualified minority applicants in orthopaedic residency and to improve the diversity and inclusion of orthopaedic surgery. Changes including increasing the diversity of the selection committee, bias training, blinding applications before review, removal of metrics with history of racial disparities from an interviewer's candidate profile before an interview, and use of holistic application review (where an applicants' experiences, attributes, and academic metrics are all considered) can improve the diversity landscape in training. In addition, cultivating an environment of inclusion will be necessary to address these long-standing trends in orthopaedic surgery. CLINICAL RELEVANCE: Race, but not gender, is associated with the odds of acceptance into orthopaedic surgery residency despite equivalent academic metrics. Changes in residency selection processes are suggested to eliminate the lower admission probability of qualified minority applicants into orthopaedic residency and to improve the diversity and inclusion of orthopaedic surgery.

Tech Connect: An Intervention to Promote Treatment Engagement for Adolescents with Depression.

Poor treatment engagement remains a challenge in effectively treating adolescents with depression. This exploratory 2-arm RCT aimed to test the feasibility and acceptability of Tech Connect for promoting treatment engagement among adolescents. Twenty youth with depression were randomized to Tech Connect (treatment) or standard community-based mental health care (control). Study aims included: (1) assess the feasibility and acceptability of Tech Connect between-session contacts for adolescents, their parents, and treatment providers and (2) conduct a preliminary analysis of engagement and mental health outcomes. Significant differences were found between the number of treatment sessions attended by the Tech Connect and control group (t = 2.00; p < .05). Adolescents receiving Tech Connect attended 91.3% (mean = 7.5 sessions; SD = 1.58) of their initial eight sessions, while 66.3% (mean = 5.3 sessions; SD = 3.09) attended in the control condition. Tech Connect is a novel, technologically-driven intervention that proved effective in improving treatment engagement among adolescents with depression.

Maternal Sensitivity Predicts Fewer Sleep Problems at Early Adolescence for Toddlers with Negative Emotionality: A Case of Differential Susceptibility.

Theory underscores the importance of parenting in sleep development, but few studies have examined whether links vary by temperament. To address this gap, we tested whether potential links between early maternal sensitivity and early adolescent sleep problems varied by child negative emotionality and delay of gratification. Using data from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development (N = 820), we found that high maternal sensitivity predicted fewer bedtime problems and longer sleep duration at 6th grade for toddlers with high negative emotionality, whereas low maternal sensitivity predicted the reverse. No differences were observed for low negative emotionality. Moreover, delay of gratification predicted fewer bedtime problems at 6th grade, but did not moderate associations between maternal sensitivity, negative emotionality, and sleep. Findings demonstrate that high, but not low, negative emotionality renders toddlers differentially susceptible and receptive to maternal sensitivity in relation to sleep.

Is the Legalization of Marijuana Associated With Its Use by Adolescents?

BACKGROUND: Growing moves in the U.S. toward relaxed laws surrounding adult use of marijuana raise concerns about concurrent increases in adolescent use of marijuana. OBJECTIVES: This study collected and analyzed primary data on the relationship between marijuana legalization status in U.S. states and adolescents' marijuana use. METHODS: Recruited through social networking sites and youth-services community agencies, a sample of 1,310 adolescents from 48 U.S. states and the District of Columbia reported their use of marijuana. Youths' use rates were compared with the marijuana legalization status of youths' states of residence. RESULTS: Study findings failed to show a relationship between adolescents' use of marijuana and state laws regarding marijuana use. Relationships were found for increased marijuana use by older youths, females, and non-Hispanic youths. Youths whose parents completed 2 or more years of college were less likely to report marijuana use than those whose parents completed fewer than 2 years of college. CONCLUSIONS: Albeit study findings do not support predictions of growing marijuana use by adolescents in states with liberalized adult use laws, further monitoring of adolescents' use with larger and more representative samples is needed.

A Comparison of the Minimal-Touch Technique and the Eversion Technique for Microvascular Anastomosis in a Rat Model.

Background During microvascular anastomosis, needle placement is facilitated by inserting the tips of the forceps into the lumen of the vessel, rather than grasping and everting the luminal wall, to minimize trauma to the vessel. This study examines whether the vessel wall can be grasped and everted during microvascular anastomosis without compromising surgical outcomes. Methods A total of 20 Sprague-Dawley rats weighing between 252 and 483 g were used. Bilateral anastomoses of the animals' femoral arteries (mean size: 0.90 mm) were performed using two different techniques: the classic minimal-touch approach and the eversion technique. The first 10 animals were survived for 48 hours and the second 10 animals were survived for 2 weeks. Patency was assessed immediately after surgery and just before sacrifice. Hematoxylin and eosin stains were performed and each anastomosis scored according to a grading rubric assessing endothelial cell loss, neointimal proliferation, medial necrosis, adventitial inflammation, and inflammation thickness. Results The patency rates of both techniques were identical (100%). There was no difference in the patency rates of anastomoses evaluated 48 hours after surgery (100%) and 2 weeks after surgery (100%). Histological outcomes between the minimal-touch technique and the eversion method were similar. The thickness of adventitial inflammation at 2 weeks was the only outcome found to be statistically different (p = 0.046) between the two treatments and this difference favored the eversion technique (i.e., less inflammation thickness). Conclusion The eversion method of performing microvascular anastomosis provides comparable results to the classic minimal-touch approach in rat femoral artery anastomoses.

Inter- and intra-observer agreement of femoroacetabular impingement (FAI) parameters comparing plain radiographs and advanced, 3D computed tomographic (CT)-generated hip models in a surgical patient cohort.

PURPOSE: The purpose of our study was to investigate whether advanced, 3D computed tomographic (CT)-generated hip models improves inter-and intra-observer agreement when compared to plain radiographs in identifying femoroacetabular impingement (FAI) morphology. METHODS: Eight consecutive patients who underwent surgery for FAI pathology were selected for this study. Preoperative CT scan image data were used to create high resolution, 3D hip reconstruction models. Four observers (two attending hip surgeons and radiologists) performed a blinded review of preselected radiographs and 3D CT hip models. Alpha and lateral center-edge angle measurements, location of cam lesion and the presence of a "crossover sign" were assessed. Inter- and intra-observer agreement was determined by calculating the intra-class correlation coefficients (ICC) or kappa coefficients to evaluate agreement for categorical variables. RESULTS: The parameter that demonstrated the highest and poorest inter-observer agreement was the presence of a "crossover sign" using 3D CT-generated high resolution hip models (ICC = 0.76, p = 0.00) and anteroposterior pelvis radiography, respectively (ICC = 0.20, p = 0.02). Alpha angle values were significantly higher using plain radiographs when compared to 3D hip reconstruction models (61.1° ± 10.4° versus 55.4° ± 14.4°, p = 0.003). Furthermore, when compared to radiographs, 3D hip reconstruction models demonstrated significantly higher intra-observer agreement (ICC = 0.856 versus 0.405, p = 0.005) when determining the presence of a "crossover sign". CONCLUSIONS: Our findings were suggestive that for most commonly used FAI morphology parameters, CT-generated hip models demonstrated little benefit over plain radiographs in improving inter-observer agreement among providers. LEVEL OF EVIDENCE: III.

Redefining the Acetabular Component Safe Zone for Posterior Approach Total Hip Arthroplasty.

BACKGROUND: Acetabular component orientation influences joint stability in total hip arthroplasty (THA). The purpose of this study was to evaluate the effect of cup orientation and other variables on hip dislocation risk and to define a posterior approach specific safe zone. METHODS: A cohort of 1289 posterior approach primary THA cases was prospectively followed and component position measured radiographically. RESULTS: Cup malposition, with respect to the Lewinnek safe zone, was an independent risk factor for dislocation (OR1.88). Modifying the anteversion safe zone limits to 10-25° strongly predicted increased dislocation risk (OR2.69). No dislocations occurred within a zone defined by a circle centered at 41.4° abduction and 17.1° anteversion, radius 4.3°. CONCLUSION: Utilizing a posterior approach specific safe zone of 10-25° anteversion and 30-50° abduction may minimize THA dislocations. LEVEL OF EVIDENCE: Level III.

Total Hip Arthroplasty Functional Outcomes Are Independent of Acetabular Component Orientation When a Polyethylene Liner Is Used.

BACKGROUND: This study evaluated patient-reported outcomes in patients undergoing primary total hip arthroplasty with a polyethylene liner to determine the influence of cup orientation and other variables on patient-reported outcomes. METHODS: A total of 477 cases were prospectively monitored through average 4.7 years follow-up. Cup position was measured on pelvis radiographs. Patients completed the Western Ontario and McMaster Universities Osteoarthritis Index and Short Form 12 Health Survey questionnaires. RESULTS: Average cup abduction was 43.1° ± 7.5° and anteversion was 13.3° ± 7.5°. Three hundred cups were within the target zone. All outcomes' improvement from baseline and cup position was not an independent risk factor for the Western Ontario and McMaster Universities Osteoarthritis Index or Short Form 12 Health Survey improvement. CONCLUSION: Accurate cup orientation may not be critical to maximizing patient-perceived outcomes if the combined anteversion is within a normal range, the hip joint is properly balanced, and a polyethylene liner is coupled with a metal or ceramic femoral head.

How does external rotation bracing influence motion and functional scores after arthroscopic shoulder stabilization?

BACKGROUND: After arthroscopic shoulder stabilization, the loss of motion or delayed recovery of motion remains a clinical problem and may lead to poor patient satisfaction. There remains no consensus regarding the optimal position for postoperative immobilization and it is not known whether the position for shoulder immobilization has an effect on motion and functional recovery. QUESTIONS/PURPOSES: We asked: (1) Do patients treated with external rotation (ER) bracing after arthroscopic anterior shoulder stabilization reliably regain ROM and shoulder function? And (2) what is the frequency of recurrent instability and brace-related complications associated with the use of ER bracing? METHODS: Forty consecutive patients with a primary diagnosis of anterior shoulder instability underwent arthroscopic stabilization and received postoperative ER bracing; 33 patients (83%; mean age, 23 years; range, 13-44 years) were followed for at least 1 year postoperatively and seven patients were lost to followup. Shoulder ROM and functional scores were recorded preoperatively and at 2 weeks, 12 weeks, 6 months, and greater than 1 year (mean, 16 months) after surgery. RESULTS: All patients recovered their preoperative ROM and most patients achieved normal ROM by 3 months after surgery. Significant improvements in American Shoulder and Elbow Surgeons (ASES) and Western Ontario Shoulder Instability (WOSI) scores were observed at each postoperative time point. The mean (± SD) final scores were 95 ± 9 for the ASES and 87% ± 17% for the WOSI (p < 0.001 compared to preoperative scores). One patient (3%) developed recurrent instability. No patients underwent reoperation for the injured shoulder for any reason during the followup period. CONCLUSIONS: ER bracing after arthroscopic shoulder stabilization is associated with a predictable recovery of ROM and functional score improvement. Future studies comparing ER bracing to traditional sling use should be conducted to determine the optimal method of postoperative immobilization. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Risk factors associated with recurrent homelessness after a first homeless episode.

Alcohol and drug use are commonly associated with the experience of homelessness. In order to better understand this, we explored the prevalence of drug and alcohol use as it related to successful re-housing within a sample of first-time single homeless adults at municipal shelters. From within this sample, we compared the features of recurrent homelessness with those of chronic homelessness and of being stably housed. We interviewed 344 subjects upon shelter entry and followed each one every six months for 18 months using standardized social and mental health measures. We analyzed baseline assessments relative to housing experiences during follow-up using Chi square and multinomial logistic regression. Eighty-one percent (N = 278) obtained housing over 18 months, of which 23.7 % (N = 66) experienced homelessness again. Recurrent homelessness was more common among those with a high school education and if initially re-housed with family. Bivariate analysis resulted in the observation of the highest rate of alcohol and other drug use among this recurrent group and multinomial logistic regression supported this only with the coupling of arrest history and diagnosed antisocial personality disorder. With relatively high rates of recurrent homelessness, there were differences between subjects who experienced recurrent homelessness compared to those who were stably housed and with chronic homelessness. That alcohol and other substance use disorders were associated with recurrent homelessness only if they were linked to other risk factors highlights the complexity of causes for homelessness and a resultant need to organize them into constellations of causal risk factors. Consistent with this, there should be initiatives that span bureaucratic boundaries so as to flexibly meet multiple complex service needs, thus improving outcomes concerning episodes of recurrent homelessness.

Hearing Loss and Reduced Income Growth: A Longitudinal Socioeconomic Analysis.

OBJECTIVE: Hearing loss (HL) has been linked to negative socioeconomic states, including low income. This study examines the relationship between HL and income growth. STUDY DESIGN: Longitudinal observational study. SETTING: Multicentered US epidemiologic study (Hispanic Community Health Study, HCHS). METHODS: Using data from 2 waves of the HCHS, we analyzed the association between HL and income growth in adults ages 18 to 74 years using generalized estimating equations. The exposure was HL, measured by 4-frequency pure-tone average (PTA). The outcome was yearly household income growth, with income graded on a 10-bracket scale from <$10,000 to >$100,000. Models controlled for demographics, hearing aid use, and vascular risk. RESULTS: A total of 1342 participants met inclusion criteria. At visit 1, average age was 47.6 years (SD = 12.2), and average PTA was 13.9 decibels (dB, SD = 9.5). Average follow-up was 5.9 years (SD = 0.6). There was a significant time × HL interaction: with each 10 dB worsening in HL, the odds of belonging to a higher versus a lower income bracket changed by a factor of 0.979 (P < .001) between waves 1 and 2. In other words, the odds of belonging to a higher income group decreased with worsening HL. At 38.6 dB, the odds for income growth became <1, indicating income loss rather than growth. CONCLUSION: Increased HL is associated with reduced income growth, including the possibility of negative growth (ie, income decline). This study emphasizes the value of including socioeconomic measures in randomized controlled trials assessing the impact of HL treatment and the importance of extended follow-up for study participants.

National Trends of Inpatient Radiation Cystitis: 2016-2019.

INTRODUCTION: Radiation cystitis with hematuria (RCH) is a potentially devastating complication after pelvic radiation. The cumulative incidence of RCH is debated, and certain severe manifestations may require hospital admission. We aimed to evaluate demographics and outcomes of patients hospitalized for RCH. METHODS: We performed a retrospective review of hospitalized patients with a primary or secondary diagnosis of RCH from 2016 to 2019 using the National Inpatient Sample. Our unit of analysis was inpatient encounters. Our primary outcome was inpatient mortality. Secondary outcomes included need for inpatient procedures, transfusion, length of stay (LOS), and cost of admission. We then performed multivariate analysis using either a logistic or linear regression to identify predictors of mortality and LOS. Cost was analyzed using a generalized linear model controlling for LOS. RESULTS: We identified 21,320 weighted cases of hospitalized patients with RCH. The average patient age was 75.4 years, with 84.7% male and 69.3% White. The median LOS was 4 days, and the median cost was $8767. The inpatient mortality rate was 1.3%. The only significant predictor for mortality was older age. The only significant predictor of both higher cost and longer LOS was an Elixhauser Comorbidity Score ≥ 3. CONCLUSIONS: RCH represents a significant burden to patients and the health care system, and we observed an increasing number of hospitalized patients over time. Additional research is needed to identify underlying causes of RCH and effective treatments for this sometimes-severe complication of pelvic radiation.

The Impact of American Board of Urology Certification on Postoperative Outcomes for Patients in New York State.

INTRODUCTION: Our goal was to determine if board certification status was associated with improved postoperative outcomes for certain urologic oncology operations. METHODS: We performed a retrospective cohort study of patients aged 65 and over having radical prostatectomy (RP), radical cystectomy (RC), and radical or partial nephrectomy (RPN) by surgeons with New York State licenses from 2015 to 2021 using the Medicare limited dataset. Our primary exposure was surgeon American Board of Urology certification determined by the New York State Physician Profile. All surgeons were in practice for at least 5 years. Our primary outcomes were 90-day mortality, 30-day unplanned readmission, and hospital length of stay (LOS). We used multivariable linear and logistic regression adjusted for surgeon, hospital, and patient characteristics. We performed the analysis in R, and 2-sided P values < .05 were considered statistically significant. RESULTS: We identified 12,601 patients who had a procedure performed. At the time of the procedure, a minority of procedures (1.3%) were performed by nonboard-certified (NBC) urologists. Among the patient cohort, there were 262 and 1419 mortality and readmission events, respectively; median LOS was 2 days (interquartile range 1155). Patients operated on by NBC urologists tended to have lower-volume surgeons who were less likely to be fellowship trained and to have surgery at smaller hospitals. Patients treated by NBC urologists were more likely to have RP, and less likely to have RC and RPN. On multivariate analysis, board certification was protective against readmission for RP (P < .001) and RC (P = .02), longer LOS for RC (P = .001), and mortality for RPN (P = .008). CONCLUSIONS: Urology board certification was associated with fewer readmissions after RP and RC, a shorter LOS after RC, and a lower risk of mortality after RPN. Given low event numbers, these findings require validation with a larger dataset.

Evaluating compliance with the 2013 best practice guidelines for preventing surgical site infection in high-risk pediatric spine surgery.

PURPOSE: Best Practice Guidelines (BPGs) were published one decade ago to decrease surgical site infection (SSI) in pediatric spinal deformity. Successful implementation has not been established. This study evaluated surgeon compliance with items on the BPG. We hypothesized that BPG authors and surgeons with more experience, higher caseload, and awareness of the BPG would have higher compliance. METHODS: We queried North American and European surgeons, authors and non-authors, and members of various spine study groups on adherence to BPGs using an anonymous survey. Mean compliance scores (MCSs) were developed by correlating Likert responses with MCSs ("None of the time" = no compliance = MCS 0, "Sometimes" = weak to moderate = MCS 1, "Most of the time" = high = MCS 2, "All the time" = perfect = MCS 3). RESULTS: Of the 142 respondents, 73.7% reported high or perfect compliance. Average compliance scores for all guidelines was 2.2 ± 0.4. There were significantly different compliance scores between North American and European surgeons (2.3 vs 1.8, p < 0.001), authors and non-authors (2.5 vs. 2.2, p = 0.023), and surgeons with and without knowledge of the BPGs (2.3 vs. 1.8, p < 0.001). There was a weak correlation between BPG awareness and compliance (r = 0.34, p < 0.001) and no correlation between years in practice (r = 0.0, p = 0.37) or yearly caseload (r = 0.2, p = 0.78) with compliance. CONCLUSIONS: Compliance among our cohort of surgeons surveyed was high. North American surgeons, authors of the BPGs and those aware of the guidelines had increased compliance. Participation in a spine study group, years in practice, and yearly caseload were not associated with compliance. LEVEL OF EVIDENCE: Level V-expert opinion.

Evaluating compliance with the best practice guidelines for wrong-level surgery prevention in high-risk pediatric spine surgery.

PURPOSE: In 2018, Best Practice Guidelines (BPGs) were published for preventing wrong-level surgery in pediatric spinal deformity, but successful implementation has not been established. The purpose of this study was to evaluate BPG compliance 5 years after publication. We hypothesized higher compliance among BPG authors and among surgeons with more experience, higher caseload, and awareness of the BPGs. METHODS: We queried North American and European surgeons, authors and nonauthors, and members of pediatric spinal study groups on adherence to BPGs using an anonymous survey consisting of 18 Likert scale questions. Respondents provided years in practice, yearly caseload, and guideline awareness. Mean compliance scores (MCS) were developed by correlating Likert responses with MCS scores ("None of the time" = no compliance = MCS 0, "Sometimes" = weak to moderate = MCS 1, "Most of the time" = high = MCS 2, and "All the time" = perfect = MCS 3). RESULTS: Of the 134 respondents, 81.5% reported high or perfect compliance. Average MCS for all guidelines was 2.4 ± 0.4. North American and European surgeons showed no compliance differences (2.4 vs. 2.3, p = 0.07). Authors and nonauthors showed significantly different compliance scores (2.8 vs 2.4, p < 0.001), as did surgeons with and without knowledge of the BPGs (2.5 vs 2.2, p < 0.001). BPG awareness and compliance showed a moderate positive correlation (r = 0.48, p < 0.001), with non-significant associations between compliance and both years in practice (r = 0.41, p = 0.64) and yearly caseload (r = 0.02, p = 0.87). CONCLUSION: Surgeons reported high or perfect compliance 81.5% of the time with BPGs for preventing wrong-level surgery. Authorship and BPG awareness showed increased compliance. Location, study group membership, years in practice, and yearly caseload did not affect compliance. LEVEL OF EVIDENCE: Level V-expert opinion.