Socioeconomic status is associated with greater hazard of post-discharge mortality than race, gender, and ballistic injury mechanism in a young, healthy, orthopedic trauma population.

OBJECTIVES: To explore the utility of legacy demographic factors and ballistic injury mechanism relative to popular markers of socioeconomic status as prognostic indicators of 10-year mortality following hospital discharge in a young, healthy patient population with isolated orthopedic trauma injuries. METHODS: A retrospective cohort study was performed to evaluate patients treated at an urban Level I trauma center from January 1, 2003, through December 31, 2016. Current Procedure Terminology (CPT) codes were used to identify upper and lower extremity fracture patients undergoing operative fixation. Exclusion criteria were selected to yield a patient population of isolated extremity trauma in young, otherwise healthy individuals between the ages of 18 and 65 years. Variables collected included injury mechanism, age, race, gender, behavior risk factors, Area Deprivation Index (ADI), and insurance status. The primary outcome was post-discharge mortality, occurring at any point during the study period. RESULTS: We identified 2539 patients with operatively treated isolated extremity fractures. The lowest two quartiles of socioeconomic status (SES) were associated with higher hazard of mortality than the highest SES quartile in multivariable analysis (Quartile 3 HR: 2.2, 95% CI: 1.2-4.1, p = 0.01; Quartile 4 HR: 2.2, 95% CI: 1.1-4.3, p = 0.02). Not having private insurance was associated with higher mortality hazard in multivariable analysis (HR 2.0, 95% CI: 1.3-3.2, p = 0.002). The presence of any behavioral risk factor was associated with higher mortality hazard in univariable analysis (HR: 1.8, p < 0.05), but this difference did not reach statistical significance in multivariable analysis (HR: 1.4, 95%: 0.8-2.3, p = 0.20). Injury mechanism (ballistic versus blunt), gender, and race were not associated with increased hazard of mortality (p > 0.20). CONCLUSION: Low SES is associated with a greater hazard of long-term mortality than ballistic injury mechanism, race, gender, and medically diagnosable behavioral risk factors in a young, healthy orthopedic trauma population with isolated extremity injury.

PROMIS cluster analysis predicts two-year outcomes in knee surgery patients.

Aims & objectives: Meaningful clinical interpretation of orthopaedic patient-reported outcome scores remains challenging. Grouping scores may be more meaningful than individual score analysis. The purpose of this study was to determine if grouping knee surgery patients into four preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) clusters would have prognostic value for two-year postoperative outcomes. Materials & methods: 488 of 697 (70%) patients undergoing elective knee surgery at a single urban institution were enrolled in an orthopaedic registry and completed two-year follow up. Patients were administered questionnaires for PROMIS, International Knee Documentation Committee Score (IKDC), Marx Activity Rating Scale (MARS), and Surgical Satisfaction (SSQ-8). A k-means cluster analysis was performed to identify preoperative PROMIS clusters. Chi-square or Kruskal-Wallis tests were conducted for bivariate analyses. Least-squares multiple linear regression models were performed to identify if cluster group was an independent predictor. Results: Cluster analysis revealed four clusters of patients. Psychological distress was most significant in determining classification. More impaired clusters were associated with higher rates of arthroplasty, African American race, preoperative opioid use, lower income, higher comorbidity index, and other sociodemographic and operative factors. Worse preoperative cluster status was associated with higher chance of achieving minimally clinically important change (MCID) on all metrics except PROMIS Pain Interference (PI), IKDC, and MARS. Multivariable analysis confirmed better preoperative cluster as predictive of better PROMIS Physical Function (PF), PI, IKDC scores, and satisfaction. Worse preoperative cluster was predictive of greater improvement on PF and PI but not IKDC. Conclusion: Preoperative PROMIS clusters have prognostic value in predicting outcomes for knee surgery patients. Better preoperative cluster function predicts superior outcomes. While worse preoperative cluster predicts worse outcome, all clusters still significantly improve, so worse preoperative cluster is not a contraindication to surgery.

Two Novel Clinical Tests for the Diagnosis of Hip Labral Tears.

BACKGROUND: There are few well-studied clinical tests for the diagnosis of hip labral tears. As the differential diagnosis for hip pain is broad, accurate clinical examination is important in guiding advanced imaging and identifying patients who may benefit from surgical management. PURPOSE: To determine the diagnostic accuracy of 2 novel clinical tests for the diagnosis of hip labral tears. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Clinical examination findings including the Arlington, twist, and flexion-adduction-internal rotation (FADIR)/impingement tests as performed by a fellowship-trained orthopaedic surgeon specializing in hip arthroscopy were obtained from retrospective chart review. The Arlington test ranges the hip from flexion-abduction-external rotation to FADIR while applying subtle internal rotation and external rotation motion. The twist test involves internal rotation and external rotation of the hip while weightbearing. Diagnostic accuracy statistics for each of the tests were calculated using magnetic resonance arthrography as the reference standard. RESULTS: A total of 283 patients were included in the study with a mean age of 40.7 years (range, 13-77 years) and 66.4% were women. The Arlington test was found to have a sensitivity of 0.94 (95% CI, 0.90-0.96), specificity of 0.33 (95% CI, 0.16-0.56), positive predictive value (PPV) of 0.95 (95% CI, 0.92-0.97), and negative predictive value (NPV) of 0.26 (95% CI, 0.13-0.46). The twist test was found to have a sensitivity of 0.68 (95% CI, 0.62-0.73), specificity of 0.72 (95% CI, 0.49-0.88), PPV of 0.97 (95% CI, 0.94-0.99), and NPV of 0.13 (95% CI, 0.08-0.21). The FADIR/impingement test was found to have a sensitivity of 0.43 (95% CI, 0.37-0.49), specificity of 0.56 (95% CI, 0.34-0.75), PPV of 0.93 (95% CI, 0.87-0.97), and NPV of 0.06 (95% CI, 0.03-0.11). The Arlington test was significantly more sensitive than both the twist and FADIR/impingement tests (P < .05), while the twist test was significantly more specific than the Arlington test (P < .05). CONCLUSION: The Arlington test is more sensitive than the traditional FADIR/impingement test, while the twist test is more specific than the FADIR/impingement test in diagnosing hip labral tears in the hands of an experienced orthopaedic surgeon.

Race and Insurance Status Association With Receiving Orthopedic Surgeon-Prescribed Foot Orthoses.

BACKGROUND: This study looked at the effect of patient demographics, insurance status, education, and patient opinion on whether various orthotic footwear prescribed for a variety of diagnoses were received by the patient. The study also assessed the effect of the orthoses on relief of symptoms. METHODS: Chart review documented patient demographics, diagnoses, and medical comorbidities. Eligible patients completed a survey either while in the clinic or by phone after their clinic visit. RESULTS: Of the 382 patients prescribed orthoses, 235 (61.5%) received their orthoses; 186 (48.7%) filled out the survey. Race and whether or not the patient received the orthosis were found to be significant predictors of survey completion. Race, type of insurance, and amount of orthotic cost covered by insurance were significant predictors of whether or not patients received their prescribed orthoses. Type of orthosis, diabetes as a comorbidity, education, income, sex, and diagnosis were not significant predictors of whether the patient received the orthosis. Qualitative results from the survey revealed that among those receiving their orthoses, 87% experienced improvement in symptoms: 21% felt completely relieved, 66% felt better, 10% felt no different, and 3% felt worse. CONCLUSION: We found that white patients had almost 3 times the odds of receiving prescribed orthoses as black patients, even after controlling for type of insurance, suggesting race to be the primary driver of discrepancies, raising the question of what can be done to address these inequalities. While large, systematic change will be necessary, some strategies can be employed by those working directly in patient care, such as informing primary care practices of their ability to see patients with limited insurance, limiting blanket refusal policies for government insurance, and educating office staff on how to efficiently work with Medicare and Medicaid. LEVEL OF EVIDENCE: Level III, comparative study.

Operating Room Personnel Determine Efficiency of Pediatric Spinal Fusions for Scoliosis.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: To investigate the effect of different surgeons, anesthesiologists, and cRNAs individually and in teams on various perioperative and operative time intervals in a large, high-volume children's hospital. SUMMARY OF BACKGROUND DATA: Along with individual factors, studies have indicated that team factors play a role in efficiency, with larger teams leading to increased procedure times. An operating room (OR) staff dedicated to orthopedics has been reported to decrease turnover time; however, the characteristics and behaviors of surgical team members, to our knowledge, have not been analyzed as possible factors contributing to pediatric OR efficiency, and limited research has been conducted in the field of orthopedic personnel. METHODS: Chart review identified consecutive pediatric and adolescent patients who had primary posterior spinal fusion (PSF) of ≥7 levels for correction of spinal deformity. Time intervals and delays were recorded based on previous studies looking at OR efficiency and adjusted to the specific time points available in our perioperative nursing records. RESULTS: Adjusted for etiology, osteotomy, fusion levels, distance from hospital, staff switch, and body mass index, there was a significant difference in patient wait time among anesthesiologists, surgeon-anesthesiologist, and anesthesiologist-certified registered nurse anesthetist (cRNA) teams; in surgery prep time and total prep among surgeons and SA teams; and in surgery time and total room time among surgeons. There were no significant differences among cRNAs, individually, in any time interval. CONCLUSIONS: Anesthesiologists have a significant effect before and surgeons have a significant effect after entry into the OR. Identification of this variability provides an opportunity to study the differences in habits and processes of high- and low-efficiency teams, which can then be applied to all teams with the goal of improving performance of all surgical teams. LEVEL OF EVIDENCE: Level IV, case series.

Neural activity in the social decision-making network of the brown anole during reproductive and agonistic encounters.

Animals have evolved flexible strategies that allow them to evaluate and respond to their social environment by integrating the salience of external stimuli with internal physiological cues into adaptive behavioral responses. A highly conserved social decision-making network (SDMN), consisting of interconnected social behavior and mesolimbic reward networks, has been proposed to underlie such adaptive behaviors across all vertebrates, although our understanding of this system in reptiles is very limited. Here we measure neural activation across the SDMN and associated regions in the male brown anole (Anolis sagrei), within both reproductive and agonistic contexts, by quantifying the expression density of the immediate early gene product Fos. We then relate this neural activity measure to social context, behavioral expression, and activation (as measured by colocalization with Fos) of different phenotypes of 'source' node neurons that produce neurotransmitters and neuropeptides known to modulate SDMN 'target' node activity. Our results demonstrate that measures of neural activation across the SDMN network are generally independent of specific behavioral output, although Fos induction in a few select nodes of the social behavior network component of the SDMN does vary with social environment and behavioral output. Under control conditions, the mesolimbic reward nodes of the SDMN actually correlate little with the social behavior nodes, but the interconnectivity of these SDMN components increases dramatically within a reproductive context. When relating behavioral output to specific source node activation profiles, we found that catecholaminergic activation is associated with the frequency and intensity of reproductive behavior output, as well as with aggression intensity. Finally, in terms of the effects of source node activation on SDMN activity, we found that Ile8-oxytocin (mesotocin) populations correlate positively, while Ile3-vasopressin (vasotocin), catecholamine, and serotonin populations correlate negatively with SDMN activity. Taken together, our findings present evidence for a highly dynamic SDMN in reptiles that is responsive to salient cues in a social context-dependent manner.

Serotonergic activation during courtship and aggression in the brown anole, Anolis sagrei.

The role of serotonin (5-hydroxytryptamine, 5-HT) in social behavior regulation is not fully understood. While 5-HT release in nuclei of the social behavior network has generally been associated with inhibition of aggressive behavior across multiple classes of vertebrates, less is known about its effects on sexual, especially non-copulatory courtship display behaviors. Furthermore, most research has examined effects at 5-HT release sites, while studies examining the behavioral relevance of source cell populations have generated contradictory findings. This study utilized immunohistochemistry to examine the colocalization of 5-HT with Fos, an immediate early gene product and marker of neural activity, in the raphe and superior reticular nuclei of male brown anoles (Anolis sagrei) exposed to either aggression, courtship, or control social interactions. Supporting previous research, copulation was associated with a decrease in 5-HT activity, while a novel link between 5-HT activity and latency to non-copulatory courtship was also found. Within the aggression group, intensity and frequency of behavior were both associated with decreased 5-HT activity. An effect of social context was also seen, with anoles exposed to either courtship or aggression encounters showing decreased 5-HT activity in certain raphe and superior reticular nuclei populations compared to controls. Interestingly, context effects and behavioral effects were seen at separate brain nuclei, suggesting the presence of separate systems with distinct functional roles.