Association of Open Reduction and Internal Fixation With Volar Locking Plate for Distal Radius Fractures With Patient-Reported Outcomes in Older Adults: A Network Meta-analysis.

Importance: Randomized clinical trials (RCTs) and meta-analyses have reported inconsistent conclusions regarding optimal distal radius fracture (DRF) treatment in older adults and are limited due to the inclusion of cohort studies with small sample sizes. A network meta-analysis (NMA) addresses these limitations by only synthesizing direct and indirect evidence from RCTs and may clarify optimal DRF treatment in older adults. Objective: To examine DRF treatment results in optimal short-term and intermediate-term patient-reported outcomes. Data Sources: Searches of MEDLINE, Embase, Scopus, and Cochrane Central Register of Controlled Trials were conducted for RCTs that investigated DRF treatment outcomes in older adults between January 1, 2000, and January 1, 2022. Study Selection: Randomized clinical trials including patients with a mean age of 50 years or older that compared the following DRF treatments were eligible for inclusion: casting, open reduction and internal fixation with volar lock plating (ORIF), external fixation, percutaneous pinning, and nail fixation. Data Extraction and Synthesis: Two reviewers independently completed all data extraction. An NMA aggregated all direct and indirect evidence among DRF treatments. Treatments were ranked by surface under the cumulative ranking curve score. Data are reported as standard mean differences (SMDs) and 95% CIs. Main Outcomes and Measures: The primary outcome was short-term (≤3 months) and intermediate-term (>3 months to 1 year) Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire scores. Secondary outcomes included Patient-Rated Wrist Evaluation (PRWE) scores and 1-year complication rates. Results: In this NMA, 23 RCTs consisting of 3054 participants (2495 women [81.7%]) with a mean (SD) age of 66 (7.8) years were included. At 3 months, DASH scores were significantly lower for nail fixation (SMD, -18.28; 95% CI, -29.93 to -6.63) and ORIF (SMD, -9.28; 95% CI, -13.90 to -4.66) compared with casting. The PRWE scores were also significantly lower for ORIF (SMD, -9.55; 95% CI, -15.31 to -3.79) at 3 months. In the intermediate term, ORIF was associated with lowered DASH (SMD, -3.35; 95% CI, -5.90 to -0.80) and PRWE (SMD, -2.90; 95% CI, -4.86 to -0.94) scores. One-year complication rates were comparable among all treatments. Conclusions and Relevance: The findings of this NMA suggest that ORIF may be associated with clinically significant improvements in short-term recovery compared with casting for multiple patient-reported outcomes measures with no increase in 1-year complication rates. Shared decision-making with patients may be useful to identify patient preferences regarding recovery to determine optimal treatment.

Using Rasch Analysis to Evaluate the Psychometric Properties of the Brief MHQ in Patients with Traumatic Finger Amputations.

Background: Digit amputations affect 45,000 Americans each year and are associated with substantial healthcare expenditures and loss of wages. Few patient-reported outcome measures (PROMs) are validated in patients with digit amputations. The brief Michigan Hand Outcomes Questionnaire (bMHQ) is a 12-item PROM used in several hand conditions. However, its psychometric properties have not been investigated in patients with digit amputations. Methods: The reliability and validity of the bMHQ was investigated using Rasch analysis. Data were collected from the Finger Replantation and Amputation Challenges in Assessing Impairment, Satisfaction, and Effectiveness (FRANCHISE) study. Participants were divided into replantation and revision amputation cohorts and then further separated into single-digit amputation (excluding thumb), thumb-only amputation and multiple-digit amputation (excluding thumb) subgroups. Each of the six subgroups were analysed for item fit, threshold ordering, targeting, differential item functioning (DIF), unidimensionality and internal consistency. Results: All treatment groups demonstrated high unidimensionality (Martin-Löf test = 1) and internal consistency (Cronbach's α > 0.85). The bMHQ is not a reliable PROM in individuals with single-digit or multiple-digit amputations. The aesthetics, satisfaction and two-handed activities of daily living (ADLs) items had the poorest fit to the Rasch model across all categories. Conclusions: The bMHQ is not well-suited for measuring outcomes in patients with digit amputations. We recommend clinicians use more comprehensive assessment tools, such as the complete MHQ, to measure outcomes in these complex patient populations. Level of Evidence: Level III (Diagnostic).

Comparison of Distal Radius Fracture Outcomes in Older Adults Stratified by Chronologic vs Physiologic Age Managed With Casting vs Surgery.

Importance: Casting is recommended for adults older than 65 years with distal radius fractures (DRFs) because similar long-term outcomes are achieved regardless of treatment. However, physiologically younger adults could benefit from operative DRF management despite advanced chronologic age. Objective: To examine how chronologic age compares with measures of physiologic age in DRF treatment recovery. Design, Setting, and Participants: This retrospective secondary analysis of the Wrist and Radius Injury Surgical Trial (WRIST) was performed from May 1 to August 31, 2022. WRIST was a 24-center randomized clinical trial that enrolled participants older than 60 years with unstable DRFs from April 1, 2012, to December 31, 2016. Interventions: Participants selected casting or surgery. Patients who selected surgery were randomly assigned to volar lock plating, percutaneous pinning, or external fixation. Participants were stratified by chronologic age, number of comorbidities, and activity status. Main Outcomes and Measures: The primary outcome was Michigan Hand Outcomes Questionnaire (MHQ) score assessed at 6 weeks, 3 months, 6 months, and 1 year. Partial correlation (PC) analysis adjusted for confounding. Results: The final cohort consisted of 293 participants (mean [SD] age, 71.1 [8.89] years; 255 [87%] female; 247 [85%] White), with 109 receiving casting and 184 receiving surgery. Increased chronologic age was associated with increased MHQ scores in the surgery group at all time points but decreased MHQ scores in the casting group at 12 months (mean [SD] score, -0.46 [0.21]; P = .03). High activity was associated with improved MHQ scores in the surgical cohort at 6 weeks (mean [SD] score, 12.21 [5.18]; PC = 0.27; P = .02) and 12 months (mean [SD] score, 13.25 [5.77]; PC = 0.17; P = .02). Comorbidities were associated with decreased MHQ scores at all time points in the casting group. Clinically significant differences in MHQ scores were associated with low physical activity, 4 or more comorbidities, or increased age by 15 years. Conclusions and Relevance: In this retrospective secondary analysis of WRIST, chronologic age was not associated with functional demand. These findings suggest that physicians should counsel active older adults with few comorbidities on earlier return to daily activities after surgery compared with casting. Trial Registration: ClinicalTrials.gov Identifier: NCT01589692.

Using Rasch Analysis to Validate the Michigan Hand Outcomes Questionnaire from the Wrist and Radius Injury Surgical Trial.

BACKGROUND: The Michigan Hand Outcomes Questionnaire is a patient-reported outcome measure that has been validated in many upper extremity disorders using classic test theory. Rasch measurement analysis is a rigorous method of questionnaire validation that offers several advantages over classic test theory and was used to assess the psychometric properties of the Michigan Hand Outcomes Questionnaire. This study used Rasch analysis to evaluate the questionnaire for distal radius fractures in older adults. The incidence and costs of distal radius fractures are rising, and reliable assessment tools are needed to measure outcomes in this growing concern. METHODS: Rasch analysis was performed using 6-month assessment data from the Wrist and Radius Injury Surgical Trial. Each domain in the Michigan Hand Outcomes Questionnaire was independently analyzed for threshold ordering, person-item targeting, item fit, differential-item functioning, response dependency, unidimensionality, and internal consistency. RESULTS: After collapsing disordered thresholds and removing any misfitting items from the model, five domains (Function, Activities of Daily Living, Work, Pain, and Satisfaction) demonstrated excellent fit to the Rasch model. The Aesthetics domain demonstrated high reliability and internal consistency but had poor fit to the Rasch model. CONCLUSIONS: Rasch analysis further supports the reliability and validity of using the Michigan Hand Outcomes Questionnaire to assess hand outcomes in older adults following treatment for distal radius fractures. Results from this study suggest that questionnaire scores should be interpreted in a condition-specific manner, with more emphasis placed on interpreting individual domain scores, rather than the summary Michigan Hand Outcomes Questionnaire score.

Factors Associated With State-Specific Medicaid Expansion and Receipt of Autologous Breast Reconstruction Among Patients Undergoing Mastectomy.

Importance: Despite demonstrated psychosocial benefits, autologous breast reconstruction remains underutilized. An analysis of the association between Medicaid expansion and autologous breast reconstruction has yet to be performed. Objective: To compare autologous breast reconstruction rates and determine the association between Medicaid expansion and breast reconstruction. Design, Setting, and Participants: A retrospective cross-sectional study was performed using the State Inpatient Database from January 1, 2012, through September 30, 2015, and included 51 340 patients. Patients were identified using the International Classification of Diseases, Ninth Revision, codes for breast cancer, mastectomy, and autologous breast reconstruction. Data from states that expanded Medicaid (New Jersey, New York, and Washington) were compared with states that did not expand Medicaid (Florida, North Carolina, and Wisconsin). Data were analyzed from June 1, 2020, through February 28, 2021. Exposures: The Patient Protection and Affordable Care Act's Medicaid expansion was implemented in 2014; the preexpansion period ranged from 2012 to 2013 (2 years), whereas the postexpansion period ranged from 2014 to 2015 quarter 3 (1.75 years). Main Outcomes and Measures: Primary outcomes included use of autologous breast reconstruction before and after expansion. Independent covariates included patient demographics, comorbidities, and state of residence. Results: Among 45 850 patients who underwent mastectomy and 9215 patients who received autologous breast reconstruction, 36 777 (67%) were White and 32 205 (59%) had private insurance. The use of immediate or delayed autologous reconstruction increased from 18.1% (4951 of 27 290) to 23.0% (4264 of 18 560) throughout the study period. Compared with 2012, the odds of reconstruction were 64% higher in 2015 (odds ratio [OR], 1.64; 95% CI, 1.48-1.80; P < .001). African American (OR, 1.43; 95% CI, 1.33-1.55; P < .001) and Hispanic (OR, 1.44; 95% CI, 1.31-1.60; P < .001) patients had higher odds of reconstruction compared with White patients regardless of state of residence. However, Medicaid expansion was associated with a 28% decrease in the odds of reconstruction (OR, 0.72; 95% CI, 0.61-0.87; P < .001) for African American patients, a 40% decrease (OR, 0.60; 95% CI, 0.50-0.74; P < .001) for Hispanic patients, and 20% decrease (OR, 0.80; 95% CI, 0.67-0.96; P = .01) for patients with Asian, Native American, or other minority race/ethnicity. Medicaid expansion was not associated with changes in the odds of reconstruction for White patients. Conclusions and Relevance: In this cross-sectional study, although the odds of receiving autologous breast reconstruction increased annually, Medicaid expansion was associated with decreased odds of reconstruction for African American patients, Hispanic patients, and other patients of color.

Validating the Michigan Hand Outcomes Questionnaire in patients with rheumatoid arthritis using Rasch analysis.

INTRODUCTION: The Michigan Hand Outcomes Questionnaire (MHQ) is a patient-reported outcome measure previously validated in patients with rheumatoid arthritis (RA) using classical test theory. Rasch analysis is a more rigorous method of questionnaire validation that has not been used to test the psychometric properties of the MHQ in patients with RA. The objective of this study is to evaluate the validity and reliability of the MHQ for measuring outcomes in patients with RA with metacarpophalangeal joint deformities. METHODS: We performed a Rasch analysis using baseline data from the Silicone Arthroplasty in Rheumatoid Arthritis (SARA) prospective cohort study. All domains were tested for threshold ordering, item fit, targeting, differential-item functioning, unidimensionality, and internal consistency. RESULTS: The Function and Work domains showed excellent fit to the Rasch model. After making adjustments, the Pain, Activities of Daily Living (ADL) and Satisfaction domains also fulfilled all Rasch model criteria. The Aesthetics domain met the majority of Rasch criteria, but could not be tested for unidimensionality. CONCLUSIONS: After collapsing disordered thresholds and removing misfitting items, the MHQ demonstrated reliability and validity for assessing outcomes in patients with RA with metacarpophalangeal joint deformities. These results suggest that interpreting individual domain scores may provide more insight into a patient's condition rather than analyzing an overall MHQ summary score. However, more Rasch analyses are needed in other RA populations before making adjustments to the MHQ.

Modulating cellular cytotoxicity and phototoxicity of fluorescent organic salts through counterion pairing.

Light-activated theranostics offer promising opportunities for disease diagnosis, image-guided surgery, and site-specific personalized therapy. However, current fluorescent dyes are limited by low brightness, high cytotoxicity, poor tissue penetration, and unwanted side effects. To overcome these limitations, we demonstrate a platform for optoelectronic tuning, which allows independent control of the optical properties from the electronic properties of fluorescent organic salts. This is achieved through cation-anion pairing of organic salts that can modulate the frontier molecular orbital without impacting the bandgap. Optoelectronic tuning enables decoupled control over the cytotoxicity and phototoxicity of fluorescent organic salts by selective generation of mitochondrial reactive oxygen species that control cell viability. We show that through counterion pairing, organic salt nanoparticles can be tuned to be either nontoxic for enhanced imaging, or phototoxic for improved photodynamic therapy.