Relationship Between Neighborhood-Level Socioeconomic Status and Functional Outcomes After Hip Arthroscopy.

BACKGROUND: Despite the growing volume of neighborhood-level health disparity research, there remains a paucity of prospective studies investigating the relationship between Area Deprivation Index (ADI) and functional outcomes for patients undergoing hip arthroscopy. PURPOSE: To investigate the relationship between neighborhood-level socioeconomic status and functional outcomes after hip arthroscopy. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective analysis of prospectively collected data was performed on patients aged ≥18 years with minimum 1-year follow-up who underwent hip arthroscopy for the treatment of symptomatic labral tears. The study population was divided into ADILow and ADIHigh cohorts according to ADI score: a validated measurement of neighborhood-level socioeconomic status standardized to yield a score between 1 and 100. Patient-reported outcome measures (PROMs) included the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports-Specific Subscale, 33-item International Hip Outcome Tool, visual analog scale for pain, and patient satisfaction. RESULTS: A total of 228 patients met inclusion criteria and were included in the final analysis. After patients were stratified by ADI score (mean ± SD), the ADILow cohort (n = 113; 5.8 ± 3.0; range, 1-12) and ADIHigh cohort (n = 115; 28.0 ± 14.5; range, 13-97) had no differences in baseline patient demographics. The ADIHigh cohort had significantly worse preoperative baseline scores for all 5 PROMs; however, these differences were not present by 1-year follow-up. Furthermore, the 2 cohorts achieved similar rates of the minimal clinically important difference for all 5 PROMs and the Patient Acceptable Symptom State for 4 PROMs. When controlling for patient demographics, patients with higher ADI scores had greater odds of achieving the minimal clinically important difference for all PROMs except the 33-item International Hip Outcome Tool. CONCLUSION: Although hip arthroscopy patients experiencing a greater neighborhood-level socioeconomic disadvantage exhibited significantly lower preoperative baseline PROM scores, this disparity resolved at 1-year follow-up. In fact, when adjusting for patient characteristics including ADI score, more disadvantaged patients achieved greater odds of achieving the minimal clinically important difference. The present study is merely a first step toward understanding health inequities among patients seeking orthopaedic care. Further development of clinical guidelines and health policy research is necessary to advance care for patients from disadvantaged communities.

Social Determinants of Health Disparities Increase 5-Year Revision Rates but Not Postoperative Complications After Primary Hip Arthroscopy.

PURPOSE: To investigate the impact of social determinants of health (SDOH) disparities on 30-day emergency department (ED) visits, 90-day postoperative complications, and 5-year secondary surgery rates after primary hip arthroscopy using a large national database. METHODS: A national administrative claims database was used to identify patients who underwent primary hip arthroscopy with femoroplasty, acetabuloplasty, and/or labral repair between 2015 and 2022. Queries were performed to identify patients who experienced any SDOH disparities, including economic, educational, environmental, or social disparities; those experiencing SDOH disparities within 1 year prior to primary hip arthroscopy were matched 1:1 by age, sex, Elixhauser Comorbidity Index score, diabetes, obesity, and tobacco use to patients not experiencing any lifetime SDOH disparities. The odds of 90-day complications and 30-day ED visits were compared using multivariable logistic regression. Rates of 5-year revision hip arthroscopy and of any secondary surgery (revision hip arthroscopy or total hip arthroplasty) were compared by Kaplan-Meier analysis. RESULTS: A total of 3,383 primary hip arthroscopy patients who experienced SDOH disparities were matched 1:1 to a control cohort of 3,383 patients who did not experience SDOH disparities (age of 41.0 years and 79.6% female sex in both cohorts). The odds of adverse events after arthroscopy were low and did not differ between the SDOH cohort (1.51%) and no-SDOH cohort (1.57%, P = .09). Additionally, there was no difference in the odds of 30-day ED visits between the SDOH cohort (5.65%) and no-SDOH cohort (4.79%, P = .10). The rate of 5-year revision hip arthroscopy was significantly greater among patients experiencing SDOH disparities (5.4% vs 4.1%, P = .02); however, there was no difference in the rate of any secondary surgery between cohorts (11.8% vs 10.4%, P = .10). CONCLUSIONS: Patients experiencing SDOH disparities had similar odds of postoperative complications and ED visits after primary hip arthroscopy but greater rates of 5-year revision hip arthroscopy compared with a matched-control cohort of patients not experiencing SDOH disparities. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Biceps tenotomy vs. tenodesis: an ACS-NSQIP analysis of postoperative outcomes and utilization trends.

Background: While studies have assessed comparative rates of restoration of shoulder function and alleviation of symptoms, comparative systemic postoperative complication rates between biceps tenotomy and tenodesis have yet to be assessed. The purpose of the present study was to use a national administrative database to perform a comprehensive investigation into 30-day complication rates after biceps tenotomy versus tenodesis, thus providing valuable insights for informed decision-making by clinicians and patients regarding the optimal surgical approach for pathologies of the long head of the biceps tendon. Methods: The National Surgical Quality Improvement Program database was queried to analyze postoperative complication rates and metrics associated with biceps tenotomy and tenodesis. Patient data spanning from 2012 to 2021 was extracted, with relevant variables assessed to identify and compare these two surgical approaches. Adjusted and unadjusted analyses were utilized to analyze patient demographics, comorbidities, operative times, lengths of stay, readmissions, adverse events, and yearly surgical volume, along with trends in usage, across cohorts. Results: Of 11,527 total patients, 264 (2.29%), 6826 (59.22%), and 4437 (38.49%) underwent tenotomy, tenodesis with open repair, and tenodesis with arthroscopic repair, respectively. Tenotomy operative times ([mean ± SD]: 66.25 ± 44.76 minutes) were shorter than those for open tenodesis (78.83 ± 41.82) and arthroscopic tenodesis (75.98 ± 40.16). Conversely, tenotomy patients had longer hospital days (0.88 ± 4.86 days) relative to open tenodesis (.08 ± 1.55) and arthroscopic tenodesis (.12 ± 2.70). Multivariable logistic regression controlling for demographics and comorbidities demonstrated that patients undergoing tenodesis were less likely to be readmitted (adjusted odds ratio [AOR]: 0.42, 95% confidence interval [CI]: 0.17-0.98, P = .050) or sustain serious adverse events (AOR: 0.27, 95% CI: 0.13-0.57, P < .001), but equally likely to sustain minor adverse events (AOR: 0.87, CI: 0.21-3.68, P = .850), compared with patients undergoing tenotomy. Lastly, comparing utilization rates from 2012 to 2021 revealed a significant decrease in the proportion of tenotomy (from 6.2% to 1.0%) compared to open tenodesis (from 41.0% to 57.3%) and arthroscopic tenodesis (52.8% to 41.64%; P trend = .001). Conclusion: To our knowledge, this is the first large national database study investigating postoperative complication rates between the various surgical treatments for pathologies of the long head of the biceps tendon. Our results suggest that tenodesis yields fewer serious adverse events and lower readmission rates than tenotomy. We also found a shorter operative time for tenotomy. These findings support the increased utilization of tenodesis relative to tenotomy in recent years.

Association Between Severity of Chondrolabral Junction Breakdown and Functional Outcomes After Hip Arthroscopy for Acetabular Labral Tears.

BACKGROUND: Despite focus on surgical preservation of the chondrolabral junction (CLJ), the transition zone between the acetabular cartilage and labrum, the association between severity of CLJ breakdown and functional outcomes after hip arthroscopy remains unexplored. PURPOSE: To assess the influence of CLJ breakdown on patient-reported outcome measures (PROMs) at a 24-month follow-up after hip arthroscopy for symptomatic labral tears. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review of prospectively collected data was conducted to identify patients ≥18 years of age with a minimum 24-month follow-up who underwent hip arthroscopy by a single surgeon for the treatment of symptomatic labral tears secondary to femoroacetabular impingement. The Beck classification of transition zone cartilage was used to grade CLJ damage; patients with grades 0 to 2 were stratified into the mild CLJ damage cohort, and those with grades 3 and 4 were stratified into the severe CLJ damage cohort. PROMs were collected at baseline and at 3, 6, 12 months, and annually thereafter postoperatively. Linear mixed-effects models were used to compare PROMs. Rates of achieving clinically meaningful thresholds and subsequent surgery rates were also compared. RESULTS: In total, 198 patients met the inclusion criteria, with a mean follow-up of 3.54 ± 1.26 years. A total of 95 patients with severe CLJ damage (mean age, 34.9 ± 10.5 years) were compared with 103 patients with mild CLJ damage (mean age, 38.2 ± 11.9 years). Hip Outcome Score-Activities of Daily Living (HOS-ADL), Non-Arthritic Hip Score (NAHS), and visual analog score for pain were inferior in the severe CLJ group at enrollment and all follow-up time points (P≤ .05). However, patients with severe CLJ breakdown exhibited greater improvements in HOS-ADL and NAHS at the 24-month follow-up and achieved clinically meaningful thresholds at equivalent rates to patients with mild CLJ breakdown. Subsequent surgery rates were 6.8% and 12.6% in patients with mild versus severe CLJ damage, respectively (P = .250). CONCLUSION: Severe CLJ breakdown is associated with increased pain and decreased functional level preoperatively and up to 24 months after hip arthroscopy. Despite this, patients with severe CLJ breakdown experienced greater improvements in functional outcomes at a 24-month follow-up and achieved clinical thresholds at similar rates to patients with mild CLJ damage. Thus, while worse baseline pain and functional levels may indicate severe CLJ breakdown, these patients still benefit substantially from hip arthroscopy.

AM-PAC Mobility Score <13 Predicts Development of Ileus Following Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective review. OBJECTIVE: To determine whether the Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" score is associated with the development of postoperative ileus. SUMMARY OF BACKGROUND DATA: Adult spinal deformity (ASD) surgery has a high complication rate. One common complication is postoperative ileus, and poor postoperative mobility has been implicated as a modifiable risk factor for this condition. METHODS: Eighty-five ASD surgeries in which ≥5 levels were fused were identified in a single institution database. A physical therapist/physiatrist collected patients' daily postoperative AM-PAC scores, for which we assessed first, last, and daily changes. We used multivariable linear regression to determine the marginal effect of ileus on continuous AM-PAC scores; threshold linear regression with Bayesian information criterion to identify a threshold AM-PAC score associated with ileus; and multivariable logistic regression to determine the utility of the score thresholds when controlling for confounding variables. RESULTS: Ten of 85 patients (12%) developed ileus. The mean day of developing ileus was postoperative day 3.3±2.35. The mean first and last AM-PAC scores were 16 and 18, respectively. On bivariate analysis, the mean first AM-PAC score was lower in patients with ileus than in those without (13 vs. 16; P<0.01). Ileus was associated with a first AM-PAC score of 3 points lower (Coef. -2.96; P<0.01) than that of patients without ileus. Patients with an AM-PAC score<13 had 8 times greater odds of developing ileus (P=0.023). Neither the last AM-PAC score nor the daily change in AM-PAC score was associated with ileus. CONCLUSIONS: In our institutional cohort, a first AM-PAC score of <13, corresponding to an inability to walk or stand for more than 1 minute, was associated with the development of ileus. Early identification of patients who cannot walk or stand after surgery can help determine which patients would benefit from prophylactic management. LEVEL OF EVIDENCE: Level-III.

Radiofrequency Chondroplasty of the Knee Yields Excellent Clinical Outcomes and Minimal Complications: A Systematic Review.

Purpose: To evaluate reported clinical outcomes and complications following radiofrequency (RF) ablation for the treatment of knee chondral lesions. Methods: A literature search was performed according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines by querying EMBASE, PubMed, and Scopus computerized databases from database inception through October 2022. Level I to IV clinical studies that reported outcomes or complications following RF-based chondroplasty were included. Postoperative outcome scores and complications were aggregated. Study quality was assessed via the Newcastle-Ottawa Scale. Results: Ten articles from 2002 to 2018 consisting of 1,107 patients (n = 1,504 lesions) were identified. Four studies were of Level I evidence, 3 studies were Level II, 1 study was Level III, and 2 studies were Level IV. The mean patient age was 41.8 ± 6.3 years (range, 12-87). Seven studies (n = 1,037 patients) used bipolar RF devices, and 3 studies (n = 70 patients) used monopolar RF devices. The overall mean postoperative Lysholm, Tegner, and IKDC scores ranged from 83 to 91, 3.8 to 7, and 49 to 90, respectively, in lesions ranging from grade I-IV according to the Outerbridge Classification. Monopolar RF devices reported qualitatively similar mean changes in Lysholm scores (83), Tegner scores (3.8), and IKDC scores (range, 49-69) compared with bipolar RF devices (range, 86.4-91, 4.5-7, 90, respectively). The incidence of complications ranged from 0% to 4%. The most commonly reported complication was osteonecrosis (range, 0% to 4%). The incidence rate of patients undergoing additional surgery ranged from 0% to 4.5%. Conclusions: The available literature on RF-based chondroplasty shows its efficacy and safety for the treatment of knee chondral lesions, with good clinical outcome scores and low complication and reoperation rates. Level of Evidence: Level IV, systematic review of Level I-IV studies.

Nonoperative Management of Tibial Stress Fractures Result in Higher Return to Sport Rates Despite Increased Failure Versus Operative Management: A Systematic Review.

Purpose: To compare return to sport (RTS) rates and complications after nonoperative versus operative management of tibial stress fractures. Methods: A literature search was conducted per the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using EMBASE, PubMed, and Scopus computerized data from database inception to February 2023. Studies evaluating RTS sport rates and complications after nonoperative or operative management of tibial stress fractures were included. Failure was defined as defined by persistent stress fracture line seen on radiographic imaging. Study quality was assessed using the Modified Coleman Methodology Score. Results: Twenty-two studies consisting of 341 patients were identified. The overall RTS rate ranged from 91.2% to 100% in the nonoperative group and 75.5% to 100% in the operative group. Failures rates ranged from 0% to 25% in the nonoperative groups and 0% to 6% in the operative group. Reoperations were reported in 0% to 6.1% of patients in the operative group, whereas 0% to 12.5% of patients initially managed nonoperatively eventually required operative treatment. Conclusions: Patients can expect high RTS rates after appropriate nonoperative and operative management of tibial stress fractures. Treatment failure rates were greater in patients undergoing nonoperative management, with up to 12.5% initially treated nonoperatively later undergoing operative treatment. Level of Evidence: Level IV; Systematic Review of level I-IV studies.

Social Media Use Among Arthroscopic and Orthopaedic Sports Medicine Specialists Varies by Subspeciality.

Purpose: To evaluate active social media use among members of the Arthroscopy Association of North America (AANA) and investigate differences in social media use based on joint-specific subspecialization. Methods: The AANA membership directory was queried to identify all active, residency-trained orthopaedic surgeons within the United States. Sex, practice location, and academic degrees earned were recorded. Google searches were conducted to find professional Facebook, Twitter, Instagram, LinkedIn, and YouTube accounts along with institutional and personal websites. The primary outcome was the Social Media Index (SMI) score, an aggregate measure of social media use across key platforms. A Poisson regression model was constructed to compare SMI scores across joint-specific subspecializations: knee, hip, shoulder, elbow, foot & ankle, and wrist. Specialization in the treatment of each joint was collected using binary indicator variables. Since surgeons were specialized in multiple groups, comparisons were made between those who do and do not treat each joint. Results: In total, 2,573 surgeons within the United States met the inclusion criteria. 64.7% had ownership of at least 1 active account, with an average SMI score of 2.29 ± 1.59. Western practicing surgeons had a significantly greater presence on at least 1 website than those in the Northeast (P = .003, P < .001) and South (P = .005, P = .002). Social media use by knee, hip, shoulder, and elbow surgeons was greater relative to those who did not treat those respective joints (P < .001 for all). Poisson regression analysis demonstrated that knee, shoulder, or wrist specialization was a significant positive predictor of a greater SMI score (P ≤ .001 for all). Foot & ankle specialization was a negative predictor (P < .001), whereas hip (P = .125) and elbow (P = .077) were not significant predictors. Conclusions: Social media use widely varies across joint subspecialties within orthopaedic sports medicine. Knee and shoulder surgeons had a greater social media use than their counterparts, whereas foot & ankle surgeons had the lowest social media use. Clinical Relevance: Social media is a vital source of information for both patients and surgeons, providing a means for marketing, networking, and education. It is important to identify variations in social media use by orthopaedic surgeons by subspecialty and explore the differences.

Apophyseal ilium avulsion fractures in young athletes: a systematic review and return to sport analysis.

The purpose of the current investigation was to synthesize the epidemiology, cause, management, and return to sport (RTS) outcomes of ilium avulsion fractures sustained during sporting activities in young athletes. Studies reporting on athletes <18 years old sustaining an avulsion fracture along the ilium [injury to the anterior superior or inferior iliac spine (ASIS or AIIS), or the iliac crest (IC)], and the athlete's RTS status were included. RTS was analyzed by injury acuity, location, mechanism of injury, and management, whereas complications were recorded. Seventy studies comprising 286 avulsions (169 ASIS, 87 AIIS, and 30 IC) were included. The mean age of athletes was 14.5 + 1.3 years (range, 8-18 years). Sprinting (n = 103/286; 36.0%) and soccer (n = 97/286; 33.9%) were the most common sports during which injuries occurred. A total of 96.5% (n = 276/286) of athletes reported successful RTS at an average of 16.2 + 19.3 weeks. The RTS rate for patients sustaining ASIS, AIIS, and IC avulsions was 95.3, 97.7, and 100%, respectively. Acute trauma was responsible for 89.8% (n = 158/176) of injuries, which demonstrated a significantly faster (13.3 + 9.3 weeks) and higher RTS rate (99.4%) compared with those with chronic avulsions (74.4 + 40.9 weeks and 83.3%, respectively). Those with complications (18.2%) had a significantly lower RTS rate (90.4%) and longer recovery (23.7 weeks) compared with athletes without complications (97.9% and 14.5 weeks, respectively). Outcomes were not significantly different based on sex or management. However, chronic avulsions and postoperative complications sustained worse RTS results. An accurate and timely diagnosis is crucial when presented with these rare injuries to avoid increasing the chronicity of injury.

Injury to the Posterior Horn of the Lateral Meniscus from a Misplaced Tibial Tunnel for Anterior Cruciate Ligament Reconstruction: A Case Report.

BACKGROUND Posterior meniscal root avulsions can cause meniscal extrusion, joint space narrowing, and progressive knee arthritis. Iatrogenic posterior meniscal root avulsions after malpositioning of the transtibial tunnels during anterior cruciate ligament (ACL) reconstruction can account for poor long-term outcomes seen in some patients following ACL reconstruction. Therefore, correct transtibial tunnel placement during ACL reconstruction is essential to avoid iatrogenic meniscal damage. CASE REPORT A 32-year-old man presented with 1 year of right knee pain and instability following a non-contact twisting injury sustained while playing soccer. An ACL tear with no meniscal involvement was diagnosed at an outside institution. A double-bundle reconstruction was performed at that time. Three months after surgery, a medial partial meniscectomy was performed after a medial meniscal tear and failure to reduce initial symptoms during the index procedure. Advanced imaging at our institution 6 months later demonstrated an iatrogenic lateral posterior meniscal root avulsions after malpositioning of the transtibial tunnels. Given the ACL graft integrity upon arthroscopic evaluation, the root tear was repaired using a 2-tunnel transtibial pull-out technique. Advanced imaging 1 year after surgery showed a well-maintained meniscal repair with no extrusion. CONCLUSIONS Accurate transtibial tunnel placement during ACL reconstructive surgery is vital to avoid meniscal root detachment and the associated complications resulting in poor patient outcomes from this iatrogenic injury. Clinicians treating patients with a history of cruciate ligament reconstruction presenting with postoperative pain and instability should consider this pathology in their differential diagnosis.

Open Access Articles Garner Increased Social Media Attention and Citation Rates Compared With Subscription Access Research Articles: An Altmetrics-Based Analysis.

BACKGROUND: To better understand the research impact on social media, alternative web-based metrics (Altmetrics) were developed. Open access (OA) publishing, which allows for widespread distribution of scientific content, has become increasingly common in the medical literature. However, the relationship between OA publishing and social media impact remains unclear. PURPOSE: To compare social media attention and citation rates between OA and subscription access (SA) research articles within the orthopaedic and sports medicine literature. STUDY DESIGN: Cross-sectional study. METHODS: Articles published as either OA or SA in 5 high-impact hybrid orthopaedic journals between January 2019 and December 2019 were analyzed. The primary outcome was the Altmetric Attention Score (AAS), a validated measure of social media attention. Secondary outcomes included citation rates, article characteristics, and the number of shares on social media. Independent t tests and chi-square analyses were used to compare outcomes between OA and SA articles. A multivariable linear regression analysis was performed to determine the association between article type and AAS while controlling for bibliometric characteristics. RESULTS: A total of 2143 articles (246 OA articles, 11.5%; 1897 SA articles, 88.5%) were included. The mean AAS among all OA articles was 62.4 ± 184.6 (range, 0-2032), whereas the mean AAS among all SA articles was 18.4 ± 109.8 (range, 0-3425), representing a statistically significant difference (P < .001). The mean citation rate among OA articles was significantly higher (17.0 ± 22.5; range, 0-139) than that of SA articles (8.6 ± 13.4; range, 0-169) (P < .001). Multivariable linear regression analysis demonstrated that OA status (ß = 15.15; P = .044), number of institutions (ß = 2.13; P = .023), studies classified as epidemiological investigations (ß = 107.40; P < .001), and disclosure of a conflict of interest (ß = -11.18; P = .032) were significantly associated with a higher AAS. CONCLUSION: OA articles resulted in significantly greater AAS and citations in comparison with SA articles. Articles published through the OA option in hybrid journals as well as those with a higher number of institutions, those that disclosed a conflict of interest, and those classified as epidemiological investigations were positively associated with greater AAS in addition to a greater number of citations. The potential for more extensive research dissemination inherent in the OA option may therefore translate into greater reach and social media attention.

Technique Articles Are More Effective at Increasing Social Media Attention in Comparison With Original Research Articles: An Altmetrics-Based Analysis.

Purpose: To compare social media attention and citation rates between technique articles and matched original research articles (ORAs) regarding surgical procedures. Methods: All technique articles published from August 2019 through July 2020 in the free, electronic versions of Arthroscopy Techniques and JBJS Essential Surgical Techniques were matched by topic to articles in the "Original Research" sections of Arthroscopy, Sports Medicine, and Rehabilitation and JBJS Open Access in a 4:1 ratio within this time frame. The primary outcome was the Altmetric Attention Score (AAS). Secondary outcomes included citations, bibliometrics, and social media metrics. Independent t tests were used to compare primary and secondary outcomes between technique articles and ORAs. A multivariate linear regression analysis was performed to determine the association between article type and social media attention while controlling for confounding bibliometric characteristics. Results: A total of 285 matched research articles (n = 57, 20.0%) and technique articles (n = 228, 80.0%) were included. The mean AAS among all technique articles was 3.63 ± 10.08 (range, 0-96) whereas the mean AAS among all ORAs was 1.30 ± 3.98 (range, 0-25), representing a statistically significant difference (P = .016). The mean citation rate among all technique articles was not significantly different from that among ORAs (P = .73). Multivariate linear regression analysis showed a statistically significant positive association between AAS and article type, with an additional mean increase in the AAS of 2.91 (95% confidence interval, 0.04-5.77; P = .047) for every technique article compared with an ORA. Furthermore, a significant positive relation was noted between the article origin and the AAS, with an increase in the AAS of 3.00 (95% confidence interval, 0.82-5.17; P = .007) for every article published in North America compared with an article originating from another continent. Conclusions: Technique articles resulted in significantly greater AASs and social media attention in comparison with open-access ORAs on similar topics. Publications that described technical procedures in a technique journal and studies from North America were positively associated with greater AASs and greater numbers of citations received by articles. Clinical Relevance: An improved understanding of how much attention is given to technique articles versus matched ORAs by social media may influence the methods authors and journals use for distributing content. The present study suggests that one option to increase the amount of social media attention received for a particular study may be to utilize an accompanying surgical technique video or illustrations as these are easily shareable on social media and offer rapid dissemination of knowledge, similar to that of an infographic. However, physicians who view multimedia within technique articles should be encouraged to review the accompanying articles and the supporting original research as a primary source before making changes in their clinical practice.

Increasing Telehealth Access to Care for Older Adults During the COVID-19 Pandemic at an Academic Medical Center: Video Visits for Elders Project (VVEP).

BACKGROUND: The COVID-19 pandemic led to a significant increase in ambulatory virtual care, threatening access to care for older adults with lower digital literacy. This report describes the Video Visits for Elders Project (VVEP), a quality improvement effort to help older adults access video visits at an academic primary care practice. METHODS: We reached out to empaneled older adults (≥ 65 years) who had a scheduled visit between March 30 and June 12, 2020. We assessed patients' readiness to engage in a virtual visit and offered to walk them through accessing the platform if they owned a compatible device. We evaluated outcomes of those phone calls and actual visit completion. RESULTS: Between March 26 and June 3, 2020, we called 1,427 patients, reaching 1,025 (71.8%). Of those reached (mean age 75.6 years), 312 (30.4%) were already video-enabled, 192 (18.7%) asked for technical assistance, 185 (18.0%) did not have access to an electronic device, and 336 (32.8%) declined assistance. Of those reached, 40.4% completed their visit by video, 26.5% by telephone, and 1.4% by in-person visit, while 29.6% canceled and 2.1% no-showed. CONCLUSION: VVEP successfully innovated to promote equitable access to telemedicine for vulnerable older patients in a time of crisis. Almost half required technical assistance or did not have access to a compatible device to engage in virtual care. As telemedicine will continue to play an important role in access to clinical care even in a postpandemic world, it is imperative for health systems to focus on technological need to promote equitable access to care for all patients.

Utilizing Lean Leadership Principles to Build an Academic Primary Care Practice of the Future.

This Perspective presents a case study of multidimensional clinical transformation in an academic general internal medicine practice. In the face of increasing internal and external pressures, health systems and individual medical practices have pursued multiple strategies to improve quality, patient experience, and efficiency, while reducing staff and provider stress and burnout. We describe a Lean-informed approach that emphasizes the importance of organizational alignment in goals, evidence-based problem solving, and leadership behaviors to support a culture of continuous improvement. Our aim in this Perspective is to provide a real-world example of a feasible process for the planning, preparation, and execution of effective transformation, and to present lessons that may be useful to other academic health center practices seeking to develop innovative models to achieve the quadruple aim.

Influences of claywater and greenwater on the skin microbiome of cultured larval sablefish (Anoplopoma fimbria).

BACKGROUND: The skin microbiome of marine fish is thought to come from bacteria in the surrounding water during the larval stages, although it is not clear how different water conditions affect the microbial communities in the water and, in turn, the composition and development of the larval skin microbiome. In aquaculture, water conditions are especially important; claywater and greenwater are often used in larval rearing tanks to increase water turbidity. Here, we explored the effects of these water additives on microbial communities in rearing water and on the skin of first-feeding sablefish larvae using 16S rRNA gene sequencing. We evaluated three treatments: greenwater, claywater, and greenwater with a switch to claywater after 1 week. RESULTS: We observed additive-specific effects on rearing water microbial communities that coincided with the addition of larvae and rotifer feed to the tanks, such as an increase in Vibrionaceae in greenwater tanks. Additionally, microbial communities from experimental tank water, especially those in claywater, began to resemble larval skin microbiomes by the end of the experiment. The differential effects of the additives on larval sablefish skin microbiomes were largest during the first week, post-first feed. Bacteria associated with greenwater, including Vibrionaceae and Pseudoalteromonas spp., were found on larval skin a week after the switch to claywater. In addition to additive-specific effects, larval skin microbiomes also retained bacterial families likely acquired from their hatchery silos. CONCLUSIONS: Our results suggest that larval sablefish skin microbiomes are most sensitive to the surrounding seawater up to 1 week following the yolk-sac stage and that claywater substituted for greenwater after 1 week post-first feed does not significantly impact skin-associated microbial communities. However, the larval skin microbiome changes over time under all experimental conditions. Furthermore, our findings suggest a potential two-way interaction between microbial communities on the host and the surrounding environment. To our knowledge, this is one of the few studies to suggest that fish might influence the microbial community of the seawater.

Follow-up of incidental pulmonary nodules and association with mortality in a safety-net cohort.

Background Though incidental pulmonary nodules are common, rates of guideline-recommended surveillance and associations between surveillance and mortality are unclear. In this study, we describe adherence (categorized as complete, partial, late and none) to guideline-recommended surveillance among patients with incidental 5-8 mm pulmonary nodules and assess associations between adherence and mortality. Methods This was a retrospective cohort study of 551 patients (≥35 years) with incidental pulmonary nodules conducted from September 1, 2008 to December 31, 2016, in an integrated safety-net health network. Results Of the 551 patients, 156 (28%) had complete, 87 (16%) had partial, 93 (17%) had late and 215 (39%) had no documented surveillance. Patients were followed for a median of 5.2 years [interquartile range (IQR), 3.6-6.7 years] and 82 (15%) died during follow-up. Adjusted all-cause mortality rates ranged from 2.24 [95% confidence interval (CI), 1.24-3.25] deaths per 100 person-years for complete follow-up to 3.30 (95% CI, 2.36-4.23) for no follow-up. In multivariable models, there were no statistically significant associations between the levels of surveillance and mortality (p > 0.16 for each comparison with complete surveillance). Compared with complete surveillance, adjusted mortality rates were non-significantly increased by 0.45 deaths per 100 person-years (95% CI, -1.10 to 2.01) for partial, 0.55 (95% CI, -1.08 to 2.17) for late and 1.05 (95% CI, -0.35 to 2.45) for no surveillance. Conclusions Although guideline-recommended surveillance of small incidental pulmonary nodules was incomplete or absent in most patients, gaps in surveillance were not associated with statistically significant increases in mortality in a safety-net population.

Inhibition of ovarian development and instances of sex reversal in genotypic female sablefish (Anoplopoma fimbria) exposed to elevated water temperature.

This study determined high temperature effects on ovarian development in a marine groundfish species, sablefish (Anoplopoma fimbria), with potential application in sex reversal or sterilization for aquaculture. Monosex female (XX-genotype) sablefish larvae (∼30 mm) were randomly divided into three groups and exposed to control (15.6 °C ±â€¯0.8 °C), moderate (20.4 °C ±â€¯0.5 °C), or high (21.7 °C ±â€¯0.5 °C) temperatures for 19 weeks. Treated fish were then tagged and transferred to ambient seawater (11.2 °C ±â€¯2.3 °C) for one year to determine whether temperature effects on reproductive development were maintained post-treatment. Fish were periodically sampled for gonadal histology, gene expression and plasma 17ß-estradiol (E2) analyses to assess gonadal development. Short-term (4-week) exposure to elevated temperatures had only minor effects, whereas longer exposure (12-19 weeks) markedly inhibited ovarian development. Fish from the moderate and high treatment groups had significantly less developed ovaries relative to controls, and mRNA levels for germ cell (vasa, zpc) and apoptosis-associated genes (p53, casp8) generally indicated gonadal degeneration. The high treatment group also had significantly reduced plasma E2 levels and elevated gonadal amh gene expression. After one year at ambient temperatures, however, ovaries of moderate and high treatment fish exhibited compensatory recovery and were indistinguishable from controls. Two genotypic females possessing immature testes (neomales) were observed in the high treatment group, indicating sex reversal had occurred (6% rate). These results demonstrate that extreme elevated temperatures may inhibit ovarian development or trigger sex reversal. High temperature treatment is likely not an effective sterilization method but may be preferable for sablefish neomale broodstock production.

Hospital discharge preparedness for patients with limited English proficiency: A mixed methods study of bedside interpreter-phones.

OBJECTIVE: Assess effects of a bedside interpreter-phone intervention on hospital discharge preparedness among patients with limited English proficiency (LEP). METHODS: Mixed-methods study compared patient-reported discharge preparedness and knowledge of medications and follow-up appointments among 189 Chinese- and Spanish-speakers before (n=94) and after (n=95) bedside interpreter-phone implementation, and examined nurse and resident-physician interpreter-phone utilization through focus groups. RESULTS: Pre-post discharge preparedness (Care Transitions Measure mean 77.2 vs. 78.5; p=0.62) and patient-reported knowledge of follow-up appointments, discharge medication administration and side effects did not differ significantly. Pre-post knowledge of medication purpose increased in bivariate (88% vs. 97%, p=0.02) and propensity score adjusted analyses [aOR (adjusted odds ratio), 4.49; 95% CI, 1.09-18.4]. Nurses and physicians reported using interpreter-phones infrequently for discharge communication, preferring in-person interpreters for complex discharges and direct communication with family for routine discharges. Post-implementation patients reported continued use of ad-hoc family interpreters (43%) or no interpretation at all (22%). CONCLUSION: Implementation of a bedside interpreter-phone systems intervention did not consistently improve patient-reported measures of discharge preparedness, possibly due to limited uptake during discharges. PRACTICE IMPLICATIONS: Hospital systems must better understand clinician preferences for discharge communication to successfully increase professional interpretation and shift culture away from using family members as interpreters.