Anomalous Flexor Carpi Radialis Tendons Giving Rise to a Novel Surgical Technique in the Treatment of Thumb Carpometacarpal Joint Arthritis: A Case Report.

Introduction: Incidental discovery of anomalous muscles and anatomical variants within the forearm and wrist through surgical exposure and advanced imaging techniques is relatively common. Case Report: The patient presented with pain and swelling in her hand that was refractory to rest and anti-inflammatory medications. Here, we describe the intraoperative discovery of an anatomical variant of the flexor carpi radialis (FCR), as well as an anomalous flexor carpi radialis brevis (FCRB) in a 58-year-old patient being treated for thumb carpometacarpal joint (CMCJ) arthritis. Conclusion: To the best of our knowledge, this is the first description of both anomalies within a single patient and the first use of the surgical technique, described here, in treating the patient's thumb CMCJ arthritis. This report reinforces the importance of meticulous dissection and identification of individual anatomy to optimize patient outcomes.

Outcomes of SARS-CoV-2 infection among patients with orthopaedic fracture surgery in the National COVID Cohort Collaborative (N3C).

BACKGROUND: The objective of this study was to investigate the outcomes of COVID-19-positive patients undergoing orthopaedic fracture surgery using data from a national database of U.S. adults with a COVID-19 test for SARS-CoV-2. METHODS: This is a retrospective cohort study using data from a national database to compare orthopaedic fracture surgery outcomes between COVID-19-positive and COVID-19-negative patients in the United States. Participants aged 18-99 with orthopaedic fracture surgery between March and December 2020 were included. The main exposure was COVID-19 status. Outcomes included perioperative complications, 30-day all-cause mortality, and overall all-cause mortality. Multivariable adjusted models were fitted to determine the association of COVID-positivity with all-cause mortality. RESULTS: The total population of 6.5 million patient records was queried, identifying 76,697 participants with a fracture. There were 7,628 participants in the National COVID Cohort who had a fracture and operative management. The Charlson Comorbidity Index was higher in the COVID-19-positive group (n = 476, 6.2 %) than the COVID-19-negative group (n = 7,152, 93.8 %) (2.2 vs 1.4, p<0.001). The COVID-19-positive group had higher mortality (13.2 % vs 5.2 %, p<0.001) than the COVID-19-negative group with higher odds of death in the fully adjusted model (Odds Ratio=1.59; 95 % Confidence Interval: 1.16-2.18). CONCLUSION: COVID-19-positive participants with a fracture requiring surgery had higher mortality and perioperative complications than COVID-19-negative patients in this national cohort of U.S. adults tested for COVID-19. The risks associated with COVID-19 can guide potential treatment options and counseling of patients and their families. Future studies can be conducted as data accumulates. LEVEL OF EVIDENCE: Level III.

Benefits of an Orthopedic Education Research Collaborative: An Innovative Approach.

Background Graduate Medical Education (GME) research in orthopedic surgery is an important but underrepresented subject in the medical literature. It was unknown if orthopedic residency leaders were interested in a surgical education research collaborative (orthopedic collaborative). The objectives of this study were to assess the potential benefit of an orthopedic collaborative from orthopedic residency leaders and investigate the factors associated with the support of a research collaborative within a surgical subspecialty. Methodology An anonymous 19-question survey-based study was distributed through REDCap (Nashville, TN, USA) to orthopedic residency leaders in the United States, from July to October 2020. The main outcome was perceived benefit. Additional aspects included program characteristics, challenges in performing resident education research, and organizational issues such as authorship, frequency of study requests, and governance. Results Almost all orthopedic faculty leadership (99%, 73/74) stated that resident education and faculty development research projects would benefit from an orthopedic education research collaborative. In comparison to unsupportive respondents, younger age (P = 0.006), 15 or fewer years in practice (P = 0.04), and having 0 to 100 peer-reviewed publications (P = 0.047) were associated with support for an orthopedic collaborative. Conclusions Challenges related to survey-based study quality and generalizability at single institutions can benefit from multi-institutional collaboration to develop high-quality studies that capture a representative sample to support orthopedic surgery program development.

Risk Factors for Prolonged Hospital Stay After Femoral Neck Fracture.

The purpose of this study was to investigate the association between pre-operative anemia and prolonged hospital stay among geriatric patients with operative femoral neck fractures. This retrospective cohort study was performed at a level I trauma center and included geriatric patients with femoral neck fractures (OTA/AO 31) and operative treatment with Current Procedural Terminology code 27236. Exclusion criteria were admission to the intensive care unit, evacuation of subdural hematoma, and conditions requiring exploratory laparotomy. A total of 207 individuals, with data collected between January 2015 and August 2019 and age 65 years and older, were included in the analysis. Linear regression was used to evaluate the association between anemia and length of stay adjusting for potential confounders. Anemia was defined using preoperative hematocrit. The primary outcome was prolonged length of stay, defined as 5 or more days. The group was 65% women. The mean age was 80.2 years (range, 64-98 years). The majority (61%) of patients had anemia. American Society of Anesthesiologists classification was associated with preoperative anemia (P=.02). Patients with anemia had a 16% higher risk of prolonged length of stay compared with patients without anemia (81% vs 65%, P=.009). In the linear regression model, preoperative hematocrit was associated with length of stay (P=.032) when adjusted for sex, age, preoperative tranexamic acid, preoperative hemoglobin, postoperative hemoglobin, and postoperative hematocrit. Length of stay was approximately 1 week in this study, with anemia being a statistically significant risk factor for prolonged length of stay. Health care providers and administrators can consider anemia on admission when predicting length of stay. [Orthopedics. 2023;46(4):211-217.].

Oncoplastic Augmentation Mastopexy in Breast Conservation Therapy: Retrospective Study and Postoperative Complications.

BACKGROUND: Oncoplastic techniques, in conjunction with lumpectomy and adjuvant radiotherapy, have been demonstrated to achieve good aesthetic results and cancer outcomes in the treatment of patients with macromastia or significant ptosis. This study evaluated a series of patients undergoing breast conservation with concomitant oncoplastic-augmentation-mastopexy and a contralateral augmentation-mastopexy. METHODS: Patients undergoing lumpectomy for breast conservation were identified via a retrospective chart review. Inclusion criteria included patients with ptosis and preexisting breast implants or insufficient breast volume undergoing oncoplastic implant placement/exchange and mastopexy. Demographic characteristics, operative details, and complications were assessed. RESULTS: Thirty-four consecutive patients (64 breasts, 4 unilateral procedures) were included in the study. Average age was 51.4 years, average body mass index was 27, and 38.2% were smokers/former smokers. The average operative time was 2.5 hours. Furthermore, 38.2% of patients received chemotherapy, and 82.4% of patients received breast adjuvant radiotherapy. The average length of follow-up was 11.7 months. In the sample that received radiation, the capsular contracture rate was 25%, with a 7.1% contracture revision rate. For the entire group, a total of 8 patients (23.5%) underwent revisions for either positive margins (8.8%), capsular contracture (8.8%), implant loss (2.9%), or cosmetic concerns (2.9%). One patient developed a pulmonary embolism. CONCLUSIONS: Oncoplastic-augmentation-mastopexy is a safe technique with acceptable complication rates. This technique is best used for breast cancer patients with breast ptosis and a paucity of breast volume or preexisting implants who wish to pursue breast-conserving therapy. The revision rates are acceptable compared with single-stage cosmetic augmentation procedures as well as other oncoplastic techniques described in the literature, but patients must be clearly counseled on contracture risk.

Civilian Ballistic Femoral Shaft Fractures Compared With Blunt Femur Shaft Fractures.

OBJECTIVE: To assess ballistic femoral shaft fracture outcomes in comparison with closed and open femoral shaft fractures sustained by blunt mechanisms. We hypothesized that ballistic femoral shaft fractures would have similar outcomes to blunt open fractures. DESIGN: Retrospective cohort study. SETTING: Academic Level I trauma center. PARTICIPANTS: Patients 16 years and older presenting with ballistic (140), blunt closed (317), or blunt open (71) femoral shaft fractures. MAIN OUTCOMES: Unplanned return to operating room, fracture-related infection, soft tissue reconstruction, nonunion, implant failure, length of stay, Injury Severity Scores, hospital charges, and compartment syndrome. RESULTS: A total of 528 femoral shaft fractures were identified. A group of 140 ballistic fractures and comparison groups of all femoral shaft fractures sustained by blunt mechanisms and treated with intramedullary nailing were included in the analysis. Among the 2 subgroups of nonballistic injuries, 317 were blunt closed fractures and 71 were blunt open fractures. The ballistic group was associated with a 3-fold increase in overall complications (30%) compared with the blunt closed group (10%, P < 0.001), had a higher occurrence of thigh compartment syndrome (P < 0.001), and required more soft tissue reconstruction (P < 0.001) than either of the blunt fracture groups. CONCLUSIONS: Ballistic femoral shaft fractures do not perfectly fit with blunt closed or open femoral fractures. A high index of suspicion for the development of thigh compartment syndrome should be maintained in ballistic femoral shaft fractures. The overall rates of nonunion and infection were comparable between all groups, but the all-cause complication rate was significantly higher in the ballistic group compared with the blunt closed group. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Ankle Fracture and Length of Stay in US Adult Population Using Data From the National COVID Cohort Collaborative.

BACKGROUND: The National COVID Cohort Collaborative (N3C) is an innovative approach to integrate real-world clinical observations into a harmonized database during the time of the COVID-19 pandemic when clinical research on ankle fracture surgery is otherwise mostly limited to expert opinion and research letters. The purpose of this manuscript is to introduce the largest cohort of US ankle fracture surgery patients to date with a comparison between lab-confirmed COVID-19-positive and COVID-19-negative. METHODS: A retrospective cohort of adults with ankle fracture surgery using data from the N3C database with patients undergoing surgery between March 2020 and June 2021. The database is an NIH-funded platform through which the harmonized clinical data from 46 sites is stored. Patient characteristics included body mass index, Charlson Comorbidity Index, and smoking status. Outcomes included 30-day mortality, overall mortality, surgical site infection (SSI), deep SSI, acute kidney injury, pulmonary embolism, deep vein thrombosis, sepsis, time to surgery, and length of stay. COVID-19-positive patients were compared to COVID-19-negative controls to investigate perioperative outcomes during the pandemic. RESULTS: A total population of 8.4 million patient records was queried, identifying 4735 adults with ankle fracture surgery. The COVID-19-positive group (n=158, 3.3%) had significantly longer times to surgery (6.5 ± 6.6 vs 5.1 ± 5.5 days, P = .001) and longer lengths of stay (8.3 ± 23.5 vs 4.3 ± 7.4 days, P < .001), compared to the COVID-19-negative group. The COVID-19-positive group also had a higher rate of 30-day mortality. CONCLUSION: Patients with ankle fracture surgery had longer time to surgery and prolonged hospitalizations in COVID-19-positive patients compared to those who tested negative (average delay was about 1 day and increased length of hospitalization was about 4 days). Few perioperative events were observed in either group. Overall, the risks associated with COVID-19 were measurable but not substantial.Level of Evidence: Level III, retrospective cohort study.

Association of Mortality and Charlson Comorbidity Index in Surgical Spinal Trauma Patients at a Level I Academic Center.

OBJECTIVES: The Charlson Comorbidity Index score (CCI) records the presence of comorbidities with various weights for a total score to estimate mortality within 1 year of hospital admission. Our study sought to assess the association of CCI with mortality rates of patients undergoing surgical intervention. STUDY DESIGN: Retrospective study. METHODS: Retrospective study of patients with surgical spinal trauma at a large academic level I trauma tertiary center from 2015 to 2018. Information collected included age, sex, American Society of Anesthesiologists physical status, body mass index, Charlson comorbidities, injury severity score, the presence of spinal cord injury, and mortality. Mortality was measured at 30 days, 90 days, and 1 year. Descriptive and bivariate analyses were completed. The results were significant at P < 0.05. RESULTS: The highest proportion of 1-year mortality was in the patients with cervical (11.3%) and thoracolumbar injuries (7.4%) (P = 0.002). Patients with low CCI had low 1-year mortality (1.7%). Patients with high CCI had high 1-year mortality (13.8%) (P < 0.001). A significant association existed between CCI and mortality at 30 days, 90 days, and 1 year (P < 0.001). Mortality was higher in patients with spinal cord injury (14/108; 13%) than in those without (11/232; 5%) (P = 0.021). No association existed between ISS and mortality (P = 0.26). DISCUSSION: The CCI was associated with a higher proportion of deaths at 30 days, 90 days, and 1 year. This association may help predict this unfortunate complication and guide the surgical team in formulating treatment plans and counseling patients and families regarding mortality associated with these injuries and the risks of surgical intervention.

Association Between COVID-19 and Mortality in Hip Fracture Surgery in the National COVID Cohort Collaborative (N3C): A Retrospective Cohort Study.

BACKGROUND: This study investigated the outcomes of coronavirus disease (COVID-19)-positive patients undergoing hip fracture surgery using a national database. METHODS: This is a retrospective cohort study comparing hip fracture surgery outcomes between COVID-19 positive and negative matched cohorts from 46 sites in the United States. Patients aged 65 and older with hip fracture surgery between March 15 and December 31, 2020, were included. The main outcomes were 30-day all-cause mortality and all-cause mortality. RESULTS: In this national study that included 3303 adults with hip fracture surgery, the 30-day mortality was 14.6% with COVID-19-positive versus 3.8% in COVID-19-negative, a notable difference. The all-cause mortality for hip fracture surgery was 27.0% in the COVID-19-positive group during the study period. DICUSSION: We found higher incidence of all-cause mortality in patients with versus without diagnosis of COVID-19 after undergoing hip fracture surgery. The mortality in hip fracture surgery in this national analysis was lower than other local and regional reports. The medical community can use this information to guide the management of hip fracture patients with a diagnosis of COVID-19.

What Are the Risk Factors for Infection After Operative Treatment of Peritalar Fracture Dislocations?

OBJECTIVE: To assess the risk factors associated with deep infection after operative treatment of peritalar fracture dislocations. DESIGN: A retrospective study was performed to identify patients who had operative treatment of a peritalar fracture dislocation over an 11-year period (2008-2019). SETTING: Level 1 trauma center. PARTICIPANTS: Patients were identified by review of all surgical billing that included open reduction of peritalar dislocation. Minimum follow-up for inclusion was 3 months or the outcome of interest. A total of 178 patients were identified, and 154 patients met inclusion criteria. MAIN OUTCOME: The primary outcome was deep infection, defined as return to the operating room for debridement with positive cultures. RESULTS: A total of 19 (12.3%) patients developed a postoperative deep infection. The most common associated fractures were talus (47%), calcaneus (33%), and fibula (9%) fractures. The infected group was significantly older (47.2 vs. 39.5 years, P = 0.03). Patients undergoing operative management for peritalar fracture dislocations with current smoking were found to have significantly higher odds of postoperative deep infection (74 vs. 34%, adjusted odds ratio = 7.4, 95% confidence interval, 2.3-24.1, P = 0.001). There was a significantly higher risk of infection in patients with a Gustilo-Anderson type 3 open fracture (32 vs. 12%, adjusted odds ratio = 5.7, 95% confidence interval, 1.6-20.3, P = 0.007). The infected group had high rates of below knee amputation when compared with the group without infection (47 vs. 1%, P < 0.001). CONCLUSION: In our retrospective study, risk factors for infection after peritalar fracture dislocation included older age, smoking, and Gustilo-Anderson type 3 open fracture. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Barriers and Resources to Optimize Bone Health in Orthopaedic Education: Own the Bone (OTB): Bone Health Education in Residency.

Osteoporosis is a critical public health issue with substantial morbidity and healthcare costs. Resident education on osteoporosis is not standardized. Little is known about the barriers to osteoporosis treatment and the usefulness of educational programming from the perspective of orthopaedic residency program directors (PDs). METHODS: This study aims to evaluate the current state and perception of bone health education from the perspective of orthopaedic residency PDs. Therefore, a self-designed 29-question online survey was sent to 129 PDs in the United States to assess bone health education. The information, collected from August to October 2020, included program characteristics, participation in the American Orthopaedic Association's Own the Bone (AOA/OTB) program or any fracture liaison service (FLS) program, availability of faculty, potential barriers, and educational resources. Data collection was performed anonymously with a 47% response rate. RESULTS: The results were compared between programs that used the AOA/OTB program (30%) or any FLS program (28%) (58% OTB or any FLS) vs. programs that did not have any program (42%). Subsequent subanalysis was performed comparing AOA/OTB vs. any FLS vs. no program. Programs that did not have any FLS were least likely to have a formal education syllabus (p = 0.01). When comparing clinical education of residents on bone health, 64% of programs without any system did not provide any formal clinical exposure such as a bone health clinic vs. assessment in patients with fracture compared with 24% of OTB programs and 44% of programs with any FLS (p = 0.02). When asked about desired resources, 47% would find a bone health rotation useful. Among all PDs, 60% support the concept of a 5-year AOA Council of Orthopaedic Residency Directors (CORD)/OTB osteoporosis curriculum. DISCUSSION: The key findings were that institutions including OTB or any FLS in their programs had better availability of specialty consultants, faculty, and a FLS coordinator.

Clinical Characterization and Prediction of Clinical Severity of SARS-CoV-2 Infection Among US Adults Using Data From the US National COVID Cohort Collaborative.

Importance: The National COVID Cohort Collaborative (N3C) is a centralized, harmonized, high-granularity electronic health record repository that is the largest, most representative COVID-19 cohort to date. This multicenter data set can support robust evidence-based development of predictive and diagnostic tools and inform clinical care and policy. Objectives: To evaluate COVID-19 severity and risk factors over time and assess the use of machine learning to predict clinical severity. Design, Setting, and Participants: In a retrospective cohort study of 1 926 526 US adults with SARS-CoV-2 infection (polymerase chain reaction >99% or antigen <1%) and adult patients without SARS-CoV-2 infection who served as controls from 34 medical centers nationwide between January 1, 2020, and December 7, 2020, patients were stratified using a World Health Organization COVID-19 severity scale and demographic characteristics. Differences between groups over time were evaluated using multivariable logistic regression. Random forest and XGBoost models were used to predict severe clinical course (death, discharge to hospice, invasive ventilatory support, or extracorporeal membrane oxygenation). Main Outcomes and Measures: Patient demographic characteristics and COVID-19 severity using the World Health Organization COVID-19 severity scale and differences between groups over time using multivariable logistic regression. Results: The cohort included 174 568 adults who tested positive for SARS-CoV-2 (mean [SD] age, 44.4 [18.6] years; 53.2% female) and 1 133 848 adult controls who tested negative for SARS-CoV-2 (mean [SD] age, 49.5 [19.2] years; 57.1% female). Of the 174 568 adults with SARS-CoV-2, 32 472 (18.6%) were hospitalized, and 6565 (20.2%) of those had a severe clinical course (invasive ventilatory support, extracorporeal membrane oxygenation, death, or discharge to hospice). Of the hospitalized patients, mortality was 11.6% overall and decreased from 16.4% in March to April 2020 to 8.6% in September to October 2020 (P = .002 for monthly trend). Using 64 inputs available on the first hospital day, this study predicted a severe clinical course using random forest and XGBoost models (area under the receiver operating curve = 0.87 for both) that were stable over time. The factor most strongly associated with clinical severity was pH; this result was consistent across machine learning methods. In a separate multivariable logistic regression model built for inference, age (odds ratio [OR], 1.03 per year; 95% CI, 1.03-1.04), male sex (OR, 1.60; 95% CI, 1.51-1.69), liver disease (OR, 1.20; 95% CI, 1.08-1.34), dementia (OR, 1.26; 95% CI, 1.13-1.41), African American (OR, 1.12; 95% CI, 1.05-1.20) and Asian (OR, 1.33; 95% CI, 1.12-1.57) race, and obesity (OR, 1.36; 95% CI, 1.27-1.46) were independently associated with higher clinical severity. Conclusions and Relevance: This cohort study found that COVID-19 mortality decreased over time during 2020 and that patient demographic characteristics and comorbidities were associated with higher clinical severity. The machine learning models accurately predicted ultimate clinical severity using commonly collected clinical data from the first 24 hours of a hospital admission.

COVID-19 Impact on Orthopedic Surgeons: Elective Procedures, Telehealth, and Income.

OBJECTIVES: The purpose of this study was to investigate the response in orthopedic surgery to the coronavirus disease 2019 (COVID-19) pandemic across the United States by surveying surgeons about their care setting, timing of restrictions on elective surgery, use of telehealth, and estimated economic impact. METHODS: A survey was distributed via REDCap through state orthopedic organizations between April and July 2020. The 22-question digital survey collected information regarding restrictions on elective procedures, location of care, utilization of telehealth, and estimated reductions in annual income. RESULTS: In this study, 192 participants responded to the survey (average age 49.9 ± 11.0 years, 92.7% male). Responses primarily originated from Alabama (30.2%), Georgia (30.2%), and Missouri (16.1%). The remainder of the responses were grouped into the category "other." Respondents did not vary significantly by state in operative setting or income type (salary, work relative value units, or collections). Most of the participants documented elective procedure restrictions in hospital and ambulatory settings. The highest frequency of closures occurred between March 18 and 20 (47% in hospital, 51% in ambulatory). Of the participants, financial loss estimates varied across states (P = 0.005), with 50% of physicians claiming >50% losses of income in Alabama (24% Georgia, 10% Missouri, 31% other). Regarding telehealth, practices set up for these services before 2020 varied across states. None of the orthopedic practices in Alabama had telehealth before the COVID-19 pandemic (Missouri 25%, Georgia 9%, other 8%, P = 0.06); however, respondents generally were split when considering the anticipation of implementing telehealth into routine practice. CONCLUSIONS: Most practices did implement restrictions for elective clinic visits and procedures early during the pandemic. COVID-19 ultimately will result in a large revenue loss for elective orthopedic practices. Services such as telehealth may help offset these losses and help deliver orthopedic care to patients remotely.

COVID-19 and Acute Cervical Spinal Cord Injury-Case Report of 2 Patients: Do We Need to Rethink Our Standard Treatment Strategy?

STUDY DESIGN: This was a case series. OBJECTIVE: The authors sought to examine the high-risk population of COVID-positive patients with acute cervical spinal cord injury (SCI) in a large level 1 trauma and tertiary referral center. SUMMARY OF BACKGROUND DATA: There are limited studies regarding the surgical management of patients with acute SCI in the setting of the recent coronavirus pandemic. METHODS: The authors describe the cases of 2 patients who died from COVID-related complications after acute cervical SCI. RESULTS: Patients with SCI are at increased risk of pulmonary complications. COVID-19 infection represents a double hit in this patient population, increasing potential morbidity and mortality in the perioperative time frame. Careful consideration must be made regarding the timing of potential surgical intervention in the treatment of acute SCI. CONCLUSIONS: Nationwide database of COVID-positive patients with acute spinal cord injury should be collected and analyzed to better understand how to manage acute SCI in the COVID-19 era. The authors recommend preoperative discussion in patients with acute cervical SCI with COVID-19, specifically emphasizing the increased risk of respiratory complications and mortality.

The National COVID Cohort Collaborative: Clinical Characterization and Early Severity Prediction.

Background: The majority of U.S. reports of COVID-19 clinical characteristics, disease course, and treatments are from single health systems or focused on one domain. Here we report the creation of the National COVID Cohort Collaborative (N3C), a centralized, harmonized, high-granularity electronic health record repository that is the largest, most representative U.S. cohort of COVID-19 cases and controls to date. This multi-center dataset supports robust evidence-based development of predictive and diagnostic tools and informs critical care and policy. Methods and Findings: In a retrospective cohort study of 1,926,526 patients from 34 medical centers nationwide, we stratified patients using a World Health Organization COVID-19 severity scale and demographics; we then evaluated differences between groups over time using multivariable logistic regression. We established vital signs and laboratory values among COVID-19 patients with different severities, providing the foundation for predictive analytics. The cohort included 174,568 adults with severe acute respiratory syndrome associated with SARS-CoV-2 (PCR >99% or antigen <1%) as well as 1,133,848 adult patients that served as lab-negative controls. Among 32,472 hospitalized patients, mortality was 11.6% overall and decreased from 16.4% in March/April 2020 to 8.6% in September/October 2020 (p = 0.002 monthly trend). In a multivariable logistic regression model, age, male sex, liver disease, dementia, African-American and Asian race, and obesity were independently associated with higher clinical severity. To demonstrate the utility of the N3C cohort for analytics, we used machine learning (ML) to predict clinical severity and risk factors over time. Using 64 inputs available on the first hospital day, we predicted a severe clinical course (death, discharge to hospice, invasive ventilation, or extracorporeal membrane oxygenation) using random forest and XGBoost models (AUROC 0.86 and 0.87 respectively) that were stable over time. The most powerful predictors in these models are patient age and widely available vital sign and laboratory values. The established expected trajectories for many vital signs and laboratory values among patients with different clinical severities validates observations from smaller studies, and provides comprehensive insight into COVID-19 characterization in U.S. patients. Conclusions: This is the first description of an ongoing longitudinal observational study of patients seen in diverse clinical settings and geographical regions and is the largest COVID-19 cohort in the United States. Such data are the foundation for ML models that can be the basis for generalizable clinical decision support tools. The N3C Data Enclave is unique in providing transparent, reproducible, easily shared, versioned, and fully auditable data and analytic provenance for national-scale patient-level EHR data. The N3C is built for intensive ML analyses by academic, industry, and citizen scientists internationally. Many observational correlations can inform trial designs and care guidelines for this new disease.

Pre- and Post-Immigration Correlates of Alcohol Misuse among Young Adult Recent Latino Immigrants: An Ecodevelopmental Approach.

Latinos in the United States experience numerous alcohol-related health disparities. There is accumulating evidence that pre-immigration factors are associated with post-immigration alcohol use, but the explanation for health disparities remains unclear. The present study is a secondary analysis of data from the Recent Latino Immigrant Study (RLIS), the first community-based cohort study to examine the pre- to post-immigration alcohol use trajectories of young adult Latino immigrants during their initial years in the United States. Exploratory analysis and hierarchical multiple logistic regression were performed to assess associations between various pre- and post-immigration factors and alcohol misuse among young adult Latino immigrants early in the immigration process. Using an ecodevelopmental approach, we examined potential social and environmental determinants across multiple levels of influence associated with post-immigration alcohol misuse in this population. The study sample consisted of 474 young adult Latino immigrants between the ages of 18-34. The sample was comprised of the following national/regional origins: Cuban (43%), South American (28.7%), and Central American (28.3%). Approximately half of the sample (49.6%) reported a family history of substance use problems (FHSUP+). Participants who reported FHSUP+ and who engaged in alcohol misuse prior to immigrating to the US were more likely to engage in post-immigration alcohol misuse. Results revealed various social and environmental factors associated with pre-immigration alcohol misuse in this population. Study findings can inform culturally tailored prevention interventions aimed at mitigating problem drinking behaviors among young adult recent Latino immigrants.