Non-COVID-19 cardiovascular pathology from return-to-play screening in college athletes after COVID-19.

OBJECTIVE: Concerns for cardiac involvement after SARS-CoV-2 infection led to widespread cardiac testing in athletes. We examined incidental non-COVID-19 cardiovascular pathology in college athletes undergoing postinfection return-to-play screening. METHODS: The Outcomes Registry for Cardiac Conditions in Athletes was a nationwide prospective multicentre observational cohort study that captured testing and outcomes data from 45 institutions (September 2020-June 2021). Athletes with an ECG and transthoracic echocardiogram (TTE) and no pre-existing conditions were included. Findings were defined as major (associated with sudden cardiac death or requiring intervention), minor (warrants surveillance), incidental (no follow-up needed) or uncertain significance (abnormal with subsequent normal testing). RESULTS: Athletes with both ECG and TTE (n=2900, mean age 20±1, 32% female, 27% black) were included. 35 (1.2%) had ECG abnormalities. Of these, 2 (5.7%) had TTE abnormalities indicating cardiomyopathy (hypertrophic-1, dilated-1), and 1 with normal TTE had atrial fibrillation. Of 2865 (98.8%) athletes with a normal ECG, 54 (1.9%) had TTE abnormalities: 3 (5.6%) with aortic root dilatation ≥40 mm, 15 (27.8%) with minor abnormalities, 25 (46.3%) with incidental findings and 11 (20.4%) with findings of uncertain significance. Overall, 6 (0.2%) athletes had major conditions; however, coronary anatomy and aortic dimensions were inconsistently reported and pathology may have been missed. CONCLUSION: Major non-COVID-19 cardiovascular pathology was identified in 1/500 college athletes undergoing return-to-play screening. In athletes without ECG abnormalities, TTE's added value was limited to pathological aortic root dilatation in 1/1000 athletes and minor abnormalities warranting surveillance in 1/160 athletes. Two-thirds of findings were incidental or of uncertain significance.

Association of Tibial Tubercle-Trochlear Groove Distance With Risk of ACL Graft Failure.

Background: Limited evidence suggests a positive correlation between tibial tubercle-trochlear groove (TT-TG) distance and the risk of native anterior cruciate ligament (ACL) tear. The relationship between TT-TG distance and the risk of ACL graft failure is unknown. Hypothesis: TT-TG distance is independently associated with risk of ACL graft failure. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who underwent ACL revision surgery between 2010 and 2018 at a single institution were identified. A control cohort underwent primary ACL reconstruction (ACLR) between 2006 and 2015, with no evidence of graft failure at 8.1 ± 2.5 years postoperatively. Record review included anthropometrics, graft type, and estimated Tegner activity score at ≥6 months after primary ACLR. Magnetic resonance imaging (MRI) scans after native ACL tear (controls) or graft failure (revision cohort) were assessed for (1) TT-TG distance, (2) proximal tibial slopes, (3) depth of tibial plateau concavity, and (4) tunnel position (revision cohort). Associations between ACL graft failure and MRI measurements, surgical variables, and patient characteristics were evaluated with logistic regression analyses. Sensitivity analyses, excluding patients with tunnel malposition, were performed to confirm multivariable results in patients with "ideal" tunnel placement. Results: Participants included 153 patients who underwent revisions and 144 controls. Controls were older than the patients who underwent revision (26.6 ± 8.8 vs 20.6 ± 7.3 years; P < .001). The mean TT-TG distance and lateral posterior tibial slope (PTS) were smaller for the control group than for the revision group (TT-TG: 9.3 ± 3.9 vs 11.2 ± 4.2 mm; P < .001; lateral PTS: 6.2° ± 3.3° vs 7.2° ± 3.6°; P = .01). TT-TG distance, lateral PTS, and age were associated with risk of ACL graft failure by multivariable analysis (OR, 1.15; 95% CI, 1.07-1.23; P < .001; OR, 1.13; 95% CI, 1.04-1.22; P = .004; and OR, 0.90; 95% CI, 0.87-0.94; P < .001, respectively). With sensitivity analyses, TT-TG distance, lateral PTS, and age at index surgery remained significantly and independently associated with ACL graft failure. Conclusion: Increased TT-TG distance, increased lateral PTS, and younger age are independently associated with increased odds of ACL graft failure. Patients with these characteristics may require a more comprehensive strategy to reduce the risk of ACL reinjury.

Three-Month Complication Rate of Ultrasound-Guided Soft Tissue Surgical Procedures Across Six Sports Medicine Clinics.

OBJECTIVES: To 1) determine the types and frequency of complications within 3 months following ultrasound-guided surgical procedures, and 2) identify any patient demographics, co-morbidities, or procedural characteristics that were associated with an increased risk of complications. METHODS: A retrospective chart review was performed at six Sports Medicine clinics across the United States. The Clavien-Dindo classification was used to categorize procedural complications on a 5-point scale from 1, representing any deviation in post-procedure care without requiring pharmacological or invasive treatment to 5, representing death. Generalized Estimating Equations for binomial outcomes with a logit link were used to estimate the overall and procedure-specific 3-month complication rates. RESULTS: Among 1902 patients, 8.1% (n = 154) had diabetes and 6.3% (n = 119) were current smokers. The analysis included 2,369 procedures, which were performed in either the upper extremity (44.1%, n = 1045) or lower extremity (55.2%, n = 1308) regions. The most common procedure was ultrasound-guided tenotomy (69.9%, n = 1655). Additional procedures included, trigger finger release (13.1%, n = 310), tendon scraping (8.0%, n = 189), carpal tunnel release (5.4%, n = 128), soft tissue release (2.1%, n = 50), and compartment fasciotomy (1.6%, n = 37). Overall, there was a complication rate of 1.2% (n = 29 complications; 95% CI: 0.8-1.7%). Individual procedures had complication rates that ranged from 0 to 2.7%. There were 13 Grade I complications in 13 patients, 12 Grade II complications in 10 patients, 4 Grade III complications in 4 patients, and 0 Grade IV or V complications. No associations between complication risk and any patient demographics (age, sex, BMI), co-morbidities (diabetes, smoker), or procedure characteristics (type, region) were identified. CONCLUSION: This retrospective review provides an evidence-based estimate supporting the low level of risk associated with ultrasound-guided surgical procedures for patients from a variety of geographical settings who are seeking care at private and academic-affiliated clinics.

Baseline Kinesiophobia and Pain Catastrophizing Scores Predict Prolonged Postoperative Shoulder Pain.

BACKGROUND: Chronic postsurgical pain remains a major hurdle in postoperative management, especially in patients undergoing shoulder surgery, for whom persistent pain rates are higher than for any other surgical site. Little is known about pain beliefs and attitudes as preoperative predictors of postoperative pain following nonarthroplasty shoulder surgery. OBJECTIVES: We evaluated predictors of pain following nonarthroplasty shoulder surgery, hypothesizing that preoperative kinesiophobia, pain catastrophizing, and neuropathic pain scores are predictive of greater postoperative pain. STUDY DESIGN: Case control study. SETTING: Division of Sports Medicine at the University of Wisconsin School of Medicine and Public Health. METHODS: Consecutive patients aged 18 and older undergoing a nonarthroplasty  shoulder operation were selected. At the preoperative appointment and 3 months postoperative, patients completed the Short-Form McGill Pain Questionnaire-2 to assess severity and quality of pain, the painDetect Questionnaire to screen for neuropathic pain, the Tampa Scale of Kinesiophobia to assess fear of movement and fear-avoidance beliefs, and the Pain Catastrophizing Scale  to gauge rumination, magnification, and pessimism. A univariable negative binomial regression model was used to identify associations between preoperative predictors and postoperative  scores, reporting risk ratios and 95% confidence intervals. RESULTS: Eighty-one patients completed the preoperative surveys and 43 patients completed at least one postoperative survey. The median pain score decreased from 3 out of 10 (interquartile range [IQR] = 2-5) in the preoperative group to one (IQR = 0-2) in the postoperative group (P < 0.001). Mean kinesiophobia scores decreased from 40.44 (standard deviation [SD] = 5.94) preoperatively to 35.40 (SD = 6.44) postoperatively (P < 0.001). Median pain catastrophizing scores decreased from 7 (IQR = 2-17]) preoperatively to 2 (IQR = 0-11]) postoperatively (P = 0.005). No significant changes in neuropathic pain scores were observed. Higher baseline kinesiophobia scores were associated with greater postoperative pain (risk ratio = 1.09, 95% confidence interval [CI] = 1.01 to 1.18), P = 0.03), as were higher pain catastrophizing scores (risk ratio = 1.05, 95% CI = 1.01 to 1.08), P = 0.01). No association between baseline neuropathic pain and degree of postoperative pain was identified. LIMITATIONS: Limitations of the study include a single institution with multiple surgeons and types of surgery. The study drop-out rate was relatively high. CONCLUSION: This study suggests that greater baseline kinesiophobia and pain catastrophizing are predictive of greater postoperative pain following nonarthroplasty shoulder surgery in an adult population.

High School Sports During the COVID-19 Pandemic: The Effect of Sport Participation on the Health of Adolescents.

CONTEXT: During the fall of 2020, some high schools across the United States allowed their students to participate in interscholastic sports while others cancelled or postponed their sport programs due to concerns regarding COVID-19 transmission. What effect this has had on the physical and mental health of adolescents is unknown. OBJECTIVE: To identify the effect of playing a sport during the COVID-19 pandemic on the health of student-athletes. DESIGN: Cross-sectional study. SETTING: Sample recruited via email. PATIENTS OR OTHER PARTICIPANTS: A total of 559 Wisconsin high school athletes (age = 15.7 ± 1.2 years, female = 43.6%, male = 56.4%) from 44 high schools completed an online survey in October 2020. A total of 171 (30.6%) athletes played (PLY) a fall sport, while 388 (69.4%) did not play (DNP). MAIN OUTCOME MEASURE(S): Demographic data included sex, grade, and sport(s) played. Assessments were the General Anxiety Disorder-7 Item for anxiety, Patient Health Questionnaire-9 Item for depression, the Hospital for Special Surgery Pediatric Functional Activity Brief Scale for physical activity, and the Pediatric Quality of Life Inventory 4.0 for quality of life. Univariable comparisons between the 2 groups were made via t tests or χ2 tests. Means for each continuous outcome measure were compared between groups using analysis-of-variance models that controlled for age, sex, teaching method (virtual, hybrid, or in person), and the percentage of students eligible for free or reduced-price lunch. RESULTS: The PLY group participants were less likely to report moderate to severe symptoms of anxiety (PLY = 6.6%, DNP = 44.1%, P < .001) and depression (PLY = 18.2%, DNP = 40.4%, P < .001). They also demonstrated higher (better) Pediatric Functional Activity Brief Scale scores (PLY = 23.2 [95% CI = 22.0, 24.5], DNP = 16.4 [95% CI = 15.0, 17.8], P < .001) and higher (better) Pediatric Quality of Life Inventory total scores (PLY = 88.4 [95% CI = 85.9, 90.9], DNP = 79.6 [95% CI = 76.8, 82.4], P < .001). CONCLUSIONS: Adolescents who played a sport during the COVID-19 pandemic described fewer symptoms of anxiety and depression and had better physical activity and quality-of-life scores compared with adolescent athletes who did not play a sport.

Medial Patellofemoral Ligament Repair for Recurrent Patellar Instability: Successful Outcomes Among Patients With Low Coronal Malalignment and Normal Patellar Height.

Medial patellofemoral ligament (MPFL) repair is discouraged for the treatment of chronic, recurrent patellar instability (RPI) because of high reported failure rates. However, the senior author uses MPFL repair for chronic RPI in the setting of low tibial tubercle-trochlear groove (TT-TG) distance. In this retrospective case series, we report results and evaluate outcome predictors. We used billing records to identify all patients, 14 years or older, who underwent isolated repair for chronic RPI performed by a single surgeon between September 2010 and February 2019. The TT-TG distance, patellar height (Caton-Deschamps Index [CDI]), and trochlear depth were measured on preoperative magnetic resonance imaging; postoperative reports were reviewed; and post hoc Kuala scores were obtained to extend outcome length. Patellar dislocation or revision surgery was considered a failure. Nonfailures were categorized as excellent or fair, based on the most recent report. Univariable generalized estimating equation models were used to evaluate associations of predictors (radiographic parameters, age, ligamentous laxity, primary presenting complaint) with failure and/or success. A total of 93 isolated MPFL repairs were performed. After exclusions were made for workers' compensation insurance (n=4), substance abuse (n=3), major secondary trauma less than 3 months postoperatively (n=3), and follow-up of less than 12 months (n=42), 41 knees (38 patients) had median follow-up of 32 months (interquartile range, 19-48 months). All repairs were patellar sided. Outcomes for 4 knees were considered failures, 23 were excellent, and 14 were fair. Only increased CDI was associated with increased risk of failure (odds ratio, 1.70; 95% CI, 0.98-2.92; P=.06). Mean CDI was 1.23 mm (SD, 0.13 mm) for failures vs 1.08 mm (SD, 0.16 mm) for nonfailures. Failure rate was less than 10% following patellar-sided MPFL repair for treatment of chronic RPI among patients with low TT-TG distance. Increased patellar height was associated with higher risk of failure. [Orthopedics. 2022;45(1):e23-e29.].

Lower Extremity Kinematic and Kinetic Asymmetries during Running.

PURPOSE: The primary aims of this investigation were to describe the magnitude of asymmetries of common variables during running among healthy athletes and to determine if sex and speed influence magnitudes of asymmetry. METHODS: This study analyzed routinely collected running gait data on healthy Division I collegiate athletes. All athletes had no history of lower extremity surgery, no lower extremity injuries for 3 months before testing, and running data available at 2.68, 2.95, 3.35, 3.80, and 4.47 m·s-1. Asymmetries were calculated for ground reaction forces, spatiotemporal metrics, joint kinematics, and joint kinetics. Separate linear mixed-effects models assessed the influence of sex, speed, and the interaction on asymmetries of interest. z Scores were calculated for significant effects to further assess the magnitude of differences. RESULTS: Results from 204 athletes were included. The magnitude of asymmetry varied depending on the variable of interest, with asymmetries ≤3° observed for joint kinematics and greater asymmetries observed among joint work asymmetries ranging from 10% to 40%. No significant interactions between sex and speed were observed. Differences in sex and speed were noted; however, the effect sizes were very small based on z score comparison (-0.17 ≤ z ≤ 0.36) and were unlikely to be meaningful. CONCLUSIONS: The magnitude of asymmetry varies considerably depending on the running gait variable. Interpretation of between-limb asymmetry in running mechanics needs to be specific to the variable of interest, whereas sex or running speed seem to be minor factors.

Screening for Microscopic Hematuria in a Urogynecologic Population.

OBJECTIVES: The objectives of this were to determine the correlation of greater than or equal to 3 red blood cells per high-power field (RBCs/HPF) with a positive urine dipstick for blood and to identify clinically relevant factors than can influence this relationship. METHODS: The charts of women with positive blood urine dipsticks were reviewed from August 2012 to August 2013. The cohort of women was divided into 2 groups; those with urine with greater than or equal to 3 RBCs/HPF on microscopy and those without. Relevant clinical and demographic variables were extracted from the electronic medical record. Data analysis was conducted using SAS version 9.4 (SAS Institute, Cary, NC). RESULTS: Most of the 203 patients eligible for analysis were Caucasian, and the total cohort had a mean age of approximately 62.8 years. Microscopy confirmed greater than or equal to 3 RBCs/HPF in 25.6% of the urine samples. A dipstick finding of moderate or large blood was significantly more likely to have greater than or equal to 3 RBCs/HPF on univariate and multivariable analyses (P < 0.001). Factors significantly associated with greater than or equal to 3 RBCs/HPF were increasing age, recurrent urinary tract infections, and urinary specific gravity of greater than 1.010. CONCLUSIONS: Lower urinary specific gravities appear to be associated with underestimating microhematuria, likely owing to the underrepresentation of the true number of red blood cells. Urine dipstick indicators of moderate or large blood increase the likelihood the microscopy samples demonstrated greater than or equal to 3 RBCs/HPF. These findings suggest that clarification of microhematuria detection and evaluation guidelines should be considered, given both important clinical and economic consequences.

No consensus on implant choice for oligometastatic disease of the femoral head and neck.

OBJECTIVES: Metastatic disease involving the femoral head and neck is often treated with a hemiarthroplasty or total hip arthroplasty (THA) to prevent pathologic fracture but there are no outcome studies demonstrating superiority of one option over the other. METHODS: This investigation was designed as a survey of the current members of the Musculoskeletal Tumor Society (MSTS). The survey contained seven clinical vignettes with identical imaging of a pathologic lesion of the femoral head and neck. The primary outcome measured was decision to treat the lesion with hemiarthroplasty or THA. Secondary outcomes included method of fixation of the femoral/acetabular components and head type utilized. RESULTS: A total of 93 members (30.0%) of the MSTS completed the survey. Across all clinical vignettes, 73.3% (p < 0.001) of the responses were in favor of hemiarthroplasty; however, there was no significant difference between hemiarthroplasty and THA in Cases 1 & 2 (p = 0.08, p = 0.6, respectively); the cases representing younger patients with a more favorable histologic diagnosis. When THA was selected the majority of respondents preferred hybrid or cementless fixation construct (56.1% and 27.0%, respectively, p < 0.001). When hemiarthroplasty was selected respondents selected a cemented, bipolar construct (86.4% and 64.2%, respectively, p < 0.001). CONCLUSIONS: When treating metastatic lesions of the femoral head and neck orthopaedic oncologists do not agree on reconstructing with THA versus hemiarthroplasty for patients with younger age and favorable histology. This investigation highlights the controversy of this clinical decision and indicates the need for a collaborative prospective trial among this specific patient population in order to determine the optimal treatment method.

A Randomized Controlled Trial for Abdominal Binder Use after Laparoendoscopic Single-Site Surgery.

STUDY OBJECTIVE: To compare postoperative pain in patients using an abdominal binder with a control group after laparoendoscopic single-site (LESS) surgery. DESIGN: A randomized controlled trial (Canadian Task Force classification level 1). SETTING: An academic gynecologic surgeon's practice. PATIENTS: Private patients undergoing surgery performed by a fellowship-trained minimally invasive gynecologic surgeon between April 2016 and April 2017. INTERVENTIONS: Ninety total patients were selected for this study, with 60 randomized to receive an abdominal binder after surgery and 30 patients randomized to the control group without a binder. MEASUREMENTS AND MAIN RESULTS: Using a 10-point verbal analog scale, patients recorded pain levels for 3 weeks postoperatively on a variety of measures, including overall and incisional pain. They recorded results on postoperative days 0, 1, 2, 3, 4, 7, 14, and 21. On average, the association between time and the overall pain score did not differ with binder use (p = .37). The overall pain decreases significantly over time (p < .001). After adjusting for time, the overall pain score differed significantly by binder status (p = .04). Those without a binder reported an average pain score that was 1.13 (standard deviation = 0.55) points higher than those with a binder across the first week. CONCLUSION: The results suggest that abdominal binder use after LESS surgery may be beneficial in reducing postoperative pain in the first week. Results from this study can provide feasibility data for future studies.

Postoperative Pain After Single-Site Versus Multiport Hysterectomy.

BACKGROUND AND OBJECTIVES: With advances in laparoscopic surgery, the goal of surgeons and patients is to minimize pain to allow for faster recovery and return to normal daily activities. One of these advances is single-site surgery. In this study, we compared postoperative pain in laparoendoscopic single-site surgery (LESS) to that in traditional multiple-incision hysterectomy. METHODS: Seventy patients were selected for this prospective cohort study, with 35 undergoing multiple-incision and 35 undergoing LESS hysterectomy. All patients were included who were undergoing hysterectomy with the primary surgeon. All multiport hysterectomies were performed laparoscopically. Six patients underwent LESS hysterectomy and 29 underwent robotic single-site surgery (rLESS). Patients recorded pain levels for 3 weeks after surgery on a variety of measures, including overall and incisional pain. Linear mixed effects models for repeated measures were used for all multivariate analyses, with an unstructured covariance matrix accounting for correlation between time points. RESULTS: Overall, across all time points, there was an average reduction in pain by 1.26 (SD 0.69) points in the single-site group (P = .06). Days 3 and 14 had a marginally significant reduction in pain (P = .06 and 0.058, respectively). On days 4 and 7 there was a significant reduction in overall pain (P = .04 and .04, respectively). CONCLUSION: Based on the results, it is likely that single-site hysterectomy leads to less postoperative pain and achieves a lower pain score faster than multiport surgery. A randomized control trial is necessary to confirm these results before accepting them in clinical practice.

The Contributing Risk of Tobacco Use for ARDS Development in Burn-Injured Adults With Inhalation Injury.

BACKGROUND: This study aims to determine the relationship between tobacco use, inhalation injury, and ARDS in burn-injured adults. METHODS: This study was an observational cohort of 2,485 primary burn admissions to a referral burn center between January 1, 2008 and March 15, 2015. Subjects were evaluated by methods used to account for mediation and traditional approaches (multivariable logistic regression and propensity score analysis). Mediation analysis examined both the (1) indirect effect of tobacco use via inhalation injury as the mediator on ARDS development and (2) the direct effect of tobacco use alone on ARDS development. RESULTS: ARDS development occurred in 6.8% (n = 170) of the cohort. Inhalation injury occurred in 5.0% (n = 125) of the cohort, and ARDS developed in 48.8% (n = 83) of the subjects with inhalation injury. Tobacco use was 2-fold more common in subjects with ARDS. In the mediated model, the direct effect of tobacco use on ARDS, including interaction between tobacco use and inhalation injury, was not significant (odds ratio [OR] 1.63, 95% CI 0.91-2.92, P = .10). However, the indirect effect of tobacco use via inhalation injury as the mediator was significant (OR 1.61, 95% CI 1.25-2.07, P < .001), and the proportion of the total effect of tobacco use operating through the mediator was 55.6%. In the non-mediation models (multivariable logistic regression and propensity score analysis), which controlled for inhalation injury and other covariables, the OR for the association between tobacco use and ARDS was 1.84 (95% CI 1.22-2.81, P < .001) and 1.69 (95% CI 1.04-2.75, P = .03), respectively. CONCLUSIONS: In mediation analysis, inhalation injury was the overwhelming predictor for ARDS development, whereas tobacco use has its strongest effect indirectly through inhalation injury. Patients with at least moderate inhalation injury are at greatest risk for ARDS development despite baseline risk factors like tobacco use.

Dedifferentiated chondrosarcoma: A survival analysis of 159 cases from the SEER database (2001-2011).

BACKGROUND AND OBJECTIVES: Dedifferentiated chondrosarcoma is a rare malignancy with reported 5-year overall survival rates ranging from 7% to 24%. The purpose of this investigation is to determine the overall survival of dedifferentiated chondrosarcoma in a modern patient series and how it is impacted by patient demographics, tumor characteristics, and surgical treatment factors. METHODS: This is a retrospective review of the Surveillance, Epidemiology, and End Results (SEER) database from 2001 to 2011. Kaplan Meier analyses were used for overall and disease-specific survival. Univariable and multivariable cox regression models were used to identify prognostic factors. RESULTS: Five year overall- and disease-specific survival was 18% (95% CI: 12-26%) and 28% (95% CI: 18-37%), respectively. Individuals with extremity tumors had a worse prognosis than individuals with a primary tumor in the chest wall or axial skeleton (HR 0.20, 95% CI: 0.07-0.56; P = 0.002 and HR 0.60, 95% CI: 0.36-0.99; P = 0.04, respectively). Patients with AJCC stage III or IV disease (HR 2.51, 95% CI: 1.50-4.20; P = 0.001), tumors larger than 8 cm (HR 2.17, 95% CI: 1.11-4.27; P = 0.046), metastatic disease at diagnosis (HR 3.25, 95% CI: 1.98-5.33; P < 0.001), and those treated without surgical resection (amputation: HR 0.43, 95% CI 0.23-0.80; P = 0.01; limb salvage/non-amputation resection: HR 0.41, 95% CI: 0.24-0.69; P = 0.001) had a significant increase in risk of mortality. CONCLUSIONS: The overall prognosis of dedifferentiated chondrosarcoma is poor with a 5-year overall survival of 18%. Patients with a primary tumor located in the chest wall had a better prognosis. Tumors larger than 8 cm, presence of metastases at diagnosis, and treatment without surgical resection were significant predictors of mortality.

Early Hospital Readmissions and Mortality in Patients With Decompensated Cirrhosis Enrolled in a Large National Health Insurance Administrative Database.

BACKGROUND: Patients with decompensated cirrhosis have high rates of morbidity and mortality and frequently require hospital admission. Few studies have examined early readmission as an indicator of 90 day and overall mortality. Analysis of large databases is needed to evaluate the association between early readmission and mortality in decompensated cirrhosis. METHODS: We analyzed 5 years of private, employer-based, health insurance claims data associated with HealthCare Services Corporation on 13.5 million members over 4 states from 2010 to 2014. We defined early readmission as an admission to a general acute care hospital within 30 days of an index hospitalization and compared mortality to those who were readmitted after 30 days (late readmission). Univariable analysis was used to compare clinical and patient characteristics associated with early readmission. Cox proportional hazard models with time-varying covariates were used to assess if an early readmission was an independent risk factor for death. RESULTS: A total of 16,107 patients with decompensated cirrhosis were analyzed. During the study period, 82% of patients with decompensated cirrhosis were hospitalized at least once. Over 50% of hospitalized patients experienced an early readmission. Patients with an early readmission received blood transfusions, transjugular intrahepatic portosystemic shunt, paracentesis, thoracentesis, and upper endoscopies more frequently than those with a late readmission. Cirrhotics with an early readmission had higher rates of hepatorenal syndrome, sepsis, hepatocellular carcinoma, hepatic encephalopathy, and ascites. Patients experiencing an early readmission had greater 90 day, 1 year and overall mortality. Early readmission was an independent predictor of worse survival when adjusting for other conditions associated with mortality in patients with cirrhosis, but the impact of an early readmission dissipated after 1 year. CONCLUSIONS: Patients with decompensated cirrhosis have high rates of hospitalization and frequently experience an early readmission. An early readmission to an acute care hospital is an independent predictor of mortality in patients with decompensated cirrhosis for at least 1 year following initial hospitalization.

Accelerometer-measured physical activity is not associated with two-year weight change in African-origin adults from five diverse populations.

BACKGROUND: Increasing population-levels of physical activity (PA) is a controversial strategy for managing the obesity epidemic, given the conflicting evidence for weight loss from PA alone per se. We measured PA and weight change in a three-year prospective cohort study in young adults from five countries (Ghana, South Africa, Jamaica, Seychelles and USA). METHODS: A total of 1,944 men and women had baseline data, and at least 1 follow-up examination including measures of anthropometry (weight/BMI), and objective PA (accelerometer, 7-day) following the three-year study period. PA was explored as 1-minute bouts of moderate and vigorous PA (MVPA) as well as daily sedentary time. RESULTS: At baseline; Ghanaian and South African men had the lowest body weights (63.4 ± 9.5, 64.9 ± 11.8 kg, respectively) and men and women from the USA the highest (93.6 ± 25.9, 91.7 ± 23.4 kg, respectively). Prevalence of normal weight ranged from 85% in Ghanaian men to 29% in USA men and 52% in Ghanaian women to 15% in USA women. Over the two-year follow-up period, USA men and Jamaican women experienced the smallest yearly weight change rate (0.1 ± 3.3 kg/yr; -0.03 ± 3.0 kg/yr, respectively), compared to South African men and Ghanaian women greatest yearly change (0.6.0 ± 3.0 kg/yr; 1.22 ± 2.6 kg/yr, respectively). Mean yearly weight gain tended to be larger among normal weight participants at baseline than overweight/obese at baseline. Neither baseline MVPA nor sedentary time were associated with weight gain. Using multiple linear regression, only baseline weight, age and gender were significantly associated with weight gain. DISCUSSION: From our study it is not evident that higher volumes of PA alone are protective against future weight gain, and by deduction our data suggest that other environmental factors such as the food environment may have a more critical role.

The microenvironment in primary cutaneous melanoma with associated spontaneous tumor regression: evaluation for T-regulatory cells and the presence of an immunosuppressive microenvironment.

Spontaneous tumor regression, regression in the absence of therapeutic intervention, can be identified histologically in over 25% of primary cutaneous melanomas at initial diagnosis. A unique subset of T lymphocytes found in areas of regression can be histologically distinguished from tumor-infiltrating T lymphocytes (TIL) found in areas of tumor progression. We call this unique subset of T lymphocytes regression-associated T lymphocytes (RATs). The aim of this study is to determine the phenotype of lymphocytes and the density of specific cell types linked to immunosuppression in areas of tumor progression compared with areas of tumor regression. These specific cell types include T-regulatory cells (Tregs) and S100A9 cells. A total of 14 primary cutaneous melanomas with areas of progression and regression were used. Immunohistochemistry staining was used to identify CD4 cells, CD8 cells, Tregs, and S100A9 cells. Two independent observers manually counted three high-powered ×40 fields. There was no predominance of CD4 or CD8 T lymphocytes in either RATs or TIL. We identified a lower density of Tregs in RATs compared with TIL when using the FOXP3/CD4 Treg marker (P=0.04) and a marginal difference when using our second, confirmatory Treg marker, FOXP3/CD25 (P=0.11). We observed a lower density of S100A9 cells in RATs compared with TIL (P=0.002). There was an observable difference in the tumor microenvironments of RATs and TIL, with RATs having a significantly lower density of Tregs and S100A9 cells. We deduce that the absence of immunosuppression in areas of regression allows for a more robust immune response and thus effective eradication of tumor cells.

Standardized Reporting of Microscopic Renal Tumor Margins: Introduction of the Renal Tumor Capsule Invasion Scoring System.

PURPOSE: Renal tumor enucleation allows for maximal parenchymal preservation. Identifying pseudocapsule integrity is critically important in nephron sparing surgery by enucleation. Tumor invasion into and through the capsule may have clinical implications, although it is not routinely commented on in standard pathological reporting. We describe a system to standardize the varying degrees of pseudocapsule invasion and identify predictors of invasion. MATERIALS AND METHODS: We performed a multicenter retrospective review between 2002 and 2014 at Indiana University Hospital and Loyola University Medical Center. A total of 327 tumors were evaluated following removal via radical nephrectomy, standard margin partial nephrectomy or enucleation partial nephrectomy. Pathologists scored tumors using our i-Cap (invasion of pseudocapsule) scoring system. Multivariate analysis was done to determine predictors of higher score tumors. RESULTS: Tumor characteristics were similar among surgical resection groups. Enucleated tumors tended to have thinner pseudocapsule rims but not higher i-Cap scores. Rates of complete capsular invasion, scored as i-Cap 3, were similar among the surgical techniques, comprising 22% of the overall cohort. Papillary histology along with increasing tumor grade was predictive of an i-Cap 3 score. CONCLUSIONS: A capsule invasion scoring system is useful to classify renal cell carcinoma pseudocapsule integrity. i-Cap scores appear to be independent of surgical technique. Complete capsular invasion is most common in papillary and high grade tumors. Further work is warranted regarding the relevance of capsular invasion depth as it relates to the oncologic outcome for local recurrence and disease specific survival.

Evaluation of the urinary microbiota of women with uncomplicated stress urinary incontinence.

BACKGROUND: Female urinary microbiota are associated with urgency urinary incontinence and response to medication. The urinary microbiota of women with stress urinary incontinence has not been described. OBJECTIVE: We sought to study the cross-sectional relationships between urinary microbiota features and demographic and clinical characteristics of women undergoing stress urinary incontinence surgery. STUDY DESIGN: Preoperative urine specimens were collected from women without urinary tract infection and were available from 197 women (174 voided, 23 catheterized) enrolled in a multicenter prospective randomized trial, the Value of Urodynamic Evaluation study. Demographic and clinical variables were obtained including stress and urgency urinary incontinence symptoms, menopausal status, and hormone use. The bacterial composition of the urine was qualitatively assessed by sequencing the bacterial 16S ribosomal RNA gene. Phylogenetic relatedness and microbial alpha diversity were compared to demographics and symptoms using generalized estimating equation models. RESULTS: The majority of 197 urine samples (86%) had detectable bacterial DNA. Bacterial diversity was significantly associated with higher body mass index (P = .02); increased Medical, Epidemiologic, and Social Aspects of Aging urge index score (P = .04); and hormonal status (P < .001). No associations were detected with stress urinary incontinence symptoms. Increased diversity was also associated with a concomitant lower frequency of Lactobacillus in hormone-negative women. CONCLUSION: Women undergoing stress urinary incontinence surgery have detectable urinary microbiota. This cross-sectional analysis revealed that increased diversity of the microbiota was associated with urgency urinary incontinence symptoms, hormonal status, and body mass index. In contrast, the female urinary microbiota were not associated with stress urinary incontinence symptoms.

Impact of Post-Hospital Syndrome on Outcomes Following Elective, Ambulatory Surgery.

OBJECTIVE: The aim of this study was to investigate whether post-hospital syndrome (PHS) places patients undergoing elective hernia repair at increased risk for adverse postoperative events. SUMMARY OF BACKGROUND DATA: PHS is a transient period of health vulnerability following inpatient hospitalization for acute illness. PHS has been well studied in nonsurgical populations, but its effect on surgical outcomes is unclear. METHODS: State-specific datasets for California in 2011 available through the Healthcare Cost and Utilization Project (HCUP) were linked. Patients older than 18 years who underwent elective hernia repair were included. The primary exposure variable was PHS, defined as any inpatient admission within 90 days of an elective hernia repair performed in an ambulatory surgery center. The primary outcome was an adverse event, defined as any unplanned emergency department visit or inpatient admission within 30 days postoperatively. Mixed-effects logistic models were used for multivariable analyses. RESULTS: A total of 57,988 patients met inclusion criteria. The 30-day risk-adjusted adverse event rate was significantly higher for PHS patients versus non-PHS patients (11.8% vs 5.8%, P < 0.001). PHS patients were more likely than non-PHS patients to experience postoperative complications (odds ratio 2.2, 95% confidence interval 1.6-3.0). Adverse events attributable to PHS cost an additional $63,533.46 per 100 cases in California. The risk of adverse events due to PHS remained elevated throughout the 90-day window between hospitalization and surgery. CONCLUSIONS: Patients hospitalized within 90 days of an elective surgery are at increased risk of adverse events postoperatively. The impact of PHS on outcomes is independent of baseline patient characteristics, medical comorbidities, quality of center performing the surgery, and reason for hospitalization before elective surgery. Adverse events owing to PHS are costly and represent a quality improvement target.

Survival in Mesenchymal Chondrosarcoma Varies Based on Age and Tumor Location: A Survival Analysis of the SEER Database.

BACKGROUND: Studies suggest that mesenchymal chondrosarcoma is associated with a poorer prognosis and a higher proportion of extraskeletal tumors than conventional chondrosarcoma. However, these investigations have been small heterogeneous cohorts, limiting analysis of prognostic factors. QUESTIONS/PURPOSES: (1) What is the 5- and 10-year survival rate of patients diagnosed with mesenchymal chondrosarcoma? (2) What is the effect of demographic and tumor characteristics on survival in patients with mesenchymal chondrosarcoma? METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was used to identify all patients diagnosed with mesenchymal chondrosarcoma from 1973 to 2011. SEER reports survival data on over 8.2 million patients with cancer and has attained 98% completeness in reporting. Using variables within the database, this study designated each patient's tumor as skeletal or extraskeletal and cranial, axial, or appendicular, respectively. Overall survival (OS) was determined for the entire series as well as each group. Median survival was calculated using Kaplan-Meier methods. Cox proportional hazards regression was used to determine whether demographic and tumor variables affected survival. Two hundred five patients with mesenchymal chondrosarcoma were identified, including 82 (40%) skeletal and 123 (60%) extraskeletal. RESULTS: OS for the entire series was 51% (95% confidence interval [CI], 43%-58%) and 43% (95% CI, 35%-51%) at 5 and 10 years, respectively. No difference in OS was detected between extraskeletal and skeletal tumors. Kaplan-Meier analyses showed OS was worse for tumors in axial locations compared with appendicular and cranial locations. Appendicular tumors demonstrated an OS of 50% (95% CI, 36%-63%) at 5 years and 39% (95% CI, 26%-52%) at 10 years. OS for axial tumors was 37% (95% CI, 25%-49%) and 31% (95% CI, 20%-43%), whereas it was 74% (95% CI, 59%-84%) and 67% (95% CI, 50%-79%) for cranial tumors at 5 and 10 years, respectively. When controlling for age, sex, tumor origin, and tumor location, the presence of metastasis (hazard ratio [HR], 12.38; 95% CI, 5.75-26.65; p < 0.001) and 1-cm size increase (HR, 1.16; 95% CI, 1.09-1.23; p < 0.001) were both independently associated with an increased risk of death. Tumor location showed different behaviors depending on patient age. In comparison to cranial tumors at age 20 years, the HR was 5.56 (95% CI, 1.47-21.05; p = 0.01) for axial tumors and 6.26 (95% CI, 1.54-25.42; p = 0.01) for appendicular tumors. At age 60 years, those ratios were 0.10 (95% CI, 0.02-0.55; p = 0.01) and 0.14 (95% CI, 0.04-0.58; p = 0.01), respectively. CONCLUSIONS: Our data suggest that extraskeletal tumors are more common than previously reported; however, this factor does not have clear prognostic value. Presence of metastatic disease and increased tumor size are the main predictors of poor survival outcome. Cranial tumors appear to have a different clinical behavior with our data suggesting better overall survival in young patients (compared with axial and appendicular locations) and a worse survival outcome in older patients. LEVEL OF EVIDENCE: Level IV, prognostic study.