Nonoperative Management of Isolated Thoracolumbar Flexion Distraction Injuries: A Single-Center Study.

BACKGROUND: Nonoperative management is an appealing option for purely transosseous thoracolumbar flexion-distraction injuries given the prospects of osseous healing and restoration of the posterior tension band complex. This study seeks to examine differences in outcomes following flexion-distraction injuries after operative and nonoperative management. METHODS: This study reviews all patients at a single Level 1 trauma center from 2004 to 2022 with AO Spine B1 thoracolumbar injuries treated operatively vs nonoperatively. Inclusion criteria were age greater than 16 years, computed tomography-confirmed transosseous flexion-distraction injuries, and at least 3 months of follow-up with available imaging. The primary outcome assessed was a change in local Cobb angles, with secondary outcomes consisting of complications, time to return to work, and need for subsequent operative fixation. RESULTS: Initial Cobb angles in the operative (n = 14) vs nonoperative group (n = 13) were -5° and -13°, respectively (P = 0.225), indicating kyphotic alignment in both cohorts. We noted a significant difference in Cobb angles between cohorts at first follow-up (2.6° and -13.9°, P = 0.015) and within the operative cohort from presentation to first follow-up (P = 0.029). At the second follow-up, there was no significant difference in Cobb angles between cohorts (3.6° and -12.6°, P = 0.07). No significant differences were noted in complication rates (P = 1), time to return to work (P = 0.193), or resolution of subjective back pain (P = 0.193). No crossover was noted. CONCLUSIONS: Nonoperative management of minimally displaced transosseous flexion-distraction injuries is a safe alternative to surgery. Patient factors, such as compliance with follow-up, and location of the injury should be factored into the surgeon's management recommendation. CLINICAL RELEVANCE: Overall, no significant differences in outcomes and complications were noted following nonoperative management of AO Spine B1 injuries, indicating the potential for these injuries to be managed conservatively.

Genital Pain and the Spectrum of Bladder-Related Symptoms: Findings from the Prevention of Lower Urinary Tract Symptoms Research Consortium RISE FOR HEALTH Study, USA.

INTRODUCTION AND HYPOTHESIS: Women with vulvovaginal or genital pain more commonly experience interstitial cystitis/bladder pain syndrome (IC/BPS) and urinary tract infections. However, the relationship between genital pain and bladder health is lacking. METHODS: Women in the Prevention of Lower Urinary Tract Symptoms Consortium's RISE FOR HEALTH population-based study answered questions about bladder health globally, and across nine bladder health domains of holding, efficacy, social-occupation, physical activity, intimacy, travel, emotion, perception, and freedom. Bladder function was assessed across six indices including urinary frequency, sensation, continence, comfort, emptying, and dysbiosis (e.g., urinary tract infections). Participants were grouped by no pain beyond transitory events (i.e., minor headaches, toothaches, or sprains), nongenital-related pain only, and any genital pain using a validated pain diagram. Mean adjusted scores and indices were compared using general linear modelling. RESULTS: Of 1,973 eligible women, 250 (12.7%) reported genital pain, 609 (30.9%) reported nongenital pain only, and 1,114 (56.5%) reported no pain. Women with any genital pain had lower (worse) adjusted mean scores across all bladder health scales (BHS; BHS global adjusted mean 47.5; 95% CI 40.8-54.1), compared with those with nongenital pain only (53.7; 95% CI 47.6-59.8), and no pain (59.3; 95% CI 53.3-65.4). Similarly, adjusted mean total Bladder Functional Index scores were lower for those with genital pain (63.1; 95% CI 58.4-67.9) compared with nongenital pain (72.1; 95% CI 67.7-76.5) and no pain (77.4; 95% CI 73.0-81.8). CONCLUSIONS: Heightened awareness of the relationship between genital pain and bladder health should prompt clinicians caring for women with genital pain to assess bladder health and function.

Teprotumumab Related Hearing Loss: A Large-Scale Analysis and Review of Voluntarily Reported Patient Complaints to the Food and Drug Administration (FDA).

PURPOSE: Accumulating case reports and series have suggested that teprotumumab may significantly increase the risk of hearing impairment that, in some cases, does not resolve. This study investigates the association between hearing impairment and teprotumumab use. METHODS: A disproportionality analysis was conducted using the United States Food and Drug Administration Adverse Event Reporting System, a publicly accessible database used for postmarketing surveillance and research. All adverse event reports containing the terms "teprotumumab" or "Tepezza" and a similar comparison group from all patients with the same indications for teprotumumab use (e.g., autoimmune thyroiditis, endocrine ophthalmopathy, and hyperthyroidism) but who had not received the drug were selected. Hearing impairment events were identified using the hearing impairment Standardized MedDRA Query. RESULTS: A total of 940 teprotumumab-associated adverse events were identified, including 84 hearing-related adverse events, with the first reported to the Food and Drug Administration in April 2020. A comparison group of 32,794 nonteprotumumab adverse events was identified with 127 hearing-related adverse events reported. Use of teprotumumab in patients with thyroid conditions was associated with a nearly 24-fold (proportional reporting ratio [PRR] 23.6, 95% confidence interval [CI]: 18.1-30.8) increased likelihood of any hearing disorder (p value <0.0001). The association was specifically elevated for a variety of deafness conditions (e.g., bilateral deafness [PRR: 41.9; 95% CI: 12.8-136.9]), Eustachian tube disorders (PRR: 34.9; 95% CI: 4.9-247.4), hypoacusis (PRR: 10.1; 95% CI: 7.6-13.3), and tinnitus (PRR: 8.7; 95% CI: 6.2-12.1). CONCLUSIONS: Patients treated with teprotumumab should receive warnings regarding the increased risk of hearing-related impairments and receive audiometry before, during, and after treatment.

Non-lesional epilepsy does not necessarily convey poor outcomes after invasive monitoring followed by resection or thermal ablation.

OBJECTIVE: We aimed to compare outcomes including seizure-free status at the last follow-up in adult patients with medically refractory focal epilepsy identified as lesional vs. non-lesional based on their magnetic resonance imaging (MRI) findings who underwent invasive evaluation followed by subsequent resection or thermal ablation (LiTT). METHODS: We identified 88 adult patients who underwent intracranial monitoring between 2014 and 2021. Of those, 40 received resection or LiTT, and they were dichotomized based on MRI findings, as lesional (N = 28) and non-lesional (N = 12). Patient demographics, seizure characteristics, non-invasive interventions, intracranial monitoring, and surgical variables were compared between the groups. Postsurgical seizure outcome at the last follow-up was rated according to the Engel classification, and postoperative seizure freedom was determined by Kaplan-Meyer survival analysis. Statistical analyses employed Fisher's exact test to compare categorical variables, while a t-test was used for continuous variables. RESULTS: There were no differences in baseline characteristics between groups except for more often noted PET abnormality in the lesional group (p = 0.0003). 64% of the lesional group and 57% of the non-lesional group received surgical resection or LiTT (p = 0.78). At the last follow-up, 78.5% of the patients with lesional MRI findings achieved Engel I outcomes compared to 66.7% of non-lesional patients (p = 0.45). Kaplan-Meier curves did not show a significant difference in seizure-free duration between both groups after surgical intervention (p = 0.49). SIGNIFICANCE: In our sample, the absence of lesion on brain MRI was not associated with worse seizure outcomes in adult patients who underwent invasive intracranial monitoring followed by resection or thermal ablation.

Social Determinants of Health and Glaucoma Screening and Detection in the SIGHT Studies.

PRCIS: Targeted glaucoma screenings in populations with high levels of poverty and high proportions of people who identify as African American or Hispanic/Latino identified a 27% rate of glaucoma and suspected glaucoma, which is 3 times the national average. PURPOSE: To describe the neighborhood-level social risk factors across the 3 SIGHT Study sites and assess potential characteristics of these populations to help other researchers effectively design and implement targeted glaucoma community-based screening and follow-up programs in high-risk groups. METHODS/RESULTS: In 2019, Columbia University, the University of Michigan, and the University of Alabama at Birmingham each received 5 years of CDC funding to test a wide spectrum of targeted telehealth delivery methods to detect glaucoma in community-based health delivery settings among high-risk populations. This collaborative initiative supported innovative strategies to better engage populations most at risk and least likely to have access to eye care to detect and manage glaucoma and other eye diseases in community-based settings. Among the initial 2379 participants enrolled in all 3 SIGHT Studies; 27% screened positive for glaucoma/glaucoma suspect. Of all SIGHT Study participants, 91% were 40 years of age and older, 64% identified as female, 60% identified as African-American, 32% identified as White, 19% identified as Hispanic/Latino, 53% had a high school education or less, 15% had no health insurance, and 38% had Medicaid insurance. Targeted glaucoma screenings in populations with high levels of poverty and high proportions of people who identify as African American or Hispanic/Latino identified a 27% rate of glaucoma and suspected glaucoma, three times the national average. CONCLUSION: These findings were consistent across each of the SIGHT Studies, which are located in 3 geographically distinct US locations in rural Alabama, small urban locations in Michigan, and urban New York City.

Workplace Violence in Orthopaedic Surgery: A Survey of Academy of Orthopaedic Surgeons Membership.

INTRODUCTION: Workplace violence (WPV) in US health care is increasing, and many workers are likely to experience WPV during their careers. This study aims to assess the scope of WPV in orthopaedics. METHODS: A 20-item survey adopted from the World Health Organization's 'Workplace Violence in the Health Sector Country Case Studies Research Instruments Survey Questionnaire' was sent to Academy of Orthopaedic Surgeons members, including residents and fellows. Deidentified responses were collected electronically over a 1-month period and assessed. RESULTS: Overall, 1,125 Academy of Orthopaedic Surgeons members participated (5% response rate). Most respondents were male (86%) and identified with the majority ethnic group (80%). WPV of any type was reported by 77.1%. Verbal abuse was the most common type (71.6%), and patients were the most common perpetrators. WPV was most prevalent among traumatologists, tumor surgeons, female surgeons, and those with 0 to 15 years in practice. Female surgeons reported more WPV events per practice year (2.25 versus 0.65, P < 0.01) and increased likelihood of physical threats and physical assaults from coworkers ( P = 0.004). DISCUSSION: WPV in orthopaedic surgery is largely perpetrated by patients and directed toward traumatologists, tumor surgeons, female surgeons, and less experienced surgeons. These data can be used to address safety measures in the workplace.

The Impact of Smoking on Hospital Course and Postoperative Outcomes in Patients With Fracture-Related Infections.

OBJECTIVES: To assess the relationship between patient smoking status and fracture-related infection (FRI) characteristics including patient symptoms at FRI presentation, bacterial species of FRI, and rates of fracture union. DESIGN: Retrospective cohort study. SETTING: Urban level 1 trauma center. PATIENT SELECTION CRITERIA: All patients undergoing reoperation for FRI from January 2013 to April 2021 were identified through manual review of an institutional database. OUTCOME MEASURES AND COMPARISONS: Data including patient demographics, fracture characteristics, infection presentation, and hospital course were collected through review of the electronic medical record. Patients were grouped based on current smoker versus nonsmoker status. Hospital course and postoperative outcomes of these groups were then compared. Risk factors of methicillin-resistant Staphylococcus aureus (MRSA) infection, Staphylococcus epidermidis infection, and sinus tract development were evaluated using multivariable logistic regression. RESULTS: A total of 301 patients, comprising 155 smokers (51%) and 146 nonsmokers (49%), undergoing FRI reoperation were included. Compared with nonsmokers, smokers were more likely male (69% vs. 56%, P = 0.024), were younger at the time of FRI reoperation (41.7 vs. 49.5 years, P < 0.001), and had lower mean body mass index (27.2 vs. 32.0, P < 0.001). Smokers also had lower prevalence of diabetes mellitus (13% vs. 25%, P = 0.008) and had higher Charlson Comorbidity Index 10-year estimated survival (93% vs. 81%, P < 0.001). Smokers had a lower proportion of S. epidermidis infections (11% vs. 20%, P = 0.037), higher risk of nonunion after index fracture surgery (74% vs. 61%, P = 0.018), and higher risk of sinus tracts at FRI presentation (38% vs. 23%, P = 0.004). On multivariable analysis, smoking was not found to be associated with increased odds of MRSA infection. CONCLUSIONS: Among patients who develop a FRI, smokers seemed to have better baseline health regarding age, body mass index, diabetes mellitus, and Charlson Comorbidity Index 10-year estimated survival compared with nonsmokers. Smoking status was not significantly associated with odds of MRSA infection. However, smoking status was associated with increased risk of sinus tract development and nonunion and lower rates of S. epidermidis infection at the time of FRI reoperation. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Shadow of Doubt: Is There Implicit Bias Among Orthopaedic Surgery Faculty and Residents Regarding Race and Gender?

BACKGROUND: Orthopaedic surgery continues to be one of the least diverse medical specialties. Recently, increasing emphasis has been placed on improving diversity in the medical field, which includes the need to better understand existing biases. Despite this, only about 6% of orthopaedic surgeons are women and 0.3% are Black. Addressing diversity, in part, requires a better understanding of existing biases. Most universities and residency programs have statements and policies against discrimination that seek to eliminate explicit biases. However, unconscious biases might negatively impact the selection, training, and career advancement of women and minorities who are underrepresented in orthopaedic surgery. Although this is difficult to measure, the Implicit Association Test (IAT) by Project Implicit might be useful to identify and measure levels of unconscious bias among orthopaedic surgeons, providing opportunities for additional interventions to improve diversity in this field. QUESTIONS/PURPOSES: (1) Do orthopaedic surgeons demonstrate implicit biases related to race and gender roles? (2) Are certain demographic characteristics (age, gender, race or ethnicity, or geographic location) or program characteristics (geographic location or size of program) associated with the presence of implicit biases? (3) Do the implicit biases of orthopaedic surgeons differ from those of other healthcare providers or the general population? METHODS: A cross-sectional study of implicit bias among orthopaedic surgeons was performed using the IAT from Project Implicit. The IAT is a computerized test that measures the time required to associate words or pictures with attributes, with faster or slower response times suggesting the ease or difficulty of associating the items. Although concerns have been raised recently about the validity and utility of the IAT, we believed it was the right study instrument to help identify the slight hesitation that can imply differences between inclusion and exclusion of a person. We used two IATs, one for Black and White race and one for gender, career, and family roles. We invited a consortium of researchers from United States and Canadian orthopaedic residency programs. Researchers at 34 programs agreed to distribute the invitation via email to their faculty, residents, and fellows for a total of 1484 invitees. Twenty-eight percent (419) of orthopaedic surgeons and trainees completed the survey. The respondents were 45% (186) residents, 55% (228) faculty, and one fellow. To evaluate response biases, the respondent population was compared with that of the American Academy of Orthopaedic Surgeons census. Responses were reported as D-scores based on response times for associations. D-scores were categorized as showing strong (≥ 0.65), moderate (≥ 0.35 to < 0.65), or slight (≥ 0.15 to < 0.35) associations. For a frame of reference, orthopaedic surgeons' mean IAT scores were compared with historical scores of other self-identified healthcare providers and that of the general population. Mean D-scores were analyzed with the Kruskal-Wallis test to determine whether demographic characteristics were associated with differences in D-scores. Bonferroni correction was applied, and p values less than 0.0056 were considered statistically significant. RESULTS: Overall, the mean IAT D-scores of orthopaedic surgeons indicated a slight preference for White people (0.29 ± 0.4) and a slight association of men with career (0.24 ± 0.3), with a normal distribution. Hence, most respondents' scores indicated slight preferences, but strong preferences for White race were noted in 27% (112 of 419) of respondents. There was a strong association of women with family and home and an association of men with work or career in 14% (60 of 419). These preferences generally did not correlate with the demographic, geographic, and program variables that were analyzed, except for a stronger association of women with family and home among women respondents. There were no differences in race IAT D-scores between orthopaedic surgeons and other healthcare providers and the general population. Gender-career IAT D-scores associating women with family and home were slightly lower among orthopaedic surgeons (0.24 ± 0.3) than among the general population (0.32 ± 0.4; p < 0.001) and other healthcare professionals (0.34 ± 0.4; p < 0.001). All of these values are in the slight preference range. CONCLUSION: Orthopaedic surgeons demonstrated slight preferences for White people, and there was a tendency to associate women with career and family on IATs, regardless of demographic and program characteristics, similar to others in healthcare and the general population. Given the similarity of scores with those in other, more diverse areas of medicine, unconscious biases alone do not explain the relative lack of diversity in orthopaedic surgery. CLINICAL RELEVANCE: Implicit biases only explain a small portion of the lack of progress in improving diversity, equity, inclusion, and belonging in our workforce and resolving healthcare disparities. Other causes including explicit biases, an unwelcoming culture, and perceptions of our specialty should be examined. Remedies including engagement of students and mentorship throughout training and early career should be sought.

The economic and clinical impact of fast- versus slow-setting cement in primary total knee arthroplasty.

INTRODUCTION: New bone cement products have been developed attempting to shorten their setting time and thus cut down time in the operating room. This study determines whether faster-setting bone cement shortens time in the operating room, and whether the quantity used compromises postoperative TKA outcomes. Additionally, this study looks at cost analyses of the quantity of bone cement used in TKA procedures. MATERIALS AND METHODS: One-hundred and sixty patients at a single institution with primary TKA surgeries between January 2019 and December 2021, and a clinic follow-up of at least one year, were identified. Five cement products used in this time period were identified and categorized by fast- or slow-setting products if their set times were marketed below or above six minutes, respectively. RESULTS: Estimated blood loss was higher in patients receiving fast-setting cements (160.0 vs 126.4 mL; p = 0.0009); however, operative time showed no difference between the cohorts (88.2 vs 89.2 min; p = 0.99). Fewer bags of cement were used for the fast cohort (1.3 vs 1.8 bags; p < 0.0001). The fast group was significantly cheaper on average per patient only when comparing between antibiotic bone cements (p = 0.007). No differences were found in postoperative outcomes between the two groups. CONCLUSIONS: No differences were found in operative times between the fast and slow cemented groups. Fewer bags of faster-setting cement only proved cost saving relative to other antibiotic bone cements studied. Nonetheless, decreased usage of fast cement did not result in any different postoperative outcomes compared to slow cements. LEVEL OF EVIDENCE: III.

Cryptococcal Meningoencephalitis in Phenotypically Normal Patients.

Cryptococcosis is an invasive fungal infection found worldwide that causes significant morbidity and mortality among a broad range of hosts. There are approximately 223,000 new cases of cryptococcosis annually throughout the world, and at least 180,000 deaths are attributed to this infection each year. Most of these are due to complications of cryptococcal meningoencephalitis among HIV-infected patients in resource-limited environments. The majority of individuals diagnosed with cryptococcosis have underlying conditions associated with immune dysfunction such as HIV, solid organ transplant, hematologic malignancy, organ failure syndromes, and/or the use of immunosuppressive agents such as glucocorticosteroids and biologic agents. In most clinical series, there is a small proportion of patients with cryptococcosis who are phenotypically normal; that is, they have no clinically obvious predisposition to disease. Cryptococcal meningoencephalitis (CME) presentation and management differ substantially between these normal individuals and their immunocompromised counterparts. In this review, we will focus on CME in the phenotypically normal host and underscore differences in the clinical presentation, management, outcome, and potential risk factors for these patients compared to immunocompromised persons who develop this potential devastating invasive fungal infection.

Intravenous tranexamic acid decreases intraoperative transfusion requirements and does not increase incidence of symptomatic venous thromboembolic events in musculoskeletal sarcoma surgery.

BACKGROUND AND OBJECTIVES: Tranexamic acid (TXA) is poorly studied in patients with bone and musculoskeletal sarcoma due to perceived increased risk of venous thromboembolism (VTE). This study aims to assess the safety and efficacy of intravenous (IV) TXA for patients undergoing surgical resection of primary bone or soft-tissue sarcoma. METHODS: A retrospective, single center review of adult patients with pelvic or extremity sarcoma who underwent surgical resections between January 2005 and March 2020 was performed. Patients between 2005 and 2012 were included as a historical comparison prior to the routine use of IV TXA for all sarcoma resections at our institution. RESULTS: Thirty-nine non-TXA and 59 TXA resections were identified. Two non-TXA patients experienced symptomatic pulmonary embolism compared to zero VTEs amongst TXA patients. IV TXA administered at any dose significantly reduced the probability of intraoperative transfusion (p = 0.003) and the median units of blood transfused at the time of any perioperative transfusion (p = 0.007). Intraoperative times were significantly shorter for TXA patients (128 vs 190 min; p = 0.004). A subset of patients who underwent wide resection with endoprosthetic reconstruction and received TXA similarly showed decreased requirement for intraoperative transfusion (p = 0.014) and decreased procedure times (p = 0.009). CONCLUSIONS: During sarcoma resection, at least 1 g of IV TXA can safely decrease the need for any intraoperative transfusion and the median number of PRBCs transfused by 2 units when any perioperative transfusion is given.

Coprescribing of opioids and psychotropic medications among Medicare-enrolled older adults on long-term opioid therapy.

BACKGROUND: Pressures to reduce opioid prescribing have potential to incentivize coprescribing of opioids (at lower dose) with psychotropic medications. Evidence concerning the extent of the problem is lacking. This study assessed trends in coprescribing and characterized coprescribing patterns among Medicare-enrolled older adults with chronic noncancer pain (CNCP) receiving long-term opioid therapy (LTOT). METHODS: A cohort study was conducted using 2012-2018 5% National Medicare claims data. Eligible beneficiaries were continuously enrolled and had no claims for cancer diagnoses or hospice use, and ≥ 2 claims with diagnoses for CNCP conditions within a 30-day period in the 12 months before the index date (LTOT initiation). Coprescribing was defined as an overlap between opioids and any class of psychotropic medication (antidepressants, benzodiazepines, antipsychotics, anticonvulsants, muscle relaxants, and nonbenzodiazepine hypnotics) based on their prescription fill dates and days of supply in a given year. The occurrence of coprescribing, coprescribing intensity, and number of days of overlap with psychotropic medications were calculated for each calendar year. RESULTS: The eligible study population of individuals on LTOT ranged from 2038 in 2013 to 1751 in 2018. The occurrence of coprescribing among eligible beneficiaries decreased from 73.41% in 2013 to 70.81% in 2015 and then increased slightly to 71.22% in 2018. Among eligible beneficiaries with at least one overlap day, the coprescribing intensity with any class of psychotropic medications showed minimal variation throughout the study period: 74.73% in 2013 and 72.67% in 2018. Across all the years, the coprescribing intensity was found to be highest with antidepressants (2013, 49.90%; 2018, 50.33%) followed by benzodiazepines (2013, 25.42%; 2018, 19.95%). CONCLUSION: Coprescribing was common among older adults with CNCP who initiated LTOT but did not rise substantially in the period studied. Future research should investigate drivers behind coprescribing and safety of various patterns of use.

Transverse posterior wall acetabular fracture pattern is associated with increased risk of periprosthetic joint infection after conversion total hip arthroplasty.

INTRODUCTION: Acetabular fracture subtypes are associated with varying rates of subsequent conversion total hip arthroplasty (THA) after open reduction internal fixation (ORIF) with transverse posterior wall (TPW) patterns having a higher risk for early conversion. Conversion THA is fraught with complications including increased rates of revision and periprosthetic joint infections (PJI). We aimed to determine if TPW pattern is associated with higher rates of readmissions and complications including PJI after conversion compared to other subtypes. METHODS: We retrospectively reviewed 1,938 acetabular fractures treated with ORIF at our institution from 2005 to 2019, of which 170 underwent conversion that met inclusion criteria, including 80 TPW fracture pattern. Conversion THA outcomes were compared by initial fracture pattern. There was no difference between the TPW and other fracture patterns in age, BMI, comorbidities, surgical variables, length of stay, ICU stay, discharge disposition, or hospital acquired complications related to their initial ORIF procedure. Multivariable analysis was performed to identify independent risk factors for PJI at both 90-days and 1-year after conversion. RESULTS: TPW fracture had higher risk of PJI after conversion THA at 1-year (16.3% vs 5.6%, p = 0.027). Multivariable analysis revealed TPW independently carried increased risk of 90-day (OR 4.89; 95% CI 1.16-20.52; p = 0.03) and 1-year PJI (OR 6.51; 95% CI 1.56-27.16; p = 0.01) compared to the other acetabular fracture patterns. There was no difference between the fracture cohorts in 90-day or 1-year mechanical complications including dislocation, periprosthetic fracture and revision THA for aseptic etiologies, or 90-day all-cause readmission after the conversion procedure. CONCLUSION: Although conversion THA after acetabular ORIF carry high rates of PJI overall, TPW fractures are associated with increased risk for PJI after conversion compared to other fracture patterns at 1-year follow-up. Novel management/treatment of these patients either at the time of ORIF and/or conversion THA procedure are needed to reduce PJI rates. LEVEL OF EVIDENCE: Therapeutic Level III (retrospective study of consecutive patients undergoing an intervention with analyses of outcomes).

COVID-19 effects on diet, sleep, and physical activity among mid- to late-adolescents residing in the deep south in the United States.

PURPOSE: This study investigated the differential impact of COVID-19 on United States (US) adolescents' physical health as a function of sociodemographic factors over 18 months. It was hypothesized that the impact of COVID-19 and its mitigation efforts on physical health factors would vary by sociodemographic factors. DESIGN AND METHODS: Data were drawn from a longitudinal study in which participants (ages 16 or 18) self-reported sleep, diet, and physical activity over 18months. Participants were enrolled between 2018 and 2022. Participants (n = 190, 73% Black/African American, 53% female) provided 1330 reports over 194 weeks (93 weeks before and 101 weeks after COVID-19 restrictions implementation). RESULTS: Physical health outcomes moderated by demographic factors were measured and assessed over 18 months. Multilevel models and general estimated equations estimated the impact of COVID-19 restrictions on participants' health outcomes. Sleep and physical activity worsened after COVID-19 regardless of moderating factors, but some specific outcomes varied across subgroups. CONCLUSIONS: This study diversifies the literature on the impact of COVID-19 and its mitigation measures on adolescents' social health. Further, it is based in the US's Deep South, largely populated by those identifying as Black/African American or of low socioeconomic status. Both subgroups are underrepresented in US-based health outcomes research. COVID-19 directly and indirectly impacted adolescents' physical health. PRACTICE IMPLICATIONS: Understanding if and how COVID-19 impacted adolescents' health will inform nursing practice to adapt to and overcome adverse sequelae to promote positive patient health outcomes.

Direct Anterior Approach Total Hip Arthroplasty Is Associated With Reduced 1-Year Mortality and Surgical Complications After Femoral Neck Fracture.

BACKGROUND: In some studies, the direct anterior approach (DAA) for elective total hip arthroplasty (THA) is associated with decreased dislocation and greater functional gains compared to the posterior approach (PA), as well as higher functional outcomes compared to the direct lateral approach (LA) at 2 weeks postoperatively. Given the paucity of literature on femoral neck fracture (FNF), we aspired to determine the association between the surgical approach used in THA and outcomes. METHODS: We conducted a retrospective review of patients undergoing THA for FNF at 9 institutions from 2010 to 2019. Patients who had high-energy injury mechanisms, were nonambulatory prior to injury, had concomitant femoral head or acetabular fractures, or did not reach minimum 1-year follow-up were excluded. The study included 622 THAs, of which 348 (56%) were performed through a DAA, 197 (32%) through a PA, and 77 (12%) through an LA. Postoperative complications and mortalities at 90 days and 1 year were compared between groups. Multivariable logistic regression models were constructed for each outcome of interest. RESULTS: The DAA was associated with a decreased risk of 90-day dislocation (odds ratio [OR] 0.25; 95% confidence interval [CI] 0.10 to 0.62; P = .01), mechanical revision (OR 0.12; 95% CI 0.02 to 0.56; P = .01), and mortality (OR 0.38; 95% CI 0.16 to 0.91; P = .03) compared to the PA. The DAA was also associated with decreased risk of dislocation (OR 0.32; 95% CI 0.14 to 0.74; P = .01), mechanical revision (OR 0.22; 95% CI 0.08 to 0.65; P = .01), and mortality at 1 year compared to PA (OR 0.43; 95% CI 0.21 to 0.85; P = .02). CONCLUSION: The DAA for THA after FNF is associated with higher in-hospital medical complications but lower risks of postoperative reoperation and mortality. Postdischarge care may impact this association and needs to be addressed in future studies. The DAA should be used among surgeons experienced with the approach for FNF to minimize complications. LEVEL OF EVIDENCE: Retrospective cohort, Level III.

The Association Between Taxane Use and Lacrimal Disorders.

PURPOSE: The current study seeks to investigate the association between lacrimal disorders and the use of docetaxel and paclitaxel. METHODS: A disproportionality analysis was conducted using the United States FDA Adverse Event Reporting System (FAERS). All adverse event reports containing the term docetaxel or paclitaxel were selected. Lacrimal adverse events were identified using the lacrimal disorders Standardized MedDRA Query (SMQ), which includes disorders that affect lacrimal gland and drainage system including blockage of nasolacrimal duct, occlusion/stenosis of punctum, lacrimal gland neoplasms, and inflammations and infections. RESULTS: The proportionate reporting ratio (PRR) comparing lacrimal events among docetaxel to paclitaxel users was 2.47 (95% CI, 2.03-3.02). With respect to specific lacrimal events, dacryostenosis (PRR 19.54 [95% CI, 7.19-53.13]), increased lacrimation (PRR 3.2 [95% CI, 2.42-4.23]), lacrimation disorder (p = 0.02), and xeropthalmia reports (p > 0.001) were significantly more common. CONCLUSIONS: The growing body of epidemiologic, clinical, and pathophysiologic research supports the case that docetaxel leads to adverse lacrimal events in certain patients and should be taken into consideration when oncologists consider docetaxel vs. paclitaxel.

How Has Statistical Testing in Orthopedics Changed Over Time? An Assessment of High Impact Journals Over 25 Years.

BACKGROUND: It is important for physicians to be familiar with statistical techniques commonly used in published medical research. Statistical errors in medical literature are common, and there is a reported lack of understanding regarding statistical knowledge necessary for data interpretation and journal reading. As study design has become increasingly complex, peer-reviewed literature poorly addresses and explains the most common statistical methods utilized across leading orthopedic journals. METHODS: Articles from 5 leading general and subspecialty orthopedic journals were compiled from 3 distinct time periods. After exclusions were applied, 9521 remained, and a random 5% sampling of these articles, balanced across journals and years, was conducted yielding 437 articles after additional exclusions. Information regarding the number of statistical tests used, power/sample size calculation, type of statistical tests used, level of evidence (LOE), study type, and study design was collected. RESULTS: The mean number of statistical tests across all 5 orthopedic journals increased from 1.39 to 2.29 by 2018 (p = 0.007). The percentage of articles that reported power/sample size analyses was not found to differ by year, but the value has increased from 2.6% in 1994 to 21.6% in 2018 (p = 0.081). The most commonly used statistical test was the t-test which was present in 20.5% of articles, followed by chi-square test (13%), Mann-Whitney analysis (12.6%) and analysis of variance (ANOVA, 9.6%). The mean number of tests was generally greater in articles from higher impact factor journals (p = 0.013). Studies with a LOE of I used the highest mean number of statistical tests (3.23) compared to studies with lower LOE ratings (range 1.66-2.69, p < 0.001). Randomized control trials used the highest mean number of statistical test (3.31), while case series used the lowest mean number of tests (1.57, p < 0.001). CONCLUSIONS: The mean number of statistical tests used per article has increased over the past 25 years with the t-test, chi-square test, Mann-Whitney analysis, and ANOVA being the most used statistical tests in leading orthopedic journals. Despite an increase in statistical tests it should be noted that there was a paucity in advance statistical testing within the orthopedic literature. This study displays important trends in data analysis and can serve as a guide to help clinicians and trainees better understand the statistics used in literature as well as identifying deficits within the literature that should be addressed to help progress the field of orthopedics.

The Impact of Surgical Timing After Ankle Fracture on Clinical and Long-Term Patient Reported Outcomes.

The goal of this study is to evaluate the effect of time-to-surgery following closed ankle fractures on long-term patient reported outcomes, fracture healing, and wound complications. To date, little research has been done focusing on the impact "time to definitive fixation" has on patient reported outcomes. We performed a retrospective analysis of 215 patient records who underwent open reduction and internal fixation (ORIF) for an ankle fracture from July 2011 to July 2018. A total of 86 patients completed the patient reported outcome measurement information systems (PROMIS) survey at long-term follow-up. Primary outcomes were the rate of delayed union, postoperative wound complications, patient reported outcome measurement information system (PROMIS) pain interference (PI), and physical function (PF) scores. No differences were found when comparing time to surgery on a continuous scale with rates of delayed union, nonunion, or wound complications (p = .84, .47, and .63, respectively). PROMIS scores were collected at a median of 4.5 years (2.0 interquartile range (IQR), range 2.5-12.3) postoperatively. The time from ankle fracture to surgery was independently associated with worse PROMIS PI scores (unstandardized ß 0.38, 95% CI 0.07-0.68) but not PROMIS PF scores. Severe Lauge-Hansen injuries were independently associated with decreased PROMIS PF scores (unstandardized ß -7.02, 95% CI -12.0 to -2.04). Increased time to surgical intervention and severe Lauge-Hansen injuries were independently associated with worse long-term patient reported outcomes. Surgical timing did not impact union rates or wound complications. Surgeons should be aware that delaying ankle fracture repair beyond 12 days after injury may negatively affect long-term patient reported pain scores.

Critical Examination of Indications for Urinalysis in the United States.

INTRODUCTION: Urinalysis is commonly performed in the United States. We critically evaluated urinalysis indications in the United States. METHODS: We obtained an Institutional Review Board exemption for this study. 2015 National Ambulatory Medical Care Survey data were queried for urinalysis testing frequency and associated International Classification of Diseases, ninth edition diagnoses. 2018 MarketScan data were queried for urinalysis testing frequency and associated International Classification of Diseases, 10th edition diagnoses. We considered International Classification of Diseases, ninth edition codes for genitourinary disease, diabetes, hypertension, hyperparathyroidism, renal artery disease, substance abuse, or pregnancy as an appropriate indication for urinalysis. We considered International Classification of Diseases, 10th edition codes A (certain infections and parasitic diseases), C, D (neoplasms), E (endocrine, nutritional, and metabolic diseases), N (disease of the genitourinary system), and select R codes (symptoms, signs, and abnormal clinical laboratory findings, not elsewhere classified) as an appropriate indication for urinalysis. RESULTS: Of 99 million 2015 urinalysis encounters, 58.5% had an International Classification of Diseases, ninth edition code for genitourinary disease, diabetes, hypertension, hyperparathyroidism, renal artery disease, substance abuse, and pregnancy. Forty percent of the 2018 urinalysis encounters did not have an International Classification of Diseases, 10th edition diagnosis. Twenty-seven percent had an appropriate primary diagnosis code, and 51% had one of the appropriate codes. The most common International Classification of Diseases, 10th edition codes were encounter for general adult examination, urinary tract infection, essential hypertension, dysuria, unspecified abdominal pain, and encounter for general adult medical examination with abnormal findings. CONCLUSIONS: Urinalysis is commonly performed without an appropriate diagnosis. Widespread urinalysis leads to a large number of evaluations for asymptomatic microhematuria, with associated cost and morbidity. Closer examination for urinalysis indications is needed to reduce costs and morbidity.