Are Social Deprivation and Low Traditional Health Literacy Associated With Higher PROMIS CAT Completion in Orthopaedic Surgery?

BACKGROUND: The Patient-Reported Outcomes Measurement Information System® (PROMIS®) may be used to assess an individual patient's perspective of their physical, mental, and social health through either standard or computer adaptive testing (CAT) patient questionnaires. These questionnaires are used across disciplines; however, they have seen considerable application in orthopaedic surgery. Patient characteristics associated with PROMIS CAT completion have not been examined within the context of social determinants of health, such as social deprivation or health literacy, nor has patient understanding of the content of PROMIS CAT been assessed. QUESTIONS/PURPOSES: (1) What patient demographics, including social deprivation, are associated with completion of PROMIS CAT questionnaires? (2) Is health literacy level associated with completion of PROMIS CAT questionnaires? (3) Do patients with lower health literacy have a higher odds of completing PROMIS CAT without fully understanding the content? METHODS: Between June 2022 and August 2022, a cross-sectional study was performed via a paper survey administered to patients at a single, urban, quaternary academic medical center in orthopaedic subspecialty clinics of foot and ankle, trauma, and hand/upper extremity surgeons. We considered all English-speaking patients aged 18 or older, including those with limited reading and/or writing abilities, as eligible provided they received an iPad in clinic to complete the PROMIS CAT questionnaire as part of their routine standard clinical care or they completed the questionnaire via a patient portal before the visit. In all, 946 patients were considered eligible during the study period and a convenience sample of 36% (339 of 946) of patients was approached for inclusion due to clinic time constraints. Fifteen percent (52 of 339) declined to participate, leaving 85% (287 of 339) of patients for analysis here. Median (range) age of study participants was 49 years (35 to 64). Fifty-eight percent (167 of 287) of study participants self-identified as non-Hispanic Black or African American and 26% (75 of 287) as non-Hispanic White. Even proportions were observed across education levels (high school graduate or less, 29% [82 of 287]; some college, 25% [73 of 287]; college graduate, 25% [71 of 287]; advanced degree, 20% [58 of 287]). Eighteen percent (52 of 287) of patients reported an annual income bracket of USD 0 to 13,000, and 17% (48 of 287) reported more than USD 120,000. Forty-six percent (132 of 287) of patients worked full-time, 21% (59 of 287) were retired, and 23% (66 of 287) were unemployed or on disability. The primary outcome of interest was self-reported PROMIS CAT questionnaire completion grouped as: fully completed, partially completed, or no part completed. Overall, self-reported PROMIS CAT questionnaire completion proportions were: 80% (229 of 287) full completion, 13% (37 of 287) partial completion, and 7% (21 of 287) no part completed. We collected the National Area Deprivation Index (ADI) score and the Brief Health Literacy Screening Tool (BRIEF) as part of the study survey to associate with level of completion. Additionally, patient understanding of PROMIS CAT was assessed through Likert-scaled responses to a study survey question that directly asked whether the patient understood all of the questions on the PROMIS CAT questionnaire. Responses to this question may have been limited by social desirability bias, and hence may overestimate how many individuals genuinely understood the questionnaire content. However, the benefit of this approach was it efficiently allowed us to estimate the ceiling effect of patient comprehension of PROMIS CAT and likely had a high degree of specificity for detecting lack of comprehension. RESULTS: ADI score adjusted for age was not associated with PROMIS CAT completion (partial completion OR 1.00 [95% CI 0.98 to 1.01]; p = 0.72, no part completed OR 1.01 [95% CI 0.99 to 1.03]; p = 0.45). Patients with lower health literacy scores, however, were more likely to not complete any part of their assigned questionnaires than patients with higher scores (no part completed OR 0.85 [95% CI 0.75 to 0.97]; p = 0.02). Additionally, 74% (26 of 35) of patients who did not fully understand all of the PROMIS CAT questionnaire questions still fully completed them-hence, 11% (26 of 229) of all patients who fully completed PROMIS CAT did not fully understand the content. Among patients self-reporting full completion of PROMIS CAT with health literacy data (99% [227 of 229]), patients with inadequate/marginal health literacy were more likely than patients with adequate health literacy to not fully understand all of the questions (21% [14 of 67] versus 8% [12 of 160], OR 3.26 [95% CI 1.42 to 7.49]; p = 0.005). CONCLUSION: Within an urban, socioeconomically diverse, orthopaedic patient population, health literacy was associated with PROMIS CAT questionnaire completion. Lower health literacy levels increased the likelihood of not completing any part of the assigned PROMIS CAT questionnaires. Additionally, patients completed PROMIS CAT without fully understanding the questions. This indicates that patient completion does not guarantee comprehension of the questions nor validity of their scores, even more so among patients with low health literacy. This is a substantive concern for fidelity of data gathered from PROMIS CAT. CLINICAL RELEVANCE: Clinical implementation of the PROMIS CAT in orthopaedic populations will benefit from further research into health literacy to increase questionnaire completion and to ensure that patients understand the content of the questions they are answering, which will increase the internal validity of the outcome measure.

Artificial turf infill associated with systematic toxicity in an amniote vertebrate.

Artificial athletic turf containing crumb rubber (CR) from shredded tires is a growing environmental and public health concern. However, the associated health risk is unknown due to the lack of toxicity data for higher vertebrates. We evaluated the toxic effects of CR in a developing amniote vertebrate embryo. CR water leachate was administered to fertilized chicken eggs via different exposure routes, i.e., coating by dropping CR leachate on the eggshell; dipping the eggs into CR leachate; microinjecting CR leachate into the air cell or yolk. After 3 or 7 d of incubation, embryonic morphology, organ development, physiology, and molecular pathways were measured. The results showed that CR leachate injected into the yolk caused mild to severe developmental malformations, reduced growth, and specifically impaired the development of the brain and cardiovascular system, which were associated with gene dysregulation in aryl hydrocarbon receptor, stress-response, and thyroid hormone pathways. The observed systematic effects were probably due to a complex mixture of toxic chemicals leaching from CR, such as metals (e.g., Zn, Cr, Pb) and amines (e.g., benzothiazole). This study points to a need to closely examine the potential regulation of the use of CR on playgrounds and artificial fields.

Hydrophilic Mechano-Bactericidal Nanopillars Require External Forces to Rapidly Kill Bacteria.

Nanopillars have been shown to mechanically damage bacteria, suggesting a promising strategy for future antibacterial surfaces. However, the mechanisms underlying this phenomena remain unclear, which ultimately limits translational potential toward real-world applications. Using real-time and end-point analysis techniques, we demonstrate that in contrast to initial expectations, bacteria on multiple hydrophilic "mechano-bactericidal" surfaces remained viable unless exposed to a moving air-liquid interface, which caused considerable cell death. Reasoning that normal forces arising from surface tension may underlie this mechano-bactericidal activity, we developed computational and experimental models to estimate, manipulate, and recreate the impact of these forces. Our experiments together demonstrate that a critical level of external force acting on cells attached to nanopillar surfaces can rapidly deform and rupture bacteria. These studies provide fundamental physical insight into how nanopillar surfaces can serve as effective antibacterial materials and suggest use-conditions under which such nanotechnology approaches may provide practical value.

Microfluidic Shear Assay to Distinguish between Bacterial Adhesion and Attachment Strength on Stiffness-Tunable Silicone Substrates.

Tuning surface composition and stiffness is now an established strategy to improve the integration of medical implants. Recent evidence suggests that matrix stiffness affects bacterial adhesion, but contradictory findings have been reported in the literature. Distinguishing between the effects of bacterial adhesion and attachment strength on these surfaces may help interpret these findings. Here, we develop a precision microfluidic shear assay to quantify bacterial adhesion strength on stiffness-tunable and biomolecule-coated silicone materials. We demonstrate that bacteria are more strongly attached to soft silicones, compared to stiff silicones; as determined by retention against increasing shear flows. Interestingly, this effect is reduced when the surface is coated with matrix biomolecules. These results demonstrate that bacteria do sense and respond to stiffness of the surrounding environment and that precisely defined assays are needed to understand the interplay among surface mechanics, composition, and bacterial binding.

3D Bioprinting of Food Grade Hydrogel Infused with Living Pleurotus ostreatus Mycelium in Non-sterile Conditions.

Mycelium is the root-like network of fungi. Mycelium biocomposites prepared by template replication (molding) can function as environmentally friendly alternatives to conventional polystyrene foams, which are energy- and carbon-intensive to manufacture. Recently, several studies have shown that 3D bioprinting technologies can be used to produce high value functional mycelium products with intricate geometries that are otherwise difficult or impossible to achieve via template replication. A diverse range of nutrients, thickeners, and gelling agents can be combined to produce hydrogels suitable for 3D bioprinting. 3D bioprinting with hydrogel formulations infused with living fungi produces engineered living materials that continue to grow after bioprinting is complete. However, a hydrogel formulation optimized for intricate 3D bioprinting of Pleurotus ostreatus mycelium, which is among the strains most commonly used in mycelium biocomposite fabrication, has yet to be described. Here, we design and evaluate a versatile hydrogel formulation consisting of malt extract (nutrient), carboxymethylcellulose and cornstarch (thickeners), and agar (gelling agent), all of which are easily sourced food grade reagents. We also outline a reproducible workflow to infuse this hydrogel with P. ostreatus liquid culture for 3D bioprinting of intricate structures comprised of living P. ostreatus mycelium and characterize the changes in height and mass as well as hardness of the prints during mycelium growth. Finally, we demonstrate that the workflow does not require a sterile bioprinting environment to achieve successful prints and that the same mycelium-infused hydrogel can be supplemented with additives such as sawdust to produce mycelium biocomposite objects. These findings demonstrate that 3D bioprinting using mycelium-based feedstocks could be a promising biofabrication technique to produce engineered living materials for applications such as mushroom cultivation, food preparation, or construction of the built environment.

Microfluidic Study of Bacterial Attachment on and Detachment from Zinc Oxide Nanopillars.

Nanopillars can influence how bacterial cells attach to a surface. Herein, we investigated whether self-assembled zinc oxide (ZnO) nanopillars synthesized on glass substrates via the conventional hydrothermal route possess anti-biofouling properties either by reducing the amount of initially attached cells or promoting the detachment of cells from the surface or both. To avoid complications associated with manual intervention methods of assessing bacterial attachment on nanopillar surfaces, we implemented a microfluidic approach. In our study, we synthesized two nanopillar topographies: a low surface density of ZnO nanopillars and a high surface density of ZnO nanopillars. Next, we mounted microfluidic channels to each of these substrates. This microfluidic approach allowed us to gently flow Pseudomonas aeruginosa, Staphylococcus aureus, or Bacillus subtilis cells onto the nanopillars for initial attachment before systematically increasing the flowrate to attempt to detach remaining attached cells without introducing air-liquid interface artefacts during the assay. Generally, initial bacterial attachment was similar across all substrates. However, cells consistently detached more readily from high-surface-density nanopillars compared to low-surface-density nanopillars. Electron microscopy revealed that cells that attached to high-surface-density nanopillars rested atop the nanopillars, fully exposed to microfluidic shear, whereas many cells became trapped in the void space between neighboring low-surface-density nanopillars, shielding these cells from detachment. Our findings indicate that self-assembled ZnO nanopillars can provide anti-biofouling properties under submerged flow but only if synthesized at high surface density.

Surface Wettability Is a Key Feature in the Mechano-Bactericidal Activity of Nanopillars.

Nanopillar-textured surfaces are of growing interest because of their ability to kill bacteria through physical damage without relying on antimicrobial chemicals. Although research on antibacterial nanopillars has progressed significantly in recent years, the effect of nanopillar hydrophobicity on bactericidal activity remains elusive. In this study, we investigated the mechano-bactericidal efficacy of etched silicon nanopillars against Pseudomonas aeruginosa at nanopillar hydrophobicities from superhydrophilic to superhydrophobic. Assessing cell viability and bacterial morphology in immersed wet conditions, we observed negligible bactericidal activity; however, air/liquid interface displacement during water evaporation established a bactericidal effect that strongly depends on substrate hydrophobicity. Specifically, bactericidal activity was highest on superhydrophilic surfaces but abated with increasing hydrophobicity, diminishing at substrate contact angles larger than 90°. Calculation of the surface tension and Laplace pressure forces during water evaporation for each substrate subsequently highlighted that the total capillary force, as an external driving force responsible for bacterial deformation, is significantly weaker on hydrophobic substrates. These findings suggest that superhydrophilic nanopillared surfaces are a superior choice for mechano-bactericidal activity, whereas superhydrophobic surfaces, although not bactericidal, may have antibiofouling properties through their self-cleaning effect. These findings provide new insights into the design and application of nanopillared surfaces as functional antibacterial materials.

Equivalent Operative Outcomes for Emergency Colon Cancer Resections Among Acute Care Surgeons and Specialists in Colorectal Surgery.

OBJECTIVES: Improved screening has decreased but not eliminated the need for emergent surgery for colon cancer (CC), many of which are performed by acute care surgery (ACS) surgeons. This retrospective review compares outcomes for CC resections on the ACS service to the surgical oncology and colorectal services (SO/CRS). METHODS: Retrospective review was performed for CC operations between 2014 and 2019. Data for margin status, cancer stage, number of lymph nodes dissected, time to medical oncology follow-up, and time to initiation of chemotherapy were collected. Patients with curative resection, who chose comfort care, presented on alternative services or with non-CC indications as well as those were lost to follow-up were excluded. RESULTS: 36 ACS patients and 269 SO/CRS patients underwent CC resections. Most ACS patients presented emergently compared to the SO/CC group (83.3% vs 1%, P < .05) as well as with more advanced tumor stage. There were no statistically significant differences for presence of metastatic disease, number of lymph nodes obtained, or time to post-surgical care (in days) and chemotherapy initiation (in days). 3 (8%) EGS patients had positive margins compared to 6 (2%) CRS/SO patients due to the presence of perforated tumors in the ACS group (p < .05). There were no statistically significant differences in 30- day or 1-year mortality despite the emergent presentation of the ACS patients. DISCUSSION: These findings suggest that despite emergent presentation and advanced disease burden, ACS surgeons provide quality care to CC patients, both in the operating room and in coordination of care.

The Story of Blood for Shock Resuscitation: How the Pendulum Swings.

Whole blood transfusion (WBT) began in 1667 as a treatment for mental illness, with predictably poor results. Its therapeutic utility and widespread use were initially limited by deficiencies in transfusion science and antisepsis. James Blundell, a British obstetrician, was recognized for the first allotransfusion in 1825. However, WBT did not become safe and therapeutic until the early 20th century, with the advent of reliable equipment, sterilization, and blood typing. The discovery of citrate preservation in World War I allowed a separation of donor from recipient and introduced the practice of blood banking. During World War II, Elliott and Strumia were the first to separate whole blood into blood component therapy (BCT), producing dried plasma as a resuscitative product for "traumatic shock." During the 1970s, infectious disease, blood fractionation, and financial opportunities further drove the change from WBT to BCT, with few supporting data. Following a period of high-volume crystalloid and BCT resuscitation well into the early 2000s, measures to avoid the resulting iatrogenic resuscitation injury were developed under the concept of damage control resuscitation. Modern transfusion strategies for hemorrhagic shock target balanced BCT to reapproximate whole blood. Contemporary research has expanded the role of WBT to therapy for the acute coagulopathy of trauma and the damaged endothelium. Many US trauma centers are now using WBT as a front-line treatment in tandem with BCT for patients suffering hemorrhagic shock. Looking ahead, it is likely that WBT will once again be the resuscitative fluid of choice for patients in hemorrhagic shock.

Intelligent optofluidic analysis for ultrafast single bacterium profiling of cellulose production and morphology.

Bacterial cellulose (BC), a renewable type of cellulose, has been used in the manufacture of foods, cosmetics, and biomedical products. To produce BC, a high-throughput single-bacterium measurement is necessary to identify the functional bacteria that can produce BC with sufficient amount and desirable morphology. In this study, a continuous-flow intelligent optofluidic device was developed to enable high-throughput single-bacterium profiling of BC. Single bacteria were incubated in agarose hydrogel particles to produce BC with varied densities and structures. An intelligent convolutional neural network (CNN) computational method was developed to analyze the scattering patterns of BC. The BC production and morphology were determined with a throughput of ∼35 bacteria per second. A total of ∼105 single-bacterium BC samples were characterized within 3 hours. The high flexibility of this approach facilitates high-throughput comprehensive single-cell production analysis for a range of applications in engineering biology.

Magnetic microboats for floating, stiffness tunable, air-liquid interface epithelial cultures.

To study respiratory diseases, in vitro airway epithelial models are commonly implemented by culturing airway cells on a porous surface at an air-liquid interface (ALI). However, these surfaces are often supraphysiologically stiff, which is known to affect the organization, maturation, and responses of cells to potential therapies in other biological culture models. While it is possible to culture cells on soft hydrogel substrates at an air-liquid interface, these techniques are challenging to implement particularly in high-throughput applications which require robust and repetitive material handling procedures. To address these two limitations and characterize epithelial cultures on substrates of varying stiffness at the ALI, we developed a novel "lung-on-a-boat", in which stiffness-tuneable hydrogels are integrated into the bottoms of polymeric microstructures, which normally float at the air-liquid interface. An embedded magnetic material can be used to sink the boat on demand when a magnetic field is applied, enabling reliable transition between submerged and ALI culture. In this work, we prototype a functional ALI microboat platform, with integrated stiffness-tunable polyacrylamide hydrogel surfaces, and validate the use of this technology with a model epithelial cell line. We verify sufficient transport through the hydrogel base to maintain cell viability and stimulate cultures, using a model nanoparticle with known toxicity. We then demonstrate significant morphological and functional effects on epithelial barrier formation, suggesting that substrate stiffness is an important parameter to consider in the design of in vitro epithelial ALI models for drug discovery and fundamental research.

Anodized Aluminum with Nanoholes Impregnated with Quaternary Ammonium Compounds Can Kill Pathogenic Bacteria within Seconds of Contact.

Bacterial contamination of surfaces results in the spread of pathogens in public spaces such as hospitals and public transport. The development of antibacterial surfaces that rapidly kill bacteria is therefore highly desirable. Here, we investigate the antibacterial efficacy of a novel anodized aluminum surface featuring nanoholes impregnated with quaternary ammonium compounds, referred to as A3S. The antimicrobial activity of A3S was assessed using both Gram-positive and Gram-negative bacteria in a novel assay which simulates pathogen transfer from a contaminated "finger" to a clean finger in a real-world scenario. Enumeration of colony-forming units shows that the number of viable bacteria on the second "finger" contacting A3S is significantly reduced compared to a control surface. Furthermore, bacterial contact with the A3S material results in compromised cell membranes in less than 1 min, and a kill zone assay shows that an exposure time as short as 5 s is sufficient to kill pathogenic bacteria. The rapid antimicrobial action of A3S was particularly evident against Gram-positive bacteria, that account for more than 70% of nosocomial infections. Taken together, these findings demonstrate that A3S is a promising candidate for the fabrication of antibacterial surfaces that can be used in a wide range of clinical and commercial applications to stop the spread of harmful bacteria.

Nanodarts, nanoblades, and nanospikes: Mechano-bactericidal nanostructures and where to find them.

Over the past ten years, a next-generation approach to combat bacterial contamination has emerged: one which employs nanostructure geometry to deliver lethal mechanical forces causing bacterial cell death. In this review, we first discuss advances in both colloidal and topographical nanostructures shown to exhibit such "mechano-bactericidal" mechanisms of action. Next, we highlight work from pioneering research groups in this area of antibacterials. Finally, we provide suggestions for unexplored research topics that would benefit the field of mechano-bactericidal nanostructures. Traditionally, antibacterial materials are loaded with antibacterial agents with the expectation that these agents will be released in a timely fashion to reach their intended bacterial metabolic target at a sufficient concentration. Such antibacterial approaches, generally categorized as chemical-based, face design drawbacks as compounds diffuse in all directions, leach into the environment, and require replenishing. In contrast, due to their mechanisms of action, mechano-bactericidal nanostructures can benefit from sustainable opportunities. Namely, mechano-bactericidal efficacy needs not replenishing since they are not consumed metabolically, nor are they designed to release or leach compounds. For this same reason, however, their action is limited to the bacterial cells that have made direct contact with mechano-bactericidal nanostructures. As suspended colloids, mechano-bactericidal nanostructures such as carbon nanotubes and graphene nanosheets can pierce or slice bacterial membranes. Alternatively, surface topography such as mechano-bactericidal nanopillars and nanospikes can inflict critical membrane damage to microorganisms perched upon them, leading to subsequent cell lysis and death. Despite the infancy of this area of research, materials constructed from these nanostructures show remarkable antibacterial potential worthy of further investigation.